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Arthroscopically Assisted Modified Jones Procedure
Technical Note
Arthroscopically Assisted Modified Jones Procedure Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S.
Abstract: The modified Jones procedure is the classic operative treatment of symptomatic clawed hallux. It is composed of transfer of the extensor hallucis longus tendon to the first metatarsal neck and fusion of the hallux interphalangeal joint. The purpose of this technical note is to report the technique of an arthroscopically assisted modified Jones procedure. This can be combined with other minimally invasive bone and soft-tissue procedures to correct all aspects of the complex cavus foot deformity.
lawed hallux is defined as extension of the first metatarsophalangeal (MTP-1) joint combined with flexion of the interphalangeal joint (IPJ).1 Clawed hallux can result from excessive motor function in 1 of 3 muscles: flexor hallucis longus (FHL), peroneus longus (PL), and extensor hallucis longus (EHL).2 The first metatarsal (MT-1) can undergo plantar flexion at the tarsometatarsal joint by combined action of the EHL and PL. Overaction of the EHL results in clawed hallux deformity through dorsiflexion of the MTP-1 joint, forcing the MT-1 head downward.3 In the absence of the stabilizing effect of the tibialis anterior on the medial tarsometatarsal joint, the PL causes plantar flexion and pronation of the MT-1.3,4 This results in pes cavus, which is commonly associated with clawed hallux deformity.3 Charcot-Marie-Tooth disease and postpolio syndrome are the most common causes of cavus foot and clawed hallux.3,5 The claw toes are usually the most symptomatic component of the complex deformity.6 Painful hyperkeratosis can occur at the dorsal aspect of the IPJ, the plantar aspect of the metatarsal head, and/or the toe tip in the region of the hyponychium.6 Jones7 popularized transferring the EHL tendon to the neck of the MT-1 and releasing
C
From the Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received July 11, 2016; accepted August 16, 2016. Address correspondence to Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16662/$36.00 http://dx.doi.org/10.1016/j.eats.2016.08.012
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the plantar aponeurosis to correct the claw toe deformity. Transfer of the EHL tendon to the neck of the MT1, in fact, can exaggerate plantar flexion deformity of the IPJ.4 The technique has been modified to include fusion of the hallux IPJ. This can prevent flexion deformity of the IPJ due to the unopposed pull of the FHL. Transfer of the EHL tendon to the MT-1 neck can prevent dorsal subluxation of the MTP-1 joint and assist ankle dorsiflexion. The tendon transfer also counters the progression of midfoot equinus and submetatarsal head pressure by elevation of the distal portion of the MT-1.6 Although some authors have proposed transfer of the FHL tendon to the proximal phalanx,1,2,8 the modified Jones procedure remains the classic operative procedure for correction of clawed hallux. The purpose of this technical note is to report the technique of an arthroscopically assisted modified Jones procedure. It is indicated for correction of symptomatic clawed hallux deformity or weak ankle dorsiflexors with EHL as the primary ankle dorsiflexor. It is contraindicated if the MTP-1 joint is degenerated or the motor power of the EHL is Medical Research Council grade IV or lower. This is because the power of a transferred muscle will lose one grade and a weak EHL will not be able to lift the head of the MT-1 and compensate for a weak tibialis anterior (Table 1).3
Table 1. Indications and Contraindications of Arthroscopically Assisted Modified Jones Procedure Indications Symptomatic clawed hallux deformity Weak ankle dorsiflexors with extensor hallucis longus as primary ankle dorsiflexor Contraindications Presence of degenerated first metatarsophalangeal joint Motor power of extensor hallucis longus of Medical Research Council grade IV or lower
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portal sites, and the subcutaneous tissue is bluntly dissected down to the joint capsule by a hemostat. The capsule is penetrated by the hemostat tip. A proximalmedial portal is made on the dorsomedial side of the MT-1 neck. A 1-cm incision is made at the portal site. This portal can be used for drilling the bone tunnel of the MT1 neck. It, together with the dorsomedial portal, allows endoscopically assisted harvest of the EHL tendon. The EHL tendon, after passing through the bone tunnel and wrapping around the MT-1 neck, can be sutured back to itself at this incision to complete the tendon transfer.
Patient Positioning The arthroscopically assisted Jones procedure consists of arthroscopic interphalangeal arthrodesis of the hallux and endoscopically assisted EHL transfer.9 The patient is in the supine position with the legs spread. A thigh tourniquet is applied to provide a bloodless operative field. A 1.9-mm 30 arthroscope (Henke Sass Wolf, Tuttlingen, Germany) is used for the arthroscopic interphalangeal arthrodesis, and a 2.7-mm 30 arthroscope (Henke Sass Wolf) is used for the endoscopically assisted EHL transfer.
Arthroscopic Interphalangeal Arthrodesis of Hallux Hallux interphalangeal arthroscopy is performed through the dorsomedial and dorsolateral portals. With the dorsomedial portal as the viewing portal, the lateral collateral ligament of the IPJ is released down to the plantar plate by means of SuperCut scissors (Stille, Lombard, IL) through the dorsolateral portal (Fig 2). The arthroscope is switched to the dorsolateral portal, and the medial collateral ligament is then released through the dorsomedial portal. Release of the collateral ligaments can facilitate distraction of the IPJ and subsequent preparation of the fusion surfaces. The dorsomedial and dorsolateral portals are interchangeable as the viewing and working portals. The articular cartilage and the subchondral bone are removed by an arthroscopic osteotome (Acufex; Smith & Nephew, Andover, MA) and an arthroscopic shaver (Dyonics; Smith & Nephew) (Fig 3). It is important to preserve the normal contour of the articular surfaces. The joint is then positioned in slight flexion and transfixed with one 4.0-mm cannulated screw (Synthes, Oberdorf, Switzerland) (Fig 4).
Portal Placement The dorsolateral and dorsomedial portals for hallux interphalangeal arthroscopy are located at the dorsolateral and dorsomedial corners of the hallux IPJ, respectively (Fig 1). Three-millimeter incisions are made at the
Endoscopically Assisted Harvest of EHL Tendon The phalangeal insertion of the FHL tendon is cut by SuperCut scissors through the dorsomedial and dorsolateral portals. EHL tendoscopy is performed through the dorsomedial interphalangeal portal and
Fig 1. Arthroscopically assisted modified Jones procedure in right foot. The hallux interphalangeal arthroscopy is performed through the dorsomedial portal (DMP) and dorsolateral portal (DLP), which are located at the dorsolateral and dorsomedial corners of the hallux interphalangeal joint, respectively. (DP, distal phalanx; EHL, extensor hallucis longus tendon; PP, proximal phalanx.)
Technique
Fig 2. Arthroscopically assisted modified Jones procedure in right foot. (A) The dorsomedial portal (DMP) is the viewing portal. The lateral collateral ligament of the interphalangeal joint is released by SuperCut scissors through the dorsolateral portal (DLP). (B) An arthroscopic view shows release of the lateral collateral ligament (LCL) by the scissors (S). (DP, distal phalanx; PP, proximal phalanx.)
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Fig 3. Arthroscopically assisted modified Jones procedure in right foot. (A) The dorsomedial portal (DMP) is the viewing portal. The articular cartilage is resected by an arthroscopic shaver through the dorsolateral portal (DLP). (B) An arthroscopic view shows debridement of the cartilage by the shaver through the dorsolateral portal. (DP, distal phalanx; PP, proximal phalanx.)
Fig 4. Arthroscopically assisted modified Jones procedure in right foot. (A) A 4.0-mm cannulated screw is inserted through a small incision at the tip of the hallux to transfix the interphalangeal joint. (B) A fluoroscopic view shows transfixation of the interphalangeal joint by the cannulated screw.
Fig 5. Arthroscopically assisted modified Jones procedure in right foot. (A) Extensor hallucis longus tendoscopy is performed through the dorsomedial portal (DMP) and proximal-medial portal (PMP). (DLP, dorsolateral portal.) (B) The dorsomedial portal is the viewing portal. The extensor hallucis longus (EHL) tendon is released from the extensor expansion by an arthroscopic shaver (S). (C) Release of the EHL tendon is completed by an open-ended tendon stripper. (D) The tendon is retrieved to the proximal-medial portal, and a stay stitch is applied with No. 0 Vicryl.
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Fig 6. Arthroscopically assisted modified Jones procedure in right foot. If extensor hallucis longus (EHL) transfer to another part of the foot is planned, a 1-cm proximal incision (PI) is made over the EHL tendon just distal to the ankle joint. The EHL tendon is then retrieved to this incision and can be rerouted to the other part of the foot. (DLP, dorsolateral portal; DMP, dorsomedial portal; PMP, proximal-medial portal.)
the proximal-medial portal. The EHL tendon is retracted to the proximal-medial portal, and a vascular sling is applied. The colored sling serves as an
endoscopic landmark of the tendon. The dorsomedial portal is the viewing portal, and the EHL tendon is released from the extensor expansion by an arthroscopic shaver and SuperCut scissors. The release is completed by an open-ended tendon stripper (Acufex; Smith & Nephew) through the proximal-medial portal. The tendon is retrieved to the proximal-medial portal, and a stay stitch is applied with No. 0 Vicryl (Ethicon) (Fig 5). If there is persistent dorsiflexion deformity after harvest of the EHL tendon, the contracted dorsal capsule of the MTP-1 joint can be resected by the arthroscopic shaver through the proximal-medial portal. Caution should be taken not to injure the extensor hallucis brevis tendon during release of the EHL tendon and endoscopic dorsal capsulectomy of the MTP-1 joint. Retrieval of EHL Tendon to Proximal Incision (Optional) If it is planned to transfer the EHL tendon to another part of the foot, a 1-cm proximal incision is made over the tendon just distal to the ankle joint. The EHL tendon is then retrieved to the proximal incision and rerouted to the other part of the foot (Fig 6).
Fig 7. Arthroscopically assisted modified Jones procedure in right foot. (A) The proximal-medial portal (PMP) incision is retracted in a plantar manner. A 2.5- to 3.5-mm bone tunnel is made at the first metatarsal neck. The tunnel is from plantarmedial to dorsal-lateral. (B) A 16-gauge angiocath is inserted through the proximal-medial portal and through the bone tunnel and pierces through the dorsal skin. The core needle is removed, and the plastic tube is left for passage of suture. A No. 1 PDS suture loop is passed through the plastic tube. (C) The plastic tube is removed, and the suture limbs are retrieved over the dorsum of the first metatarsal back to the proximal-medial portal by a hemostat. (D) The PDS suture loop serves as a suture retriever to pass the extensor hallucis longus (EHL) tendon and its stay stitches through the bone tunnel, along the dorsum of the first metatarsal neck, back to the proximal-medial portal.
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hemostat. The PDS suture loop serves as a suture retriever to pass the EHL tendon and its stay stitches through the bone tunnel, along the dorsum of the MT1 neck, back to the proximal-medial portal (Figs 7 and 8, Video 1). The EHL tendon is tensioned and sutured to itself at the proximal-medial portal. The stay stitches can be retrieved proximally to a proximal incision over the EHL tendon. The stay stitches can be sutured to the EHL tendon at the proximal site by an eyed needle (Fig 9).
Discussion Fig 8. Arthroscopically assisted modified Jones procedure in right foot. The extensor hallucis longus (EHL) passes through the bone tunnel, along the dorsum of the first metatarsal, back to the proximal-medial portal.
Transfer of EHL Tendon to MT-1 Neck The proximal-medial portal incision is retracted in a plantar manner. A 2.5- to 3.5-mm bone tunnel is made at the MT-1 neck. The tunnel is from plantar-medial to dorsal-lateral. A 16-gauge angiocath is inserted through the proximal-medial portal and through the bone tunnel and pierces through the dorsal skin. The core needle is removed, and the plastic tube is left in situ. A No. 1 PDS (Ethicon) suture loop is passed through the plastic tube. The plastic tube is removed, and the suture limbs are retrieved over the dorsum of the MT-1 back to the proximal-medial portal by a
Fig 9. Arthroscopically assisted modified Jones procedure in right foot. (A) The extensor hallucis longus (EHL) tendon is tensioned and sutured to itself at the proximal-medial portal. (B) Remnant of EHL stump after suturing to itself. (C) The stay stitches are retrieved proximally to a proximal incision (PI) over the EHL tendon. (D) The stay stitches can be sutured to the EHL tendon at the proximal site by an eyed needle. (PMP, proximal-medial portal.)
Clawed hallux can be part of a complex cavus foot deformity. A combination of procedures is needed to address all components of the complex deformity.3-5 These can be divided into soft-tissue procedures, osteotomies, and arthrodeses. Soft-tissue procedures include plantar fascia release and tendon transfers. Osteotomies may be performed on the calcaneus, midfoot, and metatarsus. Hindfoot arthrodesis including a subtalar, double or triple arthrodesis can be considered in severe hindfoot deformity with arthritis (Table 2).5 Many of these procedures can be performed in a minimally invasive manner and can be combined with the arthroscopically assisted Jones procedure to achieve full correction of the deformity.10-13 The technique of the arthroscopically assisted modified Jones procedure is based on the technology advances in interphalangeal arthroscopy9 and extensor tendoscopy of the foot.14-17 The IPJ is a small and tight joint, and interphalangeal arthroscopy is technically
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Table 2. Pearls and Pitfalls of Arthroscopically Assisted Modified Jones Procedure Pearls Release of the collateral ligaments improves the working space for arthroscopic interphalangeal arthrodesis. Distal extensor tendoscopy of the hallux can release the extensor hallucis longus tendon from the extensor expansion and resect the dorsal capsule of the first metatarsophalangeal joint. Transfer of the extensor hallucis longus tendon to the medial side of the first metatarsal neck can elevate the first metatarsal, correct the dorsiflexion deformity of the first metatarsophalangeal joint, and correct the first metatarsal pronation. The proximal incision close to the ankle allows rerouting of the extensor hallucis longus tendon for transfer to another part of the foot. It also allows suturing of the stay stitches to the extensor hallucis longus tendon at the proximal site. Pitfalls Clawed hallux can be part of a complex cavus foot deformity. A combination of procedures is needed to correct all aspects of the deformity.
difficult. Release of the collateral ligaments allows easier distraction of the IPJ and increases the working space. Endoscopic release of the EHL tendon from the extensor expansion is recommended before harvest of the tendon with the tendon stripper. This can reduce the risk of premature cutting of the tendon proximal to its insertion. EHL transfer to the medial side of the MT-1 neck can correct the metatarsal pronation (as a result of over-pulling of the PL). The proximal incision close to the ankle is useful if transfer of the EHL tendon to another part of the foot is indicated. It also allows tying of the stay stitches to the EHL tendon at the proximal site. This improves security of the tendon transfer construct. The advantages of this technique include small incisions and better cosmetic result, minimal soft-tissue dissection, and flexibility of transfer of the EHL tendon to another part of the foot. Potential risks of this procedure include injury to the digital cutaneous nerves, injury to the extensor hallucis brevis tendon, Table 3. Advantages and Risks of Arthroscopically Assisted Modified Jones Procedure Advantages Smaller wounds and better cosmetic result Minimal soft-tissue dissection Flexibility of transfer of extensor hallucis longus tendon to another part of foot Risks Injury to digital cutaneous nerves Injury to extensor hallucis brevis tendon Nonunion of interphalangeal arthrodesis with relapse of claw deformity First metatarsal dorsiflexion Recurrent pain under first metatarsal head
nonunion of the interphalangeal arthrodesis with relapse of claw deformity, MT-1 dorsiflexion, and recurrent pain under the MT-1 head (Table 3).4,5
References 1. Elias FN, Yuen TJ, Olson SL, Sangeorzan BJ, Ledoux WR. Correction of clawed hallux deformity: Comparison of the Jones procedure and FHL transfer in a cadaver model. Foot Ankle Int 2007;28:369-376. 2. Kadel NJ, Donaldson-Fletcher EA, Hansen ST, Sangeorzan BJ. Alternative to the modified Jones procedure: Outcomes of the flexor hallucis longus (FHL) tendon transfer procedure for correction of clawed hallux. Foot Ankle Int 2005;26:1021-1026. 3. Faraj AA. Modified Jones procedure for post-polio claw hallux deformity. J Foot Ankle Surg 1997;36:356-359. 4. de Palma L, Colonna E, Travasi M. The modified Jones procedure for pes cavovarus with claw hallux. J Foot Ankle Surg 1997;36:279-283. 5. Faldini C, Traina F, Nanni M, et al. Surgical treatment of cavus foot in Charcot-Marie-Tooth disease: A review of twenty-four cases. J Bone Joint Surg Am 2015;97:e30. 6. Sugathan HK, Sherlock DA. A modified Jones procedure for managing clawing of lesser toes in pes cavus: Long-term follow-up in 8 patients. J Foot Ankle Surg 2009;48:637-641. 7. Jones R. The soldier’s foot and the treatment of common deformities of the foot. Part II. Claw foot. Br Med J 1916;1: 749-752. 8. Steensma MR, Jabara M, Anderson JG, Bohay DR. Flexor hallucis longus tendon transfer for hallux claw toe deformity and vertical instability of the metatarsophalangeal joint. Foot Ankle Int 2006;27:689-692. 9. Lui TH. Interphalangeal arthroscopy of the toes. Foot 2014;24:42-46. 10. Lui TH. New technique of arthroscopic triple arthrodesis. Arthroscopy 2006;22:464.e1-464.e5. 11. Lui TH. Arthroscopic triple arthrodesis in patients with Müller Weiss disease. Foot Ankle Surg 2009;15: 119-122. 12. Lui TH. Percutaneous sagittal plane closing wedge osteotomy of the first metatarsal. Eur J Orthop Surg Traumatol 2014;24:243-246. 13. Lui TH. Percutaneous posterior calcaneal osteotomy. J Foot Ankle Surg 2015;54:1188-1192. 14. Lui TH. Extensor tendoscopy of the ankle. Foot Ankle Surg 2011;17:e1-e6. 15. Lui TH. Arthroscopically assisted Z-lengthening of extensor hallucis longus tendon. Arch Orthop Trauma Surg 2007;127:855-857. 16. Chang JJ, Lui TH. Endoscopic-assisted repair of extensor hallucis longus tendon rerupture. Foot Ankle Int 2013;34: 455-458. 17. Lui TH, Chang JJ, Maffulli N. Endoscopic-assisted repair of neglected rupture or rerupture after primary repair of extensor hallucis longus tendon. Sports Med Arthrosc 2016;24:34-37.
Video 1. Arthroscopically assisted modified Jones procedure in right foot. Interphalangeal arthroscopy is performed with the dorsomedial and dorsolateral portals. The collateral ligaments are released. The articular cartilage and subchondral bone are debrided with an arthroscopic shaver. The interphalangeal joint is reduced and transfixed with a cannulated screw. Distal extensor hallucis longus (EHL) tendoscopy is performed with the dorsomedial and proximal-medial portals. The EHL tendon is released from the extensor expansion. The tendon is harvested by an open-ended tendon stripper. A bone tunnel is created at the first metatarsal neck. The EHL tendon passes through the bone tunnel, along the dorsum of the first metatarsal, back to the proximal-medial portal. The tendon is sutured to itself at the proximal-medial portal.
Arthroscopically Assisted Modified Jones Procedure Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S.
Abstract: The modified Jones procedure is the classic operative treatment of symptomatic clawed hallux. It is composed of transfer of the extensor hallucis longus tendon to the first metatarsal neck and fusion of the hallux interphalangeal joint. The purpose of this technical note is to report the technique of an arthroscopically assisted modified Jones procedure. This can be combined with other minimally invasive bone and soft-tissue procedures to correct all aspects of the complex cavus foot deformity.
lawed hallux is defined as extension of the first metatarsophalangeal (MTP-1) joint combined with flexion of the interphalangeal joint (IPJ).1 Clawed hallux can result from excessive motor function in 1 of 3 muscles: flexor hallucis longus (FHL), peroneus longus (PL), and extensor hallucis longus (EHL).2 The first metatarsal (MT-1) can undergo plantar flexion at the tarsometatarsal joint by combined action of the EHL and PL. Overaction of the EHL results in clawed hallux deformity through dorsiflexion of the MTP-1 joint, forcing the MT-1 head downward.3 In the absence of the stabilizing effect of the tibialis anterior on the medial tarsometatarsal joint, the PL causes plantar flexion and pronation of the MT-1.3,4 This results in pes cavus, which is commonly associated with clawed hallux deformity.3 Charcot-Marie-Tooth disease and postpolio syndrome are the most common causes of cavus foot and clawed hallux.3,5 The claw toes are usually the most symptomatic component of the complex deformity.6 Painful hyperkeratosis can occur at the dorsal aspect of the IPJ, the plantar aspect of the metatarsal head, and/or the toe tip in the region of the hyponychium.6 Jones7 popularized transferring the EHL tendon to the neck of the MT-1 and releasing
C
From the Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong, China. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received July 11, 2016; accepted August 16, 2016. Address correspondence to Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail: [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16662/$36.00 http://dx.doi.org/10.1016/j.eats.2016.08.012
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the plantar aponeurosis to correct the claw toe deformity. Transfer of the EHL tendon to the neck of the MT1, in fact, can exaggerate plantar flexion deformity of the IPJ.4 The technique has been modified to include fusion of the hallux IPJ. This can prevent flexion deformity of the IPJ due to the unopposed pull of the FHL. Transfer of the EHL tendon to the MT-1 neck can prevent dorsal subluxation of the MTP-1 joint and assist ankle dorsiflexion. The tendon transfer also counters the progression of midfoot equinus and submetatarsal head pressure by elevation of the distal portion of the MT-1.6 Although some authors have proposed transfer of the FHL tendon to the proximal phalanx,1,2,8 the modified Jones procedure remains the classic operative procedure for correction of clawed hallux. The purpose of this technical note is to report the technique of an arthroscopically assisted modified Jones procedure. It is indicated for correction of symptomatic clawed hallux deformity or weak ankle dorsiflexors with EHL as the primary ankle dorsiflexor. It is contraindicated if the MTP-1 joint is degenerated or the motor power of the EHL is Medical Research Council grade IV or lower. This is because the power of a transferred muscle will lose one grade and a weak EHL will not be able to lift the head of the MT-1 and compensate for a weak tibialis anterior (Table 1).3
Table 1. Indications and Contraindications of Arthroscopically Assisted Modified Jones Procedure Indications Symptomatic clawed hallux deformity Weak ankle dorsiflexors with extensor hallucis longus as primary ankle dorsiflexor Contraindications Presence of degenerated first metatarsophalangeal joint Motor power of extensor hallucis longus of Medical Research Council grade IV or lower
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portal sites, and the subcutaneous tissue is bluntly dissected down to the joint capsule by a hemostat. The capsule is penetrated by the hemostat tip. A proximalmedial portal is made on the dorsomedial side of the MT-1 neck. A 1-cm incision is made at the portal site. This portal can be used for drilling the bone tunnel of the MT1 neck. It, together with the dorsomedial portal, allows endoscopically assisted harvest of the EHL tendon. The EHL tendon, after passing through the bone tunnel and wrapping around the MT-1 neck, can be sutured back to itself at this incision to complete the tendon transfer.
Patient Positioning The arthroscopically assisted Jones procedure consists of arthroscopic interphalangeal arthrodesis of the hallux and endoscopically assisted EHL transfer.9 The patient is in the supine position with the legs spread. A thigh tourniquet is applied to provide a bloodless operative field. A 1.9-mm 30 arthroscope (Henke Sass Wolf, Tuttlingen, Germany) is used for the arthroscopic interphalangeal arthrodesis, and a 2.7-mm 30 arthroscope (Henke Sass Wolf) is used for the endoscopically assisted EHL transfer.
Arthroscopic Interphalangeal Arthrodesis of Hallux Hallux interphalangeal arthroscopy is performed through the dorsomedial and dorsolateral portals. With the dorsomedial portal as the viewing portal, the lateral collateral ligament of the IPJ is released down to the plantar plate by means of SuperCut scissors (Stille, Lombard, IL) through the dorsolateral portal (Fig 2). The arthroscope is switched to the dorsolateral portal, and the medial collateral ligament is then released through the dorsomedial portal. Release of the collateral ligaments can facilitate distraction of the IPJ and subsequent preparation of the fusion surfaces. The dorsomedial and dorsolateral portals are interchangeable as the viewing and working portals. The articular cartilage and the subchondral bone are removed by an arthroscopic osteotome (Acufex; Smith & Nephew, Andover, MA) and an arthroscopic shaver (Dyonics; Smith & Nephew) (Fig 3). It is important to preserve the normal contour of the articular surfaces. The joint is then positioned in slight flexion and transfixed with one 4.0-mm cannulated screw (Synthes, Oberdorf, Switzerland) (Fig 4).
Portal Placement The dorsolateral and dorsomedial portals for hallux interphalangeal arthroscopy are located at the dorsolateral and dorsomedial corners of the hallux IPJ, respectively (Fig 1). Three-millimeter incisions are made at the
Endoscopically Assisted Harvest of EHL Tendon The phalangeal insertion of the FHL tendon is cut by SuperCut scissors through the dorsomedial and dorsolateral portals. EHL tendoscopy is performed through the dorsomedial interphalangeal portal and
Fig 1. Arthroscopically assisted modified Jones procedure in right foot. The hallux interphalangeal arthroscopy is performed through the dorsomedial portal (DMP) and dorsolateral portal (DLP), which are located at the dorsolateral and dorsomedial corners of the hallux interphalangeal joint, respectively. (DP, distal phalanx; EHL, extensor hallucis longus tendon; PP, proximal phalanx.)
Technique
Fig 2. Arthroscopically assisted modified Jones procedure in right foot. (A) The dorsomedial portal (DMP) is the viewing portal. The lateral collateral ligament of the interphalangeal joint is released by SuperCut scissors through the dorsolateral portal (DLP). (B) An arthroscopic view shows release of the lateral collateral ligament (LCL) by the scissors (S). (DP, distal phalanx; PP, proximal phalanx.)
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Fig 3. Arthroscopically assisted modified Jones procedure in right foot. (A) The dorsomedial portal (DMP) is the viewing portal. The articular cartilage is resected by an arthroscopic shaver through the dorsolateral portal (DLP). (B) An arthroscopic view shows debridement of the cartilage by the shaver through the dorsolateral portal. (DP, distal phalanx; PP, proximal phalanx.)
Fig 4. Arthroscopically assisted modified Jones procedure in right foot. (A) A 4.0-mm cannulated screw is inserted through a small incision at the tip of the hallux to transfix the interphalangeal joint. (B) A fluoroscopic view shows transfixation of the interphalangeal joint by the cannulated screw.
Fig 5. Arthroscopically assisted modified Jones procedure in right foot. (A) Extensor hallucis longus tendoscopy is performed through the dorsomedial portal (DMP) and proximal-medial portal (PMP). (DLP, dorsolateral portal.) (B) The dorsomedial portal is the viewing portal. The extensor hallucis longus (EHL) tendon is released from the extensor expansion by an arthroscopic shaver (S). (C) Release of the EHL tendon is completed by an open-ended tendon stripper. (D) The tendon is retrieved to the proximal-medial portal, and a stay stitch is applied with No. 0 Vicryl.
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Fig 6. Arthroscopically assisted modified Jones procedure in right foot. If extensor hallucis longus (EHL) transfer to another part of the foot is planned, a 1-cm proximal incision (PI) is made over the EHL tendon just distal to the ankle joint. The EHL tendon is then retrieved to this incision and can be rerouted to the other part of the foot. (DLP, dorsolateral portal; DMP, dorsomedial portal; PMP, proximal-medial portal.)
the proximal-medial portal. The EHL tendon is retracted to the proximal-medial portal, and a vascular sling is applied. The colored sling serves as an
endoscopic landmark of the tendon. The dorsomedial portal is the viewing portal, and the EHL tendon is released from the extensor expansion by an arthroscopic shaver and SuperCut scissors. The release is completed by an open-ended tendon stripper (Acufex; Smith & Nephew) through the proximal-medial portal. The tendon is retrieved to the proximal-medial portal, and a stay stitch is applied with No. 0 Vicryl (Ethicon) (Fig 5). If there is persistent dorsiflexion deformity after harvest of the EHL tendon, the contracted dorsal capsule of the MTP-1 joint can be resected by the arthroscopic shaver through the proximal-medial portal. Caution should be taken not to injure the extensor hallucis brevis tendon during release of the EHL tendon and endoscopic dorsal capsulectomy of the MTP-1 joint. Retrieval of EHL Tendon to Proximal Incision (Optional) If it is planned to transfer the EHL tendon to another part of the foot, a 1-cm proximal incision is made over the tendon just distal to the ankle joint. The EHL tendon is then retrieved to the proximal incision and rerouted to the other part of the foot (Fig 6).
Fig 7. Arthroscopically assisted modified Jones procedure in right foot. (A) The proximal-medial portal (PMP) incision is retracted in a plantar manner. A 2.5- to 3.5-mm bone tunnel is made at the first metatarsal neck. The tunnel is from plantarmedial to dorsal-lateral. (B) A 16-gauge angiocath is inserted through the proximal-medial portal and through the bone tunnel and pierces through the dorsal skin. The core needle is removed, and the plastic tube is left for passage of suture. A No. 1 PDS suture loop is passed through the plastic tube. (C) The plastic tube is removed, and the suture limbs are retrieved over the dorsum of the first metatarsal back to the proximal-medial portal by a hemostat. (D) The PDS suture loop serves as a suture retriever to pass the extensor hallucis longus (EHL) tendon and its stay stitches through the bone tunnel, along the dorsum of the first metatarsal neck, back to the proximal-medial portal.
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hemostat. The PDS suture loop serves as a suture retriever to pass the EHL tendon and its stay stitches through the bone tunnel, along the dorsum of the MT1 neck, back to the proximal-medial portal (Figs 7 and 8, Video 1). The EHL tendon is tensioned and sutured to itself at the proximal-medial portal. The stay stitches can be retrieved proximally to a proximal incision over the EHL tendon. The stay stitches can be sutured to the EHL tendon at the proximal site by an eyed needle (Fig 9).
Discussion Fig 8. Arthroscopically assisted modified Jones procedure in right foot. The extensor hallucis longus (EHL) passes through the bone tunnel, along the dorsum of the first metatarsal, back to the proximal-medial portal.
Transfer of EHL Tendon to MT-1 Neck The proximal-medial portal incision is retracted in a plantar manner. A 2.5- to 3.5-mm bone tunnel is made at the MT-1 neck. The tunnel is from plantar-medial to dorsal-lateral. A 16-gauge angiocath is inserted through the proximal-medial portal and through the bone tunnel and pierces through the dorsal skin. The core needle is removed, and the plastic tube is left in situ. A No. 1 PDS (Ethicon) suture loop is passed through the plastic tube. The plastic tube is removed, and the suture limbs are retrieved over the dorsum of the MT-1 back to the proximal-medial portal by a
Fig 9. Arthroscopically assisted modified Jones procedure in right foot. (A) The extensor hallucis longus (EHL) tendon is tensioned and sutured to itself at the proximal-medial portal. (B) Remnant of EHL stump after suturing to itself. (C) The stay stitches are retrieved proximally to a proximal incision (PI) over the EHL tendon. (D) The stay stitches can be sutured to the EHL tendon at the proximal site by an eyed needle. (PMP, proximal-medial portal.)
Clawed hallux can be part of a complex cavus foot deformity. A combination of procedures is needed to address all components of the complex deformity.3-5 These can be divided into soft-tissue procedures, osteotomies, and arthrodeses. Soft-tissue procedures include plantar fascia release and tendon transfers. Osteotomies may be performed on the calcaneus, midfoot, and metatarsus. Hindfoot arthrodesis including a subtalar, double or triple arthrodesis can be considered in severe hindfoot deformity with arthritis (Table 2).5 Many of these procedures can be performed in a minimally invasive manner and can be combined with the arthroscopically assisted Jones procedure to achieve full correction of the deformity.10-13 The technique of the arthroscopically assisted modified Jones procedure is based on the technology advances in interphalangeal arthroscopy9 and extensor tendoscopy of the foot.14-17 The IPJ is a small and tight joint, and interphalangeal arthroscopy is technically
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Table 2. Pearls and Pitfalls of Arthroscopically Assisted Modified Jones Procedure Pearls Release of the collateral ligaments improves the working space for arthroscopic interphalangeal arthrodesis. Distal extensor tendoscopy of the hallux can release the extensor hallucis longus tendon from the extensor expansion and resect the dorsal capsule of the first metatarsophalangeal joint. Transfer of the extensor hallucis longus tendon to the medial side of the first metatarsal neck can elevate the first metatarsal, correct the dorsiflexion deformity of the first metatarsophalangeal joint, and correct the first metatarsal pronation. The proximal incision close to the ankle allows rerouting of the extensor hallucis longus tendon for transfer to another part of the foot. It also allows suturing of the stay stitches to the extensor hallucis longus tendon at the proximal site. Pitfalls Clawed hallux can be part of a complex cavus foot deformity. A combination of procedures is needed to correct all aspects of the deformity.
difficult. Release of the collateral ligaments allows easier distraction of the IPJ and increases the working space. Endoscopic release of the EHL tendon from the extensor expansion is recommended before harvest of the tendon with the tendon stripper. This can reduce the risk of premature cutting of the tendon proximal to its insertion. EHL transfer to the medial side of the MT-1 neck can correct the metatarsal pronation (as a result of over-pulling of the PL). The proximal incision close to the ankle is useful if transfer of the EHL tendon to another part of the foot is indicated. It also allows tying of the stay stitches to the EHL tendon at the proximal site. This improves security of the tendon transfer construct. The advantages of this technique include small incisions and better cosmetic result, minimal soft-tissue dissection, and flexibility of transfer of the EHL tendon to another part of the foot. Potential risks of this procedure include injury to the digital cutaneous nerves, injury to the extensor hallucis brevis tendon, Table 3. Advantages and Risks of Arthroscopically Assisted Modified Jones Procedure Advantages Smaller wounds and better cosmetic result Minimal soft-tissue dissection Flexibility of transfer of extensor hallucis longus tendon to another part of foot Risks Injury to digital cutaneous nerves Injury to extensor hallucis brevis tendon Nonunion of interphalangeal arthrodesis with relapse of claw deformity First metatarsal dorsiflexion Recurrent pain under first metatarsal head
nonunion of the interphalangeal arthrodesis with relapse of claw deformity, MT-1 dorsiflexion, and recurrent pain under the MT-1 head (Table 3).4,5
References 1. Elias FN, Yuen TJ, Olson SL, Sangeorzan BJ, Ledoux WR. Correction of clawed hallux deformity: Comparison of the Jones procedure and FHL transfer in a cadaver model. Foot Ankle Int 2007;28:369-376. 2. Kadel NJ, Donaldson-Fletcher EA, Hansen ST, Sangeorzan BJ. Alternative to the modified Jones procedure: Outcomes of the flexor hallucis longus (FHL) tendon transfer procedure for correction of clawed hallux. Foot Ankle Int 2005;26:1021-1026. 3. Faraj AA. Modified Jones procedure for post-polio claw hallux deformity. J Foot Ankle Surg 1997;36:356-359. 4. de Palma L, Colonna E, Travasi M. The modified Jones procedure for pes cavovarus with claw hallux. J Foot Ankle Surg 1997;36:279-283. 5. Faldini C, Traina F, Nanni M, et al. Surgical treatment of cavus foot in Charcot-Marie-Tooth disease: A review of twenty-four cases. J Bone Joint Surg Am 2015;97:e30. 6. Sugathan HK, Sherlock DA. A modified Jones procedure for managing clawing of lesser toes in pes cavus: Long-term follow-up in 8 patients. J Foot Ankle Surg 2009;48:637-641. 7. Jones R. The soldier’s foot and the treatment of common deformities of the foot. Part II. Claw foot. Br Med J 1916;1: 749-752. 8. Steensma MR, Jabara M, Anderson JG, Bohay DR. Flexor hallucis longus tendon transfer for hallux claw toe deformity and vertical instability of the metatarsophalangeal joint. Foot Ankle Int 2006;27:689-692. 9. Lui TH. Interphalangeal arthroscopy of the toes. Foot 2014;24:42-46. 10. Lui TH. New technique of arthroscopic triple arthrodesis. Arthroscopy 2006;22:464.e1-464.e5. 11. Lui TH. Arthroscopic triple arthrodesis in patients with Müller Weiss disease. Foot Ankle Surg 2009;15: 119-122. 12. Lui TH. Percutaneous sagittal plane closing wedge osteotomy of the first metatarsal. Eur J Orthop Surg Traumatol 2014;24:243-246. 13. Lui TH. Percutaneous posterior calcaneal osteotomy. J Foot Ankle Surg 2015;54:1188-1192. 14. Lui TH. Extensor tendoscopy of the ankle. Foot Ankle Surg 2011;17:e1-e6. 15. Lui TH. Arthroscopically assisted Z-lengthening of extensor hallucis longus tendon. Arch Orthop Trauma Surg 2007;127:855-857. 16. Chang JJ, Lui TH. Endoscopic-assisted repair of extensor hallucis longus tendon rerupture. Foot Ankle Int 2013;34: 455-458. 17. Lui TH, Chang JJ, Maffulli N. Endoscopic-assisted repair of neglected rupture or rerupture after primary repair of extensor hallucis longus tendon. Sports Med Arthrosc 2016;24:34-37.
Video 1. Arthroscopically assisted modified Jones procedure in right foot. Interphalangeal arthroscopy is performed with the dorsomedial and dorsolateral portals. The collateral ligaments are released. The articular cartilage and subchondral bone are debrided with an arthroscopic shaver. The interphalangeal joint is reduced and transfixed with a cannulated screw. Distal extensor hallucis longus (EHL) tendoscopy is performed with the dorsomedial and proximal-medial portals. The EHL tendon is released from the extensor expansion. The tendon is harvested by an open-ended tendon stripper. A bone tunnel is created at the first metatarsal neck. The EHL tendon passes through the bone tunnel, along the dorsum of the first metatarsal, back to the proximal-medial portal. The tendon is sutured to itself at the proximal-medial portal.