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When A 64-Year-Old Male Presents With Pain, Swelling And Deformity Of The Second Toe

Podiatrists often see second toe pathology in their practices. Accordingly, this author presents a case involving spontaneous rupture of the plantar plate and subsequent surgical repair using a synthetic graft and interference screws. 

More often than not, when it comes to second toe deformities, there is concomitant hallux valgus deformity. Typically, one sees long-standing conditions with these deformities. In my experience, end-stage hammer toe deformities of the second toe often lead to dislocation and medial subluxation, creating a crossover deformity. 

Correction of a dislocated second toe involves bone work along with soft tissue releases and repair. I find that the easy part is the bone work. This will typically include hammertoe repair with fusion of the proximal interphalangeal joint. If the second metatarsal is excessively long, then shortening of the bone may be in order. 

The hard part is dealing with the soft tissue damage. When evaluating the second metatarsophalangeal joint (MPJ), we know there are contractures of the soft tissue, typically dorsally and medially, as well as stretching and/or tearing of the soft tissue on the lateral and plantar aspect of the joint. To address the transverse plane part of the deformity, in my experience, the surgeon will need to release the medial capsule and plantar medial intrinsic tendon (if necessary) along with performing some sort of capsulorrhaphy on the plantar lateral capsule. 

A dorsally dislocated second toe may or may not have a medial subluxation component. If the toe is dislocated, one can be certain that the plantar capsule/plantar plate is torn. In these cases, there are a lot of options for repair. That said, if there are a lot of options, then nothing works great. In the old days, surgeons attempted to treat this deformity by fixing the hammertoe and releasing soft tissues, typically with a McGlamry elevator. Then one would manually relocate the toe and pin the toe with K-wire across the joint for four to six weeks. The hope, and I say “hope” tongue-in-cheek, was that scar tissue would hold the toe in position. 

About 20 to 25 years ago, by my observation, podiatric surgeons did not pay much attention to the plantar plate and its role in dislocation of lesser toes. Now, in my experience, most foot and ankle surgeons agree that some sort of repair of the plantar capsule/plantar plate needs to take place to stabilize the toe for long-term correction. 

One can repair the plantar plate directly through a plantar incision. This seems to be a good option when there is not a long second metatarsal needing shortening and is typically my preferred method. Many surgeons want to avoid an incision on the bottom of the foot and there are a plethora of plantar plate repair systems to facilitate this. These systems usually address the plantar plate dorsally from inside the joint using specialized suture delivery instruments that can maneuver in a tight anatomic space. I personally find all of them to be quite cumbersome. 

With these considerations in mind, let us take a closer look at a case involving spontaneous dislocation of a second toe and subsequent surgical repair. 

What The Initial Workup Revealed For A Patient Who Noted His Second And Third Toes Were ‘Spreading Apart”

A 64-year-old male presented to my office for pain and swelling on the top of his left foot that he has had for approximately two weeks. He said that he noticed his second and third toes spreading apart. The patient tried taping his toes together until he could get in to see me. He denied any injury to the foot. I saw this patient three months prior to this visit for treatment of onychomycosis. His past medical history included non-Hodgkin’s lymphoma and benign prostatic hyperplasia. His daily medications included turmeric, glucosamine, multivitamins, tamsulosin hydrochloride (Flomax) and fish oil. His past surgical history included tonsillectomy, kidney stone removal and cholecystectomy. He was married, denied tobacco use and acknowledged mild alcohol use. 

Examination of his feet revealed palpable pulses with brisk capillary refill of the toes. His skin was warm and pink. Neurological exam revealed symmetric deep tendon reflexes and epicritic sensation as intact to the toes. The dermatological exam revealed mild to moderate forefoot edema to the bases of the lesser toes on the left foot. There were no breaks in the integument. The orthopedic exam revealed pain with palpation of the left second MPJ and pain on motion of the second toe. I also noted tenderness under the second metatarsal head. X-rays, including three views of the left foot, revealed a dorsal dislocation of the second MPJ (see first photo above). There was no evidence of acute fracture.

Step-By-Step Pearls For Addressing A Spontaneous Digital Dislocation

For surgical repair, I decided that I would perform a hammertoe repair by arthrodesis of the proximal interphalangeal joint. Since his second metatarsal was not excessively long, I did not want to do an osteotomy of the second metatarsal. For repair of the plantar plate, I decided to use a synthetic graft to create a new plantar plate (see second photo above). The patient’s larger body habitus (approximately 250 pounds) factored into this decision. 

I made a standard midline incision on the second toe and extended it to the metatarsal neck. Subsequent dissection down to the deep fascia allowed visualization of the extensor tendon. I proceeded to perform an extensor hood recession, starting at the proximal interphalangeal joint and ending at the metatarsal neck. A transverse incision at the dorsal MPJ capsule exposed the joint. With a dislocated joint, as in this case, the base of the proximal phalanx rested on top of the metatarsal head (see third photo above). 

Using a McGlamry elevator, I released adhesions to the plantar metatarsal head and neck. Dissection at the base of the proximal phalanx allowed for some exposure on the plantar side and enabled me to rough up the bone to help with soft tissue adherence. I subsequently made bone tunnels in the base of the proximal phalanx and the metatarsal neck. One can use a K-wire to act as a guide pin (see fourth photo above) and employ a cannulated drill to make the tunnel from dorsal to plantar. 

I proceeded to use a synthetic graft strip made of wet spun polycaprolactone (PCL)-based polyurethane urea measuring 0.3 cm x 0.8 cm to create a new plantar plate. The use of a suture passer through the bone tunnel on the proximal phalanx from dorsal to plantar allows one to place the aforementioned graft strip in the loop and pull it through the bone to the dorsal side (see fifth photo above). The surgeon may use a 0.3 cm interference screw to secure the graft to the phalanx (see sixth photo above). Then one inserts the suture passer through the metatarsal bone tunnel from dorsal to plantar, pulling the free end of the graft up through the bone tunnel. 

Typically, I will slightly overcorrect the deformity and when there is adequate tension on the graft, I insert the interference screw in the metatarsal and cut the excess graft with a scalpel (see seventh photo above). At this time, I repaired the hammertoe in the usual fashion by preparing the proximal interphalangeal joint and fixating the toe with a K-wire (see eighth photo above). At this point, I evaluate the repair and if there is any medial drift of the toe, I will consider releasing some of the medial capsule and performing a lateral capsulorrhaphy. 

His postoperative course was uneventful. I kept him fully weightbearing in a fracture boot after surgery. At one week postoperative, his X-rays revealed good alignment (see ninth photo above) and his clinical exam at four weeks revealed good correction (see 10th photo above). Clinically, the patient’s range of motion of the second MPJ was good and he noted no pain with motion. I did not appreciate any laxity with an anterior drawer test. 

This is a current case so I do not have any long-term follow up at this time. Pin removal took place the patient’s six week follow-up. At his three-month postoperative visit, he related no complaints or problems with the surgery. He is back to full duty at work in the construction industry as a foreman. Clinically, the toe is in a rectus position and has pain-free range of motion. Additionally, X-rays reveal no recurrence of deformity. I have performed this technique in other cases and I have not had to revise any of these cases for failure at this time.

In Summary

This case illustrates a spontaneous rupture of a plantar plate and subsequent surgical repair using a synthetic graft and interference screws. Not only is this technique easy to perform, it does not require a plantar incision or metatarsal osteotomy, and I feel it may provide greater plantar plate strength to prevent recurrent rupture.

Alternatives to wet-spun polycaprolactone (PCL) based-polyurethane urea synthetic grafts with this technique include using tendon graft or FiberTape (Arthrex). The advantage of the aforementioned synthetic graft is that it is stronger than tendon, allows for flexibility like tendon and ligament, and it will eventually be incorporated and replaced by regenerative tissues.1

Dr. Fishco is board-certified in foot surgery and reconstructive rearfoot and ankle surgery by the American Board of Foot and Ankle Surgery. He is a Fellow of the American College of Foot and Ankle Surgeons, and a faculty member of the Podiatry Institute. Dr. Fishco is in private practice in Phoenix. 

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By William Fishco, DPM, FACFAS
References

1. Petranto RD, Lubin M, Floros RC, et al. Soft tissue reconstruction with Artelon for multiple foot and ankle applications. Clin Podiatr Med Surg. 2018;35(3):331-342.

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