We need your advice! Clinical case

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Hello everyone!

We have some difficulties about surgery tactic with patient who asked for help. .

Female, 62 y.o.
Complaints:
Forefoot deformity of the left foot
painful callus on the ventral surface of the distal phalanges of the 2nd toe which cause gait disturbances and difficulties with shoes.

Medical Hystory: From patient's words.....
She had a surgery for Hallux valgus and forefoot deformity
It was done 3 years ago at one of the local hospitals.
An inflamatory complication broke out (with osteomyelitis). After several revision surgery with bone necrectomy the wound healed. She can't provide us with any X-ray or documents from that period.

Status localis:
Abscense of the Mt1 and big toe on the left foot
Deformity (medial deviation) of the residual part of forefoot
Lateral deviation of 2nd, 3rd toes can be manually (partially) corected.
Hammertoe deformity of 2-3-4-5 toes at PIPj is fixed
There are calluses (non painfull) under the heads Mt2 and Mt3
Neurovascular status is normal.
There is a postoperative scar on the dorsal surface of the IV intermetatarsal space, and it seems to me that extensor tendon of IV th toe was cutted off during previous surgery. It doesn't work and It's absent (by palpation)
Another foot is normal, without any deformities (just a mild non-painful H. valgus)


What would be the best plan for her forefoot deformity?

We will appreciate any advice
_____________________________________________________

Yershov Dmitriy

Ukraine, Sytenko Institute of Spine and Joint Pathology

 

Hi,

From the details you have supplied I believe palliative care - to include an appropriate foot orthosis and footwear - would be the best course of action for you to take for this patient.

For the foot orthosis similar cases I have seen here benefit from mild support and full-length cushioning. In my opinion a custom orthosis made from a STJ-neutral cast will work much better than an off-the-shelf device.

 

Yershov:

This is a difficult case due to the loss of the first ray and hallux. I expect that due to the loss of the weightbearing column of the first ray and hallux, over time, the patient's 2nd and 3rd metatarsal symptoms will get worse. I expect she will eventually develop plantar plate pathology at the 2nd metatarsophalangeal joint (MPJ), possibly develop a stress fracture of the 2nd metatarsal and these pathologies will also be expected to develop, to a lesser extent, at the 3rd ray.

The hammertoe deformities could be corrected by performing proximal interphalangeal joint arthrodeses with K-wire fixation at digits 2, 3, and 4, a proximal phalanx head resection at digit 5, and releases of the MPJs and plantar capsule (using a McGlamry elevator). I suggest purchasing and reading McGlamry's Comprehensive Textbook of Foot and Ankle Surgery for a more detailed description of these procedures. However, the patient may prefer the more conservative approach of using a custom foot orthosis with comfortable thick soled running/walking shoes and a removable crest pad placed on the digits or a crest pad added to the orthosis. I would offer the conservative approach first since this poor lady already has a surgical nightmare to deal with for the rest of her life.

Good luck and welcome to Podiatry Arena.:welcome:

 

Thanks to all who responded