A Closer Look At Tendon Transfers For Crossover Hammertoe

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

   Direct your attention back to the dorsum of the second MPJ and transfer the distal stump of the proximal end of the extensor digitorum brevis tendon into the proximal end of the distal stump of the extensor digitorum longus tendon via a weave graft under physiologic tension. Again, it is important to do this under physiologic tension in order to allow for the extensor digitorum brevis to dorsiflex the toe. Essentially, the modified Hibbs procedure allows the patient to maintain dorsiflexion of the toe but essentially “weakens” the dorsiflexor of the second digit.

   The modified Hibbs procedure is indicated for patients who exhibit isolated extensor substitution/recruitment or global extensor substitution/recruitment to the forefoot. Dorsal subluxations/dislocations at the MPJ are frequently linked with claw toes and hammertoes, including the crossover toe variety.

   In terms of advantages with this proposed approach, the scars with the Girdlestone-Taylor procedure are located on the medial aspect of the second digit so the procedure leaves a much more cosmetically pleasing result. There is also a much more natural appearance to the digits postoperatively. Additionally, no shortening occurs and the medial and lateral collateral ligaments remain intact so no frontal plane or transverse plane complications can occur. The cubic volume of bone is not altered so instability and shortening cannot occur. Lastly, because one limits dissection to soft tissue only, the postoperative edema is minimal in relation to bony procedures.24 Of note, any resulting bursa, hyperkeratosis and/or ulceration eventually dissipate without specifically addressing them surgically. This is because the surgeon has corrected the deforming forces and relieved the abnormal pressures.

In Conclusion

We have found the tendon balancing procedures to be successful long-term alternative approaches for second MPJ instability and resulting crossover toe deformity. We also perform a modified Lapidus and endoscopic gastrocnemius recession when these procedures are indicated.

   Our approach addresses the biomechanical cause of the instability unlike some of the more traditional or novel surgical routes. This forefoot joint sparing procedure and, if necessary, a posterior muscle lengthening along with a first ray stabilizing procedure, provide a long-term predictable outcome with limited postoperative complications.

   Dr. DiDomenico is in private practice at Ankle and Foot Care Centers in Youngstown, Ohio. He is the Section Chief of the Department of Podiatry at St. Elizabeth Hospital in Youngstown, Ohio. He is also the Director of Fellowship Training of the Reconstructive Rearfoot and Ankle Surgical Fellowship in Youngstown, Ohio. He is a faculty member of Heritage Valley Health Systems in Beaver, Pa.

   Dr. Rollandini is a third-year resident at Heritage Valley Health Systems in Beaver, Pa.

References
1. Coughlin MJ. Crossover second toe deformity. Foot Ankle. 1987; 8(1):29-39.

2. Coughlin MJ. Lesser toe abnormalities. J Bone Joint Surg Am. 2002; 84:1446-1469.

3. Weil Jr. L, Sung W, Weil LS, Glover J. Corrections of second MTP joint instability using a Weil osteotomy and dorsal approach plantar plate repair: a new technique. Tech Foot Ankle. 2011; 10:33-39.

4. Karlock LG. Second metatarsophalangeal joint fusion: a new technique for crossover hammertoe deformity. A preliminary report. J Foot Ankle Surg. 2003; 42(4):178–182.

5. Kaz AJ, Coughlin MJ. Extensor digitorum brevis transfer and Weil osteotomy for crossover second toe. Tech Foot Ankle. 2010; 9(1):32-36.

6. Curry EE. Second toe deformity correction: a treatment algorithm. Foot Ankle. 2012;11:75–83.

7. Ford LA, Collins KB, Christensen JC. Stabilization of the subluxed second metatarsophalangeal joint: flexor tendon transfer versus primary repair of the plantar plate. J Foot Ankle Surg. 1998; 37(3):217-222.

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