BACKGROUND

 

 

Varus or valgus angulation of the lesser toes can result in significant pain and disability and can be grouped broadly into the following subcategories:

 

 

 

Crossover or crossunder second toe Congenital crossover fifth toe

 

Curly toe deformity

 

 

Isolated metatarsophalangeal (MTP) joint angular deformity Clinodactyly

 

Understanding the etiology behind each type of angular toe deformity is crucial for determining whether surgical or nonsurgical management is appropriate.

 

Angular toe deformities can occur as the result of a variety of intrinsic or extrinsic factors, including inflammatory arthritis, trauma, congenital abnormalities, neuromuscular disorders, and poorly fitting shoe wear.

 

Surgical management options are based on the severity of the deformity, degree of response to nonsurgical management, and underlying cause of the deformity. A variety of surgical procedures have been proposed to address angular deformity of the lesser toes:

 

 

 

FIG 1 • A. Crossover second toe deformity. B. Congenital crossover of the fifth toe. C. Curly toe deformity. D.

Isolated MTP angular deformity. E. Clinodactyly.

 

 

 

 

Tenodesis Tenotomy Tendon transfer

 

 

Soft tissue release Soft tissue lengthening

 

 

 

Proximal basilar osteotomy Resection arthroplasty Interphalangeal fusion

 

Outcomes are predicated on the degree of return to full activity, pain relief, and recurrence of deformity.

 

 

DEFINITIONS

Crossover second toe deformity (FIG 1A) is characterized by a second toe that lies dorsomedially relative to the hallux.

Congenital crossover fifth toe (FIG 1B) represents a variable congenital anomaly involving the fifth MTP joint in which

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the small toe deviates medially and superiorly relative to the fourth toe. Patients typically complain of discomfort and irritation over the dorsum of the fifth toe, especially when wearing constrictive footwear. Curly toe deformity (FIG 1C) is a relatively common congenital anomaly, usually found in children, that

may be related to intrinsic muscle paresis, although this relationship has not been clearly established.

The deformity usually involves the fourth or fifth toe, or both, and is characterized by a flexible flexion deformity of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints with underlapping of the fourth toe on the third and of the fifth toe on the fourth.

Isolated MTP angular deformity (FIG 1D) is varus or valgus angulation of the lesser toes occurring solely through the MTP joint. This often occurs in conjunction with great toe varus or valgus deformity.

Clinodactyly (FIG 1E) is varus or valgus deviation of a toe caused by angulation within the phalanx itself. This condition is more commonly seen in the fingers and is often associated with a syndrome (eg, symphalangism) or chromosomal disorder.

 

ANATOMY

 

The extensor digitorum longus (EDL) forms three tendinous slips on the dorsum of each toe; the first inserts into the middle phalanx and the remaining two merge and insert on the distal phalanx.

 

In concert, the EDL and extensor digitorum brevis (EDB) extend the MTP, PIP, and DIP joints through their pull on the extensor hood.

 

The flexor digitorum longus (FDL) courses deep to the flexor digitorum brevis (FDB) on the plantar surface of the toe and acts as a powerful flexor at the DIP joint.

 

The PIP and MTP joints are flexed through the combined action of the FDL and FDB tendons as well as the lumbrical and interosseous muscles.

 

The intrinsics first pass plantar to the axis of MTP joint rotation and then dorsal to the axis of motion of the PIP and DIP joints. This anatomic relationship allows the intrinsics to act as flexors at the MTP joint and extensors at the PIP and DIP joints.

 

 

Disruption of this delicate balance can lead to problematic disequilibrium between the intrinsics and extrinsics, which in turn can result in characteristic lesser toe deformities and associated pressure phenomena.

 

The medial collateral ligament (MCL) and lateral collateral ligament (LCL) play a vital role in stabilizing the MTP joint by acting as static constraints to joint subluxation or dislocation. The collaterals originate from the dorsal aspect of the metatarsal head and insert distally both at the base of the proximal phalanx and at the plantar plate.

 

In addition to providing stability in the transverse plane, the collaterals resist dorsal subluxation of the proximal phalanx on the metatarsal head. Laxity of the collaterals is commonly noted intraoperatively with angular lesser toe deformities and, in some cases, is thought to play a causative role in the development of these deformities.

 

The plantar plate originates on the metatarsal head and inserts on the proximal phalanx on the plantar surface. It is arguably the most important stabilizer, as it is centrally located and has multiple attachments. The plantar plate resists tensile loads in the sagittal plane as the joint goes into dorsiflexion.

 

CROSSOVER DEFORMITY OF THE SECOND TOE

PATHOGENESIS

 

Crossover second toe deformity most commonly occurs as the result of attritional rupture of the LCL and lateral capsule of the second toe.

 

Frequently, this specific type of lesser toe deformity occurs in association with long-standing hallux valgus.

 

Association with a long second metatarsal and attenuation of the first dorsal interosseous tendon and plantar plate are also common.

 

Destabilization of the second MTP joint can also occur as the result of trauma, synovitis related to underlying inflammatory arthritides such as rheumatoid arthritis, nonspecific or chronic synovitis, overloading of the second ray, constriction from narrow toe box shoes, or connective tissue diseases such as systemic lupus erythematosus.

 

Neuromuscular disorders such as diabetic neuropathy, Charcot-Marie-Tooth disorder, poliomyelitis, or Friedreich ataxia can also disrupt the dynamic stability of the foot and, subsequently, that of the lesser toes.

 

Often, medial soft tissue such as the MCL, medial capsule, and interosseous and lumbrical tendons are contracted at the MTP joint.

 

NATURAL HISTORY

 

Early synovitis, then subluxation, and finally dorsomedial or inferomedial dislocation are the characteristic stages in the natural progression of this coronal plane deformity.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

Crossover second toe deformity presents either as a dorsomedially subluxated second toe that crosses up

and over the hallux or as an inferomedially subluxated second toe that crosses under the great toe.

 

There is often associated hyperextension or hyperflexion at the proximal phalanx at the MTP joint and adduction of the second ray from the midline.

 

A painful intractable plantar keratotic lesion beneath the second metatarsal head or dorsal corn over any portion of the second phalanges (particularly over the PIP joint) may be due to impingement of the toe box of the shoe.

 

Instability of the plantar plate can be evaluated by the drawer test applied in the sagittal plane and a positive test is pathognomonic for an unstable MTP joint.

 

IMAGING AND DIAGNOSTIC STUDIES

 

All angular deformities involving the lesser toes can be appropriately studied by examining standard anteroposterior (AP), lateral, and oblique radiographs of the affected foot.

 

Magnetic resonance imaging (MRI) can be helpful in diagnosing a plantar plate rupture. They have been useful in

 

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identifying the location and severity of the tearing in the plantar plate as well as damage to adjacent soft tissues.

 

NONOPERATIVE MANAGEMENT

 

In general, conservative measures are more effective for treatment of subluxation of the second MTP joint versus dislocation.

 

Activity modification is usually necessary to resolve underlying second MTP synovitis.

 

Some degree of relief is usually afforded by avoidance of shoes with a tight, narrow toe box and by modification of shoe wear to include a broad toe box with extra depth.

 

 

Splinting or taping the second toe in plantarflexion may relieve symptoms but does not correct deformity. Placing a metatarsal pad in the shoe may help relieve pressure on the plantar plate.

 

Wearing a shoe with a firm sole may prevent propagation of synovitis and further attenuation of the plantar plate.

 

Metatarsal bars or a full-length rocker bottom sole with metal inlay may provide additional means of relieving pressure at the second MTP joint.

 

SURGICAL MANAGEMENT

Preoperative Planning

 

All radiographs should be carefully examined to evaluate the degree of deformity of the hallux and surrounding lesser toes.

 

Clinical examination should determine whether the deformities at the interphalangeal and MTP joints are flexible or rigid.

 

 

Hallux valgus deformity, which does not allow for correction of the second toe, must be corrected. PIP deformity should be corrected with an interphalangeal joint fusion or arthroplasty.

Surgical Options and Indications

 

Dorsal capsular release and repair of the LCL is a soft tissue realignment procedure that is indicated for mild crossover toe deformities.

 

 

 

 

FIG 2 • A,B. The Weil osteotomy can be used to shorten the second metatarsal as well as to decrease the overall prominence of the second metatarsal head.

 

 

The Girdlestone-Taylor procedure, or transfer of the split FDL tendon to the dorsum of the proximal phalanx, is a well-established procedure.4,15 All grades of second toe deformity may benefit from it.

 

Initially described for the correction of flexible lesser toe deformities in patients with underlying neuromuscular disorders, this procedure has undergone various modifications throughout the years.

 

A PIP resection can be performed simultaneously for correction of rigid deformity.

 

 

The EDB tendon transfer was originally described by Haddad et al5 and is most appropriate in patients with mild to moderate deformity. Benefits include better control of sagittal plane motion and less stiffness than is associated with an FDL transfer.

 

A modification of the EDB transfer, as popularized by Lui and Chan,9 attempts to reduce the supination force of the transferred EDB as well as to provide a more robust side-toside suture repair.

 

Recently, several authors have described direct repair of the plantar plate for surgical correction of instability.11 This correction can address subluxation and dislocation of the MTP joint.

 

Proximal phalanx basilar osteotomy is indicated for resistant angular deformities of the lesser toes and for failure to achieve multiplanar correction after complete soft tissue release at the MTP joint.

 

The Weil osteotomy can be used to shorten the second metatarsal as well as to decrease the overall prominence of the second metatarsal head (FIG 2).

 

 

This procedure is used for persistent subluxation of the second MTP joint after adequate soft tissue procedures have been performed.

 

It may be used as an alternative to a flexor to extensor transfer.

 

A flexor to extensor transfer can be performed simultaneously for additional correction in refractory cases.

 

 

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TECHNIQUES

• Dorsal Capsular Release and Repair of the Lateral Collateral Ligament

   

   

  The second MTP joint is approached via a 3-cm longitudinal, curved, or Z-shaped incision. A dorsal incision in the adjacent web space is also appropriate.

   

  The EDL and EDB are sectioned, and the dorsal capsule is opened (TECH FIG 1A).

   

  Release of the EDL, EDB, and dorsal capsule allows the sagittal plane deformity to be addressed (TECH FIG 1B).

   

   

   

  TECH FIG 1 • A. The EDL and the EDB are sectioned and the dorsal capsule is opened. B. The EDL, EDB, and dorsal capsule are released. C. Repair of the LCL in a shortened fashion and release of the MCL off the metatarsal and phalanx.

   

   

  Balancing the MCL and the LCL is required to address coronal plane deformity.

   

   

  The contracted MCL is released off the metatarsal and the phalanx from dorsal to plantar. The attenuated LCL is then repaired in a shortened fashion (TECH FIG 1C).

   

  For added stabilization, the MTP joint is pinned from distal to proximal using a 0.054- or 0.062-inch Kirschner wire (K-wire).

• Flexor to Extensor Tendon Transfer (Girdlestone-Taylor Procedure)

   

  The second MTP joint is approached through a longitudinal dorsal incision extending from the MTP joint to the PIP joint.

   

   

  The extensor tendons are retracted laterally, and the MTP joint is entered through a dorsal capsulotomy. The MCL is then sectioned.

   

  In patients with more advanced deformity, further correction may be obtained with EDL lengthening and EDB tenotomy as well as a release of the interosseous and lumbrical tendons.

   

  A small transverse plantar incision is then made at the level of the proximal flexion crease, and the FDL tendon is identified using blunt dissection (TECH FIG 2A).

   

  The FDL tendon is released from its insertion onto the distal phalanx via a percutaneous tenotomy at the

  level of the DIP joint.

   

  The released FDL tendon is brought into the proximal wound and split centrally along the median raphe (TECH FIG 2B).

   

  Each limb is then passed from plantar to dorsal on either side of the proximal phalanx, avoiding injury to adjacent neurovascular structures.

   

  When a fixed contracture of the PIP is present, resection of the distal one-fourth of the proximal phalanx can be performed after the extensor hood and collateral ligaments are incised.

   

  The limbs of the split FDL are then passed over the extensor hood, tensioned (with the ankle held in a neutral or slightly dorsiflexed position), and sutured to each other with 4-0 nonabsorbable sutures (TECH FIG 2C).

   

  Manual manipulation of the proximal phalanx can be performed to assess the tensioning of the transferred tendons. The MTP joint should remain slightly mobile, not overly tight, when correct tensioning is achieved.

   

  A 0.062-inch K-wire is driven, in retrograde fashion, from the base of the proximal phalanx distally through the tip of the toe and then antegrade across the MTP joint with the toe held parallel to the floor or weight-bearing surface of the foot.

   

  The incisions are then closed in a layered fashion (TECH FIG 2D).

   

   

  09

   

   

   

  TECH FIG 2 • A. A small transverse plantar incision is then made at the level of the proximal flexion crease.

  B. The released FDL tendon is brought into the proximal wound and split centrally along the median raphe.

  C. The limbs of the split FDL are passed over the extensor hood, tensioned, and sutured. D. The incisions are then closed in a layered fashion.

• Extensor Digitorum Brevis Tendon Transfer

   

  A dorsal approach similar to that used for a flexor to extensor transfer is used to perform an EDB tendon transfer.

   

  The EDB tendon is identified and freed proximally after dissection and release of the MTP joint capsule and lengthening of the EDL tendon.

   

  After two 4-0 stay sutures have been placed longitudinally into the tendon 4 cm proximal to the MTP joint, the tendon is transected between these two sutures (TECH FIG 3A).

   

   

   

  TECH FIG 3 • A. Stay suture placement along the EDB tendon and transaction point identified by dashed line between the two sutures. The EDL tendon is also shown after Z-lengthening. B. Transfer of distal EDB stump plantar to transverse metatarsal ligament and lateral to second metatarsal. (continued)

   

   

  Care is taken to maintain the integrity of the distal EDB tendon insertion, and the distal EDB tendon stump is then passed from distal to proximal underneath the transverse metatarsal ligament and lateral to the MTP joint (TECH FIG 3B).

   

  A 0.062-inch K-wire is placed across the MTP joint with the toe held in a corrected position.

   

  The passed distal limb of the EDB is then tensioned and secured by a direct end-to-end tendon repair to the proximal stump, with the joint held in congruity (TECH FIG 3C).

   

  10

   

   

   

  TECH FIG 3 • (continued) C. End-to-end repair of the EDB tendon with the toe pinned in a corrected position. The Z-lengthened EDL tendon is also shown following repair.

• Modified Extensor Digitorum Tendon Transfer

   

  Under tourniquet control, a lazy S incision is used to expose the EDL and EDB of the second toe.

   

  A long Z incision of the EDL is made, and the EDB is released at the distal metatarsal level (TECH FIG 4A).

   

  The MTP joint is entered transversely, and the MCL is sectioned.

   

  A transverse bone tunnel is placed through the proximal aspect of the proximal phalanx using a 2.5-mm drill.

   

   

   

  TECH FIG 4 • A. Long Z incision through the EDL tendon. EDB transected at the level of the distal metatarsal shaft. B. Correction of deformity and pinning. The distal EDL stump has been shuttled through the transverse drill tunnel and anastomosed to the proximal stump of the EDB tendon. The proximal stump of EDL has been repaired side to side with the distal stump of the EDB. (Adapted from Lui TH, Chan KB. Technique tip: modified extensor digitorum brevis tendon transfer for crossover second toe correction. Foot Ankle Int 2007;28:521-523.)

   

   

  The distal stump of the EDL is passed through the bone tunnel from medial to lateral. The passed tendon is then shuttled from distal to proximal, plantar to the transverse metatarsal ligament between the second and third metatarsals.

   

  The transferred tendon is tensioned, and a 0.062-inch K-wire is inserted across the MTP joint to hold the toe in a corrected position (TECH FIG 4B).

   

  The distal stump of the EDL is then repaired side to side with the proximal stump of the EDB.

   

  The proximal stump of the EDL is then sutured to the distal stump of the EDB in side-to-side fashion.

   

   

  11

• Proximal Phalanx Basilar Osteotomy

   

  An oblique incision is made over the MTP joint extending longitudinally onto the dorsum of the base of the proximal phalanx.

   

  Extensor tenotomy or lengthening and dorsal capsular incision with collateral release can all be added for further soft tissue correction.

   

  If complete correction is not attainable following these soft tissue releases, the approach can be extended to the base of the proximal phalanx, where a proximal phalanx basilar osteotomy can subsequently be performed.

   

   

   

  TECH FIG 5 • A. A hand awl is used to make multiple perforations in the medial cortex of the proximal phalanx. B. K-wire stabilization after osteotomy completion and positional correction.

   

   

  Davis et al3 described using a small awl to make multiple perforations at the base of the proximal phalanx opposite the direction of toe deviation (TECH FIG 5A).

   

  After penetrating the appropriate cortex multiple times, taking care not to perforate the opposite cortex, finger pressure alone is used to complete the osteotomy and correct the underlying deformity (TECH FIG 5B).

   

  A 0.045-inch K-wire is placed percutaneously if added stability is needed.

• Distal Horizontal Metatarsal Osteotomy (Weil Osteotomy)

   

  A dorsal 3-cm longitudinal incision is made over the second MTP joint, the extensor tendons are retracted, and the capsule is incised to expose the MTP joint.

   

  Collaterals are then released to facilitate delivery of the second metatarsal head dorsally out of the wound.

   

  Plantarflexion at the MTP allows for optimal exposure of the articular surface of the second metatarsal.

   

   

   

  TECH FIG 6 • A. Diagram of osteotomy plane, made using an oscillating saw. Care must be taken to initiate the saw cut at the dorsal most aspect of the second metatarsal head. B. The osteotomy is slid proximally and fixed with a compression screw from dorsal to plantar. (continued)

   

   

  With use of an oscillating saw, a cut is initiated at the articular surface of the most dorsal aspect of the

  second metatarsal head.

   

  The cut is carried proximally and parallel to the plantar plane of the foot (TECH FIG 6A).

   

  The plantar osteotomy fragment is then grasped with a pointed reduction clamp and slid proximally to achieve the desired amount of shortening (TECH FIG 6B).

   

  The osteotomy is finally secured with a compression screw placed in lag fashion from dorsal to plantar (TECH FIG 6C).

   

  The excess dorsal bony prominence is shaved to a smooth surface.

   

   

  12

   

   

   

  TECH FIG 6 • (continued) C. The osteotomy is finally secured with a compression screw placed in lag fashion from dorsal to plantar.

• Direct Repair of the Plantar Plate with Weil Osteotomy

   

  Diagnostic arthroscopy prior to repair of the plantar plate has been described. This allows for confirmation of the plantar plate tear with clinical exam and MRI findings.11

   

  Two small dorsal incisions on either side of the MTP joint may be used if a diagnostic arthroscopy is performed prior to repair and can then be incorporated into an “S-shaped” incision when performing the open repair.

   

  If no diagnostic arthroscopy is performed, a dorsal 3-cm longitudinal incision is made over the second MTP joint, the extensor tendons are retracted or elongated (Z-plasty), and the capsule is incised to expose the MTP joint. A Weil osteotomy is then performed as described earlier to allow full visualization of the plantar plate.

   

  Visualization of the plantar plate can be further enhanced with longitudinal traction or various other distraction techniques (TECH FIG 7A).

   

   

   

  TECH FIG 7 • A. Distraction across the MTP joint after performing a Weil osteotomy. B. Identification of the plantar plate rupture at the base of the proximal phalanx. C. Suture is passed through the plantar plate, and the bone tunnels are prepared in the proximal phalanx. D. The completed plantar plate repair with fixation of the Weil osteotomy.

   

   

  Completion of the plantar plate tear may be necessary if a direct repair of the partial tear is possible. This should be performed as close to the phalanx as possible when needed.

   

  The plantar surface of the proximal phalanx is roughened with a rongeur or curette to facilitate healing of the repair to the bone.

   

  The plantar plate tear is then identified (TECH FIG 7B) and the plate needs to be mobilized to allow for repair with longitudinal or transverse sutures in mattress fashion based on the orientation of the tear.

   

  Two vertical holes are then drilled using a K-wire in the proximal phalanx from dorsal to plantar (TECH FIG 7C). These should exit the plantar phalanx just below the plantar surface.

   

  The sutures from the plantar plate repair are then shuttled through these holes from plantar to dorsum and tied over the top for fixation with the toe held in 20 degrees of plantarflexion.

   

  The Weil osteotomy is then stabilized as described earlier (TECH FIG 7D) and any soft tissue corrections may also be performed at this time.

   

   

   

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  PEARLS AND PITFALLS
  	Dorsal ▪ Procedure is best used to correct mild or early deformities. capsular ▪ Before pinning the second toe, the surgeon should ensure that the toe is able to release passively lie in a corrected position after adequate dorsal capsular release and LCL and repair repair. There is a high probability that if the surgeon has to rely on pin fixation to of the maintain the second toe in a corrected position, this correction will be lost over time. LCL

  Flexor to extensor tendon transfer

  • Procedure should be used for correction of moderate crossover toe deformity or for toes that display a tendency to resublux after initial correction.

  • When passing the FDL through the proximal plantar incision, flexing the toe will further relax the flexor and facilitate delivery of the tendon to the proximal plantar incision.

  • Overtensioning either limb of the FDL prior to repair can result in further malalignment of the toe and shift the toe into even greater varus or valgus deformity.

  • Rapid postoperative mobilization and early K-wire removal (2 weeks postoperatively) are crucial to preventing uncomfortable postoperative stiffness.

     

    EDB

    tendon transfer

    • Rapid postoperative mobilization and K-wire removal (2 weeks postoperatively) are crucial to preventing uncomfortable postoperative stiffness.

    • For advanced deformity (rigid stage 3 or 4), FDL transfer may be more appropriate.

    • Anchoring the brevis tendon into a metatarsal head drill hole may lead to a higher recurrence rate than an end-to-end transfer.

    • Supination of the second toe may result from overpull of the EDB.

       

      Modified EDB

      tendon transfer

  • The Z-lengthening of the EDL should be long enough to permit passage through the bone tunnel and eventual anastomosis of the transfer.

  • The EDB is cut at the distal metatarsal level to preserve adequate length to facilitate the transfer.

  • Drill tunnel placement is critical. The tunnel should be placed close to the longitudinal axis of the proximal axis and not too dorsal or plantar.

  • Correction of the hyperextension deformity relies mainly on adequate soft tissue release. Reflection of the plantar capsule and plate off the metatarsal head using an elevator may be necessary to accomplish adequate soft tissue release.

  • Placing the drill tunnel too dorsal will lead to residual supination; locating it too plantar will lead to hyperextension of the MTP joint.

 

Proximal phalanx basilar osteotomy

• If complete correction of the crossover toe deformity is not attainable following initial soft tissue releases, the approach can be extended to the base of the proximal phalanx, where a proximal phalanx basilar osteotomy can be performed.

• Care should be taken to prevent perforation of the far cortex when performing the osteotomy, or instability and delayed bony union may result.

   

  Weil osteotomy

• The distal fragment of the osteotomy can be preliminarily secured with a K-wire prior to completion of the dorsal to plantar compression screw fixation.

• Pinning across the MTP joint will decrease the risk of floating toe deformity.

• Avoid securing the distal osteotomy fragment in plantarflexion; if anything, err on the side of dorsiflexion if accepting mild angular deformity in the sagittal plane.

   

  Plantar plate repair

  • A flexor to extensor transfer in addition to the Weil osteotomy has been shown to increase the stability of the toe in the sagittal plane.2

  • It is important to hold the foot in 20 degrees of flexion as the sutures are being tied

to appropriately tension the plantar plate.

 

POSTOPERATIVE CARE

 

Dorsal capsular release and repair of the LCL

 

 

The pin is left in for approximately 3 to 4 weeks.

 

Immediate ambulation is allowed in a stiff postoperative shoe.

 

 

Once the pin is removed, the toe is taped in plantarflexion for another 3 to 4 weeks. The patient is progressed into normal shoe wear once the pin is removed.

 

Girdlestone-Taylor procedure

 

 

 

Ambulation in a hard-soled shoe using only the heel is permitted immediately following surgery. The K-wire is removed between 2 and 3 weeks postoperatively.

 

The patient is instructed to adhere to 6 additional weeks of taping the toe in slight plantarflexion and lateral deviation.

 

EDB tendon transfer

 

 

Postoperative care is essentially identical to that used for a flexor to extensor transfer.

 

The percutaneously placed K-wire is maintained for 2 to 3 weeks, followed by an additional 6 weeks of taping the corrected toe to maintain alignment.

 

Modified EDB tendon transfer: The pin is kept in place for 3 to 6 weeks followed by 6 additional weeks of toe taping.

 

Proximal phalanx basilar osteotomy

 

 

 

After surgery, dressings are placed with the toe maintained in an overcorrected position.

 

 

 

The patient is placed in a hard-soled shoe and dressing changes are performed weekly. At 6 weeks postoperatively, the patient is advanced to a soft-soled shoe as tolerated.

 

K-wire is removed at 4 weeks postoperatively.

 

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Postoperative radiographs are assessed at 4 to 6 weeks to evaluate for bony healing at the osteotomy site.

 

Weil osteotomy

 

 

 

Sterile dressings are placed intraoperatively, and the toe is taped down in an overcorrected position. Dressings are changed weekly until drainage ceases.

 

Weight bearing in a postoperative shoe is resumed immediately after surgery.

 

Plantar plate repair

 

 

A period of protected weight bearing through the heel is recommended immediately after surgery for a period of 6 weeks. This can be progressed as tolerated into athletic shoes at this time point.

 

Dressings changed as needed until no drainage is present.

 

Physical therapy may be needed to facilitate conditioning of the extrinsic flexors of the lesser digits.

 

OUTCOMES

 

 

Girdlestone-Taylor procedure

 

 

Thompson and Deland16 performed FDL flexor to extensor tendon transfers on 13 feet in 11 patients and reported that at an average follow-up of 33.4 months, all patients had substantial pain relief, with 8 of 13 becoming completely pain free.

 

They concluded that although flexor to extensor tendon transfer is successful in reestablishing MTP joint congruity and relieving pain due to instability, rapid postoperative mobilization and early K-wire removal (2 weeks postoperatively) are crucial to preventing uncomfortable postoperative stiffness.

 

EDB tendon transfer

 

 

Haddad and colleagues5 performed either flexor to extensor or EDB tendon transfer on 38 patients (42 feet) with an average follow-up of 51.6 months.

 

Of the 31 patients (35 feet) followed until their final examination, 24 were satisfied with their surgical correction, 6 were satisfied with reservations, and 1 was dissatisfied.

 

No statistical significance in clinical outcome was demonstrated between patients who underwent FDL

tendon transfer and those who underwent EDB tendon transfer; but Haddad et al5 recommended the technique because they believed that it demonstrated better patient satisfaction and improved flexibility compared with the FDL transfer.

 

Other advantages favoring EDB transfer over FDL transfer that were cited were better postoperative range of motion (78 degrees for EDB vs. 62 degrees for FDL) and hence better patient satisfaction, decrease in recurrence of deformity (14%), and better pain control (71% asymptomatic; 26% mild pain).

 

Weil osteotomy

 

 

Hofstaetter and colleagues7 analyzed their results at 1 and 7 years in 25 feet using the Weil osteotomy for treatment of instability at the MTP joint.

 

Good to excellent results were obtained in 21 feet (84%) after 1 year and in 22 (88%) after 7 years.

 

The authors demonstrated marked improvement in pain, diminished plantar callus formation, and an increase in walking capacity.

 

Adverse results included recurrent instability, floating toes, and restricted motion at the MTP joint, but these complications were often not clinically significant.

 

Plantar plate repair

 

 

Nery and colleagues11 reported that 77% of their prospective cohort of 55 plantar plate repairs had improvement of their American Orthopaedic Foot and Ankle Society (AOFAS) scores and reduction of visual analog scale (VAS) from 8 to 1 at 17 months postoperatively.

 

The authors also reported that all surgically repaired toes were congruent at 17 months with weight-bearing films.

 

Weil et al18 similarly reported a significant improvement in VAS from 7.3 to 1.7 postoperatively at 22.5 months in a retrospective group of 15 feet.

 

The authors reported that 77% (10 of 13) of their patients were either satisfied or very satisfied with their outcome.

COMPLICATIONS

 

 

Dorsal capsular release and repair of the LCL Recurrence

 

MTP stiffness

 

Persistent swelling

 

 

Failure to achieve correction Girdlestone-Taylor procedure

 

Swelling

 

 

 

Recurrent deformity Stiffness Hyperextension

 

EDB tendon transfer

 

 

Recurrent crossover toe deformity or failure to achieve complete correction of deformity Infection

 

Symptomatic incisional scar formation

 

 

Stiffness of the MTP joint, especially with flexor to extensor tendon transfer Proximal phalanx basilar osteotomy

 

Infection

 

 

Loss of correction with persistent angular deformity Failure of union at the osteotomy site

 

Weil osteotomy

 

 

Persistent dorsiflexion at the MTP joint (floating toe deformity) Claw toe

 

Nonunion or malunion at the osteotomy site

 

 

Stiffness at the MTP joint due to incorporation of articular surface into osteotomy cut Overcorrection with excessive shortening of the second metatarsal

 

 

Hardware failure or prominence Infection

 

 

Neurovascular insult Plantar plate repair

 

 

Recurrence of the crossover deformity MTP hyperextension

 

 

Metatarsalgia Infection

 

 

15

ISOLATED METATARSOPHALANGEAL ANGULAR DEFORMITY

PATHOGENESIS

 

Isolated MTP angular deformity of the lesser toes is defined as varus or valgus deformity exclusively at the MTP joint relative to the normal anatomic axis of the toe.

 

Toes second to fifth are usually involved.

 

This type of deformity characteristically follows abnormal deviation of the hallux, which is frequently in a position of varus or valgus.

 

SURGICAL MANAGEMENT

 

To achieve successful correction of the lesser toes, it is usually necessary to address any varus or valgus deformity of the hallux concomitantly.

 

Procedures that are used to correct isolated MTP angular deformity are similar to those used for surgically treating mild or moderate crossover second toe deformities and are described earlier in this chapter.

 

PEARLS AND PITFALLS

 

• Deviations in the lesser toes tend to follow angular deformities of the hallux. To create lasting correction of the lesser toes, the surgeon must address deformity of the hallux concomitantly.

   

• Failure to address associated deformity of the hallux can result in early loss of successful lesser toe correction.

 

 

CLINODACTYLY

PATHOGENESIS

 

Clinodactyly refers to the medial or lateral deviation of a toe caused by true angulation within a phalanx.

 

This type of lesser toe deformity is thought to result from a failure of segmentation between the normally transverse epiphysis and metaphysis.

 

Often bilateral and familial, clinodactyly most frequently involves the DIP joint of the fourth and fifth digits, although any digit may be involved.

 

There is also a strong predilection for involvement of the fingers with this lesser toe deformity.

 

A variety of syndromes and chromosomal disorders have been linked to clinodactyly of the lesser toes (symphalangism, brachydactyly, trisomy 21, Turner syndrome, Holt-Oram syndrome, Marfan syndrome).

 

An associated “delta phalanx,” or a triangular middle phalanx, is sometimes associated with clinodactyly.

 

NATURAL HISTORY

 

Clinodactyly is usually nonprogressive and no more than a cosmetic concern, although overlapping or underlapping of adjacent toes may occur.

 

If significant overlap or underlap is present, impingement on adjacent digits may cause the patient to be symptomatic.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

 

The affected toe is deviated medially or laterally relative to the normal longitudinal axis of the toe. The DIP of the involved toe is the most common site of angulation.

 

A complete physical examination should be performed because of the prevalence of clinodactyly with associated syndromes and chromosomal disorders.

 

Impingement on adjacent toes due to overlapping or underlapping may cause indentation on the toes, local irritation, corns, or callosities at variable locations from associated pressure phenomenon.

 

IMAGING AND DIAGNOSTIC STUDIES

 

All angular deformities involving the lesser toes can be appropriately studied by examining standard AP, lateral, and oblique radiographs of the affected foot.

 

NONOPERATIVE MANAGEMENT

 

For symptomatic toes, strategic padding, stretching, taping, and accommodative shoe wear may temporarily alleviate certain components of a patient's discomfort. These conservative approaches are often ineffective, however.

 

SURGICAL MANAGEMENT

 

 

Surgical options include wedge osteotomies, arthrodesis, and soft tissue lengthening procedures.10 Both opening and closing wedge osteotomies can effectively address angulation at the affected joint.

 

Closing wedge osteotomy or arthrodesis is indicated for the treatment of symptomatic clinodactyly of any severity grade.

 

A closing wedge osteotomy can be performed at the middle or distal phalanx through a small transverse dorsal incision.

 

Intercalary allograft can be used to perform an opening wedge osteotomy and thereby preserve much of the length of the digit, but Z-plasty of the skin must also be performed for added soft tissue correction.

 

A closing wedge arthrodesis of the affected joint is an acceptable treatment method provided that excessive shortening of the digit is not present.

 

Skin dermodesis may be added for further acceptability of correction.

16

TECHNIQUES

Closing Wedge Osteotomy or Arthrodesis

The skin over the affected middle or distal phalanx is incised through a dorsal incision. Redundant skin, equal to the planned osteotomy, is carefully removed (TECH FIG 8A).

Subperiosteal exposure is obtained at the apex of the deformity (TECH FIG 8B).

 

A microsagittal saw is used to create the desired cut at an appropriate angle to facilitate a satisfactory correction.

Care should be taken to preserve a small bridge of bone at the far cortex.

 

TECH FIG 8 • A. The affected middle or distal phalanx is approached through a dorsal incision. B. Subperiosteal exposure is obtained at the apex of the deformity. C. The osteotomy fragment is removed and the wedge is closed with manual manipulation.

The osteotomy fragment is removed and the wedge is closed with manual manipulation (TECH FIG 8C). If an arthrodesis is desired, the closing wedge may be removed through the interphalangeal joint.

Dermodesis is then performed, incorporating skin into the closure.

Alternatively, a K-wire can be placed percutaneously in retrograde fashion for added stability. Sterile dressings are placed, emphasizing overcorrection of the affected toe.

 

 

 

POSTOPERATIVE CARE

 

If a K-wire is placed, it should be removed by 4 weeks postoperatively.

 

Weight bearing in a postoperative shoe is permitted to tolerance immediately after surgery.

 

Dressings should be changed until drainage subsides, with continued emphasis on maintaining an

overcorrected position of the toe.

OUTCOMES

Reports are largely anecdotal but overall have been favorable and support the continued use of the procedure.

 

 

COMPLICATIONS

Neurovascular insult due to an overaggressive exposure Loss of reduction due to inadequate stabilization

Wound healing problems

Violation of the dorsal extensor structures Failure of bony healing at the osteotomy site

 

CONGENITAL CROSSOVER FIFTH TOE DEFORMITY

PATHOGENESIS

 

Although the underlying cause is unknown, congenital crossover fifth toe is widely recognized as a familial problem with an equal gender predilection.

 

Often bilateral (20% to 30% of cases), congenital crossover fifth toe (or congenital overriding fifth toe) deformity causes pain with restrictive shoe wear and other symptoms in about half of all patients.10

 

Pathoanatomy includes dorsomedial subluxation and adduction at the fifth MTP joint, with external rotation of the toe.

 

There is associated contracture of the fifth toe EDL tendon, skin of the dorsal fourth web space, MCL, and dorsomedial MTP joint capsule.

 

Often, impingement lesions at the base of the adjacent fourth toe identify the compressive influence of the overriding fifth toe due to its subluxated position.

 

Furthermore, dorsal subluxation of the fifth toe at the MTP joint causes excessive pressure on the metatarsal head. This abnormal pressure distribution can lead to painful plantar callosity under the metatarsal head.

 

When the fifth toe crosses under the fourth toe, painful callosity may develop under any portion of the toe that comes in abnormal contact with the ground surface during weight bearing.

 

NATURAL HISTORY

 

Crossover fifth toe deformity is almost always present from birth and therefore is usually nonprogressive with respect to its degree of deformity.

 

As stated, a painful callosity of either the fourth or fifth toes may develop over time because of pressure phenomenon in cases of long-standing deformity.

 

 

17

 

Also, abnormal pressure distribution due to subluxation at the fifth MTP joint can eventually lead to pain at the plantar surface of the fifth metatarsal head and metatarsalgia.

 

Approximately half of all patients experience symptoms due to an overriding fifth toe.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

 

On examination, the fifth toe is noted to override the fourth toe to a variable degree. The interphalangeal joints are usually in normal full extension.

 

There is often mild dorsiflexion at the MTP joint as well as malalignment and contracture of the skin at the fourth web space.

 

In patients with long-standing deformity, the toe may assume a flattened, paddle-shaped appearance in the AP plane that is usually the result of years of compression by constrictive shoe wear.

 

The toenail usually appears normal, and the toe is able to participate in active flexion and extension.

 

A hard corn of the fifth toe or a soft corn between the fourth and fifth toes may also develop because of pressure phenomenon.

 

IMAGING AND DIAGNOSTIC STUDIES

 

All angular deformities involving the lesser toes can be appropriately studied by examining standard AP, lateral, and oblique radiographs of the affected foot.

 

Radiographs show dorsolateral subluxation at the MTP joint.

 

NONOPERATIVE MANAGEMENT

 

Reliably ineffective, conservative treatment modalities include splinting, taping, accommodative shoe wear, and protective padding.

 

SURGICAL MANAGEMENT

 

Many surgical approaches have been advocated for correction of crossover fifth toe deformity and many modifications of these have been subsequently developed.

 

The type of procedure selected is based on the severity of deformity encountered.

 

Soft tissue procedures such as dorsal skin lengthening with Z-plasty of contracted skin, dermodesis of redundant skin, EDL tendon transfer, EDL lengthening or release, syndactylization of the fourth and fifth toes, and dorsal and medial capsular release have all been described and proved effective.1,6,8,9,10,11,12,13,14,17,19

 

Bony resection, performed in isolation or in conjunction with any of the aforementioned soft tissue procedures, has also been successful in correcting crossover fifth toe deformity.

 

Proposed salvage operations include the so-called Ruiz-Mora procedure (proximal phalangectomy via a plantar elliptical incision with soft tissue realignment and plantar dermodesis) with or without syndactylization of the fifth toe to the fourth, and even amputation.

 

 

The DuVries technique can be used to correct mild to moderate deformities. The Lapidus procedure can be used to address moderate to severe deformities.

 

In this technique, the EDL is isolated and rerouted under the MTP joint and attached to the abductor digiti quinti muscle or lateral joint capsule.

 

Unlike other procedures, the Lapidus technique allows for rotational correction, expanding the indications for its use.

 

TECHNIQUES

• DuVries Technique for Correction of Crossover Fifth Toe Deformity

A longitudinal incision is made over the fourth web space.

An extensor tenotomy is performed, followed by dorsal capsulotomy and MCL release (TECH FIG 9A). The toe is plantarflexed, bringing the skin along the lateral margin of the incision distally (TECH FIG 9B).

Layered suture closure is performed with the toe held in an overcorrected position of plantarflexion and lateral deviation to maximize the degree of soft tissue correction afforded by this technique (TECH FIG 9C).

Soft tissue release and skin advancement alone are usually sufficient to hold the toe in an adequately corrected position. Otherwise, a K-wire can be placed percutaneously for added stabilization and correction.

 

 

 

 

TECH FIG 9 • A. A longitudinal incision is made over the fourth metatarsal interspace and extensor tenotomy is performed. (continued)

 

 

18

 

 

 

TECH FIG 9 • (continued) B. Plantarflexion of the fifth toe brings the lateral margin of the incision distally and the medial margin proximally. C. Layered closure is undertaken with the toe held in an overcorrected position.

• Lapidus Procedure

 

A longitudinal hockey stick-shaped or curvilinear incision is carried along the dorsomedial border of the fifth toe, from the level of the medial DIP joint distally to the fourth web space proximally.

 

Through this incision, a thorough dorsomedial capsulotomy of the fifth MTP joint is made.

 

Any adhesions encountered between the plantar capsule and metatarsal head should be released with a curved elevator to prevent hyperextension deformity of the MTP joint after capsular release.

 

 

 

TECH FIG 10 • A. Incisions for the Lapidus technique. B. EDL tenotomy using the more proximal of the two incisions. (continued)

 

 

The hook of the hockey stick incision is then created by extending the incision over the dorsum of the fifth MTP joint laterally and proximally to the lateral aspect of the fifth MTP head.

 

The extensor tendon is carefully exposed, maintaining the extensor hood expansion, and the fifth toe is forcibly plantarflexed, causing the extensor tendon to become taut.

 

A second 1-cm incision is made transversely over the taut EDL tendon at the mid-diaphyseal level of the fifth metatarsal (TECH FIG 10A).

 

Using this incision, an EDL tenotomy is performed (TECH FIG 10B).

 

 

19

 

 

 

TECH FIG 10 • (continued) C. Transfer of the distal EDL limb beneath the fifth toe and repair to the conjoined tendon.

 

 

The distal limb of the EDL tendon is retrieved and then passed beneath the plantar aspect of the fifth toe from the dorsomedial DIP joint to the lateral aspect of the fifth MTP joint.

 

The passed extensor tendon is then sutured to the conjoined tendon of the abductor and short flexor of the fifth toe (TECH FIG 10C).

 

The fifth toe is held in an overcorrected position, and the transplanted extensor tendon is placed under slight tension prior to suture fixation.

 

Skin is closed with interrupted sutures or with advancement techniques if significant skin contractures are present.

 

PEARLS AND PITFALLS

 

	DuVries ▪ Procedure is best used for mild deformities without associated rotational deformity technique of the toe. If any substantial rotational deformity is present, the Lapidus procedure is a more appropriate surgical solution. Failure to hold the toe in an overcorrected position while performing soft tissue advancement and layered closure will result in a higher recurrence rate.     Lapidus ▪ Following dorsomedial capsulotomy, any adhesions encountered between the procedure plantar capsule and metatarsal head should be released with a curved elevator to prevent hyperextension deformity of the MTP joint after capsular release. If the toe is not held in an overcorrected position during repair, or if transplanted extensor tendon is incorrectly tensioned, early recurrence is common.

 

 

POSTOPERATIVE CARE

 

DuVries technique

 

The toe is taped in a slightly overcorrected (plantarflexed and lateral) position for 6 weeks in a hard-soled postoperative shoe, after which unrestricted weight bearing is permitted.

If a pin is placed, it should be removed at 4 weeks postoperatively and the toe taped for a total of 6 weeks.

Lapidus procedure

 

Postoperatively, the toe is dressed in a corrected position and weight bearing in a postoperative shoe is allowed. Sutures are removed at 2 weeks, and the toe is then taped in a corrected position for another 4 to 6 weeks. Regular shoe wear is allowed at 4 to 6 weeks.

Alternatively, if there is concern about the strength of the repair, the operative foot is maintained in a splint for a total of 3 to 4 weeks and progression to full weight bearing and activity in a wide toe box shoe is gradually allowed.

COMPLICATIONS

A 5% to 10% recurrence rate has been reported using the DuVries technique. Mild swelling and clinically insignificant postoperative edema have also been reported.

Circulatory insult and wound healing problems are potential risks of the Lapidus procedure but were not reported by Lapidus8 in his original description. Recurrence of deformity has also been reported.

 

OUTCOMES

In his original description, Lapidus8 notes that his experience with the procedure that bears his name resulted in satisfactory outcomes in all cases.

 

20

CROSSUNDER FIFTH TOE DEFORMITY (CONGENITAL CURLY TOE OR UNDERLAPPING FIFTH TOE)

PATHOGENESIS

 

Although the cause of curly toe deformity is unknown, it is thought to be familial in nature, with a high instance of bilaterality.

 

Frequently, this type of lesser toe deformity involves both fourth and fifth toes and is usually symmetric.

 

Hypoplasia of the intrinsic musculature has been proposed as a causative influence on the development of curly toe deformity, but this notion has not been substantiated in the literature.

 

 

 

The fifth toe is flexed, deviated plantarward in varus, and is laterally rotated at the DIP joint. The EDL and dorsal capsule are often attenuated, in contrast to overlapping fifth toe deformity. The plantar MTP joint capsule and FDL tendon are often contracted and shortened also.

NATURAL HISTORY

 

As curly toe deformity is frequently congenital, progression is limited, and cosmesis is the major concern of parents and caretakers.

 

The deformity is often asymptomatic in children and may improve without intervention.

 

With initiation of weight bearing and different stages of shoe wear, chronic skin irritation can develop, the toenail may become short and flattened, and other pressure phenomena such as corns and callosities may develop.

 

PATIENT HISTORY AND PHYSICAL EXAMINATION

 

As previously stated, the fifth toe is flexed, deviated plantarward in varus, and laterally rotated at the DIP joint.

 

The distal phalanx or the distal and middle phalanges underride the more medial toe as a result of these anatomic abnormalities.

 

The deformity is usually flexible in childhood but may become rigid as an adult.

 

In contrast to crossover fifth toe deformity, the skin in the web spaces is normally aligned, but it can become hyperemic from chronic irritation.

 

Patients usually present with varying degrees of symptoms caused by pressure on the weight-bearing surface of the curly toe.

 

Callosities, corns, or nail deformities can all develop and cause discomfort with curly toe deformities.

 

IMAGING AND DIAGNOSTIC STUDIES

 

All angular deformities involving the lesser toes can be appropriately studied by examining standard AP, lateral, and oblique radiographs of the affected foot.

 

Imaging of the curly toe is usually unnecessary and does not contribute significantly to management strategies.

 

NONOPERATIVE MANAGEMENT

 

Conservative treatment modalities, including splinting, taping, accommodative shoe wear, and protective padding, may relieve symptoms but are usually ineffective for correcting the deformity.

 

SURGICAL MANAGEMENT

 

For flexible deformities, FDL and FDB tenotomy have been recommended in the pediatric population.

 

Flexor to extensor transfer, syndactylization with or without partial proximal phalangectomy, middle phalangectomy, and derotational procedures have all been proposed as surgical options to address the underlying pathoanatomy.

 

A simple flexor tenotomy can be used to correct mild underlapping fifth toe deformity.

 

 

Originally described by Taylor15 and credited to Girdlestone4 in 1951, the flexor to extensor tendon transfer is based on the premise that curly toe deformity results from weakness of the intrinsic musculature. This technique was described earlier in this chapter.

 

The Thompson technique uses resection arthroplasty of the proximal phalanx in combination with Z-plasty of

the skin to achieve derotation of the toe and correction of the deformity.17 This technique is useful for addressing more rigid, severe crossunder fifth toe deformities.

 

TECHNIQUES

• Flexor Tenotomy

   

  Various surgical incisions have been successfully used to perform open flexor tenotomy, including a longitudinal incision proximal to the proximal flexor crease, a longitudinal incision distal to the proximal flexor crease, and a transverse incision 1 mm from the proximal flexor crease.

   

  It is important not to violate the proximal flexor crease with the incision, or scar formation may occur and recurrent deformity can develop.

   

  The flexor sheath is incised longitudinally, long and short flexor tendons are carefully exposed, and tendons are then transected at the same level (TECH FIG 11).

   

   

  Manual manipulation may be used to improve the adequacy of correction. The wound is closed with interrupted 3-0 absorbable sutures.

   

   

   

   

  TECH FIG 11 • The flexor sheath is incised longitudinally, the long and short flexor tendons are carefully exposed, and the tendons are then transected at the same level.

   

  21

• Thompson Procedure

A laterally based Z-type or elliptical incision is made over the proximal phalanx. Subperiosteal dissection is used to expose the distal half of the proximal phalanx.

Partial phalangectomy of the distal 25% to 50% of the proximal phalanx or complete phalangectomy is then performed using a microsagittal saw.

If persistent flexion contracture exists at the level of the PIP, a flexor tenotomy can be added for further correction.

The digit is manually derotated, and a 0.045-inch K-wire is placed in a retrograde fashion across the PIP joint for stabilization.

Additional soft tissue correction is obtained by using a reverse Z closure with 4-0 nylon vertical mattress sutures.

If an elliptical incision was used initially, full-thickness closure is performed with the toe derotated using a dermodesis.

 

Flexor

tenotomy

• Failure to transect all three plantar tendons can lead to an incomplete correction

  of the deformity.

• It is important not to violate the proximal flexor crease with the incision, or scar formation may occur and recurrent deformity can develop.

Girdlestone- ▪ Isolated flexor tenotomy and flexor to extensor transfer appear to be equally

Taylor efficacious. However, it is thought that the long flexor tenotomy represents the procedure essential portion of either procedure and that flexor to extensor transfer is

unnecessary.

Thompson

procedure

• If persistent flexion contracture exists at the level of the PIP, a flexor tenotomy

  can be added for further correction.

• Overresection of the proximal phalanx can lead to a “floppy,” unstable toe as well as a transfer lesion beneath the fourth metatarsal.

PEARLS AND PITFALLS

 

 

POSTOPERATIVE CARE

 

Flexor tenotomy: Sterile dressings and elastic straps are applied to maintain correction, and the wound is inspected 10 days postoperatively.

 

Girdlestone-Taylor procedure: Sterile dressings are applied, and full weight bearing is permitted in a short-leg plaster splint with an extended toe box. Splinting is maintained for 4 to 6 weeks.

 

Thompson procedure: The foot is placed in a hard-soled shoe postoperatively, and pins are removed at 4

weeks. Using taping techniques, the toe is maintained in a derotated position for 6 additional weeks.

 

OUTCOMES

 

Flexor tenotomy

 

 

Ross and Menelaus13 reviewed their long-term outcome data on open flexor tenotomy performed in 62 children (188 toes) and found that at an average follow-up of 9.8 years, 95% of the toes examined had maintained satisfactory correction and no patients were aware of any loss of toe function.

 

The fourth and fifth toes had significantly more fair and poor results, hypothesized to be due to greater rotational deformity of these toes, especially the fifth.

 

Overall, the authors concluded that open flexor tenotomy is a safe, reliable, and effective method for correcting curly toes in children and is preferable to flexor to extensor transfer.

 

Girdlestone-Taylor procedure

 

 

In a double-blind randomized prospective trial, Hamer and colleagues6 studied long-term data from 46 toes (19 patients) randomly assigned to either flexor tenotomy or flexor to extensor tendon transfer for operative correction of curly toe deformity.

 

In general, results were good, with all patients remaining symptom-free at final follow-up.

 

The authors concluded that neither procedure was clearly superior to the other, that long flexor tenotomy was the essential portion of either procedure, and that flexor to extensor transfer was unnecessary.

 

Biyani and colleagues1 reviewed 130 curly toes in 43 children that were treated with flexor to extensor tendon transfer over a period of 24 years.

 

At an average follow-up of 8 years (range 1 to 25 years), good to excellent results were obtained in 95 toes (73%), fair results in 25 toes (19%), and poor results in 10 toes (8%).

 

In general, results of the Thompson procedure have been acceptable.

 

 

22

 

COMPLICATIONS

 

Flexor tenotomy

 

When performing longitudinal skin incision, care should be taken to avoid crossing the flexion creases because scar formation and skin contracture have been reported.

 

Ten of 188 patients in Ross and Menelaus'13 study were found to have tethering of the plantar skin as a result of violating some aspect of the flexor crease.

 

Stiffness has also been reported as a complication of flexor tenotomy.

 

Neurovascular compromise has not been reported but, in theory, represents a significant potential complication with this procedure.

 

Recurrent deformity, failure to achieve full correction, and infection are all potential complications of the Girdlestone-Taylor procedure.

 

Thompson procedure

 

Digital edema from resection arthroplasty can result as well as neurovascular insult to the digital bundle.

Recurrence in single or multiple planes can also result from attempts at derotation.

Overresection can lead to a floppy, unstable toe as well as a transfer lesion beneath the fourth metatarsal.

 

 

REFERENCES

1. Biyani A, Jones DA, Murray JM. Flexor to extensor tendon transfer for curly toes. 43 children reviewed after 8 (1-25) years. Acta Orthop Scand 1992;63:451-454.

    

    

2. Chalayon O, Chertman C, Guss AD, et al. Role of plantar plate and surgical reconstruction techniques on static stability of lesser metatarsophalangeal joints: a biomechanical study. Foot Ankle Int 2013;34:1436-1442.

    

    

3. Davis WH, Anderson RB, Thompson FM, et al. Proximal phalanx basilar osteotomy for resistant angulation of the lesser toes. Foot Ankle Int 1997;18:103-104.

    

    

4. Girdlestone GR. Physiology for hand and foot. Physiotheraphy 1947;32:167-169.

    

    

5. Haddad SL, Sabbagh RC, Resch S, et al. Results of flexor-to-extensor and extensor brevis tendon transfer for correction of the crossover second toe deformity. Foot Ankle Int 1999;20:781-788.

    

    

6. Hamer AJ, Stanley D, Smith TW. Surgery for curly toe deformity: a double-blind, randomised, prospective trial. J Bone Joint Surg Br 1993;75(4):662-663.

    

    

7. Hofstaetter SG, Hofstaetter JG, Petroutsas JA, et al. The Weil osteotomy: a seven-year follow-up. J Bone Joint Surg Br 2005;87(11): 1507-1511.

    

    

8. Lapidus PW. Transplantation of the extensor tendon for correction of the overlapping fifth toe. J Bone Joint Surg Am 1942;24:555-559.

    

    

9. Lui TH, Chan KB. Technique tip: modified extensor digitorum brevis tendon transfer for crossover second toe correction. Foot Ankle Int 2007;28:521-523.

    

    

10. Myerson MS. Foot and Ankle Disorders. Philadelphia: WB Saunders, 2000.

     

     

11. Nery C, Coughlin MJ, Baumfeld D, et al. Lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency. Foot Ankle Int 2012;33:301-311.

     

     

12. Paton RW. V-Y plasty for correction of varus fifth toe. J Pediatr Orthop 1990;10:248-249.

     

     

13. Ross ER, Menelaus MB. Open flexor tenotomy for hammer toes and curly toes in childhood. J Bone Joint Surg Br 1984;66(5):770-771.

     

     

14. Stamm TT. Minor surgery of the foot: elevated fifth toe. In: Carling ER, Ross JP, eds. British Surgical Practice, vol 4. London: Butterworth, 1948:161-162.

     

     

15. Taylor RG. The treatment of claw toes by multiple transfers of flexor into extensor tendons. J Bone Joint Surg Br 1951;33-B(4): 539-542.

     

     

16. Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle 1993;14:385-388.

     

     

17. Thompson TC. Surgical treatment of disorders of the fore part of the foot. J Bone Joint Surg Br 1964;46(5):1117-1128.

     

     

18. Weil L Jr, Sung W, Weil LS Sr, et al. Anatomic plantar plate repair using the metatarsal osteotomy approach. Foot Ankle Spec 2011;4(3): 145-150.

     

     

19. Wilson JN. V-Y correction for varus deformity of the fifth toe. Br J Surg 1953;41:133-135.