Emerging Insights On Surgical Correction Of Laterally Deviated Toes

Author(s): 
Thomas S. Roukis, DPM, PhD, FACFAS

Given the myriad of possible etiologies for deviated second or third toes, it is valuable to have a range of treatment options. This author offers a closer look at surgical management and current concepts with the Weil distal oblique metatarsal osteotomy, the extensor digitorum brevis tendon transfer and soft tissue balancing of the lesser metatarsophalangeal joint.

   Pathology of the lesser toes and central metatarsals is complicated and involves a variety of potential etiologies.1-7 These etiologies include: soft tissue pathology; structural metatarsal deformities; functional metatarsal deformities; and intra-articular pathology.

   One of the most complex deformities involves transverse plane deviation of the lesser toes. The medially deviated second toe has received much attention, especially when it is combined with sagittal plane contracture (i.e., crossover toe).5,8 However, lateral deviation of the second and/or third toe represents commonly seen but infrequently discussed problems.7,8

   After diagnosing lateral deviation of the second and/or third toe, one can choose between symptomatic relief care, conservative measure accommodation and/or reduction of the deformity, or surgical intervention. When it comes to symptomatic relief care, options include cryotherapy, non-narcotic analgesic/anti-inflammatory, topical liniment or decreased activities. In regard to accommodation and/or reduction of the deformity, conservative measures include tape or commercially available splintage, metatarsal pad or insole use, and/or stiff-soled shoes. One may also consider surgical intervention options such as metatarsal osteotomy, digital arthrodesis and soft tissue procedures.7,9-12

   Although not all inclusive, this article will focus on the lateral transposition Weil distal oblique metatarsal osteotomy, the extensor digitorum brevis tendon transfer, and soft tissue balancing of the lesser metatarsophalangeal joint (MPJ) for surgical correction of the laterally deviated second and/or third toes.

Keys To Determining The Metatarsal Length Pattern

When deciding on operative intervention, it is critical that the surgeon determines the metatarsal length pattern. Radiographic analysis is the gold standard by which one determines the metatarsal length parabola.

   Bojsen-Møller conducted a mechanical study and determined the most mechanically effective metatarsal length pattern.13 This pattern is one in which the second metatarsal is the longest, the third is the same length as the first, the fourth is shorter than the third, and the fifth is shorter than the fourth (i.e., 2>1=3>4>5).

   Maestro and colleagues have defined the normal relative metatarsal length parabola according to the “Maestro line.”14 This refers to the line passing from the center of the fibular sesamoid, perpendicular to the longitudinal bisection of the second metatarsal, and through the fourth metatarsal head. In a series of 40 “normal” feet, employing the aforementioned Maestro line, Maestro and colleagues determined the ideal relative metatarsal length parabola.15 This length is when the first metatarsal is equal to or 2 mm shorter than the second metatarsal, the third metatarsal is 4 mm shorter than the second, the fourth metatarsal is 6 mm shorter than the third metatarsal, and the fifth metatarsal is 12 mm shorter than the fourth metatarsal (i.e., 1=2>3>4>5 or 13>4>5).

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