Lesser Metatarsalgia: Are Lesser Metatarsal Osteotomies Necessary?

Ramy Fahim, DPM, and Lawrence DiDomenico, DPM, FACFAS

   Proceed to address flexion contractures via a Girdlestone–Taylor procedure. At this time, remove all deforming forces from the deformity. The surgeon should subsequently be able to place the digit and align the toe in anatomic position to the MPJ in the desired position. Additionally, with the underlying deformity, the pathology should not be able to recur. Insert a 0.062 K-wire from the distal aspect of the toes through the distal interphalangeal joint, the proximal interphalangeal joint and the metatarsophalangeal joint to the base of the metatarsal. Ensure good anatomical alignment of the distal interphalangeal joint, the proximal interphalangeal joint and the MPJ.

   Proceed to perform a tendon transfer (a weave graft) of the distal stump of the proximal extensor digitorum brevis into the most proximal portion of the distal extensor digitorum longus stump. Perform the transfer under physiological tension with the digits in good anatomic position. Pass the distal stump of the proximal extensor digitorum longus tendon into the midfoot. Perform this with the surgical assistant loading the foot 90 degrees relative to the leg. Be sure to suture the transfer of the tendon under physiologic tension for tendon balancing.

   The modified Girdlestone-Taylor procedure is for flexion contractures of the distal interphalangeal joint and/or proximal interphalangeal joint. One can perform the procedure through a midline incision approach on the medial aspect of the toe. It is recommended that one use fine double skin hooks for retraction in order to avoid soft tissue compromise. Deepen the incisions in the same plane and be careful to avoid the neurovascular bundles. Identify the flexor digitorum longus and trace it distally to its attachment to the distal phalanx. Detach the distal aspect of the flexor digitorum longus from the distal phalanx and direct it proximal to the web space.

   Proceed to direct your attention to the flexor digitorum brevis tendon. Perform a tenotomy (both the medial and lateral slips) and capsulotomy at the interphalangeal joint (for a flexion contracture of the proximal interphalangeal joint). If the distal interphalangeal joint is contracted, perform a capsulotomy there as well.

   Insert a K-wire (preferably 0.062 inches) from the distal tip of the distal phalanx to the base of the proximal phalanx. With the toe in anatomical alignment (in relation to the metatarsal), suture the flexor digitorum longus tendon to the extensor soft tissue of the proximal phalanx under physiologic tension. This will aid in the plantarflexion of the toe.

What Are The Advantages Of This Approach?

With the scars located on the medial aspect of the second digit, the procedure leaves a much more cosmetically pleasing result. Postoperatively, there is a much more natural clinical look to the toes. The resulting bursa, hyperkeratosis and ulceration eventually dissipate as one corrects the deforming forces and relieves the pressures. Since the surgeon only performs a plantar joint capsulotomy, joint instability does not occur. Therefore, frontal (rotation) and transverse plane deviation deformities do not occur. There is no surgery on bone. Therefore, one can minimize the long-term edema that often occurs after bony procedures.

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