Hello David
It is all really a matter of degree, the individual patient and the
presenting complaint.
Personally, (and opinions do tend to vary), I think that amputation of the
2nd toe at the metatarso-phalangeal joint is entirely justified when the 2nd
toe is truly subluxated at the MTPJ AND that the patient's general health or
PVS is compromised AND that the presenting complaint (in this case fixed
flexion deformity at the PIPJ) is causing pain/threatening complications
such as ulceration. Patients who fall into this category include diabetics,
rheumatoids and others who have frank PVD or compromised peripheral
circulation and those who may be Rx immunosupressive drugs. The reason is
that the procedure is usually well tolerated, lends itself well to local
anaesthetic and although at the level of bone (obviously), does not require
osteotomy or any form of fixation. Healing is rapid and will allow early
weightbearing/activity which is obviously an advantage in patients with
cardiac or other disease where rapid mobilisation is desirable.
Adverse ractions are rare but include haematoma and superficial infection.
I agree with your podiatric surgeon that a subluxated 2nd toe does not in
fact provide butressing against hallux valgus. As a general rule, even when
carrying out 1st metatarsal osteotomies in combination with lesser toe
surgery, I prefer arthroplasties to arthrodeses because healing is rapid, no
fixation is required, there is a lower percentage of adverse reactions and
even if there is some recurrence of extension at the MTPJ, only the proximal
stump will be involved, not the entire toe. Having said that, there are
some good indications for athrodesis but these must be assessed on a case by
case basis.
These matters are discussed at length in McGlamry 'Comprehensive Textbook of
Foot Surgery', if your library can get hold of a copy.
Bill Liggins
----- Original Message -----
From: "Houghton, David" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, March 17, 2004 3:42 PM
Subject: 2nd toe amputation
> Hello all
>
> I would appreciate you comments re 2nd toe amputation for hammer toe
> deformity.
>
> The reason that I ask is that a Podiatric Surgeon was showing me pre an
> post op pics of a total 2nd toe amputation, in an active patient, I don't
> know their age, but approx in their 60's. His justification was that
> amputation is a more straightforward procedure, which I don't doubt.
>
> My argument was that with a Hallux Valgus ( which there was in the pics) ,
> then the prox phalanx would provide a buttress to prevent lateral hallux
> deviation. Perhaps I am mistaken in this assumption, and there is still a
> place for this surgery.
>
> The only example that I can think of where this could possibly be the
> procedure of choice is in a patient who has limited mobility, and has a
> screaming hammer toe, and 1st met ostotomy with 2nd toe arthrodesis would
> be like using a sledgehammer to crack a nut.
>
> I have put these points to the Pod Surgeon, and he disagrees that any
> buttress effect is provided by the 2nd toe when dorsally displaced, and
> therefore will continue to do the procedure, even in active patients.
>
> I am not a Pod Surgeon, so would appreciate some guidance about 2nd toe
> procedures, and under which circumstances they are indicated.
>
> David Houghton
>
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