Treating Severe Plantarflexion Contracture In Multiple Digits

This author details using a panmetatarsal head resection for a 24-year-old patient with bilateral digital plantarflexion deformities and a history of partial hallux amputation and osteomyelitis.

A 24-year-old man received a referral for evaluation and management of bilateral digital deformities. His past history was significant for sudden cardiac arrest in July 2015 and a subsequent coma for a one-week duration. The hypoxic event resulted in neurologic damage, specifically related to the feet in the way of plantarflexed digital deformities for the first through fifth digits on both feet.

The patient developed an ulceration that led to osteomyelitis of the left hallux, resulting in a partial amputation. He had a proximal interphalangeal joint arthrodesis as well as arthroplasty of the hallux interphalangeal joint, both with K-wire fixation.

The patient developed a postoperative infection and subsequent osteomyelitis of the right hallux distal phalanx, which was subsequently amputated. The patient continued to experience severe rigid plantarflexion deformity of the first through fifth metatarsophalangeal joints (MPJs) on both feet.

The patient’s vascular status was within normal limits. The neurological examination showed normal deep tendon reflexes, slightly decreased gross sensorium and normal vibratory examination. Dermatological examination showed surgical scars on all digits and hyperkeratotic lesions on the distal aspect of the first and second digits bilaterally. The remaining dermatological examination was within normal limits.

Musculoskeletal examination revealed partial bilateral hallux amputation. Severe plantarflexion contracture of the firsrt through fifth MPJs. MPJ total range-of-motion was less than 5 degrees (see videos at https://tinyurl.com/y8re835q and https://tinyurl.com/yb94dos2 ). Muscle strength was within normal limits and symmetrical for groups except for digital flexors and extensors. The non-weightbearing exam showed a gastrocnemius equinus deformity, slightly decreased total subtalar joint range of motion, normal midtarsal joint range of motion and a forefoot cavus deformity. The weightbearing exam revealed poor balance, an increased medial arch and a resting calcaneal stance position that was slightly inverted. The patient’s gait was a steppage type of gait with poor balance and a lack of propulsion.

Radiographs displayed plantarflexion deformities of the first through fifth digits at the MPJs, prior proximal interphalangeal joint arthrodesis, partial amputation of the hallux and a bilateral cavus deformity.

A Closer Look At The Treatment Course

I discussed treatment options with the patient. Surgical options included panmetatarsal head resection with first MPJ arthrodesis, arthroplasty of the distal interphalangeal joint and K-wire fixation of the lesser toes through the MPJs to the metatarsal bases versus transmetatarsal amputation. We also discussed custom orthoses, alteration of shoe gear and physical therapy.

I performed the panmetatarsal head resection with percutaneous K-wire fixation of the lesser toes through the MPJs to the metatarsal bases bilaterally, first MPJ arthrodesis bilaterally and arthroplasty of the right second distal interphalangeal joint. I operated on the left foot first and operated on the right foot approximately 10 weeks later. For the first MPJ arthrodesis, I utilized a locking plate and screws for fixation. I removed the 0.062-inch K-wires at four weeks.

The patient was weightbearing in a cast boot for eight weeks and then transitioned into an athletic shoe. The patient started range of motion exercises at six weeks postoperative.

Dr. DeHeer is a Fellow of the American College of Foot and Ankle Surgeons, and a Diplomate of the American Board of Podiatric Surgery. He is also a team podiatrist for the Indiana Pacers and the Indiana Fever. Dr. DeHeer is in private practice with various offices in Indianapolis and is the founder of Step by Step Haiti.