Emerging Insights On Surgical Correction Of Laterally Deviated Toes

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Thomas S. Roukis, DPM, PhD, FACFAS

   The most efficacious technique to correct lateral toe deviation following supplemental soft tissue balancing and lateral transposition Weil distal oblique metatarsal osteotomy is the extensor digitorum brevis tendon transposition.33,34 The technique involves transection of the extensor digitorum brevis tendon proximally and rerouting of the tendon on the medial side of the MPJ from distal to proximal and deep to the deep transverse intermetatarsal ligament. Following the transfer, surgeons can reattach the tendon to itself, tenodese the tendon to the medial aspect of the extensor digitorum longus tendon, weave the tendon through the medial capsule and periosteum, or transfer the tendon through a drill hole in the metatarsal shaft.7,33,34

   Following irrigation of the surgical site, hold the associated lesser toe in an over-corrected, plantarflexed and medially deviated position, and appose the extensor tendon complex with absorbable sutures. The surgeon can then approximate the remaining deep tissues and skin edges using his or her preferred technique.

   The surgical correction of laterally deviated toes I have described here allows for immediate weightbearing in a bulky, well-padded surgical dressing and postoperative shoe. Patients wear a “sling type” toe brace (such as a Budin splint) for 12 months to maintain the digit in a plantarflexed posture and limit the potential for secondary dorsal scar tissue induced migration of the digit.

   Additionally, one should instruct the patient to perform active and passive plantarflexion home physical therapy multiple times throughout the day to further prevent an extensus contracture. This also strengthens the intrinsic musculature and flexor apparatus for long-term digit stabilization.

   Since the techniques I have described are inherently stable, once one has removed the surgical dressings, the patient immediately can wear a gym shoe to limit postoperative edema. Once this subsides, patients are allowed to return to their shoe gear of choice.16,17 Occasionally, due to the transposition of the metatarsal head and small bone surface for contact, rotation of the metatarsal head or fracture of the dorsal shelf of bone occurs. However, loss of correction or the need to revise the surgery is exceptionally rare. Patients are allowed to return to activities as soon as their pain is tolerable and if they see a podiatrist at regular intervals to assess the incision site healing and any other related issues.

In Conclusion

Surgical correction of laterally deviated toes focuses on the lateral transposition Weil distal oblique metatarsal osteotomy coupled with soft tissue balancing of the MPJ and extensor digitorum longus tendon transfer to aid in transverse plane deformity correction at the lesser MPJ level. Additionally, one can correct the individual deformities of each toe and metatarsal simultaneously (i.e., medially deviated second toe and lateral deviated third toe), employing these techniques through the same incision.

   Surgeons should emphasize proper preoperative clinical and radiographic analysis, attention to surgical technique as well as appropriate and aggressive postoperative splinting and physical therapy in each instance to optimize outcomes.

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