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Modified Hoffman Procedure

- Discussion:
    - forefoot is most commonly affected portion of rheumatoid foot;
    - forefoot deformities include:
          - claw toe or hammer toe of lateral four toes;
          - severe hallux valgus
          - plantar keratosis beneath subluxed or dislocated MTP joints;
          - distal migration of the fat pad (which follows the toes);

- Dorsal Approach:
    - modified technique involves metatarsal head trimming or resection thru a dorsal incision w/ or w/o excision of all or part of the 
            proximal phalanx may resolve the symptoms;
    - two longitudinal incisions are made in the 2nd and 4th interspaces;
    - collateral ligaments, the dorsal aspect of the capsule, the plantar plate, and the interossei are released in a circumferential fashion around
             the base of the proximal phalanx and the head and metaphysis of the metatarsal;
            - long extensor tendon is left intact;
    - metatarsal head resection:
            - improve exposure of metatarsal head by clearing the base of the proximal phalanx and by distracting on the phalanx;
            - bone cutter is used to transect the second metatarsal in the region of the distal metaphysis;
            - it is essential that the metatarsal heads be transected in a distal-dorsal to plantar proximal direction;
            - larger amount of bone needs to be resected w/ more severe overlap of proximal phalanx on the metatarsal head;
            - goal is to create about 1 cm of space between the metatarsal neck and base of proximal phalanx;
            - after resection of the second metatarsal, remaining metatarsals should be progressively shorter by several mm (from 2nd to the 5th);
                   - failure to achieve a nice cascading of the metatarsal, may result in metatarsalgia;
            - attempt to preserve the base of the proximal phalanx at the MP joint (preserves the alignment and relocation of the lesser MP joints);
            - subsequent in the operative procedure the hammertoe deformities are fixed with a K wire that is also driven across the relocated MTP joint which provides stability;
    - another technique involves longitudinal "Y" incisions between the 2nd and 3rd and between the 4th and 5th metatarsal heads, so that a
             Webbing procedure can be performed on the lesser toes;
            - w/ more severe deformity, (w/ dislocation of the metatarsal heads) it may be necessary to resect the proximal bases of the lesser toes;
            - w/ more severe deformity, a more extensive Webbing procedure may have to be performed, usually past the region of phalangeal 
                     resection, to prevent drifting of the digits;
    - hammertoe deformities:
            - typically there will be a moderate or severe deformity which will require resection of the distal condyles of the proximal phalanx, and
                     subsequently the proximal articular surface of the middle phalanx is excised;
            - if there is any question of soft tissue viability, then closed osteoclasis of the fixed PIP joints of the lesser toes is performed,
                     followed by temporary pin fixation;
            - K wire is driven across the joint (retrograde technique) w/ the joint in a slightly flexed position and is subsequently driven on across 
                     the MTP joint;
    - 1st MTP Fusion:
            - great toe should be no more than 2 mm longer than the second toe;

- Plantar Approach:
    - alternatively metatarsal heads can be resected thru a plantar incision, but this approach does not allow a clean dissection and may be 
           associated w/ distasteful bleeding once the tourniquet is released

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