Turf Toe Injury Surgery to get back on the Field Robert B. - - PowerPoint PPT Presentation

Turf Toe Injury

Surgery to get back on the Field

Robert B. Anderson, MD

OrthoCarolina Charlotte, North Carolina Director, Foot and Ankle Titletown Sports Medicine and Orthopaedics Associate Team Physician, Green Bay Packers Green Bay, Wisconsin

Disclosures

Consulting/Royalties: Wright Medical, DJO, Arthrex, Zimmer Biomet Consulting: Amniox, Diamond Orthopaedic

Turf Toe = Classic Pathology

• Soft tissue injury 2°

hyperextension

– Disruption of FHB and plantar complex distal to sesamoids – Variable in degree and extent = complete vs partial

Result of Hyperextension Injury

• Can be major soft

tissue disruption

–Loss of plantar restraints

Sesamoid FHL

lDefect

Not Just Hyperextension = Variable Injury Patterns Increasing

• Consider force and what is

ruptured

– Valgus force – “medial turf toe” is most common – MCL/Abd Hall tendon rupture »May lead to traumatic bunion/progressive hallux valgus

Clinical Examination

• Standing alignment

and toe posture

• FHL function
• Lachman exam

– Vertical instability = lack of plantar restraints

Radiographic Evaluation

• Mandatory in the

evaluation of turf toe

• Comparison AP of
• pposite side

recommended

• Assess for proximal

migration of sesamoids

Radiographic Evaluation

• Forced dorsiflexion lateral view

– Assess distance from distal tibial sesamoid to base of phalanx (nl avg: 8mm)

Injured Normal

Flouroscopy Invaluable

• Assess trailing motion of the sesamoids with

dorsiflexion of the hallux; instability patterns

– Educational to patient

Treating the Turf Toe???

• Many can be treated

nonoperatively

– R.I.C.E. – Walker boot or short leg cast with toe spica

»Plantarflex hallux

– Turf toe plate/tape

Surgical Treatment – Who Needs It?

• “A Gestalt”
• My threshold for

surgical repair has lowered over the years

– Gross instability

» + Lachman » Excessive DF

– Progressive clawing

Why Early Surgical Repair?

• Restoration of

anatomy is necessary for restoration of function

• Avoid late

deformity

Return to Play Quickly?

• Severe soft tissue

injuries recover more predictably with surgical repair

– However I am not sure a Bowl game in 3 weeks is feasible…

Surgical Technique

• Exposure through

medial or J-incision

Surgical Technique

• Exposure through both

medial and plantar incisions

– Less traction on nerve – Improved lateral exposure – Better wound healing

plantar medial

Surgical Technique

• Extensile exposure and

prone positioning

– Good for chronic situation and both sesamoids retracted

Extensile vs 2-Incision Approach = Identify and Protect the Nerves!

Surgical Technique

• Transect abductor

tendon - identify defect in plantar capsule, condition

• f the FHL tendon

and sesamoids

Surgical Technique

• Primary repair to

soft tissue on base

• f proximal

phalanx usually possible

Surgical Technique

• Advance capsule and

repair

– 2-0 nonabsorbable – 10-15° plantarflexion

• Work from lateral to

medial

– Avoid nerve

Direct Repair

Surgical Technique

• If no soft tissue

attachments for primary repair

– Distal: suture anchors in proximal phalanx – Proximal: transverse drill hole in distal sesamoid

Surgical Technique

• Avoid supination

when placing suture anchors in proximal phalanx

– Be central – use flouro

Surgical Technique

• Complete repair

with advancement

• f medial capsule

– Repair abductor hallucis tendon

Surgical Technique

Check nerve one last time prior to closure

Surgical Technique

Preop (injured) Compare to Contralateral (normal) Postop

Case – Turf Toe Variant

• 28 y/o football

player

• Valgus stress with

axial load

• Pain over tibial

sesamoid

– Diastased bi-partite

• Loss of push-off

strength

Pre-injury Post-injury

Case – Turf Toe Variant

• Soft tissue avulsion

from tibial sesamoid

• Partial

sesamoidectomy

– Distal fragment

Case – Turf Toe Variant

• Repair via drill hole

in remaining sesamoid

Case – Turf Toe Variant

• Repair via drill hole

in remaining sesamoid

Case – Turf Toe Variant

• 27 y/o lineman
• Valgus stress with

axial load

• Progessive hallux

valgus

– Can not “cut” or push-off – MRI: medial capsular rupture

Case: Traumatic hallux valgus

• Treatment

– Modified McBride bunionectomy with adductor tenotomy and repair of medial defect

Postoperative Management

• Delicate balance between protection and early

ROM

– Immobilize for 5-7 days → passive plantar flexion (keep sesamoids moving)

• 2 weeks NWB then walker boot
• Active plantar flexion at 2 wks, dorsiflexion at

6-8 wks

• Accommodative shoe with insert/plate at 8

weeks and initiate active ROM

Postoperative Management

• Most run at 2 months; RTP at 3 months

»

Taping, shoewear modifications

• “Sore” for a year – risk for hallux rigidus

Prevent Dorsiflexion

References

1.

Anderson, R: Surgical management of the turf toe. Techniques in Foot and Ankle Surgery. 2003

2.

Anderson R, Watson T.: Turf toe injuries. In Advances in Foot and Ankle Reconstruction. AAOS 2003

3.

Frimenko RE, Lievers W, Coughlin MJ, Anderson RB, Crandall JR, Kent RW: Etiology and biomechanics of first metatarsophalangeal joint sprains (turf toe) in athletes. Crit Rev Biomed Eng. 2012; 40 (1); 43-61

4.

Hunt KJ, McCormick JJ, Anderson RB: Management of forefoot injuries in the athlete. Operative Techniques in Sports Medicine. Publication Date: April 2009.

5.

McCormick JJ, Anderson RB: The Great Toe: Failed Turf Toe, Chronic Turf Toe, and Complicated Sesamoid Injuries. Foot Ankle Clin. 2009 Jun; 14 (2): 135-150

6.

McCormick JJ, Anderson RB: Rehabilitation following turf toe injury and plantar plate

• repair. Clin Sports Med. 2010 Apr; 29 (2): 313-23

7.

McCormick JJ, Anderson RB: Turf toe: anatomy, diagnosis and treatment. Sports Health 2010 Nov; 2 (6): 487-94

8.

Watson T, Anderson R, Davis W: Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot and Ankle Clinics, 5 (3): 687-713, 2000

Thank You