The Modified Jones Procedure for Pes Equino-Varus with Claw Hallux 　振興醫療財團法人 振興醫院 骨科部 　　　　　　　＊ 熊永萬 　 敖曼冠　醫師

Introduction: Material & Method : A clawed hallux is a deformity of the great toe defined as the extension of the first metatarsophalangeal (MTP) joint combined with flexion of the interphalangeal (IP) joint. The aberrant mechanics of this first ray deformity can lead to increased pressure on the plantar surface of the first metatarsal and the dorsal surface of the hallux, which could potentially lead to ulceration in neuropathic patients . Jones originally described an isolated transfer of the extensor hallucis longus tendon. However, this technique does not correct and stabilize the claw hallux deformity. Therefore, this operation has been modified to include arthrodesis of the interphalangeal joint of the hallux, distal stump tenodesis of extensor hallucis longus . Material & Method : A retropective study was carried out on patients with postpoliomyelitis , arthrogryposis & sequela of neuromuscular disease etc. All the patients had symptoms related to the claw hallux deformity, foot biomechanics and gait were affected. Patients were assessed both pre- and postoperatively. . Clawing of the hallux treated by a modified Jones procedure using Kirschner wire for the interphalangeal joint fusion after tenodesis of extensor hallux longus in the first metatarsal neck Short leg cast had been applied after operation for 8 weeks. And then consulted physical therapist for ambulation training . Ankle foot orthosis was fitted for victims to maintain the corrective alignment of toe & foot.

Clawing big toe with equino-cavo-varus Case I B Clawing big toe with equino-cavo-varus Case I A Female, 42-year-old Seq.of polio. with equino-cavo-varus Case I C S/P Lengthening of Achilles tendon ( Stage I ) S/P Tenodesis of EHL in the 1st.M-T bone & fusion of the I.P. joint with pin ( Stage II )

Clawing big toe with equino-cavo-varus ( before & after operation) Case II C S/P Tenodesis of EHL in the 1st.M-T bone & fusion of the I.P. joint with pin Case II A Male, 38-year-old Seq.of menigitis Case II B Clawing big toe with equino-cavo-varus ( before & after operation) Case III B Case III A Clawing big toe with cavo-varus Male, 29-year-old Seq.of Arthrogryposis S/P Tenodesis of EHL in the 1st.M-T bone & fusion of the I.P. joint with pin

Results : Our results showed that there was a significant decrease in hallux pressure after surgery. Results were followed based on correction of deformity, absence of pain, and metatarsophalangeal joint motion. Patients were assessed both pre- and postoperatively. Mean follow-up was more than 5 years. Almost of patients had very good & fair results which was evaluated including pain free, bunion correction, interphalangeal joint angulation, improvement of foot dorsiflexion etc.. Discussion : Clinically, there is more than one etiology for clawed hallux deformity. However, we demonstrated that the modified Jones procedure and FHL transfer are equally effective at reducing the angular deformity at the MTP and IP joints. This was treated by shortening the transferred extensor hallucis longus after elongating the tight Achilles tendon. No pseudoarthrosis of the interphalangeal joint was identified. When the Jones procedure is performed, the motor power of the extensor hallucis longus should be Grade V before transfer. The Achilles tendon should be evaluated for equinus preoperative^ and lengthened when equinus deformity is present in order to avoid residual foot deformities. Pain relief with comfotable brace fitting is fundament basic requirement of the surgical treatment for these victims.