turf toe: an update - triatria.com/wp-content/uploads/2014/07/turf-toe_anderson.pdfcarolinas medical...
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Turf Toe: An Update
Robert B. Anderson, MDCarolinas Medical Center
OrthoCarolina
Carolina Panthers
Charlotte, NC
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Disclosures
Consulting/Royalties:
Wright Medical, DJO, Arthrex
Consulting: Amniox
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Carolinas Medical Center
“Turf Toe”
n Term first used in 1976 for hyperextension hallux injury on an artificial field surface
» Astrodome, Houston TX
– Now seen with all sports and on any surface
– Effect of shoes? Cleat/surface interaction?
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Carolinas Medical Center
Mechanism of Injury
n Classic scenario
– Foot fixed in
equinus
– Axial load
– Forefoot
progresses into
dorsiflexion
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Carolinas Medical Center
Classic Pathology
n Soft tissue injury
– Disruption of FHB and
plantar complex distal to
sesamoids
– Variable in degree and
extent = complete vs
partial
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Carolinas Medical Center
Another Pathology
n Can also
present as a
diastasis of
bipartite or
fractured
sesamoids =
weak link
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Carolinas Medical Center
Result of Hyperextension
Injury
n Soft tissue injury
– Loss of plantar
restraints
– If unrecognized
can lead to joint
damage and
deformity
Sesamoid
FHL
lDefect
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Carolinas Medical Center
“Turf Toe” = Not all “Classic”
n Can also occur on grass and with any sport
n Dislocation the most severe form
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Carolinas Medical Center
Other Mechanisms of Injury
n Turf toe injuries can be
highly variable
– Not all axial load
– Can be non-contact
– Some chronic “attritional”
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Carolinas Medical Center
“Turf Toe”: Variable Injury Patterns
n Direction of force
– Unlike classic turf toe
(pure hyperextension)
valgus or varus
component can occur
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Carolinas Medical Center
“Turf Toe”: Variable Injury Patterns
n Consider force and what
is ruptured
– Valgus force common
– MCL/Abd Hall rupture
»Loss of tendon balance
»Leads to traumatic
bunion/progressive
hallux valgus
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Carolinas Medical Center
Clinical Examination
n Standing alignment
and toe posture
n FHL function
n Lachman exam
– Vertical instability =
lack of plantar
restraints
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Carolinas Medical Center
Radiographic Evaluation
n Mandatory in the
evaluation of turf toe
n Comparison AP of
opposite side
recommended
n Assess for proximal
migration of sesamoids
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Carolinas Medical Center
Radiographic Evaluation
n Forced dorsiflexion lateral view
– Assess distance from distal tibial sesamoid to base of
phalanx (nl avg: 8mm)
lInjuredlNormal
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Carolinas Medical Center
Flouroscopy Invaluable
n Assess trailing motion of the sesamoids with
dorsiflexion of the hallux
– Educational to patient
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Carolinas Medical Center
Flouro: Assess for Complete
Rupture/Instability
n Example: post-reduction hallux mp dislocation;
vertical stress testing (toe Lachman/drawer test)
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Carolinas Medical Center
MRI
n Consider intra-articular
injuries that can occur
at time of incident
n Useful with subtle injuries
– Identifies osseous and
articular damage
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Carolinas Medical Center
Treatment
n Most can be treated
nonoperatively
– R.I.C.E.
– Walker boot or short
leg cast with toe spica
» Plantarflex hallux
– Turf toe plate/tape
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Carolinas Medical Center
Surgical Treatment – Who
Needs It?
n “A Gestalt”
n Failure to respond to conservative measures
– Loss of push-off strength
– Gross instability» + Lachman
» Excessive DF
– Progressive clawing
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Carolinas Medical Center
Surgical Treatment – Who
Needs It?
n Other indications for
surgical intervention
– Progressive proximal
migration of sesamoids
– Progressive diastasis of
a bipartite sesamoid
9/93
11/93
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Carolinas Medical Center
Surgical Goal
n Restoration of anatomy
is necessary for
restoration of function
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Carolinas Medical Center
Surgical Technique
n Exposure through
medial or J-incision
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Carolinas Medical Center
Surgical Technique
n Exposure through both
medial and plantar
incisions
– Less traction on nerve
– Improved lateral exposure
– Better wound healing plantar
medial
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Carolinas Medical Center
Extensile vs 2-Incision Approach =
Identify and Protect the Nerves!
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Carolinas Medical Center
Surgical Technique
n Transect abductor
tendon - identify
defect in plantar
capsule, condition
of the FHL tendon
and sesamoids
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Carolinas Medical Center
Surgical Technique
n Primary repair to
soft tissue on base
of proximal
phalanx usually
possible
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Carolinas Medical Center
Surgical Technique
n Advance capsule and
repair
– 2-0 nonabsorbable
– 10-15°plantarflexion
n Work from lateral to
medial
– Avoid nerve
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Carolinas Medical Center
Direct Repair
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Carolinas Medical Center
Case Example
n Intraop view
– Medial incision used to
identify extent of
rupture/condition of
the FHL tendon with
plan to debride and
repair primarily
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Carolinas Medical Center
Case Example
n Intraop view
– Plantar incision used to
directly repair the lateral
FHB/plate rupture
» Beware of digital nerve
– Secure with toe in 10-15
degrees of plantarflexion
and then complete medial
repair
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Carolinas Medical Center
Surgical Technique
n If no soft tissue
attachments for
primary repair
– Distal: suture anchors in
proximal phalanx
– Proximal: transverse drill
hole in distal sesamoid
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Carolinas Medical Center
Surgical Technique
n Technique Tip:
suture anchors in
proximal phalanx
– Must avoid
supination
– Be central – use
flouro
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Carolinas Medical Center
Surgical Technique
n Complete repair
with advancement
of medial capsule
– Repair abductor
hallucis tendon
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Carolinas Medical Center
Surgical Technique
Check nerve one last time prior to closure
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Carolinas Medical Center
Surgical Technique
Preop (injured) Compare to
Contralateral
(normal)
Postop
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Carolinas Medical Center
Case – Turf Toe Variant
n 27 y/o lineman
n Valgus stress with axial load
n Progessive hallux valgus
– Can not “cut” or push-off
– MRI: medial capsular rupture
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Carolinas Medical Center
Case: Traumatic hallux valgus
n Treatment
– Modified McBride
bunionectomy with
adductor tenotomy
and repair of medial
defect
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Carolinas Medical Center
Postoperative Management
n Delicate balance between protection and early ROM
– Immobilize for 5-7 days passive plantar flexion (keep sesamoids moving)
n 4 weeks NWB then walker boot
n Active plantar flexion at 4 wks, dorsiflexion at 6-8 wks
n Accommodative shoe with insert/plate at 8 weeks and initiate active ROM
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Carolinas Medical Center
Postoperative Management
n Run at 3 months; play after 4 months
n Taping, shoewear modifications
n “Sore” for a year – risk for hallux rigidus
Prevent Dorsiflexion
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Carolinas Medical Center
Late Presentation: Cock-up
Deformity
n MP hyperextension
deformity (often IP flexion
contracture)
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Carolinas Medical Center
Surgical Technique
n Late cock-up deformity
– Consider FHL tendon transfer
» Girdlestone-Taylor
» Thru drill hole in proximal phalanx
n 4 mm biotenodesis screw
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Carolinas Medical Center
Case Example
n 33 y/o wide
receiver
n Turf toe injury 3
years ago
– Tibial
sesamoidectomy
– Cock-up deformity
normal
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Carolinas Medical Center
Old Turf Toe/Sesamoidectomy
n Sudden plantar pain
while cutting
n Cock-up deformity
gone
n Hallux elevated off
ground – no push
off strength
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Carolinas Medical Center
Old Turf Toe/Sesamoidectomy
n Intraop
– Plantarmedial
incision
» Used old incision
and extended across
plantar flexion
crease
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Carolinas Medical Center
Old Turf Toe/Sesamoidectomy
n Intraop
– FHL rupture
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Carolinas Medical Center
Old Turf Toe/Sesamoidectomy
n Intraop
– Tenodesis at master
knot
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Carolinas Medical Center
Old Turf Toe/Sesamoidectomy
n Intraop
– Tenolysis at master
knot performed
» Restored excursion
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Carolinas Medical Center
Old Turf Toe/Sesamoidectomy
n Intraop
– FHL tendon
recession/transfer to
proximal phalanx
» Fixed with
interference screw
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Carolinas Medical Center
Old Turf Toe/Sesamoidectomy
n Intraop
– FHB advancement
– Hallux IP fusion
l Returned to pro
football after 6
months…
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Carolinas Medical Center
Turf Toe Summary: Beware of these hallux
mp plantar plate injuries and their
variations = best to treat early; appreciate
long term risk for hallux rigidus
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Carolinas Medical Center
Thank you
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Carolinas Medical Center
Lachman/Drawer test =
Stabilize 2nd MPJ to test hallux
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Carolinas Medical Center
“Turf Toe”: Variable Injury Pattern
– Medial based
injury =
progressive
hallux valgus
– Modified
McBride
bunionectomy
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Carolinas Medical Center
Turf Toe with Bad Sesamoids?
n Tibial sesamoid pain
with instability
n Failed cast/toe spica
in plantarflexion
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Carolinas Medical Center
Solution = Tibial Sesamoidectomy with
Abductor Hallucis Transfer
n Transfer fills plantar
defect
n Provides flexion
power
n Need to release
adductor hallucis
tendon to balance