Hammertoe surgery: arthroplasty, arthrodesis or plantar plate repair?

In cases of painful complex hammertoe deformity, there is no single approach that can be used in all circumstances. If conservative care fails, surgical management may include interphalangeal joint arthroplasty, arthrodesis, and/or plantar plate repair. The best and most pragmatic surgical plan must be patient-centered, taking the age, activity level, expectations of the patient, and precise etiology of the hammertoe deformity into account.

Tarsal coalitions: etiology, diagnosis, imaging, and stigmata.

Tarsal coalition is a congenital condition characterized by the aberrant union (osseous or fibrous) between 2 bones in the rearfoot, most commonly talocalcaneal coalition, calcaneonavicular coalition, and talonavicular coalition, that results in a restriction or absence of motion. The association between tarsal coalition and a variety of coexisting conditions has been reported over the past 60 years and continues to be better understood. These coexisting conditions (the stigmata of tarsal coalition) have been believed to be secondary effects of the coalition and/or fixed rearfoot position. Advanced imaging has provided significant insights into the concomitant pathology and understanding of tarsal coalition that the symptoms associated with tarsal coalition can be present for a myriad of different reasons. One should consider all the stigmata of tarsal coalition when considering a surgical reconstruction.

A critical evaluation of subtalar joint arthrosis associated with middle facet talocalcaneal coalition in 21 surgically managed patients: a retrospective computed tomography review. Investigations involving middle facet coalitions-part III.

Symptomatic middle facet talocalcaneal coalition is frequently associated with rearfoot arthrosis that is often managed surgically with rearfoot fusion. However, no objective method for classifying the extent of subtalar joint arthrosis exists. No study has clearly identified the extent of posterior facet arthrosis present in a large cohort treated surgically for talocalcaneal coalition through preoperative computerized axial tomography. The authors conducted a retrospective review of 21 patients (35 feet) with coalition who were surgically treated over a 12-year period for coalition on at least 1 foot. Using a predefined original staging system, the extent of the arthrosis was categorized into normal or mild (Stage I), moderate (Stage II), and severe (Stage III) arthrosis. The association of stage and age is statistically significant. All of the feet with Stage III arthrosis had fibrous coalitions. No foot with osseous coalition had Stage III arthrosis. The distribution of arthrosis staging differs between fibrous and osseous coalitions. Only fibrous coalitions had the most advanced arthrosis (Stage III), whereas osseous coalitions did not. This suggests that osseous coalitions may have a protective effect in the prevention of severe degeneration of the subtalar joint. Concomitant subtalar joint arthrosis severity progresses with age; surgeons may want to consider earlier surgical intervention to prevent arthrosis progression in patients with symptomatic middle facet talocalcaneal coalition.

The presence of calcaneal fibular remodeling associated with middle facet talocalcaneal coalition: a retrospective CT review of 35 feet. Investigations involving middle facet coalitions--Part II.

Middle facet talocalcaneal coalition is often associated with a rigid pes planovalgus. In the presence of calcaneal valgus, the fibula may come into contact with the lateral calcaneal wall during weight bearing, and develop a pseudoarticulation. Spurring, bone cysts, and other morphologic changes may concomitantly occur at the calcaneus and fibula, suggesting a pathological degenerative process. This association has not been previously studied in middle facet tarsal coalition and we term the condition calcaneal fibular remodeling, the focus of this investigation. To our knowledge, no study has specifically looked at the abutment of the calcaneus and fibula as an additional area of pathology in patients treated operatively for tarsal coalition. Computerized axial tomography was retrospectively reviewed in 21 patients (35 feet) with symptomatic middle facet talocalcaneal coalition who were surgically treated for the coalition on at least 1 foot over a 12-year period. In 19 (54%) of the 35 feet, calcaneal fibular remodeling was identified and associated with concomitant coalition and pes planovalgus deformity. Fifteen (79%) of the 19 feet with calcaneal fibular remodeling were managed surgically at the time of manuscript submission for middle facet talocalcaneal coalition. This new finding suggests that simple resection of the coalition may not fully address the entire deformity and other combined surgical approaches may be more appropriate in the face of middle facet talocalcaneal coalition with heel valgus and calcaneal fibular remodeling.

Bilateral single-stage middle facet talocalcaneal coalition resection combined with flatfoot reconstruction: a report of 3 cases and review of the literature. Investigations involving middle facet coalitions--part 1.

UNLABELLED: Talocalcaneal middle facet coalitions are associated with rigid pes planovalgus that often requires surgical intervention. Simple resection of the coalition is preferred for symptomatic cases in the absence of rearfoot arthritis. While resection of the coalition will remove the osseous restriction of motion and may eliminate pain, the procedure does not specifically correct the concomitant pes planovalgus. In this report of 6 feet in 3 patients, we advocate combining resection of the coalition with concomitant flatfoot reconstruction in a single-stage operation. The patients in this series averaged 13.67 (range 12-17) years of age at the time of their foot surgeries, and their follow-up averaged 30 (range 16-54) months. All of the patients displayed bilateral middle facet talocalcaneal coalitions and underwent bilateral resection combined with flatfoot reconstruction. Each patient had 1 foot corrected followed by a period of at least 6 months before the contralateral foot was corrected. The mean postoperative American Orthopaedic Foot and Ankle Society ankle-hindfoot score was excellent (94.33+/-2.81 points) overall. The median radiographic values for calcaneal inclination, Meary's, and anteroposterior talar-first metatarsal angles demonstrated statistically significant improvements: 9 degrees (3 degrees, 13 degrees) (P= .0273), 4 degrees (2 degrees, 7 degrees) (P= .0269), and 6 degrees (3 degrees, 11 degrees ) (P= .0277), respectively, and all feet demonstrated improved subtalar joint motion without pain. Although long-term results remain to be determined in a larger cohort, it is hoped that this combined approach to talocalcaneal coalition will delay or obviate future rearfoot arthrosis and the need for arthrodesis. LEVEL OF CLINICAL EVIDENCE: 4.