An Emerging Option For Treating Severely Subluxed Lesser MPJ Deformities In Seniors

Michael Tritto, DPM

The correction of a significantly subluxed or dislocated hammertoe in an elderly patient can be a challenge to any surgeon. Over the last 22 years, I have tried numerous ways to correct the problem, all with varying degrees of success. The use of the Weil osteotomy along with other procedures, including proximal interphalangeal joint fusion, flexor transfer and now plantar plate repair from a dorsal approach, has not given me consistent results with patients who are over 65 years of age.

   I also have found plantar plate repairs to be of limited value in the severely dislocated lesser MPJ, especially in dislocations that have been present for more than just a few months. In my experience, many times the plantar plate is in poor condition and it is difficult to achieve primary repair. However, this procedure is an excellent choice if bone quality is an issue in cases in which rigid fixation may be problematic and also works well in multiplanar deformities.

   In 2007, Vanore discussed using absorbable pin fixation along with base resection of the proximal phalanx and proximal interphalangeal joint fusion to correct the most significant MPJ subluxations and dislocations.1 I know what you are thinking about going back in time with base resections but in doing these procedures with absorbable fixation, as described by Vanore, in the right patient population, I have found the results are more consistent and the reduction of the deformity is better in the short- and long-term in comparison to the other aforementioned techniques.

   Kelikian was one of the first surgeons to address the MPJ deformity with resection of the proximal phalanx base. The long-term results and complications, especially shortening of the toe and flail toe, occurred so often that he advocated for syndactyly at the same time to allow for more stabilization.2,3 However, when you look at old X-ray images of these procedures or every now and then have a patient who had one done years ago, you will see that resection of the base of the phalanx is typically well distal to the metaphyseal flare of the base of the proximal phalanx. This excessive resection, along with any procedure that was also done at the proximal interphalangeal joint, is what will typically lead to a short, flail toe.

   I believe the key to the success of this procedure, as with all procedures, is patient selection. My criteria for patient selection are based on several factors including age, severity of the deformity and the length of the time the deformity has been present. My typical patient is someone who is usually over 65 and has a significantly subluxed, usually dislocated lesser MPJ that has been present for more than three months. Some of these patients may also have a hallux valgus deformity. I also have found this procedure to be a good choice in patients with significant MPJ degeneration, with or without digital subluxation, as well as patients who have had previous surgery on the joint that requires revision.

Step-By-Step Insights On The Procedure

The technical aspect of the procedure is relatively straightforward. I use a dorsal curvilinear incision starting at the dorsal MPJ and extending distally to just past the proximal interphalangeal joint. I perform a transverse tenotomy of the extensor tendon at the dorsal proximal interphalangeal joint and detach the tendon along its medial aspect, and reflect it back to the dorsal MPJ to expose the dorsal joint capsule. If the tendon needs lengthening, I typically do z-lengthening instead of a transverse resection.

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