Transection of the plantar plate and the flexor digitorum longus tendon of the fourth toe as a complication of endoscopic treatment of interdigital neuroma. A case report

Mallet Toes, Hammertoes, Neuromas, and Metatarsophalangeal Joint Instability: 40 Years of Development in Forefoot Surgery

BACKGROUND

Today's foot and ankle surgeon has an enhanced understanding of forefoot pathology and treatment options compared to surgeons who practiced in previous decades. This paper summarizes developments in forefoot surgery in the past 40 years, specifically in treatments for mallet toe, hammertoe, neuroma, and metatarsophalangeal joint instability.

MATERIALS AND METHODS

A review of the literature was conducted using the PubMed search engine, with key terms including, "mallet toe," "hammertoe," "neuroma," "metatarsophalangeal joint instability," "plantar plate," and "forefoot surgery." Chapters in major orthopaedic textbooks covering these topics were also reviewed. We then chronicled the history of the diagnosis and treatment of these pathologies, with a focus on the past 40 years.

CONCLUSIONS

There have been major advances in understanding and treating forefoot pathologies in the past four decades; however, there remain areas for improvement both in the diagnosis and treatment of these problems.

LEVEL OF EVIDENCE

Level V, meta-synthesis.

The role of passive plantar flexion in floating toes following Weil osteotomy

Floating toes are a common complication following Weil osteotomy. The toes are passively plantarflexed via the windlass mechanism, which may play a role in floating toe. Five cadaver lower limb specimens were loaded on a custom frame and 3 different interventions were tested, including control group, Weil osteotomy group, and Weil osteotomy plus plantar plate-shortening group. The extensor tendon to the second toe was loaded with 20 Newtons of tension during the trials, and non-weight-bearing and simulated weight-bearing radiographs were taken to measure the metatarsophalangeal joint extension angle. The extension angle passively plantarflexed 11.20 degrees +/- 3.43 degrees in the control group, 0.40 degrees +/- 0.89 degrees in the Weil osteotomy group, and 8.00 degrees +/- 1.41 degrees in the Weil osteotomy plus plantar plate-shortening group. Comparison of the amount of passive plantarflexion between the groups revealed statistically significant changes between the control and Weil osteotomy groups (P = .0001), and the Weil osteotomy compared with the Weil osteotomy plus plantar plate-shortening (P < .0001); whereas no statistically significant difference was observed between the control and Weil osteotomy plus plantar plate-shortening groups (P = .0893). These results support the idea that the toes undergo passive plantar flexion due to the windlass mechanism, which is dampened by the Weil osteotomy. Dampening of the windlass mechanism may be responsible for floating toe following a Weil osteotomy.

Endoscopic nerve decompression

Endoscopic decompression for forefoot nerve entrapments is discussed in this article from not only the perspective of preoperative indications, intraoperative technique, and postoperative management, but with reference to the changing paradigm for management of this condition. Surgical results are discussed and compared with other published reports. Complications of the surgical technique are also discussed, which will give the operating surgeon a frame of reference when comparing decompression procedures to those techniques involving nerve resection. There is also a valuable discussion of current methods of diagnosis that may help the practitioner improve patient outcomes.