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PubMed2002

Interphalangeal joint arthrodesis of the lesser toes.

Fusion of the PIP joint of the lesser toes provides sound correction of deformity of that joint. Fusion is achieved reliably in most cases and fibrous ankylosis is well tolerated in those that fail. Patients at the extremes of the age scale are perhaps less tolerant of the procedure; complaints include poor cosmesis and subjective lack of control of the toes [18]. Although fusion of the DIPJ is a sound primary procedure, it would seem prudent to reserve PIP fusion as a revision procedure [7] or for the treatment of severe, fixed hammer toe deformities. For flexible or mild, fixed hammer toe deformities, consideration should be given to the use of tendon lengthening or transfer surgery in association with joint release as the primary approach to correct the deformity. Complete failure of surgery occurs when muscular imbalance or pre-existing deformity at another level is not properly addressed. This may result in patient complaints of persistent metatarsalgia or toe deformity despite a successful PIP fusion. The use of either sound fixation or a stable bony construct is recommended, as it is likely to reduce the incidence of mal-union and non-union.

Arthrodesis↗

PubMed1999

Bioelectrical impedance sphygmography for hydrostatic toe pressure measurement: a new non-invasive method to assess limb ischaemia.

BACKGROUND: Hydrostatic measurement of systolic toe blood pressure (HSTBP) is reliable in feet with calcified arteries, when sphygmomanometry fails. When leg is lifted above heart level, weaning of the big toe's arterial pulsations indicates HSTBP. PATIENTS AND METHODS: Electrical bio-impedance was assessed to monitor the weaning of arterial pulsations (Medis GmbH, Ilmenau, Germany). In a pilot study in 30 healthy volunteers, a 12 cm cuff was placed above the ankle and inflated to 200 mmHg; ultrasound (8 MHz) and impedance sphygmography (ISG) were used simultaneously to detect arterial pulsations in the big toe, in the sitting and supine position after deflating the cuff. In a clinical study, HSTBP was assessed by big toe ISG in 50 legs (43 of diabetic patients) with suspected peripheral arterial occlusive disease, subjected to arteriography before vascular surgery. RESULTS: In the pilot study, ultrasound and ISG signals were detected at nearly identical systolic pressure levels (difference 2.4 [SEM 0.6] mmHg, r = 0.99, p < 0.001). In the clinical study, HSTBP < or = 50 mmHg was associated with multiple occlusions (2 legs with < or = 1, 9 legs with 2, and 13 legs with > 2 arteries occluded); by contrast, HSTBP > 50 mmHg indicated single occlusions (16 legs with < or = 1, 8 legs with 2, and 2 legs with > 2 occluded arteries; chi 2 contingency p < 0.02). CONCLUSIONS: Assessment of big toe arterial pulsation by ISG was reliable. HSTBP < or = 50 mmHg indicates severe peripheral arterial disease occlusive (> or = 2 arteries occluded).

Adult↗

PubMed2006

Modified Girdlestones-Taylor procedure for claw toes in spinal cord injury.

STUDY DESIGN: A combination of review of case notes and outpatient follow-up. OBJECTIVE: To evaluate the effectiveness of the modified Girdlestones-Taylor procedure in patients with spinal cord injury (SCI). SETTING: Princess Royal Spinal Injuries Centre (PRSIC), Northern General Hospital, Sheffield, UK. METHODS: Nine patients with claw toe deformities to 27 toes were treated at the PRSIC from 1996 to 2005. After examination of their medical records, their toes were assessed for pain, residual deformity and stiffness. They were also asked to grade their satisfaction with the surgical outcome. The results were tabulated. RESULTS: The average age of our series of patients was 43.3 years. The mean time from injury to surgery was 20.4 years and the mean time from surgery to last follow-up was 37.3 months. All our patients had good to excellent results, with over 70% of the toes having excellent results. CONCLUSION: The modified Girdlestones-Taylor procedure for claw toe correction appears to be a safe and effective treatment for patients with SCI.

Adult↗

PubMed2000

Vascular anatomic variations in second toe transfers.

To devise a new classification of vascular variations in second toe transfer we analyzed the anatomic details of the first dorsal metatarsal artery in 304 cases of second toe transplantation and the venous structure in 200 cases. According to location, the arterial vascularity was classified as superficial (18% of cases), intramuscular (54%), inframuscular (23%), and absent (5%). According to diameter, it was classified into large (16%), medium (64%), and small (20%). Based on branching pattern, the artery was classified into ramifying type (88%), main trunk (4%), and fine branch type (8%). The venous drainage of the second toe was categorized as greater saphenous vein main trunk type, greater saphenous vein fine branch type, dorsal digital vein main trunk type, and dorsal digital vein fine branch type. Variations of the first dorsal metatarsal artery are common. Classification should be done according to its location, diameter, and branching pattern at the toe web. Regardless of location, big vessels entering the second toe are the most important attribute for successful outcome.

Adolescent↗

PubMed2003

Long-term results of free vascularized second toe joint transfers to finger proximal interphalangeal joints.

PURPOSE: To review the long-term clinical results of free vascularized second toe joint transfers for severely damaged finger proximal interphalangeal (PIP) joints. METHODS: Eleven joints in ten patients (1 woman, 9 men) were reviewed between 10 and 22 years after surgery. The average patient age at the time of the surgery was 32 years. Patients were evaluated at a mean follow-up time of 15 years; evaluation included range of motion of the transferred PIP joints and the remaining healthy second toe PIP joints, grip strength, finger and toe pain, finger function, gait disturbance, patient satisfaction, and x-ray changes. RESULTS: The mean active range of motion was 47 degrees that lacks 41 degrees extension and flexes to 88 degrees. The mean grip strength was more than 80% that of the nonaffected hand, and no finger pain or gait disturbances were reported. All patients had some extension lag and flexion contractures but most were satisfied with the clinical and functional results of surgery. In all joints, the joint spaces were preserved, although 1 patient had arthritis and 3 had osteophytes. CONCLUSIONS: It is important to prevent extension lag and flexion contracture to get better results from free vascularized second toe joint transfers. The transferred toe PIP joint is durable.

Adult↗

PubMed2001

Toe transfer in congenital hand malformations.

Fifty-eight patients with congenital hand abnormalities underwent 65 toe-to-hand transfers. Symbrachydactyly (51 cases) was the most frequent indication. Forty-seven second toe-to-hand transfers were performed in 44 patients. The mean follow-up time was 5.2 years. Two failures occurred in cases in which only one artery was anastomosed; no failures were noted when more than one artery fed the transfer. Two patients with a single second-toe transfer presented with lateral instability of the transferred metatarsophalangeal joint. The mean active range of motion was 38 degrees, with a mean extension lag of 25 degrees. The mean two-point discrimination was 5 mm. Forty-one patients used the transferred toe well, when performing activities of daily living and playing games. Toe-to-hand transfer, prior to the establishment of the grip pattern, facilitates integration of the transfer.

Child, Preschool↗

PubMed2002

[Free microvascular transplantation of parts of the great toe for thumb reconstruction].

PURPOSE/BACKGROUND: A reconstructed thumb has to fulfil the function of opposition, pinch-grip, stability, sufficient length, sufficient sensibility, and painlessness. Next to pollicisation, these requirements can only be met satisfactory by the microvascular free great toe-to-hand transplantation. The goal of a thumb reconstruction is a compromise between an optimal functional and aesthetic outcome and a minimal morbidity of the donor site. METHOD AND CLINICAL MATERIAL: Depending on the extent of the traumatic thumb defect, not only the fibular part of the ipsilateral great toe but also its adjacent soft tissue and the first web space may be integrated into the vascularized transplant. The distal phalanx is reduced in width on its tibial side to integrate the second digital nerve to the transplant. The rest of the great toe is covered with the remaining sensible tibial flap. RESULTS: From 1993 to 1998, five male patients have been operated with the described method of partial great toe transfer and an additional deepening of the first web space. All reconstructions passed without complications. All patients present with a protective sensibility and a dynamic two-point discrimination between 8 and 15 mm. The average strength of the reconstructed thumb was 79 %, the strength of pinch-grip 90 % of the healthy thumb. CONCLUSION: Thumb reconstruction after traumatic amputation distal to the metacarpophalangeal joint can in our hands optimally be managed with free microvascular anastomosed parts of the great toe and its adjacent soft tissues.

Adult↗

PubMedDate not supplied

Undiagnosed fracture in a common foot variant: the biphalangeal little toe.

The biphalangeal little toe is an anatomical anomaly that has been previously well described in the early anatomical literature. But, as is the case with many anomalies, there is a lack of awareness of it amongst current clinicians. We report the case of a fracture through the distal phalanx of the little toe, with a delay in the diagnosis due to confusion over the X-ray findings. X-rays revealed a biphalangeal toe with a fracture through the distal phalanx, which mimicked the usual triphalangeal toe. This is the first reported case of clinical confusion over this anatomical variation. A review of 102 human skeletal feet at the Department of Anatomy, University of Melbourne, was performed to evaluate the frequency of the biphalangeal little toe variant, revealing an incidence of 26%.

Adult↗

PubMed2000

Filleted toe flap for chronic forefoot ulcer reconstruction.

Chronic plantar and dorsal forefoot ulcer may result from injury, structural deformity, and abnormal sensation or circulation. It is not uncommon that the distal portion of the affected toes is deficient functionally in these patients. A filleted toe flap from the expendable functionless toe can provide a durable, stable, and sensate skin flap of 4 to 5.5 cm for coverage of the forefoot defect. In this report, five cases of dorsal forefoot defects and four cases of plantar forefoot defects due to ischemia (N = 3), trophic change (N = 2), and diabetes (N = 4) were treated with filleted toe flaps. One flap failed due to postoperative deep infection. The other eight filleted toe flaps survived but 2 patients underwent secondary amputations 7 months and 2 two years later because of secondary diabetic foot infections.

Adult↗

PubMed2002

Local botulinum toxin type A injections in the treatment of spastic toes.

OBJECTIVE: To investigate the efficacy and safety of botulinum toxin type A treatment of spastic toes using varying doses based on the degree of spasticity (Modified Ashworth Scale). DESIGN: Single-center, open-label, prospective study. Hemiplegic patients with either hitchhiker's great toes (persistent extension of the great toes) or toe flexor spasms with pain during walking were treated with local intramuscular injections of botulinum toxin type A. Initial botulinum toxin type A dose per muscle was 25 units for patients with a baseline Ashworth score of 2, 50 units for a score of 3, and 75 units for a score of 4. Additional botulinum toxin type A injections were allowed if there was an insufficient clinical response to initial treatment. The muscles injected included flexor digitorum, extensor hallucis longus, and/or flexor hallucis longus. All injections were made using electromyographic guidance. Outcome measures were the Modified Ashworth Scale, a visual pain scale, a visual percentage of function scale, and adverse effects. RESULTS: Twenty patients were enrolled. The dose of botulinum toxin type A used ranged from 25 to 35 units per muscle for an Ashworth score of 2, from 50 to 70 units per muscle for a score of 3, and from 75 to 95 units per muscle for a score of 4. There were improvements in all outcome measures. In most patients, the benefits lasted 5-6 mo, with a few patients exhibiting benefits for > or =2 yr. There were no adverse effects. CONCLUSIONS: Botulinum toxin type A treatment using doses based on spasticity severity seems to be safe and effective in the treatment of spastic toes, and further study is warranted.

Activities of Daily Living↗

PubMedDate not supplied

Sympathetic nervous system involvement in the syndrome of painful legs and moving toes.

The objective of this study is to investigate sympathetic nervous system involvement in 2 patients with painful legs and moving toes. The first case was studied several years after the initiating trauma produced a peripheral nerve lesion and demonstrated the characteristic sequence of progression of pain and moving toes from the injured leg to the contralateral leg. The second case was initially studied within 3 months of an injury that did not produce definitive signs of a peripheral nerve lesion. Pain increased when the patients were startled and subsided temporarily after sympathetic blockade. In the first patient, toe movements and allodynia to light tactile stimulation persisted during sympathetic blockade, and pain sometimes returned before the vascular effects of blockade disappeared. In the second patient, pain and toe movements could be provoked reproducibly by light tactile stimulation of the affected foot and by sympathetic arousal. These symptoms and signs disappeared after lumbar sympathectomy, and re-emerged when signs of sympathetic reinnervation were detected. We concluded that sympathetic neuronal discharge may provoke pain by activating an impulse generator in the affected limb. Sympathetic involvement in the painful legs and moving toes syndrome appeared to be greater in the second case than the first, presumably due to differences in the initial injury or stage of the condition.

Adult↗

PubMedDate not supplied

Voluntary (normal) versus obligatory (cerebral palsy) toe-walking in children: a kinematic, kinetic, and electromyographic analysis.

Surgical management of toe-walking gait in children with cerebral palsy currently favors simultaneous, multilevel soft-tissue and bony interventions. Formulation of such a surgical plan is based on our ability to determine which of the gait deviations present are primary and which are secondary or compensatory. To evaluate this issue further, 32 normal children, walking normally and voluntarily toe-walking, were compared to 15 children with cerebral palsy walking in an obligatory toe-walking gait pattern. Computer-based analysis of gait was performed for each child, including time-distance, kinematic, kinetic, and electromyographic analyses. Significant deviations common to both normal and cerebral palsy toe-walking groups were determined to be due, at least in part, to the biomechanical constraints associated with a toe-walking gait pattern. Deviations unique to the cerebral palsy group were thought to represent primary gait deviations related to the underlying injury to the central nervous system. This study identifies the need to develop more sophisticated techniques of data collection and analysis and supports the inclusion of more varied and demanding functional activities for distinguishing between primary and secondary gait deviations in children with cerebral palsy.

Adolescent↗

PubMed1982

Grip reconstruction by double-toe transplantation in cases of a fingerless hand and a handless arm.

In two cases, a grip reconstruction by double toe-to-hand transfer is demonstrated. In the first patient, all fingers of the left hand were amputated at the metacarpophalangeal joint level. The second and third fingers were reconstructed by transplantation of the second toe from the left foot and the third toe from the right foot. Although the distal and the middle phalanx of the transplanted third toe had to be amputated because of mummification 2 weeks after the transplantation and was covered with a groin flap, good function of the newly formed grip can be demonstrated. The second patient is a 21-year-old man with amputation of both hands at the wrist. A grip formation on the right lower arm was performed by transplantation of the second toe of each foot together with the metatarsal bone and a dorsalis pedis flap. Both metatarsal bones were fixed to the ulna and radius with metal plates, and tendons and nerves, together with a vascular supply, were reconstructed. One year after the operation, a follow-up study demonstrates good function of the newly formed "hand." The patient is able to use his two new "fingers" during daily life, mainly to hold small objects. A myoelectric prosthesis has been placed on the patient's left arm, and the patient uses this to hold bigger objects. Restoration of sensation and the range of movement of the newly formed right "hand" are demonstrated and discussed.

Adult↗

PubMed1988

Simultaneous multiple toe transfers in hand reconstruction.

Our experience with simultaneous transfer of two or more toe units to the same hand where multiple digits were missing is presented. Forty-six toes from 38 feet were transferred to reconstruct 19 hands in 19 patients. The transfers consisted of 7 combined second and third toe units and 32 single toes. Three patients had a primary and 16 patients had a secondary reconstruction. There was one complete and one partial failure. The two-point discrimination ranged from 6 mm to protective sensation. Total active movement averaged 57 degrees in the thumb and 127, 93, 71, and 68 degrees, respectively, in the fingers reconstructed at middle phalanx, proximal phalanx, metacarpophalangeal joint, and metacarpal head. Pulp-to-pulp pinch averaged 2.4 kg in patients who had thumbs reconstructed and averaged 3.0 kg in patients who had normal thumbs. There was no cold intolerance, and no significantly disabled foot occurred except one with scissoring deformity. Simultaneous multiple toe transfer in hand reconstruction is feasible without increased complications both in primary and secondary wound conditions. It is time-effective and cost-effective.

Accidents, Occupational↗

PubMed1998

Direct visualization of arterial anatomy during toe harvest dissections: clinical and radiological correlations.

The arterial patterns seen during 57 clinical dissections during toe transfers were divided into four types: (1) type A: a large first dorsal metatarsal artery and present plantar vessel (27 patients, 47 percent); (2) type B: a smaller first dorsal metatarsal artery within the interosseous muscle and an equal-sized plantar vessel (17 patients, 30 percent); (3) type C: a small, interosseous first dorsal metatarsal artery and dominant plantar vessel (8 patients, 14 percent); and (4) type D: an absent first dorsal metatarsal artery (5 patients, 9 percent). A modified and more expeditious toe harvest used the early identification of the vascular pattern through the first webspace followed by a retrograde dissection. The use of a meticulous surgical technique and multiple arterial anastomoses is advocated. Preoperative angiography of the foot is no longer routine and is now used selectively for trauma, cold injuries, or congenital anomalies. All 57 toe transfers (single or multiple) were successful; three were reexplored successfully for arterial insufficiency. A clinical correlation of arterial patterns was made between the angiograms obtained on 33 of these 57 patients and on 65 adult and pediatric patients without intrinsic vascular disease of the lower limb. Contrast reached the foot and toes faster through the posterior tibial artery and plantar arch in the majority of feet studied. Like the ulnar artery in the forearm and hand, the posterior tibial artery is the dominant conduit to the foot and ankle and, through the plantar arch, the major arterial system to the toes.

Adult↗

PubMed1984

Influence of autonomic neuropathy on leg circulation and toe temperature in diabetes mellitus.

The relationship between neuropathy and peripheral circulation was assessed in 26 patients with a short to moderate duration (less than 20 years, mean 11 years) and in 26 patients with a long duration (greater than 20 years, mean 35 years) of diabetes mellitus. Peripheral nervous function was evaluated from measurements of vibration thresholds and ankle reflexes and autonomic nervous function from deep breathing, Valsalva, and tilt table tests. Peripheral circulatory tests included plethysmography, systolic blood pressure ratios, and thermography. A markedly delayed toe temperature increase after cooling followed by indirect heating occurred in diabetics of short duration with autonomic neuropathy (AN). Judging from blood flows and pressure ratios, functional vasospasm caused abnormal toe temperature reactions in short duration diabetics. No correlation existed between AN and abnormal toe temperature reactions in diabetics of long duration. Macroangiopathy rather than AN seemed to be responsible for abnormal toe temperature reactions in long duration diabetics. Thus, an abnormal toe temperature reaction indicates AN in patients with a short duration and macroangiopathy in patients with a long duration of diabetes.

Adult↗

PubMed1996

Assessment of neuromuscular block at the thumb and great toe using accelography in infants.

We assessed neuromuscular block at the thumb and great toe using accelography after the administration of vecuronium in infants. Train-of-four stimuli were simultaneously applied to the ulnar and tibial nerves using cutaneous electrodes. Anaesthesia was maintained with nitrous oxide (66%) in oxygen and sevoflurane (1%). Vecuronium 0.1 mg.kg-1 was used for paralysis and reversed with intravenous neostigmine 0.04 mg.kg-1 with atropine 0.02 mg.kg-1 when the train-of-four ratio on the right great toe returned to 25%. The mean (SD) times from initial administration of vecuronium to completion of maximal block on the thumb and great toe were 78 (21.1) s and 75 (14.3) s, respectively (p > 0.05). The times from maximal block to 25% recovery of twitch height at the thumb and great toe were 46 (9.1) min and 45 (9.0) min, respectively. The reversal time from 25% to 75% of the train-of-four ratio after the administration of neostigmine was 136 (49.1) s. We conclude that neuromuscular monitoring of the great toe in infants may be a suitable alternative when the thumb is inaccessible.

Anesthesia, General↗

PubMed1994

Anonychia of all toes with absence of phalangeal bones.

A ten year old girl suffered from anonychia of all toes, present from birth. The absence of nails was accompanied by absence of one or two phalangeal bones in toes other than the big toes. Other abnormalities consisted of short toes, incomplete syndactyly of the 2nd and 3rd toes of each foot and transfer of the dermatoglyphics from the plantar to the dorsal surface of the digits. The combined defect of the nails and the phalangeal bones can be explained by the close relationship of the two structures during the morphogenesis of the digits.

Abnormalities, Multiple↗