OKOJ, Volume 5, No. 4

Mallet Toe Deformity

Mallet toe is a flexion deformity of the distal interphalangeal (DIP) joint of a lesser toe. It may be deviated as well, either medially or laterally, with respect to the middle phalanx. Pain typically occurs as the tip of the toe repetitively strikes the ground, and a callus often develops at the tip of the toe or over the dorsal aspect of the DIP joint. Nonsurgical treatment includes pads and toe caps to protect the calluses on the toes and shoes with a roomy toe box and low heels. For flexible mallet toe deformities, percutaneous tenotomy of the flexor digitorum longus tendon may alleviate symptoms. For fixed deformities, osseous decompression of the DIP joint is necessary.

    • Keywords:
    • toe pain

    • toe callus

    • mallet toe deformity

    • fixed mallet toe deformity

    • flexible mallet toe deformity

    • DuVries arthroplasty

    • Subspecialty:
    • Foot and Ankle

Hammer and Claw Toe Deformity

A hammer toe is defined as a lesser toe that has a flexion deformity at the proximal interphalangeal. Frequently, the metatarsophalangeal joint is hyperextended, and the distal interphalangeal joint may be flexed, extended, or in a neutral position. The condition often is painful, and a painful callus may develop on the skin over the interphalangeal joints and on the tip of the toe from rubbing against the shoe. For flexible deformities, conservative treatment is recommended and may include toe stretching exercises, gauze padding to protect the toes, changing footwear, and the use of shoe inserts. Surgery is indicated if conservative measures fail to provide sufficient pain relief and depends on the flexibility and magnitude of the deformity.

    • Keywords:
    • claw toe

    • hammer toe

    • deformed toe

    • lesser toe deformity

    • deformity of the lesser toes

    • push-up test

    • flexor-to-extensor tendon transfer

    • Weil osteotomy

    • PIP joint arthrodesis

    • DuVries arthroplasty

    • MTP joint release

    • Subspecialty:
    • Foot and Ankle

Fibrous Dysplasia

Fibrous dysplasia is a benign, intramedullary, fibro-osseous lesion with a predilection for the long bones, ribs, and craniofacial skeleton. The classic lesion is a long lesion in a long bone with a"ground-glass"textured medullary calcification and cortical thinning but no periosteal reaction. The weakened bone about a fibrous dysplasia lesion fails under repetitive mechanical loading, leading to acute and/or chronic pain. Pharmacologic management of fibrous dysplasia is directed toward inhibiting osteoclastic function. Surgical intervention is indicated when the patient has intense pain that has failed to respond to nonsurgical measures. All lesions treated surgically should undergo curettage and bone grafting with some form of stabilization. Lesions located at the end of a bone are typically secured with plate and screw constructs. Long bone lesions in the metadiaphyseal junction or diaphysis can be treated with curettage, bone grafting, and intramedullary fixation.

    • Keywords:
    • fibrous dysplasia

    • café-au-lait spots

    • tibial bowing

    • McCune-Albright Syndrome

    • Mazabraud syndrome

    • Subspecialty:
    • Musculoskeletal Oncology

Arthroscopic SLAP Lesion Repair in a Baseball Pitcher

Dr. Craig Morgan performs an arthroscopic SLAP (superior labrum from anterior to posterior) lesion repair on a 20-year-old right-hand dominant college pitcher with a disabled throwing shoulder. The patient exhibited mechanical symptoms, including the inability to pitch prodromally and progressive loss of range of motion with loss of internal rotation of the shoulder. When the SLAP event occurred, the patient's pain became more severe. The patient was treated preoperatively using sleeper stretches to address the glenohumeral internal rotational deficit caused by his posteroinferior capsular contracture and was therefore identified preoperatively as a stretch responder. After performing glenohumeral joint examination arthroscopically, Dr. Morgan repairs the SLAP tear, illustrating arthroscopic portal placement, superior glenoid rim preparation, anchor placement, suture passing, and knot tying. The patient's posteroinferior capsule is left to be treated conservatively with persistent stretching.

    • Keywords:
    • superior labrum from anterior to posterior lesion

    • SLAP lesion

    • glenohumeral internal rotational deficit

    • posterior capsular contracture

    • arthroscopic glenohumeral joint examination

    • arthroscopic portal placement

    • superior glenoid rim preparation

    • anchor placement

    • Subspecialty:
    • Shoulder and Elbow

Revision ACL Reconstruction

The definition of an anterior cruciate ligament (ACL) failure is symptomatic instability, pain, extensor dysfunction, and arthrofibrosis following a surgical reconstruction. Although this is an oversimplification, and despite many ACL failures falling into one of these categories, there is still no universally accepted definition of unsatisfactory outcome following ACL reconstruction.

This article provides a working definition of revision ACL reconstruction and reviews the pathophysiology, incidence, and clinical presentation for patients who may be considered for a revision procedure. Indications, contradications and treatment options, including graft considerations, bone tunnels, femoral tunnels, and tibial tunnels are reviewed. An indepth presentation of the revision ACL reconstruction procedure is shown. Video is available. CME Credit will be available soon.

    • Keywords:
    • ACL injury

    • anterior cruciate ligament injury

    • ACL tear

    • knee injury

    • knee ligament injury

    • ACL graft failure

    • anterior cruciate ligament graft failure

    • causes of graft failure

    • Lachman test

    • pivot shift test

    • anterior drawer test

    • posterior sag test

    • posterior drawer test

    • graft considerations

    • bone tunnels

    • femoral tunnels

    • tibial tunnels

    • Subspecialty:
    • Sports Medicine

Distal Tibia Fractures

This fracture is unusual, which makes treatment particularly difficult, because experience and judgment are required for optimal results. The mechanism of injury is inherently part of the diagnosis of this category of ankle fracture. Tibial plafond or pilon fractures occur through a mechanism that must have at least a component of axial load; most occur either from a fall from a height or a motor vehicle accident, with each of these mechanisms accounting for approximately 50% of the fractures. The axial load produces the intra-articular injury, the energy release that injures the soft tissues, and the fracture patterns that are typically associated with this fracture category. Fractures caused by rotation and nonarticular fractures of the distal tibia caused predominately by bending produce different fracture patterns with different prognoses and are treated with different techniques. Definitive treatment of most distal tibial fractures includes one of the following techniques: spanning external fixation with screw fixation for the articular surface, ring/wire fixation, or delayed plating often following initial temporary spanning external fixation.

This article reviews the pathophysiology and clinical presentation of distal tibia fractures and reviews the surgical management options. The technique of spanning articulated external fixation is specifically reviewed.

    • Keywords:
    • broken leg

    • lower leg fracture

    • broken ankle

    • ankle fracture

    • tibial plafond fracture

    • pilon fracture

    • intra-articular distal tibial fracture

    • Reudi-Allgower classification

    • AO/OTA classification

    • spanning articulated external fixation

    • Subspecialty:
    • Trauma