A Closer Look At Tendon Transfers For Crossover Hammertoe

Start Page: 44
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Author(s): 
Lawrence A. DiDomenico, DPM, FACFAS, and Jobeth Rollandini, DPM

   If the surgeon appropriately addresses the multiplanar crossover deformity, he or she should be able to correct all planes of deformity. A modified Girdlestone-Taylor procedure can transfer the flexor digitorum longus tendon to the extensor hood. A modified Hibbs procedure will release the extensor medial and varus pull of the pathologic position. The modified Hibbs procedure can decrease the extensor tendon retrograde buckling of the second digit on the second metatarsal. Furthermore, this release will allow the surgeon to mobilize the crossover toe out of the varus and medially directed position while providing excellent exposure to the metatarsophalangeal joint.

   When performing the modified Hibbs procedure for a crossover hammertoe, one can make an incision that is approximately 2 to 3 cm. Begin the incision at the second MPJ and direct it proximal and lateral. Deepen the incision in the same plane to the level of the extensor digitorum longus tendon. Lateral to the extensor digitorum longus tendon lies the smaller extensor digitorum brevis tendon. Transect the extensor digitorum longus as far as proximal in the incision site and transect the extensor digitorum brevis as far as distal in the incision site.

   At this time, one can appreciate fantastic exposure to the second MPJ. The exposure of the MPJ will allow the surgeon to perform a complete release of the contracted and fibrous/deformed capsular tissue. At this time, remove all deforming forces of the MPJ. This facilitates the release of all contractures via sharp dissection and a McGlamry elevator, which allows for anatomic restoration of the MPJ. Essentially, the toe should be relaxed into a neutral “limp position” as all the deforming forces of the second MPJ pathology are gone.

   Direct your attention to the medial aspect of the second digit where you can perform a modified Girdlestone-Taylor procedure. Use a midline incision approach on the medial aspect of the toe. We recommend that the surgeon use fine double-prong skin hooks for retraction in order to avoid soft tissue compromise.

   Then deepen the incision in the same plane, taking care to avoid the neurovascular bundles. Carry the incision deep to identify the flexor digitorum longus and trace it distally to its insertion of the distal phalanx. Detach the distal insertion of the flexor digitorum longus from the distal phalanx and direct it proximal to the web space.

   Proceed to direct your attention to the flexor digitorum brevis tendon. Perform a tenotomy (both the medial and lateral slips) and capsulotomy at the interphalangeal joint (for a flexion contracture of the proximal interphalangeal joint). If the distal interphalangeal joint is contracted, perform a capsulotomy there as well. At this time, remove all flexion and extension contractures as well as the deforming forces from the second digit and MPJ.

   At this time, the surgeon can place the second toe into the desired anatomic position and insert a 0.062-inch Kirschner wire to stabilize and align the digit in the corrected position. Insert the K-wire from the distal tip of the distal phalanx to the base of the second metatarsal. With all the deforming forces gone and the digit in the desired anatomic position (in relation to the metatarsal), suture the flexor digitorum longus to the extensor hood under physiologic tension. It is imperative to suture this under physiologic tension as this tendon transfer will assist the lumbricales with plantarflexion and allow the toe to purchase the ground postoperatively.

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