Download 10Varus and Valgus (Crossover) Lesser Toe Reconstruction

10
Varus and Valgus
(Crossover)
Lesser Toe
Reconstruction
Scott Riester, Ari Kaz, and Michael Coughlin
C
rossover toe deformity is a lesser toe deformity that is a distinct entity from hammer toe
and claw toe (1–4). It occurs when a lesser toe, typically the second, deviates medially
and dorsally over the dorsum of the great toe (Fig. 10.1). In comparison to the uniplanar
instability associated with hammer toe and claw toe deformities, crossover toe results
in multiplanar instability at the second metatarsophalangeal (MTP) joint. The deformity often begins with mild pain and synovitis involving the second MTP joint. As the deformity
progresses, the ligamentous and capsular structures become either stretched or contracted; this
eventually progresses to attenuation of the plantar plate resulting in global instability at the second
MTP joint (2,5–10).
Dorsomedial subluxation of the second toe has a high association with other deformities, including hallux valgus, hallux rigidus, and hammer toe deformities. Intrinsic factors such as muscle
imbalance and second metatarsal length are thought to contribute to the development of deformity.
Acute and repetitive trauma, inflammatory arthritides, constrictive footwear, and adjacent toe deformities represent extrinsic factors that are believed to contribute to the development of crossover toe
deformity.
Crossover toe deformity has historically been a challenging problem to treat. Countless surgical
techniques have been described, with no clear consensus as to which technique is most effective
(11–17). The large number of surgical techniques that have been developed to treat this problem
simply highlights the challenges that face the treating surgeon. Surgical management of crossover
toe deformity has evolved over the years from soft tissue procedures alone, to the addition of tendon
transfers, to soft tissue releases combined with osteotomies, and to the combined use of tendon transfers with osteotomies. Resection arthroplasty of the base of the phalanx or of the metatarsal head,
proximal phalangeal closing wedge osteotomy, and second toe amputation have also been performed.
In this chapter, two surgical techniques are discussed: extensor digitorum longus (EDL) to extensor
digitorum brevis (EDB) tendon transfer, and a shortening osteotomy with EDB tendon transfer.
Indications and Contraindications
It is important to distinguish between a crossover toe deformity and a hammer toe or claw toe deformity. A crossover toe has multiplanar instability whereas a claw toe or hammer toe has only stability
in one plane. If a crossover toe is not recognized and improperly treated as a hammer toe or claw
toe, then treatment failure is likely.
The most common presenting complaint in a patient with crossover toe deformity is a painful corn
dorsally over the proximal interphalangeal (PIP) joint or vague pain at the second MTP joint. In the
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PART I Forefoot and Midfoot
FIGURE 10.1
A: Clinical photograph of a crossover toe deformity. B: Anteroposterior (AP) foot
radiograph.
early stages of this disorder, there may only be minimal medial deviation of the second toe. The
patient may report a feeling of thickness or swelling in the area of the second MTP joint, and may
report the sensation of walking on a pebble or bunched-up sock. A neuroma in the second webspace
should be considered in the differential diagnosis. Injections of local anesthetic can be helpful in
differentiating between a neuroma and second MTP synovitis.
To aid in diagnosis the drawer test can be used to test for stability of the affected MTP joint. This
is performed by dorsiflexing the involved toe to 25° and applying a dorsal force to the toe. Laxity
and pain with this maneuver is caused by attenuation of the plantar plate and collateral ligaments.
Additionally, a callus may be present on the plantar surface of the affected toe or over the dorsum
due to impingement on the toebox of footwear.
Standing anterior posterior, oblique and lateral radiographs of both feet should be obtained. These
may reveal subtle joint space widening due to synovitis in the early stages of the disease, and later
may show obvious medial deviation at the second MTP joint (see Fig. 10.1B).
Nonoperative measures should be considered first; these include the use of anti-inflammatory medications, corticosteroid injection into the second MTP joint, and footwear modification
to accommodate the deformity. The shoe upper should be made of softer, flexible material, and
stretched over the prominence with a ring and ball stretcher. A pad or silicone sleeve may be used
over the second toe to reduce pain and corn formation. The affected toe may be taped to the adjacent
toe in a more aligned position. Orthotics with excavation under the metatarsal head may be used
when the predominant symptom is metatarsalgia. When conservative management fails to provide
adequate pain relief, surgical treatment can be considered.
Relative contraindications to surgery include peripheral vascular disease, diabetes mellitus, and
an immunocompromised patient. Other contraindications include infection, inability to maintain
protected weight bearing, and severe vascular insufficiency of the toes.
Preoperative Planning
The weight-bearing radiographs should be carefully studied prior to surgical intervention. If symptomatic hallux disorders are present, these could be corrected to provide adequate room for correction of the second toe. The length of the second metatarsal should be evaluated in relation to the
neighboring metatarsals. The second metatarsal should be at approximately the same level as the
first metatarsal, and should follow the normal decreasing metatarsal length cascade. If the second
metatarsal is too long, then a shortening osteotomy should be considered. The amount of shortening required to bring the second metatarsal into alignment with the rest of the metatarsal should be
determined by measurements taken from the preoperative radiographs.
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Surgical Techniques
Technique 1: Extensor Digitorum Longus to Extensor Digitorum
Brevis Transfer For Varus/Valgus Lesser Toe Deformity
The patient is supine, and ankle block anesthesia is administered. An Esmarch bandage is used
as a tourniquet.
●● An incision is made dorsally starting over the PIP joint of the second toe and extended 5 cm proximally in line with the metatarsal shaft to expose the EDL and EDB tendons (Fig. 10.2).
●● An EDL Z-lengthening is performed. It is important to ensure that long limbs are created so that
there is adequate length to reroute the tendon (Fig. 10.3).
●● The EDL is detached from the dorsal capsule and the extensor hood from its insertion to 4 cm
proximal to the MTP joint.
●● The EDB is sectioned at the distal metatarsal level distal to the musculotendinous junction.
●● The dorsal capsule, medial collateral ligament, and associated lumbrical are completely released.
The medial capsular release should extend deep but should not involve sectioning of the medial
plantar plate (Fig. 10.4).
●● If necessary, the plantar plate at the site of its origin on the distal metatarsal should be incrementally released until axial alignment of the toe is achieved.
●● Resection of the condyles of the proximal phalanx is performed if a hammer toe deformity is
present (Fig. 10.5).
●● Lateral capsule structures can be plicated if redundancy is present.
●● A 0.062-inch Kirschner wire (K-wire) is placed antegrade through the middle and distal phalanges
and then retrograde to the base of the proximal phalanx distal, but not through it.
●● Using a 2.5-mm drill, a transverse drill hole is created from medial to lateral at the base of the
second proximal phalanx. The drill hole should be created at the base of the proximal phalanx just
plantar to the longitudinal midline (Fig. 10.6A).
●● The distal end of the EDL is passed through the bone tunnel from medial to lateral. A suture passer
is used to facilitate the passage of the tendon through the bone tunnel (Fig. 10.6B and C).
●● The toe is then held in a small degree of valgus and plantarflexion. The 0.062-inch K-wire is
advanced into the metatarsal to hold the toe in a somewhat overcorrected position.
●● The distal stump of the EDL is sutured to the proximal stump of the EDB. Some authors advocate
passing the EDL tendon under the transverse metatarsal ligament or suturing it to the plantar
plate before the distal stump of the EDL is sutured to the proximal stump of the EDB tendon
(Fig. 10.7A and B).
●●
FIGURE 10.2
A: Dorsal view of a 78-year-old female with a painful crossover toe. B: Dorsal
­i ncision over second toe showing the EDL and EDB tendons.
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PART I Forefoot and Midfoot
FIGURE 10.3
A: Z-lengthening of EDL to second toe. The EBD tendon is sectioned. B: Long Z-lengthening of EDL.
FIGURE 10.4
Dorsal (A) and medial capsule release (B).
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FIGURE 10.5
Exposure of condyles of the proximal phalanx for
hemiphalangectomy.
The proximal limb of the EDL tendon is then sutured to the distal end of the EDB tendon
(Fig. 10.7C).
●● The tourniquet is then deflated, and the vascularity of the toes is assessed
●● The skin is closed in a layered fashion with 3-0 monocryl and 3-0 nylon suture.
●●
Technique 2: Extensor Digitorum Brevis Transfer with Oblique
Metatarsal Osteotomy For Varus/Valgus Lesser Toe Deformity
A 4-cm longitudinal incision is made in the second intermetatarsal space (Fig. 10.8). Sharp dissection is continued down to the EDB tendon of the second toe.
●● The EDB tendon is isolated from the EDL tendon (Fig. 10.9) and tenotomized in the proximal
portion of the wound. A stay suture is placed in the tendon for later use.
●●
FIGURE 10.6
A: Bone tunnel in proximal phalanx with a 2.5-mm drill from medial to lateral. B: Passing of EDL through the bone
tunnel. C: Drawing shows EDL through drill hole in proximal phalanx and sutured to proximal end of EDB tendon. The
remaining proximal EDL tendon is sutured to the distal EBD tendon.
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PART I Forefoot and Midfoot
FIGURE 10.7
A: Suturing of the proximal EDB and distal EDL tendon ends. B: Suturing of the distal EDB and proximal EDL tendon ends.
C: Longitudinal K-wire used for fixation with toe in valgus.
The second MTP joint capsule and collateral ligament from the medial side are incised. If the
lateral capsular tissues are tight, a scalpel can be used to section the lateral tissue. Hypertrophied
synovial tissue is removed from the joint as needed with a small rongeur.
●● The second metatarsal head is visualized by plantarflexing the second toe.
●● An oblique (Weil) osteotomy of the second metatarsal is performed (6,18–20), taking care
to orient the saw blade correctly, with the osteotomy parallel to the plantar surface of the foot
(Fig. 10.10). If the cut is too steep, fixation may be difficult, and plantar displacement of the
capital fragment can lead to a plantar prominence, postoperative pain, and callus formation. If
the cut is too oblique, the saw blade may not be long enough to complete the cut, and the nutrient
artery to the metatarsal may be compromised. The goal of the shortening osteotomy is to restore
more normal second metatarsal length, with the second metatarsal of similar length to the first and
slightly longer than the third.
●●
FIGURE 10.8
A: Preoperative AP radiograph in a patient with a crossover toe deformity of the second and third,
severe hallux valgus, and painful hammer toe of the fourth. The second MTP joint is dislocated.
B: A dorsal longitudinal incision is made between the distal second and third metatarsals.
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FIGURE 10.9
A: EDB tendon sectioned proximally for later transfer. B: A stay suture is placed in
the proximal end of the distal EDB tendon.
FIGURE 10.10
A: Side view of metatarsal with saw oriented parallel to the plantar foot. B: Shortening of the osteotomy. C: Screw
fixation with one or two screws. Residual dorsal margin of metatarsal is removed.
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PART I Forefoot and Midfoot
FIGURE 10.10 (Continued)
D: Crossover toe, dorsal view.
E: Osteotomy with distal ­f ragment
shortened and rotated toward
­h allux and fixed with two screws.
F: Oblique osteotomy of second
­m etatarsal.
For metatarsal shortening greater than 5 mm or with an intractable plantar keratosis, two saw blades
stacked together can be used to remove a larger kerf (width of the cut) of bone. This will displace the
capital fragment dorsally as well as shorten. A pusher with millimeter striations is helpful in shortening
the capital fragment proximally by a prescribed amount as determined preoperatively (Fig. 10.11A).
●● The capital fragment is positioned with the amount of desired shortening and pinned temporarily using
a K-wire. The proposed amount of shortening is assessed under fluoroscopy. The capital fragment
in varus is rotated toward the hallux with a towel clip to further correct the deformity (Fig. 10.11B).
●● If the surgeon is satisfied with the amount of shortening and lateral deviation at the second MTP
joint, final fixation is performed. The authors prefer 2.0 mm minifragment screws, typically 10 to
12 mm in length. The first screw is placed in standard AO interfragmentary compression technique, drilling the near cortex with a 2.0 mm drill and the far cortex with a 1.5 mm drill. The
appropriate length 2.0 mm screw is then placed while pressure from plantar to dorsal is applied to
the plantar foot at the capital fragment to ensure compression (Fig. 10.12A).
●● The K-wire is removed, and the amount of shortening and position of the capital fragment are
checked under fluoroscopy. Fine-tuning of the osteotomy rotation can be accomplished by loosening the screw slightly, rotating the capital fragment the amount desired towards the hallux, and
tightening the screw (14).
●● A second 2.0 mm minifragment screw is then placed next to the first screw to provide rotational
control. This screw is not usually placed using interfragmentary compression technique unless
further compression at the osteotomy is needed (Fig. 10.12B).
●● The overhanging dorsal lip of the osteotomy is removed with a rongeur (Fig. 10.13A).
●● A K-wire is placed in an antegrade direction through the midpoint of the articular surface of
the proximal phalanx and out the tip of the toe (Fig. 10.13B). Holding the toe in valgus and
●●
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FIGURE 10.11
A: Pusher with millimeter striations can be used to measure proximal displacement of the metatarsal head. B: K-wire can
be used for temporary fixation.
plantarflexion, a K-wire is inserted retrograde across the MTP joint and into the metatarsal
(Fig. 10.13C). This maintains the toe in the desired position to allow the soft tissue structures
around the MTP joint to heal at the correct length and in the correct position.
●● The EDB tendon is sutured into the lateral capsular soft tissue, augmenting the insufficient soft
tissue structures on the lateral side of the MTP joint (Fig. 10.13D).
●● Intraoperative fluoroscopy is used to assess the metatarsal position and fixation placement
(Fig. 10.14). Routine skin closure is then performed.
Postoperative Management
The patient is placed in a hard sole postoperative shoe allowed to bear weight on the heel.
The patient should be encouraged to apply ice and elevate the operative extremity to reduce ­swelling.
●● Sutures and the K-wires are removed 2 to 3 weeks postoperatively. Taping of the second toe to
the third toe should be done as needed.
●● The patient is allowed to bear weight as tolerated in a regular shoe 6 weeks postoperatively.
●● Formal physical therapy and gait training is prescribed on an as-needed basis.
●●
●●
FIGURE 10.12
A: A 2.0-mm screw can be inserted, then loosened to allow rotation of the head in valgus using the towel clip. B: A second
2.0-mm mini-fragment screw is placed using a lag technique to compress the osteotomy.
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PART I Forefoot and Midfoot
FIGURE 10.13
A: A rongeur is used to remove overhanging bone at the osteotomy site. B: A K-wire is placed anterograde through the
midportion of the articular surface of the proximal phalanx and out the tip of the toe. C: The toe is held in valgus and
plantarflexion as the K-wire is advanced in a retrograde fashion into the metatarsal. D: The EDB tendon is sutured to
the lateral capsule soft tissue.
FIGURE 10.14
AP foot fluoroscopy shows the osteotomy position, fixation, and alignment.
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Results and Complications
The primary goal of this procedure is pain relief. It is important that patients understand this prior
to surgical intervention as recurrent or persistent deformity is possible. Fortunately, patients with
recurrent varus deformity are often asymptomatic. An associated, untreated deformity of an adjacent
toe, such as hallux valgus or third toe varus, will contribute to recurrent second toe malalignment,
and patients should understand this before surgery.
Another concern following correction of a crossover toe deformity with and without an osteotomy
is stiffness at the MTP joint. Patients will occasionally describe a sense that their second toe is “disconnected” from the rest of their foot, because of the stiffness. It is important to demonstrate and
document the MTP stiffness that is present preoperatively, as it may not be apparent to the patient
until after the operation. As with any osteotomy, delayed union or nonunion is possible. Other
complications include digital nerve injury, and vascular compromise with correction of a severe
deformity. Careful attention to detail, gentle soft tissue handling, proper preoperative planning, and
patient counseling can help to limit complications.
A wide array of surgical techniques has been reported to treat crossover toe deformity, due in
part to the dissatisfaction with previously described operations. Toe flexor tendon to extensor tendon
transfer was shown to reduce pain and improve foot function, but some patients were dissatisfied due
to residual stiffness of the toe (1). There are limited long-term follow-up data examining the outcome
after extensor digitorum longus tendon transfers; however, short-term results are encouraging. Barca
et al. utilized an extensor digitorum longus tendon transfer to treat 30 crossover toe deformities in
27 patients with average follow-up period of 21 months (range, 12 to 36 months) (2); 83% of
the patients had good or excellent results. Only one patient had a recurrence of the deformity. Some of the
more recently reported techniques, such as the Weil osteotomy with rotation of the capital fragment,
are under investigation, with encouraging early results (12). Bevernage reported a similar operation,
the translating Weil osteotomy in which a medial sliding and shortening osteotomy of the second metatarsal was performed for an overriding second toe (20). Most patients also had Scarf and Akin osteotomies performed for hallux valgus correction. Improved MTP stability was achieved in most patients.
The preferred surgical techniques continue to evolve with greater awareness of the pathoanatomy
and more critical assessment of clinical results. There is growing interest in plantar plate repair for
the crossover toe (see Chapter 11). As with other forefoot disorders, the specific operation should
be individualized to the patient.
References
1. Coughlin MJ: Crossover second toe deformity. Foot Ankle 8:29–39, 1987.
2. Coughlin MJ: Lesser toe abnormalities. Instr Course Lect 52:421–444, 2003.
3. Goldberger M: Crossover toe deformity. Oper Tech Orthop 9:45–50, 1999.
4.Kaz AJ, Coughlin MJ: Crossover second toe: demographics, etiology, and radiographic assessment. Foot Ankle Int
28:1223–1237, 2007.
5. Branch HE: Pathologic dislocation of the second toe. J Bone Joint Surg 19:978–984, 1937.
6.Davies MS, Saxby TS: Metatarsal neck osteotomy with rigid internal fixation for the treatment of lesser metatarsophalangeal joint pathology. Foot Ankle Int 20:630–635, 1999.
7. Deland JT, Sung Il-Hoon: The medial crossover toe: a cadaveric dissection. Foot Ankle Int 21:375–378, 2000.
8.Mann RA, Minzel MS: Monoarticular nontraumatic synovitis of the metatarsophalangeal joint: a new diagnosis? Foot
Ankle 6:18–21, 1985.
9. Murphy JL: Isolated dorsal dislocation of the second metatarsophalangeal joint. Foot Ankle 1:30–32, 1980.
10. Thompson FM, Hamilton WG: Problems of the second metatarsophalangeal joint. Orthopedics 10:83–89, 1987.
11. Myerson MS, Jung HG: The role of toe flexor to extensor transfer in correcting metatarsophalangeal joint instability of
the second toe. Foot Ankle Int 26:675–679, 2005.
12.Barca F, Accario AL: Surgical correction of crossover toe deformity of the second toe: a technique for tenodesis. Foot
Ankle Int 25:620–624, 2004.
13. Haddad SL: The crossover toe: use of extensor tendons in transfer techniques. Tech Foot Ankle Surg 7:45–51, 2008.
14.Kaz AJ, Coughlin MJ: Extensor digitorum brevis and weil osteotomy for crossover second toe. Tech Foot Ankle Surg
9(1):32–36, 2010.
15. Liu TH: Correction of crossover deformity of the second toe by combined plantar plate tenodesis and extensor digitorum
brevis transfer: a minimally invasive approach. Arch Orthop Trauma Surg 131:1247–1252, 2011.
16. Myerson MS: Arthroplasty of the second toe. Semin Arthroplasty 3:31–38, 1992.
17.Bevernage BD, Deleu P-A, Leemrijse T: The translating Weil osteotomy in the treatment of an overriding second toe:
a report of 25 cases. Foot and Ankle Surg 16:153–158, 2010.
18. Grimes JS, Coughlin MJ: Geometric analysis of the Weil osteotomy. Foot Ankle Int 27:985–992, 2006.
19. O’Kane C, Klmarten TE: The surgical management of central metatarsalgia. Foot Ankle Int 23:415–419, 2002.
20. Trnka HJ, Muhlbauer M, Zettl R, et al.: Comparison of the results of the Weil and Helal osteotomies for the treatment of
metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 20:72–79, 1999.
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