Balancing Digital Arthrodesis With Flexor Tendon Transfers And MPJ Corrections

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Jerome A. Slavitt, DPM, FACFAS

   Identify the long flexor tendon with the use of a curved hemostat. When isolating the flexor tendon, plantarflex the ankle to reduce tension.5 After identifying the tendon and delivering it into the joint space, clamp the tendon as distally as possible using a straight hemostat. Cut the tendon on the distal side of the clamp and apply two curved hemostats, one on either side of the tendon. Free the plantar hood around the long flexor tendon. Using the central groove along the plantar shaft of the proximal phalanx, slice the tendon through its center to the desired length.5

   Direct your attention dorsally and release the extensor hood apparatus. Incise the capsule at the MPJ dorsally, medially and laterally, and evaluate the joint. Apply a load to the second metatarsal and determine if additional soft tissue dissection is required. If contracture is still present along with dorsal displacement, release plantar structures with a McGlamry elevator. If further digital displacement is present, a metatarsal osteotomy of your choice is required.

   One may also perform plantar plate repair at this time. Once you find the base of the proximal phalanx is articulating well with the head of the metatarsal, address lateral or medial drift. Do this by tightening either the medial or lateral capsular component.

   When it comes to type II and type III deformities, after you have transferred the flexor tendon dorsally to the base, cross and suture the tendon with the appropriate tension and desired resting position. One may use the excess tendon slips medially or laterally as an adjunct ligament to strengthen the correction.2 Suture the MPJ capsular section.

   Now that you have balanced the MPJ pathology, complete the surgery by performing the fixation for the digital arthrodesis. Reapproximate the extensor tendon and perform subsequent skin closure. It is highly recommended to obtain intraoperative C-arm pictures. This will verify exact apposition of the arthrodesis components and provides a legal document prior to patient discharge. Follow appropriate postoperative instructions based on your choice of fixation devices.

In Conclusion

In order to have successful hammertoe surgery, one must also evaluate the MPJ and correct the appropriate pathology. Evaluate the pathology and determine whether you are dealing with Slavitt classification type I, II or III pathology. Then institute the appropriate surgical procedures. Perform all capsular soft tissue releases and corrections, flexor tendon transfer positioning, metatarsal osteotomies and arthrodesis fixation, ensuring complete balance. Select a fixation device with a high rate of success. At the end of the procedure, you will be satisfied and so will your patient.

   Dr. Slavitt is board-certified by the American Board of Podiatric Surgery. He is the Chief of Podiatry in the Department of Orthopedics-Division of Podiatry at the Northwest Hospital Center in Randallstown, Md. Dr. Slavitt is also the Residency Director for the Northwest rotation of the Baltimore Veterans Administration residency program. He is also a consultant and lecturer for BioPro, Inc.

1. Fishco WD. Emerging concepts in hammertoe surgery. Podiatry Today. 2009; 22(9):34-38.
2. Baravarian B. Essential insights on flexor tendon transfers. Podiatry Today. 2007; 20(4):66-74.
3. Reber L, Baravarian B. Point-counterpoint: is plantar plate repair more effective than flexor tendon transfers? Podiatry Today. 2006; 19(6):64-73.
4. Olms K, Randt T. Current concepts in treating second MPJ pathology. Podiatry Today. 2008; 21(10):44-48.
5. Chang TJ. Masters Techniques in Podiatric Surgery: The Foot and Ankle. Forefoot surgery. Lippincott Williams &Wilkins, December, 2004.

Additional References
6. Fishco WD, Roth BJ. Digital fracture after a flexor tendon transfer for hammertoe repair: a case report. J Foot Ankle Surg. 2010; 49(2):179-181.
7. DiDomenico L. Essential insights on tendon transfers for digital dysfunction. Podiatry Today. 2010; 23(4):44-51.

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