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  1. BLT]E TOES, SAI-]SAGE TOES, AND OTHER FT]NKY- LOOKING DIGITS Raymond G. Caualiere, DPM Causes of arterial insufficiency in the post- operative period include: excessive lengthening of the digit (actual or reiative); excessive surgical tralima with possible disruption of arterial supply; excessive fluid tourniquet; over-zealous use of epinephrine; excessir.e postoperative swelling; constrictive dressings; and vascular impingement due to positioning. Advanced patient age) cases of revisional surgery, prior ischemic disease, or debilitating diseases such as rheumatoid arthritis with or without associated vasculitis, are addition- al factors that can contribute to arterial insuffi- ciency. Particular situations such as syndactyly or congenital abnormalities and certain medication effects or idiosyncracies such as those seen with tricyclic anti-depressants should also be considered. Proper treatment in these specific cases begins with close, immediate observation with supportive measures for the initial postoperative course. No ice should be applied to the affected part, and the foot should be initially maintained in a horizontal position, parallel to the trunk without dependency. Reflex heat can be utilized to the popliteal fossa or the low back area. The paiient should be instructed to avoid all caffeine and nicotine. Consideration shouid be given for removal of constrictive dressings and extirpation of Kirschner wires. The physician may also con- sider using an Alpha blocker, such as Phento- lamine (Regitine to affect reversal of effects of epinephrine and norepinephrine), or an oral vasodilator such as Niacin and Cyclospasmol. In emergency situations where pallor and cyanosis continue to exist over three to six hours, one should consider Vasodilan 5 to 10mg. IM BLUE TOES Blue toes are always a cause for concern. Skin color is attributed to blood in the vessels of the dermis and subpapillary region. Therefore, blue toes represent internal changes in blood circula- tion. The amollnt of blood circulating and the color of the blood are the two factors that influ- ence the color of the skin. The color of blood sig- nifies its oxygen concentration, with poorly oxy- genated blood appearing darker than orrygenated blood. Local cyanosis always indicates decreased blood flow and is always associated with oxrygen loss. A blue toe represents stasis from poor afieri- al flow or sluggish venous return. Blue toes which occur early in the postoper- ative period represent a maior concern for the surgeon. The surgeon must recognize, diagnose and treat the blue-toe condition in a timely and appropriate manner in order to avoid complica- tions such as excessive sweiling, hematoma, infection, fibrosis, gangrene, atrophy or total loss of the toe. Three post surgical possibilities exist: arterial insufficiency, venous insufficiency, and dissecting hematoma. Arterial Insufficiency The toe may be pale or even blue. The key clini- cal finding is that the toe is cold and it does not blanch after pressure. In the early stages the digit has good turgor and no signs of cellular death. As time goes on, the toe will either improve or become gangrenous, depending upon the treat- ment rendered and the initial reversibility of the pfocess. 408

  2. (Isoxsuprine ) or 10mg. of Nifedipine (Procardia) oral1y or sr-rblingually. These medications mey provide the necessary vasodilation. Primarily, one should consider the cause of the vascular insuffi- ciency and attempt to reverse it. majority of the toe. There is no blanching and the clinical picture worsens until the superficial layers of the toe harden and atrophy. The initial extent of damage or tissue loss is variable and at times unpredictable. The toe is warm to the touch unless enough eschar is present over the toe to prevent accurate assessment of its temperature. The initial diagnostic impression is impor- tant, as treatment for arterial insufficiency may make this condition worse. Transillumination of the toe may be helpfr-rl in its initial assessment. If fluctuance is noted initially, then a dissecting hematoma should be considered in the diagnostic impression and perhaps needle aspiration may be appropriate. Yenous Insufficiency Postoperative blue toes can also be of venous eti- ology and represent the slowing of blood and its subsequent deoxygenation. The ciassic appear ance is that of a warm, blue toe following digital or neuroma surgery. Etiology of venous insuffi- ciency causing blue-toe syndrome, includes local trauma, with or without surgery and sympathec- tomy effects and perhaps, local edema and con- strictive dressings. The toe is usually blue immediately follow- ing the surgery and may even blanch on pressure with immediate capillary refill. More severe types do occur which do not blanch on pressure and may progress to patchy gangrene or even total circulatory shut-down over the next 24 to 72 hours. Initial therapy after recognition of the cause of the blue toe, inclr"ides inspection the dressing for tightness, placing the foot parallel to the trunk, and perhaps the later use of bed elevation. Under no circumstances should one attempt to increase the vascular perfusion of the toe, as this may lead to potentially irreversible changes in the digit due to increased venous insufficiency. Blue Toes Of Uncertain Etiology Blue toes that occur without any prior trauma must be studied carefully, as they represent micro-emb o lization from atheromatous plaques of the major arteries of the affected foot. In 700/o of these instances, they arise from the superficial femoral artery or the popliteal artery, however, they may arise from the iliac vessels or unsus- pected abdominal aortic aneurysm. The emboli are of fibrino platelet nature and the embolus most commonly enlarges in a digital arterial bifur- cation, causing circulatory embarrassment to one or tlvo digits. The toes are cyanotic and painful. This condition is known as blue toe syndrome and must be recognized and treated to avoid irreparable harm or loss of the foot. Dissecting Hematoma A dissecting hematoma describes excessive bleeding between layers of the subdermal skin. Bleeding begins at the time of surgery and dis- sects along the fascial planes of least resistance. Usually this occurs along the incision line and may clissect further proximaliy and distally. It is also seen typically at the pulp of the toe where a K-wire may exit. The stiperficial tissues are there- fore removed or suspended from their underlying blood supply and subseqllently undergo necrosis with eventual sloughing. The underlying tissues remain viable, however, the visual appearance is that of gangrene and tissue loss. Initially, the toe may appear cyanotic, however, this cycle contin- ues until a blue-black toe develops. The condi- tion may be local or may continue to involve the SAUSAGE TOES Sausage toes present with excessive edema of a digit, greater than that usually encountered fol- lowing a surgical procedure. The condition is usually uncomfortable or painful and the contin- ued swelling and pain can result in excessive fibrosis of the toe. The condition is not typically seen immedi- ately following surgery during the time of initial bandaging (week 1 through 3). After removal of the surgical dressings, the toe s1owly enlarges so that it is noticeably edematous and painful. Theo- retical causes include loss of venous channels and lymphatics which are important in drainage. However, excessive surgical tfauma is also an important and implicated etiologic component. 409

  3. risks, especially neurovascular compromise. Frontal plane deformities are less common and are normally seen secondary to poorly-fused or arthrodesed digits. Each deformity must be addressed separate- ly to include other associated deformities or con- clitions. Muscle tenclon function must be assessed with utmost care and the decision made to recon- struct or salvage the deformity. Direct digital reconstrllction usually consists of revisional arthrodesis as deforming influences can not always be totally eliminated and the total return of normal intrinsic and extrinsic muscle function often not accomplished. Furthel surgical recon- strlrction ancl/or stabilization may take the form of syndactyly and is usually performed as a sec- ondary procedure so that vascuiar compromise cloes not ensue. The result of surgicai reconstrlrc- tion should be the creation of a plantarp4rade and stable weightbearing foot. Direct ancl total active function is always sought, however, in many cases, this is never regained. After surgical reconstruction or salvage has been accomplished, appropriate layered wound closure is performed to decrease the possibility of further scarring ancl contracture. Dressings are carefi-rlly placed to control postoperative inflam- mation and edema which again are precursors of soft-tisstie fibrosis ancl subsequent contracture. Edema is carefully controlled throughout lhe entire postoperative period and fixation devices, whether external or internal, should be stable and left in place for an appropriate periocl of time until stability of the part is maintained inde- pendently. Aftercare is closely monitored through physical therapy and attempts to control swelling. The patient should be then followed with biome- chanical suppofi where appropriate as well as the use of digital retainers and prescription shoes. Further surgery may also be expected ancl sched- uled as neecled. Reconstruction of deformities of the forefoot following previous poorly-executed or poorly- thought-out sllrgery, is a challenging, but reward- ing area. Treatment includes cligital compression with self-adherent wraps and local physical therapy. The conclition is normally reversible, however, should be treated aggressively in the early post- operative period. Most sausage toes return to nor- mal aftel approximately 10 to 12 weeks, however, one may persist for an uncertain period of time. FI.INT(Y LOOKING DIGITS Common digitai deformities include mallet toe, cudy adducto varus toes, claw toes, shortened and contracted toes associated with brachymetalarsia, hammer toes associated with posterior equinus or neurologic disease, flexor plate dislocation associated with ha11ux valgus and toe deformities associated with primary metatarsal phalangeal joint disorders. These are not funky toes, but toe deformities that we expect to see ancl treat in our daily practice. Funky toes are usually traumatic in nature and frequently are iatrogenic. The nature ancl extent of these deformities is dependent on a variety of factors. The specific surgical procedure performed, the amount and location of bone removecl, the extent of soft tissue, tendon, and capsular disruption, the amount of scarring and fibrosis and contracture, the extent of proximal metatarsal damage or displacement as well as other associated conditions or deformities of the proximal foot segment all have a bearing on the deforrnity. Many of these digital cleformities are sagittal and transverse in nature. Sagittal plane digital deformities can fo11ow multiple arthroplasties, especiaily when they are performed in an uncon- trolled foot, or withor-rt stabilization. Sagittal plane digital deformities also follon excessive bone resection of the toes, base resections, thoughtless tenotomies and irreparable soft tissue trauma with loss of function subsequent filrrosis, contrac- tion and scarring. Other causes include metatarsal osteotomies with dorsiflexion or shortening, metatarsal head resections and condylectomies. Transverse digital deformities are more rare, however, these represent severe deformities which are due to similar factors, coupled with excessive instability of the toe itself or neighbor- ing part in a meclial or lateral direction. Recon- struction of these deformities carries significant BIBLIOGRAPTfY Mahan K: Postoperative l)ysvascular Episodes: Blrte Toes. in NlcGlamry ED (cd) 12th Armttal Surgical Seminar, Reconstnrc- tiue SutEery) of tbt: Fctot and leg Pocliatry Institute Publishing, Tucker. Georgia, 1983. 410