Metatarsophalangeal Fusion for Hallux Valgus: Indications and Effect on the First Metatarsal Ray

Metatarsophalangeal fusion for hallux valgus: indications and effect on the first metatarsal ray

J.L. HUMBERT,* MD; C. BOURBONNI.RE;t C.A. LAURIN4 MD, FACS, FRC5[C] Arthrodesis of the metatarsophalangeal plasty because it increases weight- the toe may be completely nonfunc- joint was performed in 31 cases of bearing on the first metatarsal ray tional. Other disadvantages are that severe hallux valgus. With the surgical technique used, which is described and, as Kelikian1' noted, relieves the metatarsus varus remains un- in detail, internal fixation and plaster metatarsalgia. In a study of 50 men altered and that the hallux valgus cast immobilization were not necessary. with metatarsophalangeal fusion of may persist if the metatarsus varus is Analysis of the results suggested that the big toe Joseph9 showed that loss severe. Indeed, severe metatarsus the operation is indicated for severe of metatarsophalangeal dorsiflexion varus and metatarsalgia are relative deformities in elderly patients, preferably contraindications to the Keller oper- women. The basic metatarsal deformity did not impair the "take-off" position was corrected by the procedure. of the foot as long as motion at the ation. interphalangeal joint was sufficient. In the Mayo intervention, removal L'arthrodese de l'articulation metatarso- phalangienne a Ste pratiquee dans 31 Moynihan,1' reviewing arthrodeses of the metatarsal head seriously alters cas d'hallux valgus severe. Avec Ia followed up for 10 years, found a the foot's weight-bearing pattern.6 technique chirurgicale utilisee, laquelle greater success rate and more per- Arthrodesis is free of most of these est decrite en detail, Ia fixation interne manent results than have been re- drawbacks. The main objection to et l'immobilisation a l'aide d'un plitre ported for the Keller operation. anthrodesis is the loss of motion: n'ont pas et6 necessaires. L'analyse however, while other procedures pre- des resultats indique que l'operation Arthrodesis v. arthroplasty est indiqu6e pour les difformites serve mobility, the joint motion is not importantes chez les patients &ges, Anthrodesis of the first metatarso- necessarily normal or painless. Since les femmes de pref6rence. La difformite phalangeal joint is satisfying mainly the principal function of the foot is m6tatarsienne essentielle a ete corrigee because it avoids many of the pitfalls painless weight-bearing and walking,10 par cette intervention. and complications sometimes noted joint stability may occasionally take There is understandable controversy following arthroplasty for hallux precedence over abnormal or painful concerning the indications for artliro- valgus. joint mobility.11 None the less, patient desis of the first metatarsophalangeal With the McBride arthroplasty selection is all important. joint in the treatment of hallux val- there is a distinct possibility of re- gus.1 In a review of several operations aligning the proximal phalanx onto Review of a series of arthrodeses for this condition Maschas2 claimed a portion of the metatarsal head that We undertook the following review that there is no place for fusion as a is devoid of normal articular carti- in an attempt to answer four basic primary intervention and that it is lage. Campbell1 has attributed the questions about fusion for hallux val- rarely indicated as a salvage proce- not uncommon recurrence of hallux gus. First, does the operation per- dure. Tupman3 advocated fusion for valgus following the McBride opera- manently correct the deformity and hallux valgus if there is a splay foot tion to a disruption between the bur- provide normal function? Second, is or a short first metatarsus, or follow- sal flap and the abductor hallucis a special, more demanding, postoper- ing unsuccessful Keller arthroplasty. tendon. He has also stressed that dis- ative regimen necessary? Third, is Others have been more enthusiastic.4 figuring iatrogenic hallux varus may the metatarsus primus varus cor- Mann' proposed fusion as a first occur as a result of the unopposed rected? This is the critical question operation in all middle-aged and eld- action of the abductor hallucis in view of the etiologic importance erly persons with moderate to severe muscle; clawing of the great toe and of metatarsus varus in the disability deformities. Henry and Waugh6 and a dorsal intraphalangeal bunion may and deformity of hallux valgus, as others"'.14 claimed that anthrodesis is also occur following unintentional Nicod stressed.13 Fourth, when there more effective than Keller arthro- section of the flexor hallucis brevis is severe metatarsus varus will anthro- muscle. desis of the metatarsophalangeal joint From the department of orthopedics, The Mitchell arthroplasty corrects lead to hallux varus? This serious University of Montreal, H6tel-Dieu de Montrdal the metatarsus primus varus only in iatrogenic complication could theo- *Resident in orthopedic surgery, Edouard the distal part of the first ray, as retically occur since the fusion is per- Samson program Carr and Boyd15 noted. Campbell1 formed with no attempt to compen- tMedical student, McGill University referred to delayed healing at the sate at the site of fusion for the varus IProfessor of surgery and director, osteotomy Edouard Samson program in orthopedic site with this procedure. deformity of the first metatarsus. surgery, University of Montreal The deservedly popular Keller Reprint requests to: Dr. C.A. Laurin, operation shortens the big toe and Patients D6partement d'orthopedie, H6tel-Dieu de Montreal, 3840, rue St-Urbain, permanently impairs its control; if Of 31 persons who underwent me- Montrdal, PQ H2W 1T8 too much of the phalanx is resected tatarsophalangeal fusion for excessive

CMA JOURNAL/APRIL 21, 1979/VOL. 120 937 hallux valgus without modification of cortex at the point of attachment of with such depth and width as to the operative technique 8 are not the extensor hallucis brevis muscle, provide a snug fit within the phalan- considered in this review because of a very useful landmark. Since the geal trough. The axis of the tongue a follow-up period of less than 2 angle of the trough and the plantar corresponds to the long axis of the years, and 5 were lost to follow-up or surface of the foot must be precisely first metacarpus. Care is taken to had inadequate preoperative roent- 900 to avoid fusion in any degree of protect the relatively fragile base of genograms. Of the others, 16 were rotation, a pituitary rongeur is used the tongue. It is preferable to prepare interviewed and reassessed clinically to complete the trough. The plantar the phalangeal trough first since the and radiologically, and 2 were re- phalangeal attachment of the meta- metatarsal tongue could be accident- assessed from the answers to an elab- tarsophalangeal capsule is incised to ally fractured at its base during crea- orate questionnaire mailed to them. facilitate the introduction of the tip tion of the phalangeal trough. The The 5 men and 13 women had a of the pituitary rongeur under the remaining articular cartilage on the mean age of 54.8 years (range 38 proximal phalanx. The phalangeal tip of the metatarsal tongue is then to 77 years), and the average follow- trough is then deepened to 1 cm in excised. up period was 42 months (range 24 line with the axis of the phalanx. The metatarsal tongue is then in- to 74 months). Since 16 underwent When the articular cartilage is excised serted in the phalangeal trough, with bilateral arthrodesis the total number from the proximal phalanx on either complete correction of the angular of procedures was 34. side of the trough the medial and deformity between the metatarsus and lateral capsules must remain attached the proximal phalanx. Because the Surgical technique to the phalanx to permit eventual bony shortening is fully compensated Litigation is not uncommon fol- stable closure. by the correction of the angular de- lowing operations on the foot, prob- The head of the first metatarsus is formity at the metatarsophalangeal ably because the surgical challenge then shaped like a tongue, or lug, joint, the soft tissues on the lateral is often underestimated. Careful dis- section and attention to detail are as vital for the foot as they are for the hand. It is obviously wrong to dissect a hand but to attack a foot. Although the "tongue-and-trough" method of fusion (Fig. 1) is not original, certain technical details war- rant special attention. The metatarsophalangeal joint is exposed through a single dorsal midline incision medial to the bowstringing long extensor tendon. It is important to leave the lax lateral capsule and conjoint tendon intact. The medial capsule is II incised vertically 0.5 cm from its phalangeal attachment; the capsule and periosteum are reflected proximally in continuity with the abductor hallucis muscle; this muscle is inevi- tably noted to have migrated laterally and under the metatarsophalangeal joint and has long lost its ability to abduct the joint. The bursal and capsular flap is dissected in continuity with the abductor hallucis muscle, which must be freed from the medial A sesamoid bone to facilitate medial and dorsal mobilization of the flap and prevent medial and dorsal dis- placement of the bone at the time of capsular closure. Iv A trough is then prepared precisely III in the middle of the proximal end of the proximal phalanx; an ordinary rongeur is used to excise the dorsal side of the joint are under immediate Results no deformity (Fig. 2). A good result tension; the intact lateral metatar- Postoperative results were grouped met all of the following criteria: the sophalangeal capsule and conjoint as excellent, good or poor. For an patient was partially satisfied with tendon thus provide immediate sta- excellent result all of the following the operation and would unequivocal- bility. Similar soft tissue tension must criteria were met: the patient was ly accept it again; the pain was less- then be achieved on the medial side completely satisfied and would accept ened, but local discomfort or mild of the arthrodesis. Since the angular the operation again; the fusion was metatarsalgia persisted; and the fu- deformity has been completely cor- clinically solid and painless, and no sion was clinically sound and in good rected, the medial bursal and capsular deformity was noted; and roentgeno- position, but roentgenograms revealed flap is too long; therefore, a sufficient grams showed sound bony union and fibrous ankylosis (Fig. 2). For the amount of the flap is excised to per- result to be considered poor, or the mit its reattachment to the distal por- operation a failure, only one of the tion of the capsule under tension. following criteria had to be met: the When the medial metatarsophalan- patient was dissatisfied or would re- geal capsule has been closed, there fuse the procedure if it were offered should be immediate stability at the again; the pain was unchanged or ag- arthrodesis site. Metallic internal fix- gravated; a varus or valgus deformity ation and plaster cast immobilization or excessive dorsiflexion was noted: are not necessary. or there was clinical motion at the Progressive weight-bearing is per- fusion site. mitted as tolerated, and the sutures The result was considered excellent are removed on the 10th postopera- in 16 of the 34 procedures and good tive day. The postoperative regimen FIG. 3-Poor results of arthrodesis: in 13, for a success rate of 85%. The dorsiflexion of both metatarsophalan- is identical to that of a Keller oper- geal joints and external rotation of right other five procedures were considered ation. big toe. Left, failure attributed to fusion to have failed, but only two of the in mairotation; mild valgus deformity three patients would not have ac- at interphalangeal jiint. Right, increased cepted the operation again: a 44- web space because of valgus deformity year-old man had a painful pseudo- at metatarsophalangeal joint of second toe. arthrosis on one side and excessive dorsiflexion of the fused joint on the other, and a 77-year-old man with sound bony fusion and good reduc- tion of the intermetacarpal angle in both feet (to 90 and 110) was dissatisfied with the dorsiflexion of both the fused joints and the external rotation of the big toe on one side (Fig. 3). The third patient, a 57-year-old woman, was satisfied with the func- tional and esthetic results in both feet but had a painless pseudoarthrosis on one side (Fig. 4); indeed, she had no pain in either foot. Her case illustrates well the occasional dis- crepancy between clinical and radiologic assessments. Frequency and position of fusion: Bony fusion (Fig. 5) was achieved in 24 instances, for a rate of 71 %. Stable fibrous ankylosis resulted in nine instances and usually progressed to bony fusion; only two patients reported discomfort. There were two E FB. aPOST.OP . K instances of pseudoarthrosis, but only one patient complained of pain. The acceptable rate of fusion was FIG. 2-Appearance before and after POST OP arthrodesis: lower left, excellent result; achieved without metallic internal lower right, good result, with stable FIG. 4-Poor result of arthrodesis on fixation or plaster cast immobiliza- fibrous ankylosis at 4 months. left: painless pseudoarthrosis. tion for two reasons: the tongue-and-

CMA JOURNAL/APRIL 21, 1979/VOL. 120 939 trough design provides maximal con- tarsalgia that was well controlled with range 10 to 110. Indeed, the correc- tact between spongy bone interfaces the use of a metatarsal pad. tion was frequently noted on roent- and a certain degree of immediate Radiologic evidence of correction genograms taken in the recovery stability; and once the angular de- of angular deformity: One of the room (Fig. 7), when such were avail- formity has been corrected, dynamic main objects of the radiologic evalua- able. No loss of correction was noted compression is achieved by muscles tion was to determine the orientation in 10 patients in whom postoperative on all four sides of the fusion site - of the first metatarsal ray before and roentgenograms were taken on more medially by the relocated abductor after the operation, since fusion could than one occasion. hallucis muscle, laterally by the con- conceivably produce hallux varus. joint tendon, and above and below The intermetatarsal angle was there- Discussion by the long flexor and extensor fore measured at both times with the The main object of the review was muscles (Fig. 6). aid of lines drawn parallel to the long to answer four questions: Although the valgus deformity was axis of the shaft of the first and sec- always corrected, 85% of the joints ond metatarsal bones. The angle be- 1. Does metatarsophalangeal fusion were dorsiflexed, the angle varying tween the two lines was decreased permanently correct hallux valgus from 50 to 300. postoperatively in every foot; the and provide normal function? Function and comfort: Two of the average correction was 5*70 and the An 85% success rate suggests that five men complained about the dorsi- it does, although the selection of flexed position of fusion, and their patients is important. Sound bony operations were considered to have fusion is not synonymous with suc- failed. Women willingly adjusted cess. The operation is best reserved their heel height postoperatively and for elderly patients with severe meta- reported no dissatisfaction with the tarsus varus; a Keller operation for dorsiflexion. All but the two men such patients is not uncommonly as- with poor operative results reported sociated with recurrence of symptoms an improved gait, and all the patients and metatarsalgia. with bony or fibrous ankylosis re- 2. Is a special, more demanding post- sumed their former activities. Plantar operative regimen necessary? callosities persisted in 8 of the 18 The described technique requires patients, and 3 reported mild meta- no plaster cast immobilization, and FIG. 6-Mechanical forces at metatar- progressive weight-bearing is per- sophalangeal joint: before arthrodesis mitted as tolerated. Possibly for this (left), mechanical vicious cfrcle (A = reason the degree. of dorsiflexion at medially displaced [under metatarsal headi abductor hallucis muscle; B = the fusion site is not accurately pre- conjoint tendon; C = bowslringing long dictable. Dorsiflexion was not a seri- flexor and extensor tendons); after- ous concern of the women in this wards (right), dynamic compression at series, and there were no instances fusion site and dynamic correction of of a significant difference in the de- metatarsus yams (A = relocated ab- gree of dorsiflexion between the two ductor hallucis muscle; B1 and B = adductor hallucis muscle and conjoint feet of any of them. Men were more tendon; C = relocated long flexor and frequently dissatisfied with the dorsi- extensor tendons). flexion. This problem can be con-

POST OP FIG. 5-Excellent result of arthrodesis, with bilateral bony fusion and diminu- tion of intermetatarsal angle.

940 CMA JOURNAL/APRIL 21, 1979/VOL. 120 trolled by the placement of an intra- toe. This was always attributable to been abolished by metatarsophalan- medullary Kirschner wire if the in- persistent valgus deformity at the geal fusion the metatarsus varus is dividual is not willing to modify his metatarsophalangeal joint of the sec- immediately corrected, as can be or her heel height postoperatively. ond toe and not to varus deformity noted on roentgenograms taken in of the big toe (Fig. 3). 3. Is the metatarsus primus varus the recovery room. With fusion the Severe hallux corrected? valgus associated adductor force of the conjoint tendon The intermetatarsal angle was de- with severe metatarsus varus is pro- acts on the first metatarsus to correct creased in all patients, by an average gressive and irreversible for two rea- its varus malposition.7 Hence, dimi- sons8 (Fig. 6). Because of the nution of the intermetatarsal angle is of 5*70* excessive metatarsus primus varus the not only permanent, but also may 4. When there is severe metatarsus abductor hallucis muscle, which is in decrease further with time, as we varus will fusion performed for hal- continuity with the plantar metatar- frequently noted. lux valgus ever produce iatrogenic sophalangeal capsule, eventually mi- hallux varus (Fig. 8)? grates plantar-grade and laterally to Conclusions No such complication was en- become functionless as an abductor Metatarsophalangeal arthrodesis is countered, although there were oc- of the metatarsophalangeal joint. The a reasonable and successful operation casional instances of a widened web adductors of the metatarsophalangeal for correcting serious hallux valgus space between the first and second joint are then unopposed and mild in elderly patients. It is best reserved hallux valgus is inevitable. The con- for women since the site of fusion joint tendon and the bowstringing is usually dorsiflexed. It corrects the long flexor and extensor tendons then metatarsus primus varus and is never reinforce the action of the adductor complicated by hallux varus. Gait is hallucis muscle and push the first consistently improved and metatar- metatarsal head proximally and salgia is rare. A special postoperative medially to further increase the meta- regimen and plaster cast immobiliza- tarsus primus varus - the beginning tion are not necessary. and the end of a vicious circle. The mobility of the first metatarsus References at the cuneometatarsal joint can be 1. CRENSHAW AH (ed): Campbell's Oper- easily noted preoperatively by simply ative Orthopaedics, 5th rev ed, Mosby, squeezing the foot (Fig. 9) or com- St Louis, 1971 paring roentgenograms taken 2. MASCHAS A: Conclusions sur le traite- FIG. 8-Postoperative results: left, with ment de l'hallux valgus. Rev Chir intermetatarsal angle preoperatively; the patient weight-bearing and not Orthop 60 (suppi 2): 171, 1974 middle, possible hallux varus due to weight-bearing. The mobility is sur- 3. TUPMAN 5: Arthrodesis of the first fusion of metatarsophalangeal joint; prising, metatarso-phalangeal joint. J Bone right, correction of haliux valgus and even in adults with long- standing severe hallux Joint Surg [Br] 40: 826, 1958 metatarsus varus by metatarsophalan- valgus. 4. WILSON JN: Cone arthrodesis of the geal fusion. Once the deforming forces have first metatarso-phalangeal joint. J Bone Joint Surg [Br] 49: 98, 1967 5. MARIN GA: Arthrodesis of the metatarsophalangeal joint of the big toe for hallux valgus and hallux rigidus. A new method. mt Surg 50: 175, 1968 6. HENRY APJ, WAUGH W: The use of footprints in assessing the results of operations for hallux valgus. J Bone Joint Surg [Br] 57: 478, 1975 7. FITZGERALD JA: A review of long- term results of arthrodesis of the first metatarso-phalangeal joint. J Bone Joint Surg [Br] 51: 488, 1969 8. HAINES RW, MCDOUGALL A: Ana- tomy of hallux valgus. J Bone Joint Surg [Br] 36: 272, 1954 20 9. JOSEPH J: Range of movement of great toe in men. Ibid, p 450 10. KELIKIAN H: Hallux Valgus, Allied Deformities of the Forefoot & Meta- tarsalgia, Saunders, Philadelphia, 1965 w 11. MCKEEvER DC: Arthrodesis of first metatarso-phalangeal joint for hallux valgus, hallux rigidus and metatarsus primus varus. J Bone Joint Surg [Am] FIG 9 Preoperative mobility of cuneometatarsal joint and passive correction 34: 129, 1952 of metatarsus varus with (right) and without (left) squeezing of foot by circular bandage. continued on page 956

CMA JOURNAL/APRIL 21, 1979/VOL. 120 941 action of imipramine. J Neuropsychia- M: Management of massive imipra- 0.05% emollient crea try 4: 224, 1963 mine overdosage with mannitol and 13. RAISFELD TH: Cardiovascular com- artificial dialysis. N Engi J Med 268: plications of antidepressant therapy. 33, 1963 Interactions at the adrenergic neuron. 31. BIGOs JT, SPIKER DG, PETIT JM, et Lidemol® Am Heart J 83: 129, 1972 al: Tricyclic antidepressant overdose: 14. HANSTEN PD: Tricyclic antidepressant incidence of symptoms. JAMA 238: interactions, dans Drug Interactions, 135, 1977 (fluocinonide) 3i&me 6d, Lea & Febiger, Philadelphie, 32. ASBACH HW, HOLZ F, Mc.HRING K, 1975, p 190 et al: Lipid hemodialysis versus char- 15. FREJAVILLE JP, EFTHYMIOU ML, coal hemoperfusion in imipramine MELLERIO F, et al: One hundred poisoning. Clin Toxicol 11: 211, 1977 cases of acute intoxication with imino- 33. KOELLE GB: Anticholinesterase agents, dibenzyl derivatives (imipramine, ami- dans The Pharmacological Basis of triptyline, trimeprymine). Bull Soc Therapeutics, op cit, p 445 Med Hop Paris 116: 927, 1965 34. BuRics JS, WALKER JE, RUMACK BH, 16. FREJAVILLE JP, NICAISE AM, Cmus- et al: Tricyclic antidepressant poison- T0FOROV B, et al: Statistical study ing: reversal of coma, choreoathetosis, of a second group of one hundred and myoclonus by physostigmine. cases of acute poisoning from imino- JAMA 230: 1405, 1974 dibenzyl derivatives (Tofranil, Perto- 35. MUNOZ RA, KUPLIC JB: Large over- frane, G34, Surmontil) and from di- dose of tricyclic antidepressants treated hydrobenzocycloheptadiene derivatives with physostigmine salicylate. Psycho- (Laroxyl, Elavil). Bull Soc Med Hop somatics 16: 77, 1975 Prescribing information Paris 117: 1151, 1966 36. HOLINGER PC, KLAWANS HL: Reversal Description: Lidemol (fluocinonide 0.05%) is an anti- 17. HALL R: Tricyclic antidepressant inflammatory, antipruritic and vasoconstrictor agent for tran- of tricyclic-overdosage-induced central topical use in the management of corticosteroid re- quilizers. Natl Cigh Poison Control anticholinergic syndrome by physo- sponsive dermatoses. Lidemol contains fluocinonide in a specially formulated emollient cream base. The formu- Cent Bull: May-June 1970 stigmine. Am J Psychiat,y 133: 1018. lation does not contain lanolin, parabens or phenolic 18. SPIKER DG, WEISS AN, CHANG SS, compounds 1976 Indications: Lidemo/ (fluocinonide 0.05%) is intended et al: Tricyclic antidepressant over- 37. WANG SF, MARLOWE CL: Treatment for topical use in the management of acute or chronic dose - clinical presentation and plas- corticosteriod responsive dermatoses such as of phenothiazine overdosage with phy- psoriasis, atopic dermatitis, seborrheic dermatitis, con- ma levels. Clin Pharmacol Ther 18: sostigmine. Pediatrics 59: 301, 1977 tact dermatitis, eczematous dermatitis, lichen planus, neurodermatitis, intertriginous psoriasis, nummular 539, 1975 38. RUMACK BH: Anticholinergic poison- eczema, exfoliative dermatitis, pruritus ani et vulvae, 19. SUNSHINE P, YAFFE SJ: Amitriptyline lichen simplex chronicus, intertrigo, postanal surgery, ing: treatment with physostigmine. otitis externa and stasis dermatitis. Lidemol is suitable poisoning: clinical and pathological Pediatrics 52: 449, 1973 when an emollient effect is desired. findings in a fatal case. Am J Dis Contralndlcatlons: Topical corticosteroids are con- 39. LAPAN D, SMITH JW: Atropine coma: traindicated in tubercutous, fungal and most viral le- Child 106: 501, 1963 physostigmine reversal. Ariz Med 34: sions of the skin (including herpes simplex, vaccinia 20. PETIT JM, RIGGS JT: Tricyclic anti- and varicella), untreated purulent bacterial infections, 159, 1977 and also in individuals with a history of hypersensitivity depressant overdoses in adolescent pa- 40. HEISER JF, GILLIN JC: The to its components. This preparation is not for ophthal- reversal mic use. tients. Pediatrics 59: 283, 1977 of anticholinergic drug-induced deliri- Warnings: The safety of topical corticosteroids during 21. PENNY R: Imipramine hydrochloride pregnancy or lactation has not been established. The um and coma with physostigmine. Am potential benefit, if used during pregnancy or lactation, poisoning in childhood. Am J Dis J Psychiatry 127: 1050, 1971 should be weighed against possible hazards to the Child 116: 181, 1968 fetus or the nursing infant. It is recommended that 41. GRANACHER RP, BALDESSARINI RJ, Lidemol not be used under occlusive dressings 22. DuvoISIN RC, KATZ R: Reversal of MESSNER E: Physostigmine treatment Precautions: Although side effects are not ordinarily central anticholinergic syndrome encountered with topically applied corticosteroids, as in of delirium induced by anticholiner- with all drugs, a few patients may react unfavorably man by physostigmine. JAMA 206: under certain conditions. Should sensitivity or idiosyn- gics. Am Fain Physician 13: 99, 1976 cratic reactions occur, the agent should be discon- 1963, 1968 42. BROWN TCK: Tricyclic antidepressant tinued and appropriate steps taken. In the presence of 23. HRDINA PD, LING GM, MANECKJEE an infection, the use of an appropriate anti-fungal or an- overdosage: experimental studies on tibacterial agent should be instituted, If a favorable re- A: Desipramine (DM1): effect on the the management of circulatory com- sponse does not occur promptly, the corticosteroid levels of acetylcholine (ACh) in whole cream should be discontinued until the infection has plications. Clin Toxicol 9: 255, 1976 been adequately controlled. If extensive areas are brain and in stratum of rats. Eur J treated, the possibility exists of increased systemic ab- 43. Idem: Sodium bicarbonate treatment sorption and suitable precautions should be Clin Pharmacol 15: 141, 1971 for tricyclic antidepressant arrhythmias takenPatients should be advised to inform subsequent 24. KLAWANS HL, RunovITs R: Central physicians of the prior use of corticosteroids. Causal in children. Med J Aust 2: 380, 1976 factors should be eliminated whenever possible. It is cholinergic-anticholinergic antagonism 44. SUEBLINvONG V, WILSON JF: Myo- recommended that rotation of sites of application and in Huntington's chorea. Neurology intermittent therapy be considered. 22: cardial damage due to imipramine in- Adverse reactions: Side effects have been extremely 107, 1972 toxication. J Pediatr 74: 475, rare and consist mainly of local burning, irritation and 1969 itching. When this occurs, the possibility of sensitization 25. SIGO ER, OSBORNE M, KOROL B: Car- must be kept in mind. Skin atrophy, striae, hyper- diovascular effects of imipramine. J trichosis and adrenal suppression have been shown to occur with prolonged and indiscriminate use of topical Pharmacol Exp Ther 141: 237, 1963 META TARSOPHALANGEAL corticosteroids, particularly under occlusion. Due to 26. FREEMAN JW, MUNDY GR, BEATrIE percutaneous absorption, similar phenomena could continued from page 941 conceivably occur with prolonged and excessive use of RR, et al: Cardiac abnormalities in Lidemol. Posterior subcapsular cataracts have been poisoning reported following the systemic use of corticosteroids. with tricyclic antidepres- 12. MOYNIHAN FJ: Arthrodesis of the Dosage: Lidemol (fluocinonide 0.05%) - is suitable sants. Br Med J 2: 610, 1969 when an emollient effect is desired, in dry, scaly condi- metatarso-phalangeal joint of the great tions, and on less severely inflamed surfaces, or where 27. FOURON J-C, CHICOINE R: EGG toe. J Bone Joint Surg [Br] 49: 544, there is a tendency to fissuring and cracking, as in changes hand dermatoses. A small amount should be applied in fatal imipramine (Tofranil) 1967 lightly to the affected skin area two to four times daily intoxication. Pediatrics 48: 777, 1971 13. NIcoD L: Etiologie du hallux with gentle but thorough massage. valgus. Availability: Lidemol (fluocinonide 0.05%) - 15 g and 28. VOHRA JK: Cardiovascular abnormal- Rev Chir Orthop 62: 161, 1976 45 g tubes. ities following tricyclic antidepressant 14. SMITh NR: Hallux valgus and rigidus Product monograph available on request. drug overdosage. Drugs 7: 323, 1974 treated by arthrodesis of the metatar. 29. WRIGHT SP: Usefulness of physostig- so-.pba1angeal joint. Br Med J 2:1385, mine in imipramine poisoning. A dra- 1952 matic response in a child resistant to 15. CARR CR, BoYD BM: Correctional os- S.NTEX other therapy. Cliii Pediatr 15: 1123, teotomy for metatarsus primus varus Syntex Ltd. .i1 1976 and hallux valgus. J Bone Joint Surg Montr.aI, Quebec [.] 30. HARTHORNE JW, MARcus AM, KAYE [Am] 50: 1353, 1968

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