Emerging Insights On Surgical Correction Of Laterally Deviated Toes

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

A Closer Look At Modifications To The Weil Metatarsal Osteotomy Technique

Several modifications to the Weil metatarsal osteotomy exist. These include: “tilt-up,” “tilt-down,” medial transposition and lateral transposition of the plantar capital fragment.16,22,26

   For the purpose of this article, I will focus on the lateral transposition Weil distal oblique metatarsal osteotomy modification since this is indicated in the presence of a laterally deviated toe.16,22

   One would perform the lateral transposition Weil metatarsal osteotomy as I described above with the exception of transposing the plantar capital fragment in a lateral direction up to two-thirds the width of the remaining metatarsal shaft. Through lateral transposition of the plantar capital fragment, the toe will assume a more medial position similar to the effect that lateral transposition of the first metatarsal head has on the reduction of the hallux at the first MPJ during hallux valgus correction.16 Then hold the plantar capital fragment in full apposition and fixate it as I described above. Following that, one may gently resect any redundant dorsal osseous prominence with a rongeur.

Essential Pearls On Concomitant Toe Procedures

Performing toe procedures concomitantly with a lateral transposition Weil distal oblique metatarsal osteotomy involves transverse plane deformity correction. Surgeons can achieve this with: (1) supplemental soft tissue balancing of the MPJ; (2) a flexor digitorum longus tendon transfer; (3) a mini-Akin osteotomy of the base of the proximal phalanx; or (4) an extensor digitorum brevis tendon transposition.5-7,29-34

   Supplemental soft tissue balancing of the lesser MPJ following the lateral transposition Weil distal oblique metatarsal osteotomy consists of vertical incision of the medial capsule and reinforcement of the lateral capsule. If necessary, one may also perform a partial release of the medial plantar plate off the base of the proximal phalanx.7,29

   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.

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