The Extensor Hood Release
Jay Lieberman,
DPM, FACFAS
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Jay Lieberman,
DPM, FACFAS
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Today I will speak blasphemy. "The arthroplasty is not foolproof." As confident as we all are in this procedure, they WILL fail from time to time. When performing an arthroplasty, we need to consider all the biomechanical factors before proceeding. We have to ask ourselves if there is an extensor substitution deformity, a flexor stabilization, or a flexor substitution deformity? After the procedure, we may wonder why the toe remained in varus despite the derotation arthroplasty. No matter how much we want to wish them away, transverse plane deformities do exist – no matter how subtle – and will compromise your result.
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Figure 1. Ideal Arthroplasty |
Figure 2. Medial Deviation of Arthroplasty |
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As I see it, the biggest cause of failure in arthroplasty surgery is not addressing the deformity at the metatarsophalangeal joint along with the proximal interphalangeal joint. How do you know if you have done enough? Once the capital component of the proximal phalanx is removed, does the remaining component sit in an elevated position on the sagittal plane? If so, a release of the extensor hood is warranted. This can be done easily with a periosteal elevator. Alternatively, the skin incision can be extended proximally. However, care must be taken to avoid a scar contracture.
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Figure 3. Pre-Op Hammertoe |
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Figure 4. Release Collateral Ligament |
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Figure 5. Release Extensor Hood Fibers |
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Figure 6. Proximal Dissection Extensor Hood |
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Figure 7. MPJ Capsulotomy |
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Fusing the proximal interphalangeal joint allows the long flexor to function at the metatarsophalangeal joint, enhancing your reduction. Fusing the joint may also help to prevent migration on the transverse plane. (See obliquity of IP joint with partial encroachment of hallux in case below).
We all have our preferences. K-wires (with peg-in-hole surgery), absorbable implantable wires, allogenic bone, small compression screws, and metallic implantable fusion implants. The Nextra® digital implant used below incorporates an intrinsic 15° angle, which allows for a more pleasing cosmetic-appearance. The two components of the Nextra® implant are screwed into the head of the proximal phalanx and into the base of the middle phalanx. The two implants are joined via a ratchet system. This is very easy to work with and can be easily reversed.
Our Products | Nextremity Solution
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Figure 8. Reaming Proximal Phalanx |
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Figure 9. Reaming Middle Phalanx |
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Figure 10. Proximal Implant in Place |
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Figure 11. Proximal and Distal Implants in Place |
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Figure 13. Fluoroscopic Image |
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Figure 14. Repair of the Extensor Hood |
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Nextremity Solutions is a privately held medical device company offering a new approach to the surgical intervention of small bone deformity, degeneration and trauma. The Company�s implant systems for the correction of these pathologies include extremely precise proprietary micro-technology designed to achieve repeatable clinical outcomes.
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