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hallux malleus

Discussion in 'Foot Surgery' started by bunion, Aug 2, 2007.

  1. bunion

    bunion Member


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    85 y/o post cva,MI, and pvd patient with with no ehl activity , severe fhl contracture.
    would fhl tenotomy be appropriate or would medial column collapse occur due to loss of fhl strut?
     
  2. Nat

    Nat Active Member

    Can you do an IPJ fusion?
     
  3. drsarbes

    drsarbes Well-Known Member

    Hi "bunion":
    First, let's consider the patients age. At 85 and post stroke, I would assume you may not want to put the patient through the prolonged post-op routine that would be required for a successful IP fusion. Also, at 85, and post CVA, I'm sure there is some concomitant osteoporosis which would contraindicate a fusion.
    Is the contraction reducible?
    It would be somewhat unusual to have an isolated FHL contraction with paresis of the EHL. If this is the case the MTPJ would not be dorsally contracted. Is this the clinical picture you see?
    If you do have an isolated, reducible FHL contraction then a simple "z" lengthening would help. You would need to assess the FHB as well. A tenotomy at the level of the IPJ would straighten the toe (again, if it's reducible and no other soft tissue or bony contractions exist)
    You may also want to isolate exactly where the pain is and why it is painful. Pressure, irritation. unopposed spasm, joint pain, etc.... and go on from there.
    Hope this helps
    DrSArbes
     
  4. Nat

    Nat Active Member

    On second thought, given the CVA, MI, PVD, and age, are you sure you want to do any surgery?
     
  5. bunion

    bunion Member

    patient is not a candidate for hipj fusion. . Patient has long 2nd ray so would also like to avoid keller arthroplasty.Deformity is reduced when plantarflexory force is applied to proximal hallux ceating some slack in fhl . Patient complaint is pain
    with history of tissue break down distal aspect hallux. Skin lesion is healed which is good idicator of healing potential for low impact surgery .Tube foam /recovery poron provides some relief. Thinking that tenotomy would have the least amount of vascular insult. Follow up with orthotic to provide medial support.? thanks
     
  6. drsarbes

    drsarbes Well-Known Member

    Well, it's difficult to advise. It still sounds to me as though it's a contracted EHL and not the flexor, but again, I have not seen the patient. If his pain is limited to the distal hallux from irritation, it is reducible and you're set on surgery, and tenotomy or lengthening seems like the logical procedure choice.
    Good luck
    DrSArbes
     
  7. mchad500

    mchad500 Member

    I wouldn't worry so much about medial column collapse as I have not experienced that complication with FHL tenotomy. In light of PVD I would recommend further vascular evaluation as a predictor of healing and proceed with percutaneous flexor tenotomy at HIPJ with 18ga needle as indicated.
     
  8. bob

    bob Active Member

    Hello Bunion,
    I doubt that an FHL tenotomy would lead to medial longitudinal arch collapse for a number of reasons. First is the common interconnecting tendon between FDL and FHL around the Knot of Henry. Second is the patient likely has pre-existing OA of several foot joints given their advanced age, etc... Third is that I recently saw a 40 something year old patient who suffered unnoticed trauma to FHL intra-op on an Akin osteotomy - the result was an inability to actively flex her 1st IPJ and nothing more. I got the foot ultrasound scanned and the tendon end had retracted to the level of the 1st MTP joint line (approx 1cm). As an aside, I told her not to worry about it as she is asymptomatic and the surgery that her sonographer had suggested has a better chance of causing more harm than it solves IMO.
    I can not advise you about the success of your planned surgery as I have not seen the foot, etc... but I would not worry about collapse of the arch if I were you.
    All the best,
    Bob
     
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