Proximal phalanx basilar osteotomy for resistant angulation of the lesser toes

Valgus Second Toe Deformity Treated With a Percutaneous Extracapsular Closing-Wedge Osteotomy of the Proximal Phalanx

BACKGROUND

Coronal and sagittal plane deformities of the lesser toes are common yet challenging to treat. Traditional open releases and translational Weil osteotomies can be unpredictable and lead to postoperative stiffness. We present the results of a percutaneous closing wedge extracapsular osteotomy of the proximal phalanx to treat valgus deformity of the second toe.

METHODS

Thirty-one patients underwent 40 percutaneous osteotomies at a median age of 58.6±9.4 years. Using a small dorsomedial incision, a percutaneous proximal metaphyseal medial closing-wedge extracapsular osteotomy of the second toe is performed, leaving the dorsolateral cortex intact. An irrigated low-speed, high-torque 2- × 8-mm burr is used under image guidance. The osteotomy is then closed to correct deformity and taped for 2 weeks. Patient-reported outcomes and weightbearing radiographs were obtained.

RESULTS

Questionnaire data was available for 89.7% (n=35) of cases. Most cases (91.4%) were either satisfied or extremely satisfied with the procedure. Radiographs were available for 90.0% of osteotomies, with a median length from surgery to radiographic follow-up of 1.6 years (range 0.5-6.3; SD ±1.5). Median second-toe valgus angle (STVA) decreased from 16.2±10.7 degrees to 5.0±7.0 degrees (P < .001) at final follow-up. All osteotomies united with no delayed union. There were no wound complications or infections. We found 2 cases of radiographic recurrence.

CONCLUSION

Percutaneous proximal phalanx base metaphyseal closing wedge extracapsular osteotomies of lesser toes to correct coronal plane deformity is useful adjunct to first-ray corrective surgery and is associated with high levels of patient satisfaction.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The pathology and management of lesser toe deformities

Deformities of the lesser toes are common and can be associated with significant morbidity. These deformities are often multiple, and numerous treatment strategies have been described in the literature.The goal of surgical treatment is to improve symptoms by restoring alignment and function, and avoiding recurrence. In order to achieve this, it is essential for the treating surgeon to understand the normal anatomy and pathology of the various deformities.There is a paucity of prospective studies and randomised-controlled trials assessing the efficacy of specific interventions.We describe the normal anatomy and biomechanics of the lesser toes, and the pathology of commonly adult deformities. The rationale behind various treatment strategies is discussed and the results of published literature presented. Algorithms for the management of lesser toe deformities based on current literature are proposed. Cite this article: Malhotra K, Davda K, Singh D. The pathology and management of lesser toe deformities. EFORT Open Rev 2016;1:409-419. DOI: 10.1302/2058-5241.1.160017.

Valgus toe deformity of fourth proximal phalanx due to osteochondroma treated with closing wedge osteotomy

Osteochondroma is the most common benign tumor of all benign and primary bone tumors. It rarely occurs in the proximal phalanx of the lesser toe. The treatment of osteochondroma usually consists of simple resection. However, if other deformities remain, added procedures may be considered. We report a case of a valgus toe deformity of the fourth proximal phalanx due to osteochondroma. The patient was a 21-year-old man who noticed a valgus deformity of his fourth toe over 10 years earlier. He began to experience pain in his fifth toe because of crossover of the fourth toe when wearing formal shoes. Although resection of osteochondroma was performed, the valgus deformity was not sufficiently corrected. Therefore, closing wedge osteotomy of the proximal phalanx was performed at the same time. A good outcome was achieved for this patient.

Proximal phalangeal osteotomy with proximal interphalangeal joint arthrodesis for multiplanar deformities of the second toe: historical perspectives and review of a case series

Combined transverse and sagittal plane deformities of the second toe represent a common painful condition encountered by the foot surgeon. After a period of conservative management, surgical intervention is often required. Historically, a number of surgical options have been described for the treatment of this condition, with the universal acknowledgment that an ideal surgical outcome is difficult to achieve and prone to failure. In this report, a review of previously described surgical techniques is presented, along with a retrospective analysis of 20 second toe surgical reconstructions, in 16 patients, performed between June 2003 and October 2010. Subjective outcomes were assessed by means of a mailed questionnaire, and a subset (15 second toes in 11 patients) returned for follow-up evaluation, including ascertainment of American Orthopaedic Foot & Ankle Society Clinical Rating System for Lesser Metatarsophalangeal-Interphalangeal Joint Surgery scores. Overall, the duration of follow-up was 38.25 ± 25.82 months, and the subset was followed up for 36.07 ± 27.95 months. The preoperative visual analog pain score was 4.9 ± 2.7, whereas the postoperative pain score was 1.6 ± 2.47 (p < .001). The preoperative American Orthopaedic Foot & Ankle Society score was 44.57 ± 17.76, whereas the postoperative score was 91.27 ± 12.27 (p < .001). Based on the results of this investigation, pairing a basilar proximal phalangeal osteotomy with arthrodesis of the proximal interphalangeal joint, for correction of combined transverse and sagittal plane deformities, appears to yield satisfactory long-term results.

Dorsal opening wedge osteotomy of second proximal phalanx for second MTP dorsiflexion

Level of Evidence: V, Expert Opinion

Correction of valgus second toe by closing wedge osteotomy of the proximal phalanx

BACKGROUND

Valgus deviation of the second toe can be associated with metatarsophalangeal joint pain, footwear fitting problems, and cosmetic concerns. It also reduces the buttress effect of the second toe on the hallux and may allow progression of hallux valgus. The traditional operative approaches for digital arthrodesis or lesser metatarsal osteotomy have unpredictable results.

METHODS

This study reviewed the effect of a closing wedge osteotomy on the proximal phalanx in 26 women with an average age of 59 years (SD 10) who had a valgus second toe. The patients had weightbearing radiographs preoperatively and at an average 28 months postoperatively. Clinical examination assessed for floating toe, range of metatarsophalangeal joint motion, and patient satisfaction.

RESULTS

Before surgery the average second toe valgus angle measured 28 degrees and at final review this had reduced to 14 degrees (p < 0.001). Postoperatively, the average range of dorsiflexion of the digit was 42 degrees (SD 20). The average plantarflexion was 16 degrees (SD 10). Floating of the digit was noted in five patients and recurrence of the deformity in four patients. Nineteen patients (73%) were completely satisfied with the outcome of their surgery, seven were satisfied with reservations, and no patient was dissatisfied. Twenty five patients (96%) considered their second toe to be better than before the operation.

CONCLUSIONS

Closing wedge osteotomy of the second toe is technically simple, reasonably safe, and relatively effective for valgus deformity of the second toe. Recurrence of the second toe valgus usually was associated with recurrence of hallux valgus.

Central metatarsal head-neck osteotomies: indications and operative techniques

The author presents the history and indications of various central metatarsal head-neck osteotomies with special emphasis on the radiographic assessment, vascular supply, and regional anatomy. The surgical techniques described include (1) minimal incision osteotomy; (2) Weil metatarsal osteotomy and various modifications; and (3) a novel "telescoping" osteotomy. Ancillary soft-tissue and osseous digital procedures as well as the prevention and management of potential complications are presented in detail.

Second metatarsophalangeal joint fusion: a new technique for crossover hammertoe deformity. A preliminary report

The author reports on second metatarsophalangeal joint arthrodesis for the severe crossover hammertoe deformity. Eleven patients underwent an arthrodesis of the second metatarsophalangeal joint with a.062 Kirschner wire intramedullary fixation and a dorsal small bone staple and resection of the proximal phalangeal head of the second digit. Outcomes were retrospectively reviewed at average follow-up time of 19 months. A subjective patient satisfaction survey along with a clinical and radiographic evaluation was undertaken in the postoperative period. Ten of 11 patients scored good to excellent results based on the patient subjective survey at final follow-up. Ten of 11 patients obtained primary arthrodesis. One patient experienced an asymptomatic nonunion. This new technique appears to be reliable for the maintenance of long-term correction of a crossover second toe with arthrodesis of the second metatarsophalangeal joint.

Concurrent interdigital neuroma and MTP joint instability: long-term results of treatment

INTRODUCTION

An interdigital neuroma is a common source of forefoot pain, and while second metatarsophalangeal joint instability is a less common entity, it can be a concomitant source of pain. The purpose of this study was to evaluate the long-term clinical course and surgical outcomes of the treatment of these concomitant problems.

METHODS

121 consecutive patients (131 feet and 136 neuromas) were evaluated and treated for a symptomatic interdigital neuroma from 1981 to 1997. Of these, 24 patients (20%) had a concurrent interdigital neuroma (IDN) and second metatarsophalangeal (MTP) capsular instability that underwent surgical treatment. At the final follow-up examination, 20 patients (21 feet) were evaluated by an independent orthopaedic surgeon with a standardized clinical and radiographic examination, patient self-assessment and outcome measures.

RESULTS

Overall, there were 18 females and two males (21 feet) treated with an average age of 54 years at the time of surgery that returned for examination and follow-up at an average of 80 months (48 to 108 months) following surgery. Seventeen patients (85%) rated their result as good or excellent and three as fair. Six patients had mild continued symptoms referable to the second toe and none to the neuroma. Simultaneous neuroma excision and second MTP stabilization was performed in 15 cases and in six cases a staged repair was performed. The mean visual analog pain score was 1.4 (0=no pain, 10=severe pain) and mean MHAQ score was 1.13 (1-1.625) with activity modification stemming from hip, back and knee complaints.

CONCLUSION

With careful patient selection and preoperative assessment, resection of an interdigital neuroma and stabilization of second metatarsophalangeal joint instability resulted in a high percentage of successful results at greater than four years following the procedure. Objective results were comparable to previous reports on the surgical treatment of isolated interdigital neuroma and crossover second toe reconstruction. Subjective patient satisfaction was high but both subjective and objective results were lower in patients with persistent symptoms of MTP instability.

Complications of lesser toe surgery

Surgical procedures for lesser toe problems are among the most common surgeries done on the foot. In a shoe wearing population, the incidence of lesser toe pathologic disorders is high. The complications associated with lesser toe surgery can be troublesome for patients and physicians. Understanding the possible common complications and how to avoid them is essential to maximizing satisfactory clinical results.