Hello Podiatry colleagues,

I have a patient who is diabetic, has very pes cavus type of feet with claw toes of all toes including hallux.  His claw toes are from the pes cavus foot type, but he has neuropathy and that likely contributed also.  He has small distal hallux ulcers I'm able to resolve with buttress pads, silopos toe caps and local wound care; but they keep returning.  

In the past, I've resolved distal toe ulcers of lesser toes, toe 2-4, with flexor tenotomy at sulcus.  I make a small 0.3 cm horizontal incision, swipe a #67 blade on flexor tendons and that straightens the toe enough to stop the ulcers.  It doesn't make the toe perfectly straight, but enough to stop the ulcers it seems.  I tell patients before that they'll never have plantarflexion of the toe again and they understand.  These patients are usually diabetic with other comorbidities arthrodesis of toe would be hard to recover from. 

My question is, I was thinking of doing flexor tenotomy of the bilateral hallux for this patient.  I've never heard of this being done.  I would release the flexor  hallucis longus and not the the flexor hallucis brevis to maintain some plantarflexion of the 1st mpj for stability.  So, the incision would be plantar ipj of the hallux.   

What would be the biomechanical consequences of this?  I know there is possibility of the adjacent toes clawing more in articles I've read about flexor tenotomy, but I"ve not seen that in my experience too much.  Would it occur more with hallux flexor tenotomy?  Normally I would do arthrodesis of hallux with crossed k-wires, but with this patient it would be too much.  

Thank you.

  • Comments (19)
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  • I underwent a FHL tenotomy and the outcome was the loss of my medial longitudinal arch.  My foot immediately began hyper-flexing dorsally and I developed sesamoiditis within a few weeks.  (The ball of my foot began to pound on the floor when I walked or stood.)  

    I do not have diabetes, neuropathy or any ulcers.  The surgeon did the procedure to deal with a hallux claw toe.  The claw toe did go away immediately, but the claw toe problem was insignificant compared to the forefoot pain caused by the loss of the FHL tendon.  The chief of foot surgery at Mass General Hospital attempted to repair and re-attach the FHL tendon, but he found it was too scarred to be of any value....  I have since been trying to use orthotics, carbon fiber plates, braces and padding for 2.5 years in order to deal with my forefoot pain.  They shift the pain around, but there is no real improvement.  

    The FHL tenotomy is an office surgical procedure that sometimes seems to be treated as if it is benign.  In my case, a more appropriate description would be, "This ruined my foot."

     

  •  Dont use a  needle.  Use  either  67 or 64 .  If the flexor tenotomy fails.  Do a distal partial  MIS   partial ostetomy . Now that will get rid of the problem I promise.   

  •  As for the use of 18 guage needle to sever the tendon.  It's been a few years since I've been in the OR, but the tendon lengthenings that I did then, you had to use a blade to be able cut the tendon fibers.  Tendons are pretty tuff and the shaft of the needle is not that sharp.  

    Eric

    I disagree ... the bevelled tip of the 18 G needle is VERY sharp. I recently recommeded a colleague to try it out on a mallet toe. My doctor colleague was delighted with the outcome.

  • Dr. Dale - so what happened? what did you/ how did it work out?

  • Might want to check out Clinic Podiatric Med Surgery 1991:8:1-8

  • Quote:

    Hello Podiatry colleagues,

    I have a patient who is diabetic, has very pes cavus type of feet with claw toes of all toes including hallux.  His claw toes are from the pes cavus foot type, but he has neuropathy and that likely contributed also.  He has small distal hallux ulcers I'm able to resolve with buttress pads, silopos toe caps and local wound care; but they keep returning.  

    In the past, I've resolved distal toe ulcers of lesser toes, toe 2-4, with flexor tenotomy at sulcus.  I make a small 0.3 cm horizontal incision, swipe a #67 blade on flexor tendons and that straightens the toe enough to stop the ulcers.  It doesn't make the toe perfectly straight, but enough to stop the ulcers it seems.  I tell patients before that they'll never have plantarflexion of the toe again and they understand.  These patients are usually diabetic with other comorbidities arthrodesis of toe would be hard to recover from. 

    My question is, I was thinking of doing flexor tenotomy of the bilateral hallux for this patient.  I've never heard of this being done.  I would release the flexor  hallucis longus and not the the flexor hallucis brevis to maintain some plantarflexion of the 1st mpj for stability.  So, the incision would be plantar ipj of the hallux.   

    What would be the biomechanical consequences of this?  I know there is possibility of the adjacent toes clawing more in articles I've read about flexor tenotomy, but I"ve not seen that in my experience too much.  Would it occur more with hallux flexor tenotomy?  Normally I would do arthrodesis of hallux with crossed k-wires, but with this patient it would be too much.  

    Thank you.

    The master knot of Henry is a, somewhat variable across people, slip from the FHL tendon to the separate slips of the FDL tendon.  The affect of the master knot  can be seen when you attempt to contract your own FHL tendon to plantar flex your own IPJ.  Most people, when they attempt this, will also have plantar flexion of the 2nd and 3rd toes.  So if you cut the flexor tendon in the first toe, the FHL tendon will still have distal pull of the muscle acting on the second and third toe increasing chances of plantar flexion contracture of the lesser toe IPJ's.  The FHL tendon is also a plantar flexor of the ankle joint and if there is weakness of the gastroc/soleus, the patient may have been trying to use the FHL muscle to get some ankle plantar flexion.  When the FHL is used to plantar flex the ankle joint, there will also be contraction at the IPJ.  A shoe with a rocker tip could reduce the need for ankle plantar flexion muscle as well as directly reduce pressure at the tip of the toe. 

    The FHL tenotomy will work if the problem is too much plantar flexion moment at the IPJ.  However, there is sometimes a decrease in plantarflexion moment at the MPJ.  In a hallux hammer toe there is plantar flexion of the ipj and dorsiflexion of the mpj.   To figure this out you would have to watch the patient walk barefoot, to see if the FHL is causing plantar flexion of the tip of the toe into ground/shoe insole.  High extensor activity could create the claw toe deformity.   If this is really a pressure ulcer, it is probably caused by the FHL tendon.  It would still be a good idea to document the barefoot gait.  

    As for the use of 18 guage needle to sever the tendon.  It's been a few years since I've been in the OR, but the tendon lengthenings that I did then, you had to use a blade to be able cut the tendon fibers.  Tendons are pretty tuff and the shaft of the needle is not that sharp.  

    Eric

  • There are articles stating elective cases should have a minimal hgA1c. (The number escapes me - I'm sure Dieter will have it for you shortly.)


    The ADA recommends that outpatient management of diabetes should ideally include a combination of a target HbA1c 7% (normal 4%–7%), a preprandial blood glucose level of 90 to 130 mg/dL and a peak postprandial blood glucose level of 180 mg/dL,22 although this has not been verified in the ambulatory surgical population.

    Ref: Society for Ambulatory Anesthesia Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery Girish P. Joshi, MB, BS, MD, FFARSCI,* Frances Chung, MD, FRCPC,† Mary Ann Vann, MD,‡ Shireen Ahmad, MD,§ Tong J. Gan,

  • Quote:

    I vote for the blade over the 18 gauge needle.


    I haven't used the 18g approach but certainly met a few Attendings in the last few years who advocate the same; and would even perform an on-the-spot correction in the office - probably less traumatic than a partial nail ablation ... 

  • Quote:

    Yes, I've given him a cork heel lift to use in shoe of shorter side.  leg length difference was addressed.  I'll look up that Dr. goldman, thank you for the information.

    http://walkingwellagain.com/

  • I vote for the blade over the 18 gauge needle.
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