McGlamry's Forefoot Surgery

McGlamry's Forefoot Surgery

1st Edition
2004
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10 9 8 7 6 5 4 3 2 1
Editors
Alan S. Banks D.P.M., F.A.C.F.A.S.
Director of Residency Training

Emory Northlake Regional Medical Center
Private Practice
Peachtree Podiatry Group, P.C.
Tucker, Georgia
Michael S. Downey D.P.M., F.A.C.F.A.S.
Chief
Division of Podiatric Surgery
Presbyterian Medical Center
University of Pennsylvania Health System
Professor and Immediate Past Chairman
Department of Surgery
Temple University School of Podiatric Medicine
Philadelphia, Pennsylvania
Dennis E. Martin D.P.M., F.A.C.F.A.S.

Departments of Podiatry and Orthopedics
Trident Regional Medical Center
North Charleston, South Carolina
Stephen J. Miller D.P.M., F.A.C.F.A.S.
Clinical Adjunct Faculty

Surgical Clinics
Temple University School of Podiatric Medicine
Philadelphia, Pennsylvania
Chief, Quality Assurance
Island Hospital
Anacortes, Washington
P.vii
Contributing Authors
Patrick S. Agnew D.P.M. Albert E. Burns D.P.M.
Podiatry Residency Director Professor

Eastern Virginia Medical School Department of Podiatric Surgery
President California College of Podiatric Medicine
American College of Foot and Ankle Pediatrics Past Chief and Staff
Norfolk, Virginia Department of Surgery
Pacific Coast Hospital
San Francisco, California
Robert G. Aguilar D.P.M.
Podiatry Section
Veteran's Administration Medical Center Craig A. Camasta D.P.M., F.A.C.F.A.S.
Augusta, Georgia
Faculty
The Podiatry Institute Tucker, Georgia Chief
Tzvi Bar-David D.P.M. Department of Surgery
Emory Park Medical Center
Lecturer
Lithia Springs, Georgia
Department of Orthopaedic Surgery
Columbia University College of Physicians and
Surgeons Bradley D. Castellano D.P.M.
Professional Associate
Section Chief of Podiatry
Department of Orthopaedic Surgery
New York Presbyterian Hospital-Columbia
Lee Memorial Hospital
Presbyterian Medical Center
Fort Myers, Florida
New York, New York
Alan R. Catanzariti D.P.M.

Gary R. Bauer D.P.M.
Department of Surgery Director
Temple University Podiatric Residency Training Program
School of Podiatric Medicine Department of Surgery
Philadelphia, Pennsylvania Division of Foot and Ankle Surgery
The Western Pennsylvania Hospital
Pittsburgh, Pennsylvania
Marc R. Bernbach D.P.M.
Community Faculty
Thomas J. Chang D.P.M.
Yale Primary Care Residency Program
Podiatric Section Past Professor and Chairman
Department of Surgery Department of Podiatric Surgery
Waterbury Hospital Health Center California College of Podiatric Medicine
Waterbury, Connecticut Chief of Podiatry
Department of Orthopedics
University of California, San Francisco—Mt. Zion
Edwin L. Blitch IV D.P.M.
Hospital
Private Practice San Francisco, California
Lowcountry Family Podiatry
P.viii
Luke D. Cicchinelli D.P.M. Paul M. Greenberg D.P.M.
Faculty Attending Surgeon
The Podiatry Institute Tucker, Georgia Chief Department of Surgery
Division of Podiatry St. Luke's—Roosevelt Hospital
Pitt County Memorial Hospital New York, New York
Greenville, North Carolina
Charles J. Gudas D.P.M.
Mary E. Crawford D.P.M., F.A.C.F.A.S. Bon Secours—St. Francis Hospital
Board of Advisors Charleston, South Carolina
Northwest Podiatric Foundation for Education
and Research, U.S.A. Louis A. Jimenez D.P.M.
Director of Education and Residency Training Faculty
Northwest Podiatric Surgical Residency Program The Podiatry Institute
Swedish Medical Center Department of Podiatry
Seattle, Washington Emory Northlake Regional Medical Center
Tucker, Georgia
Gary L. Dockery D.P.M., F.A.C.F.A.S. Residency Instructor
Founder and Scientific Chairman Department of Podiatry
Northwest Podiatric Foundation for Education Atlanta VA Medical Center
and Research, U.S.A. Decatur, Georgia
Seattle, Washington
Sonya Kurichh D.P.M.
Michael S. Downey D.P.M., F.A.C.F.A.S. Resident
Chief Podiatry Section
Division of Podiatric Surgery Veteran's Administration Medical Center
Presbyterian Medical Center Augusta, Georgia
Professor and Immediate Past Chairman Scot D. Malay D.P.M., F.A.C.F.A.S.
Department of Surgery Director
Temple University School of Podiatric Medicine Resident Research
Philadelphia, Pennsylvania Presbyterian Medical Center
William D. Fishco M.S., D.P.M. Philadelphia, Pennsylvania
Faculty
The Podiatry Institute Tucker, Georgia Private Dennis E. Martin D.P.M., F.A.C.F.A.S.
Practice Departments of Podiatry and Orthopedics
Flagstaff, Arizona Trident Regional Medical Center
Donald R. Green D.P.M.
Clinical Assistant Professor Dalton E. McGlamry D.P.M., F.A.C.F.A.S.,
Department of Orthopedics D.SC.(HON.), D.H.L.
University of California, San Diego Medical Peachtree Podiatry Group, P.C.
Center Founding Member
Podiatric Residency Director The Podiatry Institute
Department of Surgery Tucker, Georgia
Scripps Mercy Medical Center
San Diego, California Michael C. McGlamry D.P.M., F.A.C.F.A.S.
Staff
North Florida Regional Medical Center
Gainesville, Florida
P.ix
Stephanie Comer Merritt D.P.M. Department of Podiatry
Private Practice Emory Northlake Regional Medical Center
Roswell, Georgia Tucker, Georgia
Stephen J. Miller D.P.M., F.A.C.F.A.S. Molly Schnirring-Judge D.P.M.

Clinical Adjunct Faculty Director
Surgical Clinics Externship Program
Temple University School of Podiatric Medicine Section of Podiatric Surgery
Philadelphia, Pennsylvania St. Vincent Charity Hospital
Chief, Quality Assurance Cleveland, Ohio
Island Hospital Staff Surgeon
Anacortes, Washington Department of Surgery
Editorial Advisor St. Charles Hospital
Journal of the American Podiatric Medical Oregon, Ohio
Association
Bethesda, Maryland Carolyn J. Sharrock-Maher D.P.M.
Resident in Podiatric Surgery
Robb A. Mothershed D.P.M. Department of Surgery
Faculty Saint Francis Hospital and Medical Center
The Podiatry Institute Tucker, Georgia AO Hartford, Connecticut
Alumni Department of Orthopedics
University of Washington Jeffrey E. Shook D.P.M.
Seattle, Washington Residency Director
Private Practice Huntington Podiatric Surgical Program
Winston-Salem, North Carolina St. Mary's Hospital
Huntington, West Virginia
Aprajita Nakra D.P.M.
Private Practice Thomas F. Smith D.P.M.
Mesa, Arizona Faculty and Board Member
The Podiatry Institute
Charles F. Peebles D.P.M. Tucker, Georgia
Faculty Residency Director, Podiatry Service
The Podiatry Institute Tucker, Georgia Private Department of Surgery
Practice Dwight David Eisenhower Army Medical Center
Ft. Walton Beach, Florida Fort Gordon, Georgia
Chief, Podiatry Section
Keith D. Pfeifer D.P.M. Department of Surgery
Staff Podiatrist University Hospital
Dwight David Eisenhower Army Medical Center Augusta, Georgia
Fort Gordon, Georgia
Joe T. Southerland D.P.M., F.A.C.F.A.S.
Jane Pontious D.P.M. Faculty
Associate Professor The Podiatry Institute Tucker, Georgia Private
Department of Surgery Practice
Temple University School of Podiatric Medicine Arlington Podiatry
Philadelphia, Pennsylvania Arlington, Texas
John A. Ruch D.P.M., F.A.C.F.A.S. Claire A. Sun D.P.M.

Director Resident
Medical Education Department of Podiatric Surgery
The Podiatry Institute Emory Northlake Regional Medical Center
Staff Tucker, Georgia
P.x
John V. Vanore D.P.M.
Medical Staff
Riverview Regional Medical Center
Private Practice
Gadsden, Alabama
Harold W. Vogler D.P.M., F.A.C.F.A.S.
Research Fellow
Laboratory of Functional Anatomy and
Biomechanics
University of Copenhagen, Panum Institute
Copenhagen, Denmark
Section of Foot Surgery
Sarasota Memorial Hospital
Sarasota Orthopedic Associates
Sarasota, Florida
Carl R. Wagreich D.P.M.
Co-Director
Baja Project for Crippled Children
Mexicali, Mexico
Director of Residency Education
Department of Podiatric Surgery
Healthsouth Surgery Center of South Bay
Torrance, California
Gerard V. Yu D.P.M.
Senior Clinical Instructor

Department of Family Practice
Case Western Reserve University School of
Medicine
Director, Podiatric Medical Education
Section of Podiatry
Division of Orthopedic Surgery
St. Vincent Charity Hospital
Cleveland, Ohio
P.xi
Preface
McGlamry's Forefoot Surgery consists of a compilation of the most popular chapters from the third edition of McGlamry's Comprehensive
Textbook of Foot and Ankle Surgery. We are providing this information in a separate format in response to requests from foot and ankle
surgeons both here and abroad who are interested primarily in forefoot surgery. The interest in foot surgery is rapidly expanding
throughout many areas of the world, and with that, there is a growing need for readily available material that will assist in the
development of knowledge and skills for the management of the more common conditions of foot surgery. The chapters in this volume are
taken without alteration from the more comprehensive reference book. The editors hope that providing this version of the material will
lead to improved treatment of common foot problems.
Contents
Preface
Editors
Contributing Authors
Contents
Chapter 1 Nails
Chapter 2 Morton's Neuroma
Chapter 3 Lesser Ray Deformities
Chapter 4 Implants
Chapter 5 Introduction and Evaluation of Hallux Abducto Valgus
Chapter 6 Anatomic Dissection of the First Metatarsophalangeal Joint for Hallux Valgus Surgery
Chapter 7 Distal Metaphyseal Osteotomies in Hallux Abducto Valgus Surgery
Chapter 8 Proximal Procedures of the First Ray
Chapter 9 Osteotomies of the First Metatarsal Shaft in Hallux Abducto Valgus
Chapter 10 Arthrodesis of the First Metatarsophalangeal Joint
Chapter 11 Juvenile Hallux Abducto Valgus Deformity
Chapter 12 Traditional Procedures for the Repair of Hallux Abducto Valgus
Chapter 13 Surgical Procedures of the Hallux
Chapter 14 Complications of Hallux Abducto Valgus Surgery
Chapter 15 Hallux Limitus and Hallux Rigidus
Chapter 16 Metatarsus Adductus and Allied Disorders
Chapter 17 Congenital Deformities
Chapter 18 Trauma to the Nail and Associated Structures
Chapter 19 Dislocations
Chapter 20 Digital and Sesamoid Fractures
Chapter 21 Callus Distraction Principles and Indications
Subject Index
P.1
Chapter 1
Nails
Gary L. Dockery
The toenail is a specialized keratinized appendage with a primary function of protection for the distal phalanx. It is capable of only a
limited number of pathologic responses, many of which are reviewed in this chapter.
Unlike skin and hair, the nail does not shed or desquamate and is not cyclic. Nails are hard because of a relative lack of water content as
compared with the stratum corneum (1 ). Water flux across the nail is ten times that across skin; however, the nail plate is unable to hold
water because of its low (less than 5% by weight) lipid content (2 ). Moreover, the relatively high sulfur content in nails, predominantly in
the form of cystine, appears to contribute to their hardness. Nails are 9.4% cystine by weight compared with 1% in callus (3 ).
Because the nail is hard and does not desquamate, many of the conditions involving the nails become more difficult to treat either with
medication or by surgical means. A thorough knowledge of the properties of the nail and its surrounding anatomic structures increases the
effectiveness of all treatment programs and enables the physician to provide better cosmetic results (4 ).
ANATOMY
The nail consists of a nail plate and the supporting tissues surrounding it (Fig. 1 ). Nail growth appears to be continuous, with little change
in the overall rate. Toenails extend distally approximately 0.03 to 0.05 mm a day. The thickness of the toenail is between 0.05 and 1.0 mm.
The toenail is set on the dorsal surface of the distal end of the toes in grooves that are referred to as the lateral and proximal nail grooves
(Fig. 2 ). The grooves are covered by corresponding folds, the lateral and proximal nail folds. The nail plate itself appears translucent in
areas where it is not attached to the underlying nail bed. The areas that are attached to the underlying adherent and vascular nail bed
appear pink as the result of the transmission of color from this area.
Many digits display a white semicircular lunula at the proximal end of the nail plate, which is the topographic marker of the nail matrix.
The lunula represents the junction point between the nail matrix and the nail bed. The nail matrix, which synthesizes the nail plate
substance, extends proximally under the nail fold about 5 to 10 mm in depth. The region underlying the free edge of the nail plate distal to
the nail bed and proximal to the epidermis of the tip of the digit is the hyponychium. Overlapping the matrix of the nail is the proximal
nail fold, the stratum corneum of which is prolonged distally as a thin, cuticular fold, the eponychium. Below the nail lies the germinative
zone that, together with the subjacent corium, forms the nail bed (5 ).
Circulation to the nail is supplied by two arterial arches derived from the two digital arteries. The digital arteries course laterally on the
digits and give off multiple small dorsal branches into the pulp space of the distal phalanx. These dorsal branches, in turn, divide to form
the distal and proximal arches (Fig. 3 ). An additional branch leaves the digital artery at the midportion of the middle phalanx and does not
enter the pulp space but courses over the distal interphalangeal joint space. This serves the proximal matrix and provides the corollary
circulation (6 ).
The hallux receives its innervation from four nerves: (a) a digital branch of the deep peroneal that supplies the lateral dorsal area, (b) the
medial dorsal cutaneous nerve, (c) the lateral common digital nerve from the medial plantar nerve that supplies the lateral plantar area,
and (d) the medial digital nerve from the medial plantar nerve that supplies the medial plantar area of the hallux (7 ) (Fig. 4 ).
Because of the orientation of the matrix cells in a forward position and because of pressure exerted by the posterior nail fold, the nail
grows forward and flat rather than upward. If a portion of the nail matrix is rearranged because of injury or surgery, or if it is grafted on
the skin away from the nail fold, it will produce a nail that projects straight up from its surface (8 ). If the nail is completely removed, the
upward pressure will force the distal nail bed to bend and elevate upward, causing a deformation of the distal nail bed. As the new nail
begins to grow out, it approaches the end of the toe only to meet this soft tissue wall, which tends to bulge the soft tissues upward around
the distal part of the new nail, and the result is the creation of an ingrown or clubbed nail (9 ) (Fig. 5 ).
P.2
FIG. 1. Clinical appearance of the toenail. A, free nail edge; B, point of separation of the nail from the bed; C, nail plate; D, lunula;
E, cuticle; F, eponychium; G, skin overlying the posterior nail fold.
FIG. 2. Illustrative anatomy of the nail and diagram depicting the longitudinal cross section of the toenail.
FIG. 3. Blood supply to the hallux. (Redrawn from Scher RK. Nail surgery. In: Epstein E, Epstein E Jr, eds. Techniques in skin surgery.
Philadelphia: Lea & Febiger, 1979:164-170, with permission.)
FIG. 4. Nerve supply to the hallux.

P.3
FIG. 5. Avulsion of the nail allows the distal nail bed to deform upward, causing hypertrophy of nail lip that may result in an
embedded or clubbed nail as the new nail grows outward.
PATHOLOGIC CONSIDERATIONS
Changes in the toenails may be caused by disease, trauma, infection, biomechanical abnormalities, hereditary or genetic factors, and the
effects of aging (10 ). The toenails offer little or no benefit, with the possible exception of protection to the dorsal toes; however, they
represent a large number of complaints in patients with foot problems (11 ). Krausz in 1950 reported a nail survey of 4,600 podiatric
patients with a total of 2,788 nail disorders that comprised 60% of the complaints (12 ). In a follow-up article in 1970 (13 ), he reported on
10,900 podiatric patients with a total of 6,754 nail problems (61%). The 4 most commonly reported problems were as follows:
onychocryptosis, 1,765; onychauxis and onychogryposis, 1,493; onychophosis, 1,334; and onychomycosis, 551.
The nail itself is capable of only a few types of reaction patterns and is therefore predictable in its changes. Similar changes are shared by
many different types of conditions and diseases. Skin and nail changes begin to occur as people age. The toenails thicken and show a
slowing in growth, and they become more susceptible to disease (14 ). Other factors such as associated osseous disorders may also cause
changes in nail growth and may create problems affecting toenails (15 ). Nail changes may occur during pregnancy (as early as the sixth
week) and consist of transverse grooving, increased brittleness, softening, and distal onycholysis (16 ).
Pathologic Anatomy
Diseases and disorders of the nails may be classified into divisions according to (a) maladies peculiar to the nails themselves, (b)
onychodystrophies, (c) ungual manifestations of dermatitis, (d) ungual manifestations of systemic disease, and (e) congenital conditions of
the nails (17 ). The diseases themselves can be grouped into different classifications according to the most common types, which include (a)
infection, (b) psoriasis, (c) contact dermatitis, (d) eczematous dermatitis, (e) hypovitaminosis, (f) tumor, (g) trauma, and (h) general
disease (18 ).
Anonychia, the absence of nails, affects one or more nails and is usually congenital. It may be seen in nail-patella syndrome (hereditary
onychoosteodysplasia) (19 ). Beau's lines are transverse lines or grooves in the nail plate that may be associated with trauma or a disease
process.
Brittleness of nails is common and may be caused by local or general factors, including nutritional disturbances, thyroid disorders, skin
conditions, and aging. Constant immersion in water and exposure to certain chemicals may also cause brittleness of the toenails.
Clubbing of the nails may be seen in congenital heart disease and chronic pulmonary diseases and may also be associated with subacute
bacterial endocarditis. Discoloration of nails may be caused by external or internal causes and may give clues to underlying systemic
disease.
Dystrophic fissured nails are usually secondary to trauma but may also be a response to infection (Fig. 6 ). Hemorrhage may be visualized
by subungual hematoma, which is almost always the result of trauma (Figs. 7 and 8 ). Splinter hemorrhages of the toenails may also be
seen in subacute bacterial endocarditis and in certain types of dermatoses. Splinter hemorrhages have been reported in adult vitamin C
deficiency syndrome (20 ).
Hypertrophy of the toenails may result from trauma or from developmental anomalies such as pachyonychia congenita (21 ). Other causes
of nail hypertrophy are psoriasis, fungal infections, and Darier's disease (22 ).
Koilonychia, spoon-shaped nails, are most commonly seen as a symptom of iron deficiency anemia. This may be a temporary disorder in
young children and is also seen as a congenital anomaly.
Onychauxis is caused by hyperkeratosis of the nail bed itself. This may be secondary to local or systemic disease
P.4
and may be the result of trauma. Fungal and bacterial infections also cause onychauxis.
FIG. 6. Dystrophic fissured toenail secondary to infection.
Onychoclavus, a type of onychophosis of the edge of the fifth toenail, appears as a complication of wearing shoes with narrow or pointed
toes or from pressure of deformed nail margins (23 ). This may also occur as a result of bony spurring beneath the margin of the nail or
from varus rotation of the toe that causes the patient to walk on the side of the digit.
Onychocryptosis, ingrowing of toenails, is seen more frequently than any other nail condition. Considerable time is spent dealing with the
medical and surgical treatment of this particular problem.
Onycholysis, a separation of the nail from the nail bed, is one of the most common nail symptoms and is found as a result of trauma,
psoriasis, fungal infections, and certain drug reactions (6 ).
FIG. 7. Subungual hematoma of the hallux caused by trauma.
FIG. 8. Subungual hematomas typically seen in runners.
Pitting of the toenails is common in several types of dermatoses and is also seen in alopecia areata and fungal infections. Minor degrees of
pitting are seen in healthy nails, and when no other skin complaints are found, it is considered to be a normal variant. Psoriasis is the
condition in which pitting is seen most frequently (24 ); however, pitting can be found in patients with other conditions, including lichen
nitidus (25 ).
Pterygium formation is a condition in which the cuticle appears to grow forward on the nail plate and the nail is split into two portions
that gradually become smaller as the pterygium widens. This condition occurs as a result of impaired peripheral circulation and is seen in
lichen planus (Fig. 9 ). Shedding of the nail may result from loosening of the base, as in onychomadesis, or separation from the nail bed
(onycholysis) as a result of injury or disease.
FIG. 9. Pterygium of the hallux toenail in lichen planus.

P.5
FIG. 10. Vascular disease may cause painful toes that may be misdiagnosed as paronychia or subungual hematoma.
Splitting and striation appear longitudinally and may be the result of trauma and aging. These conditions are also seen in patients with
rheumatoid arthritis and may be secondary to nutritional deficiencies (17 ). Thinning of the nail plate is seen secondary to decreased
peripheral circulation, lichen planus, iron deficiency anemia, and epidermolysis bullosa.
Systemic Diseases
Nail changes accompanying systemic disease are relatively common complaints among patients. These changes are frequently good
indicators of internal disease. Nail changes have been reported in patients who have iron deficiency anemia, Plummer-Vinson syndrome,
idiopathic hemochromatosis, Raynaud's disease, rheumatoid arthritis, and hepatolenticular degeneration (Wilson's disease) (26 ). Painful
toes may also be misdiagnosed as onychocryptosis or paronychia when the condition is actually secondary to the ischemic pain of vascular
disease (27 ) (Fig. 10 ).
FIG. 11. Cross section of subungual exostosis showing how this osseous condition may cause deformation of the nail bed and
incurvation of the nail plate. This condition is sometimes referred to as pincer nail.
FIG. 12. Pincer nail formation caused by subungual exostosis of the distal phalanx.
Trauma
Obvious damage to the nail plate and nail bed causes pathologic changes of the nail. Damage to the nail matrix also causes defects ranging
from grooves, pits, and ridges to frank abnormalities of the newly growing nail. Trauma may also result in the complete loss of the nail by
avulsion, and if the nail root is damaged, a thicker, discolored nail may be the result. Injury to the underlying distal phalanx may also
cause osseous change that results in deformity of the outgrowing nail. One of those lesions is the subungual exostosis that is believed to be
secondary to trauma to the dorsal toe area (Fig. 11 ). The underlying subungual exostosis may result directly in onychocryptosis (28 ). In
more pronounced cases the resultant condition is a pincer nail (Fig. 12 ). Some investigators believe that the osseous configuration of the
distal phalanx is responsible for ingrown toenails, whether it be a dorsal spur of the tip of the phalanx or the upward sweep of the phalanx
(29 ). Other reports indicate that the distal pulp of the digit, as well as the nail, may be changed because of the exostosis formation (30 )
(Fig. 13 ). Most subungual lesions occur over the distal phalanx of the
P.6
hallux (31 ,32 ). In many of these cases, in which the exostosis is a result of trauma to the distal phalanx, the moderately growing lesion
becomes painful as it enlarges, and surgical intervention is warranted (33 ) (Fig. 14 ).
FIG. 13. Lateral view showing how distal exostosis may change the configuration of the distal pulp of the digit.
FIG. 14. Traumatic exostosis of the distal phalanx that may become painful as it enlarges.
Also considered to be of traumatic origin are osteochondroma and enchondroma. Much confusion exists in the literature between
osteochondroma and subungual exostosis. Most authors agree that osteochondroma can be differentiated from exostosis because
osteochondroma has a cartilage-capped external surface. Because growth begins at or before puberty and the condition frequently is found
in patients between 10 and 25 years of age, osteochondroma sometimes is listed as congenital (34 ) (Fig. 15 ). Exostosis differs from
osteochondroma in that it has a female-to-male ratio of 2:1, whereas osteochondroma has a male predilection. The cartilaginous cap in the
exostosis is made up of fibrocartilage rather than the hyaline cartilage of osteochondromas, and finally exostoses occur away from the
epiphyseal line (35 ) (Table 1 ).
FIG. 15. Subungual hallux osteochondroma in a 13-year-old boy.
Paronychia or nail plate deformity and discoloration may occur with a solitary osteochondroma. However, this condition is rare in the distal
phalanges as compared with exostoses and osteoma (36 ).
Infections
The two main types of infections involving toenails are fungal and bacterial. Onychomycosis, infection of the toenail by fungi, is divided
into four clinical types: (a) distal subungual onychomycosis, (b) proximal subungual onychomycosis, (c) superficial white onychomycosis,
and (d) candidal onychomycosis (37 ) (Table 2 ).
A distal subungual onychomycosis is the most common variety of fungal infection of the nail. The initial infection is in the area of the
stratum corneum of the nail bed. The discoloration begins at the edge of the nail and spreads proximally. Onycholysis begins with
thickening and irregularities of the nail plate as it separates from the nail bed. The subungual debris begins to accumulate and secondary
bacterial infection may ensue. Trichophyton rubrum is the most common cause of this condition.
Proximal subungual onychomycosis begins in the stratum corneum of the proximal nail fold. It usually begins as a small, white area located
proximally on the nail plate and subsequently enlarges laterally and spreads distally. Again,
P.7
T. rubrum is the most common cause. This is also the rarest clinical form of nail fungus (26 ).
TABLE 1. Differential characteristics of exostosis, osteochondroma, and enchondroma

Tumor Age (yr) Sex ratio History of trauma Rate growth X-ray
Exostosis 20- Female/male Occasionally Moderate Trabeculated osseous

40 2:1 growth with expanded
distal portion covered
with radiolucent
fibrocartilage
Osteochondroma 10- Male/female Often Slow Well-defined sessile
25 2:1 bone growth with
hyaline cartilage cap
Enchondroma 20- Male = Often Rapid Loculated bone cyst
40 female showing radiolucent
defect, bone
expansion, and flecks
of calcification
From Norton LA. Nail disorders. J Am Acad Dermatol 1980;2:457, with permission.
Superficial white onychomycosis begins by directly invading the nail plate itself rather than extending onto the nail plate from the
adjacent stratum corneum. This form of fungal infection does not occur in the fingernails but is a relatively common infection of the
toenails. It creates a soft, white island on the surface of the nail that may spread to form large patches and encompass the entire surface
of the nail. T. mentagrophytes is the most common cause of white superficial onychomycosis (37 ).
Candidal onychomycosis usually occurs in patients with mucocutaneous candidiasis. The infection, caused by Candida albicans, begins at
the distal portion of the nail, spreads proximally the entire length of the nail, and can cause serious disfiguration. C. parapsilosis is rarely
found in the fingernails; however, this organism is isolated frequently from toenails (26 ).
Bacterial infections usually involve the tissue surrounding the toenail rather than infecting the toenail itself. Paronychia is one of the more
common nail complaints seen by the clinician treating the foot and ankle (Figs. 16 , 17 , 18 , 19 and 20 ). Various organisms such as
Staphylococcus, Streptococcus, Escherichia coli, and Pseudomonas have all been isolated from paronychial infections. Pseudomonas, one of
the few bacteria capable of infecting the nail plate, produces pyocyanin, a blue-green discoloration of the nail (26 ). Some authors believe
that onychocryptosis is actually secondary to infection rather than a problem of the nail itself (38 ). Others believe that paronychias and
onychias are actually classified incorrectly and are really subungual granuloma pyogenicum (39 ).
TABLE 2. Organisms in onychomycosis

Toenails
1. Distal subungual onychomycosis:
Dermatophytes: Trichophylon rubrum, T. mentagrophytes, Epidermophyton floccosum
Yeasts and molds: Candida parapsilosis, Scopulariopsis brevicaulis, Aspergillus, Cephalosporium, Fusarium
2. Proximal subungual onychomycosis:
Trichophyton rubrum, T. megninii, T. schoenleini, T. tonsurans
3. Superficial white onychomycosis:
Trichophyton mentagrophytes, Cephalosporium, Aspergillus, Fusarium
4. Candida onychomycosis:
Candida parapsilosis, Candida albicans
Modified from Norton LA. Nail disorders. J Am Acad Dermatol 1980;2:451-467, with permission.
FIG. 16. Stage I (mild) paronychia.
FIG. 17. Stage II (moderate) paronychia.

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FIG. 18. Stage III (severe) paronychia.
FIG. 19. Acute streptococcal paronychia with characteristic erythema surrounding an infected nail border.
FIG. 20. Pseudomonas paronychia with underlying blue-green nail plate discoloration.
TABLE 3. Benign and malignant tumors involving the nails

Benign tumors
Warts (periungual and subungual)
Fibroma (e.g., tuberous sclerosis)
Acquired digital fibrokeratoma
Neurofibroma
Myxoid cyst
Pyogenic granuloma (periungual and subungual)
Glomus tumor
Pigmented nevus
Keratoacanthoma
Bone cyst
Subungual exostosis
Osteochondroma
Enchondroma
Solitary bone cyst (e.g., aneurysmal bone cyst)
Malignant tumors
Squamous cell carcinoma (most common)
Malignant melanoma
Basal cell carcinoma
Metastatic carcinoma (e.g., club nails)
Bowen's disease
Modified from Gunnoe RE. Diseases of the nails. Postgrad Med 1983;74:357-362, with permission.
Benign and Malignant Tumors

Many different benign and malignant tumors affect the tissue surrounding the nails and involve the nails themselves (Table 3 ). The most
common type of benign tumor involving the nail is the verruca (either periungual or subungual in location) (Fig. 21 ). Acquired digital
fibrokeratoma is a benign hyperplasia caused by trauma to the digits that clinically appears as firm, hyperkeratotic nodules impinging on
the nail plate and causing a groovelike deformity similar to that seen with a mucoid cyst. It is also similar to the periungual fibroma seen in
tuberous sclerosis (40 ). Periungual fibromas may be solitary and may also occur subungually (41 ). Pyogenic
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granuloma may be periungual or subungual (39 ) and may cause malformation of the nails in a fashion similar to a painful subungual
glomus tumor, a small benign neoplasm of the skin and subcutaneous tissues, which may involve the nail bed (42 ). Benign bone cysts and
tumors may also cause changes to the overlying nail bed and subsequently changes in the nail. In a similar effect, a distal phalanx
aneurysmal bone cyst can cause secondary changes in the nail bed and the external appearance of the toenail (43 ). All these conditions
may produce pain, and the patient may complain of discomfort in the subungual region, with or without a visible mass, before actual
changes in the nail occur. Paronychia or nail plate deformity and discoloration may follow the subjective complaint of pain.
FIG. 21. Subungual and periungual verrucae of the hallux.
FIG. 22. Long-standing ulceration that was eventually diagnosed by biopsy as squamous cell carcinoma.
Malignant tumors that cause nail change are usually seen in the subungual region. Other clinical findings may include pain, swelling, and
inflammation, and most patients have a history of chronic paronychia or trauma to the distal phalanx (44 ). Long-standing recalcitrant
subungual ulcerations should be suspected to be possible squamous cell carcinoma (45 ) (Fig. 22 ). The prognosis is generally good,
although squamous cell carcinoma of the skin occasionally metastasizes to the inguinal lymph nodes. This is much less of a problem with
subungual squamous cell carcinoma. Punch biopsy diagnosis makes examination of such slow-healing ulcerations an atraumatic procedure
and may preclude extensive growth of the lesion and permit early recognition and adequate removal (46 ).
Malignant melanoma below the nail plate is not as damaging to the nail as are other types of malignant lesions. This particular malignant
process is frequently misdiagnosed as a subungual hemorrhage; however, unlike flat lesions of malignant melanoma that develop slowly
over years, the hemorrhagic subungual lesions develop quickly, and, in contradistinction to malignant melanomas, hemorrhagic lesions are
usually uniformly deep black (47 ). In a series of 72 patients with subungual melanoma, nearly one-half gave a history of trauma, 65% of
the lesions were either on the thumb or the great toe, and 36% had lymph node metastases at the time of surgery (48 ). In another series
of 25 patients with subungual melanoma, the prognosis was poor. Only 36% of the patients were alive after 9 months, so the 5-year
mortality rate was high (49 ).
Basal cell carcinoma is the least common cutaneous malignant disease involving the nail bed. Most cases of subungual basal cell carcinoma
have been reported on the hand. As in the case of other malignant lesions, biologic behavior and resistance to treatment may be a clue to
the ultimate diagnosis (50 ).
Bowen's disease of the nail bed has been reported (51 ,52 ). These lesions are slow growing, with an insidious onset, and are different in
appearance from Bowen's disease on the skin (53 ). The lesion usually starts in the lateral nail fold and subsequently involves the nail bed,
with secondary destructive changes of the nail plate. Mikhail in 1984 reported 21 cases of sublingual epidermoid carcinoma (which includes
Bowen's disease and invasive squamous cell carcinoma), which involved only a single case of squamous cell carcinoma of the hallux (54 )
(Fig. 23 ). He also reviewed the literature and found that of 113 cases there were 13 subungual lesions involving the toes.
Finally, any tumor under or about the nail should be suspected to be malignant whenever the patient has persistent infection, pain or
swelling, or a visible mass that does not respond to standard therapeutic approaches. Radiographic and biopsy examination should be done
as early as possible and repeatedly, if necessary, to provide an accurate diagnosis.
Biomechanical Abnormalities
One of the most frequent causes of ingrown toenails in children and adolescents is biomechanical imbalance. Onychocryptosis
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of the lateral nail margin of the hallux results from compression of the lateral nail fold between the hallux and the second digit. This
forces the nail fold to overgrow the nail plate, causes the nail margin to become imbedded within the tissue, and results in pain and
secondary infection. A similar problem occurs on the medial nail fold when the foot excessively pronates and weight is transferred through
the great toe from lateral to medial (55 ). Abnormal dorsiflexion of the digits results in trauma to the hallux toenail and irritation to the
dorsum of the lesser toes. As the hallux dorsiflexes, the distal phalanx is extended. The tip of the hallux contacts the shoe cap and
traumatizes the hallux toenail, which thickens because of intermittent pressure.
FIG. 23. Bowen's disease of the hallux nail plate.
FIG. 24. Ingrowing medial toenail with an incurvated nail plate secondary to laterally directed pressure on the medial hallux.
McGlamry (Doctors Hospital seminar notes, 1969) also reported a predictable pattern of onychocryptosis and onychoincurvatus resulting
from the laterally directed pressures on the nails produced by wearing snug or tight-fitting hosiery (Fig. 24 ). This condition is especially
noticeable with the use of snug elastic stockings and pantyhose. The normal care of the nail margins becomes difficult with this incurvation,
and consequently keratinous debris accumulates beneath the nail and begins to decay, a situation that provides an ideal medium for the
growth of microorganisms.
TABLE 4. Genetic disorders with nail changes

Genetic disease or syndrome Mode of inheritance Associated findings of interest
Nail-patella syndrome Autosomal Hemiatrophy, atrophy, triangular lunulae
(onychoosteodysplasia) dominant
Pachyonychia congenita Autosomal Hypertrophy of nail plates with massive thickening and
(Jaddassohn-Lewandowsky dominant yellow-brown discoloration
syndrome)
Dyskeratosis congenita X-linked or Thinning of the nail plate, fusion with proximal nail
autosomal fold, ridging, atrophy
dominant
Darier's disease (Darier-White Autosomal Distal subungual wedge-shaped keratoses, longitudinal
disease) dominant red and white striations, variable thickening and
thinning, splinter hemorrhages, papules on proximal nail
folds
DOOR syndrome (deafness Autosomal Absent or atrophic nails
onychoosteo-dystrophy, mental recessive
retardation)
Modified from Norton LA. Nail disorders. J Am Acad Dermatol 1980;2:451-467, with permission.
Hereditary and Genetic Factors

Hereditary and congenital nail deformities have been mentioned but have yet to be clearly outlined. Patients may have an inherited
tendency for the great toenails to grow inward, a condition that may be seen early after birth and compounded with a prone sleeping
position or early compression of the toes with baby booties (56 ). In many genetic diseases, the skin, hair, and nails are involved. Table 4
outlines a few of the genetic syndromes with their mode of inheritance and associated nail changes. Pachyonychia congenita is probably
one of the most visual and clinically obvious of this group and has been frequently reported in the literature (21 ). In this condition, the
nail disorder is confined entirely to the nail bed, where longitudinal splitting occurs within the keratin layer that adheres the plate to the
bed. This continuous keratinization and lack of cohesiveness of the nail plate to the bed result in elevation of the distal nail plate. The
resultant nail is thick, incurvated, and elevated. Congenital lymphedema and lymphedema praecox also show secondary nail changes
called yellow nail syndrome (57 ). Yellow nail syndrome consists of slow-growing yellow nails with secondary edema. Lower extremity and
ankle edema may follow the nail changes by several months or even years, and the yellow discoloration may be a significant prediagnostic
finding (58 ).
Another congenital disorder, Darier's disease, has characteristic nail changes consisting of thinness, splintering of the edges, longitudinal
discolored streaks, and subungual hyperkeratosis. One of the early characteristic features is the presence of red longitudinal striations in
the nail plate that run over the lunula, and one may also see distal nail plate notching (22 ).
Samman in 1978 described several cases of congenital nail dystrophies involving the great toenails of one or both feet in children (59 ). In
1979, Baran and associates termed
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this condition congenital malalignment of the big toenail, and they emphasized that this condition's main characteristic was the lateral
deviation of the nail plate with respect to the longitudinal axis of the distal phalanx (60 ). In a later article, Baran and Bureau reviewed 30
cases and discussed the pathology and surgical treatment (61 ). This condition becomes more serious as the deviated nail begins to receive
trauma from pressure against the shoe or against a small margin of heaped-up tissue in front of the nail. The nail begins to impinge on the
soft tissue anteriorly and becomes imbedded. Onychodystrophy results, and secondary problems such as pain and infection may follow.
Treatment is designed to realign the whole nail apparatus (Fig. 25 ). A crescentic wedge is created that is carried back proximal to and
below the nail bed and matrix. The crescent has to be larger on the medial aspect than on the lateral side, and a small triangular excision
is performed at the start of the lateral incision that will enable the whole nail apparatus to be swung over the resected area so it may be
realigned and sutured in the corrected position. Bureau and colleagues suggested that the best results are achieved when the congenital
malalignment is corrected surgically before the patient is 2 years old (62 ).
FIG. 25. Surgical correction of congenital malalignment of the great toenail. (Redrawn from Baran R, Bureau H, Sayag J. Congenital
malalignment of the big toenail as a cause of ingrowing toenail in infancy: pathology and treatment. Clin Exp Dermatol 1983;8:619,
with permission.)
DIAGNOSIS AND METHODS

The diagnosis of nail conditions is primarily based on the clinical evaluation of the nail itself and the associated presenting factors. The
pathologic processes that are responsible for most nail changes are not well understood, and the nails can react in relatively few ways, so
the same clinical symptoms and appearances may occur in several different states.
Specimens of the nails and surrounding structures may be taken for further diagnostic evaluation by using a test medium such as potassium
hydroxide, which dissolves the keratin portions and allows microscopic examination of any other elements. This test is useful in the
diagnosis of fungal and candidal infections of the toenails. Specimens may also be placed on a culture medium such as the dermatophyte
test medium or standard laboratory test media. These cultures help to confirm the diagnosis of fungal or bacterial infections.
Biopsies may also prove helpful in determining the cause of certain types of nail disorders; however, they are more difficult to perform and
risk the possibility of damaging the nail or nail bed. Even though biopsy techniques are listed as surgical procedures, they should be
thought of strictly as special forms of tests or diagnostic tools. The primary reasons for performing nail biopsies are (a) to make a diagnosis,
(b) to confirm a suspected condition before beginning definitive care, (c) to follow the progression of a disease, (d) to assess the
effectiveness of treatment, (e) to understand nail diseases better (i.e., research), and (f) to discover new or undiagnosed diseases (63 ).
Techniques of Biopsy
Shave Biopsy
A shave biopsy is probably the simplest procedure for obtaining a sample of nail and surrounding tissue for evaluation (Fig. 26 ). With a No.
15 surgical blade, the surgeon excises a slice of tissue from the nail fold down to the matrix area (64 ).
Longitudinal Biopsy
A No. 15 surgical blade is used in a longitudinal biopsy to make two parallel incisions from the proximal nail fold to the tip of the toe,
usually in the central portion of the nail. The distance between these incisions should not exceed 3 mm or severe scarring may occur. The
tip of the surgical blade should glide over the bony phalanx to create a wedge-shaped section. The shorter ends of the rectangular
specimen are then cut, and the entire section is carefully dissected free from the underlying phalanx with fine-point surgical scissors or
with the surgical blade. The proximal nail fold and the nail bed (but not the matrix) should be sutured with finegauge suture material,
which may be removed in 5 to 10 days. This technique produces remarkably little discomfort or deformity and may provide a great deal of
information regarding the nail or nail bed condition (65 ).
Punch Biopsy
The punch biopsy is the most commonly used procedure for obtaining an accurate diagnosis of nail and surrounding tissue conditions. I
believe that the punch biopsy should be used more frequently by physicians who treat patients with skin and nail diseases on a regular
basis. A 3- or 4-mm new sterile disposable punch is used to bore directly through the nail plate into the nail bed or hyponychium. The
matrix site (lunula) is avoided to prevent distortion of the outgrowing nail. If biopsy of the nail matrix is required, the technique
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of longitudinal biopsy is preferred. When the punch reaches the periosteum, it is withdrawn, and a fine, sharp pair of dissecting scissors is
used to remove the specimen. Generally, bleeding is minimal; however, if present, bleeding may be stopped by applying a small amount of
Monsel's hemostatic solution (ferric subsulfate), or other suitable hemostatic agent, to the site. Typically, no suturing is needed, and the
biopsy site granulates quickly and heals without nail distortion (66 ).
FIG. 26. Nail biopsies: 1, longitudinal biopsy (Zaias); 2, punch biopsy (Scher); 3, shave biopsy (Baran and Sayag); 4, lateral biopsy
(Bennett); 5, horizontal biopsy; nail is avulsed (Fosnaugh); 6, horizontal biopsy in which only the proximal nail is avulsed (Fosnaugh).
Lateral and Horizontal Biopsy

The lateral nail and tissue biopsy is relatively easy to perform. However, the amount of tissue obtained and the information received from
the specimen may not be adequate (67 ).
The horizontal nail biopsy is more difficult to perform but may provide more accurate information. In this technique, the nail is totally
avulsed before the procedure is begun, and the biopsy procedure is performed horizontally in the nail matrix. Another approach is to
avulse only the proximal part of the nail to obtain the specimen and to leave the distal portion of the nail intact (68 ).
CLINICAL TREATMENT
The proper treatment of painful, diseased, infected, dystrophic, ingrown, or damaged toenails falls into three classifications: prevention,
conservative management, and surgical management.
Prevention
Prevention of toenail problems should be one of the primary goals of all physicians who treat these conditions on a regular basis. Teaching
patients how to care for their nails, how to perform simple preventive care for infection and injury, and how to choose the proper hosiery
and shoes is essential. As early as 1830, Michaelis reviewed the importance of cutting the toenails square with both corners exposed and
recommended wearing well-fitted shoes to prevent ingrown toenails (69 ). He also reported that Heister, in 1763, elevated the edges of
the ingrowing nail and maintained it in position with a piece of cotton used as a splint. There was also early recognition that foot
imbalance, such as pronation of the forefoot or uneven weight bearing, could cause an increased burden of weight on the medial border of
the foot that could force the soft tissues over the nail
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margin, and these static imbalances should be corrected to prevent this condition from occurring (70 ).
Conservative Management
Conservative treatment of toenails varies from the simple approach of preventive measures such as regular trimming and smoothing of the
toenails and avoidance of tight-fitting elastic stockings, socks, pantyhose, and shoes to the medical treatment of fungal and bacterial
infections to much more elaborate methods of nonsurgical nail removal.
Fungally infected toenails, ideally confirmed by mycologic identification, are treated with either a topical or oral antifungal drug. For
topical treatment, the involved toenail is débrided and is filed smooth, and terbinafine hydrochloride 1% cream (Lamisil, Novartis
Pharmaceuticals, East Hanover, NJ) is applied and is rubbed in well on a daily basis. Oral treatment consists of taking one terbinafine
hydrochloride 250-mg tablet (Lamisil) daily for 90 days. For more involved toenail fungal infections, I use both topical and oral antifungal
therapy. The patient is provided with all the written information regarding the drug's side effects and benefits, as well as a description of
the long-term goals and results of therapy. This treatment program has been extremely successful in correcting fungal toenails and in
relieving much of the discomfort and secondary problems noted with this condition.
When painful nail symptoms of the great toe are associated with dorsiflexion of the digit, often accompanied by a close approximation of
the second digit, Ostroff proposed that plantar stimulation of the long flexor muscle of the great toe to lower its plane in walking and
stimulation of the abductor hallucis to separate the hallux from the second toe would eliminate all the mechanical and functional pressure
on the toes (71 ). This would then improve conditions such as callused nail grooves with corns imbedded in the edges, extrasensitive groove
linings, and nail groove irritations caused by deformity in the nail plate. The effectiveness of this treatment has not been documented.
Simple conservative care may involve careful trimming of the incurvated nail edge (partial nail avulsion) with smoothing of the new edge
and then packing the lateral groove with an antibiotic ointment and sterile cotton. This dressing may be held in place with cohesive gauze.
If the nail groove is callused and painful, 40% salicylic acid in hydrous lanolin may be applied under the free distal end of the nail and along
the painful nail groove. This dressing is kept dry and intact for 7 to 10 days, and when it is removed, the callus will be soft and can be
lifted off easily. Repacking the nail groove with a soothing ointment and cotton at that time provides considerable relief of symptoms. This
treatment usually has to be provided on a regular basis until the nails have grown out far enough to relieve the pressure (72 ).
When the patient has a secondary bacterial infection with a mildly ingrown or incurvated nail, this same procedure can be performed, but
instead of using salicylic acid in lanolin, nitrofurazone soluble dressing (Furacin) is packed into the nail groove and is covered with a first-
aid bandage that is changed daily by the patient until the problem is resolved (73 ). A variation of this approach involves shaping a piece of
cotton into a roll twice the size of a candlewick and gently packing this into the nail groove to separate the edge of the nail from the skin.
It should be long enough so about half an inch remains at the distal end. This end is then pushed under the distal end of the nail to keep
the edge spike from contacting the skin. Adhesive tape is placed over the distal phalanx, to leave about half an inch of skin open, and the
cotton is saturated with iodine tincture. Granulation tissue is treated at the same time by firmly pressing the area with a 50% solution of
silver nitrate. Three to six weekly visits are recommended to obtain complete relief of symptoms (74 ).
Chemical Nail Avulsion

After thick, dystrophic toenails have been manually and mechanically débrided, the remaining portion of the nail may be removed by
several different topical methods. The nail and the nail bed may be painted with an adherent, and a 40% to 60% salicylic acid plaster may
be applied. The entire toe is then wrapped with a cohesive bandage that is changed on a weekly basis until the desired results are
obtained, usually in 6 to 8 weeks (75 ). Using a similar approach, but with a urea compound as opposed to salicylic acid, Farber and South
in 1978 described a technique of nonsurgical removal of dystrophic nails (76 ). They used both a 22% and a 40% urea base and found that
the 40% combination was better. In a later report, they presented the results of a 2-year follow-up and a modified version of the urea
formula. They believed that treatment with the urea ointment had the advantages of being nontoxic, nonallergenic, and nonsurgical and
therefore was much simpler and less expensive (77 ). The new formula and the one I currently use is as follows:
Urea 40%
White wax 5%
Anhydrous lanolin 20%
White petrolatum 25%
Silica gel type H 10%
Port and Sanicola, in 1980, presented a series of 18 patients treated with the urea compound for the removal of dystrophic toenails (78 ).
They found little difference in the 22% and the 40% urea ointment; however, they recommended using the stronger combination under
occlusion.
This urea compound ointment has been used successfully on dystrophic nails but is not effective on nondystrophic or normal nails. As a
result, Buselmeier in 1980 prepared a compound consisting of 20% (40 g) urea and 10% (20 g) salicylic acid combined with 110 g Aquaphor
solution, which is composed of 10% lanolin, 20% petrolatum, 30%
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mineral oil, and 40% water (79 ). This compound ointment effectively avulses painful nondystrophic nails when it is applied under occlusion,
as outlined by Farber and South (76 ).
After this nonsurgical chemical nail avulsion therapy has been completed, the dystrophic nails may then be further treated by other topical
or injectable medications. For onychomycotic nails, I prefer topical treatment with 1% terbinafine hydrochloride cream. This cream is
applied by the patient twice a day and is rubbed into the nail bed completely.
After nail avulsion for onychomycosis, the nail bed may be carefully débrided of any diseased tissue and the area may be painted with pure
phenol for 10 to 20 seconds (Fig. 27 ). After healing has occurred, borotannic complex is applied twice a day, and a report noted that the
new nails appeared to be healthy with no recurrence of the fungal infection on follow-up (80 ). Topical terbinafine hydrochloride 1% cream
applied twice a day is also effective.
In patients with psoriatic dystrophic nails, the nail bed may be treated topically with high-potency corticosteroids, such as 0.5%
triamcinolone acetonide or 0.2% fluocinolone acetonide, in a similar fashion. Intralesional injection of triamcinolone, 2.5 mg/mL, in small
amounts (0.2 to 0.4 mL per nail) into the proximal nail folds may also be useful in severe psoriatic nail dystrophy (81 ).
FIG. 27. Total nail avulsion with nail bed phenolization. A: Straight spatula is used to free the nail borders and the posterior nail fold.
B: Nail is completely avulsed. C: Nail bed is lightly curetted to remove any debris and to smooth the bed. D: Phenol is carefully
painted onto all surfaces exposed.
Subungual and periungual warts may also be treated with topical acids, by blunt dissection techniques as described by Pringle and Helms in
1973 (82 ), or, surprisingly enough, by the cloth tape occlusion method described by Litt in 1978 (83 ), which works well. I have used this
technique on a wide variety of verrucous lesions under and around the toenails, with about an 80% cure rate.
Surgical Management
The surgical treatment of incurvated or ingrown nails and hypertrophied or painful nail borders ranges from simple surgical nail avulsions
to complex plastic reconstructive lip procedures to distal amputations. An emphasis is placed on procedures that alter the matrix or growth
of the toenail. Because most, if not all, surgical procedures on toenails are done using local anesthesia, a brief review of anesthetic
techniques is covered first.
Local Anesthesia
Infiltration of a local anesthetic agent in digital nerve block fashion is commonly employed to reduce the patient's discomfort when
treatment is provided to the toenail area
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(Fig. 28 ). The techniques of nerve block and local anesthesia were discussed by Locke and Locke (84 ). Many different local anesthetic
agents are available either with or without epinephrine. Lidocaine hydrochloride is still the primary agent used. However, mepivacaine
hydrochloride and bupivacaine hydrochloride are used regularly. Procaine hydrochloride is seldom used today.
FIG. 28. Typical proximal lateral infiltration nerve block of the hallux.
Techniques for infiltration digital blocks vary, but the most commonly used methods are the two-point block (7 ,85 ) (Fig. 29 ), the
unilateral infiltration block (86 ) (Fig. 30 ), the plantar-V infiltration block (B. Hara, personal communication) (Fig. 31 ), the H-block (87 )
(Fig. 32 ), and the triangular block (88 ) (Fig. 33 ).
FIG. 29. Two-point local anesthesia block of Mercado, seen in cross section.
FIG. 30. Unilateral infiltration block of Steinberg beginning in position 1 and advancing to 3.
All of these procedures, except the unilateral infiltration block, have the possible disadvantage of causing complete vascular compression
by increased pressure from the injected local anesthetic agent that may totally surround the digit. Most authors, however, recommend
relatively small amounts of local anesthetic agent that is accurately placed to cause the necessary anesthetic effect. The addition of
hyaluronidase to the local anesthetic agent may facilitate the anesthesia and may prevent the agent from causing too much
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compression, because the mixture readily spreads throughout the subcutaneous tissues (89 ).
FIG. 31. Plantar-V infiltration block of Hara.
FIG. 32. H-block of Frost.
FIG. 33. Triangular block of Ross.
The use of vasoconstrictors, such as epinephrine, is still debated by some investigators, even though no good evidence indicates that this agent causes any serious untoward effects when it is
used properly. Kaplan and Kashuk, in 1971, reported the findings in thousands of well-documented cases, based on hospital records, in which digital procedures were performed employing
anesthetic-epinephrine mixtures without serious complications either systemically or locally (90 ). Steinberg and Block, in 1971, also reported on the use of epinephrine in local anesthetics in a
large series of patients and recommended the use of this agent in healthy patients with patent circulation whenever its actions were desirable (91 ).
Toxicity from local anesthetic agents does not seem to be a problem, but all anesthetic agents are toxic in varying degrees, and the possibility of toxicity increases with the volume and
concentration of the agent (92 ). As stated earlier, the smallest amount of drug necessary to produce complete anesthesia should be used.
Surgical Procedures
Soft Tissue Corrections

The most common soft tissue procedure in use today is a modification of the DuVries skin plasty (93 ). This procedure
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involves taking a large segment of tissue from the side of the toe with two semielliptic incisions closed with suture. This procedure is
designed to relieve all the soft tissue pressure from the toenail margin (Fig. 34 ).
FIG. 34. Soft tissue wedge resection. A triangular section of tissue is removed from the side of the toe, and the nail lip and nail
groove are pulled down after suturing the nail margins, thus relieving pressure on the tissues. (Redrawn from Mann R, ed. DuVries'
surgery of the foot. St. Louis: CV Mosby, 1978:502, with permission.)
FIG. 35. Total nail avulsion. After local anesthesia, blunt dissection is performed under the proximal and lateral nail folds with
hemostat. Once the nail plate is free from the nail bed, little effort is required to roll the nail plate out and off. (Redrawn from
Moschella SL, Pillsbury DM, Hurley HJ. Dermatology. Philadelphia: WB Saunders, 1975:235, with permission.)
Partial and Total Nail Avulsion

The simplest form of surgical nail treatment is nail avulsion, which is usually performed using local anesthesia. When the patient manifests
an acutely painful nail groove or ingrown nail, the offending border may simply be cut back to, but not through, the matrix, and the nail
edge is removed (94 ). If this is the first occurrence of the problem, Morley recommends a partial nail avulsion (95 ). If the entire nail is
involved, then the total nail avulsion is appropriate (Fig. 35 ). Albom in 1977 and Scher in 1981 modified the standard total nail avulsion by
recommending that the nail plate be removed by a proximal to distal technique using a small dental spatula to free up the posterior
proximal nail fold (96 ,97 ). This approach is especially useful in severe onychodystrophies in which scarring or distortion of the nail unit
components occurs, such as in chronic mucocutaneous candidiasis or chronic onychomycosis.
Partial Matrixectomy
A partial nail avulsion may be combined with removal of a small segment of the germinal matrix, thereby preventing its regrowth. This
procedure has been popular for many years and has several different versions or modifications.
FIG. 36. Winograd partial matrixectomy procedure for relief of onychocryptosis.
One of the early, and still one of the best-known, procedures was developed by Winograd in 1929, who modified standard methods and
reported his results (98 ). The procedure involves splitting and removing an edge of the nail one-fourth inch long, excising or curetting
away the matrix and nail bed, and removing a strip of the nail fold, to create a semielliptic wedge down to bone. The margins are then
undermined, and the incision is closed with suture (Fig. 36 ). Keyes, in 1934, did a comparison study of the Winograd procedure and the
“usual” procedure described by Foote and Livingston in 1930 (99 ). He believed that the “usual” procedure gave much better results.
Winograd in 1936 did an 18-month follow-up study of 20 patients and reported 3 recurrences (100 ) (Figs. 37 and 38 ).
Frost, in 1950, developed another modification by creating a transverse incision at the end of the proximal portion of the first incision for
better visibility of the underlying matrix (101 ) (Fig. 39 ). In his original description of the procedure, Frost recommended that sutures not
be used and that the incisions be held together by the compression bandage.
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Later, he advocated the use of sterile tape strips for better closure (102 ) (see Chapter 5 ). This is still a popular procedure today among
foot and ankle surgeons. Some surgeons believe that no need exists to create this corner flap, for fear of delayed healing; however, I have
not seen this complication. Updates of this technique by Frost have been published, with continued success of the procedure
(87 ,102 ,103 ). Reviews show that, at some institutions, the Frost and Winograd procedures are still the most frequently performed
techniques for dealing with ingrown toenails (104 ).
FIG. 37. Amount of tissue resected from the lateral nail and the border with the Winograd procedure.
FIG. 38. Modified suture closure of the Winograd procedure.
Variations of the Partial Matrixectomy
Phenol-Alcohol Chemical Partial Matrixectomy.

The phenol-alcohol procedure is extremely popular among foot and ankle physicians and surgeons, but it does not appear to be well known
by the general medical community. The procedure uses the techniques for the partial nail avulsion, described previously, followed by the
application of 89% pure liquified phenol, USP, to the nail bed and beneath the posterior nail fold into the germinal matrix area to be
destroyed. The adjacent tissues are protected to prevent burning from the acid, and the procedure is terminated by the application of
alcohol solution that erroneously was thought to neutralize the phenol (Fig. 40 ). Actually, the alcohol serves to irrigate or flush the phenol
from the tissue rather than neutralizing it. The procedure may also be used to treat incurvated and ingrown toenails with or without
adjacent pyogenic granuloma or hypertrophy of the periungual skin (105 ). Some authors recommend that the phenol-alcohol procedure be
combined with partial nail wedge resections (106 ) or with surgical removal of the underlying nail germinal matrix (107 ).
FIG. 39. Frost partial matrixectomy procedure (modified with suture closure).
Greene, in 1964, recommended that the phenol treatment not be followed by the traditional alcohol flush because the alcohol may
actually increase the postoperative suppuration rather than just dilute the phenol (108 ). He believed that his patients did much better
after this modification and had a much shorter recovery time. This approach has been reported by other investigators, with similar results
(109 ). Many authors continue to refer to the alcohol flush as a necessary step in the dilution and removal of the phenol and recommend
that it be used (110 , 111 , 112 , 113 , 114 , 115 , 116 ).
Dagnall recommended that the length of application of the phenol should depend on the tissue response, which should blanch white, and
that it was important to work with a dry field (113 ,114 ). He believed it was much wiser to overtreat than to undertreat ingrown toenail
problems with the phenol solution. Yale and McGlamry both have excellent articles showing the step-by-step procedures for the phenol-
alcohol technique of partial nail matrixectomy (72 ,115 ).
Finally, it is important to exsanguinate the toe properly and to maintain hemostasis during the procedure, because any contact of the
phenol with blood alters the pH of the phenol and turns it black. In addition, the phenol must be freshly prepared in liquified form as an
89% pure solution and must be kept in a brown glass container stored in a cool, dry, and dark place between applications. The phenol
solution should be changed on a regular basis to ensure its effectiveness because it can deteriorate quickly once the initial exposure to air
occurs (116 ).
Sodium Hydroxide Chemical Partial Matrixectomy.

Travers and Ammon, in 1980, first described this technique as a modification of the phenol-alcohol procedure (117 ). Technically, the
procedure is performed in a manner similar to that of the phenol-alcohol technique, except a 10% sodium hydroxide solution is substituted
for the phenol. The application of sodium hydroxide continues for 3 seconds to 3 minutes, depending on the patient, until there is visible
coagulation of the capillaries of the nail bed. The sodium hydroxide is neutralized by 5% acetic acid. The postoperative regimen is similar
to that for the phenol procedure. These authors reported that the procedure provided a high success rate, a low recurrence ratio with less
drainage, and faster healing times.
In a commentary on the sodium hydroxide chemical matrixectomy, Greenwald and Robbins in 1981 stated that the
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use of sodium hydroxide with liberal dilute vinegar lavage produced far less postoperative inflammation than the phenol-alcohol
combination (118 ). Curettage of the dry field eponychial socket between applications of the agent reduces the application time and the
amount of agent required. These investigators recommended two applications of sodium hydroxide for 15 seconds with curettage between
applications to remove the necrotic tissue and precipitated proteins, thereby providing a fresh new surface for the second application of
the acid.
FIG. 40. Phenol-alcohol technique for partial matrixectomy. A: Ingrown nail border is freed with a spatula. B: English-anvil nail
splitter is used to split the offending edge. C: Nail spicule is removed. D: Matrix area and the nail bed are curetted to remove debris.
E: Phenolization is performed.
Additional recommendations on this procedure were provided by Glatzer in 1984, who believed that the aftercare with this procedure is
important (119 ). After the patient's foot had been elevated for 5 hours, foot soaks were instituted with saline or dilute acetic acid for 20
to 25 minutes, three times per day. This regimen continued for 7 to 10 days, depending on the amount of drainage present. Glatzer
believed that recovery time was reduced by at least 50% with this technique.
Carbon Dioxide Laser Partial Matrixectomy.

Treatment of ingrown toenails by performing a matrixectomy using the destructive forces of the carbon dioxide laser was described by
Kaplan and Labandter in 1976 (120 ). They first performed the nail avulsion technique and then used the laser in the nail bed under the
proximal nail cuticle down to the interphalangeal joint. They reported no bleeding after the procedure and believed that this was a quick
and easy procedure to perform. Apfelberg and associates, in 1983, reported on a larger series of patients treated with the carbon dioxide
laser technique (121 ). They believed that the cure rates for
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this procedure were equivalent to those with current standard forms of treatment, but pain was markedly reduced over traditional
methods of treatment and the time to comfortable ambulation was dramatically shortened. Borovoy and associates in 1983 also reported
on this technique and reviewed the present and future status of the procedure (122 ). At this point, the main disadvantage appears to be
the equipment cost and subsequent expense to the patient.
FIG. 41. Terminal Syme operation for total nail removal.
Miscellaneous Variations of Partial Matrixectomies.

Owens, in 1965, reported on the surgical correction of structural malformation of the nail plate in the lesser toes by removing a central
segment of nail, nail bed, and matrix (123 ). This procedure is used for those toenails that have curved completely around and the lateral
and medial borders almost approximate each other. This is a similar approach to nails as reported by Suzuki and associates in 1979 for the
treatment of pincer nail syndrome of fingernails (124 ). In their description of the procedure, the nail plate and underlying nail bed were
centrally cut in a triangular fashion and were reapproximated, but the posterior segment of the nail matrix was left untouched. This
apparently gives a good cosmetic result and can easily be used for toenails with similar symptoms and appearance.
FIG. 42. Zadik (Quenu) total matrixectomy procedure.
Total Matrixectomies
Terminal Syme Operation.

The most radical treatment for ingrown or dystrophic toenails is the terminal resection procedure, which involves the surgical removal of
the entire nail, nail wall, and matrix, with closure of the defect by a plantar skin flap fashioned from the end of the toe after the toe has
been shortened by resection of the distal half of the distal phalanx (Fig. 41 ). This procedure was first described by Hukill in 1874, and it
was revived by Lapidus in 1933 (125 ,126 ). Lapidus also illustrated the procedure clearly in his article and is generally given credit for
popularizing the technique. However, the procedure acquired the name of Syme because the plantar flap, which is brought up and over the
terminal phalanx, is similar to that used in the Syme amputation through the ankle joint (127 ).
This technique may be most useful in dealing with underlying terminal phalangeal lesions with secondary toenail involvement. The
procedure was graphically illustrated by Mowbray in 1935 for the great toe and by Gastwirth and associates for the lesser digit in 1981
(128 ,129 ). The operation has certain disadvantages, such as shortening of the toe, creation of a bulbous terminal stub, the potential for
sloughing of the flap, scar formation (10 ), the possibility of epidermoid cysts (130 ), and recurrences of nail spicules (131 ). All these may
be unacceptable cosmetically and unnecessary when other, more effective total matrixectomies are available.
Some authors believe that the radical total matrixectomies are performed far too widely and should not be performed when less traumatic
procedures are available that have the same results (132 ).
Zadik Procedure.
The original procedure now usually referred to as the Zadik operation was first described by Quenu in 1887 (133 ). A review of 36 cases
treated by this technique with no recurrences noted was reported by Wilson in 1944 (134 ). In 1950, Zadik reported on 16 cases in patients
treated with the original technique described by Quenu, with good
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cosmetic results and no regrowths (135 ). The purpose of the operation is to remove the nail-forming part of the nail bed and to provide
adequate skin cover without shortening the distal phalanx (as occurs in the terminal Syme operation). The skin over the base of the nail
bed proximal to the lunula border and the germinal matrix is excised, and the skin flap is advanced and sutured, without tension, to the
edge of the distal part of the nail bed (Fig. 42 ). This procedure is especially useful when dealing with large distal exostoses (Figs. 43 , 44 ,
45 , 46 , 47 , 48 and 49 ).
FIG. 43. Preoperative status of a chronic painful ingrown hallux toenail with subungual exostosis.
FIG. 44. Technique for total nail avulsion.
FIG. 45. H-shaped incisions to expose the nail matrix area.
FIG. 46. Partial excision of the nail bed for complete exposure to exostosis.
Miscellaneous Total Matrixectomies.

All the aforementioned procedures from pure surgical excision to phenolization
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to laser ablation of the matrix may be used to eliminate the entire toenail germinal matrix tissue for a permanent matrixectomy procedure
(Figs. 50 , 51 , 52 , 53 , 54 , 55 and 56 ).
FIG. 47. Surgical excision of subungual exostosis.
FIG. 48. Complete suture closure of an H-shaped incision.
FIG. 49. Six-month postoperative status of total matrixectomy and excision of subungual exostosis.
FIG. 50. Preoperative status of a chronic ingrown hallux toenail.
FIG. 51. Preoperative status. Note the appearance of the distal nail and digital pulp.
Variations in Skin Closure and Suture Techniques

A few variations of skin closure and suturing techniques have been described that may be useful in certain circumstances. Mendelsohn, in
1964, presented his modification of
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a suture technique to be used with the modified Winograd surgical procedures (136 ) (Fig. 57 ). Smith, in 1973, described a variation of the
Frost procedures in which he drilled two small holes in the nail plate for suturing the nail fold (137 ). One drill hole is made approximately
3 mm distal to the posterior nail fold, and the other is placed 3 mm proximal to the anterior free edge of the nail. Both drill holes are 3
mm in from the affected nail labia (Fig. 58 ).
FIG. 52. Total hallux nail avulsion.
FIG. 53. Proximal nail fold incisions for total matrixectomy.
Lepird in 1966, Frost in 1976, and Siegle and Swanson in 1982 all recommended the use of sterile paper tape strips (Steristrips) one-eighth
to one-fourth inch long rather than sutures to close the incisions (102 ,138 ,139 ). These strips are left on for 7 to 14 days to allow
complete healing, and the
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authors suggested that they be placed on the incisions without tension. Palmer and
FIG. 58. Smith variation of the Frost procedure with nail drill holes for suture
Stevenson believed that the strips that are one-half inch (13 mm) long are better and that
closure.
they should be covered with a firm compression bandage that is removed in 8 days (140 ).
POSTOPERATIVE CARE
Various precautions may be taken by the physician to prevent postoperative problems such
as recurrence, pain, infection, or prolonged drainage. Glick, in 1961, described a series of
events he believed would prevent recurrence of ingrown toenails after radical toenail
procedures (141 ). These principles are still appropriate today and include (a) the use of
single uninterrupted incisions, (b) careful differentiation of tissue levels, (c) proper use of
instruments, (d) elimination of exostosis discovered during the toenail surgery, and (e)
incorporation of adjacent toes in the postoperative bandages.
Stone, in 1962, suggested three reasons for failure after chemosurgical nail removal: (a)
using “old” phenol for the acid portion of the procedure, (b) not applying the phenol to all
areas where it should be used, and (c) removing insufficient amounts of toenail during the
FIG. 54. Complete exposure of the nail matrix area of the hallux.
original procedure (142 ). He recommended changing the phenol solution completely every 6
months or sooner if there is a change in appearance or activity. Furthermore, he suggested
that the phenol be applied along the medial and lateral nail grooves, to the underside of the
posterior nail fold (eponychium) extending from about 0.75 mm back and from side to side,
and at the junction of the posterior lateral and posterior medial nail folds, as well as to the
matrix area. Finally, enough toenail should be removed so the remaining portion of nail
should not have any perceptible incurvation in its new lateral or medial sides. If an adequate
midportion of nail will not remain, then Stone recommended removing the entire nail (Fig.
59 ).
Preventing the postoperative sequelae of phenolization of the nail bed and matrix was the
subject of discussion in several articles published in the past, and many of the
recommendations presented for postoperative care are still used today. Suppan and Ritchlin,
in 1962, recommended the use of chymotrypsin ointment (Chymar), which is a combination
enzyme, steroid, and antibiotic (107 ). They believed that this treatment reduced the
number of infections and shortened the number of days of postoperative drainage. Roven, in
1964, and Cooper, in 1965, also recommended the use of chymotrypsin ointment after
FIG. 55. Suture closure of incisions. phenolization treatment for ingrown toenails (143 ,144 ).
FIG. 59. Postoperative complication resulting from “phenol burn” and secondary
bacterial infection after a partial matrixectomy procedure.
FIG. 56. Four-week postoperative status of total nail matrixectomy.
The use of oral enzymes (chymotrypsin) for the postoperative treatment program was
presented by Bornstein in 1963 (145 ). He believed that this significantly reduced the healing
time, postoperative pain, and the use of narcotic pain medication after phenolization nail
procedures. In 1968, Acker reported the use of another topical enzyme ointment (Elase:
fibrinolysin and desoxyribonuclease ointment), which he believed greatly enhanced the
postoperative period by shortening the healing time and eliminating other untoward
sequelae (146 ).
Fulp and McGlamry, in 1972, in a year-long study of postoperative care of 118 phenolization
procedures performed on 68 patients, reported excellent results using topical application of
yet another enzyme (Travase: sutilains ointment) (147 ). Postoperative drainage was
reduced to 4 or 5 days in most cases and to less than 2 weeks in all other cases. However,
some problems occurred involving secondary inflammation of adjacent tissue apparently
FIG. 57. Mendelsohn modification suture technique. related to the enzyme.
I currently prescribe, for all my patients who have undergone phenol nail procedures, daily
postoperative foot soaks of warm water and Epsom salts followed by the application of
several drops of Cortisporin Otic solution (neomycin and polymyxin B sulfates and
hydrocortisone otic solution) the day after the procedure is performed. Drainage and
postoperative pain appear to be extremely limited, and the recurrence rate is less than 5%
in all patients during follow-up.
Another form of treatment recommended to reduce the

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amount of postoperative pain and drainage after total phenol chemical matrixectomy was reported in 1977 by Elleby and associates with
the use of porcine xenografts on the nail beds (148 ). This technique uses a commercially available sterile fresh-frozen porcine xenograft as
a biologic dressing for the exposed nail bed. The thawed sterile graft is cut into the shape of the nail bed and is placed into position
without the use of sutures. A sterile dressing is applied, and the patient is given instructions to soak the bandage for 30 minutes twice daily.
In 3 days, the dressing is removed, and the graft is inspected. Cortisporin Otic solution is started, with instructions to apply two drops to
the posterior nail groove twice daily after 15-minute foot soaks. After each application, the toe is dressed in a loose-fitting first-aid
bandage. This is continued until the graft is rejected by the host, between the fourth and sixth postoperative week, at which time a pink
and viable nail bed is revealed. In 55 of 64 procedures performed, patients related no postoperative pain and required no analgesic
medication after the procedure. No postoperative infections were noted in any of these patients. These authors believed that this
technique directly improved the outcome of phenol total matrixectomy procedures and sped the postoperative recovery phase.
Rinaldi and associates submitted that the prolonged drainage after phenol matrixectomies is the result of subacute bacterial infections
rather than the result of a chemical burn (149 ). They reported that in 40 patients studied after chemomatrixectomy procedures, 35
developed positive wound cultures. After beginning treatment with povidone-iodine (Betadine) solution following the standard procedures,
the postoperative healing time decreased and the postoperative disability decreased. For these reasons, these authors recommend
applying povidone-iodine microbicides directly to the surgical site after the phenol procedure and before the dry sterile dressing is applied,
as well as keeping these preparations in constant contact with the wound during the healing period to reduce the healing time and to keep
the wound clean and free of infection.
CONCLUSION
I have reviewed the formation and anatomic aspects of toenails and adjacent structures and the associated pathologic changes that may
involve these tissues. From this review, it is obvious that much information has been published regarding conditions involving toenails, an
indication of the frequent presentation of these problems. The treatment of onychomycosis has taken on a new perspective with the
advent of safer oral antifungal drugs, such as terbinafine hydrochloride. Because onychocryptosis appears to be one of the most frequently
reported conditions, the principles and general techniques of conservative and surgical nail care are presented as a background for the
discussion of several of the most commonly employed surgical procedures.
Most patients have a significant level of fear of having surgical procedures performed on their toenails. The underlying feeling is that this
treatment will cause severe pain and possible disability and is frequently likened to a form of torture used to extract information from
prisoners during wartime. Thorough and careful explanations of the treatment plans and expectations, as well as good anesthesia
techniques, are required for complete patient acceptance. With this background information, the physician treating the lower extremity
should be able to treat conditions of the toenail both conservatively and surgically and should be able to offer the patient the best possible
evaluation and treatment for a particular toenail problem.
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105. Hill JH. Radical onychectomy, partial with onychoplasty and sterilization. J Foot Surg 1969;8:34-36.
106. Lathrop RG. Ingrowing toenails: causes and treatment. Cutis 1977; 20:119-122.
107. Suppan RJ, Ritchlin JD. A non-disabilitating surgical procedure for ingrown toenail. J Am Podiatr Assoc 1962;52:900-902.
108. Greene AA. A modification of the phenol-alcohol technique for toenail correction. Curr Podiatr 1964;13:20-23.
109. Wee GC, Tucker GL. Phenolic cauterization of the matrix in the surgical cure of ingrown toenails. Mo Med 1969;66:802-803.
110. Sepherdson A. Nail matrix phenolization: a preferred alternative to surgical excision. Practitioner 1977;219:725-728.
111. Robb JE, Murray WR. Phenol cauterisation in the management of ingrowing toenails. Scott Med J 1982;27:236-239.
112. Waldron VD, Josephs RL. A simple technique for the permanent removal of toenail. Orthop Rev 1983;12:96-97.
113. Dagnall JC. Nail matrix phenolization queries. Br J Chirop 1976;41: 125-127.
114. Dagnall JC. The history, development and current status of nail matrix phenolization. Chiropodist 1981;36:315-324.
115. Yale JF. Phenol-alcohol technique for correction of infected ingrown toenail. J Am Podiatr Assoc 1974;64:46-53.
116. Andrew TA. Ingrowing toenails: an evaluation of two treatments [Letter]. BMJ 1982;284:118.
117. Travers GR, Ammon RG. The sodium hydroxide chemical matricectomy procedure. J Am Podiatr Assoc 1980;70:476-478.
118. Greenwald L, Robbins HM. The chemical matricectomy. J Am Podiatr Assoc 1981;71:388-389.
119. Glatzer HJ. Sodium hydroxide in nail matrix eradication. Br J Chirop 1984;49:49-50.
120. Kaplan I, Labandter H. Onychogryphosis treated with the CO2 surgical laser. Br J Plast Surg 1976;29:102-103.
121. Apfelberg DB, Rothermel E, Widtfeldt A, et al. Progress report on use of carbon dioxide laser for nail disorders. Curr Podiatr 1983;32: 29-31.
122. Borovoy M, Fuller TA, Holtz P, et al. Laser surgery in podiatric medicine: present and future. J Foot Surg 1983;22:353-357.
123. Owens RE. Surgical correction of structural malformation of the nail plate in the lesser toes. J Foot Surg 1965;4:14-15.
124. Suzuki K, Yagi I, Kondo M. Surgical treatment of pincer nail syndrome. Plast Reconstr Surg 1979;63:570-573.
125. Howard AW. Ingrown toenail: its surgical treatment. N Y Med Surg J 1893;57:579-584.
126. Lapidus PW. Complete and permanent removal of toe nail in onychogryphosis and subungual osteoma. Am J Surg 1933;19:92-94.
127. Thompson TC, Terwilliger C. The terminal Syme operation for ingrown toenail. Surg Clin North Am 1951;31:575-584.
128. Mowbray DT. Surgical excision of the great toe nail. Chirop Rec 1935;18:145.
129. Gastwirth BW, Anton VM, Martin RA. The terminal Syme procedure. J Foot Surg 1981;20:95-97.
130. Rees RW. Radical surgery for embedded or deformed great toenails. Proc R Soc Med 1964;57:355.
131. Fine WW. Evaluation of subtotal amputation (resection of distal phalanx). J Foot Surg 1965;4:12-13.
132. Chambers DG. Ingrown toenails [Letter]. Med J Aust 1968;1:608.
133. Quenu M. Applications au traitement de l'ongle incarné. Bull Soc Chir Paris 1887;13:252-255.
134. Wilson TE. The treatment of ingrowing toenails. Med J Aust 1944; 2:33.
135. Zadik FR. Obliteration of the nail bed of the great toe without shortening of the terminal phalanx. J Bone Joint Surg Br 1950;32:66.
136. Mendelsohn SA. A modification of suture technique in inverted nail surgery complicated by hypertrophied ungualabium. Mich Podiatr 1964;1:6-7.
137. Smith RA. A variation of the Frost nail procedure. J Foot Surg 1973; 12:89.
138. Lepird RN. Skin closures adaptable to onychoplasty. J Foot Surg 1966;5:42-43.
139. Siegle RJ, Swanson NA. Nail surgery: a review. J Dermatol Surg Oncol 1982;8:659-666.
140. Palmer BV, Stevenson DL. Modified operation for ingrowing toenails [Letter]. BMJ 1976;2:367.
141. Glick M. Prevention of recurrence in radical toenail procedures. Curr Podiatr 1961;10:26-27.
142. Stone DA. Suggestions for elimination of failures in chemo-surgery of the nails. Curr Podiatr 1962;11:14-15.
143. Roven MD. A study of some procedures for eradication of hypertrophied nail: a preliminary report. J Am Podiatr Assoc 1964;54:543.
144. Cooper C. Phenol-alcohol nail procedure: postoperative care. J Am Podiatr Assoc 1965;55:661-663.
145. Bornstein B. Effects of oral chymotrypsin on surgical sequelae. J Am Podiatr Assoc 1963;53:349-355.
146. Acker I. Preventing the postoperative sequelae to phenolization of nail bed and matrix. J Am Podiatr Assoc 1968;58:351.
147. Fulp M, McGlamry ED. New enzyme aids phenol technique in nail surgery. J Am Podiatr Assoc 1972;62:395-398.
148. Elleby DH, Well LS, Sorto LA, et al. The use of porcine xenografts on nail beds following total nail avulsion and phenol chemomatrixectomy. J Foot Surg 1977;16:85-91.
149. Rinaldi R, Sabis M, Gross J. The treatment and prevention of infection in phenol alcohol matricectomies. J Am Podiatr Assoc 1982;72: 453-457.
SELECTED READINGS
Bouché RT. Distal skin plasty of the hallux for clubbing deformity after total nail loss. J Am Podiatr Med Assoc 1995;85:11-14.
Dockery GL. Cutaneous disorders of the lower extremity. Philadelphia: WB Saunders, 1997.
Drake LA. Impact of onychomycosis on quality of life. J Am Podiatr Med Assoc 1997;87:507-511.
Gupta AK, Scher RK, De Doncker P. Current management of onychomycosis: an overview. Dermatol Clin 1997;15:121-132.
Joseph WS. Oral treatment options for onychomycosis. J Am Podiatr Med Assoc 1997;87:520-531.
Lemont H. Pathologic and diagnostic considerations in onychomycosis. J Am Podiatr Med Assoc 1997;87:498-506.
Markinson BC, Monter SI, Cabrera G. Traditional approaches to treatment of onychomycosis. J Am Podiatr Med Assoc 1997;87:551-556.
McInnes BD, Dockery GL. Surgical treatment of mycotic toenails. J Am Podiatr Med Assoc 1997;87:557-564.
Parrinello JF, Japour CJ, Dykyj D. Incurvated nail: does the phalanx determine nail plate shape? J Am Podiatr Med Assoc 1995;85:696-698.
Pollak R, Billstein SA. Safety of oral terbinafine for toenail onychomycosis. J Am Podiatr Med Assoc 1997;87:565-570.
Schein JR, Gause D, Stier D, et al. Onychomycosis: baseline results of an observational study. J Am Podiatr Med Assoc 1997;87:512-519.
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Chapter 2
Morton's Neuroma
Stephen J. Miller
Aprajita Nakra
Metatarsalgia or generalized pain in the plantar forefoot area has many causes. A common source of such exasperating discomfort is a
peripheral nerve affliction that may involve one or more common digital plantar nerves as they pass through the intermetatarsal spaces.
The first anatomic description of this localized nerve enlargement was clearly illustrated by the Italian anatomist di Civinini in 1835 (1 ).
However, the neuralgic symptoms of this disorder were first accurately described by the English chiropodist, Durlacher, in 1845 (2 ). He
characterized it as attacking “the plantar nerve … between the third and fourth metatarsal bones.”
Ironically, this entity was named after T.G. Morton of Philadelphia, who believed that the pain developed about the fourth
metatarsophalangeal articulation because of nerve irritation from its lateral osseous neighbor (3 ). He should not be confused with T.S.K.
Morton, who reported six cases of “Morton's metatarsalgia” in 1893 (4 ), or with D.J. Morton, who described the functional anatomic entity,
Morton's syndrome, in 1935 as a cause of metatarsalgia (5 ).
DEFINITION, ANATOMY, AND INCIDENCE

Morton's neuroma is a misnomer used to describe this painful pedal neuropathy. The lesion is a benign enlargement of the third common
digital branch of the medial plantar nerve located between, and often distal to, the third and fourth metatarsal heads. The region is
supplied by a communicating branch from the lateral plantar nerve as well (6 , 7 , 8 , 9 ) (Fig. 1 ).
Classically, the nerve passes beneath the deep transverse intermetatarsal ligament on its plantar aspect. The only other structures passing
in this immediate area are the third plantar metatarsal artery, with its accompanying vein or veins, and the tendon slip from the third
lumbrical muscle that inserts into the extensor hood apparatus on the medial aspect of the fourth toe. This is also the area in which
pacinian corpuscles are normally found in the subcutaneous tissues (10 ). The neurofibrous lesion is separated from the sole by the fat pad,
plantar fascia, and connective tissue compartments. The superficial transverse metatarsal ligament is situated superior to the nerve when
the region is viewed from the plantar aspect (Fig. 2 ).
The incidence of Morton's neuroma in the general population has not yet been determined. Youngswick observed that of 4,000 patients
presenting to his clinic with foot complaints, 9.3% were diagnosed with a neuroma (11 ).
In addition to the third intermetatarsal space, an intermetatarsal neuroma may also occur in other locations, usually within the second
intermetatarsal space but rarely in the first or fourth. Out of 113 histologically confirmed neuromas, Bartolomei and Wertheimer found 64%
in the third intermetatarsal space, 29% in the second, 6% in the fourth, and 1% in the first (12 ). Addante et al. evaluated 152 neuroma
resections and found that 66% involved the third intermetatarsal space, 18% the second, 4% the fourth, and 2.6% the first (13 ). Mann and
Reynolds found the neuromas evenly distributed between the second and third intermetatarsal spaces (14 ), whereas Bennett et al. found
68% in the third interspace and 32% in the second (15 ). Friscia et al. evaluated 366 patients with neuromas and found that 91% of these
lesions involved the third intermetatarsal space (16 ).
The lesions can occur bilaterally as well (0% to 12%) (12 ,14 ,17 ). Less frequently (1% to 4%), neuromas can be found in two intermetatarsal
spaces in one foot and rarely in three intermetatarsal spaces in the same foot (12 ,14 ,17 , 18 ).
Histologic evidence strongly supports the concept that Morton's neuroma syndrome is an entrapment neuropathy, resulting from
compressive forces, especially against the deep transverse intermetatarsal ligament (19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ). Incriminating
factors include densely packed whorls of collagen, Renaut's bodies, and thickened endoneural capillaries all formed within the
subperineural space of interdigital nerves (25 ). Also seen are local demyelination and telescoping of myelin in opposite directions on
either side of the lesion (26 ). Confusion has resulted from the many names applied to this lesion, which may be better described as a
perineural fibroma (Table 1 ).
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FIG. 1. Anatomy of the plantar nerves and location of classic Morton's neuroma beneath the deep transverse intermetatarsal
ligament. Note the contribution from segments of the medial and lateral plantar nerves.
FIG. 2. Cross section through the forefoot at the level of the metatarsophalangeal joints. The metatarsal artery lies above the
neuroma with its accompanying venae comitantes. The lumbrical tendon lies lateral to the neuroma.
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TABLE 1. Terminology used to describe Morton's neuroma

Term Authors and year
Neuralgic affection … plantar nerve Durlacher, 1845
A peculiar and painful affection of the fourth metatarsophalangeal joint Morton, 1876
Luxation podalgia Dana, 1885
Anterior metatarsalgia Pollosson, 1889
Metatarsal neuralgia Bradford, 1891
Morton's metatarsalgia Morton, 1893
Morton's painful affection of the foot Hoadley, 1893
Morton's disease Tubby, 1896
Plantar neuralgia Jones and Robert, 1897
Morton's painful disease Stern, 1904
Morton's neuralgia Cush, 1937
Neuritis of the fourth digital nerve Bettx, 1940
Morton's toe McElvenny, 1943
Plantar neuromas Bickel and Dockerty, 1947
Morton's toe syndrome Kite, 1947
Plantar digital neuritis Nissen, 1948
Lateral plantar neuritis Hiss, 1949
Metatarsal neuroma Sandel, 1958
Plantar metatarsal neuritis Pincus, 1962
Interdigital neuroma Hauser, 1971
Morton-Durlacher neuralgia Silverman, 1976
Intermetatarsal neuroma Goldman, 1979
Thomas Morton disease Gauthier, 1979
Morton's neuritis Milgram, 1980
Plantar interdigital neuroma Viladot, 1982
Pseudoneuroma Alexander, Johnson, and Parr, 1987
DIAGNOSIS
Signs and Symptoms

Most symptomatic intermetatarsal neuromas are found in women (12 ,14 ,15 ) and are commonly diagnosed between the fourth and the
sixth decades, although these lesions may sometimes be found in teenagers. The patient may be overweight (12 ). In milder or early cases,
the patient may describe a sensation of walking on a wrinkle in the stocking or a lump in the shoe. If the neuroma is large enough, the
adjacent toes may be forced to spread apart on weight bearing. Because Morton's neuroma causes a distinct set of symptoms, the diagnosis
can most often be made from the patient's history (Table 2 ).
Pain
The pain from this syndrome has been described as sharp, dull, or throbbing, but it classically manifests as a paroxysmal burning sensation
“like walking on a hot pebble” or “having a hot poker thrust between the toes.” It is most often localized to the region of the third and
fourth plantar metatarsal heads and may radiate distally into adjacent toes, transversely to adjacent metatarsal heads, or proximally up
the leg to the knee and, in rare instances, as high as the hip. Bizarre symptoms such as metatarsalgia during orgasm or defecation have
been reported, with relief on excision of the neuroma (27 ).
Even though the patient may describe numbness in the third and fourth toes, a sensory deficit is seldom present. At times, the digits may
be hyperesthetic. Patients may describe a cramping sensation in the arch, forefoot, or toes; however, there is no evidence of muscle
cramping (28 ).
The pain is greatly aggravated by walking in shoes and is relieved somewhat by rest, although in acute stages, lancinating or aching pains
may occur during periods of inactivity. Sometimes the patient finds irritation even from bed sheets intolerable. A characteristic and
virtually pathognomonic indication of a neuroma is the overwhelming desire to remove the shoe, rub the forefoot, and flex the toes. This
usually provides dramatic, although transient, relief of pain.
Symptoms are present for a few weeks to several years. However, if the pain is acute, the patient usually seeks help within a few weeks.
In many instances, acute pain appears after an incident of trauma which may or may not seem mild. Examples would be stepping on a rock,
twisting an ankle, striking the edge of a curb, jamming the foot into the floorboard
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in a motor vehicle accident, or simply changing into a new pair of shoes or doing an extraordinary amount of walking. The use of narrow or tight-fitting shoes can both instigate and aggravate symptoms.
TABLE 2. Symptoms of unoperated Morton's neuroma as reported by patients from two studies
Study A percentage (n = 65) Study B percentage (n = 115)
Pain increased with walking 91 —
Relief by rest 89 —
Plantar pain 77 —
Pain in forefoot — 76
Relief by removing shoe 70 60
Pain radiating to toes 62 —
Burning pain 54 —
Pain between toes — 43
Numbness into toes or foot 40 23
Aching or sharp pain 40 —
Inability to wear fashionable shoes — 39
Pain up foot or leg 34 11
Cramping sensation 34 —
Pain at rest — 19
History of associated injuries 15 —
Pain at night — 10
Pain in entire foot — 9
A, From Mann RA, Reynolds JC. Interdigital neuroma: a critical clinical analysis. Foot Ankle 1983;3:238. B, From Bennett GL, Graham CE, Mauldin DM. Morton's interdigital neuroma: a comprehensive
treatment protocol. Foot Ankle Int 1995;16:762.
Palpation
Tenderness and sometimes reproduction of pain can be elicited by squeezing each intermetatarsal space in a dorsoplantar direction at or distal to the metatarsophalangeal joints. On occasion, this maneuver deliver a palpable mass dorsally or
plantarly, especially during the application of simultaneous transverse compression of the first and fifth metatarsal heads in the plantar sulcus when the toes are hyperextended. This maneuver also causes the patient a varying amount of pain.
Hyperextending the patient's toes with one hand and rolling the opposite thumb transversely across the metatarsal hands on the sulcus side may reveal a palpably thickened longitudinal mass (Bratkowski's sign), which is tender when Morton's neuroma
is present (29 ).
Mulder's sign is positive when lateral compression of the forefoot combined with plantar and dorsal pressure produces a silent, palpable, and sometimes painful click in the affected intermetatarsal space as the neuromatous lesion is squeezed plantarly
between the adjacent metatarsal heads (30 ,31 ). This clicking may also be caused by an adventitial bursa that forms in close association with the neuroma between the metatarsal heads (32 ).
Local tenderness should be differentiated from arthritic pain by direct palpation of the adjacent metatarsophalangeal joints. Further palpation of the nearby metatarsal shafts helps to rule out a stress fracture.
Differential Diagnosis
Many other disorders have symptoms that may resemble Morton's neuroma. Some of these are listed in Table 3 . Differentiation can usually be made by means of a thorough history and physical examination, although when an element of doubt remains
in the face of persistent symptoms, diagnostic testing may be implemented. Even though Morton's neuroma is a benign lesion, local malignant sarcomas have caused similar presenting symptoms in rare instances (33 ,34 ). In addition, other benign
neoplasms have been reported to cause “Morton's metatarsalgia” (35 ,36 ).
TABLE 3. Differential diagnosis of Morton's neuroma

Metatarsal stress fracture
Rheumatoid arthritis
Autoimmune arthritides
Osteochondritis dissecans (Freiberg's)
Localized vasculitis
Ischemia
Tarsal tunnel syndrome
Nerve root compression syndromes
Peripheral neuritis
Peripheral neuropathy (e.g., diabetic)
Intermetatarsal bursitis
Metatarsophalangeal joint capsulitis
Metatarsophalangeal joint predislocation syndrome
Transfer metatarsalgia
Diagnostic Tests
Radiographs
Weight-bearing radiographs may be taken to help rule out other pathologic conditions and also to evaluate for rotation, enlargement, or juxtaposition of the metatarsal heads that may contribute to the origin of the neuroma (37 , 38 , 39 ). Grace et
al., in their study of 48 feet with pathologic confirmation of neuroma and 100 asymptomatic patients, found no statistical relationship between radiologic findings or metatarsus proximus and digital divergence (“Sullivan's sign”) and the physical
occurrence of neuromas (40 ,41 ). Instead, an increased intermetatarsal angle of the affected interspace was noted in the neuroma-afflicted group. The neuroma itself is not visible on x-ray films or xeroradiography.
Sensory Nerve Conduction Tests

Electrodiagnostic techniques for evaluating Morton's neuroma are not highly accurate, primarily because of the difficulty in isolating a single interdigital nerve with an electrode (24 ). However, in one study, the diagnosis was confirmed by
electrophysiologic testing of five patients. Positive results were characterized by an abnormal-dip phenomenon, a relatively normal conduction velocity, and normal duration of the sensory compound nerve action potential. These findings are the
hallmarks of a neuropathy with a predominant axonal degeneration (42 ). Therefore, such testing may be reserved for further assessment of patients with metatarsalgia who lack the classic physical signs of Morton's neuroma (22 ,43 ).
Magnetic Resonance Imaging

Cross-sectional magnetic resonance imaging (MRI) through the forefoot has differentiated a Morton's neuroma mass from the surrounding bone and soft tissues (44 ). The neuroma appears isointense relative to muscle on T1-weighted images and
homogenously or inhomogenously hypointense relative to fat tissue on T2-weighted images. In other words, it is best seen on T1-weighted images as a well-demarcated mass of lower signal intensity (45 ) (Fig. 3 ). Studies have shown that T1-weighted
axial and coronal images with an axial fast spin-echo T2-weighted sequence detect neuromas more consistently than an enhanced T1-weighted fat-suppressed sequence (46 ,47 ). Although the neuroma is often invisible on T2-weighted images, on
occasion the presence of fluid-filled bursae will lead to a high signal intensity proximal to the neuroma (48 ,49 ).
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FIG. 3. Magnetic resonance image of an intermetatarsal neuroma. Coronal T2-weighted image of a neuroma in the third interspace.
(Courtesy of George Vito, D.P.M.)
However, MRI has been shown to produce false-negative images, so the accuracy of the scans is not ensured (50 ). For this reason, as well
as for cost considerations, MRI for the diagnosis of Morton's neuroma may be best considered in patients with recurrent neuroma, atypical
symptoms, or coexisting neurologic conditions (51 ), or it may be used when a neuroma is suspected in an adjacent interspace.
Ultrasonograhy
High-resolution ultrasound appears to be the most promising of the objective imaging techniques for visualizing Morton's neuroma (52 ).
Studies of ultrasound evaluation compared with surgical and pathologic confirmation have demonstrated a diagnostic accuracy of 95% to
98% (18 ,53 , 54 , 55 ). However, one limitation is that ultrasonography is highly dependent on the operator and the machine. An
ultrasonographer with inadequate experience or the use of a low-resolution transducer can produce false-negative test results. The typical
sonographic appearance of a neuroma is that of an ovoid, hypoechoic mass oriented parallel to the long axis of the metatarsals, best seen
on coronal section through the forefoot (52 ,55 ) (Fig. 4 ). Normal interdigital nerve diameter in that area is about 2 mm. Initial data
suggest that the lesion becomes symptomatic when it reaches 5 mm or more in diameter. This test is especially helpful for determining the
presence of neuromas in adjacent intermetatarsal spaces preoperatively. It can also be of assistance in diagnosing postsurgical recurrence
of intermetatarsal neuroma (56 ).
FIG. 4. Sonographic image of Morton's intermetatarsal neuroma. Note the hypoechoic mass oriented parallel to the long axis of the
metatarsals. (Courtesy of George Vito, D.P.M.)
Histopathology
On gross examination, a resected specimen of Morton's neuroma has a shiny, glistening surface that is white to buff yellow. It is generally
fusiform and should have two or more easily identifiable digital branches with a distinct bifurcation. Either branch may have a swelling
along its course as well. Usually, the nodule can be dissected easily from the surrounding fibroadipose tissue. However, it can be firmly
attached to the intermetatarsal bursa or enwrapped in the bursa itself (Fig. 5 ). In some instances, the bursa may also envelop the
lumbrical tendon. The findings of several investigators indicate that the neuroma does not have to be particularly large, nor does it have to
be present for a substantial amount of time, to cause pain and for the nerve to undergo significant pathologic changes (38 ,57 ,58 ).
The histopathology is central to the diagnosis and origin of Morton's neuroma. No histologic examinations of Morton's neuroma were
published until that of Betts in 1940 (59 ). Since then, there have been many investigations into the histopathology of this lesion (Table 4 ).
Actually, Morton's neuroma is neither a true neuroma nor a neoplasm. The term neuroma refers only to tumorous nodules that are formed
by neural proliferation and dense fibrosis involving both axons and sheath (Schwann's cells) (60 ).
The histopathologic investigations of numerous authors support the observations that Morton's neuroma consists of degenerative alterations
of one or more intermetatarsal nerves (Fig. 6 ). This process is characterized by the following: endoneural and neural edema (early stages);
perineural, epineural, and endoneural fibrosis and hypertrophy (late stages); Renaut's body formation, usually in a subperineural location;
hyalinization of the walls of endoneural blood vessels; subintimal and perivascular fibrosis that may lead to occlusion of local blood vessels
(resembling a healed vasculitis); mucinous changes endoneurally and perineurally; and demyelination with axonal loss (60 , 61 , 62 , 63 ,
64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ). Goldman noted perineural epithelial cells lying freely in the endoneurium and assumed
that they played a phagocytic role (64 ) (Fig. 7 ).
FIG. 5. Gross specimen of resected Morton's neuroma. Bifurcate digital branches and the fusiform enlargement are clearly visible.
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TABLE 4. Histopathology of Morton's neuroma: a chronology

Authors and year Material Findings
Betts, 1940 19 cases The first to make a histologic examination; found increased fibrous tissue
elements
Cottrell, 1940 — Found progressive thickening of the walls of the endoneural vessels and the
perineurium with aging in normal nerves
McElvenny, 1943 12 specimens, Neurofibromas or angioneurofibromas; Renaut's bodies
11 patients
Baker and Kuhn, 14 specimens, Resembled amputation neuroma: reactive hyperplasia
1944 11 patients
King, 1946 5 cases “Sclerosing neuroma”
Bickel and 18 cases Interstitial edema and irregular demyelination
Dockerty, 1947
Nissen, 1948 27 cases Local vascular degeneration: an ischemic lesion
Winkler, Felner, 20 cases Essentially a degenerative process
and
Kimmelstiel,
1948
Ringertz and 18 specimens, Endoneural edema and demyelination are the characteristic features of
Unander- 21 controls Morton's neuroma
Scharin, 1950
Scotti, 1957 17 cases “Endarteritis-fibrosis complex’
Viladot and 7 cases Similar degenerative changes; no sign of inflammation or thrombotic injury
Moragas, 1966
Meachin and 23 specimens, Nonspecific degenerative reactive changes
Abberton, 1971 19 patients,
23 controls
Reed and Bliss, 118 cases “Regressive and productive intermetatarsal elastofibrositis;” elastin tissue
1973 proliferation in the fibroadipose tissue surrounding Morton's neuroma
May, 1976 31 specimens “Traumatic neuritis” with proliferation of connective tissue elements:
neurofibroma
Lassmann, 1976 105 patients Thickened perineurium, thickened walls of endoneural vessels, endoneural
edema and sclerosis, axonal degeneration without wallerian degeneration
Tate and Rusin, 50 specimens Marked fibrosis and collagenous infiltration; demyelination; axonal
1978 degeneration
Goldman, 1979, 133 cases Demyelination diagnostic of intermetatarsal neuroma; observed distal
1980 wallerian degeneration as evidence of axonal degeneration and shift to left
in axon diameter population; pathologic process not sparing any components
of the peripheral nerve; detailed degenerative activity plus some axon
regeneration; Renaut's bodies
Lassmann, 1979 133 cases Endoneural vascular fibrosis
Mann and 65 specimens, Similar degenerative changes; classic pathologic findings of neuromas a
Reynolds, 1983 11 recurrent traumatic neuroma in recurrent lesions
neuromas
Graham and 24 neuromas Venous congestion, entrapment changes, nerve enlargement distal to the
Graham, 1984 transverse metatarsal ligament
Guiloff, 16 patients Similar degenerative changes: Renaut's bodies common
Scadding, and
Klenerman,
1984
Shereff and 10 specimens Edema of the endoneurium, fibrosis beneath the perineurium, axonal
Grande, 1991 degeneration and necrosis characteristic of nerve impingement
Bourke, Owen 15 patients “Except for possible demyelination, the so-called typical histologic changes
and Machet, of fibrosis and swelling are similar to that seen as presumed degenerative
1994 disease in elderly patients”
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FIG. 6. A: Light micrograph. Note the endoneural and perineural fibrosis, the large hyalinzed nodules in the endoneurium, and the
dropping out of myelimated fibers (800× magnification). B: Light micrograph. Note the vessels with thickened walls, the hyalinized
nodules, and the endoneural fibrosis (2,000× magnification). (Courtesy of Flair Goldman, D.P.M.)
In advanced cases of Morton's neuroma, Renaut's bodies (hyaline granules) have been observed in the endoneural tissue (25 ,61 ,64 ). These
degenerative structures, first described in 1881 (75 ), are a nonspecific response to nerve trauma, particularly to compression (76 , 77 ,
78 ).
FIG. 7. A: Electron micrograph. Note the giant vacuolated endoneural fibroblast (20,000× magnification). B: Electron micrograph.
Note the degenerating myelin engulfed by the perineural epithelial cell. Also note multiple micropinocytotic vesicles (25,000×
magnification). (Courtesy of Flair Goldman, D.P.M.)
Finally, wallerian degeneration, or fatty degeneration of a nerve fiber caused by loss of nutrition, has been observed in Morton's neuroma.
In addition, evidence of regeneration of axons may in part explain the symptoms associated with the neuroma (24 ,42 ,79 ) (Fig. 8 ).
Several of the degenerative changes seen histologically in the plantar intermetatarsal nerves are the same in both control specimens and in
patients with symptomatic pathologically confirmed Morton's neuroma. More characteristic
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of Morton's neuroma are demyelination, endoneural edema, and a greater degree of subperineural fibrosis (74 ,80 ). Although endoneural
edema can be associated with inflammation, only one study observed a leukocytic infiltration into the nerve, and that was only in half of
their specimens (n = 10) (73 ).
FIG. 8. A: Electron micrograph. Note the vesicular degeneration of myelin (18,200× magnification). B: Electron micrograph. Note the
cluster of regenerating axons (34,000× magnification). (Courtesy of Flair Goldman, D.P.M.)
In summary, Morton's neuroma is a progressive, degenerative, and at times regenerative process in which early and late pathologic changes
maybe found. Although the intermetatarsal nerves and blood vessels undergo many degenerative changes, endoneural edema, excess
fibrosis, and demyelination are diagnostic of the disorder. Therefore, perineural fibroma may be a better term for this lesion. It appears
from histopathologic studies that Morton's neuroma is the result of both crushing and stretching trauma to the interdigital nerves,
particularly in the third intermetatarsal space. Goldman was more specific and suggested that the epineurium responds to mechanical
compression, whereas the perineurium responds to stretch (64 ).
ETIOLOGY AND BIOMECHANICS

Many theories have been proposed for the etiology of Morton's neuroma (Table 5 ). Histologic findings leave little doubt that the syndrome
is indeed a mechanical entrapment neuropathy (23 , 24 , 25 , 26 ,73 ). The deep transverse intermetatarsal ligament appears to be the
anatomic structure most likely to be responsible for this process.
Less clear is the exact source of these mechanical entrapment forces. A common observation is that most intermetatarsal neuromas occur
in the pronated foot (12 ,38 ,81 ,82 ), where there are not only excessive stretch forces imposed on the interdigital nerves but also
compressive and shearing forces from the adjacent hypermobile metatarsal heads (83 , 84 , 85 ). The nerve is also subjected to increased
trauma by the motion occurring between the medial and lateral columns of the foot, which are divided between the third and fourth
metatarsals.
In addition, as the medial and lateral plantar nerves dive plantarly under the arch, a stretch is placed on these nerves during prolonged
midstance pronation as the foot is everted, abducted, and dorsiflexed. Tension is increased as these nerves travel around the flexor
digitorum brevis sling and are drawn up tightly against the plantar and anterior edge of the unyielding deep transverse intermetatarsal
ligament (65 ). This may help to tether the nerves in both the third and the second intermetatarsal spaces. Further tension and
compression on the nerve occurs across this ligament when the toes hyperextend at the metatarsophalangeal joint (23 ,57 ,59 ,61 ,65 ,86 ,
87 , 88 ). Thus, occupations requiring repetitive toe hyperextension can result in the development of an intermetatarsal neuroma,
regardless of foot type.
Finally, pointed-toe or narrow shoes can further add compressive forces that favor the production of intermetatarsal neuromas in any foot
type (61 ,65 ). High-heeled shoes not only throw weight forward onto the ball of the foot and jam the toes into the narrow front of the
shoe, but also they force the toes into hyperextension and encourage nerve compression.
Intermetatarsal Bursa
At the level of adjacent metatarsophalangeal joints, an intermetatarsal bursa lies in close proximity to Morton's neuromas
(12 ,38 ,58 ,62 ,66 ,67 ,89 , 90 , 91 , 92 , 93 , 94 , 95 ). These features have been confirmed on MRI scans (49 ). Inflammation of these
structures creates swelling and compression on the adjacent nerve and may explain some of the acute symptoms associated with neuromas,
especially when the patient has a prompt response to corticosteroid injections.
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TABLE 5. Theories on the origin of Morton's neuroma

Authors and year Hypothesis
Morton, 1876 Pinching compression of the lateral plantar nerve branch by adjacent metatarsal heads 4 and 5;
supported by Bradford (1891) and Guthrie (1892)
Hoadley, 1893 Third intermetatarsal “neuroma” caused by impingement between the third and fourth
metatarsal heads
Gibney, 1894 Secondary to flatfoot
Goldthwait, 1894 Laxity of the transverse metatarsal ligament with subsequent collapse of the transverse arch;
supported by Pollosson (1899)
Jones, 1897 Pressure on the nerves, but not pinching between the toes
Betts, 1940 Stretching neuritis of the conjoined “fourth digital nerve” by the flexor brevis around the
unyielding transverse metatarsal ligament during toe dorsiflexion; supported by McElvenny
(1943), Baker and Kuhn (1944), and Bickel and Dockerty (1947)
McElvenny, 1943 Small or ill-fitting shoes
King, 1946 Chronic trauma
Bickel and Trauma from weight bearing in ill-fitting shoes
Dockerty, 1947
Nissen, 1948 Local vascular degeneration-occlusion after ischemia; caused by trauma
Hiss, 1949 Impingement or irritation of the lateral plantar nerve between a dysfunctional cuboid joint
complex and the quadratus plantae muscle
Mulder, 1951 Pinching of the plantar nerve between the metatarsal heads during the abnormal movements
associated with weak transverse arches
Reed and Bliss, Trauma from impingement of the intermetatarsal bursa and neurovascular bundle between the
1973 heads of the metatarsal bones
Carrier et al., 1975 Biomechanical tension and shearing of the third interdigital nerve caused by medial and lateral
column shear during supination and especially during pronation
Silverman, 1976 Biomechanical disorder
Tate and Rusin, Abnormal and excess shearing stress on the communication between the medial and lateral
1978 plantar nerves caused by compensated forefoot varus
Gauthier, 1979 Trauma as the nerve is squeezed between the plantar soft tissue and the anterior edge of the
plantar fascia
Goldman, 1979 Compression (epineurium) and stretching (perineurium)
Lassmann, 1979 Chronic trauma plus a possible metabolic or hormonal factor
Graham and Entrapment at the distal edge of the intermetatarsal ligament
Graham, 1984
Alexander, Johnson, Taut transverse metatarsal ligament compressing and Parr, the interdigital nerve
and Parr, 1987
Classic symptoms of this syndrome have been seen in patients with rheumatoid arthritis (96 ,97 ). Intense inflammation of the bursae and
rheumatoid nodules may be found with secondary impingement on the local nerves (12 ,89 ,97 , 98 , 99 , 100 ).
CONSERVATIVE MANAGEMENT
Initial treatment may consist of measures to avoid irritation of the neuroma. Wider shoes with adequate toe space along with good arch
support are a sound recommendation. Avoiding high-heeled shoes is also a reasonable choice (101 ).
Metatarsal pads constructed out of any material may be applied to the proximal edge of the second, third, and fourth metatarsal heads to
help draw the weight proximally off the neuroma and to splay the metatarsals. Several other padding techniques have been described (102 ,
103 , 104 , 105 , 106 , 107 , 108 ). Balance padding, with support under the first, second, and fifth metatarsal heads may help to alleviate
some of the direct pressure to the symptomatic area. Most padding measures may be combined with a low-Dye strapping to add more
support. Toe crest pads are also sometimes helpful.
If pads and strappings provide good relief, then neutral position orthoses may be successful. The goal of this therapy is to limit the
hypermobility of the forefoot that may irritate the neuroma (37 ,108 , 109 , 110 ).
Injection therapy may provide some measure of relief (111 ). Blocking the intermetatarsal nerve with a local anesthetic, or even the
posterior tibial nerve, is rarely therapeutic, but it may provide helpful diagnostic information (112 ). The injection of vitamin B12 or
cyanocobalamin, as advocated by Steinberg (113 ), may result in some success, although the response may be due to the sclerosing effects
of the preserving agent, 1% benzoyl alcohol.
Injection with a corticosteroid and local anesthetic mixture has been advocated by several authors and used my most practitioners for
years (15 ,114 , 115 , 116 , 117 , 118 ). Although the specific local anesthetic and steroid used are the clinician's choice, most authors
suggest a series of three injections given at 1-to 3-week intervals. Alternatively, the injections may be given at greater intervals as needed
when combined with other treatment modalities. More than three injections may be used as long as the clinician is judicious and aware of
adverse steroid effects that can cause subcutaneous fat pad atrophy and local tendon or ligament ruptures.
The steroid mixture may be injected between the metatarsal necks, directly between the toes through the web in an anteroposterior
direction, or into the sulcus between the involved
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metatarsal heads. The patient should be cautioned that painful symptoms may occur for several days at the site of injection before the
desired effects are obtained. This steroidflare reaction is observed especially when less-soluble steroid salts are used. Pain may also be
accentuated by the infiltration of the fluid into the nerve or surrounding tissue.
The therapeutic success of local anesthetic and steroid injection has been variable, with complete relief noted in 11% (118 ), 24% (81 ),
30% (116 ), and 47% (15 ) of patients in several studies. Partial relief was achieved in a greater percentage of patients, and better results
were obtained with multiple injections. Duration of relief was also variable. Greenfield et al. reported that of the 80% of 47 patients who
had experienced total or partial relief of pain, 65% had no pain 2 years later (116 ).
Infiltration with a dilute 4% alcohol solution may be effective for chronic neuroma. Serial injections using approximately 1 mL at a time to
provide the necessary sclerosing effect are usually necessary (119 ). The alcohol concentration can be increased as determined by the
experience of the clinician. However, care must be taken not to use large volumes of pure alcohol, which can have disastrous results,
including sloughing of the skin and intervening tissues (120 ).
Kirvela and Nieminen evaluated phenol-glycerol (50 mg/1,000 mg/ml) as a neurolytic agent on operatively treated recalcitrant painful
neuromas and reported a 90% success rate (121 ). Phenol or carbolic acid has been used as a topical analgesic, disinfectant, and
cauterizing agent. It also impairs conduction of small nerve fibers that serve pain and spasticity. Dissolving phenol in glycerin delays its
release into the tissues and renders it less destructive. This neurolytic agent has a quicker onset than alcohol, is less toxic to the tissues,
and is less likely to cause painful neuritis. The solution is believed to spread along the perineural sheath, and nerve destruction is followed
by a gradual regeneration of the fibers, a process that may take up to 2 weeks. Extreme caution should be used in the delivery of this
injection because any of the phenol that trails back to the surface can irritate the subcutaneous tissue and skin.
The general consensus is that the overall success for conservative treatment of the intermetatarsal neuroma is less than 80%, considerably
less for full resolution of symptoms (117 ). Patients should be made aware of this prognosis before treatment is begun. A logical approach
to managing Morton's neuroma is to institute treatment in stages (15 ). The first stage consists of patient education, shoe modifications,
pads, and orthotics. Failing one or more of these, then injection therapy may be instituted as a second stage. When most conservative
measures have been unsuccessful, the third stage can then be implemented: release or excision of the neuroma.
SURGICAL MANAGEMENT
General Considerations
When conservative treatment fails and painful symptoms exist, surgical treatment becomes the next option (6 ,14 ,20 , 28 ,30 ,59 , 60 , 61 ,
62 ,69 ,90 ,91 ,106 ,122 , 123 , 124 , 125 , 126 ). However, by current analysis of surgical outcomes, a 5% to 24% rate of unsatisfactory
results can be expected (14 ,21 ,117 ,127 ,128 ).
When local anesthesia is used for surgical procedures, field infiltration may be supplemented with a posterior tibial nerve block to prevent
the lancinating pain that can at times result when the proximal nerve trunk is sharply severed. Alternatively, blocking the adjacent
intermetatarsal spaces also prevents discomfort with transection of the proximal nerve trunk.
Since its initial description, many changes have been made in the surgical procedures used for interdigital neuroma. Various new
techniques have been described for the surgical management of a primary intermetatarsal neuroma. The most commonly recommended
surgical treatment is excision of the involved interdigital nerve. The clinician should be aware of the benefits and shortfalls of different
incisional approaches for this procedure. As an alternative to nerve resection, some surgeons advocate true epineural neurolysis or
decompression as similarly performed for other entrapment neuropathies. Treatment of Morton's neuroma using endoscopic
instrumentation, percutaneous electrocoagulation, and carbon dioxide laser techniques reflects some of the advances in modern medical
technology.
Neuroma Resection
Planning
Successful resection of Morton's neuroma hinges on three factors: (a) an accurate diagnosis, (b) good operative technique, and (c)
responsible postoperative management. The infamous clean-out procedure, or “interspacectomy” in which all structures in the
intermetatarsal space are resected en bloc cannot be justified (6 ,129 ).
Surgical Approaches
Four approaches have been described for access to the intermetatarsal neuroma: dorsal (125 ,130 ), plantar longitudinal (30 ,59 ,65 ,131 ),
plantar transverse (63 ,91 ,131 ), and wet splitting (61 ,124 ) (Fig. 9 ). The most frequently used techniques are described. Regardless of
the approach, the digital branches should be identified and transected, and the nerve trunk should be cut proximal to the metatarsal
heads, to minimize complications resulting from inadequate resection or regrowth.
Dorsal Approach
The greatest advantage with the dorsal approach is that early ambulation is possible because the incision is on a non-weight-bearing
surface. Healing is a little faster than on the plantar skin. The disadvantage lies in reaching deep between the metatarsal heads and having
to incise the deep transverse intermetatarsal ligament. These tasks are facilitated by the use of a Schink metatarsal retractor, a baby Inge
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laminar spreader, a self-retaining Weitlaner retractor, or a large Kelly hemostat. There is also greater potential dead space, and the dorsal
cutaneous nerve branches can be damaged.
FIG. 9. Incisional approaches for resection of Morton's neuroma. A: Longitudinal plantar incision: Hoadley (1893), Betts (1940). B:
Transverse plantar incision: Nissen (1948). C: Web-splitting incision: McElvenny (1943). D: Dorsal incision: McKeever (1952).
A dorsal incision is made directly over the intermetatarsal space and extending to the web or distally onto an adjacent toe for additional
exposure. Blunt dissection is then used to reach the deep transverse intermetatarsal ligament, which is incised sharply. Minimal probing
reveals the fusiform portion of the neuroma. A curved mosquito hemostat is now inserted at the distal bifurcation, and each nerve branch
is isolated and clamped in turn. These branches are severed. The neuroma is dissected as far proximally as possible and transected. Care is
taken not to damage the intermetatarsal artery and vein, which usually lie above the nerve, by keeping the scalpel blade or dissection
scissors coaxial to the neuroma. Routine layered closure is obtained. A closedsuction drain may be inserted if concern exists for
postoperative bleeding.
Elevation and limited weight bearing in a surgical shoe are recommended for the first 48 hours. Crutches are not typically required, but
they may be used based on the level of patient comfort and ambulatory stability. A return to wearing soft shoes is allowed after 2 to 3
weeks.
Several studies regarding neurectomy by the dorsal approach cite an average success rate greater than 84% (14 ,51 ,127 ,132 , 133 , 134 ,
135 ). Keh et al. reported 93% patient satisfaction among 53 patients with 70 previously unoperated neuromas with a postoperative follow-
up of 4.8 years (133 ). Dereymaeker et al. achieved 81% satisfaction among 32 patients with an average follow-up of 44.7 months (134 ).
Ruuskanen showed improvement in 80% of 45 patients after a mean follow-up period of 6 years (135 ). Mann and Reynolds reported
retrospectively on 56 previously unoperated neuromas; 80% of these patients were greatly improved, and 14% were considered treatment
failures (14 ). Friscia et al. evaluated the efficacy of neurectomy on 366 feet, the largest study group to date, and reported a 79% success
rate at an average of 5.9 years of follow-up (16 ).
Plantar Approach, Longitudinal Incision

For the best exposure, the plantar longitudinal incision is unsurpassed (Fig. 10 ). It allows good visibility, making all portions of the
neuroma easily accessible (65 ). Other than a painful stump neuroma, the potential complication of greatest concern is an irritating scar on
the weight-bearing surface of the foot. Painful scar formation is best avoided by careful placement of the incision between the metatarsal
heads and instituting a period of non-weight bearing for three weeks after surgery.
Once the plantar incision is made and hemostasis is achieved, minimal dissection usually provides exposure to the entire neuroma. Vascular
structures are easily identified and preserved, and the deep transverse intermetatarsal ligament remains undisturbed because the neuroma
lies plantar to this structure. Thus, the stabilizing influence of the ligament is preserved. The digital branches are isolated and are clearly
transected, followed by the proximal nerve trunk and, if present, accessory branches.
Sectioning of the nerve trunk is performed proximal to the weight-bearing portion of the forefoot, where the nerve is surrounded by the
intrinsic musculature. Downey and Karges recommended ligating the proximal stump and suturing the epineurium into neighboring intrinsic
muscle (lumbrical) or bone without tension (136 ,137 ). Research has suggested that cut nerve endings implanted into innervated muscle
are least likely to demonstrate significant “neurotrop(h)ism” or regeneration (138 ,139 ).
FIG. 10. Plantar resection of Morton's neuroma while preserving the deep transverse intermetatarsal ligament.
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The incision site is irrigated, and then the skin edges are closed with nonabsorbable suture of choice. Little or no dead space should remain.
Youngswick advised against using deep sutures in the plantar dermis because the inflammatory reaction can cause a keratotic plug to form
(11 ). However, this is not an overriding concern, and some degree of subcutaneous closure is acceptable.
Nashi et al. reported a greater propensity for painful scar formation using the plantar approach in patients who were evaluated an average
of 3.1 years after surgery (140 ). Symptomatic scars were observed in 28% of 47 patients seen from 1 to 20 years postoperatively by
Klenerman et al. (141 ). In contrast, Richardson et al. obtained a 96% patient satisfaction rate with plantar incisions for a variety of
problems in a much larger study population (142 ). Moshein and Portis found no painful incisions over 5 years postoperatively in 31 neuroma
excisions (143 ). Karges, based on his retrospective study of 51 patients, with a 93% success rate, concluded that the plantar approach is
technically simple and results in a comfortable scar (137 ). In his opinion, the ability to resect the nerve more proximally with the plantar
approach resulted in the higher rate of success. Wu also advocated the plantar approach (144 ).
Plantar Approach, Transverse Incision

This approach generally provides good visualization of the neuroma itself. However, the major disadvantage is that it may be difficult to
cut the nerve trunk far enough proximal to the metatarsal heads. The resultant plantar scar is distal to the metatarsal heads at the sulcus
of the toes and results in less irritation with weight bearing (145 ).
The incision begins at the medial aspect of the medial metatarsal and continues to the lateral aspect of the lateral metatarsal of the
corresponding interspace. It is placed half-way between the metatarsophalangeal joint and the web space and is deepened by sharp
dissection through the subcutaneous tissue and then bluntly in a linear fashion toward the affected intermetatarsal space. A bursa may be
frequently encountered at this level and is excised. The digital nerve branches are identified and are sharply transected as distally as
possible. Closure of incision and postoperative protocol are similar to the plantar longitudinal approach.
Burns and Stewart reported 100% patient satisfaction using this approach in five patients with a 6- to 12-month follow-up (91 ). Out of 80
neuromas resected from 75 feet, Viladot obtained a success rate of 94% with an average follow-up of 58 months compared with a 95%
success rate for an equal number of patients using the dorsal approach (145 ). Youngswick observed a lesser success rate of only 83% with
extended follow-up after neuroma excision through the plantar transverse incision (11 ).
Adjacent Interspaces
Neuromas commonly develop in adjacent intermetatarsal spaces. The major concern is the potential for vascular embarrassment, whether
through one central or two separate incisions. When one uses two dorsal incisions, the distance between the two should be as great as
possible to avoid necrosis of the intervening skin. When a single incision is used, adding a slight curve to the incision as it crosses the
metatarsophalangeal joint allows for scar contracture without affecting the digit and should facilitate access to each interspace.
If a single incision is used, dissection should be carried down to a level below the subcutaneous tissue that contains the neurovascular
structures before undermining into either interspace. Extensor tendon adhesions and dorsal nerve entrapments are possible complications
of the single incision approach. This risk can be minimized by preserving the paratenon and by careful closure of the superficial fascia.
When circulation is marginal, the more painful neuroma may be excised first, and then the adjacent interspace neuroma can be resected 1
to 2 months after the primary incision has healed. Another option is to excise one neuroma through a dorsal approach and the other
through a plantar approach.
Neurolysis
Morton's neuroma is the only frequently performed neurectomy in the human body. Peripheral neurectomy can result in continuing pain
secondary to stump neuroma formation, sensorimotor alterations of the components of the nerve, and reflex sympathetic dystrophy or
causalgia if the sympathetic component of the nerve is irritated (136 ). Studies have described a 14% to 21% failure rate for neurectomy
(14 ,146 ,147 ). The recurrence of symptoms is largely the result of the severed nerve's attempt to regenerate, a situation that produces
reinnervation of the interspace skin, adhesions about the metatarsal heads, or a stump neuroma.
In response to this observation, Dellon and other authors advocated neurolysis as a surgical solution to painful Morton's neuroma that
resists conservative measures, thus preserving the continuity of the nerve itself (21 ,148 , 149 , 150 ). Unfortunately, the term “neurolysis”
has been applied broadly throughout the literature, so it is important to define the procedure to which it refers (151 ).
Anatomically, the corrective tissue stroma of peripheral nerves is found in layers at different yet confluent locations. The endoneurium
envelops individual nerve fibers, a bundle of which forms a fasciculus or funiculus, surrounded by a relatively thin but dense connective
tissue layer called the perineurium. The connective tissue that surrounds the entire nerve, outside the perineurium, is called the
epineurium. This layer consists of loose areolar tissue that provides a cushion for external trauma and also contains the major blood supply
inside the nerve (vasa nervosum) as well as the lymphatic vessels. The outer investing layer of the epineurium is known as the superficial
or epifascicular epineurium, whereas the layer of connective tissue that extends between the individual fasciculi is called the
interfascicular epineurium. Under normal conditions, the proportion of epineurium
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to the cross section of the nerve trunk ranges from 30% to 75% (29 ) (Fig. 11 ).
FIG. 11. Anatomy of peripheral nerve showing the basic support structures.
External neurolysis is defined as the freeing of the nerve trunk from impingements external to the nerve, including scar tissue adherent to
the superficial epineurium. Thus, it is sometimes referred to as epineural neurolysis. Epineurotomy indicates incising the superficial
epineurium itself along the area of neural compression or expansion, whereas epineurectomy means the actual excising of the superficial
epineurium from the scarred area of the nerve. Finally, the term internal neurolysis is best defined as the freeing of the individual
fascicles within the nerve trunk, to separate them from each other as well as from the epineurial scar. Another term preferred for this
procedure is interfascicular neurolysis (151 ).
The concept of epineural or external neurolysis was introduced by Gilmore and Gauthier (21 ,152 ). Gauthier performed dorsal epineural
neurolysis procedures on 304 neuromas in 204 patients and reported excellent results in 83% of the study group; 14% were improved, and
3% showed no change. Okafor et al. performed external neurolysis on 35 patients and achieved complete resolution of symptoms in 17
patients, with 12 reporting minimal discomfort with activity (112 ). The overall patient satisfaction was 98%. Diebold et al. performed an
epineural neurolysis on 40 patients and reported excellent results in 93% at 5 years follow-up (153 ). Thirty-nine patients also stated that
they would undergo the operation again if necessary.
Gilmore and Gauthier recommended division of the intermetatarsal ligament and neurolysis to allow free dorsal transfer of the entrapped
nerve (21 ,152 ). Vito's modification to this technique consisted of suturing of the epineurium of the decompressed nerve to the adjacent
metatarsal's deep fascia or periosteum (154 ).
This procedure is typically performed with the help of magnifying loupes, yet it can be performed without this aid. Epineural neurolysis is
usually performed through a dorsal incision, but a plantar approach is also acceptable. The intermetatarsal ligament is identified and
incised the vessels underneath are protected. When the nerve is identified, a vessel loupe is passed beneath it, to suspend the nerve
without creating significant traction. Proximally and distally, the nerve is retracted with a vessel loupe and is gently freed from adherent
soft tissue. Proximally, the nerve frequently adheres to the medial metatarsal of the interspace. Distally, the digital nerves are dissected
carefully from the vascular bundle that is over the nerve. After complete release of the nerve, 6-0 or 7-0 nylon or Prolene suture is passed
longitudinally through the epineurium, thus preventing impingement of the fascicles (Fig. 12 ). This suture is tied to the adjacent
metatarsal's deep fascia or periosteum to suspend the nerve. The vessel loupe is removed, with the nerve decompressed and relocated
above the epicondyles of the adjacent metatarsals. The deep transverse intermetatarsal ligament, which is now plantar to the nerve, is
not repaired. The superficial fascia and skin are then closed.
The patient is instructed to remain non-weight bearing for 48 hours and is then permitted partial weight bearing with a surgical shoe. After
2 weeks, the patient is allowed to return to normal activities as tolerated. Price and Miller reported their results from a combined external
and internal neurolysis of Morton's neuroma using 3.5× loupes and microsurgical techniques (155 ). In their study, 16 of 17 patients (94%)
were described as improved, although all required postoperative paraneural injections to assist in their recovery. Compared with the
success of external neurolysis, the more complex internal neurolysis does not appear necessary for surgical relief of Morton's neuroma.
Endoscopic Decompression of Intermetatarsal Neuroma

The endoscopic decompression technique is essentially a minimal form of external neurolysis using endoscopic equipment that permits
visualization of anatomy with less tissue trauma. Proponents of this technique advocate that transection of the rigid transverse
intermetatarsal ligament reduces the compression and stretching forces on the common digital nerve during propulsion and thus alleviates
the symptoms associated with Morton's neuroma. This rationale is based on the study by Graham and Graham, who noted that the
characteristic degenerative changes of the nerve occurred immediately distal to the distal margin of the transverse intermetatarsal
ligament (23 ).
The endoscopic decompression of intermetatarsal neuroma procedure, described by Barrett and Pignetti in 1994, is not unlike the
endoscopic plantar fasciotomy (156 ). Two small transverse dorsal incisions and one small transverse plantar incision are used for
instrument insertion. A hook blade is used to transect the deep transverse intermetatarsal
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ligament, and the nerve is left intact. Care is taken to avoid sectioning the proximate lumbrical tendon.
FIG. 12. A: Suspension of the neuroma with a vessel loop after transection of the deep transverse intermetatarsal ligament. B: The
epineurium is tagged, and the suture is then anchored into the adjacent structures to maintain the nerve in its new position.
Barrett and Pignetti performed this procedure on 17 patients and reported excellent outcomes in 15 patients, a fair in a single patient, and
a poor in a patient who later required neurectomy (156 ). All patients were fully weight bearing in surgical shoes immediately
postoperatively and in regular shoes the day after surgery. However, no long-term studies have been conducted to support or disclaim the
endoscopic decompression of intermetatarsal neuroma procedure as an effective cure for intermetatarsal neuroma.
Radiosurgical Destruction
Another minimally invasive procedure for resolving painful Morton's neuroma involves the percutaneous insertion of radiosurgical
electrodes to interrupt the proximal nerve trunk by means of electrocoagulation. The first commercial radiofrequency generators were
introduced in the early 1950s by Cossman and Cossman (157 ). Radiofrequency electrodes are used to generate an electric field that
destroys nerve tissue and interrupts pain impulses to the central nervous system (Fig. 13 ). Radiofrequency produces heat lesions that lead
to neurolysis of the affected nerve. Finney et al. used a Radionics (Burlington, MA) nerve lesion generator to treat Morton's neuroma and
reported a 68% satisfaction rate, although long-term results were not available (51 ). Rahimi and Muehleman, using a Surgitron
radiosurgical instrument in rats, demonstrated that controlled electrocoagulation sealed the epineurium tightly around the proximal nerve
stump and thereby minimized stump neuroma formation (158 ).
Two electrodes, an insulated active electrode and an inactive grounding electrode, are used. The electrical line voltage is converted to
radiofrequency and is transmitted through the active electrode tip, to cause an electric field, ionic motion, and heat generation (51 ). The
active electrode is positioned such that a pain response similar to the neuroma pain is obtained. The electrode tip temperature is then
maintained at 85°C for 90 seconds.
Carbon Dioxide Laser Treatment

Laser modalities have also been advocated for the surgical treatment of Morton's neuroma. The purported advantages of the carbon
dioxide laser technique include a reduced incidence of stump neuroma formation, good hemostasis secondary to the coagulating effect of
the carbon dioxide laser on small blood vessels, increased antisepsis from the sterilizing nature of the laser, and a purported reduction in
postoperative pain (159 ). The most commonly used technique consists of a 4- to 5-cm linear incision overlying the affected interspace.
The laser is used to dissect through the skin and deep fascia. Wasserman recommends using a power density of at least 40,000 W/cm2 for
the skin incision because repeated passes through the skin may create an accumulative thermal buildup and may increase postoperative
discomfort (159 ). The neuroma is excised at a power density between 15,000 and 20,000 W/cm2 and is severed at the most proximal
aspect. Dissection is then extended distally, where the proper digital branches are excised with the laser. The nerve stump is brushed
lightly, with the laser in a defocused mode, to seal the nerve fibers. The incision is closed, and a soft dressing is applied. Wasserman
presented three cases and a
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detailed technical description of this procedure. He reported successful results for 8 months, 9 months, and 2 years of follow-up (159 ).
FIG. 13. Schematic illustration of the technique of radiosurgical destruction of Morton's neuroma. (Redrawn from Finney W, Wiener
SN, Catanzariti F. Treatment of Morton's neuroma using percutaneous electrocoagulation. J Am Podiatr Med Assoc 1989;79:617, with
permission.)
At high-power density settings, the carbon dioxide laser is advocated as a cutting laser, but it can fuse or seal at a lowpower density.
Because 99% of the carbon dioxide beam is absorbed by water, thermal sealing of the nerve end has been found to be incomplete.
Postoperatively, axon sprouts have been visualized histologically. It has been further proposed that the use of the neodymium-yttrium-
aluminum-garnet device for laser neurectomy may provide more secure thermal sealing (160 ).
Cryogenic Denervation
Another treatment method that may avoid the complications associated with nerve transection is cryoanalgesia. The cryoanalgesia device
consists of a nerve stimulator, with a frequency choice of 2 Hz for motor nerves or 100 Hz for sensory nerves, and a coding probe. The
probe or cryoneedle is either 14 gauge, which forms a 5.5-mm ice ball at the tips, or 18 gauge, which forms a 3.5-mm ice ball.
The probe has a small orifice at the tip through which a gas under pressure escapes, expands rapidly, cools the immediate area to between
−50° and −70°C, and causes a cryolesion. This is known as the Joule-Thompson effect. The gas used is either nitrous oxide or carbon
dioxide delivered at a pressure of 600 psi.
Cryogenic damage to the peripheral nerve results in two separate pathologic processes: extensive vascular damage to the endoneurial
capillaries followed by demyelinization and wallerian degeneration of the nerve axons. Once the probe is introduced through an
angiocatheter that has been inserted after local anesthesia is administered, the nerve stimulator is activated. Reproduction of the patient's
pain or symptoms confirms the correct position for the tip. The gas is then delivered, usually in three 2-minute freeze cycles with a 1-
minute thaw cycle in between using an instant defrost pedal. The apparatus is removed, a light dressing is applied, and a mild analgesic
agent is prescribed. The patient remains ambulatory.
Theoretically, the advantage of cryoanalgesia is that, although demyelinization and degeneration of the axon occur, the endoneurium,
perineurium, and epineurium are preserved, thereby allowing axon regeneration without neuroma or scar formation. Postoperative
inconvenience is minimal. Hoder et al. described a single case of a traumatically induced intermetatarsal neuroma when the patient was
free of pain 6 months after cryogenic denervation (161 ).
Complications
Whatever approach is used for surgical intervention of the symptomatic and persistent intermetatarsal neuroma, observance of several
principles minimizes complications. These include, but are not limited to, the following:
 Gentle handling of tissues is necessary at all times.

 Meticulous hemostasis is important; a tourniquet is not necessary, it but may be used at the discretion of the surgeon.
 The digital branches and proximal trunk should be identified to ensure complete resection, when necessary.
 The neuroma should be dissected without damaging the intermetatarsal artery or the local lumbrical tendon.
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 When one is transecting the nerve, it should be cut as far proximally as possible.
 A firm, even compression dressing helps to prevent postoperative hematoma formation.
Hematoma
Hematoma may form in the dead space as a result of blood and serum accumulation after a neuroma resection. Not only does this prolong
the initial inflammatory phase of healing, but also it may compound the patient's pain and frustration. It is also an excellent medium for
bacterial proliferation. As a general rule, this problem is easily overcome by a compliant patient and by the use of a dressing that provides
good compression. Once a hematoma is present, treatment usually consists of reduced ambulation and compression dressings. In more
difficult circumstances, the hematoma may be aspirated, or the sutures may be removed for full expression of the fluid and evaluation of
the wound.
Vascular Embarrassment
Vascular ischemia of the toes is an uncommon event, yet it may result from interruption of the arterial supply, vasospasm, or congestion
secondary to postoperative edema. Early recognition should lead to prompt treatment, which may include the following: loosening of any
tight dressings, removal of ice, reflex heat, sympathetic nerve blocks, reversal of epinephrine effects by the use of local infiltration with
phentolamine (Regitine), abstinence from caffeine and nicotine, and warming of the surrounding environment. In emergency situations, 5
to 10 mg isoxsuprine (Vasodilan) intramuscularly or 10 mg of nifedipine (Procardia) orally should stimulate effective vasodilation.
Unchecked, a dysvascular toe can progress to frank gangrene requiring subsequent amputation.
However, a discolored digit may also manifest postoperatively as a result of venous congestion, which is not an urgent condition. In this
circumstance, the digit is warm and typically blanches with compression and refills quickly. This condition typically results from the tissue
disruption that accompanies the surgical procedure and is temporary, although it may be aggravated by a dressing that is too tight.
Hammer Toes
When the deep transverse intermetatarsal ligament is severed to access the neuroma, the toes on either side of the surgical site may begin
to contract dorsally. This condition occurs because of loss of the ligament fulcrum for the lumbrical tendon that helps to stabilize the toe
(162 ). Suturing the adjacent metatarsal heads (joint capsules) together has been purported to allow the ligament to heal and to help
prevent any tendency for such instability (14 ). However, this is not a common complication, and such measures may not be warranted.
Interspacectomy
The unrestricted cleaning out of the intermetatarsal space has several potentially adverse effects including digital instability, hematoma
from unsecured bleeding, and excessive adhesion formation. The protective plantar fat padding may be lost, and the chance of painful
stump neuroma formation leading to prolonged and debilitating metatarsalgia may be greater. Specific dissection to identify the nerve and
its branches is recommended.
Continued Pain
As attention to approach and technique have improved, so have the patient satisfaction rates for resection of Morton's neuroma. A review
of 20 studies revealed an average success rate of 85% (Table 6 ). Success varies depending on the surgical approach, with the following
averages noted for each technique: dorsal longitudinal incision, 84%; plantar longitudinal incision, 82%; and, plantar transverse incision,
92%. Some patients always have some uncomfortable yet tolerable sensations that linger, and a few patients have symptoms that either do
not improve or worsen after neurectomy, regardless of the approach used. Although fewer studies have been performed on neurolysis
techniques, these patients have demonstrated consistently better satisfaction rates, in the mid-90% range.
For neurectomy, results are better when only the third intermetatarsal space is involved; rates decrease dramatically when involvement is
bilateral or when there is excision from more than one interspace on the same foot (16 ,127 ,129 ). Beskin and Baxter identified two
clinical groups of patients who experience pain after neurectomy: those who remain symptomatic after neurectomy and those who have a
recurrence after a quiescent period (146 ). Applying this observation to the finding at reoperation, in which 67% of the surgical sites
showed evidence of missed or incomplete resection of the original neuroma, Johnson et al. and Amis believed that the source of the
persistent pain after surgery could be determined by the patient's history (147 ,163 ). If local interspace pain returned quickly, within a
few days or weeks, then the resection had likely been incomplete. If the pain returned much later, such as several weeks to months after a
pain-free interval, then the pain was most likely caused by stump neuroma formation. Identifying patients preoperatively who are at risk
for recurrent neuroma formation is virtually impossible, although it is a goal worthy of pursuing.
Continued pain may also result from other factors that may not be directly related to the nerve itself. The same mechanical aberrations
that may lead to a neuroma may also create localized inflammation and pain in the joints, capsule, or tendinous structures. In this
circumstance, the patient may
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describe and present with symptoms and findings consistent with a neuroma and may undergo successful surgery only to have some
residual symptoms that persist, yet these symptoms will have other sources.
TABLE 6. Studies of results of intermetatarsal neurectomy

Authors and year Approach Patients (n) Average age (yr) Follow-up (mo) Success (%)
Bickel and Dockerty, 1947 Plantar 18 (18) ? ? 81
Bradley et al., 1976 ? 85 (111) 50.2 21.5 87
Burns and Stewart, 1982 Plantar transverse 5 (5) 36-66 6-12 100
Klenerman et al., 1983 Plantar long 47 (59) ? 12-240 87
Mann and Reynolds, 1983 Dorsal long 45 (65) 55 22 80
Gudas and Mattana, 1986 Dorsal long 43 (59) 43.5 51 79
Karges, 1988 Plantar long 51 (57) 19.5 35 93
Gaynor et al., 1989 ? 60 (65) 57 ? 76
Johnson, 1989 Dorsal long 124 (149) ? ? 81
Friscia et al., 1991 Dorsal web space 259 (305) 54.7 70.5 79
Keh et al., 1992 Dorsal long 53 (70) 58 57.5 93
Viladot, 1992 Plantar transverse 75 (80) 44 58 94
Ruuskanen et al., 1994 Dorsal long 45 (58) 50 72 80
Youngswick, 1994 Dorsal long 25 (25) 56.5 40 94.9
Youngswick, 1994 Plantar transverse 25 (25) 47.3 62 83
Bennett et al., 1995 ? 24 (?) 48 42 96
Dereymaeker et al., 1996 Dorsal long 31 (32) ? 44.7 81
Wu, 1996 Plantar long 91 (93) 51 ? ?
Nashi et al., 1997 Dorsal long 26 (28) 53 37 80
Nashi et al., 1997 Plantar long 26 (27) 54 37 65
Recurrent or Stump Neuroma

Although incomplete resection of the intermetatarsal neuroma may be noted at reoperation, probably the most troublesome complication
is painful stump neuroma or recurrent neuroma. Actually, a true bulbous stump neuroma is a less common finding at secondary operation.
In most instances, the “recurrent neuroma” consists of nerve fibers that have incompletely regenerated and then have become attached to
the plantar joint capsule or tendon. This, in turn, may create traction on the nerve with weight bearing. In other patients, incomplete
resection of the original neuroma was believed to be the case (14 ,144 ,164 ). Mann and Reynolds identified, in one-third of their operated
cases, an accessory (communicating) nerve trunk passing under the deep transverse intermetatarsal ligament (14 ). It appeared to have
developed into a recurrent neuroma and had been damaged at the time of the primary surgical procedure (22 ).
Another potential cause of persistent pain as a result of failed neuroma resections has evolved from anatomic dissection studies (165 ,166 ).
Observed was the consistent finding of multiple, mostly plantar nerve branches from the common digital nerves of the second and third
intermetatarsal spaces. Investigators proposed that these nerve branches could prevent retraction of the sectioned nerve trunk proximally
and could thereby leave the nerve end in a position where the stump would be more susceptible to weight-bearing pressure. These
branches also innervate the adjacent metatarsals and metatarsophalangeal joints, and they are larger when they traverse those structures
medial to the common digital nerve from which they emanate. Therefore, recurrent neuromas and adhesions would most likely be found
under the posterior and plantar aspect of the metatarsal medial to the interspace from which the original neuroma was resected.
Physiologically, what remains after neurectomy is a severed nerve, the same as when a limb is amputated. Spontaneous firing starts the
day the nerve is cut and has two peaks of activity: the first occurs on about the third day, and the second occurs within the third week
(167 ). For some people, this is a much more sensitive phenomenon than for others, perhaps moderated or enhanced by accompanying
sympathetic fibers (168 ,169 ).
As the end of the nerve degenerates, immature axon sprouts form. These can be sensitive, especially to mechanical pressure. The axons
extrude with unlimited growth potential; they seek to bridge the gap and to connect with the distal endoneurial tubules. When blocked by
local tissues or scar, the axons may convolute into a painful stump neuroma. If they can connect to the distal endoneurial tubules, then the
function of the nerve may be partially restored, or a recurrent neuroma may form.
Simultaneously, the fibroblasts within the supporting perineurium and epineurium are proliferating scar tissue that can adhere to the end
of the nerve, which may then be placed under traction, tension, or compression. If the nerve stump rests underneath or is attached to a
metatarsal head or joint structure, ambulation may stimulate intense pain (Fig. 14 ).
The recurrent neuroma is identified by sharp, often lancinating or burning paresthesias radiating into adjacent toes and metatarsal heads,
aggravated by weight bearing and persisting well after local tissues have healed. The plantar skin is usually hypesthetic, sensitive to even
light touch. Symptoms may even be described as the same or similar to those experienced before the initial surgical procedure.
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FIG. 14. The usual location of recurrent or stump neuroma is slightly proximal to the metatarsal heads.
Conservative treatment may consist of padding techniques, desensitization procedures, or repeated nerve stimulation by percussion,
massage, ultrasound, or electrical stimulation (170 , 171 , 172 ). Injection of steroids is thought to soften the scar tissue lysing the nerve
end from surrounding tissue and thus to provide a measure of release (100 ). Corticosteroids have been shown to reduce action potentials
and thereby to suppress neural discharge (173 ). Chemical neurolysis injections with dilute alcohol or phenol solution may also be used with
relatively little risk.
If required, a plantar incision facilitates visualization of the more proximal nerve trunk (Fig. 15 ). The goal is to free the nerve from any
adhesions and to provide a clean transection of the nerve further proximally. The end is then preferably implanted into intrinsic
musculature. Investigators have demonstrated that freshly cut nerve ends implanted into innervated muscle do not develop strong
adhesions, and the character of the nerve stump is different. Therefore, the resulting nerve stump is less likely to become painful in such
an environment (174 ,175 ).
TABLE 7. Results of reoperation for failed Morton's neuroma excision

Patients Satisfactory
Authors and year Approach Nerve technique (n) results Percentage
Bradley et al., 1976 Dorsal long Transection 5 1 20
(128)
Mann and Reynolds, Dorsal long Transection 11 9 82
1983 (14)
Nelms et al., 1984 Plantar Osseous implantation 27 24 89
(164) long
Beskin and Baxter, Dorsal long Transection 14 8 57
1988 (146)
Beskin and Baxter, Plantar Transection 24 17 71
1988 (146) long
Johnson et al., 1988 Plantar Transection 4 4 100
(147) long
Dellon, 1989 (161) Plantar Muscle implantation 1 1 100
long
DiNapoli, 1994 (176) Dorsal long Transection 2 2 100
DiNapoli, 1994 (176) Plantar Z Epineuroplasty or muscle 9 8 89
or S implantation
Banks et al., 1996 Plantar Z Epineuroplasty or muscle 16 14 88
(177) or S implantation
FIG. 15. In this patient with a recurrent neuroma, two segments are noted: one extends distally into the interspace, and a second
adheres to the plantar capsule of the metatarsophalangeal joint.
Results of reoperation for intermetatarsal neuromas vary widely (Table 7 ). Bradley and associates found unsatisfactory results in 4 of 5
reexplored cases (128 ), whereas Mann and Reynolds reported significant improvement in 9 of 11 patients (14 ). Beskin and Baxter achieved
50% or more improvement in 33 of 38 patients (86%) overall using a plantar approach (146 ). They chose to cut the nerve trunk proximal to
the metatarsal heads and to allow the nerve end to retract into the non-weight-bearing arch, as opposed to excision of the recurrent
neuroma itself.
Johnson et al. resected 39 recurrent neuromas in 34 patients and reported a 67% (22 of 34) success rate whereby patients obtained
complete relief or maximal improvement with only minor reservations (147 ). In examining the rate of recurrence, these authors found the
third intermetatarsal space to be the most prevalent (74.4%), followed by the second (23%) and finally the fourth (2.6%). Interestingly,
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in 65% of the cases, these investigators found intact nerve that had not even been excised at the time of the initial operation through the dorsal incision.
Experiments on rats have shown that pursestringing the epineurium over the cut nerve end can contain the sensitive axon sprouts and can allow the formation of a smaller and presumably less
painful stump neuroma (175 ). DiNapoli applied this concept to most of 13 recurrent neuromas he resected (176 ). The results indicated that the plantar curvilinear approach (11 of 13),
combined with suturing an epineurial barrier and implantation into the intrinsic musculature (8 of 9), was more predictable in achieving a greater percentage of patient satisfaction by relief of
symptoms (92%). Banks et al. used a similar epineuriplasty technique combined with implantation into muscle for an overall success of 88% (14 of 16) in relieving symptoms (177 ). From a
physiologic standpoint, implantation of the nerve end into innervated muscle appears to offer the best chance to limit recurrent symptoms.
FUTURE CONSIDERATIONS
Neurectomy for Morton's neuroma is not a benign procedure, even though it can provide satisfactory results in about 85% of operations. The ideal treatment would be nonsurgical, but that is not
possible in all clinical cases to achieve relief. Evidence indicates that chemical neurolytic agents may provide safe, effective relief, although the ideal agent has yet to be discovered.
Less invasive nerve destruction techniques, such as radiosurgery and cryogenic denervation, show promise but require further long-term evaluation. In theory, preserving the continuity of the
nerve, as advocated by Dellon and Vito, is a logical approach, so neurolysis and ligament release procedures may evolve and may become more widely accepted (148 ,154 ).
Thermal sealing of the cut end of the nerve using radiosurgery or neodymium-yttrium-aluminum-garnet (Nd:YAG) laser appears to be feasible, yet sufficient clinical studies are lacking. The use
of neurotoxins to inhibit axon growth is another approach that needs refinement (178 ).
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110. Milgram JE. Design and use of pads and strappings for office relief of the painful foot. In: Kiene RH, Johnson KA, eds. Symposium of the foot and ankle. St. Louis: CV Mosby, 1983:95-101.
111. Nunan PJ, Giesy BD. Management of Morton's neuroma in athletes. Sports Med Rehabil 1997;14:489-501.
112. Okafor B, Shergill G, Angel J. Treatment of Morton's neuroma by neurolysis. Foot Ankle Int 1997;18:284-287.
113. Steinberg MD. The use of vitamin B-12 in Morton's neuralgia. J Am Podiatry Assoc 1955;45:566-567.
114. Wright EW. Injection therapy in Morton's neuralgia. J Am Podiatry Assoc 1955;45:556-567.
115. Cozen L. Neuroma of plantar digital nerve. In: Clinical orthopedics, vol 2. Philadelphia: JB Lippincott, 1958:224-226.
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120. Lapidus PW, Wilson MJ. Morton's metatarsalgia. Bull N Y Med Coll 1949;12:34-46.
121. Kirvela O, Nieminen S. Treatment of painful neuromas with neurolytic blockade. Pain 1990;41:161-165.
122. Strong G, Thomas PS. Conservative treatment of Morton's neuroma. Orthop Rev 1987;16:343-345.
123. May VR Jr. The enigma of Morton's neuroma. In: Bateman JE, ed. Foot science. Philadelphia: WB Saunders, 1976:222-234.
124. Joplin RJ. Some common foot disorders amenable to surgery. AAOS Instruct Course Lect 1958;15:144-158.
125. McKeever DC. Surgical approach for neuroma of plantar digital nerve (Morton's metatarsalgia). J Bone Joint Surg Am 1952;34:490.
126. Kelikian H. Hallux valgus, allied deformities of the forefoot, metatarsalgia. Philadelphia: WB Saunders, 1965:359-368.
127. Gudas CJ, Mattana GM. Retrospective analysis of intermetatarsal neuroma excision with preservation of the transverse metatarsal ligament. J Foot Surg 1986;25:259-463.
128. Bradley MD, Miller WA, Evans JP. Plantar neuroma: analysis of results following surgical excision in 145 patients. South Med J 1976;69:853-854.
129. Johnson KA. Surgery of the foot and ankle. New York: Raven, 1989:69-82.
130. Kitting RW, McGlamry ED. Removal of an intermetatarsal neuroma. J Am Podiatry Assoc 1973;63:274-276.
131. Kaplan EB. Surgical approach to the plantar digital nerves. Bull Hosp Joint Dis Orthop Inst 1950;1:96-97.
132. Johnson JE. Secondary interdigital neuroma resection. In: Johnson KA, ed. The foot and ankle: master techniques in orthopaedic surgery. New York: Raven Press, 1994:179-188.
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135. Ruuskanen MM, Niinimaki T, Jalovaara P. Results of the surgical treatment of Morton's neuralgia in 58 operated intermetatarsal spaces followed over 6 (2-12) years. Arch Orthop Trauma Surg 1994;113:78-80.
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137. Karges DE. Plantar excision of primary interdigital neuroma. Foot Ankle 1988;9:120-124.
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148. Dellon AL. Treatment of Morton's neuroma as a nerve compression: the role of neurolysis. J Am Podiatr Med Assoc 1992;82:399-402.
149. Diebold PF, Delagoutte JP. True neurolysis in the treatment of Morton's neuroma. Acta Orthop Belg 1989;53:467-471.
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160. Haugland LM, Collier MA, Panciera RJ, et al. The effect of CO2 laser neurectomy on neuroma formation an axonal regeneration. Vet Surg 1992;21:351-354.
161. Dellon AL. Treatment of recurrent metatarsalgia by neuroma resection and muscle implantation: case report and proposed algorithm of management for Morton's “neuroma.” Microsurgery 1989;10:256-259.
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Chapter 3
Lesser Ray Deformities
PART 1 Deformities of the Intermediate Digits and the Metatarsophalangeal Joint

Dalton E. McGlamry
Louis A. Jimenez
Donald R. Green
Lesser ray deformities should be classified as a group of related conditions. In 1927, Schuster defined hammer toe as “… a deformity in
which the proximal phalanx of one of the smaller toes is bent upward or is dorsiflexed at the metatarsophalangeal joint, and the median
and distal phalanges are sharply bent downward, so that they form a more or less acute angle with the proximal phalanx” (1 ). Sometimes
the distal phalanx is extended so it and the second phalanx form another angle. That definition provided some early insight into the
deformities that involve the lesser rays. In fact, deformities of the lesser rays are complex and involve the interphalangeal joints,
metatarsophalangeal joints, and the related tendon and ligamentous structures. Metatarsal and digital disorders are considered related
conditions.
ETIOLOGY OF LESSER RAY DEFORMITIES

The causes of lesser ray deformities may be congenital or acquired. Genetic influences are responsible for many of the deformities of the
lesser toes and metatarsophalangeal joints. Often, the genetic influence of a given structural foot type may not be recognized for many
years until the deformity becomes manifest. Neuromuscular disorders are a major cause of multiple claw toes. Unquestionably, general
biomechanical dysfunction has more to do with digital function than any other single factor.
BIOMECHANICS OF LESSER DIGITAL FUNCTION

To analyze digital function, the functional anatomy of the lesser toes must be discussed. This includes the role of the extrinsic muscles
(muscles that originate outside the foot but insert into the foot), the intrinsic muscles (muscles that originate and insert within the foot),
and the various joints and bony relationships within the foot and ankle. Muscles that cross more than one joint have multiple functions and
affect activity across each level. The muscle direction, force, and relation to joint axis and range of joint motion are all modifying factors
influencing the muscle activity.
Muscles of primary concern in lesser digital function are the extensor digitorum longus, the extensor digitorum brevis, the flexor digitorum
longus, the flexor digitorum brevis, the interossei (and the flexor digiti quinti brevis), the lumbricales, and the quadratus plantae. The
extensor digitorum longus aids dorsiflexion of the lesser toes during the swing phase of gait and at heel contact (2 ). The extensor
digitorum longus and brevis function in the propulsive phase of gait to stabilize the proximal phalanx against the metatarsal heads to
prepare for foot lift and to dorsiflex the metatarsophalangeal joints (3 ). The extensor digitorum longus is an extrinsic muscle that
originates from the anterior compartment of the leg. The tendon passes underneath the extensor retinaculum at the ankle, where it
divides into four separate tendon slips (one going to each of the lesser toes) (Fig. 1 ).
At the level of the metatarsophalangeal joint, each tendon provides multiple medial and lateral fibrous extensions that unite plantarly to
encircle the proximal phalanx (Fig. 2 ). The more proximal fibrous extensions are oriented vertically to the extensor tendon and encircle
the metatarsophalangeal joint. Plantarly, the fibers unite with the capsule, the deep transverse metatarsal ligament, and the flexor
tendon sheath.
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The more distal fibrous extensions have oblique fiber directions and extend from near the metatarsophalangeal joint to the head of the proximal phalanx (4 ,5 ).
FIG. 1. The extensor digitorum longus muscle originates from anterior compartment of the leg and passes underneath the extensor retinaculum of the ankle where it divides into four
separate tendon slips. One slips goes to each of the lesser toes. The extensor digitorum brevis muscle belly originates from the dorsolateral aspect of the calcaneus. Three individual
tendon slips arise and course lateral to the corresponding longus tendons to the second, third, and fourth toes. (There is no extensor digitorum brevis to the fifth toe.)
The extensor digitorum brevis muscle belly originates from the dorsolateral aspect of the calcaneus. Three individual tendon slips arise and course to the corresponding second, third, and
fourth toes. (There is no extensor digitorum brevis to the fifth toe.) The extensor digitorum brevis tendons approach the lesser metatarsophalangeal joints from the lateral side and combine
with the extensor digitorum longus tendon slip to form the extensor expansion to the lesser toes. The extensor tendon complex divides into three slips, with the center slip inserting dorsally
into the middle phalanx. The medial and lateral wings rejoin to insert into the dorsum of the distal phalanx. Occasionally, the extensor digitorum brevis tendon serves as a separate lateral wing
of this extensor expansion (Fig. 3 ). Medial and lateral fibrous extensions of the extensor tendon are also known as the hood apparatus. This hood apparatus is part of the sling mechanism,
which, by wrapping around the base of the proximal phalanx, can lift the proximal phalanx like a sling. The extensor apparatus has no specific attachments into the proximal phalanx.
FIG. 2. A: Medial view of the lesser metatarsophalangeal joint and digit. The extensor hood expansions encircle the proximal phalanx to attach to themselves. The expansion fibers are
more oblique as they near the proximal interphalangeal joint. The interossei insert into the plantarmost aspect of the proximal phalanx above the deep transverse ligament and insert
into the plantar pad and deep transverse metatarsal ligament. The lumbricales pass plantar to the deep transverse metatarsal ligament and insert medially into the proximal phalanx
and the extensor hood. B: Transverse diagram at the level of the metatarsophalangeal joint demonstrates the relationships of the muscles with the osseous and soft tissue structures.
Extensor expansions encircle the metatarsophalangeal joint and unite with fibers of the plantar capsule, deep transverse ligament, and flexor sheath. Interossei insert into the deep
transverse metatarsal ligament, the plantar pad, and the plantarmost aspect of the proximal phalanx. The lumbricales pass underneath the deep transverse metatarsal ligament on the
medial side of the joint.
The pull of the long or short extensor tendons creates a significant dorsiflexion of the proximal phalanx at the metatarsophalangeal joint by the sling mechanism. Most of the force is directed
into the sling; not much force is conveyed onto the proximal interphalangeal joint or the distal interphalangeal joint (4 ,5 ) (Fig. 4 ). The flexor digitorum brevis and longus are placed on
stretch when the metatarsophalangeal joint is dorsiflexed. This exerts a passive pull on the proximal and the distal interphalangeal joints. This plantarflexion force at these joints can provide
the final influence to complete a hammer toe deformity. Thus, the force of the extensors exerts a relatively small passive plantarflexory force on the proximal or distal interphalangeal joints.
The extensor digitorum longus functions not only on the digits, but also across the ankle joint, thus creating ankle joint dorsiflexion, and across the subtalar and midtarsal joints, thus creating
pronation. The extensor digitorum longus is one of the primary dorsiflexors of the foot at the ankle, along with the extensor hallucis longus and the tibialis anterior.
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FIG. 3. A: The extensor digitorum brevis tendon approaches the lesser metatarsophalangeal joint from the lateral side and combines
with the extensor digitorum longus tendon to form the extensor expansion. The extensor complex divides into three slips over the
proximal phalanx. The middle slip inserts into the base of the middle phalanx. Medial and lateral slips rejoin to insert into the base of
the distal phalanx. B: Occasionally, the extensor digitorum brevis forms a separate lateral wing. Usually, this is incorporated into the
extensor apparatus and becomes indistinguishable as a separate entity at its insertion. This is demonstrated with the extensor
expansion removed. A set of interossei muscles is also depicted arising from the corresponding intermetatarsal space and coursing to
the medial or lateral side of metatarsophalangeal joint, inserting into the deep transverse metatarsal ligament and into the
plantarmost aspect of the base of the proximal phalanx.
FIG. 4. A: With pull on the extensor digitorum longus and brevis muscles, force is directed through the sling mechanism to create
significant dorsiflexory force at the metatarsophalangeal joint. B: With the flexor digitorum longus and brevis severed, the force on
the extensor digitorum longus and brevis results in excessive dorsiflexion of the metatarsophalangeal joint and a slight dorsiflexory
force on the interphalangeal joints. C: When the extensor digitorum longus and brevis create dorsiflexion at metatarsophalangeal
joint, passive force is applied to the intact flexor digitorum longus and brevis. This passive force easily overpowers the slight
dorsiflexory force of the extensors at interphalangeal joints. Plantarflexion occurs at the interphalangeal joints, to complete the
hammer toe deformity.
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The flexor digitorum longus and brevis muscles function together in aiding plantarflexion of the lesser digits during the stance phase of
gait (3 ). They primarily create a plantarflexory force on the interphalangeal joints. The flexor digitorum longus is an extrinsic muscle that
originates from the deep posterior compartment of the leg. The tendon passes underneath the flexor retinaculum on the medial side of the
foot. It divides into four separate tendon slips within the second layer of musculature of the plantar aspect of the foot. Each of these
tendons runs to a lesser digit. The quadratus plantae muscle originates from the plantar calcaneus and inserts into the conjoined tendon of
the flexor digitorum longus. Four small lumbricales muscles originate from the medial aspect of each flexor digitorum longus tendon slip
and insert into the corresponding digits (Fig. 5 ).
The flexor digitorum brevis muscle originates from the plantar aspect of the calcaneus in the first layer (most superficial layer) of the
plantar muscles. Four individual muscle tendon slips arise and course to each of the corresponding lesser digits. The long and short flexor
tendons pass plantar to the metatarsophalangeal joint in a groove created by the thickened plantar capsule. At the level of the proximal
phalanx, the flexor digitorum brevis tendon splits into two segments to allow the flexor digitorum longus tendon to penetrate the tendon,
to become more superficial and to insert into the distal phalanx. The two segments of the flexor digitorum brevis tendon insert together
more proximally into the base of the middle phalanx (3 ,4 ) (Fig. 6 ).
FIG. 5. The flexor digitorum longus muscle originates from the deep posterior compartment of leg and passes medially behind the
tibial malleolus and under the sustentaculum tali into the second layer of muscles of foot. The tendon divides into four separate
tendon slips (one to each lesser toe) and inserts into the corresponding toe. Four small lumbricales muscles originate from the medial
side of the individual tendons of flexor digitorum longus and insert medially into the corresponding toe. The quadratus plantae
muscle originates in two muscle bellies from the plantar aspect of the calcaneus. (The lateral segment is the larger of the two.) The
quadratus plantae inserts from lateral into the tendon of the flexor digitorum longus at the level where it divides into four tendon
slips. The quadratus plantae helps to straighten the pull of the flexor digitorum longus.
The pull of the flexor digitorum longus and brevis muscles creates significant plantarflexory force at the interphalangeal joints (Fig. 7 ).
However, the flexors primarily function during the stance phase of gait with the toes on the ground (2 ). In a weight-bearing situation, a
strong plantarflexory force remains at the interphalangeal joint, but because the phalanges cannot be plantarflexed through the ground,
the retrograde force may cause dorsiflexion at the metatarsophalangeal joint (Fig. 8 ). When the flexor digitorum brevis is the primary
plantarflexory force, plantarflexion occurs strongly at the proximal interphalangeal joint, and the strong plantarflexory force at the distal
interphalangeal joint is absent. This may yield a contracted toe with the distal interphalangeal joint hyperextended. When the flexor
digitorum longus is active, force is generated primarily at the distal interphalangeal joint. A strong secondary force occurs at the proximal
interphalangeal joint. This leads to a contracted toe with the distal interphalangeal joint plantarflexed (4 ).
The flexor digitorum longus is an extrinsic muscle, and it functions not only on the digits but also across the ankle joint, the subtalar joint,
and the midtarsal joint. The flexor digitorum longus has a vector of force that can aid in plantarflexion of the ankle, deceleration of the
forward motion of the leg, supination of the subtalar and midtarsal joints, and external rotation of the leg (3 ).
The dorsal and plantar interossei and the flexor digiti quinti brevis are discussed together. These eight intrinsic muscles seem to function
as four sets of muscles (one pair of muscles for each lesser digit). The dorsal interossei are bipennate muscles that originate from the
adjacent sides of the corresponding metatarsals. The first dorsal interosseous muscle originates from the first and second metatarsal shafts
and inserts medially into the second toe. The dorsal interossei in the second, third, and fourth intermetatarsal spaces originate from the
adjacent sides of the corresponding lesser metatarsals and insert laterally into digits 2, 3, and 4 (6 ) (Fig. 9A ).
The plantar interossei are unipennate muscles that originate from the plantar medial aspect of the metatarsal shaft of the digit into which
they insert. The plantar interossei insert medially into the third, fourth, and fifth digits. The flexor digiti quinti brevis is a unipennate
muscle that originates from the lateral plantar aspect of the fifth metatarsal shaft and inserts laterally into the fifth digit (Fig. 9B ).
Thus, eight small muscles originate from the metatarsal shafts. One muscle inserts medially and one laterally into each lesser toe (Fig. 9C ).
These tendons insert into the plantarmost medial or lateral aspect of the base of the proximal phalanx (Fig. 10A ). The tendons also insert
into the plantar pad or plate (a glenoid cartilaginous cap inferior to the metatarsal head). The transverse intermetatarsal ligament, the
capsular tissues, the strands of the plantar fascia, and the extensor hood apparatus also insert here (Fig. 10B ). Sarrafian and Topouzian
indicated that some attachments of these tendons into the extensor sling mechanism are usually present (5 ), although Jarrett and
associates did not find any significant attachments of this nature (4 ).
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FIG. 6. A: The flexor digitorum brevis (FDB) muscle originates from the plantar aspect of the calcaneus in the first layer (most
superficial layer) of plantar muscles. Four individual tendon slips arise and course to each of the corresponding lesser toes. B: The
flexor digitorum longus (FDL) and brevis tendons pass beneath the deep transverse metatarsal ligament and plantar pad of the
metatarsophalangeal joint in a groove for flexor sheath. At the level of the proximal phalanx, the flexor digitorum brevis divides into
two segments to allow the flexor digitorum longus to penetrate it, to become more superficial, and to insert distally into distal
phalanx. The two segments of the flexor brevis insert together into the intermediate phalanx. 1, Groove for flexor tendons; 2, FDB;
3, FDL.
FIG. 7. A: Pull of the flexor digitorum longus (FDL) and flexor digitorum brevis (FDB) muscles creates significant plantarflexory force
at the interphalangeal joints (IPJ) and a weak secondary plantarflexory force at the metatarsophalangeal joint (MPJ). B: Pull on the
flexors in a non-weight-bearing cadaver specimen demonstrates the plantarflexory force. 1, MPJ flexion; 2, IPJ flexion.
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FIG. 8. In a weight-bearing situation in which the phalanges cannot be plantarflexed through the ground, the strong plantarflexory
force exerted by the flexors occurs in retrograde fashion proximally, thus creating dorsiflexion at the metatarsophalangeal joint
(MPJ). A: When the flexor digitorum brevis muscle is the primary plantarflexory force, the proximal interphalangeal joint (PIPJ) is
plantarflexed with extension of the distal interphalangeal joint (DIPJ). B: When the flexor digitorum longus is the primary
plantarflexory force, the DIPJ and PIPJ are both plantarflexed. 1, MPJ extension; 2, PIPJ flexion; 3, DIPJ flexion; 4, ground reactive
force.
FIG. 9. A: Dorsal view of the four dorsal interossei. B: Plantar view of the three plantar interossei. C: Dorsal view of the four sets of
muscles (including the flexor digiti quinti brevis).
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FIG. 10. A: The interossei insert into the plantarmost base of proximal phalanx and into the plantar “plate.” The fibers are
superficial to the capsule of the metatarsophalangeal joint and deep to the vertical fibers of the extensor apparatus. 1, Extensor
expansion (reflected); 2, metatarsal head; 3, collateral ligament; 4, base of proximal phalanx; 5, insertion interossei. B: Interossei
tendons (1) merge with the plantar capsule and glenoid plate (2) of the lesser metatarsophalangeal joints.
In discussing the forces and the functions of these four sets of muscles, we call the muscles collectively interossei. The interossei function
as stabilizing muscles in the transverse plane. When force is applied to the medial interossei, the toes adduct and slightly plantarflex.
When force is applied to the lateral interossei, the toes abduct and plantarflex. When force is applied to each set of interossei on both
sides of the respective digits, the toe is stabilized in the transverse plane and is plantarflexed at the metatarsophalangeal joint (Fig. 11 ).
Because the interossei function during the stance phase of gait, the proximal phalanx cannot be plantarflexed through the ground (2 ).
However, a simultaneous pull of the interosseous muscles does neutralize or limit the dorsiflexory forces that occur at the
metatarsophalangeal joint during gait. Normal, unopposed forces generated by the flexor digitorum longus and brevis muscles produce the
contracted lesser toe in a weight-bearing situation. However, this stance-phase metatarsophalangeal joint dorsiflexion does not occur in a
normal foot. Mild, passive buckling at the metatarsophalangeal joint created by the flexor digitorum longus and brevis muscles is easily
neutralized by the interosseous muscles if these muscles gain mechanical advantage. When the interossei function before contraction of
the short flexors, a rigid beam effect is created within the toe. The long flexors cross many joints, and the interossei function after they
begin their stance-phase activity but well before completion of that activity (2 ). This normally eliminates the stance-phase contraction of
the lesser toes (Fig. 12 ).
The lumbricales are four small muscles that have an unusual tendon origin. Most muscles originate from bone. Each of the lumbricales
originates from the medial side of the corresponding flexor digitorum longus slip to the lesser toe. They course beneath (plantar to) the
deep transverse metatarsal ligament and insert medially into the base of the proximal phalanx and the oblique portion of the extensor
hood apparatus. These muscles have not as yet been recorded electromyographically in gait (2 , 3 , 4 ). Therefore, their action in gait is
theoretic at present.
Although the muscles are extremely small, they have a good mechanical advantage to create plantarflexion of the proximal phalanx with a
mild adduction component. The lumbricales dorsiflex the proximal and distal interphalangeal joints through the extensor sling apparatus
(4 ). An additional unique force is generated by the contraction of the lumbricales on their movable origin, the tendon of the flexor
digitorum longus.
When a muscle contracts, the forces occur in both directions to cause contraction. However, if muscles originate from immobile bone, the
cumulative pull is all directed toward the tendon. Because the lumbricales arise from tendon, the resultant forces are placed on the flexor
digitorum longus tendon, on the insertions into the proximal phalanx, and on the extensor sling (Fig. 13 ). Thus, the flexor digitorum longus
muscle-tendon complex is put on stretch proximally and is relaxed distally. This creates slack in the flexor digitorum longus tendon distally.
Pull on the extensors alone creates more than 90 degrees of lesser metatarsophalangeal joint dorsiflexion.
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FIG. 11. A: The interossei can create force around the vertical axis or horizontal axis of the metatarsophalangeal joint. When both
interossei are active, motion around vertical axis is neutralized (stabilization without transverse plane motion). However, a
plantarflexory force is created. B: Metatarsophalangeal plantarflexion (1) results when the force is applied to both interossei
simultaneously. 2, Metatarsal; 3, simultaneous pull of both interossei by a hemostat.
FIG. 12. A: Unchecked pull of the flexors in a weight-bearing situation results in interphalangeal joint (IPJ) plantarflexion and
dorsiflexion buckling of the metatarsophalangeal joint (MTPJ). 1, MTPJ extension; 2, flexion of IPJs. B: “Rigid beam” effect of the
digit, showing stabilization of the MTPJ and IPJs results from the simultaneous pull on the interossei, flexor digitorum longus (FDL),
and flexor digitorum brevis (FDB). 1, Tension on the FDL and FDB; 2, tension on both interossei; 3, proximal IPJ extension; 4, distal
IPJ extension.
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FIG. 13. A: Diagram depicting the normal physiologic contraction of the lumbricales muscle that results in a proximally directed pull
on the lumbricales tendon. This causes plantarflexion at the metatarsophalangeal joint and dorsiflexion of the interphalangeal joints
by a sling mechanism. Distally directed pull is also placed on the long flexor tendon (FDL), thus reducing flexor's passive deforming
force that occurs with long extensor (EDL) contraction. B: Two hemostats are used to simulate contraction of the small first
lumbricales muscle (1). C: As the hemostats are pulled together (simulating contraction), slack is created on the corresponding FDL
tendon distally (1). D: Unchecked pull of the EDL results in excessive dorsiflexion at the metatarsophalangeal joint. Note the pin (2)
in the metatarsal and the suture marker (5) in the lumbricales muscle (4). 1, Pull on FDL; 2, pin marker in the metatarsal; 3, extensor
expansion (sling). E: Significant limitation of metatarsophalangeal joint dorsiflexion is created when the lumbricales muscle is
activated before creating the same force on the extensors as demonstrated in D. Note that suture marker (4) on lumbricales muscle
(3) is proximal to needle marker. 1, Pull on the EDL; 2, pin marker in the metatarsal.
When the flexors are intact, a passive plantarflexion at the proximal and distal interphalangeal joints occurs. This is not normally seen in
gait. Pulling by the lumbricales before the initiation of force on the extensors allows only the normal 20 to 40 degrees of dorsiflexion at
the metatarsophalangeal joints. The lumbricales neutralize the passive plantarflexory force of the flexors. Furthermore, if the lumbricales
do stabilize the metatarsophalangeal joint in the swing phase of gait, the extensor digitorum longus can function as a primary dorsiflexor
of the foot at the ankle. The lumbricales create an early end range of motion of the lesser metatarsophalangeal joints and allow direction
of the extensor digitorum longus forces toward the ankle joint at an early and effective time during the gait cycle. The lumbricales appear
well positioned to function in unison with the extensors. This theory of the
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function of the lumbricales adds logic to the function of the extensor digitorum longus as a primary dorsiflexory force at the ankle joint.
Because the hand is a non-weight-bearing structure, direct analogies between it and the foot are not always acceptable. The anatomic
similarities of the lumbricales and the interossei of the hand and foot argue well for the validity of some correlation. That the hand
lumbricales function in unison with the hand extensors lends further support to this theory (7 ).
In summary, the lumbricales create plantarflexion of the metatarsophalangeal joint, dorsiflexion of the proximal and distal interphalangeal
joints, distal slack in the flexor digitorum longus tendon, and a slight adductory force. This action limits the excessive swing-phase
contraction of the toes that would otherwise be created by the extensor tendons. Excessive dorsiflexion of the metatarsophalangeal joints
would be limited. The mild abduction created by the extensor digitorum brevis muscle would also be neutralized by the mild adduction
force of the lumbricales. Plantarflexion of the distal interphalangeal and proximal interphalangeal joints by the passive pull of the flexors
would be resisted by the dorsiflexory force created at the proximal and distal interphalangeal joints. This is accomplished by the sling
mechanism and by the slack created in the tendons of the flexor digitorum longus. Thus, the theory of Jarrett and associates (4 ), that the
lumbricales function in unison with the extensors during the swing phase of gait to prevent the excessive dorsiflexion of the
metatarsophalangeal joint in the normal foot, is logical and probably correct. This theory must await further electromyographic analysis of
gait, including the lumbricales, to obtain confirmation.
The quadratus plantae muscle originates from the inferior surface of the calcaneus with two muscle bellies. The smaller medial muscle
belly originates from the medial surface of the calcaneus, and the larger belly originates from the lateral inferior surface of the calcaneus.
The quadratus plantae forms a wide tendinous lateral proximal insertion into the flexor digitorum longus tendon at the level of division
into its four slips (6 ). The quadratus plantae muscle provides proximal stability to both the lumbricales and the flexor digitorum longus (3 ).
The quadratus plantae also functions to straighten the medial proximal pull of the flexor digitorum longus. The quadratus plantae muscle
pulls laterally and proximally and, coupled with the medial proximal forces of the flexor digitorum longus, creates a resultant vector of
force that is more or less a straight proximal pull (3 ). When the quadratus plantae loses its mechanical advantage, the resultant medial
proximal pull by the flexor digitorum longus creates an adductovarus pull to the fifth toe and, to a lesser extent, to the fourth and third
toes. The direction of force of the flexor digitorum longus to the second toe is primarily a proximal force with little to no medial pull.
Consequently, the pull on the second toe is primarily a straight digital contraction force in the sagittal plane (3 ) (Fig. 14 ).
FIG. 14. The loss of the mechanical pull of the quadratus plantae leads to a medial pull of the flexor digitorum longus (FDL). This
results in an adductovarus pull on the fifth toe and, to a lesser extent, the fourth and third toes. There is still very little medial pull
on the second toe. Adductovarus contraction of the lateral toes usually results.
The static structures surrounding the lesser metatarsophalangeal joints have not been discussed in detail. These structures are important
in limiting severe momentary disruptive forces that could otherwise lead to dislocation of the joints. However, these structures slowly
adapt in a contracted or lengthened state according to Wolff's law in response to chronic deforming forces. These structures include the
collateral ligaments, the capsular structures, the transverse metatarsal ligaments, and the plantar fascia. The transverse pedis (the
transverse head of the adductor hallucis) arises in part from the deep transverse ligament as well as from the plantar metatarsal ligaments
of the third, fourth, and fifth toes. This may give a dynamic component to these soft tissue structures. The flexor digitorum brevis muscle,
the adductor hallucis muscle, and the abductor digiti quinti muscle all arise in part from the plantar fascia. This may also confer a dynamic
component to the plantar fascia (6 ,8 ).
PATHOMECHANICS
Hammer toe syndrome occurs when the normal delicate balance of power surrounding the lesser metatarsophalangeal
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joints is lost. The hammer toe can manifest itself in several different ways, including the classic hammer toe, claw toe, or mallet toe (Fig.
15 ). The cause of this abnormal digital function is variable, but it falls into three major categories: flexor stabilization, flexor substitution,
and extensor substitution.
FIG. 15. A: Hammered digit syndrome can lead to a classic hammer toe with dorsiflexion of the metatarsophalangeal joint (MPJ),
plantarflexion of the proximal interphalangeal joint (PIPJ), and hyperextension of the distal interphalangeal joint (DIPJ). B: Claw toe
results in dorsiflexion of the metatarsophalangeal joint and plantarflexion of both the proximal and distal interphalangeal joints. C:
Mallet toe primarily results in plantarflexion deformity of the distal interphalangeal joint.
Flexor Stabilization
Flexor stabilization occurs in a pronated foot in the late-stance phase of gait when the flexor digitorum longus or brevis muscles have
gained mechanical advantage over the interossei. There is often an associated adductovarus of the fifth toe and possibly the fourth toe
because the quadratus plantae muscle usually loses its mechanical advantage as well, so the long flexor tendons pull on those toes at an
angle. The flexors can gain mechanical advantage over the interossei in several ways. The first is most commonly associated with the
flexible pes planovalgus deformity with excessive subtalar joint pronation. Pronation of the subtalar joint allows hypermobility and
unlocking of the midtarsal joint and leads to hypermobility of the forefoot. The flexors fire earlier and stay contracted longer than normal
in gait, in an attempt to stabilize the osseous structures of the forefoot (9 ). These muscles are usually ineffective in stabilizing the
forefoot. However, the flexors usually are effective in overpowering the small interosseous muscles, and they cause digital hammering or
clawing (Fig. 16 ).
Gray demonstrated that the deep posterior muscle groups, including the flexor hallucis longus, fire earlier and longer in the pes valgus foot
(10 ). However, the action of the flexor digitorum longus muscle was not recorded, and the assumption has been made that this muscle
also fires earlier (10 ,11 ). With subtalar joint pronation and unlocking of the midtarsal joint, relative forefoot abduction on the rearfoot
usually occurs. This usually occurs by medial deviation and collapse of the midfoot because the heel and the ball of the foot remain on the
ground. This changes the normal lateral vector of force created by the quadratus plantae. A more medial pull by the flexor digitorum
longus results and creates the adductovarus rotation of the fifth toe, possibly the fourth toe, and occasionally the third toe (3 ).
Weak interosseous muscles can also lead to an increased mechanical advantage for the flexors. Peripheral neuropathy can lead to loss of
muscle power of the small intrinsic muscles that allows the normal flexor activity to create stance-phase contraction of the toes. Spasticity
of the flexor digitorum longus can also lead to overpowering of the interossei and to flexor stabilization contracture of the toes (4 ). The
subtalar joint usually appears pronated in this situation, but
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it may appear normal in the early stages. Flexor stabilization is the most common cause of hammer toes.
FIG. 16. Flexor stabilization leads to late-stance-phase contraction of the lesser digits as the flexors gain mechanical advantage over
the interossei. Adductovarus contraction of the lateral toes usually results.
Flexor Substitution
Flexor substitution occurs in a supinated foot in the late-stance phase of gait when the flexors have gained mechanical advantage over the
interossei muscles. There is usually a straight contraction of all lesser toes (no adductovarus of the fourth and fifth toes). This situation
develops when the triceps surae muscle is weak and the deep posterior and lateral leg muscles try to substitute for the weak triceps (3 ). A
calcaneus gait results. The flexor hallucis longus, the flexor digitorum longus, the tibialis posterior, the peroneus longus, and the peroneus
brevis muscles all pass posterior to the ankle joint axis and have a potential for plantarflexion of the ankle. However, the plantarflexion
lever arm for these muscles is short, and the plantarflexory force is not extremely effective. In a weight-bearing situation, all these
muscles except the peroneus brevis can supinate the subtalar joint.
The tibialis posterior is the primary decelerator of pronation and supinator of the rearfoot (3 ). The flexor hallucis longus and the flexor
digitorum longus also have axes of supination around the subtalar joint. In the presence of a weak triceps surae, these muscles fire earlier
and longer than usual and cause severe contraction of the digits and some subtalar joint supination. The pull of the peroneus longus muscle
leads to plantarflexion of the first ray, which creates subtalar joint supination in a weight-bearing state. The pronatory force of the
peroneus brevis is not adequate to resist these other strong supinatory forces. Thus, a high-arched, late-stance supinated foot occurs with
contraction of all the toes (Fig. 17 ). The early and sustained firing of the flexor group easily gains mechanical advantage over the
interossei. The attempt to substitute for the weak triceps surae is usually inadequate to create heel lift. However, this action does lead to
hammer digit syndrome. Flexor substitution is the least common of the three major categories that create the pathologic hammer digit
syndrome of the lesser digits.
Extensor Substitution
Extensor substitution is seen with a swing-phase excessive digital contraction in which the extensor digitorum longus has gained
mechanical advantage over the lumbricales. The severe dorsal hyperextension at the lesser metatarsophalangeal joints is usually a straight
dorsal contraction greater than the normal 20 to 40 degrees (12 ,13 ). An adductovarus type of contracted toe is usually not seen with
extensor substitution. This severe dorsal contraction occurs during propulsion, swing phase, and heel contact when the extensor digitorum
longus and brevis muscles are normally active (2 ,3 ). Occasionally, the first metatarsophalangeal joint may also be excessively contracted.
Bowstringing of the extensor digitorum longus tendons and plantar prominence of the metatarsal heads usually accompany this excessive
dorsiflexion contracture of the metatarsophalangeal joints (Fig. 18 ).
FIG. 17. Flexor substitution results when deep posterior and lateral muscle groups attempt to “substitute” for a weak triceps surae.
A supinated high-arch foot with contracted toes results from the early and prolonged contracture of the flexor digitorum longus,
flexor hallucis longus, tibialis posterior, and peroneus longus muscles.
This deformity often begins as a flexible deformity that may reduce completely during weight bearing. The structural changes become
more rigid as accommodative contractures develop. The hammered digits can be demonstrated in a non-weight-bearing situation by having
the patient dorsiflex the ankles (Fig. 19 ). Excessive dorsiflexion of the metatarsophalangeal joints can reach as much as 90 to 130 degrees.
The extensor digitorum longus is an extrinsic muscle and also functions to dorsiflex the foot at the ankle. The extensor digitorum longus
must move the joints of least resistance (the metatarsophalangeal joints) to their end range of motion before functioning significantly on
the ankle. Without the stabilizing effect of the lumbricales, the metatarsophalangeal joints are excessively dorsiflexed as the extensors
fire. The extensors can gain this mechanical advantage in many different circumstances. A pes cavus (especially a flexible type),
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an ankle equinus, weakness of the lumbricales, spasticity of the extensor digitorum longus muscle, and reaction to metatarsalgia can all
lead to this mechanical advantage.
FIG. 18. With extensor substitution, the extensor muscles gain mechanical advantage over the lumbricale muscles. Excessive
dorsiflexion occurs at the metatarsophalangeal joints at heel contact (A) and during swing phase (B).
Patients with the pes cavus foot type have an increased declination of the forefoot. With the increased declination, the extensor digitorum
longus tendons have a longer distance to course. The tendons do not lengthen; rather, a passive pull is created as the forefoot drops into
excessive plantarflexion. This is especially true in the flexible pes cavus (Fig. 20 ). This leads to dorsiflexion at the metatarsophalangeal
joints. Consequently, in a non-weight-bearing situation, the extensor digitorum longus muscle is already on stretch and begins with a
mechanical advantage. An additional passive pull of the flexors occurs at the interphalangeal joints. In a weight-bearing position, the
flexible component to the anterior pes cavus may be eliminated, and the toes may straighten (Fig. 21 ).
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When the toes become excessively dorsiflexed, the increased retrograde force on the metatarsal heads tends to increase the cavus
deformity, thus leading to more dorsiflexion at the metatarsophalangeal joint and creating a further vicious cycle (Fig. 22 ). The more rigid
the hammer digit syndrome becomes, the greater the amount of toe deformity will remain during weight-bearing (14 ).
FIG. 19. Excessive dorsiflexion of the metatarsophalangeal joints in extensor substitution can be demonstrated clinically in gait or on
the examining table by having the patient dorsiflex the foot. A: Normally, the patient has 20 degrees to 40 degrees of
metatarsophalangeal dorsiflexion. B: With extensor substitution, excessive dorsiflexion occurs, and the metatarsal heads become
prominent plantarly. More than 90 degrees of metatarsophalangeal joint dorsiflexion is demonstrated in this patient.
FIG. 20. A: Diagram of a normal foot. B: In a pes cavus foot, the forefoot drops into an excessively plantar declinated position. Thus,
the extensor tendons would have to lengthen to allow the toes to remain straight; however, they do not lengthen. This excessive,
plantar declinated position of the metatarsals creates “passive” pull on the extensors and causes dorsiflexion at the
metatarsophalangeal joint.
The extensor substitution phenomenon may also result from significant limited ankle joint dorsiflexion. The anterior muscle group (tibialis
anterior, extensor hallucis longus, and extensor digitorum longus) fires earlier and longer in an attempt to increase ankle joint dorsiflexion
to gain ground clearance during the swing phase of gait. This ineffective attempt to increase ankle dorsiflexion leads to recruitment of the
extensor digitorum longus, which then gains mechanical advantage over the lumbricales.
FIG. 21. In a flexible pes cavus, the cavus component is reduced by the reactive force of gravity in a weight-bearing situation.
Contracted toes usually also reduce if they are flexible.
Weakness of the lumbricales or spasticity of the extensor digitorum longus can also create the extensor substitution phenomenon. In
patients with neuromuscular disease with peripheral neuropathies, the intrinsic muscles are often affected first. With loss of function of
the lumbricales, the extensor digitorum longus gains the mechanical advantage and leads to the extensor substitution phenomenon.
Spasticity of the extensor digitorum longus can also lead to overpowering of the small intrinsic lumbricales.
Anything that causes the extensor digitorum longus to gain mechanical advantage over the lumbricales creates extensor substitution. The
patient may voluntarily lift the feet off the ground, rather than having a normal propulsive gait pattern, or may resist putting the forefoot
on the ground during normal forefoot loading. This action can be caused by pain in the foot, instability in gait pattern, or an active
attempt to walk differently. The anterior muscle group must actively function earlier than normal to accomplish this movement. Such
action results in its gaining a mechanical advantage over the lumbricales muscles. If the cause of this voluntary foot lift is eliminated by
reducing pain or increasing stability, the extensor substitution will often be eliminated.
Transverse plane deformities of the lesser digits also occur. An adducted or abducted digit is usually a result of a loss of balance of power
between the set of interosseous muscles to a given digit. It may also result from mechanical pressure on the toes by an adjacent toe.
Tumor or joint effusion or joint inflammation may also lead to the transverse plane instability. Structural transverse plane foot deformities
such as metatarsus adductus can lead to abnormal transverse positioning of the toes (Fig. 23 ).
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FIG. 22. Excessive dorsiflexion of the toes creates a plantarflexory force on the metatarsals, thereby plantarflexing the metatarsal
heads. This leads to more dorsiflexion of the toes and initiates a vicious cycle of events. A: Preoperative non-weight-bearing lateral
radiograph shows the extreme effect of retrograde force on the metatarsals. B: Resting medial view 3 years after digital stabilization
and dorsiflexory osteotomy of the first metatarsal. C: Dorsal view of the same foot 3 years postoperatively. D: Dorsoplantar
radiograph 3 years postoperatively. Digital stabilization has resulted in restoration of metatarsophalangeal joint stability.
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FIG. 23. X-ray film demonstrates loss of transverse plane stability to all metatarsophalangeal joints.
DIGITAL DEFORMITIES
Digital deformities can occur in the sagittal, transverse, or frontal planes.
Mallet Toe
Mallet toe is a sagittal plane deformity in which the distal phalanx is flexed on the middle. It does not normally involve the proximal
interphalangeal or the metatarsophalangeal joint. Mallet toe is often associated with a long digit and presents clinically as a flexion
contracture of the distal interphalangeal joint.
Clinical evaluation may reveal hyperkeratosis on the distal aspect of the digit in addition to a dorsal heloma, with limited extension of that
joint. Early in its development, mallet toe is easily reduced, but later, as adaptation occurs, manual reduction becomes difficult. The
condition may be associated with hammer toe and claw toe deformities. Other possible causes of mallet toe are poor visual acuity, in
which the patient may need to use the end of the digit for tactile sensation as an aid to balance with decreasing reliance on sight, and a
long toe accommodating to short shoes. This may also occur after arthrodesing procedures of the proximal interphalangeal joints and on
occasion after a cerebrovascular accident, as a result of residual spasticity of the long flexors.
Radiographic findings include obvious contracture of the distal interphalangeal joint, superimposition of the middle phalanx on the distal
phalanx, and an evident gun barrel sign of the distal phalanx.
Goals of surgical treatment usually include releasing the long flexor tendon or shortening the toe to relieve the painful hyperkeratosis at
the dorsal aspect of the distal interphalangeal joint as well as distally at the end of the toe. Surgical treatment is usually directed at the
distal interphalangeal joint. The most common procedure is resection of the head of the middle phalanx through two transverse
semielliptic skin incisions. Occasionally, flexion contracture is so severe that skin tension inferiorly at the distal interphalangeal joint or
contracture of the flexor digitorum longus hinders correction. Simple transverse flexor tenotomy and capsulotomy can be performed
through a plantar stab incision in the flexion crease. The tendon can also be released through the dorsal incision when arthroplasty is
performed. Skin tension can be relieved by resection of appropriate amounts of bone. Occasionally, arthrodesis of the distal
interphalangeal joint is required. This is usually accomplished by articular resection of both sides of the joint. Kirschner wire (K-wire)
fixation generally does not need to cross the metatarsophalangeal joint. Postoperatively, the toe is bandaged and splinted in corrected
alignment for 4 weeks. Appropriate supportive bandaging assists in reduction of edema while maintaining alignment as fibrosis of healing
sets the joint in a rectus position.
Curly Toes (Varus Toes)

Curly toes, or underlapping toes, are most often congenital. They often involve the third, fourth, and fifth toes, although sometimes all
lesser toes may be affected. The deformity represents flexion and varus rotation of the distal phalanx at the interphalangeal joint. Some
adduction is likewise present, and in more severe cases the proximal interphalangeal joint is also involved. Curly toes are often evident
long before a child wears shoes or socks. They are seen with flexion, varus, and adduction of the distal aspect of the toe. They are usually
bilateral.
Symptoms are usually related to hyperkeratoses that develop on the lateral side of the distal or proximal interphalangeal joints. Painful
callus nail groove or Lister's corn in the lateral nail groove (usually of the fifth toe) may develop as a result of transferring weight off the
side of the underlapping toe. Radiographs show actual varus rotation of the phalanges, with medial deviation of the middle phalanx on the
proximal phalanx or medial deviation of the distal phalanx on the middle phalanx.
Goals of treatment are to achieve a rectus digit, free of painful clavi, flexible enough to absorb shock and to allow
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transference of weight during toe off. Surgical therapy is determined by the age of the patient, flexibility, and the degree of the deformity.
When curly toes occur in infants, tape splinting of the toes may be adequate to effect correction. In flexible deformities in a child,
tenotomy or derotational skin ellipses may be required (15 ). In the older child and adult with less flexibility in the deformity, varus
rotation at the distal or proximal interphalangeal joint may require simple arthroplasty with a teardrop skin incision to assist in digital
derotation. Flexor digitorum longus tenotomy may be necessary in some deformities. K-wires may be used for several weeks to encourage
the digit to heal in a more rectus alignment. Postoperative toe bandaging and splinting are recommended for a minimum of 4 weeks.
Hammer Toe
Hammer toe is probably the most common digital deformity and is principally a deformity occurring on the sagittal plane. The proximal
phalanx is dorsiflexed, and the middle phalanx is plantarflexed. The distal phalanx is classically plantarflexed, but it may be extended at
the distal interphalangeal joint. The metatarsophalangeal joint can be buckled plantarly, to create plantar protrusion of the metatarsal
head (1 ). Hammer toe deformity is more frequently thought of as involving isolated toes.
Hammer toes have been widely attributed to wearing improper shoes and stockings. Whereas no doubt exists that foot gear does play a
role, the biomechanical function of the foot is probably infinitely more important as a cause of disorders of the lesser toes and the lesser
rays. One concrete but persuasive example of biomechanical influence is seen in the pronated foot with a hypermobile first ray. The
hypermobility of the first ray results in loading of the second metatarsophalangeal joint. Chronic metatarsalgia commonly develops and
results in chronic synovitis of the second metatarsophalangeal joint. Such synovitis maintains a chronic low-grade temperature increase
within the joint that contributes to the weakening and eventual herniation of the retinacula that maintain the ordered relationship of the
flexor plate to the metatarsophalangeal joint. The flexor plate along with the flexor tendons may slip medially, thus drawing the second
toe into digital adduction and varus and resulting in an overlapping second toe. This condition and many others have all too frequently
been attributed to wearing narrow or short shoes. No evidence supports foot gear as a cause. To the contrary, overwhelming evidence
suggests biomechanical dysfunction as the genesis.
The unusually long second toe shows a significant tendency to develop hammer toe deformity. Investigators have postulated that deformity
of the long toe is related to its subjection to greater shoe pressures. Whitney (unpublished data) has observed that whenever a toe is
excessively long, it tends to contract until it functions in line with the adjacent toes. This result may indeed be influenced by the break
line of the shoe and by the toe-off pressures. However, the condition has been perpetuated through numerous generations, as reported by
Schuster in 1927 (1 ). It appears more probable that the inherited structure and resultant biomechanical dysfunction of the foot have far
more to do with the deformity.
The long second toe perhaps best exemplifies the typical hammer toe, although any toe may be involved. The deformity may be present
with a heloma on the end of the toe and a dorsal heloma over the proximal or distal interphalangeal joint or both. The deformity is
frequently associated with long second or with long second and third metatarsals. A plantar lesion may be pressure beneath the second
metatarsophalangeal joint associated with plantar protrusion of the metatarsal head.
Radiographic findings confirm a dorsiflexed proximal phalanx with flexion of the middle and dorsiflexion of the distal phalanx. With long-
term adaptation of the joints, degenerative changes can occur in the interphalangeal and metatarsophalangeal joints. In more severe
deformities, dislocation of the metatarsophalangeal joint may be evident.
Surgical treatment for an isolated hammer toe is directed at reestablishing a rectus alignment to the toe, shortening the toe if necessary
to place it in appropriate length relative to its two adjacent toes, and providing sufficient stability to resist recurrence if the deforming
forces persist. When deforming forces on the toe have been removed or neutralized, resection arthroplasty with appropriate shortening
may be an ideal solution. However, when deforming influences are expected to continue, arthrodesis of the proximal interphalangeal joint
provides much greater stability and improved leverage for the long and short flexor tendons to assist metatarsophalangeal joint stability.
Occasionally, a combined hammer toe-mallet toe (double corn) deformity occurs that requires a double resection arthroplasty (16 ) or a
proximal interphalangeal arthrodesis with a distal interphalangeal arthroplasty. This usually occurs in a patient with a pronated foot type
undergoing flexor stabilization contracture. In patients with lesser forms of distal contracture with proximal lesions, the shortening that
accompanies the hammer toe repair may relax the long flexor tendon so the contractile force is reduced at the distal interphalangeal level.
Claw Toe
Claw toe is a deformity in which the middle and distal phalanges are flexed on a markedly dorsiflexed proximal phalanx. The
metatarsophalangeal joint is buckled plantarly. The deformity usually is more severe than hammer toe. True claw toe deformity is often
associated with cavus foot deformity or neuromuscular conditions.
Claw toe deformity most often involves all the lesser toes, with the hallux included in a substantial percentage of patients. It is always
associated with dorsal contracture of the metatarsophalangeal joints and plantar contracture of the interphalangeal joints.
Plantar protrusion of the metatarsophalangeal joints is evident, and with adaptive changes in the joints and soft tissue contractures, the
metatarsals function in their position of maximum plantarflexion. This situation exaggerates any
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cavus deformity that may be present. Hyperkeratosis and painful metatarsalgia beneath the metatarsal heads are the rule. Late changes in
the metatarsophalangeal joints frequently include subluxation or dislocation.
In the early and more flexible stages of the deformity, the toes straighten on weight bearing or with the push-up test loading of the
metatarsals. In later stages of contracture, the interphalangeal joints flex when the metatarsals are loaded, but the metatarsophalangeal
joints fail to straighten.
Radiographic changes vary with the degree of rigidity of the deformity. In earlier stages, the deformities appear most severe on non-
weight-bearing films. In later stages, the deformities are exaggerated with weight bearing. Findings generally demonstrate dorsiflexed
positions of the proximal phalanges and plantarflexed positions of the middle and distal phalanges. Often, a positive gun barrel sign is
displayed with the x-ray projection of the dorsoplantar view looking directly down the shafts of the proximal phalanges. Treatment
objectives include not only restoration of rectus alignment of the toes but also establishment of stability of the digit to resist redeformity.
Digitus Adductus
Digitus adductus occurs principally on the transverse plane and represents adduction of the toe at either the interphalangeal or
metatarsophalangeal joint. With the passage of time, sagittal plane deformity may also develop. Congenital digitus adductus more often
involves an adduction deformity of the distal phalanx with the middle phalanx less frequently affected. Acquired digitus adductus is usually
related to metatarsophalangeal joint derangement or to iatrogenic or traumatic causes. Metatarsophalangeal joint derangement usually
involves deformity in three planes and is a complex condition.
Digitus Abductus
Digitus abductus is the opposite of digitus adductus, with the deformity representing abduction of the digit at either the interphalangeal or
the metatarsophalangeal joint. These transverse plane deformities usually represent congenital deformities when the deformity occurs at
the interphalangeal joints, or they may result from derangement of the tendons and flexor plate when the deformity occurs at the
metatarsophalangeal joint. The latter circumstance commonly occurs with rheumatoid arthritis.
Heloma Molle
Heloma molle (soft corn) is commonly associated with the underlapping fifth toe or with adductus deformity of the fifth
metatarsophalangeal joint. Typically, the head of the proximal phalanx of the fifth toe is displaced against the lateral condyle of the base
of the fourth proximal phalanx. Radiographic changes frequently show bone adaptation of both the base of the fourth proximal and the
head of the fifth proximal phalanges. The heloma may also occur at the distal interphalangeal joint of the fifth opposed by the proximal
interphalangeal joint of the fourth. Less frequently, it occurs between the third and fourth toes or the second and third. It can even occur
between the first and second toes.
Clinical presentation is a painful lesion on one or both sides of the proximal or distal interphalangeal joints or an interdigital clavus at the
web space. Toes may not necessarily be hammered or clawed. The fourth toe may be longer or shorter than usual, thus altering the normal
convex-to-concave relationship between the toes. When the fourth or fifth digit is long, lesions are prevalent on the dorsum of the toes as
well. With chronicity, large hyperkeratoses can develop and may become infected. Intertrigo and sinus tracts leading from the
hyperkeratosis to bone are common.
Often the fourth and fifth toes are long and in varus. Exostoses, or bony prominences, may be evident beneath corresponding pressure
areas. The fifth metatarsal may be short, thereby causing the phalanges of the fifth digit to rest further proximal and resulting in the
pathologic features previously described. The latter is most commonly the condition that causes the deep interdigital web-space heloma
molle. In other patients, one may note a synostosis between the middle and distal phalanges of the fifth, and occasionally, the fourth toe.
This condition reduces flexibility of the digit and renders the area more susceptible to irritation and subsequent lesion formation.
Surgical treatment is directed at remodeling of the head of the proximal phalanx of the fifth toe and resection of any bony prominence
from the lateral condylar base of the fourth proximal phalanx. In patients with interdigital lesions located distally, condylectomies on the
adjacent digits, or a combination of an arthroplasty of the fourth toe with an condylectomy of the fifth toe, may prove successful. In
recalcitrant cases, total phalangectomy or syndactyly is sometimes used.
METATARSAL DISORDERS
Disorders of purely metatarsal origin occur, but they are much less common than generally believed. Some of these conditions, such as
osteochondrosis and brachymetatarsia, are described in other segments of the text.
Metatarsal Cavus (Equinus)

Metatarsal cavus, or the so-called plantar declinated lesser metatarsal, does occur on rare occasion as a purely developmental condition.
More often, the condition termed metatarsal cavus (equinus) is merely a metatarsal that is plantar declinated as a result of plantar
buckling of the metatarsophalangeal joint caused by retrograde force from a contracted and deformed toe. A metatarsal cavus is an excess
plantar declination of the metatarsals with the apex of the deformity seen at Lisfranc's joint. If the apex of the deformity is at Chopart's
joint, the deformity is called a forefoot cavus (equinus).
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Long Metatarsals
Long metatarsals occur rarely, and unless they are extremely long, they produce minimum difficulty except when associated with plantar
declination. When substantially longer than the adjacent metatarsals, they may become symptomatic. A long metatarsal may be associated
with an abnormally long toe. The tendency is for the long toe to contract gradually until its tip functions in line with the ends of the
adjacent toes. Such a tendency may be associated with the break point of the toe of the shoe or with biomechanical accommodation. With
the long toe functioning in a contracted position, retrograde force is placed against the metatarsal head, and the long metatarsal
protrudes plantarly, thus receiving increased trauma.
Long metatarsals are hereditary, seen in one generation after another, but they may be unrecognized as a problem until after maturity,
when the added weight bearing on the particular metatarsals begins to result in secondary digital deformities and metatarsalgia.
The most common long metatarsal bones are the second or the second and the third. In patients with long second and third metatarsal
bones, long second and third toes are likewise noted. Symptomatic callus and metatarsalgia beneath the second and third metatarsal heads
may be evident. These lesions are usually slightly more distal under the metatarsal heads as propulsive lesions. If the toe is contracted, the
resulting force may be located more directly plantar to the metatarsal head. The second and third toes may show contracture, and fixed
contractures may develop in time. As the toes contract into hammer toe deformity, retrograde force against the metatarsals forces them
plantarly and exaggerates their already excessive length. When the deformity has been present for a prolonged period without adequate
accommodation, dislocation of the metatarsophalangeal joints and contracture of all the lesser toes may be found.
FIG. 24. Brachymetatarsia. A: The fourth toe is short, extended, and retracted and does not purchase ground. Note the third and
fifth digits filling the void left by the short fourth digit. B: The fourth metatarsal epiphyseal plate is closed. Growth has ceased in this
bone, whereas growth of the other four metatarsals continues until normal skeletal maturity. C: Excellent length has been regained
to the fourth metatarsal 15 months after autogenous bone graft. The fourth toe regained function because plantar fascia, muscular,
and tendinous structures are now placed on stretch with weight bearing.
Radiographic findings confirm the digital deformity and the long second and third metatarsal bones. Treatment is directed at reestablishing
a rectus alignment of the toes and providing sufficient stability of the digit to allow the long and short flexor function to maintain
metatarsophalangeal joint alignment. Metatarsal shortening or osteotomy may be necessary.
Brachymetatarsia
Brachymetatarsia (short metatarsal) or brachymetapody (multiple short metatarsals) occurs infrequently as a result of premature closure
of the growth center of a metatarsal or metatarsals (17 ,18 ). As the other metatarsals continue to grow, the difference in length becomes
exaggerated, and the condition becomes clinically manifest (Fig. 24 ). Brachymetatarsia
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can also result from trauma to a metatarsal that then results in premature closure of the growth center.
The condition apparently is largely hereditary and does result in substantial overloading of adjacent metatarsals. The short metatarsal
bears no weight. Consequently, its flexor plate fails to load on weight bearing, and the result is an unstable and floating digit. The
adjacent metatarsals may present with metatarsalgia and plantar keratosis, especially in the adult patient. A deep sulcus is usually found
beneath the involved short metatarsal. Adjacent toes tend to migrate into the space vacated by the floating toe. Failure of the extrinsic
tendons to load on the short ray results in an increased loading on the other toes, and some degree of digital deformity of the adjacent
toes usually results. Although most often genetic in origin, the condition often goes unrecognized until premature closure of the involved
growth center.
Radiographic findings include a short, underdeveloped metatarsal, at times with deficient bone content in general and with osteoporosis of
the metatarsal head in particular. The toe is usually straight but in an extended position, and it floats above the weight-bearing plane.
Historically, surgical treatment has consisted of the insertion of bone grafts in an attempt to lengthen the metatarsal (17 ). However, in
most instances today the lengthening is performed by callus distraction (19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ). Surgical treatment of the
condition is discussed in Chapter 67.
LESSER METATARSOPHALANGEAL JOINT DERANGEMENT

Lesser metatarsophalangeal joint derangement occurs in various different forms, many of which are directly related to simultaneously
occurring digital deformities.
FIG. 25. A: Adduction and extension deformity of the second digit. The flexor tendons are displaced medially, and as the foot is
loaded, the deformity is exaggerated. B: The medial view shows the extension at the metatarsophalangeal joint and the flexion of
the proximal interphalangeal joint.
Flexor Dislocation
Flexor dislocation is a condition in which the flexor tendons dislocate distally or to the medial or lateral side of the metatarsal head. The
derangement can be caused by chronic inflammation of a lesser metatarsophalangeal joint that results in weakening or herniation of the
retinacula that maintain the stability of the flexor plate to the metatarsal head. The flexor tendons may dislocate medially or, less
frequently, laterally and may result in drawing the toe into varus or valgus rotation and often overlapping the adjacent toe. The tendons
may also become attenuated or ruptured in the sagittal plane, and this condition may lead to instability of the metatarsophalangeal joint.
Once the flexor tendons have dislocated to the medial or lateral side of the joint, they exert their influence to draw the toe and the joint
in that direction. The extensor tendons are left unopposed, and they begin to create dorsal contractures. A dorsoplantar radiograph usually
demonstrates rotation of the proximal phalanx, so the plantar aspect of the phalangeal base is profiled medially or laterally. The articular
base of the proximal phalanx is displaced medially or laterally, and the metatarsal head is displaced in the opposite direction.
Metatarsophalangeal Joint Adductus or Abductus

When deranged metatarsophalangeal joints are present, the patient may present with overlapping second or second and third toes (Fig.
25 ). This condition frequently indicates a medially displaced flexor tendon (Fig. 26 ). The clinical examination shows obvious medial
displacement and usually some torsion or varus rotation of the toe.
In medially displaced or adductus deformities, the cause is usually mechanically induced synovitis that results in
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weakening of the supportive structures of the joint. The opposite deformity is seen in patients with rheumatoid arthritis in whom lateral
dislocation or deviation is the rule. Regardless of the direction of the metatarsophalangeal joint derangement, digital deformities may be
present as claw toes or hammer toes.
FIG. 26. Radiopaque dye has been injected into the flexor canal in this patient with long-term metatarsophalangeal joint adduction
deformity and demonstrates the medial displacement of the flexor apparatus.
The push-up test shows adduction or abduction of the toes at the metatarsophalangeal joint (rather than the usual flexion) (28 ). Moreover,
stimulation of the plantar reflex results in digital adduction or abduction, rather than flexion.
The longer the condition is present, the more severe and fixed the contractures tend to become. The more severe the deformity, the more
difficult is the correction. A strong argument can therefore be made for early surgical correction. As with all digital deformities, the
tendency is toward a corresponding increase in plantar metatarsal protrusion. This increased protrusion is largely responsible for the
development of metatarsalgia and intractable plantar keratosis in such patients.
Treatment is directed at restoration of metatarsophalangeal joint alignment and replacement of the flexor structures beneath the
metatarsal head. In some instances, this may be accomplished with a variety of capsular release and plication techniques. The digit may be
stabilized by arthrodesis of the proximal interphalangeal joint. Such arthrodesis allows the long and short flexors to contribute to
maintaining metatarsophalangeal joint reduction. Flexor tendon transfers may be employed, particularly if the patient has dorsal
metatarsophalangeal joint instability. In more difficult or recurrent cases, resection of the base of the proximal phalanx and
syndactylization may prove more effective.
When metatarsophalangeal joint arthrosis is present, treatment may include implant arthroplasty, appropriate resection arthroplasty, and
possible stabilization arthrodesis of the digits. An important consideration is to maintain alignment until healing is complete.
Metatarsophalangeal Joint Limitation

Limitation of motion of the lesser metatarsophalangeal joints occurs as a result of degenerative change in and around the joint.
Limitation can occur after relocation of a dislocated joint if sufficient degeneration of the articular cartilage has occurred. Such
degeneration can provide an anchor for capsular tissues that, once attached, prevents smooth motion and effectively limits active or
passive dorsiflexion of the metatarsophalangeal joint. More often, lesser metatarsophalangeal joint limitation results from chronic synovitis
of the joint related to multiple continuing traumas and to biomechanical dysfunction, a localized form of overuse syndrome. With time,
the chronic inflammation is able to cause the plexor plate to adhere to the margin of the metatarsal neck, and thus dorsiflexion is limited.
Plantarflexion can likewise be limited by dorsal capsular scarring or contracture (Fig. 27 ). Limitation of plantarflexion of the joint
produces plantar protrusion of the metatarsal head and a floating toe. In addition, the digit becomes unstable because of the absence of
loading of the flexor plate to the base of the proximal phalanx. Instead, the loading is shifted to the metatarsal neck, and it fails to render
stability to the toe.
FIG. 27. Two months after routine proximal interphalangeal joint arthroplasty, severe dorsal contracture of the extensor structures
has created this floating toe.
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Radiographic findings include narrowing of the metatarsophalangeal joint space and often flattening of the metatarsal head. Commonly,
the condition is associated with a dislocated or subluxed metatarsophalangeal joint. Surgical objectives are reduction of the joint if it is
dislocated, release of the flexor plate if it is attached, resection or implant arthroplasty if substantial arthrosis is present, and possible
stabilization arthrodesis of the digit to encourage more stable metatarsophalangeal joint function. Tendon balancing techniques may be
required. These range from simple lengthening of the extensor digitorum longus to transposition of the extensor digitorum longus into the
corresponding metatarsal neck area or flexor digitorum transfer to the proximal phalanx. If the flexor plate has been destroyed, either
arthroplasty or implant arthroplasty may be necessary along with tendon balancing techniques. Aftercare must include early range-of-
motion exercises of the metatarsophalangeal joints. If K-wires are used, they either should not cross the metatarsophalangeal joints or
should be retracted from across the joints by 21 days postoperatively. In either event, range-of-motion exercise should be actively pursued
at 3 weeks after surgery. Failure to institute exercise often results in recurrent fibrosis of the flexor plate and joint limitation.
Predislocation Syndrome of the Lesser Metatarsophalangeal Joint

Predislocation syndrome of the lesser metatarsophalangeal joint presents as an acute or subacute inflammatory condition localized to the
plantar aspect of the joint. Yu and Judge indicated that the tenderness is localized to the periarticular structures plantar and distal to the
metatarsophalangeal joint (29 ). This finding is in contrast to the intraarticular disease and painful motion usually associated with
degenerative joint disease or with digital contractures. The pain associated with the plantar capsulitis is generally out of proportion to the
clinical presentation, which may show minimal digital contracture or instability. Mild edematous changes may be obvious only after close
comparison with the opposite foot. A benign history is commonplace, without any indication of acute trauma. Often, a recent increase in
activity or a routine of a high level of activity such as aerobics or running is noted.
Many patients describe the feeling of walking on a pebble or lump on the bottom of their foot. The associated pain can be sharp to
throbbing or bruiselike soreness. Severe pain may be reproduced by vertical displacement of the proximal phalanx on the metatarsal.
Coughlin indicated that a vertical shift of more than 50% of the proximal phalanx on the metatarsal head is considered a positive test (30 ).
Because the pain may be intense, the patient may contract the muscles so the phalanx may not be shifted. If the test is positive, the
patient may not allow the test to be performed more than once.
Standard radiographs, bone scans, magnetic resonance imaging, and arthrography are usually of little assistance in making the diagnosis,
but these methods may be helpful in ruling out other causes of pain. Radiographs may be normal. Bone scans may be most pronounced in
the initial flow phase or inflammatory phase and may have some increased uptake in the third phase. Magnetic resonance imaging studies
may show edematous changes around the joint structures, especially noted on T2-weighted images. Careful clinical history and physical
examination with a high index of suspicion are usually adequate to make the diagnosis.
The goals of therapy are to reduce pain and to interrupt the progression of deformity. Pads and splints may be employed from simple
dorsiflexion-limiting strapping or padding or buttress padding to shift weight-bearing stress to the adjacent metatarsals. Antiinflammatory
medications or a short course of oral prednisone can be initiated. An oral dose of 80 mg of prednisone that is decreased by 10 mg per day
may be adequate as a short course of antiinflammatory treatment to arrest the acute symptoms. A limited number of local cortisone
injections may be used. Crossover taping can significantly limit the dorsiflexion of the metatarsal phalangeal joint. However, dorsiflexion
limitation may be required for months, a finding suggesting that a removable splint is more practical after the initial treatment phase. A
simple tubegauze moleskin sling pad (Fig. 28 ), a Budin splint, or a Darco Velcro digital pad can be used to limit dorsiflexion of the
metatarsophalangeal joint. Orthotic devices may also be helpful in redirecting forces across the forefoot and in limiting stress to the
affected joint. When subluxation or dislocation has already occurred at the metatarsophalangeal joint, then surgical correction may be the
only logical treatment. This may include a flexor tendon transfer with relocation of the metatarsophalangeal joint and temporary K-wire
fixation or release of the joint and capsular plication. Proximal phalangeal joint arthrodesis may also be considered (29 , 30 , 31 ).
FIG. 28. A simple antidorsiflexion device made up of two moleskin pads and digital tube gauze that can slip over the affected toe.
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METATARSOPHALANGEAL JOINT DISLOCATION

Metatarsophalangeal joint dislocation may occur as a result of acute or chronic trauma. Acute traumatic dislocation is infrequent. Chronic
continuing trauma such as that experienced daily in a biomechanically unsound forefoot is a much more frequent cause. Early in the course
of this condition, the clinical presentation may be pain at the joint associated with a mild swelling that can only be noticed by careful
comparison with the opposite foot (predislocation syndrome). As the clinical presentation progresses, the metatarsal head becomes more
plantarly prominent. A painful plantar keratosis is often present beneath the head. The patient is unable to dorsiflex and plantarflex the
metatarsophalangeal joint actively through a normal range of motion. The push-up test shows some flexion of the interphalangeal joints
but no realignment of the metatarsophalangeal joint. Passive motion may be possible but is of poor quality. Dorsiflexion of the joint is
sharply limited.
Radiographic examination confirms the dislocation. The dorsoplantar radiograph shows superimposition of the base of the phalanx on the
metatarsal head. The oblique view accurately assesses the degree of telescoping of the phalanx over the metatarsal and likewise gives an
excellent appraisal of the plantar condyles of the metatarsal head.
Treatment objectives are much the same as those described for metatarsophalangeal joint limitation. Relocation of the joint is usually
possible if the flexor plate is reasonably intact. When the flexor plate is badly damaged, implant arthroplasty or resection arthroplasty or
resection of the base of the proximal phalanx with syndactyly is often necessary. In either instance, arthrodesis of the proximal
interphalangeal joint may be required to provide a stable lever on which the long and short flexors can function to help stabilize the
SURGICAL MANAGEMENT OF DIGITAL DEFORMITIES

Various different procedures may be employed for the repair of hammer toe deformities. If the cause of the deformity is understood, then
one may be able to determine the stability that may be required to neutralize the deforming forces (32 ). During normal propulsion, the
digit must be stable in a rectus position on the supporting surface. This requires stability of the proximal, middle, and distal phalanges. For
the rigid beam effect to occur, the muscles of the foot will need to fire in proper sequence. Whenever this sequence is disrupted, the toes
lose their ability to purchase the ground from that point distally (4 ,6 ). In flexible deformities, these forces may at times be neutralized
biomechanically. Less extensive surgery may be effective if the deforming forces can be neutralized by mechanical means in the
postoperative setting. In a patient with a forefoot varus and hammer toes resulting from flexor stabilization, an orthotic support may work
well in the postoperative setting to control the deforming forces. However, swing-phase extensor substitution is difficult to control with
mechanical measures because functional orthoses primarily exert an influence during the stance phase of gait. Therefore, these orthoses
are ineffective in extensor substitution. Definitive surgery, such as the Hibbs suspension or arthrodesis of the proximal interphalangeal
joint, may be more practical. In patients with extensor substitution, simple proximal phalangeal head resection or soft tissue release may
lead to recurrence of the deformity.
Other considerations are necessary when dealing with digital deformities. Digital length patterns, congenital deformity of the digits,
prominent exostoses, shoe gear considerations, and adductovarus deformities all need to be considered. In providing surgical correction for
the hammered-digit syndrome, both adequate intraoperative reduction of the deformity and the effectiveness of postoperative
neutralization of the deforming forces must be considered.
Soft Tissue Surgery for Deformed Lesser Toes
Tenotomy
Tenotomy of a segment of the extensor or flexor digitorum longus tendons can eliminate the effects of these structures on that toe. Such
an effect is generally temporary because the tendon tends to heal by bridging the gap created by the tenotomy. The procedure is
occasionally indicated in the pediatric or the elderly patient in whom more definitive surgical correction is contraindicated. An orthodigital
retainer is suggested until healing is complete and the toe appears stable in the new position.
Procedure
The approach to simple extensor tenotomy is usually proximal to the metatarsophalangeal joint. A No. 15 scalpel blade or a No. 67 Beaver
blade is used to make a small stab incision just medial or lateral to the tendon. The knife blade is slipped percutaneously beneath the
tendon, and it is rotated 90 degrees to face the underside of the tendon. With the knife held securely in that position, the surgeon firmly
plantarflexes the toe at the metatarsophalangeal and interphalangeal joints. The tendon is severed as it is stretched across the knife blade.
Flexor tenotomy is usually performed at the head of the proximal phalanx or the head of the middle phalanx. A stab incision is made with a
small blade just medial or lateral to the tendon. The blade is slipped deep to the tendon and is rotated 90 degrees. The toe is gently
dorsiflexed until the tendon is severed. A simple suture or two closes the skin but is often not necessary.
Aftercare
The toe is held in the corrected position by bandaging the proximal phalanx in plantarflexion for approximately 3 to 4
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weeks. Then an orthodigital retainer of choice may be used to maintain corrected alignment while healing occurs, often for months
afterward.
Discussion
Tenotomy as an isolated procedure has limited usage. First, the tendon tends to regenerate in most instances. Second, unless the toe
alignment is effectively controlled while regeneration is occurring, the tendon contractures may result in a worse deformity than was
present originally.
Loading phenomenon, or the transfer of tendon load to an adjacent tendon, provides additional loading to an adjacent toe or toes when a
tenotomy or tendon lengthening is performed. Because the four long extensors and the four long flexor tendons to the lesser toes originate
from a common muscle belly, when one tendon is released by tenotomy, each of the remaining tendons will have one-third more force on
it. This loading phenomenon can be observed during surgery and often necessitates performing a tenotomy or tendon lengthening in all the
toes to prevent subsequent deformity of the nontreated toes.
Extensor Tenotomy and Capsulotomy

Tenotomy and capsulotomy as isolated procedures are used in those patients in whom the deformity is semi-flexible. The procedures are
often used as a part of a more complex surgical correction. The isolated procedures are sometimes indicated in the older patient who
cannot undergo reconstructive surgery but who, with appropriate supportive follow-up, may obtain years of help from simple releases.
Procedure
The approach is similar to that used for tenotomy, but a 1- to 2-cm linear skin incision is recommended to permit direct visualization over
the metatarsophalangeal joint. If the tendon is severed at the joint level, the extensor hood must usually be released to obtain full benefit
of the release. Severing the tendon proximal to the hood fibers accomplishes the same effect. Once the tendon has been severed, the toe
is placed under distal traction, to result in a dorsal transverse dimpling of the metatarsophalangeal joint capsule. The surgical blade is
introduced into the transverse dimple of capsule while the toe is held distracted. This approach permits sectioning of the capsule medially,
laterally, and dorsally without damaging the articular cartilage. Closure is by one or two simple sutures in the skin.
Aftercare
The postoperative bandaging and splinting protocol is similar to that for tenotomy.
Discussion
Extensor tenotomy and metatarsophalangeal joint capsulotomy are simple, relatively atraumatic procedures that are considered palliative
rather than corrective surgery. However, they should not be viewed as completely innocuous. As with tenotomy, severing of a single
tendon results in increased load (loading phenomenon) to each of the other divisions of that same tendon. The adjacent toe apparently is
affected most. When two extensor tendons are severed, the tension to the two remaining ones is doubled, and the possible result is
immediate or gradual dynamic deformity. The surgeon should be prepared to perform tenotomy or appropriate lengthening on all divisions
of the extensor digitorum longus tendons whenever tenotomy is performed on one division. If there is clinical evidence of loading
phenomenon, then the additional tenotomies are suggested.
Flexor Tenotomy and Capsulotomy

Tenotomy of the flexor digitorum longus tendon is rarely performed as an isolated procedure in the adult, but it may be done in isolation
in the young child. More often, flexor tenotomy and capsulotomy of the interphalangeal joint are combined with extensor tenotomy and
metatarsophalangeal joint capsulotomy. As with other tenotomy procedures, flexor tenotomy and capsulotomy find greatest application in
the young child or in the older patient in whom more definitive reconstructive surgery is not possible. Flexor tenotomy does sacrifice some
digital purchase. This is rarely a problem in the older patient in whom an apropulsive gait is already present, but it may be a problem in
the younger patient.
Procedure
The approach is through a medial or lateral percutaneous incision along the side of the toe or through a plantar stab incision directly
beneath the interphalangeal joint. The flexor retinaculum that binds the tendons to the underside of the phalanges is incised. The surgical
blade is rotated to face against the plantar side of the tendon. The toe is placed on stretch, and the tendon and capsule are severed. The
interphalangeal joint is manipulated into hyperextension. The skin incision may be closed with one or two simple sutures, but often these
are not necessary (Fig. 29 ).
Aftercare
The toe is bandaged and is splinted in corrected alignment for a full 3 to 4 weeks. A postoperative retainer can then be worn for an
additional period. Range-of-motion exercises of the metatarsophalangeal joint may be instituted to enhance flexibility of the joint.
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FIG. 29. Long flexor tenotomy. A: Location of insertion of a No. 67 blade between the middle phalanx and the flexor digitorum longus
tendon. The sharp edge of the blade is then rotated toward the tendon to sever it. B: A No. 67 blade entering the lateral side of a toe
at the level of the middle phalanx. By entering the middle of the lateral surface, the neurovascular structures are avoided.
Discussion
Wherever hammer toe deformity is present, the long flexor tendon is converted to a dorsiflexor of the metatarsophalangeal joint because
the phalanges cannot be plantarflexed through the ground. Once the metatarsophalangeal joint is dorsiflexed, the flexors become
responsible for the flexion deformity of the interphalangeal joints. Flexor tenotomy and capsulotomy alone or, when appropriate, in
conjunction with other procedures can remove the retrograde deforming force. The procedure and orthodigital support can provide years
of improved comfort with minimal surgical trauma. In the absence of orthodigital follow-up, the toes may tend to redeform. Digital
purchase or toe off is sacrificed, but this is rarely a problem in the older patient. Like the extensor tenotomy and capsulotomy, the flexor
tenotomy and capsulotomy are considered palliative rather than corrective surgical procedures.
Extensor Tendon Lengthening

Rarely is an extensor tendon lengthening done as an isolated procedure. The indications and the results are similar to those for the
tenotomy procedures. The major difference is that the amount of tendon lengthening can be controlled with a Z-plasty technique. Care
must be taken to evaluate the transfer loading that occurs on adjacent tendons.
Procedure
A small incision is made over the extensor tendons proximal to the extensor hood over the third metatarsal shaft area. The peritenon tissue
is incised over each extensor digitorum longus tendon in turn. Individual Z-plasty lengthening is performed and is secured with simple
suture technique, and the wound is closed.
Aftercare
The patient is treated with bandaging and splinting in the same manner as after tenotomy.
Discussion
Extensor tendon lengthening procedures are simple, relatively atraumatic procedures that are considered palliative rather than corrective
surgery. However, they should not be viewed as completely innocuous. As with tenotomy, the lengthening of a single tendon results in
increased loading phenomenon to each of the other divisions of that same tendon. The surgeon should be prepared to perform appropriate
lengthening on all divisions of the extensor digitorum longus tendons whenever tendon lengthening is performed on one division. If there is
clinical evidence of loading phenomenon, then the additional tenoplasties are recommended.
Flexor Tendon Transfer

Forrester-Brown, in 1928, used transfer of the long flexor tendon to the extensor tendons to replace lost intrinsic function to the hallux
(33 ). In 1947, Girdlestone transferred flexor digitorum longus and brevis tendons into dorsal expansions of the extensor tendons (34 ). The
theory was that
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the flexor muscles would take over the function of the lost intrinsic muscles. Taylor reported performing the same procedure on 112 feet
(35 ). He followed 68 of these surgical cases. Thirty-seven were cavus feet, and 27 were valgus feet; 59 feet had good results.
Pyper reviewed 45 feet in which flexor transfer had been performed and found an almost equal number of good and poor results (36 ). Best
results were obtained in patients with the mildest deformities. He found a straight digit with loss of interphalangeal joint motion resulted.
The toe was converted to a rigid lever on which the long extensors and flexors could work at the metatarsophalangeal joint. For this reason,
he recommended proximal interphalangeal joint arthrodesis as a better alternative.
Sgarlato reported on 53 cases of flexor transfers. He used 2 different techniques (37 ). He severed the flexor digitorum longus tendon from
its attachment to the distal phalanx, split it longitudinally, and attached it as a sling over the proximal phalanx. It was sutured to itself and
to the extensor expansions over the proximal phalanx. Pain associated with dorsal clavi was completely relieved, and impressive results
were reported in repositioning the phalanx on the metatarsal head and in repositioning the plantar fat pad. He reported a single “elevated
and fat toe.”
Barbari and Brevig reported on 39 operations using the Girdlestone-Taylor-type procedure (38 ). In 28 operations, these surgeons used
Parrish's modification in which the long flexor tendon was split longitudinally and the ends were sutured to themselves and to the dorsal
expansion of the extensor tendon (39 ). Best cosmetic results were reported in younger patients, although this group complained most of
toe stiffness. The elderly patients did not complain of stiffness, even though motion was decreased or absent. Results were considered
satisfactory in 28 of 31 patients. However, when metatarsalgia was the dominant preoperative complaint, no improvement was noted,
even though the toe was straight and the range of motion was acceptable.
Kuwada and Dockery reported a modification of the flexor transfer in which the flexor tendon was brought through a drill hole in the
anatomic neck of the proximal phalanx (40 ). Kuwada found this transfer effective in cavus foot structures when other procedures failed to
reduce the hammer toe deformities (41 ). Schuberth transferred the flexor digitorum longus tendon through a drill hole at the base of the
proximal phalanx (42 ) (Fig. 30 ). He believed that attaching the flexor at the base of the proximal phalanx was more anatomic. This
approach also allowed for arthrodesis of the proximal interphalangeal joint.
Flexor transfer to the extensor hood has been employed in patients with myelodysplasia with flexible hammer toe deformities. These
patients had residual paralysis from myelomeningocele (43 ). Results of tendon transfer without bone surgery were good to fair in 94% of
the cases. Marcinko and associates reported the modification used when flexor tendon transfer is performed as an isolated procedure
without an associated arthroplasty or arthrodesis of the proximal interphalangeal joint (44 ) (Fig. 31 ).
FIG. 30. Flexor digitorum longus transfer through a drill hole. This shows the location and orientation of the drill hole at the base of
the proximal phalanx. Note the direction of the tendon after it passes from plantar to dorsal.
Procedure
When this operation is performed as an isolated procedure, two skin incisions are employed, one on the side of the digit that provides the
most exposure and the other over the dorsum of the base of the proximal phalanx but on the opposite side from the first incision. The
incision on the side of the toe is usually medial on the second toe and lateral on the third, fourth, and fifth toes, to provide the greatest
exposure.
The medial or lateral incision is carried from the web space to the distal interphalangeal joint. The incision is between the dorsal and
plantar neurovascular bundles. Sharp dissection is used to open the retinacula that bind the flexor tendons to the underside of the
phalanges. The flexor longus tendon is traced distally and is severed close to its attachment to the distal phalanx.
The long flexor tendon is split longitudinally to the base of the proximal phalanx. One slip is tagged with a straight hemostat and the other
with a curved hemostat. A tenotomy is performed on the flexor digitorum brevis tendon in cases of extreme contracture.
The second incision is made dorsomedially or dorsolaterally, but on the side opposite to that on which the first incision is made. The
incision is deepened to the periosteal level. A channel is created, with a periosteal elevator passed medially and laterally around the bone
but superficial to the periosteum.
A curved pediatric hemostat is introduced first through

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one channel and then through the other, and the tendons are drawn dorsally adjacent to the phalanx. The tendons are crossed to create a
sling and are tightened appropriately. They are then sutured to themselves with 3-0 nonabsorbable braided suture. They are also sutured
to the extensor expansions. Excess tendon is cut away. Skin closure may be accomplished with several interrupted sutures.
FIG. 31. Flexor digitorum longus (FDL) transfer. A: The FDL tendon (1) is isolated by a lateral approach to the fifth digit (2). B: The
FDL has been sacrificed from its insertion into distal phalanx and longitudinally divided into medial (1) and lateral (2) portions. C: A
dorsal incision is placed over the proximal phalanx. The medial tendon segment is redirected medial to the proximal phalanx but
inferior to the neurovascular structures exiting the dorsal incision. 1, FDL medial portion; 2, FDL lateral portion. D: A curved
mosquito hemostat (1) is used to grasp and redirect the lateral portion of the tendon. E: Both tendon portions now exit the wound
dorsally. F: With the proximal phalanx in a rectus position, the FDL tendon segments are sutured (1) around the proximal phalanx
under physiologic tension. Excess tendon is then excised.
When the flexor transfer in performed in conjunction with osseous procedures, access to the flexor tendon is much easier. The tendon can
be easily located plantarly once the head of the proximal phalanx has been freed. A linear incision is made in the plantar capsule of the
proximal interphalangeal joint, and the long flexor tendon is isolated from the brevis (Fig. 32 ). The tendon is transected and is freed
proximally for transfer through a drill hole in the proximal phalanx or is split and delivered dorsally around each side of the shaft of the
proximal phalanx. The tendon is secured under appropriate tension. The stump of the long flexor tendon can be sutured to the short flexor
tendon at the proximal interphalangeal joint if desired. Typically, the normal skin incision for the osseous procedure is adequate for the
tendon transfer as well.
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FIG. 32. Flexor digitorum longus (FDL) transfer with an osseous procedure. A: After the head of the proximal phalanx is freed, a
linear incision is made in the plantar capsule, and the FDL tendon is isolated. B: The tendon is transected and is freed proximally for
transfer. C: The tendon is split longitudinally. D: Medial and lateral slips are transferred dorsally on either side of the proximal
phalanx. E: The two tendon slips are sutured under appropriate tension. The stump of the FDL can be sutured to the brevis at the
proximal interphalangeal joint.
Aftercare
Postoperative bandaging is used to retain the toes and metatarsophalangeal joints in corrected alignment for 3 weeks. After that, digital
retainers are used if needed.
Complications
Complications have included an occasional fat toe, with edema sometimes lasting for several months. We have also seen a reverse
deformity in which the toe developed a reverse curve or swan's neck deformity, with painful pressure occurring under the head or stump of
the proximal phalanx (Fig. 33 ). Stiffness may develop at the proximal interphalangeal joint, and it may create the functional effect of an
arthrodesis.
Discussion
Flexor tendon transfers may have greatest application in those cases in which flexor stability has been lost, such as in patients with
deranged metatarsophalangeal joint function. We believe that arthrodesis of the interphalangeal joints of the three middle toes is a
preferred approach to converting the long flexor tension into an effective plantarflexor of the
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metatarsophalangeal joint. Because arthrodesis of the fifth toe tends to create problems of shoe irritation, flexor tendon transfer may be
well suited for assisting stabilization of that toe. It is sometimes difficult to determine the correct amount of tension under which to suture
the flexor tendon. Too little tension can lead to poor toe purchase. Too much tension can lead to stiffness or reverse hammer toe
deformity.
FIG. 33. The second toe is a reverse hammer toe with limited motion at the metatarsophalangeal joint and a painful corn at the
plantar aspect of the head of the proximal phalanx.
Syndactyly
Syndactyly is the side-to-side anastomosis of two neighboring toes by resection dermoplasty. This is generally performed to help stabilize a
flail toe or to eliminate an interdigital soft corn or heloma molle (45 , 46 , 47 ). This may be done as an isolated procedure or in
combination with osseous procedures. The key conditions for successful correction are that the deforming forces be eliminated from the
flail toe and that the adjacent toe be a stable functioning rectus digit. The dermoplasty itself is inadequate to neutralize deforming forces.
Procedure
A triangular or rectangular area of skin is marked on the side of the flail toe to be anastomosed to the adjacent toe. The base of the
triangle is at the proximal web space, and the tip is distal. The dorsal arm of the skin resection is located slightly below the dorsal aspect
of the web space. This approach allows a short fold between the toes, to enhance the cosmetic appearance. The distal tip of the triangle
curls plantarly from the dorsum and dorsally from the plantar to meet, bisecting the toe. The toes are pressed together to form a mirror-
image triangle on the adjacent toe. This mirror-image triangle can be marked in blood on the adjacent toe after the initial incision on the
flail toe as an alternate marking system. This forms a trapezoid between the two toes. A controlled-depth incision is placed along the
marked area to penetrate only the dermis. The dermis is undermined carefully so as not to disturb the underlying vasculature and is
excised in toto. The plantar incision is then approximated with simple interrupted sutures that are initially not tied together but held with
hemostats. Suturing is begun at the proximal edges of the wound and continues distally. The dorsal skin edges are likewise approximated.
These sutures are also placed individually from proximal to distal and are initially not tied to allow for easy access to the skin for
subsequent sutures. Once all the sutures are placed, the plantar sutures are tied starting from proximal to distal. Next the dorsal sutures
are tied in order from proximal to distal. The suture ends are left slightly longer than normal to facilitate their removal (Fig. 34 ).
Aftercare
The toes are bandaged and splinted together for 10 to 14 days when the sutures can be removed. Little tension should exist between the
toes if the flail toe has no deforming force remaining on it. If the two toes have any deforming forces on them, the toes can be splinted
together for an additional 1 to 2 weeks.
Discussion
Whenever a syndactyly procedure is performed for a flail toe, all deforming forces on the adjacent toe should be neutralized before the
procedure. The flail anastomosed toe will deform along with the adjacent toe if deforming forces remain present. In the case of a soft corn,
syndactyly can readily eliminate the corn between the two toes. The results can be rewarding cosmetically if the deforming forces are
neutralized in both toes. Often, additional osseous procedures for the toes are necessary concurrent with surgical syndactyly.
Osseous Procedures to Correct Digital Deformities
Historical Review
Post, in 1882, “excised distal extremities” of the proximal phalanges (48 ). This procedure is the predecessor of the present-day proximal
interphalangeal joint arthroplasty, the most common procedure used for hammer toe surgery. In 1888, Terrier resected the base of the
proximal phalanx in addition to performing head resection (49 ). Soule described the intentional arthrodesis of the proximal
interphalangeal joint (50 ), and Higgs performed a fusion that consisted of using a spike-and-hole method after dovetailing the proximal
phalanx after removal of the articular surface (51 ). Young remodeled the proximal phalanx into a truncated cone, removed the
appropriate intramedullary bone from the middle phalanx, and locked them together (52 ). Taylor is credited with the first use of the K-
wire for achieving intramedullary
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fixation in hammer toe surgery (53 ). Selig bent the K-wire to stop proximal migration (54 ).
FIG. 34. Digital syndactyly. A-C: A triangular area of skin is marked on the side of the fifth toe, and the toes are pressed together to
form a mirror-image triangle on the adjacent fourth toe. D: A controlled-depth incision is placed along the marked area, and the
dermis is undermined so as not to disturb the underlying vasculature. E: The plantar incision is then approximated. The dorsal skin
edges are likewise approximated. F: The suture ends are left slightly longer than normal to facilitate their removal.
Arthroplasty of Proximal Interphalangeal Joint
Indications
Arthroplasty of a proximal interphalangeal joint is often indicated in those digits with a flexible to semirigid deformity. The procedure
shortens the toe and relaxes the soft tissues, and it lessens the tension of deforming extensor and flexor forces on the toe.
Procedure
The digit is approached through a linear or transverse incision at the level of the proximal interphalangeal joint (Fig. 35 ). Two semielliptic
transverse incisions may be employed to remove redundant tissue. The incision is carried through the subcutaneous tissues to the level of
the extensor digitorum longus tendon. The extensor tendon is freed from its soft tissue attachments to the dorsal aspect of the proximal
phalanx. A curved mosquito hemostat can be used to retract the tendon. The medial and lateral collateral ligaments are then incised, and
the head of the proximal phalanx is delivered into the wound. Soft tissue from the distal one-third of the proximal phalanx is removed. The
head is resected at its appropriate level. The amount of bone resected depends on the amount required to relieve soft tissue tension while
keeping the toe's length appropriate to that of the adjacent toes. The remaining bone may be rasped smooth.
Occasionally, the extensor digitorum longus tendon is divided for access to the joint. If the tendon has been divided, it is resutured at
closure. When a tendon has been retracted, it is repositioned on the dorsal aspect of the proximal phalanx and is sutured either medially
or laterally to create stability. The wound is closed in a manner of preference.
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FIG. 35. A: A linear skin incision starts distal to metatarsophalangeal joint and extends to the distal interphalangeal joint. B: Two
converging transverse, semielliptic, controlled-depth incisions remove redundant tissue and help to hold the digit in a more rectus
alignment. Care should be taken to control the incision depth, to avoid injury to the digital vessels. C: The extensor digitorum longus
(EDL) tendon has loose attachments to the dorsal aspect of proximal phalanx and insertions into the middle and distal phalanges. D:
Sharp dissection frees the extensor tendon from the proximal phalanx. E: A curved mosquito hemostat retracts the extensor tendon
medially or laterally. F: The medial and lateral collateral ligaments are divided at the proximal interphalangeal joint. G: Care is
taken not to injure the flexor tendon. H: Resection of the proximal phalangeal head is performed. Enough bone is resected to relieve
soft tissue tension while maintaining appropriate length in relation to the adjacent toes.
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Aftercare
Postoperative care includes supportive bandaging until skin and tendon have healed, usually for 3 to 6 weeks. When the procedure is
performed on multiple toes, supportive bandaging may be continued for a longer interval and is of assistance in controlling edema.
Discussion
Arthroplasty of the proximal or distal interphalangeal joint is probably the most widely used procedure for correction of digital deformity.
It is an excellent procedure to correct an isolated hammer toe, provided the cause of the deformity has been removed. If the deforming
influence is still present, arthroplasty will leave a flexible joint that may subsequently redeform. Furthermore, arthroplasty of a toe
relaxes both flexor tendons. The extensor tendons to that toe are also relaxed to some extent. However, because of the extensor hood
attachments, the hood fibers would need to be released to gain the full benefit of the relaxation. This relaxation of the soft tissues is
beneficial to that toe, but the tension is transferred to the other slips of the long extensor and long flexor tendons. In effect, loading of
the tendons to the adjacent toes may occur, especially if too much bone is resected for the digital arthroplasty.
Other procedures to consider for neutralizing deforming forces include extensor hood release and proximal interphalangeal joint
arthrodesis. If a transverse incision is used, there will be limited access to releasing the extensor hood. Tenotomy or Z-plasty tendon
lengthening would best be performed through a separate incision proximal to the hood fibers if extensor contraction is not adequately
released by bone resection in such a situation.
Interphalangeal Arthrodesis with Kirschner Wire Fixation

Interphalangeal arthrodesis with K-wire fixation consists of resecting the articular cartilage from both surfaces of the joint and fixing the
bones in close apposition with a K-wire. This method converts the toe to a rigid lever on which the extensor and flexor digitorum longus
tendons can function effectively. Arthrodesis is indicated in those patients in whom intrinsic muscle function has been compromised and
digital and metatarsophalangeal joint stability are lacking. In fact, the principal indication is to provide a stable lever arm on which the
long and short flexors can function to assist metatarsophalangeal joint stability. The procedure shortens the toe slightly because only
cartilage is resected to expose subchondral cancellous bone. In fact, the straightening process may appear to lengthen the toe. The
cartilage and bone that are resected do relax the soft tissues, and this again helps to remove some of the deforming forces. In some cases,
an additional degree of shortening may be combined with the arthrodesis to provide better relaxation of soft tissue tension.
Procedure
The area is approached through a linear incision, but a transverse incision, or two transverse converging semielliptic incisions, may be used
in special circumstances. The extensor digitorum longus tendon is identified and is generally divided into proximal and distal segments.
This is done in a Z fashion if the tendon needs to be lengthened. The extensor tendon is then freed from its attachments to the proximal
phalanx dorsally and is elevated from the proximal portion of the middle phalanx dorsally approximately 2 mm from the joint. The
collateral ligaments are divided, and the joint is opened. The distal end of the proximal phalanx and the base of the middle phalanx are
freed from soft tissue attachments. The cartilage is then resected, leaving exposed cancellous bone. At this point, extra bone can be
removed from the proximal phalanx if shortening the digit is desired.
The K-wire is then driven distally through the middle and distal phalanges, and it exits through the distal end of the toe. The distal phalanx
must be dorsiflexed so the nail bed and plate are not injured. The middle and proximal phalanges are then aligned. The K-wire tip is
visually seated into the intramedullary canal of the proximal phalanx and is directed in retrograde fashion to the base of the bone.
Stability is then checked. The wire can be placed in retrograde manner across the metatarsophalangeal joint while the joint is held in
corrected or slightly overcorrected alignment.
The extensor digitorum longus tendon is sutured into corrected position, and any redundant tendon may be removed. The K-wire is bent 90
degrees at the distal end, to allow approximately one-fourth inch of space between skin and the distal aspect of the K-wire. This space
accommodates occasional edema, which can create tension of pin against the skin. A K-wire cap can be used to protect the K-wire. The
toe is then splinted with gauze as the bandage is applied.
Aftercare
The K-wire is usually left in place for 6 to 8 weeks, and ambulation is allowed to tolerance. If the wire crosses the metatarsophalangeal
joint, it must be protected against bending force. At heel off, pressure is normally exerted by the ground against the tips of the toes. If
wires are limited to the toes, the metatarsophalangeal joint will dorsiflex freely. If the wires cross the metatarsophalangeal joint, the
bending force will disturb the pin-soft tissue interface and can contribute to pin tract infections or bending of the wire at the
metatarsophalangeal joint. In addition, the repetitive force against the wire may cause metal fatigue that can result in breakage of the
wire. The wire is usually protected against bending force for the entire 6 weeks by supportive splinting.
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To accomplish this, the insole of the surgical shoe can be built up with felt or cork from heel to the web area. The toes are thus allowed to
float over the end, to prevent contact with the shoe (Fig. 36 ). Supportive splinting is used with the bandaging, even when the shoe insole
is built up, and it may prevent flexion stress with metatarsal loading.
FIG. 36. A: A Kirschner wire (K-wire) maintains the arthrodesis of the proximal interphalangeal joint and is in place across
metatarsophalangeal joint for at least the first 3 postoperative weeks. The K-wire is protected from bending forces by cork buildup in
surgical shoe from heel to the sulcus beneath the toes. The end of the toe floats freely. A cast is an alternate method to prevent toe
contact and to protect the metatarsophalangeal joint from bending forces. The distal end of wire is bent 90 degrees to prevent
possible migration into tissues. A plastic cap on the end of the wire protects the wire from catching on clothes or sheets. B: After the
first 3 to 3½ weeks, the K-wire can be withdrawn from across the metatarsophalangeal joint; the tip of wire again is bent to a right
angle, and the cap is replaced. This permits exercise of metatarsophalangeal joint to minimize the chance of joint limitation. C:
Postoperative shoe is illustrated with ¼-inch cork buildup (1) extending from the heel to the sulcus beneath the toes.
Once the K-wires are removed, edema may be present for several weeks, especially where multiple wires cross metatarsophalangeal joints.
This edema is managed with moist heat, compressive bandaging, range-of-motion exercises, and nonsteroidal antiinflammatory agents.
Elastic tape bandaging is most helpful. The edema and related soreness are usually short lived, lasting from 2 weeks to as long as 2 or 3
months.
Discussion
After arthrodesis, the digit usually can grasp the ground. Flexibility of the toe is reduced because all motion then occurs at the distal
interphalangeal or the metatarsophalangeal joints. The decreased motion occasionally presents a problem in extremely active, athletically
inclined patients. In this circumstance, delaying arthrodesing procedures or compromising by performing arthroplasty may be considered.
Peg-in-Hole Arthrodesis
Peg-in-hole arthrodesis has been used extensively for more than 50 years. One advantage of the procedure as compared with end-to-end
arthrodesis is the snug fit created between the middle and proximal phalanges even without fixation. Generally, fixation is added with a K-
wire, although its use is not essential.
Procedure
The approach for peg-in-hole arthrodesis is through a linear, transverse incision, or through two transverse, converging semielliptic
incisions, depending on the degree of deformity (Fig. 37A ). Generally, a linear incision is used when there is also deformity at the
metatarsophalangeal joint. Use of two converging, transverse semielliptic incisions with removal of a wedge of dorsal skin is well suited to
digits when the principal deformity is at the interphalangeal joint. If extensive deformity exists at both joints, it is helpful to combine
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two converging, controlled-depth semielliptic incisions at the interphalangeal joint with a longitudinal incision that curves as it courses
proximally over the metatarsophalangeal joint. The longitudinal incision in this latter instance provides surgical access, whereas the
transverse, controlled-depth incisions simply remove redundant skin without penetrating the neurovascular structures.
FIG. 37. Peg-and-hole digital arthrodesis. A: Dorsal and lateral views of the toe and metatarsophalangeal joint deformities. B: The
medial, lateral, and plantar condyles are resected from the proximal phalangeal head. Care is taken to maintain the dorsal cortex
intact because this lends strength to the bone. The middle phalanx is drilled to receive the proximal phalanx (peg). C: The remodeled
proximal phalangeal peg is inserted into the middle phalanx, to create a stable reduction.
The longitudinal incision is deepened, and the extensor tendon is exposed. The tendon is severed transversely unless there is considerable
dorsal contracture at the metatarsophalangeal joint. In the latter case, the tendon is separated by Z-plasty to accommodate the longer
length required when the toe is straightened. The tendon ends are retracted, and the interphalangeal joint is opened. The head of the
proximal phalanx and the distal one-third of the shaft are freed. The medial, lateral, and plantar condyles are resected from the
phalangeal head (Fig. 37B ). The distal cap of cartilage is also resected. The dorsal cortex is carefully protected, as is the cancellous
center of the bone.
The intramedullary canal of the phalanx is opened with a hand-held K-wire before remodeling of the peg. Finding the canal after
remodeling the peg can otherwise be difficult to impossible. The peg is then shaped to appropriate size and contour with a rotary bur, with
care taken to preserve the dorsal cortex for structural stability. The base of the middle phalanx is drilled the length of the canal with a
drill bit and is reamed with a ball bur to prepare to receive the peg. A trial seating is done to ensure the fitting (Fig. 37C ).
A K-wire is drilled through the middle phalanx and out the end of the toe slightly plantar to the central area of the medullary canal to
accommodate the dorsal cortex of the proximal phalanx. The toe is aligned, and the proximal end of the wire is introduced into the
previously established intramedullary canal in the proximal phalanx. The wire is moved in retrograde fashion into the proximal phalanx. If
required, it is drilled across the metatarsophalangeal joint and into the distal one-third of the metatarsal while the joint is held
appropriately reduced.
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The peg is seated securely, the wire is bent 90 degrees at the end of the toe, and a wire cap is placed on the tip. If the extensor tendon
contracture through the hood fibers remains a deforming force, extensor hood recession may be required. The extensor tendon is repaired,
and the subcutaneous tissue and skin are closed in layers.
Aftercare
Postoperative care is much the same as for end-to-end interphalangeal joint arthrodesis, except osseous stability is greater and thus
permits earlier removal of the wires. The K-wires must be protected at the tip, and if the wires cross the metatarsophalangeal joint, they
must also be protected against bending force. Postoperative supportive bandaging is usually continued for 6 weeks until the K-wires are
removed. In actual practice, the wires may be removed by the third postoperative week when the peg is well seated and when the toes
can be adequately protected. A digital retainer may be used after removal of multiple wires and helps to control postoperative edema.
Range-of-motion exercises for the metatarsophalangeal joints and moist heat are helpful once bandaging is removed. Passive range-of-
motion exercises may also be helpful.
Discussion
An advantage of peg-in-hole arthrodesis is that it shortens the toe, relaxes soft tissues, and allows for ease of correction. When the toe is
already short, performing an end-to-end arthrodesis may be preferred. The procedure has the added advantage of providing more bone-to-
bone contact and has a higher union rate than does the end-to-end fusion. No fixation is actually required, especially when a cast is used
and a snug fit is present between the proximal and middle phalanges. Disadvantages include a general shortening of the toe (if the toe is
already short). The possibility of dorsal cortical fracture of the proximal phalanx always looms, and this could create instability between
the proximal and middle phalanges. This is the one reason that a K-wire is usually used. Another disadvantage is that the procedure is
technically more difficult when compared with the end-to-end arthrodesis.
When performing an arthrodesis of the fourth toe on a young patient who enjoys fashionable or snug shoes, it is wise to shorten the peg
just enough so the end of the fourth toe will be sheltered by an imaginary line drawn between the ends of the third and fifth toes. The toe
is thus protected from pressure against the curve of the shoe. Rigid toes do not tolerate shoe pressures well, and this is the principal
reason that arthrodesis is rarely, if ever, performed on the fifth toe. This excellent procedure provides a stable toe and usually results in
greatly improved metatarsophalangeal joint function, provided adequate soft tissue releases have been performed in conjunction with the
procedure.
Digital Arthrodesis Using Internal Pins

Fixing a digital arthrodesis site by means of a K-wire protruding out the end of the toe poses certain problems. Exiting the skin for a
protracted period exposes the site to potential infection, pin trauma, pin bending, and accidental removal, although the actual incidence
of such occurrences is low. In addition, the patient must keep the wound dry for up to 6 weeks. Finally, the anticipation of pin removal can
generate considerable anxiety, and the extraction itself may be painful. All these factors can be frustrating to the patient and challenging
to the surgeon. In response to these considerations, internally placed pins have been used to provide digital fixation.
Two types of pins have been implanted across digital arthrodesis sites for internal fixation. Patton used a 1.3-mm para-dioxanone
absorbable pin that dissolved by hydrolysis approximately 6 months after insertion (55 ). Miller implanted a 2.4-mm diameter pin fashioned
out of cortical allograft bone (56 ). This bone pin, placed in the intramedullary canals across the arthrodesis site, is actually incorporated
into the local bone to form a framework for bone fusion. Small screws have also been placed internally for proximal interphalangeal joint
fusion; the main disadvantage is that, for insertion, they must pass through or across the distal interphalangeal joint.
Procedure
Once the proximal interphalangeal joint is exposed, the opposing articular surfaces are resected, and both intramedullary canals are
drilled with a 2.4-mm smooth K-wire. The two channels are measured, and the results are totaled to determine the appropriate length for
the allograft bone pin. The pin is first placed into the proximal phalanx using a plunger, and then the middle phalanx and distal end of the
toe are manipulated onto the protruding end of the pin to complete the fixation. One main advantage of the bone allograft pin over the
absorbable pin is that the former pin is visible on radiographs, a feature allowing a periodic assessment of the incorporation arthrodesis
(Fig. 38 ).
Discussion
Internal fixation pins function as rigid intramedullary rods. Although both types of pins provide rigidity and resist shearing forces, the
absorbable pins lack strength related to bending and compressive forces, whereas the processes for preparing the bone allograft pins tend
to reduce their torsional and bending strength. These modest limitations have not affected the success of digital corrections with either
device.
In contrast to the polymeric pins that are hydrolysed for linear resorption and bone replacement without incorporation, the bone pins act
as a lattice on which new bone can form by osteoconduction. Some bone morphogenic protein
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is preserved in the bone allograft pins so they possess osteoinduction capabilities as well. The result is total incorporation and the ability
to bridge gaps. Besides their low antigenicity, these processed bone bins are associated with a negligible risk of infection calculated at
1:1.6 × 106. There have been no reported diseases to date as a result of the implantation of bone allograft pins.
FIG. 38. Internal pin digital arthrodesis. A: Drilling intramedullary holes after joint resection. B: Using the plunger to place the pin in
proximal phalanx. C,D: Technique for setting the middle phalanx onto the pin to transfix the two bones. E: Completed fixation for
arthrodesis. The cortical bone pin is easily visible as an internal fixation device. The pin is placed deeply into the proximal phalanx to
eliminate the danger of its slipping and disengaging the arthrodesis site.
One disadvantage of internal pins for toe surgery is the lack of compression for the acceleration of bone healing. As rigid devices, they can
fracture, but this has not proven to be a problem. Another disadvantage is that the pins cannot cross the metatarsophalangeal joint when
it is necessary to maintain the reduction of a subluxed or dislocated articulation. This problem can usually be overcome with the addition
of a flexor digitorum longus tendon transfer.
Resection of the Base of the Proximal Phalanx

Resection of the base of the proximal phalanx was first described by Kreuz in 1923 for correcting dislocation of the
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metatarsophalangeal joint (57 ). However, the procedure has been used for the correction of hammer toe deformities. The operation is
intended to increase motion at the metatarsophalangeal joint.
Performing resection of the proximal phalangeal base by itself is contrary to all logic in trying to maintain digital stability. Loss of the
digits' intrinsic muscle function is obvious because their attachments to the proximal phalanx are sacrificed. Instability is created, and this
allows the digit to retract dorsally, often creating plantar protrusion of the metatarsal head and causing a plantar keratosis. The toe floats
or dangles and cannot act as a lever for weight transfer. The procedure is justified in patients with bone tumors and in those with
osteomyelitis involving the base of the proximal phalanx. It is commonly used as an adjunct procedure in severe rheumatoid foot surgery
and in patients with derangement of the metatarsophalangeal joint.
When proximal phalangeal base resection is performed, Kelikian recommends constructing a web between the involved digit and the
adjacent toe to enhance the grasping effects of the combined toes and thus to decrease instability and the tendency to shorten (28 ). The
combined action of the long flexors is at least partially transferred to the metatarsophalangeal joint where flexion is indispensable.
However, this is an ineffective way to stabilize the toe. Conklin and Smith found that when they included an extensor tenotomy, the
satisfaction with the procedure increased (58 ). They also found that those cases in patients with transverse plane deviation, metatarsalgia,
and metatarsophalangeal subluxation or dislocation had lower rates of success. In 1979, Jim Ganley indicated that resection of the base of
the proximal phalanx worked well for him in digital surgery (59 ). He showed some excellent cases in which malalignment and poor toe
purchase did not occur. The reason for the good results achieved were believed to be derived from the transfer of the extensor digitorum
longus tendon into the corresponding metatarsal. The extensor digitorum brevis tendon was preserved to allow some continued dorsiflexion
force.
Ganley seemed to be using the principle of tendon balancing similar to that seen in the Keller arthroplasty for the first
metatarsophalangeal joint. In the Keller bunionectomy, Ganley had advocated lengthening the extensor hallucis longus tendon (60 ).
McGlamry recommended attaching the flexor hallucis longus or brevis to the stump of the proximal phalanx (61 ). These tendon balancing
procedures have allowed better digital function for the hallux along with the good pain relief of the traditional joint-destructive procedure.
Although we do not recommend the base resection of the proximal phalanx as a first-line procedure for correcting hammer toes, it can be
used effectively when the patient has arthrosis or degeneration at the lesser metatarsal joints or if there is difficulty in relocating severe
dorsal or transverse plane contracture at the metatarsophalangeal joint. We recommend Ganley's extensor digitorum longus transfer to the
metatarsal and McGlamry's flexor digitorum longus transfer to the stump of the proximal phalanx along with the traditional base resection
and capsulorrhaphy.
Procedure
A curvilinear skin incision is placed over the base of the involved digit and metatarsophalangeal joint. The extensor digitorum longus and
brevis tendons are identified. The extensor hood is incised, and the extensor apparatus is reflected. The extensor digitorum longus tendon
is divided transversely at the metatarsal neck and is retracted. The extensor digitorum brevis is preserved. The periosteum and capsule are
reflected in a linear fashion, to expose the proximal one-third of the proximal phalanx. The proximal phalangeal base is resected, and the
remaining bone may be rasped smoothed. A drill hole is placed centrally through the plantar cortex of the stump of the proximal phalanx.
The metatarsal head may be freed of any restrictive soft tissue attachments with the aid of a McGlamry elevator. A linear incision is made
through the plantar capsule, and the flexor digitorum longus and brevis tendons are identified. The flexor digitorum longus is isolated and
is attached by the drill hole to the plantar stump of the proximal phalanx. The tendon is secured under tension with the toe held in a
slightly overcorrected position. The extensor digitorum longus is secured to the metatarsal neck with the foot held at right angles to the
leg. The periosteum is closed over the tendon and is further secured to the tendon. If desired, one may “pursestring” the capsule into the
void from side to side. A K-wire may be driven out through the tip of the toe from the stump of the proximal phalanx and may be moved in
retrograde fashion back across the metatarsophalangeal joint. The wire should hold the toe in a mildly plantarflexed attitude. The
extensor hood apparatus is relocated with the extensor digitorum brevis, and the wound is closed in layers. The range of motion is
evaluated intraoperatively to ensure adequate motion if no K-wire is used (Fig. 39 ).
Aftercare
A K-wire may be used for a sufficient period of time to allow fibrous tissue organization to help stabilize the digit. The wire may also be
used to anchor the pursestring capsule in the joint space during healing.
Discussion
When conservative therapy and joint preservation techniques are inadequate, the tendon balancing technique described in conjunction
with base resection has proven successful in the surgical treatment of painful arthrosis of the lesser metatarsophalangeal joints. The
advantages to this procedure are that it preserves the weight-bearing metatarsal head, it neutralizes the dynamic forces across the
metatarsophalangeal joint, it helps to replace the intrinsic forces at least in the sagittal plane, and it stabilizes the digit. Like most other
joint-destructive procedures of the lesser metatarsophalangeal joints, the procedure also eliminates painful motion. It can be combined
with arthrodesis or arthroplasty of the proximal interphalangeal joint or with implant arthroplasty of the metatarsophalangeal joint.
Neutralization of transverse plane deformities is often not necessary because the interossei on both sides of the metatarsophalangeal joint
have been released with the resection of the base of the proximal phalanx. However, this procedure does not stabilize the
metatarsophalangeal joint in the transverse plane. Additional techniques may be necessary to maintain stability in the transverse plane.
The key to the successful positioning of the toe is the tendon balancing.
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FIG. 39. Phalangeal base resection with tendon transfer. A: Intraoperative appearance after the extensor hood recession with the
extensor apparatus reflected. The extensor digitorum longus tendon is divided transversely at the metatarsal neck and is retracted.
The extensor digitorum brevis is preserved. B: A linear periosteal-capsular incision is made extending from the neck of the metatarsal
to the shaft of the proximal phalanx. The proximal phalangeal base is identified, freed of its soft tissue attachments, and excised. C:
A drill hole is placed centrally through the plantar cortex of the stump of the proximal phalanx. D: A linear incision is made through
the plantar capsule, and the flexor digitorum longus and brevis tendons are identified. The flexor digitorum longus is isolated, and
with the toe, held in a slightly overcorrected position, is attached through the drill hole to the plantar stump of the proximal
phalanx. E: The extensor digitorum longus is secured to the metatarsal neck by a bone anchor with the foot held at right angles to
the leg. F: The periosteum is closed over the tendon and is further secured to the tendon. One may “pursestring” the capsule into
the void from side to side. G: The extensor hood apparatus is relocated with the extensor digitorum brevis and is sutured if
necessary. H: Preoperative (left) and postoperative (right) radiographs.
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FIG. 39. Continued.
Bone Grafting in Digital Repair

In most cases of digital surgery, bone shortening techniques are beneficial to help release soft tissue contractures. However, some patients
may have a flail toe as a result of overaggressive bone resection with previous surgery. In this circumstance, lengthening the toe may be
desirable to reestablish function (62 ). Bone graft arthrodesis and implant
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arthroplasty are options to achieve this result. Syndactyly is an alternate procedure, but this does not have the benefit of restoring length
and function to the toe.
A flail toe can be defined as one that lacks stability and structural integrity. Often, the patient complains of catching the toe on stockings
or shoes. The flail toe presents a functional, cosmetic, and sometimes symptomatic problem (Fig. 40A ). Mahan described a bone graft
stabilization technique for a flail toe using cortical cancellous calcaneal graft that has proven successful (63 ).
FIG. 40. A: flail toe is defined as one that lacks stability and structural integrity. This can lead to functional, cosmetic, and
symptomatic problems often involving catching the toe on stockings and shoes. B: Toe with a calcaneal bone graft and a Kirschner
wire in place. C: Functionally stable toe postoperatively.
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Procedure
A linear incision is made over the digit (usually encompassing a previous scar if present). The extensor tendon is lengthened in a Z-plasty
technique. The distal portion of the proximal phalanx and the base of the intermediate phalanx are resected to raw bleeding bone, with
removal of any sclerotic tissue. Any plantar scarring that would restrict lengthening of the digit is released.
A corticocancellous autograft is procured from the dorsolateral aspect of the calcaneus or other suitable area. The graft is trimmed to the
necessary length and width and is predrilled with a 0.035-inch K-wire. A 0.045-inch K-wire is inserted in retrograde fashion through the
intermediate and distal phalanges out the end of the toe. The graft is placed between the proximal and intermediate phalanges so the
cortical surface is on the dorsal side of the toe for stability. The K-wire is then driven from distal to proximal through the bone graft, the
proximal phalanx, and into the corresponding metatarsal (Fig. 40B ). The wound is closed in layers. The vascular status to the digit is
checked to ensure that lengthening has not compromised the circulation to the toe.
Aftercare
A below-knee non-weight-bearing cast is used. When consolidation of the graft is noted (usually around 8 weeks postoperatively), the K-
wire is removed. The cast is continued for an additional 2 weeks, but partial weight bearing may be allowed. A surgical shoe is used for an
additional 3 weeks. If good consolidation and stability are noted along the graft at 3 months, then the patient is allowed into a flexible
shoe.
Discussion
Bone grafting in digital surgery is not a common procedure. Fortunately, the flail toe is becoming less common. Postoperative disability,
the small graft-host interface, the additional surgical procedure required to obtain the donor graft, and the potential risks including failure
of the graft and vascular compromise must all be weighed in the preoperative decision. Implant arthroplasty, syndactyly, and amputation
can be considered as alternative techniques. However, the bone grafting technique can be successful in restoring structural and functional
stability to the flail toe (Fig. 40C ).
Intraoperative Stepwise Approach to Digital Surgery

Hammer toe surgery is best approached in a stepwise manner. The degree of fixed deformity is determined by the push-up test and by
range-of-motion examination of the involved joints. A flexible deformity allows the digit to assume a rectus position when the foot is
loaded. Semirigid or rigid deformities are evidenced by continued flexion of the interphalangeal joint and extended metatarsophalangeal
joints when the forefoot is loaded. The surgeon should have a good understanding of digital pathomechanics. Clinical judgment should
allow for presurgical planning regarding whether an arthroplasty procedure will be adequate or whether soft tissue releases combined with
digital stabilization arthrodesis will be necessary. However, adequate anatomic relocation of the digit and release of deforming soft tissue
structures should be performed intraoperatively.
Resecting the Head of the Proximal Phalanx (Post Procedure)

Resecting the head of the proximal phalanx is most commonly performed to reduce the bony prominence under painful corns on the digit
(48 ) (Fig. 41 ). This procedure also releases some of the deforming force of the flexor digitorum longus and brevis by shortening the origin
to insertion of these tendons. However, the extensor sling, which provides the primary pull of the extensor tendons, is proximal to the
resected bone. Therefore, simple head resection of the proximal phalanx may be inadequate to release the contracture of the extensors.
When the toe returns to anatomic alignment after loading of the metatarsal (push-up test), the extensor contraction is not a significant
deterrent to correction. In the event the joint does not realign and the proximal phalangeal stump remains extended, an additional
surgical step is necessary.
Extensor Hood Recession

Distal relaxation is created in the extensor tendons by relatively lengthening the origin to the insertion with the resection of the head of
the proximal phalanx. This slack can be transmitted proximally by releasing the extensor hood fibers on either side of the extensor
digitorum longus and brevis tendons and at the metatarsophalangeal joint. Extensor hood recession is performed by placing the tendon on
stretch distally and severing the hood fibers medially and laterally at their attachments to the joint capsule and the proximal phalangeal
sling. The metatarsal ray is then loaded by the push-up test. If the metatarsophalangeal joint completely realigns, adequate correction has
been obtained. If the proximal phalangeal stump stays in an extended position, an additional surgical step will be needed. An alternative
procedure to the hood recession is lengthening or tenotomy of the extensor digitorum longus tendon. However, this must be accomplished
proximal to the hood fibers to be effective.
Extensor Tenotomy or Lengthening

Lengthening of the extensor digitorum longus tendon can be achieved by tenotomy or a Z-plasty lengthening. Caution should be used if all
the extensors are not lengthened. All four of the tendons originate from the same muscle. Releasing the tension on any one tendon
segment will apply additional load on the others. This may result in significant loading force on these adjacent toes and may cause
pathologic contracture. The tendons can be lengthened in a Z-plasty technique through a single longitudinal incision over the metatarsal
shafts proximal to the extensor hoods. However, in the stepwise approach when the hood recession has been done, the Z-plasty
lengthening can be accomplished at the digital or metatarsophalangeal joint area. The long extensor tendon is split by open Z-plasty, and
the ends are retracted from the wound. The foot is again loaded, and the proximal phalangeal alignment is evaluated. If the proximal
phalanx stays in an extended position when the ray is loaded, additional surgical treatment will be needed.
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FIG. 41. Stepwise approach to hammer toe repair. A: A curvilinear incision is placed over the metatarsophalangeal joint to minimize
the effects of contracture during healing. B: Transverse converging semielliptic controlled-depth incisions may be combined with a
curvilinear incision (1). Removal of the transverse ellipse helps to eliminate redundant tissue and assists in holding the digit in rectus
position (if necessary). C: Broken lines indicate the section of the extensor digitorum longus (EDL) tendon to undermine from the
proximal and middle phalanges. D: A curved hemostat is used to retract the extensor tendon. E: The proximal phalangeal head is
resected. F: The push-up test loads the metatarsal ray. If the metatarsophalangeal joint does not realign and the proximal phalanx
remains extended, an extensor hood recession will be required. G: An extensor hood recession is performed. H: The extensor tendon
is distracted distally, and the hood fibers are released medially and laterally at their attachment to the proximal phalanx and joint
capsule. 1, EDL. I: A repeat push-up test revealed that the proximal phalanx remained extended, and the extensor digitorum longus
tendon is divided in an open Z-plasty technique. This can be done at this level because the extensor hood has already been released.
J,K: If the proximal phalanx remains extended with a repeat push-up test, this indicates dorsal capsular contracture. As the proximal
phalanx is distally distracted, a dorsal, medial, and lateral capsulotomy is performed. L: A repeat push-up test may reveal that the
digit and the metatarsophalangeal joint are in rectus alignment. M: Arrow shows the fibrosis of capsule to the inferoproximal aspect
of the metatarsal head. This capsulodesis prevents realignment of toe and metatarsophalangeal joint in response to the push-up test.
N: With the metatarsophalangeal joint flexed 90 degrees, an 11- or 13-mm metatarsal elevator is used to release the flexor
capsulodesis from the proximal plantar aspect of the metatarsal head and neck. O: The head of the proximal phalanx is shaped to
form a peg (2), and the middle phalanx has been reamed to accept a peg (1). P: The arthrodesis site is reduced. Extreme care must
be taken to preserve the dorsal cortex of the proximal phalanx. 1, Arthrodesis of the proximal interphalangeal joint. Q: The
arthrodesis and metatarsophalangeal joint alignment are maintained with a Kirschner wire (1). Note the slight overcorrection of the
metatarsophalangeal joint, with the proximal phalanx resting abducted and plantarflexed on the second metatarsal head (2).
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FIG. 41. Continued.

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FIG. 41. Continued.
Capsulotomy
Contracture of the metatarsophalangeal joint capsule can prevent anatomic realignment, as evidenced with the push-up test. A dorsal,
dorsomedial, and dorsolateral capsulotomy at the metatarsophalangeal joint may be necessary to release deforming forces. The phalanx is
grasped distally and is placed under traction. The metatarsophalangeal joint capsule dimples across the joint line. The proximal phalanx is
held distracted while the capsule is severed dorsally, medially, and laterally. With repetition of the push-up test, the interphalangeal joint
usually realigns.
Plantar Capsular Release

Two conditions can prevent realignment of the joint even after the previously mentioned releases. The first is capsulodesis of the flexor
plate to the metatarsal neck or head. This often occurs in arthrosis of the metatarsophalangeal joint and results in flexor plate loading of
the metatarsal head rather than loading of the base of the proximal phalanx when the push-up test is performed. The second condition is
medial or lateral dislocation of the flexor tendon. Lateral dislocation of the flexor tendon typically occurs in patients with rheumatoid
arthritis. Medial dislocation of the tendon occurs in patients with chronic metatarsalgia. In both instances, the chronic inflammatory
processes result in weakening of the retinacular ligaments that normally maintain the ordered relationship of the flexor apparatus to the
plantar joint. The flexor tendons dislocate medially or laterally. The toe contracts dorsally and medially or laterally.
With dislocation of the flexor plate and flexor tendons, the push-up test results in adduction or abduction of the toe. In effect, the test
loads the flexor structures regardless of where they are displaced. The result is a toe that is displaced in the direction of the pull. If the
metatarsophalangeal joint shows no change in alignment when the foot is loaded, the flexor structures at the metatarsophalangeal joint
may require release, the next step in sequential repair. The proximal phalanx is again placed under distal traction. The McGlamry
metatarsal elevator is slipped gently into the metatarsophalangeal joint and beneath the metatarsal head, with care taken not to damage
the articular cartilage. The proximal phalanx is flexed 90 degrees while the elevator is used to deglove the plantar aspect of the
metatarsal head. The push-up test should then result in easy realignment of the metatarsophalangeal joint. However, when the plantar
plate has become unstable, it is necessary to go on to the next step. This entails
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either flexor tendon transfer or proximal interphalangeal arthrodesis (37 ,39 ).
Flexor Tendon Transfer to the Proximal Phalanx

In a patient with severe metatarsophalangeal joint derangement, long-term soft tissue and often joint adaptation are present. In such
circumstances, it is unrealistic to expect the intrinsic muscles to recapture their stabilizing function even after correction of digital
alignment. Therefore, one may need to employ flexor transfer or stabilizing arthrodesis of the interphalangeal joint as a principal part of
surgical correction. This provides a stable lever on which the long and short flexors can function to stabilize metatarsophalangeal joint
function. These procedures should prevent passive buckling at the metatarsophalangeal joint and may restore the rigid beam effect.
Because the head of the proximal phalanx has been resected or remodeled in preparation for arthroplasty or arthrodesis of the proximal
interphalangeal joint, the long flexor tendon can be identified at the proximal interphalangeal joint level. The tendon can then be severed
and either split to be sutured to itself on the dorsum of the proximal phalanx or transferred through a drill hole in the proximal phalanx
under tension. The toe is splinted in a slightly overcorrected position with a K-wire across the metatarsophalangeal joint or with bandaging
for 3 to 6 weeks. If the plantar plate has been released or was disrupted, the K-wire can be withdrawn from across the
metatarsophalangeal joint at 3 weeks, to allow early mobilization of that joint and to prevent capsulodesis.
Arthrodesis of the Proximal Interphalangeal Joint

When indicated, arthrodesis of the proximal interphalangeal joint can be accomplished by articular resection of both sides of the joint or
by the peg-and-hole technique that was described earlier in the chapter. A 0.045-inch K-wire is used to maintain the toe in slight
overcorrected alignment for 3 to 6 weeks. The extensor tendon is repaired in a lengthened position.
Whenever a K-wire is placed across the metatarsophalangeal joint, it is best to protect the toe and the pin. A onefourth-inch cork buildup
in a wooden-soled surgical shoe extending from the heel to the sulcus beneath the toes allows the toes to float and thus prevents bending
forces on the pin.
Extensor Digitorum Transfer to the Metatarsal

After complete release of the metatarsophalangeal joint and before the insertion of the K-wire, the push-up test is repeated. If difficulty
in maintaining a rectus digital alignment persists, extensor digitorum longus transfer to the metatarsal neck may be considered in an
attempt to enhance overall alignment. The tendon must be anchored to the bone and covered by the periosteum. A small bone anchor can
be used for this purpose, or a drill hole with suture. The tendency may exist for the tendon to regenerate across the metatarsophalangeal
joint through the paratenon. The extensor digitorum brevis may be preserved to allow some dorsiflexion force across the joint.
Proximal Phalangeal Base Resection with Muscle Tendon Balancing

If in spite of all the releases, the metatarsophalangeal joint cannot be relocated or arthrosis exists at the joint level, proximal phalangeal
base resection can be instituted. Because this procedure does disrupt the intrinsic interossei muscles, transfer of the extensor digitorum
longus to the metatarsal is considered an important step to eliminate later deformity. Furthermore, anchoring the flexor digitorum longus
to the plantar stump of the proximal phalanx is strongly recommended. K-wire fixation and proximal interphalangeal fusion may be
necessary as well.
Aftercare
When capsulodesis is present, the wire is best withdrawn across the metatarsophalangeal joint approximately 3 weeks postoperatively, and
passive range-of-motion exercises started to prevent adherence of the capsule to the metatarsal head. When medial or lateral dislocation
of the flexor cap is present, the joint capsule can be tightly closed with oblique derotation sutures on one side of the joint while the other
side is left open. The K-wire usually retains the overcorrected alignment for as long as is indicated. A period of 6 weeks is appropriate
unless the flexor plate was degloved from the metatarsal head. In such circumstances, the wire is withdrawn across the
metatarsophalangeal joint and into the toe 3 weeks postoperatively to allow joint mobilization.
Discussion
The sequential approach to severe claw toe and hammer toe deformity has proven essential to reestablish the integrity of the flexor plate.
Without free gliding of the flexor structures beneath the metatarsophalangeal joint, there can be no stability of toe function (Fig. 42 ). We
further believe that
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the determination regarding whether to perform an arthroplasty or an arthrodesis procedure for severe claw toe or hammer toe deformity
should rest on the answers to two questions: first, has the deforming influence been corrected or neutralized; and second, can one
reasonably expect return of normal intrinsic muscle and flexor function? If the answers to these questions are yes, performing arthroplasty
and soft tissue release is appropriate. If the answer to either question is no, arthrodesis of the proximal interphalangeal joint may provide
a more stable lever arm on which the long and short flexors can function to help stabilize metatarsophalangeal joint function.
FIG. 42. A normal flexor plate-to-metatarsal relationship must be maintained to reestablish gliding function between these two
structures.
Hammer Toe Deformity of the Fifth Digit

Hammer toe deformities of the fifth digit present with several unique problems. In addition, certain conditions and deformities of the
fifth toe that are not, strictly speaking, hammer toes are frequently grouped together with the hammer toe condition. These conditions
and unique features are discussed in Part 2 of this chapter . In addition, overlapping fifth toes present a special problem and are discussed
in Chapter 42.
Additional Considerations
As mentioned previously, it is difficult to control the extensor substitution swing-phase forces postoperatively, short of using a dropfoot leg
brace, an ankle-foot orthosis, or a Richie brace. Therefore, surgical procedures short of arthrodesis of the proximal interphalangeal joint
or tendon balancing procedures usually prove inadequate for correcting deformities with this origin. If the interphalangeal joint is fused,
the flexor digitorum brevis and, to some extent, the flexor digitorum longus will be able to resist dorsiflexion at the metatarsophalangeal
joint (4 ). Before arthrodesis, the flexors could add to the passive buckling (dorsiflexion) at the metatarsophalangeal joint by creating
plantarflexion force at the proximal interphalangeal joint.
An alternative treatment in a patient without neuromuscular disease is the Hibbs suspension. The long extensor tendons are transferred
into the midfoot area, usually the base of the third metatarsal. The extensor digitorum brevis tendons continue to create a small
dorsiflexory force across the metatarsophalangeal joints. The distal stump of the extensor digitorum longus to the fifth toe needs to be
attached to the extensor digitorum brevis to the fourth toe because there is no extensor digitorum brevis to the fifth toe. This allows the
extensor digitorum longus to continue to function primarily at the ankle joint but removes the excessive dorsiflexory force across the
metatarsophalangeal joint. In many patients with neuromuscular disease, the intrinsic muscles are weak. Although the Hibbs suspension
neutralizes the extensor substitution swing-phase contraction, there is usually a concomitant stance-phase contraction that is not
neutralized by the Hibbs suspension. In this situation, arthrodesis of the proximal interphalangeal joint is a better choice.
Thus, the Hibbs suspension is a good procedure within a narrow clinical spectrum. The indication for the Hibbs suspension is extensor
substitution swing-phase contraction that is flexible in patients without neuromuscular disease and without uncontrollable flexor
stabilization or flexor substitution contracture.
Finally, in patients with flexor substitution and a weak gastrocnemius-soleus complex, arthrodesis of the proximal interphalangeal joint is
often required. Muscle-tendon balancing procedures such as the transfer of the tibialis posterior and the peroneus longus to the calcaneus
to substitute for the weakened gastrocnemius-soleus complex may prove adequate to reduce significant grasping forces across the
metatarsophalangeal joint. On occasion, digital arthrodesis may be necessary in conjunction with the tendon balancing procedures.
Lesser Metatarsal Surgery
Biomechanics of the Central Three Rays

The biomechanical features of the three central rays are similar, and the rays are generally considered as one unit. Whereas the first and
fifth rays have triplane motion because their axes are oriented oblique to all three body planes, the three central rays share a common
transverse axis. This axis allows for only a small amount of sagittal plane motion.
The second and fourth rays have slightly more excursion than the third ray. Frontal plane motion is minimal in either segment. Perhaps
because of the triplane motion of the first and fifth rays in combination with this limited motion of the central three rays, and the
resulting weight transfer, hyperkeratoses occur most commonly under these three metatarsal heads. During the stance phase of gait, as
the fifth ray dorsiflexes and everts, it bears decreased weight (Fig. 43 ). Therefore, more weight is borne on the fourth metatarsal.
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In the chronically pronated foot, as the first ray dorsiflexes and inverts, more pressure is placed on the central three rays (Fig. 44 ). The
second ray usually receives most of the pressure, with a result that most of the hyperkeratosis occurs under this metatarsal (64 ,65 ).
FIG. 43. During stance phase of gait, the fifth ray can dorsiflex, and it bears decreased weight. This throws increased weight bearing
under the fourth metatarsal bone.
FIG. 44. When the first metatarsal bone is unstable or hypermobile, the second or second and third metatarsal bones must carry
increased weight-bearing stress.
FIG. 45. A: As claw toe deformity develops, the toes create a retrograde force from toe pushing the metatarsal head plantarly and
posteriorly. FDL, flexor digitorum longus. B: Relaxed preoperative stance view of a patient with Charcot-Marie-Tooth disease and
severe claw toe deformity. The digital deformity is reduced on weight bearing. C: A 7½-month postoperative view after rearfoot
correction and digital arthrodesis of the first through fourth toes. Arthroplasty and extensor lengthening with capsular release was
performed on the fifth toe. D: An 11-month postoperative view of the same patient, right foot, and 7½-month postoperative view of
the left foot. Note excellent digital stabilization and the resulting metatarsophalangeal joint alignment.
With cavus foot, forefoot equinus, and other conditions in which the metatarsals are more plantarly angulated, reactive hyperkeratoses
usually develop from shearing forces (Fig. 45 ). They can be seen under every metatarsal, as opposed to the findings in a pronated foot, in
which the lesions are frequently beneath metatarsals 2 and 4 and occasionally on the medial aspect of the first metatarsal head and
plantar lateral aspect of the fifth metatarsal head.
In the pronated foot, treatment is directed at controlling hypermobility and creating more even pressure across all metatarsal heads. In
the cavus foot, treatment is directed at improving shock absorption and relieving stresses directly on the metatarsal heads. The pronated
foot alters the mechanical
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axes about which all joints distal to the subtalar joint function. The axes are altered to make the foot more mobile (i.e., “loose bag of
bones”). Muscle function likewise is altered, often creating hammer digit syndrome, with retrograde forces causing plantarflexion of the
metatarsal heads. This situation perpetuates the digital and metatarsal head hyperkeratoses. In patients with severely chronically pronated
feet with metatarsophalangeal joint derangement and dislocation, the foot ceases to function in an orderly manner. The foot may become
a nonfunctioning rigid structure without the ability to respond to shock. Once this stage is reached, severe callosities are usually present
under the forefoot that can be associated with ulcerative changes. A discussion of lesser metatarsal diseases and surgical procedures is
provided in the section on lesser metatarsal surgery.
SURGICAL MANAGEMENT OF METATARSOPHALANGEAL JOINT DERANGEMENT
Transverse Plane Deformity

Transverse plane deformity of the lesser metatarsophalangeal joint is a common condition that may prove difficult to correct fully. The
deformity can be defined as an adduction or abduction of the digit on the metatarsal. In simplest terms a reciprocal relationship exists. As
the toe moves in one direction, the metatarsal head is displaced in the opposite direction. The deformity may involve one or multiple rays.
The cause is varied but is usually related to long-term inflammation of the joint.
Regardless of the biomechanical or arthritic processes responsible, chronic inflammation of the joint weakens the retinacular ligaments
responsible for maintaining the ordered relationship of the flexor structures with the metatarsal head. The flexor structures displace
medially or laterally and pull the toe in that direction. Loss of the plantar position of the flexor structures sacrifices the plantar stabilizing
force and allows the extensor tendons to drag the toe dorsally as well. The toe can also rotate on the frontal plane, and the flexor tendons
become established as adductors or abductors of the metatarsophalangeal joint. This is one of the more difficult forefoot deformities to
correct (66 ,67 ).
In addition to abnormal biomechanics, trauma, arthritis, and neuromuscular disorders, causes of the disorder include surgical damage to
the intrinsic tendons. Any surgical procedure that alters the normal dynamic function around the metatarsophalangeal joint could
conceivably cause this deformity (66 ). For example, it can occur after procedures for neuroma in which dissection or scarring may have
damaged the plantar or dorsal interossei or lumbricales. In such instances, the result may be a toe that adducts on one metatarsal and
abducts on the adjacent metatarsal and thereby causes divergent toes.
Radiographically, the dorsoplantar view can show the base of the proximal phalanx adducted on the metatarsal head while the metatarsal
is abducted. The joint is deviated, and uneven narrowing of the joint space may be present. The digit may be dorsally contracted and the
metatarsal plantarly displaced as well. With long-term deformity, articular adaptation with joint contractures is often evident. A full
discussion of this problem is found in Part 5 of this chapter .
Dislocated Metatarsophalangeal Joint

Dorsal dislocation of the metatarsophalangeal joint primarily in the sagittal plane can occur as a result of trauma, but these conditions are
more commonly related to long-term inflammation of the joint. The inflammation may be associated with systemic processes such as
rheumatoid arthritis, although this is most often a direct result of chronic metatarsalgia of biomechanical origin.
Clinical Presentation
The patient with dislocation of one or more lesser metatarsophalangeal joints usually presents with hallux valgus, moderately severe
hammer toe or claw toe deformity, plantar protrusion of the involved metatarsal head, painful plantar callus beneath the metatarsal head,
and chronic metatarsalgia of the involved forefoot structures. The soft tissue has gradually adapted to the deformed position with possible
cartilage adaptation dorsally. The soft tissue contracture restricts relocation of the proximal phalanx into a more anatomically correct
position. The attached toe is able to contract, but it is not able actively to purchase the weight-bearing surface. The push-up test results
in some flexion of the interphalangeal joints, but with little or no improvement in alignment of the metatarsophalangeal joint. This type of
dislocation is invariably associated with a contracted toe and a dorsal corn over the proximal phalangeal head. Such dislocation sometimes
occurs in the absence of hallux valgus, and in such instances it may be associated with structurally long metatarsals and chronic
metatarsalgia or with rheumatoid arthritis. This type of dislocation usually requires surgical intervention.
Radiographic findings include superimposition of the base of the proximal phalanx on the head of the metatarsal and flexion deformity of
the proximal and distal interphalangeal joints. Osseous adaptation often occurs at the metatarsal head and the base of the phalanx.
Surgical Treatment
Surgical correction is directed at relocation of the joint and stabilization of the digit to provide a reasonable return of function
(64 ,65 ,68 ,69 ). When the joint shows substantial degeneration, once the deforming forces have been neutralized, implant arthroplasty
with a double-stem silicone hinge implant or base resection of the proximal phalanx with tendon rebalancing may be used. The flexor
capsule may need to be released with a metatarsal elevator. Arthrodesis of the
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proximal interphalangeal joint or flexor transfer is performed to allow the long and short flexors to take over the role of stabilizing and
flexing the metatarsophalangeal joint. Intramedullary wire fixation in slightly overcorrected position is suggested for 3 to 6 weeks, except
when implants are used.
FIG. 46. When degenerative change and adaptation of metatarsal head are present, it may be necessary to resect the articular end
and the plantar condyles of the metatarsal head to form a more appropriate functional shape.
The surgical approach is similar to the stepwise approach to digital surgery, with the preoperative expectation that most of the steps are
required to correct the deformity. When severe osseous adaptation or joint degeneration has occurred (Fig. 46 ), or when relocation of the
toe puts sufficient tension on the local vessels to risk vascular compromise to the toe, a joint-destructive procedure can be used (Fig. 47 ).
Provided the joint contours are suitable, a primary repair is recommended (70 ), beginning with digital arthrodesis. Flexor tendon transfer
to the proximal phalanx (30 ) or extensor digitorum longus to the corresponding metatarsal neck may be necessary in the more severe
deformities even if a joint-destructive procedure is not necessary.
A K-wire is then used to fix the realigned toe and metatarsophalangeal joint with the toe in slight overcorrection on the metatarsal head.
The lengthened extensor tendon is repaired under physiologic tension with the foot held at a right angle to the leg (64 ).
FIG. 47. Appropriate restructuring of the metatarsal head when degenerative joint change is present.
Aftercare
Postoperative care is especially important in this condition. The reduced position of the metatarsophalangeal joint must be maintained
long enough for the capsule to begin lamination to its corrected position. Conversely, the joint must not be immobilized long enough for
limitation of motion to develop. We have found it best to leave the K-wire in place across the metatarsophalangeal joint for about 3 weeks.
At that time, a radiograph is taken, and the wire is measured. The wire is withdrawn just enough to clear the metatarsophalangeal joint
and is left in place for an additional 3 weeks. Retaining the digital portion of the wire makes stabilization of the metatarsophalangeal
joints much easier for the additional 3 weeks than when the entire wire is removed. While the K-wires are in position across the
metatarsophalangeal joint, they are best protected by either a cast or a surgical shoe with the insole built up from the heel forward to the
sulcus.
Once the K-wires have been withdrawn across the metatarsophalangeal joint, the patient may begin range-of-motion exercises to mobilize
the flexor cap and joint capsule, to reduce joint limitation with subsequent jamming. Surgical bandaging is discontinued when the
remainder of the wire is removed. Some type of splint may be beneficial for an additional period.
Discussion
These reliable techniques for relocating the metatarsophalangeal joints proved successful in our experience for the past 20 years.
Occasionally, a joint is still painful after surgery, usually the result of limitation of joint motion, with resultant jamming of the joint, or
when a primary repair was attempted in a joint that should have undergone arthroplasty or implant arthroplasty. Our experience, for the
most part, has been that the reduction of this dislocation has held up well at long-term evaluation (2 years or more). Much of the long-
term stability can be attributed to the stabilizing arthrodesis performed in the digit as a part of the repair. This procedure also often
relieves metatarsalgia and reduces
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the plantar calluses, if it does not eliminate them completely because reverse buckling pressure from the contracted digit is eliminated,
without the need for primary metatarsal surgery (71 ).
Complications of Digital Surgery

Complications of digital surgery may fall into one or more major categories. Recurrence of deformity may develop for a variety of reasons.
Failure to release all the deforming forces intraoperatively can result in residual deformity, recurrence, or a floating toe. The stepwise
approach is often used to assess digital contractures and should greatly assist in the reduction of the digital deformities present. The
Kelikian push-up test, or loading of the metatarsal, should allow more anatomic location of the digit, especially the proximal phalanx after
each step. Adequate postoperative control is necessary for completion of healing in the realigned position. Recurrence is the likely result if
this is not accomplished. With a K-wire across the metatarsophalangeal joint, a period of 3 to 6 weeks of control is usually adequate.
More extensive correction and postoperative care may be required if the cause of the deformity cannot be adequately controlled
postoperatively. Flexor stabilization can at times be adequately neutralized with functional orthotics. Extensor substitution and flexor
substitution may require tendon transfer or arthrodesis to neutralize the forces.
Lemm et al. indicated, in their study of arthroplastyarthrodesis techniques, that transverse plane deformities eventually tend to recur
(72 ). When the surgical procedure is arthroplasty, the transverse plane deformity tends to recur at the proximal interphalangeal joint.
When the surgical technique is arthrodesis, then the deformity generally occurs at the metatarsophalangeal joint level. This situation, as a
rule, is expected to occur unless additional surgical techniques are used to eliminate the transverse plane deformity at the
An abnormal digital length pattern, if not corrected, may cause difficulty with shoe gear and possibly recurrence of contracture. Shoe gear
requirements need to be taken into consideration, especially with women's stylish shoes. The fifth toe needs to maintain some degree of
flexibility. Therefore, because of potential shoe irritation, seldom, if ever, is arthrodesis of the fifth proximal interphalangeal joint
performed. Arthrodesis of the fourth toe may also require special considerations in patients who intend to wear stylish shoes. In this
circumstance, the toe must be sufficiently short so it is shielded in between the third and fifth toes.
Bone regeneration after digital arthroplasty can be an additional complication. Most often, the bone does not regenerate to any significant
extent, but exostosis formation or spurring can lead to bone prominences (73 ). On occasion, the head of the proximal phalanx may
completely regenerate over a period of years, but it usually occurs in a shortened form as the stump remodels itself. However, exostosis
may lead to prominent lesions and corns. Using power equipment generally reduces the amount of exostosis and bone regeneration.
One can expect some scarring around the incision site, but entrapment of the digital nerves appears to be infrequent. Occasionally, with
the scarring, impingement on nerves creates a burning sensation. Injections with cortisone or hyaluronidase may prove helpful. Surgical
reintervention may be necessary to excise the involved nerve.
Hypertrophic scarring, hyperpigmentation, or depigmentation can occur. On occasion, the formation may occur when the patient is a
keloid former. If the scar formation tends to be hypertrophic, cortisone or hyaluronidase injections or possible revisional surgery may be
required. Postoperative taping or splinting of the toe also tends to reduce swelling and scar formation.
Nonunions and delayed unions are generally not a problem in the toe. A fibrous union is rarely painful and most often is stable. In some
patients undergoing end-to-end arthrodesis, a true radiographic osseous union may not develop, even though the digit is rectus, stable, and
asymptomatic.
Flail toes usually result from excessive bone removal from the toe or failure of the scar tissue to form a stable interface in the previous
joint space. If the adjacent toe functions well as a rigid beam, syndactyly can create a good result. Bone grafting arthrodesis or implant
arthroplasty has the greatest chance of reestablishing digital function with significant shortening.
Floating toe syndrome is a condition in which one or more toes fail to purchase the weight-bearing surface during stance or ambulation
(66 ). The problem is one in which the long and short flexors and plantar fascia to the involved segment fail to load during weight bearing.
On weight bearing, the normal lesser ray places tension on the flexors and plantar fascia, thus stabilizing the proximal phalanx on the
metatarsal head. Failure of the ray to load results in failure to load that strand of plantar fascia and flexor cap (Fig. 48 ). This results in an
unstable and floating toe.
FIG. 48. Any metatarsal that is located above the weight-bearing plane of the other metatarsals contributes to instability of the
metatarsophalangeal joint and floating toe syndrome.
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Specific causes of floating toe include congenitally short metatarsals, shortened or excessively elevated metatarsals or toes postoperatively, contracted extensor tendons or dorsal capsular
structures, postoperative scarring about the metatarsophalangeal joint, and dislocation of the flexor plate. In a patient with brachymetatarsia, the metatarsal is congenitally short. Loss of
internal cubic content at the metatarsophalangeal joint may cause similar problems. Plantar condylectomy, osteoplasty, and head resection all remove a certain amount of bone mass from the
metatarsophalangeal joint. This loss of internal cubic content can be enough to diminish loading of the flexor cap and plantar fascial strand. The flexor structures are thus slack, and the
proximal phalanx fails to load on weight bearing. Because the flexors attach to the intermediate and distal phalanges, shortening of the toe can also lead to laxity of the flexors. The result is a
floating toe.
Severe chronic hammer toe and claw toe deformities encourage capsulodesis to the inferior aspect of the metatarsal neck. During weight bearing, the flexor plate thus loads the metatarsal
neck rather than the proximal phalanx. The toe loses the stabilizing tension, and the deformity progresses. With dislocation of the plantar structures to the medial or lateral side of the joint,
loading may occur but results in drawing the proximal phalanx in the direction of the dislocation. The toe loses its plantar stabilization and floats.
Treatment of floating toe is generally directed toward restoration of normal weight bearing of the ray and toward converting the long and short flexors into effective stabilizers and
plantarflexors of the metatarsophalangeal joint. This is accomplished by release of any dorsal contractures, stabilization arthrodesis of the proximal interphalangeal joint, performance of
lengthening or plantarflexory metatarsal osteotomies when the metatarsal is excessively elevated or short, and occasional tendon balancing techniques. Accompanying disorders such as transfer
lesions beneath adjacent metatarsals may resolve when weight bearing and function are restored to the involved ray.
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PART 2 Surgical Repair of Fifth Digit Deformities

Thomas F. Smith
Keith D. Pfeifer
The opinions and assertions of the authors are not to be construed as reflecting official policy of the Department of Defense or the Army
Medical Department.
The fifth digit can be a source of significant patient complaints whether as a result of deformities, hyperkeratoses, or other entities.
Treating conditions of this digit can be a challenge. The toe box of the shoe or the adjacent lesser digits may compress the fifth toe, with
resulting pressures that produce discomfort. These pressures can originate from ill-fitting shoes, forefoot or rearfoot malalignments, or
deformity within the fifth digit itself. Reducing fifth toe contracture also alleviates the retrograde buckling forces at the fifth
metatarsophalangeal joint, to relieve or improve plantar lesions. Clinical assessment of the fifth toe deformity, combined with an
appreciation for the patient complaints, enables the surgeon to formulate the most optimal treatment plan. In some patients, the fifth
digit itself may need treatment as the primary complaint, whereas in others, the fifth toe may be a component of a major forefoot
reconstruction that addresses a complex foot deformity overall. The purpose of this chapter is to review the special considerations unique
to the fifth toe, especially the role of surgery.
ANATOMY
The fifth digit consists of three phalanges: proximal, middle, and distal. The middle and distal phalanges are often fused and function as a
coalition (Fig. 49 ). With loss of flexibility created by this synostosis, it is often more difficult for the digit to accommodate irritation from
shoes or other sources, and therefore this condition predisposes the fifth toe to the development of painful pressure keratoses or nail
dystrophy (1 ).
The anatomy of the fifth metatarsophalangeal joint is analogous to that of the other lesser metatarsophalangeal joints, although the
specific intrinsic muscles and tendons at this level differ. No short extensor tendon segment inserts into the long extensor as in the first
through fourth toes. An anomaly sometimes present is a slip of tendon extending distally from the peroneus brevis or tertius on the dorsal
lateral aspect of the fifth metatarsophalangeal joint (2 ).
After the fourth lumbricales muscle originates from the medial and lateral aspects of the long flexor tendons to the fourth and fifth toes
respectively, its tendon courses plantar to the deep transverse intermetatarsal ligament and inserts into the medial fibers of the extensor
wing of the fifth metatarsophalangeal joint. Its function is to aid in extension and adduction of the fifth proximal phalanx through the
extensor sling apparatus. Although the fifth toe has no dorsal interosseous muscle, the third plantar interosseous muscle originates from
the medial surface of the fifth metatarsal, and it courses superficial to the deep transverse intermetatarsal ligament to insert into the
medial aspect of the base of the proximal phalanx.
The flexor digiti quinti brevis is a unipennate muscle that arises from the plantar surface of the base of the fifth metatarsal and inserts
into the plantar lateral surface of the proximal phalanx. The purpose of the third plantar interosseous and the flexor digit quinti brevis
muscles is to stabilize the fifth metatarsophalangeal joint before the contracture of the long flexor tendon. The abductor digiti minimi is a
long
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fusiform muscle originating from the calcaneal tuberosity and inserting into the plantar plate and plantar lateral aspect of the proximal
phalanx of the fifth toe. This muscle abducts the fifth toe at the level of the metatarsophalangeal joint (Fig. 50 ).
FIG. 49. Radiograph of a fifth toe with a synostosis of the middle and distal phalanges.
FIG. 50. Anatomy of the fifth toe. A: Lateral perspective of the fifth ray: 1, long extensor to the fifth toe; 2, supplementary slip of
the peroneus brevis; 3, abductor digiti quinti; 4, flexor digitorum longus. B: Dorsal perspective of the fifth ray: 1, long extensor to
the fifth toe; 2, supplementary slip of the peroneus brevis; 3, abductor digiti quinti; 4, third plantar interossei; 5, fourth lumbrical
(at pickup).
SURGICAL PRINCIPLES
Planes of Deformity
The classic complaints associated with a painful fifth toe are a pressure keratosis, or “hard corn,” laterally or an interdigital pressure
keratosis, or “soft corn,” medially. Other hyperkeratoses or pressure-type complaints are also possible such as skin irritation, blister
formation, or irritation of deeper soft tissues or bone. The location and number of lesions may vary and may be related to the plane of
deformity in the toe or other specific anatomic features.
Deformities of the fifth toe may involve one or all three body planes. The sagittal plane deformities are hammer toe, claw toe, and mallet
toe. Hammer toe deformity of the fifth digit presents with extension at the metatarsophalangeal joint and flexion contracture at the
proximal interphalangeal joint. Claw toe deformity consists of flexion deformity at the proximal interphalangeal and distal interphalangeal
joints with extension deformity at the metatarsophalangeal joint. Generally, all the lesser digits can be involved with this clinical
presentation. Mallet toe deformity with flexion contracture of only the distal interphalangeal joint is not typically seen in the fifth digit.
The frontal plane component of fifth toe deformities is almost always varus rotation with the toenail directed laterally (Fig. 51 ). As this
deformity develops, the weight-bearing tuft of the fifth toe becomes medially displaced, and primary weight-bearing pressure is exerted
on the lateral aspect of the toe. As a consequence, keratoses may develop over the lateral aspect of the distal phalanx or distal
interphalangeal joint. Frontal plane varus rotation of the fifth toe may also result in underlapping of the fifth toe beneath the fourth toe.
The transverse plane deformity of the fifth toe involves either adduction or abduction of the digit (Fig. 52 ). Adductory deformity is an
exaggeration of the frontal plane varus rotation. At times, radiographs may demonstrate a wedge-shaped middle phalanx with a shortened
medial margin as opposed to a more symmetric shape. The transverse plane deformity can be so severe that the fifth toe significantly
underlaps the fourth toe and causes complaints of pain associated with the fourth digit. Abductory deformity of the fifth toe can be seen
after injury or surgery. In this situation, the medial collateral ligaments of the metatarsophalangeal or proximal interphalangeal joints may
be weakened and compromised. Without adequate medial joint stability, the fifth toe can deviate laterally. Abduction deformity of the
fifth toe may make patients more prone to injury when they pull on socks or walk barefoot and may create pressure discomfort when
patients wear closed shoes.
Flexibility
The joints of the fifth ray may be manipulated to determine the ease of reducibility of any deformity that is present. Correlation with the
weight-bearing stance evaluation is also helpful. The actual range of motion available in the joints of the fifth digit can be important for
development of pain or lesions. Some patients with painful keratoses on the digit may have little actual deformity, yet little motion. A
pressure keratosis can be the result primarily of a lack of flexibility within the toe that limits the ability of the digit to conform to shoes. In
patients with contracture of the toe, long-standing deformities may tend to become more fixed with time. In
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addition, the fifth toe is often subject to fracture and injury, with the occasional development of posttraumatic arthrosis and ankylosis.
FIG. 51. Frontal plane varus deformity of the fifth toe. A: Diagrammatic representation. B: Radiographic presentation. C: Clinical
presentation.
Rigid extension at the metatarsophalangeal joint results in dorsal joint contracture requiring surgical release, whereas a more flexible
extension contracture may be a response to rigid flexion deformity at the proximal interphalangeal joint that may reduce with more distal
digital correction. Rigid flexion contracture at the proximal interphalangeal joint suggests the need for bone resection of the proximal
phalanx to release tension on the flexor tendon. Flexible flexion contracture of the proximal interphalangeal joint may represent muscular
imbalance and may require more stabilizing types of surgical repairs, as opposed to soft tissue release. Spasticity of the flexor muscles,
such as after a cerebral vascular accident, may present as a rigid plantarflexory contracture of the lesser digits, including the fifth toe,
during weight bearing that becomes a supple flexion deformity in the non-weight-bearing configuration.
Lesion Pattern and Types

Different lesion patterns that may develop on the fifth toe. The location of these lesions affects the selection of the surgical procedure for
correction. For example, a common location for pressure keratoses is the lateral or dorsolateral region of the proximal interphalangeal
joint, typically associated with a flexion deformity at this level (Fig. 53A ). A significant degree of metatarsophalangeal joint dorsiflexion
may be noted as well. In some patients, a painful bursa may develop beneath the keratosis as a result of the discrete pressure at the
margins of the proximal interphalangeal joint. In the absence of sagittal plane flexion contracture, there is often an exostosis or a reduced
flexibility of the toe. Even a normal fifth toe may develop symptoms or lesions as a result of poorly fitting shoes.
The lateral or dorsolateral keratosis may extend over the middle phalanx (Fig. 53B ). A combination of sagittal plane digital contracture
and frontal plane varus rotation can result
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in a broader area for irritation of the fifth toe. A lesser degree of extension contracture is generally noted at the metatarsophalangeal
joint with this type of enlarged lesion pattern.
FIG. 52. Transverse plane deformity of the fifth toe. A: Diagrammatic representation. B: Radiographic representation. C: Clinical
presentation, dorsal view with underlapping of the fifth toe. D: Clinical presentation, plantar view with underlapping of the fifth toe
and “pinch” or peripheral callus and medial displacement of the fat pad.
Various morphologic types of fifth toe keratosis can be identified. For example, it may be discrete and deep-seated, in which case more
acute tenderness is typically evident. A more diffuse keratosis tends to be less symptomatic but covers a larger area. Some patients may
have only a thickening of the skin with lichenification, yet without distinct callus formation (Fig. 53C ). The area about the lesion may be
tender because of skin pressure and callus formation alone, or the deeper tissues may contribute to the pain complex. Pressure on the
underlying digital nerve can cause neuralgictype pain, whereas neuropraxia is possible, resulting in
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numbness and paresthesia distal to the lesion (3 ). In addition, an adventious bursa can form beneath the keratoses accompanied by local
swelling, soft tissue thickening, and erythema. Joint pain is a deeper, aching type of discomfort that may persist, even after débridement
and accommodative padding of the dermal keratosis.
FIG. 53. Morphologic types of pressure keratoses found on the fifth toe. A: Discrete lesion over the dorsolateral aspect of the
proximal interphalangeal joint. B: Enlarged and diffuse dorsolateral lesion over the proximal interphalangeal joint, sometimes
extending over the middle phalanx. C: Knuckle pad thickening of the skin with lichenification, but without keratosis.
Interdigital pressure keratoses can develop in the webs or on the sides of the digits when direct apposition of the usually enlarged osseous
joint margins exists. This type of problem is frequently seen between the fourth and fifth toes or in the deep web space, or it may be
evident more distally along side the interphalangeal joints (Fig. 54 ). The proximal interdigital lesions are the result of apposition of the
lateral aspect of fourth toe against the medial aspect of the proximal interphalangeal joint of the fifth toe. The more distal interdigital
lesions may occur from apposition of the lateral aspect of the proximal interphalangeal joint of the fourth toe against the medial aspect of
the distal interphalangeal joint of the fifth toe.
Sagittal plane hammer toe or frontal plane varus rotation of the fifth digit may lead to altered pressure patterns that create interdigital
keratoses. Osseous prominences or exostoses with or without additional digital deformity may also be a source of lesions. Interdigital
lesions are more common in women than in men (4 ). Foreshortening of a phalanx or a metatarsal after fracture or surgical osteotomy can
change the alignment of the digital joints so abnormal pressure occurs in an area that would otherwise be unopposed. However, in some
instances, it may be difficult to determine why a particular interdigital lesion has developed.
Isolated lesions over the lateral aspect of the distal interphalangeal joint of the fifth toe may also be encountered (Fig. 55A ). These
lesions are often tender because of their proximity to the toenail. Hyperkeratosis at this level may result from exostoses about the joint,
laterally or medially, or frontal plane rotation of the fifth toe. In the latter circumstance, the rotation of the digit places an otherwise
normal osseous structure into a direct weight-bearing position.
Combinations of lesions are also observed about the fifth toe. If multiple lesions are present, yet with minimal digital deformity, a primary
dermatologic predilection may coexist that promotes callus formation even in the presence of minimal pathologic pressure. Interdigital
lesions can at times be confused with tinea or psoriasis. An abscess may be an unfortunate complication of any interdigital lesion. If the
interdigital tissue is macerated, then the skin will be even more compromised and will be susceptible to overt ulceration. If possible, it is
preferable in elective cases to resolve the interdigital maceration preoperatively (5 ).
Clinical Appearance
Extension contracture or flexor tendon weakness can prevent the fifth toe from adequately purchasing the weight-bearing surface and is a
frequent finding in patients with fifth toe deformities. At times, this may accentuate the irritation
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from shoes. Postoperatively, this problem may persist, but it is less likely if extensor contracture is alleviated at the time of surgery.
However, reestablishing digital purchase can be difficult during correction of fifth toe deformities.
FIG. 54. Interdigital keratoses of the fifth toe. A: Lesion deep in the fourth interdigital space associated with the medial aspect of
the proximal interphalangeal joint of the fifth toe. B: Lesion more distal in the fourth interdigital space associated with the medial
aspect of the distal interphalangeal joint of the fifth toe.
The presence of extensor contracture at the fifth metatarsophalangeal joint is an important clinical finding. Congenital digiti quinti varus
deformity is the most profound example of extensor contracture and involves all soft tissue levels: capsule, tendon, hood apparatus,
ligament, and skin. Surgical considerations related to congenital digiti quinti varus deformity are covered in Chapter 17 .
FIG. 55. Distal lateral lesions of the fifth toe over the distal interphalangeal joint. A: An isolated lesion resulting from an exostosis.
B: An isolated lesion resulting from an exostosis with an associated dystrophy of the nail.
Severe extensor contracture of the metatarsophalangeal joint can result in painful keratoses involving the fifth toe as well as plantar to
the fifth metatarsal head because of the retrograde pressures from the hammer toe contracture. The extensor tendon, extensor hood
apparatus, joint capsule, flexor capsular adhesions, and even the dorsal skin may be involved in the metatarsophalangeal joint contracture
of the fifth hammer toe deformity.
Thickening and dystrophy of the toenail are also possible because of shoe irritation and pressure. The toenail of the fifth digit can be as
symptomatic, if not more so, when pressure keratosis is caused by pressure on the nail bed from shoes (Fig. 55B ). Permanent partial or
total avulsion of the nail may not be an unreasonable adjunctive procedure necessary to alleviate the overall pain complex.
The position of the nail indicates the alignment of the distal phalanx and can therefore be used as an aid to assess frontal plane deformity
of the fifth toe. The nail is seen to rotate more laterally in frontal plane varus rotation deformity of the fifth toe. This lateral rotation
places the edge of the nail and nail matrix against the inside of the shoes, the pressure of which can result in thickening and dystrophy and
ultimately in pain.
SURGICAL PROCEDURES
Metatarsophalangeal Joint Release

As with hammer toe deformity of the central digits, significant extensor contracture of the metatarsophalangeal joint may be seen in
association with hammer toe deformities of the fifth toe and needs to be addressed to achieve a successful
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surgical result. Arthroplasty of the proximal interphalangeal joint can usually release the flexion contracture of the hammer toe deformity.
However, the procedure provides little reduction of extensor contracture at the metatarsophalangeal joint. Reducing the deformity often
requires release of the extensor hood, lengthening of the tendon, and when necessary, capsulotomy of the metatarsophalangeal joint, as
described for correction of deformities in the central digits (6 ).
If dorsal contracture is present at the metatarsophalangeal joint after the resection of the proximal phalangeal head, a poor choice is to
remove more bone to eliminate the remaining “prominence.” This may result in significant shortening of the phalanx with digital instability
and does not address the cause of the remaining deformity (Fig. 56 ). When the proximal phalangeal stump remains in a dorsiflexed
attitude after resection of the head of the proximal phalanx, attention should be proximal to the metatarsophalangeal joint to address
tendon and skin contracture.
Significant extensor contracture can involve more than the fifth toe alone. Multiple digital deformities may require simultaneous surgical
correction. If the fifth digit hammer toe contracture is the more prominent deformity, an isolated symptomatic lesion may appear on the
fifth toe even in the presence of other nonsymptomatic lesser digit deformities. In some instances, if the fifth digit deformity is corrected
individually, the protective effect of the fifth toe that is provided to another lesser toe deformity is lost. The adjacent lesser toe deformity
is then unmasked, and exposure may allow it to become symptomatic. In addition, release of the extensor contracture at the fifth toe
level can increase the loading power to the intact extensor tendon slip to the fourth toe and can exaggerate a hammer toe deformity in
this digit.
FIG. 56. A: Clinical appearance of a patient with a fifth toe heloma, hammer toe contracture, and dorsal metatarsophalangeal joint
contracture. B: Failure to address the dorsal contracture at the metatarsophalangeal joint may result in the resection of too much
bone from the proximal phalanx, as demonstrated in this radiograph.
Arthroplasty
Arthroplasty of the fifth toe involves resection of the head of the proximal phalanx. This is a common and usually effective procedure for
lesions of the proximal interphalangeal joint. The procedure assists in relieving flexion contracture of the proximal interphalangeal joint,
yet it provides minimal extensor release at the metatarsophalangeal joint. Extension contracture at the metatarsophalangeal joint may
necessitate release with or without pinning as an adjunct to the hammer toe repair. However, many patients present with isolated dorsal
or dorsolateral lesions overlying the proximal interphalangeal joint, yet without sagittal plane deformity.
Arthroplasty of the proximal interphalangeal joint can also result in some improvement in the frontal plane rotation of the fifth toe. The
relaxation of the long flexor tendon should alleviate some measure of contracture. Alternatively, other steps may be taken in more
resistant cases or as a means of enhancing correction. The incorporation of a derotational skin plasty is an effective adjunctive approach
that may be employed to obtain both sagittal and frontal plane correction of fifth toe adductovarus deformities. Such skin wedges may also
be used in conjunction with the arthroplasty to excise deep-seated lesions and to promote earlier resolution of the pressure keratosis. The
use of a temporary Kirschner wire across the proximal interphalangeal joint space may also be helpful in encouraging the toe to heal in a
rectus alignment.
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Correction is usually well maintained if the pin is left in place for 3 to 4 weeks.
FIG. 57. Incisional approaches for arthroplasty of the fifth toe. A: Dorsal linear incision. B: Two semielliptic incisions for excision of
the skin lesion.
The basic surgical approach for arthroplasty of the proximal interphalangeal joint of the fifth toe is the same as that used for the other
lesser digits. Most commonly, a dorsolinear incision is employed beginning over the midshaft or proximal portion of the proximal phalanx
and extending distally to the middle phalanx. Two semielliptic incisions oriented from proximal lateral to distal medial may be used
alternatively to derotate the toe (Fig. 57 ). Any lesion present may be included in the skin wedge for excision. Alternatively, the oblique
incision, without excision of a skin wedge may be suitable for exposure.
The dissection is carried through the superficial fascia to the level of the long extensor tendon, which is transected just proximal to the
middle phalanx leaving a distal tab of extensor tendon for subsequent suture repair. The extensor tendon may also be transected in Z-
plasty fashion if lengthening of the tendon is anticipated.
The proximal interphalangeal joint capsule and collateral ligaments are then incised and are reflected to maintain tissue for medial and
lateral repair after the bone resection, to aid in the postoperative stability of the toe. At this point, the head of the proximal phalanx is
resected, and the amount of bone removed depends on the degree of flexion contracture at the proximal interphalangeal joint. After the
proximal phalangeal stump is contoured, the long extensor tendon is repaired. The medial and lateral collateral ligaments of the proximal
interphalangeal joint may be reapproximated and repaired to enhance overall stability and to minimize the possibility of a flail toe. Skin is
repaired with suture of choice (Fig. 58 ).
A sterile dressing is best applied with the fifth digit held in a corrected position including derotation. After suture removal, digital splinting
is helpful for an additional period to support the ligaments and other soft tissues during healing and scar remodeling. This approach
enhances the stability of the digit and helps to maintain its corrected position.
Arthroplasty with Hemiphalangectomy

A painful keratosis can occur on the fifth digit covering the proximal interphalangeal area as well as extending distally onto the middle or
distal phalanges. When discrete keratoses occur over both the proximal and distal joint areas simultaneously, resection of the head of the
proximal phalanx alone may not adequately relieve the formation of distal keratoses postoperatively. To prevent this, the overall osseous
structure of the fifth toe, including all phalanges, may need to be surgically shortened or narrowed to correct the deformity adequately
(Fig. 59 ).
Painful keratoses that develop between the fourth and fifth toes may be seen in conjunction with either the proximal or distal
interphalangeal areas. Resection of the head of the proximal phalanx of the fifth toe can resolve painful interdigital keratoses by
alleviation of direct pressure to the symptomatic area. In affected patients, a proximal interphalangeal joint arthroplasty may also resolve
more distal lesions of the fifth toe because the shortening associated with the procedure secondarily alters distal lesion pressure patterns.
However, in some instances, this is inadequate to prevent recurrence of the lesion. After proximal interphalangeal arthroplasty, the
middle and distal phalanges may recede proximally and may fill the void created by removal of the head of the proximal phalanx.
Increased interdigital pressures may then develop against the middle phalanx that allow the interdigital lesion to recur (7 ). Thus, a middle
phalanx that is surgically narrowed is less susceptible to this persistent, pressure-induced clavus.
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FIG. 58. Bone resection for the proximal interphalangeal joint arthroplasty. Preoperative (A) and postoperative (B) radiographs.
FIG. 59. Diagrammatic representation (A) and radiographic presentation (B) of a proximal interphalangeal joint arthroplasty with
hemiphalangectomy. Note the narrowed appearance of the middle and distal phalanges and the loss of the space at the proximal
interphalangeal level resulting from proximal migration of the middle phalanx.
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In patients with both proximal and distal helomas of the fifth toe, an adjunctive procedure to address the distal lesion may be helpful in
conjunction with the proximal interphalangeal arthroplasty. Therefore, in the presence of dorsolateral or lateral keratoses, proximal and
distal lesions, or interdigital clavi, a longitudinal hemiphalangectomy may be useful (8 ). Hemiphalangectomy of the middle and distal
bones narrows the bony column of the toe to a width more consistent with the resected proximal phalangeal stump. By narrowing the
entire bony column, any proximal migration of the middle and distal phalanges is less likely to result in recurrence of pressure-induced
lesions. Because no criteria to determine which patients would benefit from this approach as opposed to arthroplasty alone have been
defined, implementation is left to the surgeon's judgment after assessing the widths of the phalanges in question.
Accurate placement of the skin incision is critical to obtaining adequate exposure of all three phalanges to perform arthroplasty with
hemiphalangectomy. An S-shaped incision on the dorsolateral aspect of the fifth digit is commonly employed. Proximally, the incision is
centered over the extensor tendon and curves over the middle and distal phalanges so it is centered between the lateral nail fold and the
plantar digital tuft distally. A derotational skin plasty can be incorporated into the lazy-S incision if needed (Fig. 60 ).
Deep dissection through the subcutaneous tissue should be initiated proximally over the extensor tendon and carried down to the extensor
apparatus at the proximal interphalangeal joint level, then extended distally along this same tissue plane to expose the lateral aspect of
the middle and distal phalanges. This process creates dorsal and plantar skin flaps that include the skin and superficial fascia. The extensor
tendon is sectioned or reflected medially. Dissection must be extended distally to expose the lateral condyle at the base of the distal
phalanx. Resection of this condyle assists in narrowing the osseous column of the fifth toe to alleviate the periungual or distolateral
heloma.
FIG. 60. Incisional approaches for arthroplasty with hemiphalangectomy. A: Lazy-S approach. B: Lazy-S approach with inclusion of
two semielliptic incisions as a derotational skin plasty.
A standard arthroplasty of the proximal interphalangeal joint is performed, and the lateral aspects of the middle and distal phalanges are
then resected. All sharp margins of bone are rasped smooth, with careful attention to the exposed cortical margins (Fig. 61 ).
Wound closure begins with realignment or repair of the long extensor tendon and the collateral ligaments. Subcutaneous closure is optional,
and skin approximation should be performed to maintain reduction of the deformity. The postoperative care is essentially the same as that
for an arthroplasty of the proximal interphalangeal joint.
Condylectomy
A painful keratosis can occur on the fifth digit overlying the base of the distal phalanx in the lateral nail groove or, less commonly, in the
medial nail groove area. In many patients, this lesion appears as an additional segment of nail and may be confused with an ingrown nail
because of the location and degree of discomfort. The lesion, termed Lister's corn, is well localized and often deep seated. A palpable
bony prominence may be noted beneath the keratosis at the base of the distal phalanx. The fifth toe is often noted to be rotated into an
adductovarus or varus malalignment, and this may result in weight-bearing pressure against the nail groove (Fig. 62 ). If little frontal plane
deformity is noted in the presence of Lister's corn, then one may suspect an isolated exostosis at the base of the distal phalanx. The lesion
can appear as an isolated complaint or in combination with other
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fifth toe keratoses. In addition, the fifth digit nail may be thickened and dystrophic, thus aggravating the pain.
FIG. 61. Bone resection for the hemiphalangectomy. A: Resection of the lateral aspects of the middle and distal phalanges is most
often performed with hand instruments. B: Contouring with a rotary bur may enhance the result.
Radiographs generally do not usually demonstrate significant sagittal plane deformity because frontal plane rotation is more common. The
phalanges may appear flattened or narrow because of the oblique orientation when compared with the adjacent lesser digits.
Conservative treatment consists of débridement, padding, and shoe modifications. The surgical approach includes excision of the lesion
and resection of any underlying bony prominence of the distal phalanx. Frontal plane derotation may be considered as an adjunctive
measure based on the clinical presentation.
FIG. 62. Clinical presentation possibilities for the distal keratosis overlying the lateral aspect of the distal phalanx of the fifth toe. A:
Rectus alignment of the fifth toe consistent with exostosis of the distal phalanx. B: Varus frontal plane malposition of the fifth toe
with the lateral condyles of the distal interphalangeal joint in a weight-bearing position.
The surgical approach is made through two longitudinal semielliptic incisions, generally 1 to 1.5 cm in length, that encompass the painful
lesion (9 ). The more superior incision
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follows the lateral margin of the nail plate. The elliptic incision includes the skin and the subcutaneous tissue with the lesion and, when
necessary, the edge of the matrix at the base of the nail. Any exostoses including the lateral condyle of the base of the distal phalanx are
exposed. Hand instruments such as bone nippers or rongeurs can be used to resect the bony prominence, or a power bur may be employed
to reduce the prominence, and the remaining surface is rasped smooth (Fig. 63 ).
FIG. 63. Surgical technique for lateral condylectomy of the distal phalanx of the fifth toe. A: Two semielliptic incisional approach
with excision of skin lesion. B: Resection of the exostosis from the lateral aspect of the distal phalanx. C: Long-term follow-up of the
surgical scar. D: Preoperative radiograph. E: Postoperative radiograph.
The skin is closed with the sutures placed directly through the fifth digital nail plate and nail bed if necessary. No deep closure is necessary.
A similar technique can be applied in patients with a medial condylar prominence and painful keratosis.
Complications of Arthroplasty
Complications of the proximal interphalangeal joint arthroplasty with or without hemiphalangectomy include persistent edema and digital
induration. Anatomic dissection tends to minimize the risk of this problem, as does good patient compliance in reducing activity during the
postoperative period. Once the dressings are removed, additional splinting with elastic tape or other materials will help to maintain
compression on the area and reduce edema. Should swelling persist, then injections of corticosteroid, massage, and ultrasound modalities
may be instituted. Generally, swelling reduces with time, but in some cases residual edema persists indefinitely despite the best efforts of
surgeon and patient.
A loose or unstable toe may develop in some patients. Repair of the collateral ligaments after arthroplasty of the proximal interphalangeal
joint may help to prevent a residual flail digit. Splinting the toe once the surgical dressings are removed assists the healing of deeper
tissues and encourages greater stability. Alternatively, one may elect to use a Kirschner wire across the joint space for 4 to 6 weeks to
maintain stability.
Recurrence of the lesion may also be a problem. In some patients, the lesion may result from a primary dermatologic
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predilection, as opposed to pressure irritation. In this circumstance, arthroplasty does not tend to resolve the keratosis. Recurrent
contracture or incomplete extensor release may also result in mechanical irritation and may predispose the patient to a reestablished
keratosis. A new lesion may also be caused by regeneration of bone at the stump of the proximal phalanx. In one study, bone regeneration
was found to be common, yet it did not correlate highly with recurrence of the lesions (10 ). Radiographs may not fully represent the
presence of a cartilaginous, yet firm regrowth at the phalangeal stump. Ossification of this firm cartilaginous head may be slow to form.
Thus, scar or cartilaginous tissue may be palpable in some instances, but not evident radiographically.
In patients undergoing hemiphalangectomy or condylectomy, the most common long-term complication is recurrence of the lesion over the
base of the distal phalanx laterally. This may occur with inadequate resection of the base of the distal phalanx, or it may result from
continued or renewed adductovarus deformity of the toe.
Loss of digital purchase is the result of inadequate flexor power postoperatively because of the relative increase in length of the long
flexor tendon. An overzealous proximal phalangeal resection can result in such flexor instability. More commonly, this complication is
caused by the failure of the tissues to heal in a stable position.
Distal Phalangectomy
Painful keratoses can occur medially or laterally about the distal interphalangeal joint of the fifth digit. Exostoses or frontal plane varus
rotational deformities are primary sources of this type of problem. The nail can become thickened and dystrophic with shoe irritation
involving the distal aspect of the toe. As the nail thickens, compression of the nail bed can combine with the medial and lateral keratoses
to produce a painful condition. The differentiation of the nail dystrophy from other dermatologic conditions can be helpful, but it does not
often affect the surgical approach.
FIG. 64. Distal phalangectomy of the fifth toe. A: A two-incisional approach is used to excise the distal phalanx and nail bed. B:
Clinical appearance after wound closure.
When the nail and keratoses of the distal interphalangeal joint area or Lister's corns are symptomatic and unresponsive to conservative
care, then one may consider excision of the nail, nail bed, and all or part of the distal phalanx. With this surgical approach, all areas of
pressure and pain are removed. Condylectomy of the distal phalanx or distal interphalangeal joint in the presence of a painful and
dystrophic nail may not provide adequate symptomatic relief. Condylectomy of the head of the middle phalanx, either medial or lateral,
can be included if a prominence exists at this level as well. This surgical approach shortens and narrows the fifth toe, but it does little to
reduce the classic hammer toe sagittal plane deformity if it is present. Therefore, this procedure is intended for distal digital symptoms
without significant contracture or proximal toe deformity.
Two transverse incisions are made to permit excision of the nail, nail bed, and distal phalanx. The first incision begins at the medial and
lateral aspects of the toe and curves distally and dorsally just proximal to the posterior nail fold. The second incision is placed from the
medial and lateral margins of the original incision distally about the tip of the toe below the nail. The ellipse of skin with the nail plate,
nail bed, and distal phalanx is excised from the remaining soft tissues. The long extensor and flexor tendons are transected, the ligaments
and capsule are incised, and the joint is disarticulated. If the long extensor and flexor tendon functions are to be maintained, a distal
anchor suture can be used to secure them or only the distal portion of the distal phalanx can be resected, leaving the base to preserve
their insertion.
Any prominence of the medial or lateral condyles of the head of the middle phalanx can be resected and contoured at this point. The
articular cartilage on the head of the middle phalanx may be removed to encourage fibrosis of the distal fat pad to the middle phalanx to
provide greater stability of the distal soft tissues. The skin margins are then reapproximated by suturing the plantar skin flap up to the
dorsal incision line (Fig. 64 ).
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The result of the procedure is a shortened toe with absence of the nail. Complications are rare. When they do occur, they usually involve
problems with wound healing or recurrence of the lesions. Careful attention to any bony prominence on the medial or lateral aspects of
the middle phalanx helps to avoid painful pressure in this area postoperatively.
SOFT TISSUE PROCEDURES
Skin Plasty
The frontal plane rotation evident in the fifth toe occurs primarily at the proximal interphalangeal joint and middle phalanx area. The
degree of frontal plane malalignment can be appreciated by evaluating the relationship of the toenail with the floor in stance. The varus
rotation of the toe places the lateral condyles of the distal interphalangeal joint into a plantargrade weight-bearing attitude. The weight-
bearing tuft of the fifth toe is aligned medially such that the fifth toe underlaps the adjacent fourth toe, thus possibly creating symptoms
and or lesions on the more medial digit. The clinical significance of frontal plane varus rotation has long been recognized, but poorly
studied.
The frontal plane varus rotation of the toe is usually improved after arthroplasty of the proximal interphalangeal joint. However, in some
patients, this procedure alone may not be adequate to address this component of deformity. Reduction of varus rotation of the fifth toe
may be aided by skin plasty, although the literature has no precise guidelines to direct the surgeon in determining the degree of derotation
necessary to realign the digit. In patients with a wedge-shaped middle phalanx, excision of this bone may be considered with or without
resection of a skin wedge (Fig. 65 ). This approach directs the osseous correction at the apex of the deformity and, coupled with skin
plasty, can provide significant frontal plane derotation of the toe (11 ). However, the relaxation of tissues that is acquired with an
arthroplasty of the proximal interphalangeal joint may be adequate to avoid excision of the middle phalanx.
FIG. 65. Middle phalangectomy of the fifth toe. A: Preoperative radiograph. B: Postoperative radiograph.
Skin plasties may also be employed to excise deep-seated keratoses, which may represent a permanent scarring of the dermis. Excision of
deep-seated lesions can be a helpful as an adjunctive measure to promote faster resolution of symptoms.
The surgical approach for derotational skin wedge plasty includes two semielliptic incisions oriented obliquely across the toe. These two
incisions extend from distal medial to proximal lateral and typically cross the dorsal aspect of the toe to include the proximal
interphalangeal joint centrally. The skin wedge that is removed includes only the epidermal and dermal layers, with care taken not to
damage the neurovascular structures. The specific angular orientation of the incision must take into account not only the frontal plane
correction needs of the toe, but also the surgical exposure necessary for osseous or soft tissue correction (Fig. 66 ). The excision of a skin
wedge that is too large may result in a toe that can appear as though it has a stricture with an apparently
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widened distal pulp. This may also delay the resolution of postoperative edema. Deeper dissection is carried out more linearly through the
superficial fascia, again to accommodate and avoid the neurovascular structures. After osseous correction, closure of the skin wedge is
performed with the toe held in corrected position. Postoperatively, the lateral condyles of the distal interphalangeal joint should assume a
more rectus alignment.
FIG. 66. Angular orientation options for derotational skin plasty of the fifth toe. A: A more vertical orientation allows greater
abductory correction in the transverse plane. B: A more horizontal orientation allows greater valgus derotation in the frontal plane.
Maintaining the corrected alignment of the toe may be further augmented by the insertion of a Kirschner wire while the digit is held in the
corrected position. This approach allows postoperative fibrosis to develop and to hold the toe in a more favorable position. The wire
typically remains for 4 to 6 weeks. Implant arthroplasty of the proximal interphalangeal joint has been proposed for correction of varus
deformity of the fifth toe (12 ), but it does not appear to be a primary means of addressing this condition. It is important to dress the
realigned toe using a derotational wrapping technique.
A nonpurchasing fifth toe may be caused by either extensor contracture or flexor weakness and may result in lesions and irritation of the
toe from shoe pressure. The extensor release may require a Z-plasty or V-Y-plasty of the contracted skin to aid the realignment.
FIG. 67. Plantar skin wedge plasty to aid in plantarflexion of the fifth toe. A: Appearance after excision of plantar skin wedge from
digital sulcus. B: Closure with fifth toe held in a corrected position.
Establishing flexor power to a fifth toe is a difficult surgical challenge. The typical arthroplasty of the proximal interphalangeal joint is
intended to weaken or relax flexor contracture. Therefore, arthroplasty in a fifth toe that has weakened flexor power preoperatively can
fail to provide later flexor power and toe purchase. Flexor transfer to the proximal phalanx is possible, but it is rarely necessary to
stabilize the fifth toe to the weight-bearing surface. Arthrodesis of the fifth toe is rarely considered because of the tendency for the rigid
toe to become more susceptible to shoe irritation.
Plantar skin plasty may be an effective adjunctive procedure to aid plantarflexory alignment of the fifth toe. The sulcus skin at the base of
the fifth toe is excised as a wedge such that the toe is plantarflexed at the metatarsophalangeal joint (Fig. 67 ). The fifth toe is the only
digit in which plantar
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skin wedge plasty can be performed because of the proximity of the pulp of the fifth toe to the skin of the sulcus. One potential
complication of this approach is limitation of digital dorsiflexion.
Plantar skin wedge plasty is performed in a fashion similar to derotational skin wedge plasty. The skin at the plantar sulcus is excised
transversely across the base of the fifth toe. The wedge of skin includes only the epidermal and dermal layers. The procedure can be
included with other dorsal surgical approaches because the neurovascular structures are respected within the subcutaneous tissue layer
and are not violated. The procedure is best performed as the final step when multiple procedures are employed to address the fifth toe.
This allows the surgeon to perform a more accurate assessment of the amount of skin resection that is necessary to complete the
correction.
Syndactyly
Syndactyly of the fourth and fifth toes can provide stability for an otherwise unstable or flail fifth toe (13 ). Complications of surgery or
fracture of the fifth toe can result in instability of the metatarsophalangeal and interphalangeal joints. Suitable procedures to remedy this
problem by addressing the fifth toe itself may be insufficient. If the fourth toe is functional and possesses adequate stability and flexor
power, then syndactyly of the two digits can provide for better function and alignment of the fifth toe.
In rare circumstances after surgical procedures for a painful interdigital corn, the lesion may recur. In other situations, the interdigital skin
can become scarred and may remain sensitive even with resolution of the lesion. Although syndactyly is rarely employed as a primary
approach to interdigital keratoses, the procedure may be helpful in more difficult cases or in patients with recurrent lesions or symptoms.
The fourth and fifth toes are joined by two incisions that encompass the interdigital sulcus. The skin incision is initially inscribed on the
medial fifth toe with a surgical pen. The two toes are then compressed, and a shadow of the marker is left on the fourth toe. This
technique provides a matching mirror image so an equivalent size and shape of tissue will be removed from each toe. The skin is excised to
the level of the superficial fascia. The goal is to remove the full thickness of skin without any underlying subcutaneous tissue. The
syndactyly skin wedge can be carried further plantarly to include the sulcus skin of the fifth toe after excision of the interdigital skin. By
combining syndactyly with an additional excision of skin from the plantar sulcus of the fifth toe, further plantarflexory realignment can be
promoted (Fig. 68 ).
Closure of the surgical site is facilitated by placing all the sutures before approximating the wound margins and tying the knots. This allows
the surgeon to separate the two digits so the needle may be easily passed between the skin margins of each toe. If the sutures are secured
as the closure proceeds, then it will become difficult, if not impossible, to approximate all of the wound margins adequately.
FIG. 68. Clinical appearance after syndactyly of the fourth and fifth toes combined with plantar skin wedge plasty of the fifth toe. A:
Dorsal view. B: Plantar view.
Postoperative care consists of a sterile dressing that is maintained for 2 to 3 weeks. Splinting for an additional 2 to 4 weeks may be helpful
to reduce shearing at the syndactyly site and to prevent disruption. Weight bearing is allowed with a surgical shoe, and the patient is
returned to a closed shoe as tolerated after several weeks.
AMPUTATION
Amputation of the fifth toe is not an unreasonable approach to chronic or recurrent problems that have failed to be resolved by previous
operations. The procedure rarely results in any meaningful loss of function of the foot, although postoperatively the fourth toe may be
more easily irritated in tight shoes because of the loss of the lateral buttress provided by the fifth digit. Amputation of the fifth toe as a
primary procedure is rarely indicated, although this
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approach may be considered in compromised patients, especially if pressure keratoses have resulted in open wounds with deeper infection
or osteomyelitis.
REFERENCES
1. Thompson FM, Chang VK. The two-boned fifth toe: clinical implications. Foot Ankle 1995;16:34.
2. Sarrafian SK. Anatomy of the foot and ankle. Philadelphia: JB Lippincott, 1983:209.
3. Feller SR. Proper digital neuroma of the fifth toe. J Am Podiatr Med Assoc 1996;86:187.
4. Zeringue GN, Harkless LB. Evaluation and management of the web corn involving the fourth interdigital space. J Am Podiatr Med
Assoc 1986;76:210.
5. Bernbach MR. Heloma molle. In: Vickers NS et al., eds. Reconstructive surgery of the foot and leg: update '96. Tucker, GA:
Podiatry Institute, 1996:180-182.
6. Boberg JS. Surgical decision making in hammertoe surgery. In: Vickers NS et al., eds. Reconstructive surgery of the foot and leg:
update '97. Tucker, GA: Podiatry Institute, 1997:3-6.
7. Smith TF, Schleissinger RJ. The arthroplasty with hemi-middle and distal phalangectomy of the fifth toe: update on indications and
technique. In: Vickers NS et al., eds. Reconstructive surgery of the foot and leg: update '98. Tucker, GA: Podiatry Institute,
1998:117-123.
8. Korn SH. The lazy S approach for correction of painful underlapping fifth digit. J Am Podiatr Med Assoc 1980;70:30.
9. Alder DC, Fishco WD, Ruch JA. Surgical treatment of Lister's corn: a case illustration. J Am Podiatr Med Assoc 1998;88:30.
10. Bauman ML, Steiner I, Mandresh RS, et al. Bone regeneration in digital surgery. J Am Podiatr Med Assoc 1981;71:430.
11. Friend G. Correction of elongated and underlapping lesser toes by middle phalangectomy and skin plasty. J Foot Surg 1984;23:470.
12. Sgarlato TE, Tafuri SA. Digital implant arthroplasty. Clin Podiatr Med Surg 1996;13:255.
13. Marek L, Giacopelli J, Granoff D. Syndactylization for the treatment of fifth toe deformities. J Am Podiatr Med Assoc 1991;81:248.
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PART 3 Central Metatarsals

Louis A. Jimenez
William D. Fishco
Patients with lesser metatarsal symptoms are commonly seen in clinical practice. Often, the patient's complaint manifests as a painful
plantar hyperkeratosis. In other patients, the pain may be caused by various other problems because numerous structures are present in
this confined area, and this configuration may make a specific diagnosis difficult. Complaints may be derived from the
metatarsophalangeal joint or the surrounding tendons or they may be secondary to problems associated with the structure, alignment, or
stresses applied to the lesser metatarsals with weight bearing or metabolic or systemic disease states.
Historically, lesser metatarsal osteotomies have been employed in an attempt to alleviate forefoot complaints. Many different procedures
have been described, and success has at times been difficult to achieve. Nonetheless, these procedures are still an important part of the
overall management of forefoot symptoms.
ANATOMY
The lesser metatarsophalangeal joint and the periarticular structures are complex arrangements of bone, joint, tendon, and ligament that
are subjected to a significant amount of weight-bearing stress during normal gait (Fig. 69 ). An increase in the weight-bearing pressure
within the forefoot may provide the impetus for destabilization and ultimately for symptoms and deformity at this level. The joint itself
may be rendered more susceptible to inflammation and subsequent pain. One critical stabilizing structure is the plantar (flexor) plate of
the metatarsophalangeal joint. This begins proximally from the periosteum of the plantar metatarsal as a flimsy, almost synovial tissue.
The portion that lies beneath the metatarsal head is thick and broad. The plate inserts into the base of the proximal phalanx by a firm
attachment. The flexor tendon sheath attaches to the medial and lateral borders of the plantar surface, which is grooved for passage of
the flexors. The collateral ligaments of the metatarsophalangeal joint are securely attached to the plantar plate. A portion of the
lumbrical and plantar interossei tendons insert into this structure. Furthermore, the plantar plate also serves as a portion of the origin for
the adductor hallucis muscle. The functions of the plantar plate have been described as a shock-absorbing device and a central stabilizing
structure for the joint (1 ,2 ). In addition, the plantar plate has been described as the major insertion of the distal segments of the plantar
fascia, and it may be an integral part of the windlass mechanism (1 ).
The deep transverse intermetatarsal ligament is another important stabilizing structure that attaches to the capsule and flexor plate of
each metatarsophalangeal joint. The ligament tends to resist significant displacement of the metatarsal head after fracture or osteotomy
of the lesser metatarsals, particularly in the central three rays. The medial and lateral collateral ligaments lie intracapsularly and provide
important transverse plane stability to the joint.
Critical landmarks of the metatarsal include the site of attachment of the joint capsule, the tubercle noted dorsally and slightly proximal
to the capsule attachment, the plantar condyles, and the flare of the metatarsal neck. The distal metaphysis is located just proximal to
the articular cartilage and dorsal tubercle and posterior to the plantar condyles (Fig. 70 ).
FIG. 69. A,B: Anatomy of the lesser metatarsophalangeal joint.

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FIG. 70. The distal aspect of the lesser metatarsal with critical landmarks and features.
ETIOLOGY OF LESSER METATARSAL SYMPTOMS

Lesser metatarsal pain may be caused by various factors including biomechanical abnormalities, structural aberrations, primary
dermatologic conditions, inflammatory processes, and other systemic or metabolic problems.
Biomechanical Problems
The central three metatarsal rays possess relatively little motion compared with the first and fifth rays. Only sagittal plane mobility is
present about a common axis, which is oriented in the transverse plane. The motion is greatest in the fourth ray because of its articulation
with the cuboid. As a result, many of the pathologic features under the central metatarsal heads may be caused by hypermobility of the
medial or lateral column associated with abnormal pronation of the foot. This may be referred to as lesser metatarsal overload and is a
common source of pain and hyperkeratosis beneath the second metatarsal head, particularly in patients with hallux abducto valgus
deformity (3 ,4 ). Similarly, the fifth ray moves about an independent axis of motion, and hypermobility may often lead to symptoms
beneath the fourth metatarsal (Fig. 71 ).
A cavus foot with an associated forefoot equinus has an accentuated plantar declination of the metatarsals that may increase loading
pressures in the forefoot. Extensor substitution may also be present in patients with pes cavus, thus creating additional weight-bearing
stress within the forefoot in the stance phase of gait secondary to the retrograde forces exerted at the lesser metatarsophalangeal joint
level (Fig. 72 ).
Regardless of the foot type, plantarflexed metatarsals are commonly seen secondary to the buckling forces at the metatarsophalangeal
joint associated with hammer toe deformity.
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As the toe becomes more dorsally subluxed, the metatarsal head is diminishes loading beneath the lesser metatarsal heads.
forced plantarly to a greater degree. With time, the position is
reinforced by soft tissue contractures and eventually becomes
nonreducible. When hammer toes are addressed by appropriate
stabilization, a reduction of plantargrade forces on the metatarsal Transverse plane conditions such as metatarsus adductus may alter
head is appreciated (Fig. 73 ). Digital stabilization includes the normal weight-bearing pattern within the forefoot and may
appropriate metatarsophalangeal joint reduction with arthrodesis lead to lesser metatarsal pain. Ankle joint equinus may contribute
of the proximal interphalangeal joint. This technique converts the to a higher degree of forefoot loading, especially in more rigid foot
toe into a rigid lever on which the short and long flexors can types, in which the foot may not compensate for the tight heel
function effectively to stabilize the metatarsophalangeal joint (5 ). cord by excessive pronation. Patients with hallux limitus may tend
Malay and associates performed pedobarographic studies to shift weight into the lateral forefoot during propulsion, because
confirming the importance of digital stabilization for treatment of inadequate dorsiflexion is available at the first
metatarsalgia (6 ). metatarsophalangeal joint.
Structural Aberrations
Structural deformities that may lead to lesser metatarsal pain or
hyperkeratoses include a metatarsal that is excessively long or
short compared with the adjacent segments. A metatarsal may be
short because of an inherited problem or previous trauma or
surgery. Prominent or deformed metatarsal heads may also be
seen after Freiberg's infraction. A plantarly displaced metatarsal
or a metatarsal equinus may also exist in some circumstances.
Conversely, an elevated metatarsal may also be noted, most often
after a fracture or previous surgery.
Dermatopathologies
Historically, most physicians have presumed that plantar
hyperkeratoses are a direct result of excessive weight-bearing
pressure. However, some patients may present with primary
dermatosis that leads to the symptoms without aberration of the
associated metatarsal. This may be confirmed by the finding that
some patients may undergo lesser metatarsal surgery or excision of
a lesion, yet they experience recurrence at a subsequent time.
Various terms have been employed and different processes have
been described to indicate a primary skin disorder. Some of these
include punctate keratoderma, neurofibrous corn, cutaneous horn,
and porokeratosis. Older patients may tend to lose the integrity of
the fat padding in the ball of the foot, and this change renders
them more susceptible to complaints of pain in this area even
when hyperkeratosis is absent.
FIG. 71. A: When the first ray is hypermobile or unstable,

the second and third metatarsal bones are generally
subjected to increased weight-bearing stress. B: Arthropathies
Hypermobility of the fifth ray causes greater degrees of
weight-bearing stress to be applied to the fourth metatarsal. Inflammatory conditions may also manifest within the forefoot. In
these circumstances, patients usually have some degree of
swelling or induration in the tissues that may be appreciated when
compared with the opposite foot. Additional conservative
measures may be employed to address the inflammation itself in
addition to reducing the mechanical stress on the affected area. In
many instances, the inflammation may be directly related to
mechanical overload of the tissues, as opposed to a systemic
process. This may affect the joint itself or the flexor tendons.
Joint symptoms may also result from Freiberg's infraction, which is
generally managed through a different surgical approach.
Systemic or Metabolic Conditions

In addition, some patients may have metatarsalgia associated with
disorders of the neurologic and vascular systems. Certain
metabolic disorders have also been reported as presumptive
causes of metatarsalgia (7 , 8 , 9 , 10 , 11 , 12 ). However, as a
FIG. 72. In patients with a pes cavus or anterior equinus, general rule, forefoot symptoms resulting from these types of
additional loading is placed on the long extensor tendons, conditions are typically more diffuse, and suspicions are raised
with resulting dorsal digital and metatarsophalangeal based on the history and clinical evaluation of the patient.
contracture. This places a retrograde pressure on the lesser
metatarsal heads and increases weight-bearing pressure in
the plantar forefoot.
CLINICAL EXAMINATION
Lesser metatarsal pain is often derived from hyperkeratotic lesions.
Even when the callus itself is not symptomatic, the hyperkeratosis
may provide an indication of the areas of primary or excessive
weight-bearing load. Soft tissue swelling may indicate associated
bursitis, tendinitis, or joint inflammation.
Palpation of the patient's forefoot generally identifies the area of
maximal tenderness and assists the clinician in confirming
suspicions based on the patient's history. The clinical evaluation is
also helpful in determining the relative mobility of the medial and
lateral columns and whether or not any of the metatarsal
FIG. 73. Correction of a hammer toe deformity reduces segments may be deviated in the sagittal plane compared with the
buckling forces at the metatarsophalangeal joint and adjacent counterparts.
Radiographs may play an important role in the assessment of
patients with lesser metatarsal complaints. The dorsoplantar
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view provides a good overall depiction of the relationship of the individual metatarsal segments. In particular, the length pattern or
metatarsal parabola is clearly defined with this image. In some instances, the lesser metatarsals may be of appropriate length, but the
patient may possess a short first metatarsal that creates increased weight-bearing stress in the lesser rays. An excessively long metatarsal
bears more load than the neighboring metatarsals, whereas a metatarsal that is shorter than anticipated tends to cause more weight to be
carried by the adjacent segments.
FIG. 74. Dorsoplantar (A) and oblique (B) radiographs of a patient after previous dorsiflexory osteotomy of the third metatarsal.
Although the dorsoplantar radiograph is a good means of assessing overall length patterns and relationships, the oblique view clearly
demonstrates the sagittal plane elevation of the metatarsal head which is not readily apparent on the other view.
The lateral oblique projection is a good means of assessing the sagittal plane alignment of the lesser metatarsals (Fig. 74 ). Although the
sesamoid axial view has traditionally been used for this purpose, this technique may be less reliable because changes in the position of the
foot at the time of imaging may result in variable findings. The metatarsal alignment and the comparative relationships tend to be less
strongly affected when an oblique view is made. However, in some instances, the sesamoid axial view may still provide valuable
information.
The lateral view has a more limited role in the evaluation of the lesser metatarsals as a result of superimposition of these structures with
this image. However, one may still at times identify individual metatarsal segments on close evaluation. In addition, the lateral view may
be helpful in assessing the alignment or function of the first ray or medial column, which may be significant in lesser metatarsal disorders.
In some patients, the weight-bearing and non-weight-bearing position of a hyperkeratosis may not be totally consistent. At times, the
lesion may appear to lie between two metatarsals. Therefore, a lesion marker or wire may be placed around the lesion before radiographic
imaging, in an attempt to identify more clearly the specific metatarsal segment implicated in the formation of the lesion.
CONSERVATIVE TREATMENT OPTIONS

Many treatment options exist for metatarsalgia and painful plantar lesions. Periodic débridement generally alleviates symptoms related to
hyperkeratoses for brief intervals. When this approach is combined with mechanical or accommodative orthoses, the interval of relief is
usually extended. Generally, the approach to orthotics varies depending on the patient's foot type, age, and activity level. In the pronated
foot, treatment may be centered around fashioning a device that may make the foot less mobile and may more evenly distribute the
pressures across the forefoot. In the cavus foot, orthotic treatment is typically aimed at increasing shock absorption and relieving stresses
across the metatarsal heads. Adjusting shoes may also help to some extent. Oral antiinflammatory
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agents, physical therapy modalities, and injections may also be of benefit in patients with an inflammatory component of their symptoms.
Repair of hammer toe deformities may reduce weight-bearing forces in the forefoot.
HISTORICAL REVIEW OF LESSER METATARSAL SURGERY

The approach to lesser metatarsal surgery has changed significantly through the years. Some early authors believed that lesions underlying
the lesser metatarsal heads were the result of verruca and advocated resection of the ray and digit to remedy the problem (13 ). Resection
of the metatarsal head associated with a plantar lesion has also been described (13 , 14 , 15 ). Fortunately, most surgeons recognize that
far less radical approaches to address these problems exist, and the current role of amputation and metatarsal head resection appears to
be minimal.
Historically, patients with complaints recalcitrant to conservative measures underwent lesser metatarsal osteotomies. The nature and
location of the procedure were limited only by the imagination. However, one may broadly categorize these types of procedures based on
the anatomic location of the osteotomy itself.
Diaphyseal Osteotomies
Some of the earliest reported cases of lesser metatarsal surgery date back to 1916, when Meisenbach described a nonfixed, complete
osteotomy through the diaphysis of the metatarsal (16 ). Later surgeons described an oblique diaphyseal osteotomy oriented from dorsal
proximal to plantar distal (17 ). Complications included infection, stiffness of the metatarsophalangeal joint, and fibrous union.
Giannestras was convinced that the solution to plantar keratosis was to shorten the metatarsal (18 ) (Fig. 75 ). He originally performed a
“step-down” midshaft osteotomy with catgut suture for fixation. A 90% success rate was reported, with failures attributed to recurrence of
the keratosis. A few years later, the original procedure was modified and performed in the proximal metaphyseal portion of the metatarsal.
Basilar Osteotomy
Mau was the first to describe a proximal metaphyseal osteotomy for the treatment of plantar keratoses (19 ). His goal was to shorten and
elevate the metatarsal by resecting a dorsally based trapezoidal wedge with four-cortex cerclage wire fixation. Sgarlato also advocated a
dorsiflexory wedge osteotomy of the proximal metaphysis (20 ) (Fig. 76 ). Spence et al. reported on a 0.5-cm cylindric resection of bone in
the proximal metatarsal shaft (21 ). Fixation was not employed, and a nonunion rate of 76% was encountered.
FIG. 75. A,B: Step-down type of lesser metatarsal osteotomy.
Distal Metaphyseal Osteotomies

Distal metaphyseal osteotomies have proven to be the most popular site for lesser metatarsal surgery. Numerous configurations have been
proposed, both with and without fixation. Early surgeons employed the removal of a trapezoidal wedge (22 ) or a peg-in-hole approach
whereby the proximal shaft was inserted into a hole created in the metatarsal head (23 ).
By the late 1960s and early 1970s, various modifications of the distal metatarsal osteotomy had been described. Thomas and Wolf
described a partial osteotomy of the metatarsal neck (24 ,25 ). Plantar pressure was then applied to the metatarsal head to create a
greenstick fracture. A modification of the approach has been employed with the osteotomy performed at a more distal location, almost
over the metatarsal head (26 ). A procedure known as osteoclasis was developed that consisted of a complete osteotomy performed at the
distal metatarsal neck (27 ). Fixation was not employed
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because it was believed that with weight bearing, nature would
determine the amount of elevation needed to relieve the plantar
keratosis. The procedure was later modified to an oblique cut from
dorsal proximal to plantar distal (28 ). Other modifications were
described for floating transverse osteotomies, but without
significant variation (29 ).
FIG. 78. A,B: Dorsiflexory wedge osteotomy of the metatarsal
neck.
FIG. 76. Dorsiflexory wedge osteotomy of the metatarsal

base.
FIG. 79. Plantar condylectomy.
SURGICAL CONSIDERATIONS
When biomechanical causes for intractable plantar keratoses have
been ruled out and structural deformities are to be addressed with
a metatarsal osteotomy, certain principles play an important role
FIG. 77. A,B: V-osteotomy of the lesser metatarsal. in procedure selection. Because of a longer lever arm, the same
In 1973, Jacoby described the benefits of performing a V size wedge of bone removed from the proximal metatarsal yields
osteotomy of the metatarsal neck (30 ). He was discouraged with greater elevation than if the bone is removed from the distal
the osteoclasis procedure because of lateral displacement of the metatarsal (Fig. 80 ). The major disadvantage of the proximal
metatarsal head seen in some cases. The V osteotomy was osteotomy is that the longer lever arm has a smaller margin of
believed to be more stable (Fig. 77 ). The procedure was modified error. Therefore, there is greater risk of creating a metatarsus
by other surgeons, with the arms of the osteotomy performed in elevatus or disruption of the osteotomy with weight bearing.
the opposite direction (31 ). Lauf and Weintraub designed an
asymmetric V osteotomy of the distal metaphysis so the longer arm
of the osteotomy was amenable to screw fixation (32 ). SURGICAL APPROACH
Numerous authors have described an oblique osteotomy of the Dissection for distal procedures begins with a skin incision
metatarsal neck (33 , 34 , 35 , 36 ). The plantar cortex is generally overlying the metatarsal head and neck. The subcutaneous tissue
left intact (Fig. 78 ). Different forms of fixation may be employed is then gently separated from the underlying deep fascia by sharp
including Kirschner wires and small cortical screws. Because a and blunt dissection. The deep fascia, represented by the long
cortical hinge remains intact, this type of osteotomy is stable. extensor tendon and its hood fibers, is then incised either medial
or lateral to the tendon. The tendon is then retracted, and the
dorsal capsule and periosteum of the metatarsophalangeal joint
Plantar Condylectomy are visualized.
Other approaches have also been employed to address lesser A linear incision is made in the midline of the periosteum overlying
metatarsal problems, yet without osteotomy. DuVries described a the neck of the metatarsal. The periosteum is usually separated
resection of the plantar condyles of the metatarsal head for the from the metatarsal shaft with a Freer elevator. It is important to
treatment of plantar lesions (37 ) (Fig. 79 ). He later modified the create a well-defined collar of periosteum that can be gently
procedure to resect 2 to 3 mm of the articular cartilage in addition retracted. Once visualization of the metatarsal neck is adequate,
to the condyles (38 ). the osteotomy of choice can be performed.
For proximal osteotomies, an incision is placed over the proximal

metaphysis and the base of the corresponding metatarsal.
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Once the thin superficial fascia has been incised and retracted, the deep fascia, characterized by the long extensor tendon sheath, is
incised as well. Segments of the extensor digitorum brevis muscle belly need to be undermined and retracted to allow access to the
metatarsal base. It is important to locate the flare of the metatarsal base at the site of the articulation with the adjacent metatarsals.
This serves as a landmark for orientation. The periosteal incision is made in the midline of the metatarsal base, and this layer is reflected
and gently retracted to aid in visualization of the flare of the metatarsal at the metaphyseal level.
FIG. 80. A,B: Because of the longer lever arm, resection of the same size wedge from the base of the metatarsal results in a greater
amount of elevation than when the same size wedge is removed from the distal metatarsal.
SURGICAL PROCEDURES
Long or Plantarly Displaced Metatarsals

At times, a metatarsal protrudes beyond the parabola set by the remaining metatarsals. If associated pathologic processes cannot be
adequately neutralized with biomechanical control, then surgical shortening is considered. This type of approach may also be considered to
decompress a joint that is chronically inflamed. Controlled shortening should be performed with careful attention to avoid dorsal
displacement and rotation of the metatarsal head. Internal fixation is recommended to maintain the desired alignment. Once radiographic
evidence of bony union is noted, fixation can be removed if so desired.
Dorsiflexory Osteotomies
Distal Oblique Osteotomy

A power saw with a fine, narrow blade is used to make an incomplete osteotomy oriented from a dorsal distal to proximal plantar in the
distal metaphysis of the metatarsal. The plantar hinge is preserved. In many instances, it is unnecessary to remove a wedge of bone
because the loss of osseous substance created by the osteotomy itself is often sufficient to achieve the necessary amount of correction.
When additional correction is necessary, planing of the osteotomy is usually sufficient to allow adequate dorsiflexion of the metatarsal
head. The osteotomy is closed with manual pressure, and the position is evaluated. Fixation can be achieved with a Kirschner wire or a
small cortical screw, such as a 2.0- or 2.7-mm screw (Fig. 81 ).
Protected weight bearing with a surgical shoe or partial weight bearing with crutch assistance may be employed as is deemed appropriate.
A wedge postoperative surgical shoe, a removable walking cast, or a standard cast may also be used. Serial radiographs are taken to
monitor osseous healing. Unprotected weight bearing may usually commence at 6 to 8 weeks postoperatively.
Distal V Osteotomy
Once visualization of the metatarsal neck is adequate, a fine saw blade is used to create a V-shaped osteotomy in the distal metaphysis of
the metatarsal with the apex directed distally. The arms of the V are oriented approximately 60 degrees to the long axis of the metatarsal.
Once the osteotomy is completed, the toe is distracted, and the capital fragment is translocated dorsally to the desired level. Fixation may
be performed with a smooth Kirschner wire directed through the osteotomy from superior and proximal to inferior and distal. Ideally, the
Kirschner wire should not remain within the joint. Once the position and stability are evaluated, the Kirschner wire may be bent, turned
against the metatarsal and buried, or left percutaneously (Fig. 82 ).
Although nonfixed osteotomies have been believed to provide a less predictable outcome, one study demonstrated better results with
nonfixed V osteotomies (39 ). Because the design of the osteotomy is inherently stable, fixation is not mandatory, although non-weight
bearing is helpful in maintaining the position of the capital fragment.
Proximal Oblique Osteotomy

The osteotomy is performed in metaphyseal bone in an oblique direction from dorsal distal to proximal plantar. Care is taken to try to
preserve an intact plantar hinge. Once the osteotomy is reduced, a small screw may be used for fixation and is usually oriented from
proximal dorsal to distal plantar. Alternatively, one or two Kirschner wires may be employed. Double-wire transfixation maintains position
and resists axial and rotary stresses (Fig. 83 ).
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FIG. 81. A,B: Radiographic appearance before and after a dorsiflexory wedge osteotomy at the second metatarsal neck with
concomitant shortening.
Postoperatively, the patient is usually maintained non-weight bearing or is placed in a weight-bearing cast because the more proximal
location of the osteotomy provides a longer lever arm for potential disruption with ambulation. If the patient is to remain non-weight
bearing, casting may or may not be employed, depending on the patient and the surgeon's preference. Serial radiographs are made to
monitor healing. Unprotected weight bearing may usually be initiated at 6 weeks.
FIG. 82. Radiographic appearance of a V osteotomy 3 months postoperatively. The wings of the osteotomy are still visible. Fixation
was provided with a Kirschner wire, which was turned flush against the bone.
Shortening Osteotomies
Numerous different approaches may be employed to address a metatarsal that is too long. A standard V osteotomy may be performed with
the resection of an appropriately sized segment of bone to achieve shortening (Fig. 84 ). However, in some patients, the metatarsal neck is
thin, and achieving adequate apposition between the two surfaces may be difficult. Furthermore, achieving good stable fixation may be
difficult as well. Protected partial weight bearing may be allowed if internal fixation is adequate. Alternatively, one may elect to use a
period of non-weight bearing.
The Giannestras step-down osteotomy is well suited to this type of problem, especially when significant shortening is required. The
osteotomy is easily stabilized, and the degree of shortening can usually be well controlled (Fig. 85 ).
Another alternative is to perform an oblique osteotomy at the metatarsal neck oriented from dorsal distal to plantar proximal. Once the
osteotomy is completed, the capital portion of the metatarsal is slid proximally to achieve the desired amount of shortening. Different
forms of fixation may be employed for stabilization.
Provided internal fixation is used, protected weight bearing can be prescribed. Because the osteotomy is oblique to the metatarsal head
and fixation is oblique to the osteotomy, rotation of the capital fragment is uncommon. Protected weight bearing may include the use of a
well-padded postoperative shoe with a cutout corresponding to the osteotomy
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site, a wedge-heel postoperative shoe, a removable cast boot, or a cast with a walking heel. Strict cast immobilization is typically
employed if the osteotomy is not fixed. Serial radiographs are taken to monitor bony union. After 6 to 8 weeks, or when bony consolidation
is evident, internal fixation may be removed if it is causing symptoms, and unprotected weight bearing may begin.
FIG. 83. A,B: Preoperative radiographs of a patient with a plantarly displaced second metatarsal. C: Intraoperative appearance after
fixation of the proximal dorsiflexory wedge osteotomy with screw fixation. Notice the fracture of the dorsal cortex from the
compression of the screw.
FIG. 84. A,B: The V osteotomy can also be used to shorten the metatarsal by removing a wedge of bone from the osteotomy site.
Elevated or Short Metatarsals

In some instances, a metatarsal may be elevated, leading to lesions or pain in the adjacent segments. Most often, this type of problem is
seen after a fracture or previous osteotomy in a lesser metatarsal. Surgical correction may at times be most efficiently directed at the
shortened or elevated metatarsal, as opposed to primarily addressing the more normal adjacent structures. Therefore, plantarflexion or
lengthening of a metatarsal may be necessary.
Opening Wedge Osteotomy

Efficient plantarflexion of a lesser metatarsal may be achieved with an opening wedge osteotomy at the base of the metatarsal. The
standard dissection is performed to expose the proximal metaphysis of the metatarsal. An oblique osteotomy is created from dorsal and
distal to plantar and proximal, with care to maintain the plantar cortical hinge. A small bone graft is then inserted into the osteotomy to
achieve plantarflexion. A corticocancellous graft may be taken from the lateral aspect of the calcaneus, or a section of freeze-dried bone
may be employed (Fig. 86 ).
The final position of the metatarsal is evaluated. Adjustments to the metatarsal alignment may be made by either inserting the graft
further or partially withdrawing the graft. The graft may then be stabilized with a small staple or a cortical screw without overdrilling the
proximal cortex. In this latter circumstance, the screw maintains the position of the alignment without creating compression (Fig. 87 ).
Non-weight bearing is employed until adequate incorporation of the graft is noted.
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FIG. 85. A: Intraoperative appearance during a Z osteotomy of the second metatarsal. B: Once it is completed, an equivalent
segment of bone is removed from the proximal and distal arms to allow shortening. C: After shortening. D: Postoperative radiograph.
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FIG. 86. A,B: An elevated lesser metatarsal can be plantarflexed by inserting a wedge of bone graft in the base of the metatarsal.
Lengthening Osteotomy
Lengthening of a lesser metatarsal may be accomplished in numerous ways. The preferred method depends on the lengthening that is
required and on the degree of scarring or quality of the local tissues. Callus distraction may work well for patients who need a large
amount of lengthening or when significant scar or soft tissue contracture would limit the ability to perform distraction in an acute setting.
In other instances, a sagittal plane oblique or Z osteotomy, similar to the Giannestras step-down procedure, allows for lengthening of the
metatarsal to an appropriate level (Fig. 88 ).
Plantarflexion of a lesser extent may also be achieved with a long oblique osteotomy centered at the point of maximal deformity. This may
work well in patients with previous stress fractures with gradual or progressive elevation over a wide area. Once the osteotomy is
performed, then the distal fragment may be rotated plantarly. Two points of fixation are required, and a period of non-weight bearing is
recommended.
En Bloc Grafting
Large segments of bone graft were originally employed to assist in lengthening lesser metatarsals in patients with brachymetatarsia. In
general, this technique has been replaced by callus distraction. However, some patients may present with multiple components of
deformity that may include shortening, dorsiflexion, or angulation of the metatarsal, and in these patients, a trapezoidal bone graft may
help to reestablish a more normal alignment. In some instances, plate fixation can be employed to provide maximum stability should the
graft be of adequate size. Non-weight bearing is typically enforced postoperatively until osseous union has been achieved.
Plantar Condylectomy
DuVries popularized this procedure to alleviate intractable plantar keratoses. The traditional plantar condylectomy may still be useful,
especially in older, more sedentary patients who may have osteopenic bone. Additionally, neuropathic patients, with noninfected,
neurotrophic ulcers, may benefit from condylectomy, which can be approached from a plantar ulceration.
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FIG. 87. A: Preoperative radiograph demonstrating a shortened and elevated second metatarsal after previous surgery. B: Insertion of
the bone graft into the metatarsal base. C: Stabilization in this case was provided by a small staple. D,E: Radiographic appearance
immediately postoperatively. F: Radiographic appearance 3 months postoperatively.
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FIG. 87. Continued.
FIG. 88. A: Preoperative radiograph demonstrating a short second metatarsal after previous fracture. B: Intraoperative appearance
after a lengthening sagittal Z osteotomy. C: Radiographic appearance postoperatively.
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The skin incision begins at the distal metatarsal and extends onto the base of the proximal phalanx. The periosteal incision is extended
over the capsule of the metatarsophalangeal joint. The collateral ligaments are identified and are released. By plantarflexing the toe 90
degrees, the condyles of the metatarsal head can be visualized. A sesamoid clamp or towel clamp may be used to grasp and retract the
metatarsal head superiorly. An 11-mm metatarsal elevator may be used to reflect soft tissue plantarly. An osteotome or power saw can be
used to resect the condyles. A rasp is then used to smooth any bony prominences. A Kirschner wire can be used to stabilize the repair for
several weeks to allow more controlled healing if desired. This technique may also be used if concomitant digital surgery is performed. The
wound is closed in anatomic layers (Figs. 89 and 90 ).
FIG. 89. Plantar condylectomy. Surgical approach. A: A Z-plasty incision is made in the extensor tendon to facilitate retraction. B:
The tendon ends are retracted, and dissection is performed medial and lateral to the metatarsal head plantarly to the floor of the
interspace. C: An H-shaped capsulotomy may be performed to access the joint with a minimum of trauma. D: A McGlamry metatarsal
elevator may be used to help achieve access to the plantar condyles. E: The plantar condyles are removed in line with the weight-
bearing plane of the plantar forefoot. F: The remaining bone is smoothed with a rasp before closure.
Protected weight bearing in a standard postoperative shoe is allowed. As soon as the Kirschner wire is removed, range-of-motion exercises
are begun to prevent any lesser metatarsophalangeal joint limitus. To protect Kirschner wires that extend into the metatarsal head, a cork
or felt pad is placed in the postoperative shoe that extends to the sulcus. This prevents any bending and pressure at the pin-soft tissue
interface. Gradually, the patient can wear soft sneakers as tolerated. An accommodative insole may be beneficial as a permanent form of
shoe therapy after return to normal everyday shoe wear.
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FIG. 90. A-F: Alternative approach to plantar condylectomy with complete degloving of the metatarsal head.
The plantar condylectomy is not commonly performed. Unlike metaphyseal osteotomies, the condylectomy requires joint invasion, and
degenerative changes can result after the procedure. The biomechanical effects of the condylectomy are reduction of the internal cubic
content of the joint and resultant relaxation of the plantar plate. These changes may cause joint instability and ultimately a floating toe
syndrome (5 ,40 ). In addition, resection of too much bone may lead to an increased load on the neighboring metatarsals, with resultant
metatarsalgia and transfer lesions.
CRITICAL ANALYSIS OF LESSER METATARSAL OSTEOTOMIES

Most studies that have evaluated the efficacy of lesser metatarsal osteotomies report a large number of complications (39 ,41 , 42 , 43 ,
44 , 45 ). Hatcher et al. evaluated patients undergoing 238 central ray operations (41 ). The overall success rate was only 56.5%. Transfer
lesions were reported in 39% of patients. The best results appeared to have been achieved with distal osteotomies.
After a review of 114 feet undergoing the Helal osteotomy, iinvestigators concluded that patients were unlikely to achieve sustained
predictable relief of symptoms (42 ). Winson et al. evaluated 124 feet undergoing a distal sliding metatarsal osteotomy for central ray
metatarsalgia (43 ). The mean follow-up was more than 3 years. Fewer than half of the feet had results rated as good (47%), fair results
were reported in 34%, and 19% were rated as poor. Moreover, 14% of the feet underwent surgical revision. In a 10-year follow-up of the
oblique metatarsal osteotomy for intractable plantar keratoses, half of the patients continued to possess some degree of pain, and most
patients had limitations in footwear (44 ).
Dreeben et al. concluded that it was not possible accurately to predict the amount of elevation of the metatarsal head required to provide
relief of symptoms (45 ). Pontious and colleagues evaluated 29 patients who had undergone 40 V osteotomies, both with and without
fixation (39 ). Fixation of the osteotomy did not improve the results, except for time to consolidation, which was faster in patients with
fixation. Forty-two percent of the procedures resulted in transfer lesions or metatarsalgia, which had a higher incidence in the group of
patients whose feet underwent fixation. Ten percent of the patients sustained recurrent lesions, and a lack of digital purchase was noted
in 25%.
In a review of 49 patients with chronic ulceration from diabetic neuropathy, 55% were considered asymptomatic at follow-up evaluation
after undergoing 1 of 4 different types of distal lesser metatarsal osteotomy (46 ). In addition, 26.5% developed transfer ulceration, 12%
had a transfer callus, and 6% had recurrent ulceration at the original site. Two patients
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later underwent ray resection, and a third underwent transmetatarsal amputation. The complication rate was noted to be higher for patients undergoing osteotomy of the second or third
metatarsal.
On the contrary, an 86% success rate was reported by Leventen and Pearson, who used a transverse V-shaped trough across the junction of the metatarsal head and neck. However, these
authors also performed osteotomy on the adjacent lesser metatarsal to prevent transfer lesions or problems (26 ).
Recurrence of the original callus or lesion may be attributed to an inadequate amount of dorsiflexion, continued pathologic biomechanical influences, or primary dermatosis that is unrelated to
the mechanics or structure of the foot. At times, transfer lesions do not develop until several months postoperatively, a finding leading the surgeon to believe that the patient has had an
otherwise good result.
After dorsiflexion of the metatarsal, one may see the development of transfer lesions or pain at the adjacent metatarsals. A few patients may suffer stress fractures in the adjacent segments. A
dorsal bump may also develop over the metatarsal head that has undergone previous osteotomy. One may also note that the associated digit does not purchase the ground if the flexor
structures are not adequately loaded during stance. As a consequence, the patient may also begin to develop irritation across the top of the toe from shoes. Dislocation or subluxation of the
metatarsal head from the more proximal shaft was all but eliminated by the advent of fixation. However, the osteotomy may still become disrupted and may lead to loss of position, delayed
union, or nonunion. In many instances, this problem is not symptomatic, but it is more of a radiographic anomaly. Therefore, clinical evaluation of the foot and assessment of the patient's
symptoms are the primary determinants of whether this type of problem will need further treatment.
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38. DuVries HL. Surgery of the foot. St. Louis: CV Mosby, 1965.
39. Pontious J, Lane GD, Moritz JC, et al. Lesser metatarsal V-osteotomy for chronic intractable plantar keratosis: retrospective analysis of 40 procedures. J Am Podiatr Med Assoc
1998;88:323-331.
40. McGlamry ED. Floating toe syndrome. J Am Podiatry Assoc 1982;72: 561-568.
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44. Idusuyi OB, Kitaoka HB, Patzer GL. Oblique metatarsal osteotomy for intractable plantar keratosis: a 10-year follow-up. Foot
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study. Foot Ankle 1989;9:214-218.
46. Tillo TH, Giurini JM, Habershaw GM, et al. Review of metatarsal osteotomies for the treatment of neuropathic ulcerations. J Am
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SELECTED READINGS
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Addante JB, Kaufmann BA. The metatarsal osteotomy: a 10 year follow-up on the second, third, and fourth metatarsal osteotomies
and a new approach to the fifth metatarsal osteotomy. J Foot Surg 1977;16:92-96.
Bass SJ, Weinstock RE. The pivotal metatarsal osteotomy: a modification of the metatarsal metaphyseal osteotomy. J Foot Surg
1977;16:12-14.
Bellacosa RA, Pollak RA. Complications of lesser metatarsal surgery. Clin Podiatr Med Surg 1991;8:383-397.
Betts RP. The measurement of pressures under the foot. Foot Ankle 1982; 3:130-141.
Costa AJ. Delayed union in metatarsal osteotomies. J Foot Surg 1977;16: 127-131.
Davidson M. A simple method for correcting second, third and fourth plantar metatarsal head pathology, especially intractable
keratomas. J Foot Surg 1969;8:23-26.
Duckworth T. The measurement of pressures under the foot. Foot Ankle 1982;3:130-141.
Durant J. Metatarsal head resection without transference of lesion. J Foot Surg 1969;8:28.
Fenton CF, Butlin WE. Displaced V-osteotomies. J Am Podiatry Assoc 1982;72:150-152.
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Goforth PN, Karlin JM, DeValentine S. Distal metatarsal osteotomy. J Am Podiatry Assoc 1984;74:402-405.
Graver H. Recurrence of overlapping toe following metatarsal head resection and subsequent success with soft tissue correction: a
case report. J Foot Surg 1971;10:71-73.
Grundy M, Blackburn PA. An investigation of the centers of pressure under the foot while walking. J Bone Joint Surg Br 1975;57:98-
103.
Gunther R, Hennacy RA. A piezoelectric crystal method for measuring states and dynamic pressure distribution in the feet. J Am
Podiatry Assoc 1975;65:444-449.
Hadden R. Metatarsal base resection. J Foot Surg 1972;11:1-7.
Hutton WC, Stott JR, Stokes IA. Forces under the foot. J Bone Joint Surg Br 1973;55:344.
Jaworek T. Diaphyseal resection: a modified approach to contracted digits. J Foot Surg 1973;12:118-119.
Maglietta T, DeAngelis G, DeLiberis WJ, et al. A regional screening approach for common hyperkeratotic foot lesions. J Am Podiatry
Assoc 1981;71:517-559.
Reese H. Surgical treatment of intractable plantar keratosis. J Foot Surg 1973;12:92-95.
Reinherz RP, Toren OJ. Bone healing after adjacent metatarsal osteotomies. J Foot Surg 1981;20:198-203.
Rutherford R. Metatarsal shortening for the relief of symptomatic plantar keratosis. J Foot Surg 1970;9:13-16.
Schweitzer DA, Lew H, Shuken J, et al. Central metatarsal shortening following osteotomies and its clinical significance. J Am
Podiatry Assoc 1982;72:610.
Scranton DE, McMaster JH. Momentary distribution of forces under the foot. J Biomech 1976;9:45-48.
Thompson CT. Surgical treatment of disorders of the forepart of the foot. J Bone Joint Surg Am 1964;46:1119.
Veres G. Graphic analysis of forces acting upon a simplified model of the foot. Prosthet Orthot Int 1977;1:161-172.
Wilner RJ. Osteoclasis. J Am Podiatry Assoc 1973;63:1-7.
Yu GV, Judge M. Predislocation syndrome of the lesser metatarsophalangeal joint: a distinct clinical entity. In: Camasta CA, Vickers
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PART 4 Deformities of the Fifth Metatarsal

Mary E. Crawford
The fifth ray is a common site for numerous problems affecting the foot. In many ways, this segment is different from the other lesser
metatarsals because of the more direct effects of shoes against the lateral border of the foot and because this lateral metatarsal segment
has a greater degree of motion. Deformities involving the fifth metatarsal or metatarsophalangeal joint may include tailor's bunion or
bunionette, plantar hyperkeratoses, splay foot, overlapping fifth toes, and hammer toes.
TAILOR'S BUNION
The most common symptomatic condition of the fifth metatarsal is the tailor's bunion deformity, sometimes referred to as a bunionette
(Fig. 91 ). A tailor's bunion is a prominence that may be caused by hypertrophy or irritation of bone or soft tissue about the dorsolateral or
lateral aspect of the fifth metatarsal head. In most instances, patients have a structural deformity involving the metatarsal itself with soft
tissue problems occurring in response to the osseous prominence. Symptoms most often result from shoe pressure over the osseous
prominence, local nerve irritation, capsulitis at the fifth metatarsophalangeal joint, or an adventitious bursa. One common finding may be
an associated splay foot deformity. A splay foot is characterized by abnormal widening of the metatarsals in the transverse plane in
relation to the heel (1 ). This aberration primarily occurs between the first and second metatarsals and the fourth and fifth metatarsals,
but with some additional width developing between the central three segments as well (Fig. 92 ). In some patients, addressing the splay
foot may be an integral part of treating a symptomatic tailor's bunion.
Signs and Symptoms

A tailor's bunion deformity may be seen with symptoms isolated to the fifth metatarsal or with associated symptoms involving the fifth toe.
The prominence creates an obvious site for potential irritation with shoes, especially when narrow or pointed-toed styles are worn.
Walking barefoot or with open-toed shoes often alleviates the pain. The irritation from shoes often creates redness or swelling in the area.
One of the more painful conditions is when an inflamed adventitious bursa develops overlying the prominent lateral fifth metatarsal head.
The inflamed bursa results in pain, swelling, erythema, and increased warmth along the lateral side of the foot. Another source of
discomfort associated with a tailor's bunion may include some type of hyperkeratosis. Lesions may be noted laterally or at the dorsolateral
aspect of the fifth metatarsal head.
A plantar callosity, or intractable plantar keratosis, may be present if the ray is rigid or plantarflexed. Weight bearing is usually the
primary aggravating factor with these types of lesions, and a change in the type of shoes worn may or may not influence the symptoms. In
some instances, the plantar lesion may be deep or nucleated.
The fifth toe is rarely rectus in patients with a tailor's bunion deformity and is often in a varus or adductovarus position. This malalignment
can lead to greater amounts of pressure over the lateral side of the digit and result in a hard callus or heloma formation. A heloma molle
(or soft corn) may also form between the fourth and fifth toes because of the abnormal position of the toe. The varus rotation of the toe
may create additional pressure at the distal aspect of the toe and may lead to a corn adjacent to the nail (i.e., onychoclavus).
Etiology
Numerous theories have been proposed for the development of a tailor's bunion deformity (2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ). The
fifth metatarsal is the most flexible of the metatarsals, largely because of the independent axis of motion of the fifth ray. Investigators
have suggested that laxity of the fourth intermetatarsal ligament may result in greater degrees of mobility and may thereby allow further
splaying of the fifth metatarsal (2 ). Davies proposed that incomplete or faulty development of the transverse metatarsal ligament during
embryonic growth was the causative factor in tailor's bunion formation (3 ). This would allow for greater amounts of intermetatarsal splay
between the fourth and fifth metatarsals. Other authors have also suggested that abnormalities in the embryonic development of the foot
may be implicated (4 ,5 ). Gray believed that a malinsertion of the adductor hallucis muscle without attachment to the fifth metatarsal or
the deep transverse metatarsal ligament between the fourth and fifth metatarsal heads was responsible for a deviated fifth metatarsal (4 ).
Lelievre believed that lateral displacement of the fifth metatarsal could develop because of one of three potential causes: (a) an
abductory pressure exerted by a supernumerary
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bone attached to the lateral aspect of the fourth metatarsal head, (b) splaying of the forefoot, and (c) continual pressure on the lateral
side of the foot caused by a shoe, from an externally rotated limb, or as a result of sitting crossed legged in a manner similar to a tailor
(hence the name, tailor's bunion) (7 ). Duvries speculated that three conditions, independently or in combination with each other, resulted
in a tailor's bunion deformity: (a) hypertrophy of the soft tissue structures overlying the fifth metatarsal and metatarsophalangeal joint, (b)
a congenitally wide fifth metatarsal head, or (c) lateral deviation of the fifth metatarsal shaft or head with resultant malposition (8 ).
FIG. 91. Clinical appearance of a tailor's bunion.
FIG. 92. Splay foot deformity with widening of the metatarsals in the transverse plane.
Yancey described congenital bowing of the fifth metatarsal as the primary source of this deformity (5 ). Other investigators have also
agreed that structural bowing may be seen in patients with tailor's bunions (13 , 14 , 15 , 16 ). However, Nestor and associates determined
that whereas lateral deviation of the fifth metatarsal did exist, there was no correlation between patients' symptoms and the amount of
bowing noted (6 ). Other investigators have suggested that an increase in the intermetatarsal angle between the fourth and fifth
metatarsals may be responsible for the lateral prominence of the fifth metatarsal head (3 ,6 ,13 , 14 , 15 ,17 ), and a strong association
does appear to exist between symptomatic tailor's bunion and a splay foot (3 ,15 ,18 , 19 , 20 , 21 , 22 ). Although prominence of the fifth
metatarsal base is often seen with metatarsus adductus, one may also note a lateral prominence of the fifth
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metatarsal head because the central three rays adduct to a greater degree than the fifth (9 ).
As in other areas of the forefoot, the biomechanics of the foot may play a significant role in the development of deformities at the fifth
metatarsophalangeal joint. Hicks described the axis of motion for the fifth ray, which is parallel to the oblique axis of the midtarsal joint
(12 ). Thus, triplanar motion occurs in the direction of dorsiflexion, abduction, and eversion and plantarflexion, adduction, and inversion.
In similar fashion, Root et al. noted that abnormal subtalar joint pronation in combination with other conditions would potentially lead to a
tailor's bunion (11 ). These additive factors include an uncompensated forefoot or rearfoot varus position in a fully pronated foot, a
congenitally plantarflexed or dorsiflexed fifth ray, and other unidentified problems. Abnormal subtalar joint pronation during the
midstance and propulsive phases of gait results in hypermobility of the fifth ray that produces shearing between the fifth metatarsal head
and the overlying skin, the latter of which may be immobile because of shoe pressure.
Root et al. also discussed in some detail the pathomechanics surrounding the splay foot deformity (11 ). The primary factor leading to this
condition was believed to be the loss of function of the adductor hallucis muscle resulting in transverse instability of the metatarsals.
Abnormal subtalar joint pronation and the subluxation of the rays at the naviculocuneiform joints, the cuboid, and with each other may
also result in the eventual development of the splay foot.
Uncompensated or partially compensated varus conditions of the forefoot and rearfoot result in an abnormally high distribution of pressure
beneath the fifth metatarsal head, with possible pain and callus formation. A forefoot valgus foot type may also lead to lesions beneath
the fifth metatarsal head because the late-stance subtalar supinatory motion required to bring the lateral forefoot to the ground results in
increased weight bearing beneath the fifth metatarsal (11 ).
Regnauld believed that overloading of the fifth metatarsal developed in response to a reduction in vertical motion available in the fifth ray
accompanied by lateral imbalance, such as in cavovarus foot deformity (10 ). Limited dorsiflexion of the fifth ray could result from clawing
of the fifth toe, fibrosis of contiguous surfaces of the fourth and fifth metatarsals, or longitudinal cavus deformity in which the base of the
metatarsal is off the ground and all the weight is transferred to the metatarsal head.
Other potential causes of tailor's bunion formation include malunited fracture or osteotomy of the fifth metatarsal, neoplasms,
inflammatory diseases, degenerative joint disease, fifth metatarsophalangeal joint contracture, and systemic diseases. Therefore, the true
origin of a tailor's bunion may be multifactorial, with a combination of biomechanical, congenital, developmental, and systemic factors.
Clinical Evaluation
Evaluation of the fifth ray may reveal a prominent metatarsal head dorsally, laterally, or plantarly, at times with corresponding
hyperkeratosis, erythema, or an adventitious bursa. Plantar hyperkeratoses beneath the fifth metatarsal are not typically seen with
sagittal plane hypermobility of the fifth ray. More commonly, one may note a diffuse lesion beneath the fourth metatarsal head. The fifth
metatarsophalangeal joint is most often deviated with an adductovarus or varus fifth digit. The adducted position of the digit may exert a
retrograde force on the fifth metatarsal that may increase the amount of intermetatarsal splay. Dorsal subluxation of the digit increases
loading at the plantar aspect of the joint. In most instances, the joint itself is not painful to palpation. The fifth digit may exhibit varying
degrees of deformity, and it may impinge on the fourth digit, with resulting hyperkeratosis both laterally on the fifth digit and in the
fourth web space.
When the patient is non-weight bearing, the forefoot may appear normal, with no excessive prominence or splay foot identified. However,
with palpation, one may note the frontal, sagittal, and transverse plane position of the fifth metatarsal and its relation to the other
metatarsals. The overall flexibility of the fifth ray may also be important in the selection of the treatment for any given patient. With the
patient in a relaxed stance position, the fifth ray deformity typically becomes accentuated, especially if the rearfoot is pronated. With
significant hypermobility, the fifth ray tends to demonstrate excessive splaying and dorsiflexion. The forefoot may appear wider, and the
digital malalignment becomes more evident.
Radiographic Evaluation
Radiographic analysis of the fifth ray may be difficult because of the variability of the shape of the fifth metatarsal. Although certain
features may be recognized as important to the overall evaluation of the radiographs, specific measurements have generally not been
universally accepted as an essential part of the process. In part, this is caused by the inconsistency noted between purportedly important
deviations in radiographic measurements and patients' symptoms. Nonetheless, certain different findings may be derived from radiographs
to help evaluate tailor's bunion and fifth ray deformities, and the challenge is to try to correlate those findings with a successful treatment
protocol.
The dorsoplantar and lateral radiographs have generally been the standard views made for the evaluation of foot deformities, with the
former being of greater importance in assessing the fifth metatarsal and metatarsophalangeal joint and the relationship of the adjacent
structures. The medial oblique view may be helpful in demonstrating lateral flare or deviation of the fifth metatarsal, which is not as
readily evident on the dorsoplantar view. Axial views are generally not of benefit in the overall evaluation of the fifth ray.
Fallat and Buckholz described six different entities relative to the radiographic evaluation of a tailor's bunion that were believed to be of
significance: an increased intermetatarsal angle, an increased lateral deviation angle, rotation of
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the lateral plantar tubercle of the fifth metatarsal head into a more lateral position, a large round dumbbell-shaped fifth metatarsal head,
arthritic changes resulting in bony exostosis formation at the fifth metatarsophalangeal joint, and any combination of the foregoing
conditions (13 ,14 ). The most common findings were an increased intermetatarsal angle and an increased lateral deviation angle.
Intermetatarsal Angle of the Fourth and Fifth Metatarsals

Traditionally, the fourth and fifth intermetatarsal angle was created from a bisection of the shafts of each respective metatarsal. The
method proposed by Fallat and Buckholz for estimating this relationship is the angle created from a line bisecting the fourth metatarsal
shaft and a line drawn adjacent and parallel to the medial surface of the proximal fifth metatarsal shaft (13 ) (Fig. 93 ). In their study, the
mean normal intermetatarsal angle measured with the traditional method was 6.22 degrees and 6.47 degrees with the newer assessment.
In patients with tailor's bunion deformities, the intermetatarsal angle increased to an average of 9.62 degrees with the traditional method
and 8.71 degrees with the new measurement. These authors also noted that the intermetatarsal angle increased an average of 3 degrees
when the foot was pronated, thus leading to the conclusion that this angle has a positional component. Numerous other authors have also
incorporated measurement of this relationship (6 ,23 , 24 , 25 , 26 , 27 ), and investigators have proposed that an intermetatarsal angle of
9 degrees or greater tends to cause symptoms (28 ).
FIG. 93. The two means of assessing the intermetatarsal angle between the fourth and fifth metatarsals. Angle ABD represents the
traditional method, bisecting the shafts of the respective metatarsals. Angle ABC represents the method recommended by Fallat,
with the medial shaft of the fifth metatarsal identified.
Lateral Deviation Angle

Lateral bowing in the distal third of the fifth metatarsal shaft is considered a structural problem. The lateral deviation angle has been
described as a means of quantifying this relationship (13 ). The angle is formed by a line bisecting the fifth metatarsal head and neck and a
line drawn adjacent and parallel to the medial cortex of the proximal fifth metatarsal (Fig. 94 ). Fallat and Buckholz noted that the lateral
deviation angle in the normal foot averaged 2.64 degrees, but it measured 8.05 degrees in patients with tailor's bunions. This relationship
did not change when the foot position was altered, and as such, the deviation was believed to be fixed and structural.
The findings of subsequent authors relative to the lateral deviation angle have not been entirely consistent. In some instances, patients
with tailor's bunion deformities were noted to have lateral deviation angles between 4.84 and 7.5 degrees (25 ,27 ). Frankel and associates
stated that lateral bowing was found in most patients with tailor's bunion deformities (16 ). In contrast, Steinke and Boll noted lateral
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deviation of 5 degrees in only 1 of 49 feet undergoing surgical procedures (23 ). Nestor et al. found no significant change in the lateral
deviation angle between patients with symptoms and the symptom-free control group (6 ). It appears that lateral deviation of the fifth
metatarsal is found in a subset of patients with tailor's bunions, but it is not always present. When present, it is usually significant and
should be taken into account in planning the surgical correction.
FIG. 94. Lateral deviation angle as described by Fallat is represented by the angle ABC.
FIG. 95. A,B: Dorsoplantar and oblique radiographs of a patient with tailor's bunion deformity. The oblique view is more
demonstrative relative to the site of maximal deformity within the fifth ray.
Although most investigators have concentrated on assessing this relationship through the dorsoplantar radiograph, the lateral flare of the
fifth metatarsal is most apparent on the medial oblique view. At times, the dorsoplantar radiograph fails to demonstrate significant
deviations, yet an oblique view clearly demonstrates this type of deformity. Although the oblique view may not be optimal for performing
actual angular measurements, it is certainly a means by which this component of deformity may be more clearly defined (Fig. 95 ).
One additional measurement may be used in an attempt to determine the location of maximum deformity of the fifth metatarsal. The
angle is created by a bisection of the base of the fifth metatarsal and the bisection of the head and neck of the fifth metatarsal. The site
of intersection of these two lines indicates the location of greatest deformity of the metatarsal (Fig. 96 ).
Other radiographic measurements have been described, but they are generally considered far less important in evaluating patients with a
tailor's bunion. One may assess the
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intermetatarsal angle between the second and fifth metatarsals. A normal value has been purported to be 16 ± 2 degrees (29 ). Splay foot
has been considered present when the intermetatarsal angle between the first and second metatarsals is greater than 12 degrees and that
of the fourth and fifth metatarsals is greater than 8 degrees (19 ).
FIG. 96. The location of the maximum deformity (B) as determined by lines intersecting the bisection of the fifth metatarsal base (C)
and the distal metatarsal head and neck (A).
FIG. 97. Fifth metatarsal declination angle.

On the weight-bearing lateral view, one may measure the fifth metatarsal declination angle. This is created by the angle between the
bisection of the fifth metatarsal with a line drawn from the inferior surface of the calcaneus to the inferior aspect of the fifth metatarsal
head. A value greater than 10 degrees is said to represent a plantarflexed metatarsal (Fig. 97 ). Catanzariti et al. described a sagittal
plane deviation angle of the fifth metatarsal head (27 ). This is formed by the angle bisecting the fifth metatarsal shaft with its head and
neck at the level of the articular surface (Fig. 98 ). They found that postoperative patients with angular increases of 16.2 ± 4.5 degrees
were at risk of transfer lesions under the fourth metatarsal.
Treatment
Conservative Treatment
A painful tailor's bunion may respond to conservative management, depending on the patient's symptoms and the degree of deformity.
Conservative care can include shoe modifications and padding of prominent areas, oral antiinflammatory medications, local injections of
corticosteroid into an inflamed bursa, or débridement of painful hyperkeratotic lesions. Physical therapy modalities, such as ultrasound or
phonophoresis, may also help to reduce inflammation associated with bursitis, neuritis, or capsulitis. Orthotic devices can be used to
alleviate pressure points and to obtain functional control of abnormal foot mechanics. However, conservative therapy is rarely curative and
should be considered palliative. In healthy patients, surgery is often the treatment of choice.
FIG. 98. Sagittal plane deviation angle of the fifth metatarsal determined by the bisection of the shaft and distal head and neck of
the metatarsal.
Surgical Treatment
Many different approaches have been described for the surgical management of fifth ray deformity. Ideally, the procedure should alleviate
patients' complaints, improve fifth ray alignment, and allow for a restoration of function. The procedures may be categorized into distinct
groups.
Exostectomy
The removal of the prominent lateral eminence of the fifth metatarsal head is the easiest surgical approach for a tailor's bunion deformity.
Davies advocated this procedure and believed that metatarsal osteotomies were unnecessary unless the fifth metatarsal was abducted (3 )
(Fig. 99 ). DuVries countered that a simple exostectomy should be performed only when the patient had a wide metatarsal head (8 ). Other
surgeons have advocated a concomitant removal of the lateral condyle of the base of the fifth digit (30 ), excision of the inflamed bursa
(31 ), and resection of the base of the proximal phalanx of the fifth toe (7 ). Kitaoka and Holiday noted that patients experienced good
relief of symptoms with exostectomy of the fifth metatarsal for tailor's bunion deformity, but the varus alignment of the fifth toe was
essentially unchanged (32 ). In patients with unsatisfactory results, the source of failure was cited as being caused by inadequate bone
resection, metatarsophalangeal joint subluxation, and severe forefoot splaying.
For many patients, simple exostectomy may prove inadequate as an isolated procedure because some structural problem needs to be
addressed in most cases. Removal of a small amount of bone may not alleviate the prominence, and removal of a large segment of bone
may destabilize the fifth metatarsophalangeal joint (6 ,17 ,32 ,33 ) (Fig. 100 ). The lateral stabilizing structures of the fifth
metatarsophalangeal joint are incised or reflected during the procedure and may not provide adequate function to resist medial drift of
the fifth toe postoperatively. Most patients do not report this as a symptomatic process unless the bone prominence recurs. Nonetheless,
this finding has led some investigators to suggest a lateral capsulorrhaphy in an attempt to enhance stability (1 ). In the presence of
increased metatarsal splay or bowing, the fifth toe usually continues to adduct over time and
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may render the metatarsal head prominent once again. However, this approach may still be applicable in patients with a stable fifth ray,
with little angular deviation, or with isolated hypertrophy of the metatarsal head or in patients in whom osteotomy is not feasible.
Exostectomy may also be used in conjunction with a metatarsal osteotomy.
FIG. 99. Exostectomy of the fifth metatarsal head for tailor's bunion. Note the preservation of the greatest portion of the articular
surface of the fifth metatarsal.
Arthroplasty Procedure
One way virtually to guarantee that a tailor's bunion will not recur is to resect a portion of the fifth ray. This approach has been
recommended by various surgeons (17 ,20 ,34 , 35 , 36 , 37 ), all of whom have their own methods designed to improve the overall
outcome with fewer complications. McKeever proposed the resection of one-third to one-half of the fifth metatarsal angled distal medial
to proximal lateral to prevent any of the remaining fifth metatarsal from being prominent (17 ). Brown advocated removal of the entire
fifth metatarsal (20 ). Because of the extensive digital retraction that was associated with resection of the metatarsal head, Kelikian
recommended concomitant syndactylization of the fourth and fifth toes (34 ). An interpositional silicone sphere has also been used to
maintain length and alignment of the fifth toe in conjunction with excision of the metatarsal head (35 ,36 ).
FIG. 100. A patient after fifth metatarsal head exostectomy for tailor's bunion deformity. Note the adduction of the fifth
metatarsophalangeal joint after destabilization of the lateral aspect of the joint.
Successful early results may be noted in some patients after fifth metatarsal head resection. Dorris and Mandel evaluated 34 patients
undergoing a total of 50 fifth metatarsal head resections for various complaints (37 ). Eighty-four percent of these patients were either
very satisfied or satisfied with their results. Twenty-one of the patients were evaluated clinically, and symptomatic transfer lesions were
noted in a single patient, but 59% of patients demonstrated some form of fifth toe malposition. The average time elapsed since surgery was
17 months.
Less favorable results have been noted in a set of patients evaluated with an average follow-up of 9 years. In this series of eight feet, only
one result was considered to be good. Two fair and five poor results were reported. However, in each instance, the level of resection was
noted to extend to the diaphysis of the fifth metatarsal (38 ). Therefore, further long-term studies are needed to evaluate this procedure
with the more judicious resection that is performed in most situations.
Sporadic clinical experience with this procedure would tend to confirm these problems, with other complications noted in some patients.
These may include a flail fifth digit, which makes applying socks or stockings difficult, shoe irritation over the fifth toe, transfer lesions to
the fourth metatarsal,
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contracture of the fourth toe to stabilize the additional load, irritation of the fourth toe from loss of shielding from the shortened fifth
digit, and other positional deformities of the fifth digit resulting from both ligamentous and muscle laxity.
FIG. 101. A,B: Optimal angles for resection of the fifth metatarsal head.
When this operation is performed, an oblique cut extending from distal medial to proximal lateral helps to prevent any remaining lateral
prominence from developing (28 ) (Figs. 101 and 102 ). The joint capsule may be imbricated into the dead space to reduce the potential
for digital retraction. Alternatively, a Kirschner wire may be introduced through the fifth digit and into the metatarsal for 4 to 6 weeks.
This latter approach allows the scar tissue to organize and holds the digit in a more rectus alignment. If the patient is to remain weight
bearing when a wire is used, then a surgical shoe padded from the heel to the digital sulcus will help to suspend the digit and will alleviate
bending stress to the wire.
Indications. Fifth metatarsal head resections are appropriate in patients with severe deformity in whom osteotomies are contraindicated,
in patients whose metatarsal head is destroyed or in whom reconstruction is not viable (28 ), or in patients with arthritis. Other
considerations include geriatric patients or patients with a more limited ambulatory status, as well as patients with recurrent deformity or
hyperkeratosis. Although some surgeons may expand on these indications, long-term follow-up studies have been few. The limited
objective evidence appears to indicate that problems that evolve may do so over time. However, if future objective evaluation reveals
that the results obtained initially are maintained without significant loss of function or subsequent deformity, then this procedure would
be viewed in a more favorable light.
Distal Metaphyseal Osteotomies

The treatment of tailor's bunion deformities includes numerous surgical procedures to correct increased intermetatarsal and lateral
deviation angles. One of the most common approaches involves distal metaphyseal osteotomy of the fifth metatarsal. Several different
types of procedures have been proposed, including the following:
• A transverse osteotomy with medial transposition of the capital fragment (39 ) (Fig. 103 )
• Orientation of the axis of the osteotomy from distal lateral to proximal medial to shorten the fifth metatarsal with transposition of
the metatarsal head (21 ) (Fig. 104 )
• Modification of the oblique osteotomy by performing it perpendicular to the weight-bearing surface that allowed telescoping of the
distal fragment toward the adjacent metatarsals (40 )
• A reverse Mitchell type of step-down osteotomy (32 )
• A crescentic osteotomy (22 )
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FIG. 102. Radiographic (A) and clinical (B) appearance of a patient after a fifth metatarsal head resection with the retracted fifth
toe.
FIG. 103. Hohmann type of medial displacement osteotomy for repair of tailor's bunion deformity.
FIG. 104. Wilson type of medial displacement osteotomy with shortening for repair of tailor's bunion deformity.
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Historically, fixation was not employed for these procedures, and certain complications were noted including overcorrection or
undercorrection of the deformity, transfer lesions under the fourth metatarsal, a floating fifth digit, malunion, and painful delayed or
nonunion of the osteotomy.
In an attempt to provide a more stable distal procedure without fixation, Hansson attempted to improve the distal oblique osteotomy by
fixing the fragments with absorbable suture (41 ). The Hohmann procedure, a transverse osteotomy, was also modified at one point so a
peg was fashioned from the medial aspect of the metatarsal shaft and a hole in the lateral aspect of the fifth metatarsal neck (42 ). When
the head and neck were transposed medially to reduce the tailor's bunion deformity, the distal segment (hole) was impacted onto the
medial shaft (peg) of the fifth metatarsal. Success rates of 85% (26 ) and 88% (23 ) were noted with this procedure, with the primary
complication being transfer lesions. Kitaoka and Leventen designed a similar procedure several years later that they termed the medial
displacement metatarsal osteotomy (24 ). An oblique osteotomy was made from distal medial to proximal lateral. The lateral portion of
the surgical neck on the distal segment was removed. This allowed for medial transposition of the fifth metatarsal head, which was then
impacted onto the proximal metatarsal. No fixation was employed. Kaplan and associates performed a uniplanar adductory or biplanar
dorsiflexion adductory wedge osteotomy at the surgical neck with 2-0 wire loop fixation in an attempt to provide some stability (9 ).
A distal chevron or transverse plane V osteotomy has also been described for the repair of tailor's bunion deformity (43 ) (Fig. 105 ). The
head of the fifth metatarsal is transposed medially in the transverse plane and is impacted on the shaft for fixation. Many surgeons
increase the stability of the distal fragment with the use of a Kirschner wire or absorbable pin. This procedure provides good transverse
plane correction, and the axis of the osteotomy may be altered to afford a small degree of simultaneous sagittal plane manipulation.
Studies have demonstrated good results regardless of the degree of deformity, so some surgeons have advocated abdicating more proximal
procedures (44 ). The only reported complication has apparently been transfer metatarsalgia in a few patients (44 ,45 ).
FIG. 105. Lateral view of the fifth metatarsal demonstrating the chevron osteotomy.
As previously noted, in most of the procedures described from a historical perspective, surgeons employed limited or no fixation for the
osteotomy. In fact, some authors asserted that fixation for these types of procedures was not required (46 ,47 ). Keating and associates
reported an overall success rate of 56% for the unfixed distal oblique osteotomy (25 ). Cantanzariti et al. noted 67% objective and 80%
subjective favorable results after nonfixed oblique osteotomies of the fifth metatarsal (27 ). Although good correction of the
intermetatarsal angle and lateral deviation angles was achieved, many of the complications were attributed to the dorsal displacement of
the capital fragment. These authors indicated that the high incidence of recurrent or transfer lesions and malunion should prompt the
surgeon to consider fixation of the osteotomy.
Pontious and associates were the first to evaluate the efficacy of fifth metatarsal osteotomies with and without fixation (48 ). They
concluded that fixation of fifth metatarsal osteotomies provided for a more predictable and successful result. In particular, fixation helped
to control dorsal displacement of the capital fragment and limited shortening of the metatarsal, problems that were responsible for lesser
metatarsalgia. Furthermore, radiographic evidence of healing was more reliable when the osteotomy underwent fixation. Consolidation
time was faster in patients in whom fixation was employed, and in some instances, patients who did not undergo fixation failed to
demonstrate radiographic healing of the osteotomy, although each was asymptomatic.
Various fixation methods may be used to provide stability for a fifth metatarsal osteotomy, and numerous different procedures have been
described. The Hohmann procedure has been modified to allow fixation with a 2.0-mm cortical bone screw (16 ). A different technique
employs an osteotomy angled from dorsal distal to plantar proximal in the fifth metatarsal neck. The plantar lateral hinge is left intact by
careful reciprocal planing of the osteotomy. Pressure is applied laterally to the fifth metatarsal head until the desired amount of medial
rotation of the distal fifth metatarsal head is achieved. A Kirschner wire or cortical screw fixation is then placed across the osteotomy for
fixation (49 ). Subsequent follow-up evaluation of the procedure revealed a patient satisfaction rate of 96% (50 ). The fifth metatarsal
chevron osteotomy may also be readily stabilized with Kirschner wires or absorbable wires.
Crawford described an L-shaped osteotomy designed for moderate tailor's bunion deformities with bowing in the middle to distal shaft of
the fifth metatarsal (51 ) (Figs. 106 and 107 ). The osteotomy is performed in the transverse plane and allows for the medial transposition
of the head, neck, and distal shaft of the fifth metatarsal. The plantar L-shaped configuration of the bone cuts is made with a short dorsal
cut and a long plantar cut in the metatarsal. The long plantar osteotomy is performed approximately 60 to 90 degrees to the dorsal
osteotomy. Once the osteotomy is completed, the distal segment of the metatarsal is transposed one-third to one-half the width of the
fifth metatarsal shaft and is fixed
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with one to two cortical screws. The complication rate was reported to be less than 4%, with the primary problem reported as later
irritation over the screws.
FIG. 106. Lateral view demonstrating the L-shaped osteotomy proposed by Crawford.
Wedge osteotomies may also be employed and provide good inherent stability because the intact cortical hinge functions as an additional
point of stabilization. Yancey is generally credited with describing this type of approach (5 ), but in the more proximal middiaphyseal area
of the metatarsal. A transverse wedge osteotomy is the most stable configuration, and fixation may consist of a horizontal wire loop or a
Kirschner wire (Figs. 108 and 109 ). Oblique osteotomies are also effective in reducing deformity. Yu et al. described an intramedullary
wire for fixation that provided stability to the osteotomy through a tension band effect (1 ). However, a later study found that the lateral
cortical hinge was unable to tolerate the stresses of weight bearing, and fractures were noted in some patients (52 ). Subsequent authors
employed screw fixation for the oblique osteotomy with good results
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(53 ). The configuration of the oblique procedure lends itself well
FIG. 109. Preoperative (A) and postoperative (B) radiographs
to this type of stabilization (Figs. 110 and 111 ).
of a patient undergoing repair of tailor's bunion deformity
with the transverse wedge osteotomy. Fixation is this case
consists of a transverse wire loop.
FIG. 107. Preoperative (A) and postoperative (B) radiographs

in a patient undergoing the L-shaped osteotomy for repair of
tailor's bunion deformity.
FIG. 110. Oblique wedge osteotomy for repair of tailor's

bunion deformity.
Disadvantages of the hinged wedge osteotomies include the

greater degree of difficulty required to execute the procedure and
fixation successfully. In addition, these procedures do not allow
for actual transposition of the fifth metatarsal head, although one
could argue that this is of little significance as long as the actual
prominence of the fifth metatarsal head is alleviated. Other
FIG. 108. Transverse wedge osteotomy for repair of tailor's
difficulties may arise when the distal aspect of the fifth metatarsal
bunion deformity.
is narrow, a configuration that renders hinge fracture more likely.
In some instances, patients may benefit from a period of non-
weight bearing or a greater degree of protected weight bearing to
reduce the risk of disrupting the osteotomy.
Indications. Distal metatarsal osteotomies are the most common

procedures employed in the repair of tailor's bunion deformities
and as a means of alleviating plantar hyperkeratoses. Each surgeon
has his or her own preference regarding the specific configuration
for the osteotomy and choices for fixation. From the previous
discussion, one can tell that many procedures have been successful.
If the intermetatarsal angle is increased a mild to moderate
degree and the majority of the bowing occurs in the distal one-
third of the metatarsal, then a distal metaphyseal osteotomy can
be successful in the treatment of painful tailor's bunion. This
osteotomy can correct a mild to moderate increase in the
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intermetatarsal angle and a moderate to severe lateral deviation angle. In the latter circumstance, performing the osteotomy at the point
of maximum lateral deviation of the fifth metatarsal may enhance the effectiveness of the procedure. Fixation should be considered for
the transverse or oblique type of osteotomy. Although this does not ensure a good result, and success can be noted without fixation, the
stability provided tends to reduce the likelihood of malunion.
FIG. 111. Preoperative (A) and postoperative (B) radiographs of a patient undergoing repair of tailor's bunion deformity with the
oblique wedge osteotomy. Fixation in this case consists of two small cortical screws and a wire loop.
Surgical Exposure for the Distal Fifth Metatarsal. The incisional and dissection approaches for exostectomy, arthroplasty, and osteotomy
of the distal metatarsal are essentially the same. A linear incision is generally employed that overlies the dorsolateral aspect of the distal
metatarsal, and it may extend slightly onto the fifth toe. At this level, no major structures are encountered in the subcutaneous layer.
Dissection is carried through the typically thin subcutaneous tissue until the deep fascia and periosteum are identified throughout the
course of the wound. After adequate tissue layer separation, the periosteum and deep fascia are incised lateral to the extensor tendon and
parallel to the corresponding skin incision. One should carefully palpate the fifth metatarsal shaft before this maneuver because one may
easily direct the deep incision too far medially, by crossing the fifth metatarsal crest and entering the intermetatarsal space. Once the
joint is identified, a scalpel may be introduced laterally to free the capsule and ligaments from the fifth metatarsal head. A Freer elevator
is then used to dissect the periosteum from the fifth metatarsal. This tissue layer becomes thin as dissection proceeds proximally along the
metatarsal shaft.
Once the lateral aspect of the fifth metatarsal head is exposed, one may then resect the prominent bone with either power or hand
instruments. Generally, the bone is resected so the lateral aspect of the fifth metatarsal head is parallel to the shaft of the metatarsal.
However, in some cases in which an osteotomy may be performed, a lesser degree of bone may be resected initially to provide a wider
bone surface for transposition, or the exostectomy may be performed after the osteotomy itself.
Postoperative Care. In most instances in which distal metatarsal osteotomies have been performed, the patient may ambulate with some
protective device. In some circumstances, a surgical shoe alone may be adequate. However, better protection may be provided by adding a
felt pad with a fifth ray cutout or by using one of the many removable castlike devices that are available. Healing is monitored by clinical
evaluation and periodic radiographs. The return to more normal activities and shoe gear is usually based on the procedure performed, the
clinical and radiographic findings, the typical protocols of the surgeon, and patient's symptoms.
Proximal Base Osteotomies

Some patients with tailor's bunion deformity may have a significantly increased intermetatarsal splay between the
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fourth and fifth metatarsals. In these circumstances, one may consider a proximal osteotomy at the base of the fifth metatarsal. This type
of approach has been advocated by numerous authors (7 ,15 ,17 ,18 ,54 , 55 , 56 , 57 ). Proximal fifth metatarsal osteotomies may also
work well in patients with a splay foot deformity.
FIG. 112. Transverse (A) oblique (B) proximal wedge osteotomies of the fifth metatarsal for repair of tailor's bunion deformity.
Gerbert and colleagues (55 ) and Rappaport (15 ) discussed removal of a proximal wedge of bone to afford correction. This procedure may
be either transverse or oblique in its orientation (Fig. 112 ). Kirschner wires are generally used for fixation in the former procedure,
whereas the longer oblique osteotomy is easily stabilized with screw fixation. A proximal opening wedge osteotomy of the metatarsal base
with autogenous bone graft has also been described (56 ), although this procedure does not appear to have gained much support. Other
surgeons have described successful results with a proximal V osteotomy made from dorsal to plantar with the apex directed proximally
(18 ,57 ). The metatarsal is then pivoted medially and is fixed with one or two wires driven into the fourth metatarsal.
Surgical Considerations. In patients with significant deformity, the proximal osteotomy offers the potential for greater levels of correction.
Good stabilization of the osteotomy is important to optimize healing. As with all wedge osteotomies, the axis may be altered to provide
either simultaneous dorsiflexion or plantarflexion of the distal fragment. An opening wedge procedure with a graft generally increases
healing time and the risk of complications, but it may be advantageous in patients with a significantly shortened fifth metatarsal.
Surgical Exposure of the Proximal Aspect of the Fifth Metatarsal. A linear incision is placed over the dorsolateral aspect of the proximal
aspect of the fifth metatarsal. At times, the lateral dorsal cutaneous nerve may be encountered within the subcutaneous tissue. The
periosteum is more easily identified at the distal aspect of the incision over the shaft of the metatarsal. The insertion of the peroneus
tertius tendon is evident proximally. The periosteum is incised parallel to the skin incision once the tissues are reflected. The articulation
between the fourth and fifth metatarsal bases needs to be identified to ensure that the medial aspect of the osteotomy will avoid this
joint interface.
Postoperative Care. After these types of osteotomies, non-weight bearing is generally considered in most cases. The proximal nature of the
procedure means that there is a long lever arm for potential disruption with weight bearing. Periodic radiographs are made to monitor
healing. Weight bearing may be instituted once consolidation is believed to be adequate.
PLANTAR KERATOMAS
Hyperkeratoses that are seen beneath the fifth metatarsal head are often the direct result of biomechanical problems, and accordingly,
orthotics and other conservative measures render good to adequate relief of symptoms for many patients. Generally, these patients also
have a flexible fifth ray, and the lesions tend to be more diffuse, as opposed to the more nucleated type of lesions often noted in patients
with a rigid deformity.
In most instances, distal metaphyseal osteotomies are employed to dorsiflex the metatarsal head in an attempt to alleviate a plantar
hyperkeratosis (58 ). The procedures are similar or the same as those used in the central metatarsals. Trepal also noted that proximal
osteotomies could be employed in the management of plantar lesions for patients with rigid fifth metatarsal deformity (28 ). He advocated
a dorsal wedge resection that would leave the plantar hinge intact. Longer osteotomies could be fixated with screws. Shorter osteotomies
could be stabilized with Kirschner wires or wire loops.
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14. Fallat LM. Pathology of the fifth ray, including the tailor's bunion deformity. Clin Podiatr Med Surg 1990;7:689-715.
15. Rappaport MJ. Wedge osteotomy for tailor's bunion. In: McGlamry ED, ed. Reconstructive surgery of the foot and leg. New York: Intercontinental Medical Book, 1974:127-134.
16. Frankel JP, Turf RM, King BA. Tailor's bunion: clinical evaluation and correction by distal metaphyseal osteotomy with cortical screw fixation. J Foot Surg 1989;28:237-243.
17. McKeever DC. Excision of the fifth metatarsal head. Clin Orthop 1959; 13:321-322.
18. Diebold PF, Bejjani FJ. Basal osteotomy of the fifth metatarsal with intermetatarsal pinning: a new approach to the tailor's bunion. Foot Ankle 1987;8:40-45.
19. Bishop J, Kahn A, Turha JE. Surgical correction of the splayfoot: the Giannestras procedure. Clin Orthop 1980;146:234-238.
20. Brown JE. Functional and cosmetic correction of metatarsus latus (splayfoot). Clin Orthop 1959;14:166-170.
21. Sponsel KH. Bunionette correction by metatarsal osteotomy: preliminary report. Orthop Podiatr North Am 1976;7:809-819.
22. Haber JH, Kraft J. Crescentic osteotomy for fifth metatarsal head lesions. J Foot Surg 1980;19:66-67.
23. Steinke MS, Boll KL. Hohmann-Thomasen metatarsal osteotomy for tailor's bunion (bunionette). J Bone Joint Surg Am 1989;71:423-426.
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26. Konradsen L, Nielsen PT. Distal metatarsal osteotomy for bunionette deformity. J Foot Surg 1988;27:493-496.
27. Catanzariti AR, Friedman D, Distazio J. Oblique osteotomy of the fifth metatarsal: a five year review. J Foot Surg 1988;27:316-320.
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29. Schoenhaus H, Rotman S, Meshon AL. A review of normal intermetatarsal angles. J Am Podiatry Assoc 1980;70:597-603.
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37. Dorris MF, Mandel LM. Fifth metatarsal head resection for correction of tailor's bunions and sub-fifth metatarsal head keratoma: a retrospective analysis. J Foot Surg 1991;30:269-275.
38. Kitaoka HB, Holiday AD. Metatarsal head resection for bunionette: long-term follow-up. Foot Ankle 1991;11:345-349.
39. Hohmann G. Fuss und Bien. Munich: JF Bergmann, 1951:145.
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42. Mygind H. Operations for hallux valgus. J Bone Joint Surg Br 1952; 34:529.
43. Throckmorton JK, Bradlee N. Transverse V sliding osteotomy: a new surgical procedure for correction of tailor's bunion deformity. J Foot Surg 1978;18:117-121.
44. Kitaoka HB, Holiday AD, Campbell DC. Distal chevron metatarsal osteotomy for bunionette. Foot Ankle 1991;12:80-85.
45. Moran MM, Claridge RJ. Chevron osteotomy for bunionette. Foot Ankle 1994;15:684-688.
46. Zvijac JE, Janecki CJ, Freeling RM. Distal oblique osteotomy for tailor's bunion. Foot Ankle 1991;12:171.
47. White DL. Minimal incision approach to osteotomies of the lesser metatarsals for treatment of intractable keratosis, metatarsalgia, and tailor's bunion. Clin Podiatr Med Surg
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48. Pontious J, Brook JW, Hillstrom HJ. Tailor's bunion: is fixation necessary? J Am Podiatr Med Assoc 1996;86:63-73.
49. Sakoff M, Levy AI, Hanft JR. Metaphyseal osteotomy for the treatment of tailor's bunions. J Foot Surg 1989;28:537-541.
50. Schabler JA, Toney J, Hanft JR, et al. Oblique metaphyseal osteotomy for the correction of Tailor's bunions: a 3-year review. J Foot Surg 1992;31:79-84.
51. Crawford ME. Fifth metatarsal bunionette deformity: aetiology and correction. Br J Podiatr Med Surg 1993;5:8-11.
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1987. Tucker, GA: Podiatry Institute, 1987:90-95.
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55. Gerbert J, Sgarlato TE, Subotnick SI. Preliminary study of a closing wedge osteotomy of the fifth metatarsal for correction of a tailor's bunion deformity. J Am Podiatry Assoc
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56. Estersohn HS, Scherer PR, Bogdan R. A preliminary report on opening wedge osteotomy of the fifth metatarsal. Arch Podiatr Med Foot Surg 1974;1:317-327.
57. Diebold PF. Basal osteotomy of the fifth metatarsal for the bunionette. Foot Ankle 1991;12:74-79.
58. Schwartz N, Williams JE, Marcinko DE. Double oblique lesser metatarsal osteotomy. J Am Podiatr Med Assoc 1983;73:218-220.
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PART 5 Transverse Plane Digital Deformities

Michael S. Downey
Michael C. McGlamry
Until recent years, discussion of the transverse plane deviation of lesser digits was given nothing more than cursory mention in the
literature. Whether this resulted from limited observation or oversight, unwillingness to describe a condition that was poorly understood,
or overshadowing by the more common sagittal plane contracture and subluxation of the digits can only be speculated. Fortunately, this
condition is now readily recognized and is described along with several hypotheses regarding the etiology, perhaps all of which have some
merit.
In this chapter, the transverse plane digital deformity is defined as the medial or lateral deviation of the longitudinal axis of the proximal
phalanx compared with the longitudinal axis of the metatarsal both clinically and radiographically (Fig. 113 ). Occasionally, splaying of
adjacent digits is noted.
Most frequently this problem seems to affect the second digit with medial subluxation at the metatarsophalangeal joint (MTPJ). This
condition was described as the “crossover second toe” by Coughlin (1 ). Whereas the condition is certainly more common at the second
MTPJ, the deformity does occasionally occur in other rays (Fig. 114 ).
Although transverse plane deformity of the lesser MTPJ is now well documented, its origin is not clearly understood, and its treatment is
not universally agreed on by clinicians. In recent years, many articles have suggested potential causes and have proposed potential
treatment options. This chapter reviews the currently popular ideas on the etiology, evaluation, and treatment of this still developing and
challenging clinical deformity.
ETIOLOGY
The transverse plane digital deformity seems to be the result of lateral capsular and collateral ligament disruption and displacement of the
plantar plate. The deformity can have a variety of causes and is likely multifactorial. Trauma is clearly the most commonly implicated
cause. Other espoused causes include biomechanical factors (e.g., a long second metatarsal), inflammatory joint disease, and anatomic
variants.
Although trauma is credited as the most frequent underlying cause of the transverse plane digital deformity, rarely can a focal initiating
incident be identified. More commonly, repetitive microtrauma is credited for causing the deformity. Anatomically, this may result from
gradual stretching or disruption of the lateral collateral ligament, joint capsule, and plantar plate. Coughlin (1 ) and Bogy (2 ) believed
that high-heeled or narrow-toed shoes may lead to chronic hyperextension or transverse plane forces at the MTPJ that destabilize the joint
over time. Thompson and Hamilton believed that a long metatarsal increased the amount of weight-bearing force through the associated
MTPJ and caused deterioration of the plantar plate with time (3 ).
Biomechanically, the deformity is often associated with a long or plantarflexed metatarsal, a structurally or functionally short adjacent ray,
or the presence of a previous stress fracture of an adjacent metatarsal. Each of these conditions leads to increased mechanical forces on
the lesser MTPJ and the potential for inflammatory synovitis of the joint. In turn, this may lead to rupture or attenuation of the collateral
ligaments, capsule, or plantar plate to cause the clinically evident transverse plane digital deformity. Miller described the
pathomechanical influence of the deep transverse intermetatarsal ligament on the development of a transverse plane deformity of the
second MTPJ (4 ). He stated that with a congenitally or iatrogenically short first metatarsal, the deep transverse intermetatarsal ligament
pulls the plantar plate and proximal phalanx of the second toe toward the hallux and thereby instigates transverse plane digital deformity.
Then, over time, the medial second MTPJ structures contract, and the thicker lateral joint structures stretch. As the plantar plate shifts
medially, it carries with it the flexor tendons, which are firmly held within the sheathed groove of the plantar plate. Once the flexor
tendons have moved medial to the vertical axis of the second MTPJ, their force vector pulls the second toe into further adduction. As the
imbalance proceeds, the first dorsal interosseous muscle and lumbrical muscle gain mechanical advantage amd also contribute to the
adduction deformity at the second MTPJ. Similarly, this mechanism is thought to cause the deformity when a metatarsal is pathologically
longer than its adjacent metatarsals.
Another example of a biomechanical origin is the common situation of a patient presenting with both a transverse plane digital deformity
and a hallux valgus deformity (Fig. 115 ). Careful biomechanical evaluation often reveals several findings, including a pronated foot with
significant obliquity of the midtarsal joint in stance and a hypermobile first ray with a hallux valgus deformity. When a hallux valgus
deformity is present, medial deviation of the second digit is even easier to explain. As the first metatarsal is relatively displaced medially,
significant tension is applied to the sesamoid apparatus. The sesamoid apparatus, in turn, applies significant medially directed tension to
the deep transverse intermetatarsal ligament, which is intimately associated with the medial aspect of the second MTPJ capsular
structures and plantar plate. This tension can cause medial subluxation or luxation of the plantar plate and flexor apparatus.
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FIG. 113. A-D: Severe transverse plane deformity of the second metatarsophalangeal joint with medial deviation or adduction. In C,
note the medial deviation of the longitudinal axis of the proximal phalanx of the second toe in relation to the longitudinal axis of the
second metatarsal. The angle formed between these two axes has been referred to as the “digital deviation angle.”
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FIG. 114. Severe transverse plane adduction deformity of all the lesser metatarsophalangeal joints.
FIG. 115. A,B: “Crossover” second toe deformity with associated hallux abducto valgus deformity.
Sagittal plane instability of the first ray may also lead to deviation of the lesser toe joints without transverse plane involvement of the first
MTPJ. Elevation of the first ray increases the relative loading of the lesser joints, and this may lead to chronic capsulitis and resultant
plantar plate rupture and flexor tendon dislocation.
Inflammatory joint disease and nontraumatic synovitis have been offered as causes of MTPJ deformity in the transverse plane (5 ).
Inflammatory conditions such as rheumatoid arthritis, psoriatic arthritis, Reiter's syndrome, and nontraumatic synovitis can cause synovial
tissue hypertrophy with eventual joint distention and later disruption of joint capsular and ligamentous structures. This can ultimately
result in a transverse MTPJ deformity. Typically, these deformities begin as a subtle medial or lateral deviation of the digit at the MTPJ. Yu
and Judge coined the term predislocation syndrome to describe the acute, subacute, or chronic inflammatory condition of a lesser MTPJ
that they believed was a precursor to a lesser MTPJ dislocation (6 ).
From a purely anatomic standpoint, Berens attributed some transverse plane digital deformities to the smaller medial plantar condyle of
the metatarsal head or the longer lateral aspect of the metatarsal head, both allowing medial deviation of the flexor apparatus (7 ). In
addition to the structural metatarsal abnormalities, the pull of the flexor digitorum longus tendon slip is oblique to the longitudinal axis of
the MTPJ. This oblique pull of the flexor tendon is accentuated in the pronated foot.
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EVALUATION
Evaluation of the transverse plane digital deformity includes the standard history and physical examination. Of particular importance are
any history of prior inflammatory joint conditions, a history of metabolic disease, a past surgical history, and a history of any local trauma
to the involved area. Careful evaluation should include inspection and palpation, evaluation of the local tissue temperature, active and
passive range of motion evaluation, stance evaluation, and radiographs.
Of specific interest, especially in the early stages of this problem, are localized edema or calor in the flexor tendon sheath or plantar plate
at the base of the involved digit or in the joint area. With a local increase in temperature or edema, an early joint problem can often be
suspected, even if deformity is not yet apparent. Similarly, significant tenderness is often appreciated with palpation of the base of the
proximal phalanx and plantarflexor plate area at the MTPJ level. In the visual absence of deformity, these findings can suggest problems
that may ultimately result in deformity.
Neuritic symptoms may often be present, and the diagnosis of an interdigital neuroma must be differentiated from a transverse plane
digital deformity. Patients with interdigital neuritis often complain of pain radiating into the toes, they have pain more localized to the
interdigital space than the MTPJ, and they have greater pain with Mulder's compression technique (8 ). A diagnostic injection of local
anesthetic into the joint typically helps patients with a deviated MTPJ problem, but it does not help those with interdigital neuritis (9 ).
Gentle, passive range-of-motion evaluation should show an accentuation of the deformity at the dorsal end range of motion, as may be
seen with a trackbound hallux valgus deformity. This finding is of particular interest because the primary underlying pathologic force with
lesser MTPJ transverse plane deviation seems to be dislocation of the flexor apparatus. Additionally, passive range-of-motion examination
may confirm any abnormality in the quality or quantity of motion. Poor quality of motion or crepitus, or decreased joint motion, may be
produced by an articular defect associated with local trauma, such as transient dislocation with cartilage damage at the time of injury or
relocation. Passive range-of-motion examination may also include the Lachman test (3 ,10 ), the dorsal drawer test (11 ), or the vertical
stress test (12 ) of the lesser MTPJ. These tests are similar and are performed with the metatarsal immobilized firmly in one hand and the
proximal phalanx held firmly in the other hand with approximately 20 to 25 degrees of dorsiflexion at the MTPJ (i.e., longitudinal axis of
the proximal phalanx relative to the longitudinal axis of the metatarsal) (Fig. 116 ). A vertical shear force is then applied, with an attempt
made to dislocate the proximal phalanx vertically at the MTPJ. Deland et al. defined a significantly positive test as more than 2 mm of
dorsal displacement (12 ).
Active range-of-motion evaluation often suggests dislocation of the flexor apparatus and plantar plate because the toe medially or
laterally deviates with flexion of the MTPJ. McGlamry found that eliciting the plantar Babinski reflex by stroking the plantar surface of the
foot results not in pure plantarflexion of the toes, but in limited flexion along with medial or lateral deviation in patients with transverse
plane deformities (13 ). Limited motion or pain with either passive or active range of motion can also suggest joint damage or arthritis.
The stance examination is particularly important because many of these deformities are not evident, especially in the early stages, on non-
weight-bearing examination. If weight-bearing evaluation is not possible, the stance position can be predicted with the use of the Kelikian
push-up test (i.e., manual loading of the plantar plates by applying pressure to the plantar aspects of the metatarsals). Note should be
taken of the transverse plane position as well as sagittal plane deviation of each of the lesser rays. Sagittal plane contracture is often
associated with the transverse plane deformity. A gap is often noted between toes when an isolated transverse plane deformity is present.
In other instances, all the toes deviate in the same direction. Often, patients with transverse plane deformity have concomitant sagittal
plane deformity, and the toe deviates medially or laterally during stance and also fails to purchase the weight-bearing surface.
Radiographic evaluation should be undertaken in relaxed stance. For obvious reasons, non-weight-bearing radiographs may not adequately
reflect the degree of the deformity. Although no standard angle has been reported in the literature, it is often helpful to record the digital
deviation angle or the angle created by the longitudinal axis of the proximal phalanx of the toe and the longitudinal axis of the metatarsal
shaft.
Other diagnostic imaging techniques have also been described, but they are usually unnecessary because the clinical findings typically
provide the clinician with the means to make the diagnosis. In the early stages of the process, when the condition is suspected without
significant clinical deviation of the MTPJ, magnetic resonance imaging may be helpful when the diagnosis is equivocal (14 , 15 , 16 ).
Magnetic resonance imaging shows gross pathologic changes within the tendon apparatus, joint, or plantar plate, but it also demonstrates
increased signal intensity even before any rupture or displacement of the flexor apparatus (Fig. 117 ). Arthrography has also been noted to
demonstrate partial or complete damage to the plantar plate as well as small defects in the joint surfaces (14 ).
The early condition that potentially leads to transverse plane deviation of the digit was well described by Yu and Judge as predislocation
syndrome (6 ). Coughlin similarly described various stages of crossover deformity: stage I, synovitis and mild deformity; stage II,
dorsomedial deviation; stage III, overlapping of the hallux; and stage IV, frank MTPJ dislocation (10 ). As with many conditions, early
understanding and diagnosis may be the key to the most successful treatments.
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FIG. 116. Clinical stress test of the lesser metatarsophalangeal joint (MTPJ) to check for stability. A: Initial position to evaluate the
second MTPJ. B: Dorsal stress applied. Note dorsal dislocation of proximal phalangeal base at the second MTPJ. More than 2 mm of
displacement is considered to be abnormal. C,D: The stress test may also be done with radiography or fluoroscopy. Radiographic
appearance before stress (C) and with stress applied (D).
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FIG. 117. Magnetic resonance imaging fat-saturation images of the lesser metatarsophalangeal joint (MTPJ) predislocation syndrome.
A: Coronal section through the forefoot. Both the second and third MTPJs are involved and demonstrate increased signal intensity in
the area of the plantar plate. B: Sagittal plane section of the second MTPJ. Note the increased signal intensity in the area of the
plantar plate and flexor tendon apparatus.
TREATMENT
Conservative Treatment
An appropriate trial of conservative care should be attempted before considering surgical intervention. This is especially true when a
patient presents in the early stages with capsulitis-type symptoms and is diagnosed with predislocation syndrome. In milder or acute cases
of transverse plane deviation of the digits or in cases of predislocation syndrome, treatment with digital strapping and taping, balance
padding, and oral antiinflammatory agents (nonsteroidal and steroidal agents as needed) may completely relieve the patient's symptoms.
Extra-depth or extra-width shoes and toe splints are used for subacute or more chronic conditions. Our preference for initial treatment
consists of mechanical therapy with a submetatarsal buildup or forefoot balance sling pad that off-loads the affected toe joint directly and
indirectly (Fig. 118 ). In conjunction with the mechanical treatment, nonsteroidal antiinflammatory drugs or oral steroids are administered
(e.g., methylprednisolone [double Medrol DosePak]) to reduce the associated capsulitis. A few carefully placed corticosteroid injections
are employed by many clinicians as well, although this approach is not without some controversy, because other investigators believe that
such injections can aggravate the deformity. In longerstanding or more severe cases, conservative treatment is seldom effective in
alleviating a patient's symptoms, and surgical treatment is often required. Moreover, if conservative treatment is attempted and the
deformity continues to progress or is persistently painful, surgical intervention is indicated.
Surgical Treatment
Many different surgical options have been described from simple percutaneous capsulotomy to complex repair and rebalancing of the joint
with or without osseous procedures. The specific procedures required should be based on the underlying cause, the degree of deformity,
the duration of symptoms, and the response to past treatment.
Soft Tissue Procedures

Soft tissue procedures for the correction of transverse plane digital deformities have been described including percutaneous or open
capsulotomy and capsulorrhaphy, extensor tendon lengthening or tenotomy, plantar plate release, relocation and repair, and tendon
transfer. Often, these soft tissue procedures are performed in a sequential or stepwise manner.
Simple capsulotomy of the MTPJ has been described (17 ), but it is rarely effective for complete correction of the transverse plane digital
deformity. This becomes obvious when one understands the origin of the deformity. Simple capsulotomy does not realign the displaced
flexor apparatus. Capsulotomy is only effective for full correction when an acute traumatic episode causing rupture of the joint capsule
has healed with significant medial or lateral scar contracture. In such a circumstance, release of the capsule on the side to which the toe is
deviating may be successful in correcting the deformity. More often, however, capsulotomy is used in combination with other procedures
to correct the deformity.
Similarly, capsulorrhaphy of the MTPJ and extensor tenotomy have been described, but they are rarely indicated as isolated procedures for
the correction of the transverse plane digital deformity. Capsulorrhaphy is performed on the side opposite the transverse plane deviation.
For example, in the medially deviated second toe, a lateral MTPJ capsulorrhaphy may be helpful as an adjunctive procedure in the
correction of the deformity. An extensor tendon lengthening or tenotomy can be helpful if the toe is deviating in both the transverse and
sagittal planes. Minimal transverse plane
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correction is achieved with an isolated extensor tendon lengthening or tenotomy.
FIG. 118. Conservative treatment modalities. A: Digital strapping to maintain the metatarsophalangeal joint alignment. B,C: Toe
separators, metatarsal pads, and digital sling pads are helpful in certain clinical situations.
Release of the plantar plate may be employed as an adjunct in repairing the transverse plane deformity. Plantar plate release is
performed through a dorsal longitudinal capsular incision, with care taken to protect the articular surface of the MTPJ. The collateral
ligament on the side of the joint to which the toe is deviating is then released. The capsule is retracted medially and laterally to allow
passage of a McGlamry metatarsal elevator or similar instrument. The joint should be held distracted and the elevator gently inserted to
avoid damage to the articular surface. The elevator is then rotated, thus advancing its leading or cutting edge plantarly and proximally.
Experience with this release and instrumentation confirms to the surgeon the significant adhesion of the plantar plate to the undersurface
of the metatarsal in the transverse plane digital deformity and severe hammer toe contracture. Although seldom effective as an isolated
procedure, the plantar plate release may prove an important component of the overall repair process in some patients. In the past, many
surgeons believed that once the plantar plate was released, correction could be gained by simply pinning the toe in a slightly
overcorrected position and allowing the plantar plate to “scar down” in the corrected alignment. In practice, this approach did not provide
reproducible, lasting correction. The reason may be, in part, that whereas the flexor plate may be relocated, in some patients the long
flexor tendon maintains a medial deviation beneath the MTPJ.
Ruch described a partial sectioning of the medial portion of the plantar plate for a medially deviated toe (18 ) (Fig. 119 ). He reported that
the procedure worked well for patients with milder cases of transverse plane digital deformity.
Although no specific follow-up reports are noted in the literature, Castellano described a direct plantar approach to repair and relocate
the displaced plantar plate and flexor apparatus (19 ,20 ). Ford and associates studied the lesser MTPJ stability provided by both flexor
tendon transfer and primary repair of the plantar plate in fresh-frozen cadaver specimens and concluded that primary repair of the plantar
plate is a viable alternative to the flexor tendon transfer (11 ). To perform a primary repair of the plantar plate, a plantar longitudinal
incision is placed directly under the involved MTPJ. Dissection is carried deeply to the MTPJ area. The plantar plate is identified, repaired
as needed, and directly sutured in a rectus position.
Various tendon transfers have also been used with varying degrees of success. These procedures seem to offer the most promise for future
nonosseous reconstruction of the transverse plane deviated lesser MTPJ.
In 1984, Collins and Collins described a threefold procedure they advocated for correction of a transverse plane digital deformity (21 ).
Their procedure consisted of the following: (a) sectioning of the short interosseous tendon on the side of the deviation; (b) dividing and
transferring the extensor digitorum longus tendon to a more central location at the base of the proximal phalanx; and (c) dividing the
contracted extensor sling. Unfortunately, this procedure failed to address the malposition of the plantar plate or flexor apparatus and has
not become popular.
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FIG. 119. A: Preoperative radiograph demonstrating early medial subluxation of the second metatarsophalangeal joint. B: Dissection
exposes the medial and lateral aspects of the medially deviated second metatarsophalangeal joint. C: Metzenbaum scissors are used
to section the medial one-half of the plantar plate. This incision enters the flexor canal, and the long flexor tendon to the toe is
visualized. D: Lateral capsulorrhaphy is performed. E: Postoperative radiograph 6 months after the relocation procedure. (From Ruch
JA. A surgical technique for repair of the “pre-dislocation syndrome.” In: Vickers NS, et al., ed. Reconstructive surgery of the foot
and leg: update '97. Tucker, GA: Podiatry Institute, 1997:7-10, with permission.)
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Although it is more effective for a sagittal plane MTPJ deformity, the flexor tendon transfer, also known as the flexor-to-extensor transfer,
has been popular as a corrective procedure for a transverse plane digital deformity. For a flexor tendon transfer, the contracted structures
on the side of the MTPJ to which the toe is deviated are released through a dorsal incision. Two plantar transverse incisions are then made
at the levels of the proximal and distal interphalangeal joints. The flexor longus tendon is isolated and released through the distal incision,
and it is brought out through the proximal incision. The tendon is then split longitudinally, and each end of the tendon is passed dorsally
around the medial or lateral sides of the proximal phalanx and is sutured together or to the extensor hood apparatus. Care must be taken
to pass the tendon slips deep to the neurovascular structures. In a study that included six feet with medial crossover deformity of the
second toe, Thompson and Deland reported success with the procedure. Although these authors concluded that the flexor tendon transfer
does not reliably reduce the joint anatomically, they believed that it does provide satisfactory pain relief albeit with some joint stiffness
(22 ).
In 1992, Deland and colleagues described and studied a more anatomic reconstruction of the lesser MTPJ with restoration of the collateral
ligaments of the joint with a dorsal or plantar interosseous tendon (12 ) (Fig. 120 ). In their procedure, the interosseous tendon graft is
harvested just distal to its musculotendinous junction and is dissected to the level of the plantar plate. Thus, the tendon is left attached to
the proximal phalangeal base and plantar plate and is freed proximally. A 2.0-mm drill hole is then made 2 to 3 mm proximal and inferior
to the lateral epicondyle of the metatarsal. The tendon is then passed through the hole, placed under appropriate tension (i.e., tension
significant enough to correct the deformity and yet not compress the joint), and sutured in place. Alternatively, a small bone anchor can
be used to accomplish the tenodesis of the tendon to the metatarsal. Deland et al. performed their procedure in 10 cadaver specimens and
found that it provided consistent stability and no restriction of MTPJ motion. To date, their laboratory-proven procedure has not been
reported in clinical trials.
In 1995, Ruch described two methods of transferring the extensor digitorum brevis (EDB) tendon for correction of a transverse plane digital
deformity (23 ). In the first technique, a portion of the EDB tendon was harvested as a free tendon graft and was used through drill holes in
the proximal phalanx and metatarsal to recreate a medial ligamentous structure in a laterally deviated toe (Fig. 121 ). In the same article,
Ruch also described transfer of the EDB to the plantar lateral aspect of the base of the proximal phalanx for a medial transverse plane
digital deformity (Fig. 122 ). Ruch reported only one clinical case of each reconstruction, and further studies on these tendon transfers
have not been reported.
FIG. 120. A: Anatomic drawing shows the relationship between the interosseous muscle tendon (IT) and the plantar plate (PP). The
dotted line demonstrates where the tendon is sectioned. B: A drill hole is created in the metatarsal for passage of the tendon slip. C:
The tendon slip is passed through the hole and is tightened until correction of the deformity is achieved. The tendon is then sutured
to the soft tissues on the opposite side of the metatarsal or is sutured back on top of the metatarsal to itself. (Redrawn from Deland
JT, Sobel M, Arnoczky SP, et al. Collateral ligament reconstruction of the unstable metatarsophalangeal joint: an in vitro study. Foot
Ankle 1992;13:391-395, with permission.)
In 1999, Haddad and associates described another method of using the EDB tendon to reconstruct the medially deviated lesser MTPJ (24 )
(Fig. 123 ). They isolated the EDB tendon along its length and sectioned it approximately 4 cm proximal to the MTPJ. The distal stump was
then rerouted from distal to proximal, plantar to the deep transverse intermetatarsal ligament, and lateral to the MTPJ. The joint was
then held in a corrected, neutral position, and the tendon was reapproximated to itself, thus completing an end-to-end repair of the
rerouted EDB tendon. Extensor digitorum longus tendon lengthening, dorsal and medial capsular release, and plantar plate release or
repair can be performed as needed. Haddad et al. performed their procedure on 19 feet and reported good results with minimal loss of
MTPJ motion. These authors compared the results of their EDB tendon transfer to the flexor tendon transfer procedure (which they
performed on 16 feet) and found that both techniques provided good results for the transverse plane deformity, but less recurrence of
deformity and more joint stiffness were associated with the flexor tendon transfer. They therefore advocated the EDB transfer for Coughlin
stage I and stage II and flexible stage III deformities and the flexor tendon transfer for Coughlin rigid stage III and stage IV deformities.
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FIG. 121. A,B: Lateral dislocation of the lesser metatarsophalangeal joint of the right foot. Base resection of the proximal phalanx
may be performed, if necessary. Z-plasty lengthening of the extensor digitorum longus tendon is accomplished along with proximal
sectioning of the extensor digitorum brevis (EDB) tendon to create a long tendinous strap for transfer. C: A 2.0-mm drill hole is
created from distal lateral to proximal medial through the proximal phalangeal base. D: The EDB is rerouted through the drill hole. E:
The drill hole through the neck of the metatarsal is oriented from proximal lateral dorsal to plantar medial distal. F,G: The EDB
tendon slip is then routed through the drill hole in the metatarsal from medial to lateral. The tendon is tightened until the deformity
is corrected, preferably without jamming the medial aspect of the joint. H: The remaining soft tissues are repaired. A K-wire is
inserted, as needed, to help maintain the corrected position. (From Ruch JA. Use of the EDB tendon transfer for muscle-tendon
balance of the lesser MTPJ. In: Camasta CA, Vickers NS, Carter SB, eds. Reconstructive surgery of the foot and leg: update '95.
Tucker, GA: Podiatry Institute, 1995:114-118, with permission.)
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FIG. 121. Continued.
FIG. 122. A,B: Medial subluxation of a second metatarsophalangeal joint of the left foot. C,D: The extensor digitorum brevis (EDB)
tendon slip is isolated and detached from its distal insertion. E,F: The EDB tendon slip is drawn through the plantar lateral aspect of
the base of the proximal phalanx and is sutured back onto itself. (From Ruch JA. Use of the EDB tendon transfer for muscle-tendon
balance of the lesser MTPJ. In: Camasta CA, Vickers NS, Carter SB, eds. Reconstructive surgery of the foot and leg: update '95.
Tucker, GA: Podiatry Institute, 1995:114-118, with permission.)
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FIG. 122. Continued.
FIG. 123. Extensor digitorum brevis (EDB) tendon transfer as described by Haddad et al. A: Z-plasty lengthening of extensor
digitorum longus (EDL) tendon and sectioning of EDB tendon with stay sutures. B: Rerouting of distal stump of EDB plantar to the
deep transverse intermetatarsal ligament, to preserve the distal attachment of the tendon. C: The EDB tendon is repaired with
appropriate tension to correct the transverse plane deformity. The EDL is repaired, and a Kirschner wire is used to assist in
maintenance of the correction. (Redrawn from Haddad SL, Sabbagh RC, Resch S, et al. Results of flexor-to-extensor and extensor
brevis tendon transfer for correction of the crossover second toe deformity. Foot Ankle Int 1999;20:781-788, with permission.)
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Finally, in resistant cases, syndactyly with or without a proximal phalangeal base resection of the deviated toe may be considered (13 ).
The deviated toe is syndactylized to an adjacent rectus digit.
Osseous Procedures
In reviewing the literature relative to transverse plane digital deformities, osseous procedures described have run the gamut from joint-
preservation procedures, such as transpositional or shortening metatarsal osteotomies, to joint-destructive procedures, such as partial or
complete metatarsal head or phalangeal base resections or implant arthroplasty. A cadaveric study by Deland and Sung on the medial
crossover toe deformity suggested that soft tissue procedures alone may not be predictably capable of fully correcting more severe
deformities (25 ). These investigators suggested that bony procedures may be necessary “to alleviate some of the stress on the soft
tissues” (25 ).
FIG. 124. Distal transpositional osteotomy for the correction of a medial crossover second toe deformity. A: Preoperative appearance
of the deformity. B: Transpositional osteotomy of the distal second metatarsal. Temporary fixation in place. Permanent fixation was
achieved with internal absorbable fixation pins. C: Final position before closure. A Kirschner wire is inserted to help maintain the
corrected position of the metatarsophalangeal joint for 4 to 6 weeks.
Joint-Preservation Procedures
Metatarsal osteotomies have been described for the correction of the transverse plane digital deformity. Their genesis arises from the
hypothesis that realignment of the joint may better be accomplished by placing the joint back on top of the plantar plate, as opposed to
trying to force the plantar plate back underneath the head. This most commonly is accomplished with a distal osteotomy of the metatarsal
and transposition of the capital fragment in the direction of the deviation of the toe or, in other words, back on top of the flexor tendon
and plantar plate. The limitation of this approach is the instability that is generated with the transposition of the metatarsal head.
Transposition of roughly one-third of the width of the metatarsal head can be achieved, and undercorrection will occur if more
transposition is required. Early results of these osteotomies have been promising and have shown some improvement in the alignment of
the joints.
Transpositional metatarsal osteotomy was first described by Johnson and Price in 1989 as an aid in relocating the flexor apparatus (26 ).
They presented cases in which either a proximal or a distal metatarsal osteotomy was performed, transposing the distal aspect of the
metatarsal in a medial direction, as needed for realignment of a medially deviated MTPJ (Fig. 124 ). These investigators did this in
conjunction with appropriate soft tissue rebalancing of the joint. They reported successful realignment of the joint in the two cases they
reported.
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In 1992, Bogy et al. described a through-and-through osteotomy performed in the distal metaphysis of the metatarsal (2 ). The osteotomy
was performed with a rongeur with slightly more bone taken laterally. The capital fragment was then transposed medially for a medially
deviated toe and was fixed with a 0.045-inch Kirschner wire (K-wire). The procedure was performed in seven patients with eight medially
deviated second toes. Six patients were interviewed postoperatively; three were noted to be very satisfied and three were noted to be
satisfied with their outcomes. No patients were noted to be dissatisfied with their result. In some cases, a decrease in joint motion and
lack of toe purchase were noted objective sequelae.
In 1996, Goforth and Urteaga discussed a distal through-and-through transpositional osteotomy for the correction of a crossover second toe
deformity (27 ). The osteotomy was fixed with a small screw or a K-wire. They performed the procedure on seven toes that overlapped the
hallux and reported good alignment in all cases, but some problems with toe purchase were reported.
In 1996, Berens postulated that a distal head osteotomy could be performed to realign the joint without transposition of the metatarsal
head (7 ) (Fig. 125 ). A distal wedge cut was described to realign the articular surface of the lesser metatarsal, similar to the Reverdin
osteotomy of the first metatarsal. The base of the wedge was placed on the side of the joint opposite the direction of deviation of the
digit. Berens determined the most desirable level for the osteotomy to be just proximal to the articular cartilage of the metatarsal head
and not in the central portion of the metatarsal head. The osteotomy was then fixed with absorbable fixation or a K-wire. Berens reported
performing this osteotomy in 25 patients with a medially deviated second toe. He reported that patient satisfaction was achieved in all his
cases, although poor alignment continued in 3 cases.
Several surgeons have espoused shortening osteotomies as adjunctive procedures for the correction of a transverse plane digital deformity
(4 ,28 ,29 ). In 1996, Graziano performed a shortening, chevron osteotomy in the distal metatarsal metaphysis when transverse plane
deformity persisted after a complete MTPJ release (28 ). In 1998, Miller described either a shortening, cylindric, diaphyseal osteotomy with
plate and screw fixation, or a step-down Z osteotomy with screw fixation (4 ) (Fig. 126 ). He advocated both osteotomies for cases in which
the transverse plane deformity was believed to be secondary to a long metatarsal. Tonka and colleagues compared the Weil and Helal
shortening osteotomies for primarily dorsally dislocated MTPJs, but they did conclude that “even correction of preoperatively deviated
toes by medial or lateral shift of the capital fragment is possible using the Weil osteotomy” (29 ).
Fixation of the head osteotomies can be accomplished by any means desired. Absorbable pins are generally effective and can be less
difficult than trying to stabilize the fragment with traditional wires from a proximal direction. When absorbable fixation is used, two
crossed pins are inserted from an intraarticular position to fix the free, distal fragment, thus preventing rotation and any further
translocation.
Another procedure espoused for the correction of the deviated lesser toe is a proximal phalangeal base osteotomy. Davis and colleagues
used a hand awl to perforate the cortex of the phalangeal base on the side opposite the direction of digital deviation (i.e., perforate the
medial cortex with lateral transverse plane deviation) (30 ) (Fig. 127 ). The toe is then shifted into improved alignment and is fixed with a
K-wire. These surgeons described the indications for the procedure as: (a) resistant or recurrent angular deformity of the lesser toe, and (b)
persistent angular deformity of the lesser toe after complete soft tissue release of the deformity at the MTPJ. This procedure often leaves
a residual subluxation or dislocation at the MTPJ, and it was not described as a primary technique.
Joint-Destructive Procedures
In some cases, it may become evident that it will be impossible to rebalance the joint and achieve normal function because of severe long-
standing soft tissue contracture, poor soft tissue quality that will not support repair, or intraarticular damage. In such instances, joint-
destructive procedures may allow for improved alignment and function. Procedures in this category, which were described in the past,
include partial or complete metatarsal head resection, phalangeal base resection, and lesser MTPJ implant arthroplasty.
Although complete metatarsal head resection is effective in the short term, it frequently leads to dorsal contracture of the associated toe
and disruption of the metatarsal parabola. This often produces new symptoms at adjacent joints or metatarsals that make it a less
attractive option for procedural selection (31 ). Similarly, although partial metatarsal head resections are popular (1 ,31 ), these can also
result in transfer metatarsalgia, floating toes, and recurrent deformity.
Base resection of the proximal phalanx is another option (32 ,33 ). The advantage of the base resection-type procedure over metatarsal
head resection lies in that the metatarsal parabola is not directly disturbed. Dorsal displacement of the digit is still a potential problem;
however, the likelihood of this sequelae can be diminished if the long flexor tendon is reattached to the remaining or “new” base of the
proximal phalanx, as described by Green (32 ). This procedure is performed with a nonabsorbable suture. This is analogous to the
modification of the Keller arthroplasty of the first MTPJ in which the flexor hallucis longus tendon is reattached to the remaining portion of
the proximal phalanx. In the hallux, this procedure has been found to increase stability and purchase of the hallux. Conklin and Smith
reported that 12 of 17 patients (71%) who had a proximal phalangeal base resection performed for a transverse plane digital deformity
were satisfied with the result (33 ). These surgeons did not perform the flexor reattachment modification. In the dissatisfied patients, the
predominant complaints were recurrent deformity, hammering of the digit, and metatarsalgia.
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FIG. 125. Wedge osteotomy as described by Berens (7). A,B: Preoperative clinical and radiographic appearance of the medially
deviated second metatarsophalangeal joint. C,D: Wedge osteotomy of the second metatarsal head with the base of the wedge lateral
and the apex medial. Soft tissue rebalancing at the metatarsophalangeal joint and an arthroplasty of the proximal interphalangeal
joint were also performed simultaneously. E,F: Immediate postoperative clinical and radiographic appearance. The osteotomy is
fixed with a Kirschner wire in this case.
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FIG. 126. Shortening Z osteotomy of the second metatarsal with multiple screw fixation for a medially deviated second
metatarsophalangeal joint. A: Preoperative radiographic appearance of the foot. Note the long second metatarsal. B: Postoperative
radiograph. The patient also had concomitant metatarsus primus elevatus and underwent a simultaneous first metatarsocuneiform
joint arthrodesis. (Courtesy of Stephen J. Miller, D.P.M.)
FIG. 127. Technique for proximal phalangeal base osteotomy. A: An awl or saw is used to perforate the medial cortex in chronic
lateral deviation of a lesser toe. B: The toe is shifted into a corrected position and is fixed with a Kirschner wire. (Redrawn from
Davis WH, Anderson RB, Thompson FM, et al. Proximal phalanx basilar osteotomy for resistant angulation of the lesser toes. Foot
Ankle Int 1997;18: 103-104, with permission.)
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Lesser MTPJ implant arthroplasty is generally reserved for older patients, for rare situations such as salvage of previous failed procedures,
or for cases in which other joint-destructive procedures are less desirable. Cracchiolo and associates reported that 63% of their patients
were satisfied when a lesser MTPJ silicone implant arthroplasty was performed for an MTPJ deformity (34 ). Transfer metatarsalgia was the
main long-term complication.
Our Preferred Technique

In most instances, we believe that sequential release and repair of the soft tissues are indicated in the correction of the transverse plane
digital deformity. The procedure begins with an extensor tendon lengthening and associated extensor hood recession, a dorsal MTPJ
capsulotomy, and a plantar plate release. After the plantar plate is released, the alignment of the joint is reevaluated. In most cases,
incomplete reduction of the deformity is noted. The next step in the sequential release of the transverse plane digital deformity involves
capsulotomy of the joint, again on the side of deviation of the toe. The capsule should be released plantarly until the long flexor tendon is
identified. Again, after capsulotomy, the alignment of the joint is reevaluated. If minimal deformity remains, or if the deformity is fully
corrected, a capsulorrhaphy of the opposite side of the joint and final closure may be performed. If deformity continues after the
capsulotomy, then other procedures are considered including a plantar plate repair or relocation, collateral ligament repair with EDB or
interosseous tendon slip, EDB transfer, flexor tendon transfer, or osseous correction. Correction should continue until full realignment of
the MTPJ is accomplished. In most instances, the MTPJ is stabilized with a 0.062-inch K-wire. If digital deformity exists, it is concomitantly
corrected with an arthroplasty or arthrodesis, as indicated.
Postoperative Management
Postoperatively, these patients are typically managed with protected weight bearing in a surgical shoe. An accommodative insole is placed
into the surgical shoe to protect the area from weight bearing as much as possible. If a metatarsal osteotomy is performed, non-weight
bearing with or without a short leg cast may be employed for 4 to 12 weeks. K-wires are typically maintained for 3 to 6 weeks, with longer
times used for more severe deformities and when digital arthrodesis is used as an adjunctive procedure. The patients are allowed to
resume wearing athletic shoes on removal of the dressings and K-wires, and full unrestricted activities are permitted at 10 to 12 weeks.
Complications
Complications of metatarsal osteotomies have included delayed union or nonunion, malunion, displacement of the capital fragment,
incomplete correction of the deformity, and fracture through the previous osteotomy site. Delayed union and nonunion seem to be more
prevalent with greater osteotomy displacement. Accurate alignment of the capital fragment can also be challenging as a result of
complete freedom of rotation in the coronal plane after completion of a through-and-through osteotomy. The best results are achieved by
keeping the osteotomy at the midpoint of the metatarsal head or distally, though the cut can be oriented obliquely from dorsal distal to
plantar proximal to facilitate fixation and to generate slightly greater stability.
The other commonly observed complications have been recurrence of the deformity, weakness or lack of purchase of the toe, and transfer
metatarsal problems. Less common complications include prolonged digital edema, vascular compromise of the toe, nerve entrapment or
damage, infection, and joint stiffness or arthritis.
CONCLUSION
Despite significant advances in the correction of the transverse plane digital deformity, difficulty in achieving predictable results persists.
Attempts at refinement of the procedures and evaluation of alternative options are ongoing. In selecting surgical procedures, the ultimate
goals of surgical repair are restoration of anatomic alignment and function of the joint using any procedure or combination of procedures
necessary. Moreover, care should be taken to minimize disruption of the normal weight-bearing parabola to prevent transfer of pressures
to adjacent metatarsals as well as to maintain normal flexor function.
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6. Yu GV, Judge M. Predislocation syndrome of the lesser metatarsophalangeal joint: a distinct clinical entity. In: Camasta CA,
Vickers NS, Carter SR, eds. Reconstructive surgery of the foot and leg: update '95. Tucker, GA: Podiatry Institute, 1995:109-112.
7. Berens TA. Laterally closing metatarsal head osteotomy in the correction of a medially overlapping digit. Clin Podiatr Med Surg
1996;13: 293-307.
8. McNerney JE. Sports-medicine considerations of lesser metatarsalgia. Clin Podiatr Med Surg 1990;7:645-687.
9. Weinfeld SB. Evaluation and management of crossover second toe deformity. Foot Ankle Clin 1998;3:215-228.
10. Coughlin MJ. Subluxation and dislocation of the second metatarsophalangeal joint. Orthop Clin North Am 1989;20:535-551.
11. Ford LA, Collins KB, Christensen JC. Stabilization of the subluxed second metatarsophalangeal joint: flexor tendon transfer versus
primary repair of the plantar plate. J Foot Ankle Surg 1998;37:217-222.
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12. Deland JT, Sobel M, Arnoczky SP, et al. Collateral ligament reconstruction of the unstable metatarsophalangeal joint: an in vitro
study. Foot Ankle 1992;13:391-395.
13. McGlamry ED. Lesser ray deformities. In: McGlamry ED, Banks AS, Downey MS, eds. Comprehensive textbook of foot surgery, 2nd
ed. Baltimore: Williams & Wilkins, 1992:321-378.
14. Karpman RR, MacCollum I. Arthrography of the metatarsophalangeal joint. Foot Ankle 1988;9:125-129.
15. Yao L, Do HM, Cracchiolo A, et al. Plantar plate of the foot: findings on conventional arthrography and MR imaging. AJR Am J
Roentgenol 1994;63:641-644.
16. Yao L, Cracchiolo A, Farahani K, et al. Magnetic resonance imaging of plantar plate rupture. Foot Ankle Int 1997;17:33-36.
17. Jimenez AL. Digiti adductus. In: Camasta CA, Vickers NS, Ruch JA, eds. Reconstructive surgery of the foot and leg: update '93.
Tucker, GA: Podiatry Institute, 1993:68-71.
18. Ruch JA. A surgical technique for repair of the “pre-dislocation syndrome.” In: Vickers NS, ed. Reconstructive surgery of the foot
19. Castellano BD. The overlapping second toe: a preliminary investigation. In: DiNapoli DR, ed. Reconstructive surgery of the foot
20. Castellano BD. Transverse plane dislocations of the lesser metatarsophalangeal joints. In: Ruch JA, Vickers NS, eds.
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21. Collins B, Collins W. Surgical correction of transverse plane deformities at the lesser metatarsophalangeal joints. J Foot Surg
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22. Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle 1993;14:385-
388.
23. Ruch JA. Use of the EDB tendon transfer for muscle-tendon balance of the lesser MTPJ. In: Camasta CA, Vickers NS, Carter SB, eds.
Reconstructive surgery of the foot and leg: update '95. Tucker, GA: Podiatry Institute, 1995:114-118.
24. Haddad SL, Sabbagh RC, Resch S, et al. Results of flexor-to-extensor and extensor brevis tendon transfer for correction of the
crossover second toe deformity. Foot Ankle Int 1999;20:781-788.
25. Deland JT, Sung IH. The medial crossover toe: a cadaveric dissection. Foot Ankle Int 2000;21:375-378.
26. Johnson JB, Price TW IV. Crossover second toe deformity: etiology and treatment. J Foot Surg 1989;28:417-420.
27. Goforth WP, Urteaga AJ. Displacement osteotomy for the treatment of digital transverse plane deformities. Clin Podiatr Med Surg
1996; 13:279-292.
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29. Tonka HJ, Muhlbauer M, Zettl R, et al. Comparison of the results of the Weil and Helal osteotomies for the treatment of
metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999;20:72-79.
30. Davis WH, Anderson RB, Thompson FM, et al. Proximal phalanx basilar osteotomy for resistant angulation of the lesser toes. Foot
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Chapter 4
Implants
John V. Vanore
Joint implant arthroplasty may be used to correct deformity, to restore motion, or to eliminate pain. Over the last 4 decades, significant
advances have been made in biomedical engineering, biomaterials and surgical techniques. Implant arthroplasty has evolved from the
simple silicone hemiimplant, through an era of commonplace use of the silicone hinged implant, to hopeful total joint designs analogous to
knee and hip replacement, and then back to simple metallic hemiimplants.
Many of the same problems that perplexed early pioneers of joint implant surgery continue to provide similar problems for today's surgeons.
The selection of biomaterials, the design of the joint implants, and the response of the body to these implanted devices remain as objects
of study. These devices have been manufactured from a variety of materials or combination of materials. The implants have varied greatly
from simple designs with basic concerns to implant systems that attempt to incorporate design parameters for the complex biomechanics
of the first metatarsophalangeal joint (1 , 2 , 3 ). The most difficult conclusion that surgeons have come to appreciate may be that the
simple designs offer advantages over the complex ones.
Few topics have sparked as much debate as that of first metatarsophalangeal joint implant arthroplasty. There are advocates and critics of
the various implants and those who have completely abandoned or condemned the use of these devices (4 ). Surgeons' views have evolved
with the changing clinical and medicolegal situations. Yes, there have been failures for numerous reasons, from use in patients who were
simply too active to use in patients who did not have sufficient joint disease to warrant a joint-destructive procedure (2 ,5 ).
Biomechanical problems are often the most difficult to avoid, and this may simply be an error of patient selection by the surgeon or
unrealistic expectations on the part of the patient (6 ).
EVOLUTION OF FIRST METATARSOPHALANGEAL JOINT IMPLANT ARTHROPLASTY

The reader is referred to earlier editions of this textbook for many of the historical details regarding first metatarso-phalangeal joint
implant arthroplasty (7 ,8 ). Generally, there were some early total joint systems, for example, those devised by Weil and Smith (9 ) and
the Johnson Mayo Clinic (10 ,11 ) designs for the first metatarsophalangeal joint, but once Swanson developed the silicone hemiimplants
and later the double-stem hinged implants, this can be viewed as stimulation for the first widespread use of implantation in these joints.
Early on, clinicians were mistaken in their application of these devices. Several errors were noted. Implants were used in patients who did
not have joint disease to warrant a joint-destructive procedure, and implants were used in young patients whose activity demands were
more than the implant and reconstruction could withstand. Implants, specifically silicone hemiimplants, were used in situations in which
complication were likely, for example, in patients generally too young and too active, although end-stage degenerative arthrosis may have
been present (12 ).
Double-stem silicone implants were widely employed in the 1980s, initially with the Swanson design predominating, but numerous other
double-stem hinge silicone implants were developed and were marketed through Sutter Biomedical (San Jose, CA). These later implants
attempted to incorporate design modifications to improve the functional result. Most notable of these was the Lawrence design, which
limited resection of the hallucal phalangeal base in an attempt to avoid detachment of the short flexor tendon (13 ). Later, with the
introduction of titanium grommets, the Swanson design regained popularity because of the protective function provided by the grommets
that improved the durability of the reconstruction (2 ,14 ).
In the late 1980s, the crisis surrounding silicone breast implants made the daily headlines, and people became aware of silicone as a
biomaterial, be it good or bad. During this time, other implants similar in design to their silicone counterparts were developed, but they
failed to achieve much clinical success, the most notable of these being pyrolytic carbon by Intermedics Orthopedics (15 ). Little clinical
success
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was noted with this implant, but it heralded the oncoming new generation of total joint systems. The development of the Biomet Total Toe
(Biomet, Warsaw, IN) by Koenig and Dow Corning-Wright was the first of a group of true total joint systems offering various design
characteristics (16 ). Although four additional total joint systems were eventually introduced, none achieved widespread usage (2 ). In fact,
as each successive total joint system was devised, it incorporated various features for potential correction of deformity and restoration of
normal anatomy and bony alignment. None of these joint systems was simple to insert, and most were extremely complex even for the
experienced surgeon (2 ). Postoperatively, complications, not unlike those of prior implants, were noted, and the functional advantages
that these implants were intended to produce did not materialize (6 ).
Out of the past came the introduction of an old concept, the hemiphalangeal metal implant. Townley had been using a thin metallic button
with a small phalangeal stem for more than 40 years. In 1994, this device was reported in the literature, and his success attracted renewed
interest in the concept of hemiarthroplasty (17 ). Swanson et al. had been using titanium small joint implants similar in design to his
silicone devices since the middle 1980s (18 ), and they reported a good success rate in both the foot and hand. Unfortunately, Swanson did
not change the basic design of the hemigreat toe when it was remanufactured of titanium. In 1998, Lawrence, an originator of several
silicone implants, introduced a metallic phalangeal implant incorporating design features of both earlier silicone implants and Townley's
implant (19 ). Lawrence's implant offers a thin articulating base whose geometry more closely matches the anatomy that it was intended to
replace. It allows for limited resection of the phalangeal base, particularly plantarly.
Some surgeons continued to use hinged silicone implants in a discriminatory manner and to achieve good results with limited complications.
During the late 1990s, several other double-stem silicone implants were introduced, including the GAIT (Sgarlato Labs, San Jose, CA) design
by Sgarlato Labs and the Primus (Futura Biomedial, San Diego, CA) by Futura (20 ). Later, protective grommets were released for the
Futura implant.
As yet, I have not achieved a totally satisfactory joint implant for the first metatarsophalangeal joint. Historically, total joint replacement
has been difficult and has not achieved widespread usage, and failed total joint arthroplasty is extremely difficult to revise (21 ). The
hemiimplant offers a design that is easy to insert, may be associated with less complications particularly with regard to durability and
function, and is usually not too difficult to revise, if necessary.
BIOMATERIALS OF IMPLANT ARTHROPLASTY

Most materials chosen for joint implantation were considered because of expected inert qualities. In the modern era of joint replacement,
metals have been the initial choice, as for example, in total joint replacement of the hip (22 , 23 , 24 ). So too in the foot, Swanson began
with stainless steel to replace the first metatarsal head (2 ,25 ). Soon, total joint systems became a composite system of components of
various materials generally incorporating a metallic convex component articulating with an ultrahigh-molecular-weight (UHMW)
polyethylene concave component. Many different concepts regarding bonding or adherence of implant materials to bone have evolved.
Initial implants for the hip, toe, and other areas were not cemented, but simply impacted or “press fit.” Failures were encountered as a
result of resorption and loosening. Acrylic bone cement was used as a grouting agent that stabilized the implant by means of mechanical
interlock. The phenomenon of biologic ingrowth of bone then heralded the next generation of implants with surface coatings to enhance
biointegration, for example, plasma-sprayed titanium or hydroxyapatite. A major problem with revision was then encountered with loss of
bone mass. Today, major joint replacement systems are combinations of components manufactured for biologic ingrowth, mechanical
interlock, press fit, screw fixation, or cementing. In each area of the intended arthroplasty, the most beneficial interface between implant
and biologic material is assessed and is implemented.
Metallic and nonmetallic materials are used in joint implant systems (Table 1 ). The body's corrosive environment and its poor tolerance or
toxicity to even trace amounts of many elements make only a few metals potentially useful (24 ,26 ).
Metals
Metals generally begin as a liquid, in a heated state, and as they cool, metals take on a crystalline form. During this process, grains
develop, and the size of the grain, its uniformity, and its orientation contribute to the physical properties of the metal. The crystalline
structure of pure metals is often manipulated with the forging process or inclusion of additional elements that thus form mixtures or alloys.
Both alloys and pure metals are used in the formation of joint implants. Some of the major metals are discussed.
Stainless Steel
Stainless steels have long been the biomaterials of choice for fixation systems because of their combination of strength, machinability, and
cost of production. Stainless steel is an iron-based alloy with a chromium content of between 11% and 30% that comes in many forms,
although generally either type 316 or 317 low carbon varieties are used in orthopedic applications (27 ). Stainless steels are less likely to
be used in the joint implant market, but they deserve mention. Stainless steels possess good physical properties (ultimate tensile strength)
for tensile loading, which is useful in fixation implants. Stainless steels have poor wear characteristics as a force-bearing surface as well as
corrosion deficiencies, and so in the modern age of joint implantation,
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the use of stainless steels has essentially been abandoned (26 ,28 ).
TABLE 1. Biomaterials in implant arthroplasty

Biomaterials Predominant use Physical properties
Metals
Stainless steels Fixation implants Excellent tensile strength, poor bearing material
Excellent compressive strength, good bearing
Cobalt chromium alloys TJR: convex surface surface
Titanium (chemically TJR: trays for concave
pure) surface Excellent compressive strength
Titanium alloys Fixation implants Good biointegration
TJR: stems; fixation
implants
Polymers
Polyethylene (UHMW) TJR: concave surface Microfragmentation
Polymethylmethacrylate Bone cement Interface
Silicone Interpositional implants Viscoelastic
Soft tissue augmentation
Ceramics TJR: bearing surfaces Excellent coefficient of friction
Carbon Investigational Low elastic modulus
TJR, total joint replacement; UHMW, ultrahigh-molecular weight.
Cobalt Chromium
Cobalt chromium metals are alloys with cobalt as the dominant element with lesser degrees of chromium and nickel. Cobalt may be
present in a weight percent basis of 50% to 60% with a 20% to 30% chromium content and additional elements of nickel, molybdenum, and
tungsten varying mainly on wrought versus cast alloys. Tungsten is formulated in wrought alloys to provide ductility, the deformation of a
material that includes both elastic and plastic strain. Cast alloys are manufactured through molds with liquid metals that solidify in the
desired shape, whereas wrought alloys are heated and forged with application of “pressing” techniques. Chromium improves corrosion
resistance and nickel adds strength, but it is a bioactive element and may elicit tissue reactions including hypersensitivity (29 , 30 , 31 ).
Cobalt chrome alloys are often chosen for the metallic component in total joint systems because of their excellent corrosion resistance and
wear properties with the articulated polymeric component, usually UHMW polyethylene (24 ,28 ). This alloy is generally heavy in overall
weight but possess excellent strength in compression, a desirable characteristic for joint implants. The manufacturing process is also more
involved with the use of cobalt chromium alloys and is more expensive, particularly for fabrication of small joint implants.
Vitallium is the trade name of a cobalt chromium that was used in the Seeburger implants. During the development of a Swanson metallic
hemiimplant, Weil used a cobalt chromium version of his angled great toe implant, but clinical trials did not warrant further investigation
(Weil, personal communication, 1987).
Titanium
Titanium may be used in either its pure metallic form or as an alloy with aluminum and vanadium. The alloy is substantially stronger and is
more resistant to brittle fatigue than pure titanium (27 ). Both are extremely inert and resistant to corrosion and have similar elastic
moduli (32 ,33 ). Titanium is light in weight compared with cobalt chrome and stainless steel and is generally considered to have excellent
characteristics with regard to osseous compatibility and biointegration. Titanium and its alloys used for implantation are attempts at
introducing materials with properties that more closely approximate the physical properties of biologic tissues intended for replacement or
implantation, that is, bone.
Today, Wright Medical (Arlington, VA) manufactures the Swanson hemigreat toe implant, as well as the hinged great toe grommets of
commercially pure titanium (34 ,35 ). Titanium is usually not considered for articulating systems because of its poor resistance to erosion
and production of wear debris (32 ,36 , 37 , 38 ). Biomet initially produced their Total Toe implant with a titanium metatarsal component
treated with ionized nitrogen to improve its wear characteristics. Questions were raised regarding the durability and longevity of this
nitrogen coating. Subsequently, Biomet changed to a cobalt chromium metatarsal component.
Ceramics
Ceramics used for orthopedic purposes include the crystalline ceramics silica and alumina. Generally, two classes of bioceramics are used:
the biostable or inert and the bioactive or degradable. The former group has application as a component of a joint system, whereas the
latter is used as a coating to enhance osseous integration.
Although ceramics are extremely inert and possess a high resistance to wear and a low coefficient of friction, their initial use was limited
by their brittle behavior and low resistance to crack propagation (36 ,38 ). Today, the improved properties of aluminum and zirconium
oxide ceramics have revived the application of bioceramics for joint implant systems. Some of the newest developments are with
magnesium stabilized ceramics that show superior properties of fatigue.
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Ceramics are excellent materials for situations of compression loading and articulation as a load-bearing surface and are generally
considered superior to even cobalt chromium as the convex or ball component of a low-friction arthroplasty. Ceramics are currently used
in various large joint replacement arthroplasties, and a great toe version was investigated by Diebold in France.
Carbon
Carbon is one of the most compatible materials for implantation, and several forms are under investigation. The pyrolytic form possesses
mechanical properties superior to those of graphite. Pyrolytic carbon is a two-phase graphite composite formed by pyrolysis to produce
silicon carbide whiskers within a pyrolytic graphite matrix. This material possesses a low elastic modulus, similar to bone, yet with good
strength and easy machinability (15 ).
A pyrolytic carbon nonconstrained first metatarsophalangeal joint was developed by Intermedics in the 1980s. This two-component system
with oval convex and concave surfaces corresponding to the metatarsal head and phalangeal base, respectively (39 ), underwent clinical
trials by Kampner (3 ,15 ,40 ). Although advocated for its low coefficient of friction, problems encountered included squeaking of the
device with joint movement (V. Hetherington, personal communication, 1989). No further developments in small joint orthopedics were
pursued.
Polymers
Polymers are long-chain molecules made up of simple repetitive subunits. These include the carbon-based thermoplastics—polyethylene,
polypropylene, polymethylmethacrylate—as well as the silicon-based elastomer, silicone rubber. Polymers often develop their physical
characteristics from processes during synthesis, including use of catalysts, antioxidants, plasticizers, and lubricants. Additives may
preclude biologic implantation because adverse reactions may occur with leaching of even trace amounts of these substances. Polymers
are interesting materials in that their physical properties are more complex than their metal counterparts, with a viscoelastic nature that
more closely approximates biologic tissues.
Ultrahigh-Molecular-Weight Polyethylene
UHMW polyethylene is a plastic with good bearing characteristics, that is, a low coefficient of friction when it is articulated with metals
and ceramics, although it has been associated with cold flow deformation or creep (27 ). It is best used as the concave component of total
joint systems in which it is implanted with a titanium tray to improve its physical characteristics and to minimize host reactions. Good
success has been achieved with low-friction arthroplasty with convex cobalt chromium or ceramic convex components. Polyethylene is
considered an inert biomaterial because it is physically and chemically stable in vivo with little degradation. However, UHMW polyethylene
wear debris may incite host reactions. Specifically, UHMW polyethylene produces small particles that have been associated with osteolysis
and granulomatous reactions (41 , 42 , 43 ). These types of reactions generally lead to failure of a total joint reconstruction, often with
instability of the component implants.
Polymethylmethacrylate
Bone cement is a polymeric grouting agent often used during the implantation of total joint systems for “cementing” components into the
respective bones of the joint arthroplasty. Polymerization is a highly exothermic reaction, and this may be responsible for cellular death of
a thin layer of bone after implantation. Bone cement requires a nominal thickness for it to be effective as a grouting agent, and the bone
cement interface is usually the weak link in the total joint arthroplasty. Polymethylmethacrylate self-polymerizes and early on possesses
low viscosity to allow intrusion and molding to both the internal bone structure and the implant stem. Difficulty may be encountered in
small joint orthopedics because of the limited size of the implant and the area of bone implanted. Loosening may be encountered and
subsequently failure of the reconstruction.
Silicone Rubber
Silicone rubber is an elastomer with a low elastic modulus, and thus it is a soft material. Clinically, this means that when subjected to
loads within a functional range, the implant would deform, but on release, the implant would return to its original configuration (44 , 45 ,
46 , 47 , 48 ). The low elastic modulus would also allow for the material to act as a shock absorber, not unlike the function of articular
cartilage and subchondral bone (1 ). Therefore, the physical properties of silicone rubber are such that it would be unlikely to cause
resorption of adjacent bone, as was seen with metallic cup arthroplasty.
Swanson championed flexible implant arthroplasty with silicone rubber devices. Instead of fibrous tissue coating a device and heralding
loosening, his nonporous interpositional material encouraged fibrous tissue production to augment resection arthroplasty with newfound
connective tissue stability (45 ,49 ). This is the basis for Swanson's concept of “fixation by encapsulation.”
Metallurgists manipulate alloys or the manufacturing process to design the properties of implanted materials, rather than simply selecting
from a limited group of materials. Compounds that may have once been discarded because of their brittleness or inadequate strength may
now be manipulated to give the desired or even superior properties, such as magnesium-stabilized ceramics. Biomaterials are currently
under development today, but because of the responsibility
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of manufacturers, medical professionals, and government to our human implantees, a great deal of study and research must be done
before new materials are available for general use. One of the other concerns in today's society is the realization of the potential liability
with human implantation. Manufacturers who once may have supplied basic biomaterials to the implant manufacturing companies now may
be reluctant to do so in light of threats such as the silicone beast implant crisis, wherein not only was the implant manufacturer held
responsible, but also the supplier of the silicone rubber. Dow Chemical and DuPont have discontinued the supply of several materials used
for medical implants including polyester, silicone, Teflon, Dacron, and polyurethane. Montell/North America, a supplier of UHMW
polyethylene, informed medical device manufacturers that they would no longer supply the raw material for surgical implants out of fear
of litigation. This leaves only Hoechst Celanese Corporation, a German company, as the remaining supplier of UHMW polyethylene.
IMPLANT DESIGN AND FUNCTION

A synovial joint is a system that allows movement between connecting osseous lever arms, allows smooth transmission of forces, and does
so with an incredible efficiency and a minimum of wear (50 ). It is when a joint deteriorates that reconstruction is necessary.
Reconstruction of the first metatarsophalangeal joint is the focus of this chapter and discussion.
FIG. 1. A,B: Normal joint motion requires plantarflexion of the first metatarsal after heel lift to attain full extension while in
patients with an unstable medial column. C,D: Hallux motion is restricted by elevatus or inability to plantarflex with abutment of the
metatarsal and phalangeal articular surfaces that generally leads to degenerative joint disease.
Normally, during the stance phase of gait, the intrinsic musculature stabilizes the hallucal proximal phalanx against the ground and the
metatarsal (51 ). From the time of heel off to the end of stance, the first metatarsal is moving relative to the phalanx. Sagittal plane
motion predominates, although a small degree of frontal plane inversion occurs (52 , 53 , 54 , 55 , 56 ). The motion of the first metatarsal
and first ray allows for weight transmission through the foot, medial column, and finally the hallux before toe off and the repetition of the
cycle (44 ,57 ,58 ).
In the pronated foot, or with first ray hypermobility, instead of stabilizing the hallux, the musculature contributes to subluxation at the
first metatarsophalangeal joint (52 ,59 ). This situation eventually leads to either transverse plane or sagittal plane deformities, hallux
abducto valgus or hallux rigidus, respectively. Deterioration of the joint usually occurs with end-stage hallux valgus deformities, as a result
of progressive joint subluxation, or in the case of hallux rigidus, the arthrosis occurs more rapidly because of pathologic joint abutment
(Fig. 1 ). Arthritic joint changes are degenerative and are associated with a limitation of motion and with pain (60 ,61 ). Trauma, whether
it be a previous injury or surgery,
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usually leads to a much more rapid progression of joint arthrosis (62 ).
FIG. 2. Types of arthroplasties of the first metatarsophalangeal joint. A: Resection arthroplasty: 1, Keller; 2, Mayo. B: Interpositional
arthroplasty: 1, hemi; 2, double-stem hinge; 3, soft tissue. C: Total joint replacement: 1, Biomet (Biomet, Warsaw, IN); 2, Bio-Action
(MicroAire Surgical Instruments, Valencia, CA). D: Arthrodesis: 1, planar resection; 2, curettage with screw fixation.
The most important attribute of a diarthrodial articulation is the integrity of its joint space. Joint movement depends on maintenance of a
joint space. Unfortunately, this ultralow friction system undergoes narrowing and or disruption during aging or as a result of arthritic
conditions (63 ,64 ). Surgical reconstruction of arthritic joints is predicated on the reestablishment of the joint space to provide normal
joint mechanics.
Instability or joint deformity is addressed with bone resection and soft tissue release (Fig. 2 ). Reestablishment of the joint space also
depends on bone resection. In the case of the first metatarsophalangeal joint, resection arthroplasty, particularly on the phalangeal side of
the joint, is a wellaccepted technique (65 , 66 , 67 , 68 , 69 ). An interesting development has been advocated that uses external fixation
placed across a joint in tension mode to open up a joint space gradually and thereby to reestablish joint motion (70 ).
Interpositional arthroplasty uses soft tissue or artificial materials to maintain the joint space after osseous resection (23 ,45 ,49 ,71 ,72 ).
With total replacement arthroplasty, both sides of the joint are replaced with an articulation that will conform to or maintain contact
with the opposite side and allow for movement (73 ). Difficulties arise because of differences in mechanical properties, limited areas of
contact, and wear in the artificial system.
Implant arthroplasty of the first metatarsophalangeal joint can be viewed as two categories: interpositional arthroplasty and total joint
replacement. The former was much more widely performed and can also be divided into two types, hemiimplant and flexible hinge.
Numerous designs of each are available.
Interpositional Implants
Interpositional joint implants are an adjunct to resection arthroplasty. The intention was that the implant would improve short and long-
term alignment and movement, and overall would yield a cosmetically superior reconstruction compared with resection arthroplasty alone.
Interpositional devices are generally either of the concave cap with an intramedullary stem or a convex ball type of design also with an
intramedullary stem. The former is best illustrated by the Swanson type great toe hemiimplant, and the latter is best illustrated by the
ulnar head design or the original Swanson design for the first metatarsal. Interpositional devices are also fabricated as double-stem hinge
implants. These designs generally only allow motion in one plane, that is, perpendicular to the hinge.
The early silicone implants were probably the best example of hemiimplants (Fig. 3 ). The standard great toe or hemiimplant was designed
by Alfred Swanson after analysis of the normal proximal phalanx (71 ,74 ). He introduced the implant as an interpositional spacer to
maintain the joint space of resection arthroplasty. He described the process of reparative fibrosis or encapsulation as an intimate
component of flexible implant arthroplasty wherein he believed that the implant acted as an internal mold for development of a new
capsuloligamentous system. His concept of implant
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arthroplasty was summarized by the equation: “bone resection + implant + encapsulation = new joint” (45 ,74 ).
FIG. 3. A,B: Swanson great toe hemiimplant. Dorsal (A) and oblique (B) views of this phalangeal base design. C,D: Weil modification
of Swanson great toe implant. The Swanson design implant possessed a long awkward stem with a plantar radius of the stem that he
believed reflected the anatomy of the proximal phalanx. Weil's modification simplified the stem design with a shorter stem that
limited reaming of the medullary canal, whereas its articular surface possessed a small radius that also more accurately reflected the
articular anatomy of the first metatarsal head.
Swanson's original great toe implant can be described as a base or collar with a medullary stem. The base represents the resected portion
of the phalanx and is ovoid, being wider from medial to lateral than its height from dorsal to plantar. The articulating portion of the base
possesses a shallow concavity corresponding to the convex shape of the first metatarsal head. This can actually be defined by separate
dorsal to plantar and medial to lateral arcs, each with a defined radius (75 ). The stem possesses a certain overall length and is rectangular
at the end while being square at the juncture with the base. Because the phalanx was concave plantarly, Swanson incorporated this into
the design of the stem (74 ). Most of the initial medullary stems of the hemiimplants were large and required significant reaming of the
respective phalanx.
FIG. 4. Swanson titanium hemiimplant. A,B: Swanson modified his silicone design in a metallic version with the titanium
hemiimplant. C: Weil chose to have a design identical to his silicone variety manufactured of cobalt chromium alloy. These designs
still possess a thick articular base and large medullary stems.
Later, Swanson and Weil each designed analogous metallic versions of their original hemiimplants (Fig. 4 ). The design
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of Townley (Fig. 5 ) incorporated two unique differences. The first was a small stem that did not require reaming of the proximal phalanx,
and the other was a thin articular base. Because Townley's implant was manufactured from metal, cobalt chromium, he realized that the
base could be reduced to a nominal thickness and still provide superior physical properties (17 ). This design allowed for limited resection
of the phalangeal base, better quality of remaining bone, and limited loss of soft tissue attachment to the base of the proximal phalanx. In
fact, it eliminated the requirement for reaming of the phalanx by introducing a thin, swordlike stem.
FIG. 5. First metatarsophalangeal joint metallic hemiimplants. A: Charles Townley's design used the physical properties of the metal,
which allowed for a thin articulating surface and minimized the size of the medullary stem and simplified insertion and required
instrumentation. Intraoperative anteroposterior (B) and lateral views (C,D) with companion radiographs (E,F) illustrate the design of
the implant and limited bone resection required for its insertion.
More recently, Futura Biomedical also released a metallic hemiimplant (Fig. 6 ), which may be considered a hybrid between the Swanson
and Townley designs. This implant has a thin base but incorporates a plantar angulatory resection of the phalangeal base as noted on the
Lawrence hinged silicone implant (19 ). In addition, the medullary stem is significantly reduced in size from the Swanson implant but still is
more of a traditional medullary stem than that of the Townley design.
Several double-stem silicone implants are available for interpositional arthroplasty (Fig. 7 ). The two earliest designs were the Swanson
flexible hinge and the Cutter hinged implants. Later, variations of the theme were introduced by Sutter, Sgarlato, and Futura Biomedical.
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FIG. 5. Continued.
FIG. 6. A: The Futura design (Futura Biomedical, San Diego, CA) is a hybrid of the older-model Swanson-like hemiimplant and the
Townley design. B: Instrumentation allows for ease of insertion.
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FIG. 7. First metatarsophalangeal joint: double-stem hinged silicone implants. A: Swanson's original great toe hinged implant was
later modified as a short stem version. B: Sutter (Sutter Biomedical, San Jose, CA) had an early design with a barrel-like stem,
whereas later modifications (C) by LaPorta (1) and (2) and Lawrence (3) attempted to increase implant hinge motion and more
accurately to replicate normal anatomy. D: Sgarlato later introduced his design as the “GAIT” implant.
The Swanson design was available in seven anatomic sizes (76 ). A central hinge in a U-shaped configuration allows for dorsiflexion. An
intramedullary stem on either side stabilizes the implant within the phalanx and metatarsal. This hinge has been criticized for not allowing
a physiologic amount of motion (77 ). The stems are a square, tapered configuration, with the phalangeal side shorter and narrower. There
is no angulation of the stems in the sagittal or transverse plane. With the original design, it was often necessary for the surgeon to shorten
the phalangeal implant stem. In an effort to avoid any tampering or modification of the implant, Dow Corning-Wright introduced a short-
stem variation of the double-stem design that quickly supplanted most use of the original design. This implant is manufactured in six sizes:
0S, 1S, 2S, 3S, 4S, and 5S (76 ).
Wright Medical, which later manufactured the Swanson design Silastic implants, introduced titanium grommets for the double-stem
implant (35 ) (Fig. 8 ). These grommets were designed as a protective interface between the cut surface of bone and the implant hinge
(14 ,78 ). The grommets were press fit into the respective medullary canals before insertion of the implant.
Sutter Biomedical introduced several designs of a hinged great toe metatarsophalangeal implant, the LaPorta (79 ) and the Lawrence (80 ),
and these devices are now manufactured by Futura Biomedical. Both designs incorporate the more stable design of rectangular tapered
stems. The proximal stem is slightly larger and longer than the distal and is angled 15 degrees dorsally in the sagittal plane. This feature
was incorporated into the design to allow for the declination of the first metatarsal without compromising the excursion of sagittal plane
motion inherent to the hinge. This design characteristic also limited tensile strain on the implant that results from dorsiflexion of the toe.
The LaPorta implant comes in a right, left, and neutral design, terms referring to the deviation of the stems in the transverse plane (79 ).
The neutral design possesses the stems at 180 degrees from each other, whereas the right and left varieties possess a 10-degree angulation
lateralward in the transverse plane. The Lawrence implant is neutral (80 ).
The hinge of both Sutter implants is an hourglass-type design with flexion occurring at the central juncture. The LaPorta design is
symmetric from dorsal to plantar and is designed to allow 60 degrees of motion in the hinge alone (81 ). Either side of the hinge proximal
and distal is flat to allow flush apposition with the resected joint surfaces.
The Lawrence hinge differs in that the hinge is elongated dorsally and is angled inferiorward (80 ). The hinge design
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functionally has several advantages. It was designed to allow 85 degrees of dorsiflexion (82 ). The plantar angulation on the phalangeal
side of the hinge ideally reduces the degree of basal resection of the phalanx and thereby maximizes hallucal stability through maintaining
intrinsic tendon insertions. Lawrence also recommended angulating the metatarsal osteotomy, in an effort to preserve length and stability,
as well as the metatarsal articulation with the sesamoids (13 ).
FIG. 8. Swanson flexible hinge toe with grommets. A: Line diagram of protective jacket or bone liner introduced for the Swanson
hinged great toe implant. B: The Swanson hinge toe implant and protective grommet.
The Sgarlato design is a hybrid between the Swanson and Sutter designs incorporating a hinge not dissimilar from Swanson, with the stems
at 180 degrees in both the sagittal and transverse planes (83 ).
Sammarco showed that the normal first metatarsophalangeal joint axis is constantly changing but it remains within the first metatarsal
head (53 ,55 ,56 ). With a hemiimplant, normal joint dynamics are changed to a lesser extent than the double-stem implants. With the
double-stem implants, the joint axis and function are significantly altered. Depending on the degree of bone resection on either side of the
joint, the joint axis will now fall distal to the axis before surgery. There is also a loss of Hick's effect or the reciprocal motion between the
phalanx and its metatarsal that reduces medial column stability (7 ). These functional limitations are the result of the constraint of the
hinge that allows only simple rotatory motion about the axis defined by the location of the hinge of the implant.
TOTAL JOINT REPLACEMENT

Total joint systems have been designed as two-component semiconstrained or nonconstrained articulations for the first
metatarsophalangeal joint. The former allows for only sagittal plane motion, whereas the latter allows motion in more than one plane.
Materials used for opposing articular surfaces are chosen for their low coefficient of friction and their minimum wear characteristics.
Certainly, there were some early attempts by several surgeons including Joplin, Johnson (10 ), and Weil and Smith (9 ), but none of these
designs proved successful enough to warrant general release. In examining the reports by early surgeon inventors, several conclusions can
be drawn. Metatarsal components, whether cemented or simply press fit, generally loosened as a result of loading on the weight-bearing
side of the joint. This instability was preceded by resorption around the stem on follow-up radiographs. Often, the joint reconstruction was
compromised by pain or joint stiffness, which was the original reason for performance of the procedure.
Biomet Total Toe (Biomet, Warsaw, IN)

The concept of a total joint system was again revived by Koenig (16 ), who modeled his design after the Whiteside knee system, both
developed at Dow Corning-Wright (Dow Corning-Wright, personal communication, 1991). This involved a two-component articulating device
with the metatarsal component made of titanium and the phalangeal one of UHMW polyethylene (Fig. 9 ). The metatarsal component
possessed a large plantar flange that interlocked the plantar cortex and could provide for an articulating surface for the sesamoids,
although Koenig later reported difficulties with the sesamoid implant articulation (84 ).
Titanium components are often advocated for their qualities of osseous integration and biocompatibility with bone. Problems with earlier
metal components for the metatarsal involved bone resorption and loosening of the stem resulting from imposed stresses (11 ,71 ). The
plantar ledge of this design was devised not for weight bearing but for translation of loading forces from the stem and into the greater
portion of the metatarsal. In addition, the cobalt chromium metatarsal component was coated with plasma-sprayed titanium to enhance its
osseous stability by means of tissue ingrowth.
The Biomet Total Toe system has been available for general use since 1989, after initial clinical trials were conducted by the surgeon
inventor. Koenig reported a mean range of motion of 50 degrees in 18 procedures 18 months postoperatively (16 ). He recommended the
implant for a wide range of deformities with arthrosis.
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FIG. 9. A: Two-component total joint replacement system. B: Full complement of instrumentation is required for proper insertion
and fit. C,D: Three sizes are available: small, medium, and large, in corresponding metatarsal and phalangeal components.
Bio-Action Great Toe Implant (MicroAire Surgical Instruments, Valencia, CA)

The Bio-Action implant is a spheric articular design the goal of which is to allow motion in all planes. It consists of a cobalt chromium
metatarsal component and an UHMW polyethylene phalangeal component in two anatomic sizes with some variation, as described here (Fig.
10 ). The phalangeal component is available in a small or modified version. The small component is circular with a neutral stem 90 degrees
to the articulating surface. The modified version provides a titanium flare to extend beyond the circular polyethylene articulating surface
to provide additional stability when bone resection of the base of the proximal phalanx leaves a medial and lateral metaphyseal flare. This
component is also flattened on its plantar surface but is otherwise neutral in the transverse and sagittal planes.
The metatarsal components are a spheric cap with a tapered rectangular stem. The implant comes in a small and large neutral version or a
small right and left modification. All components possess tapered rectangular stems. On the neutral components, the stems are at 90
degrees to the articulating surface, whereas with the right and left versions of the metatarsal component, the stem is deviated 10 degrees
in the transverse plane to allow for a degree of abduction of the great toe, as normally found. This does require that the distal metatarsal
head be resected at an 80-degree angle and is proposed to improve the excursion of motion with the reconstruction.
Zang et al. stated that this implant was used in more than 250 patients, and these investigators examined 34 of these patients, randomly
selected, with an average follow-up of 26 months. The patients, 30 women and 4 men, ranged in age from 19 to 79 years, with an average
of 61.5 years, and they were selected for joint implantation with a variety of disorders from hallux valgus with degenerative arthrosis to
hallux limitus, rheumatoid arthritis, and failed prior first metatarsophalangeal joint procedures. These investigators reported good range of
motion postoperatively without delineating dorsiflexion from total range of motion (85 ).
More recently, Gerbert and Chang reported on use of 10 Bio-Action implants over a 3-year period in patients with an average age of 49
years (6 ). Two implants required removal, and this article discusses indications and complications of total joint replacement implants in
general.
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FIG. 10. Bio-Action great toe implant (MicroAire Surgical Instruments, Valencia, CA). A: This two-component system consisted of a
cobalt chrome metatarsal component and a metallic phalangeal component with an articular surface of ultrahigh-molecular-weight
polyethylene. B: The phalangeal component was available with variable diameters that corresponded to the remaining portion of
proximal phalanx. C: Instrumentation was supplied in an effort to simplify insertion. D: This intraoperative view is followed by
preoperative (E) and postoperative (F) radiographs in a patient with chronic joint pain after failed bunionectomy.
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Acumed Great Toe System (Acumed, Beaverton, OR)

The Acumed system is another of the component joint replacement systems. This is the only total joint replacement system that was
designed to be press fit, although it may also be cemented (R. Hubner, personal communication, 1995). This system also combines a cobalt
chromium metatarsal component and a UHMW polyethylene phalangeal component (Fig. 11 ). The metatarsal component possesses a dorsal
flange or dorsal extension of the articular surface to allow an increased range of dorsiflexion of the first metatarsophalangeal joint. A
beaded area on the metatarsal component allows for biointegration with the distal resected surface of the metatarsal head.
FIG. 11. Acumed great toe system (Acumed, Beaverton, OR). A: This two-component implant system possesses a dorsal flange to the
metatarsal component that requires osteotomy, whereas the titanium phalangeal component has an ultrahigh-molecular-weight
polyethylene articular surface. Three sizes are available and are interchangeable. B: Instrumentation is supplied to aid insertion.
Intraoperative dorsal (C) and lateral (D) views illustrate ideal positioning. Preoperative (E) and postoperative (F) anteroposterior
radiographs show use in a 64-year-old man with late-stage hallux rigidus.
The metatarsal component is available in three anatomic sizes: small, medium, and large, all with the same-size tapered cylindric
medullary stems to allow complete interchangeability of the various sizes. The phalangeal components are available in small and large
sizes in both a standard and + 2 mm size, one with a narrow and other with a wider thickness of the base portion. The phalangeal stems
are of a tapered rectangular configuration, and again all are the same and are interchangeable.
The only preliminary report involving use of this implant was published by Gerbert and Chang (6 ). They reported use of 21 implants in
patients with an average age of 50 years. Dorsiflexion increased from an average of 25 degrees preoperatively
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to 53 degrees postoperatively. No implants required removal, but several complications were noted, although these authors discussed their
observations on the use of both Acumed and Bio-Action total joint replacement systems collectively.
FIG. 11. Continued.
Kinetik Great Toe Implant (Kinetikos Medical Inc., San Diego, CA)
The Kinetik Great Toe Implant joint replacement system is marketed as an anatomic design attempting to incorporate features to
accommodate metatarsal declination, intermetatarsal angle, and proximal articular set angle. The metatarsal component is manufactured
from cast cobalt chromium, whereas the phalangeal component is a titanium alloy (Fig. 12 ). A UHMW polyethylene articular inset is found
within a thick phalangeal base. The metatarsal component is available in right and left designs incorporating a 13-degree offset of the
stem in the transverse plane as well as a 12-degree inclination in the sagittal plane. The articular surface is a spheric design but is
extended dorsally to provide a surface for further joint extension; this does require resection of a portion of the dorsal cortex.
The metatarsal component is available in three sizes in both left and right models, whereas the phalangeal component is available in four
sizes, and each is interchangeable with any of the six, left and right, metatarsal components.
The metatarsal stems are a tapered rectangular configuration, whereas the phalangeal ones are round with a distal point and a flute not
dissimilar to that found on a tap or selftaping screw. All the stems on the respective metatarsal and phalangeal implants are the same size,
meaning that the final implant size may be varied right to the point of insertion of the implants. The stems possess a roughened surface
and grooves on the stems to improve the likelihood of osseous integration. The metatarsal component is available in three anatomic sizes:
small, medium, and large, all with the same size tapered rectangular medullary stems to allow complete interchangeability of the various
sizes. Each size metatarsal component is available in right and left versions. The phalangeal components are available in small and large
sizes, one with a narrow and another with a wider thickness of the base portion. The phalangeal stems are of a round naillike configuration
with the tip pointed and a fluted surface to the stem. All stems are the same size and therefore are interchangeable.
A full set of instruments is available and is numbered 1 to 8, to facilitate chronologic use and the recommended surgical technique. As with
all the total joint systems, familiarization with the implant design and with surgical instrumentation is pivotal for success.
Osteomed Reflexion First Metatarsophalangeal Joint Implant System (Osteomed Corp.,

Irving, TX)
The Osteomed total joint system, the last of the currently available first metatarsophalangeal joint replacement systems
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to be introduced, is markedly different from the preceding four implants. This implant also has a metatarsal and a phalangeal component,
but the metatarsal prosthesis is actually two separate implants (Fig. 13 ). The titanium alloy metatarsal stem is round with ridges cut into
the peripheral proximal stem with a conical portion distally. This serves as the foundation for a cobalt chromium convex articulating cap
that snaps onto the distal stem. The conical portion of the metatarsal stem is dorsally angulated from the proximal stem, so it also
provides for greater excursion of dorsiflexion or extension. As a result of this offset design, it is anticipated that it will provide increased
stability of the metatarsal component.
FIG. 12. Kinetik great toe implant (Kinetikos Medical Inc., San Diego, CA). This two-component total joint system incorporated design
features for hallux abduction and metatarsal declination (A), and is supplied with instrumentation to allow a stepwise insertion (B).
An intraoperative photograph (C), and postoperative radiograph (D) illustrate correct placement of the joint system. (Courtesy of
Fred Youngswick, San Francisco, CA.)
The phalangeal portion of this implant system is a circular polyethylene concave articulating disc integrated onto a titanium-backed stem.
The stem itself is round and distally flattened on two surfaces, whereas the proximal portion is also conical.
The articular surfaces of this spherical system have been designed so the one-size metatarsal head is completely compatible with any size
phalangeal component. The metatarsal stems and phalangeal components come in small, medium, and large, whereas the metatarsal head
is available in small, large, and extralarge.
Instrumentation is provided to allow precise fitting of the joint replacement system, although as with all these systems, each possesses
individual surgical details and subtleties that must be mastered.
Synopis of Total Joint Replacement Systems

Total joint systems have been designed as two-component nonconstrained articulations for the first metatarsophalangeal joint that allow
for not only sagittal plane motion but also small amounts of motion in the frontal or transverse plane as required by the excursion of the
resultant joint reconstruction. Materials used for opposing articular surfaces are chosen for their low coefficient of friction and their
minimum wear characteristics. The accepted standard is a cobalt chromium alloy with UHMW polyethylene. Many of the total joint systems
have incorporated design features to resemble normal anatomy more closely and, one hopes, to improve the functional result of the
reconstruction. As yet, there is no consensus that the use of these implant systems has any value. These systems have been recommended
for many reasons, but as yet clinical studies to warrant the widescale use of these devices have not materialized. Only a few reports have
been written, and most are little more than preliminary case reports.
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FIG. 13. Osteomed Reflexion first metatarsophalangeal joint implant system (Osteomed, Irving, TX). This total joint system is
actually more analogous to a hip replacement, with three pieces to the system that are interchangeable. A: The metatarsal titanium
stem is coupled with a cobalt chrome articular cap, whereas the phalangeal component is a titanium stem and tray with an ultrahigh-
molecular-weight polyethylene articular surface. B: Instrumentation is supplied, and insertion requires significant reaming (C). D: The
implant system intraoperatively.
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HOST RESPONSE
Host response encompasses both the long-term tissue response and the consequences of the surgical act of implantation. Problems
associated with either may lead to failure of the procedure. No matter what the material, there is some tissue response to implantation.
To provide a lasting benefit, the implant material must be inert and durable. The biocompatibility of inert internal implants is reviewed as
it affects host response.
Ideally, biocompatibility requires the implant to be (a) chemically inert or free from biodegradation, (b) capable of withstanding the
stresses imposed on it, (c) durable or possess an integrity of structure without modification of its physical properties because of the
biologic environment, and (d) nonirritating, eliciting only a benign, local tissue response particularly in regard to the absence of local or
systemic toxicity, including allergy or hypersensitivity, carcinogenicity, and pyrogenicity (86 ).
Much attention has been given to immune reactions to implant materials and, in particular, the wear debris of these materials. Various
host reactions are described, but they generally can be divided into an immune response with sensitized T lymphocytes or that of simple
phagocytosis of microscopic debris by the tissue macrophages. This latter response is that usually encountered clinically, particularly with
implant loosening associated with osteolysis. This nonspecific tissue response is encountered with a range of biomaterials from
polyethylene to bone cement to silicone, and it is usually granulomatous (37 ,38 ,42 ,43 ,87 , 88 , 89 , 90 , 91 , 92 ). Problems encountered
are with the so-called “frustrated macrophage,” which elaborates tissue cytokines that incite inflammatory reactions including osteolysis
(41 ).
Metals
Metals were initially the biomaterial of choice because of their inert quality. Stainless steels are easily machined and demonstrate
excellent strength in tension, whereas cobalt chrome alloys are more suited as bearing surfaces and for compression loading. In vivo
degradation, particularly with release of free metal ions in the adjacent tissues, may be problematic. Most metals elicit a benign tissue
reaction on implantation generally verified by a thin pseudocapsule or fibrous tissue. Metals are resistant to corrosion by virtue of their
elemental composition, crystalline homogenicity, and surface oxides that form (93 ). Metals possess high surface energies that encourage
binding of glycoproteins and colonizing cells including bacteria. Titanium is an extremely inert material, but implant movement results in
the release of alloy and oxide particles that may elicit a histocytic and giant cell response (94 ).
Wear of metallic components may release particles of the metal, debris of the metallic oxide, or ionic elemental contaminants. Particulate
debris (Fig. 14 ) may be sequestered locally, phagocytized by tissue macrophages, or carried to distant sites. Metal ions released during
wear or corrosive phenomena may combine with proteins and cell surfaces and may subsequently be distributed during the normal
biochemical processes (32 ).
Elemental constituents of alloys are generally handled much like any trace metal found in the body. These are absorbed, transported into
the circulation, and excreted by the kidneys such as, for example, aluminum, nickel, and molybdenum. Some metals tend to be
transported, for example, cobalt, and others tend to accumulate within the tissues, for example, chromium (26 ). There was initially a
considerable amount of concern for the element vanadium. Vanadium is a toxic element, but absorbed vanadium is rapidly excreted into
the urine.
Polymers
Polymers are large-molecular-weight compounds of carbon-based elements that are the composition of biologic structures. In podiatric
surgery, there seems to be a fixation on silicone rubber, but in orthopedics as a whole, polyethylene is of prime focus because this
produces some of the maj or wear particles of total joint replacement systems. Most tissue reactions to implanted materials are
nonimmune granulomatous or foreign body types of reactions and debrisgenerated reactions, predominantly from mechanical wear. These
make up most of the reactions to polymers exhibited clinically.
Polyethylene
Most failures of total joint replacement are related to reactions to wear particles of UHMW polyethylene. The smallest particulate debris
has been attributed to polyethylene, and these small particles are most likely to produce tissue reactions. In large joint orthopedics in
which polyethylene is widely used for total joint replacement systems, loosening of the implant system is a major cause of failure
(37 ,38 ,92 , 95 ). This generally begins with wear debris and identified radiographically as resorption of bone in the vicinity of the joint
arthroplasty. Resorption may lead to loosening of the implants, movement, local pain, and further generation of wear debris and
inflammatory reactions within the periprosthetic tissues.
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FIG. 14. Host response to stainless steel. Histologic specimen of tissue surrounding a stainless steel screw, ANSI 316LC, revealing iron
deposition or corrosion products. This tissue is from a granulomatous reaction adjacent to a screw head on the dorsal surface of the
first metatarsal, 14 months after implantation. A,B: Iron stains at 40× and 400×, respectively, demonstrate iron deposition,
hyperplasia, and histocytic invasion with giant cell formation.
Polymethylmethacrylate
Polymethylmethacrylate or bone cement is often used in large joint orthopedics to stabilize the respective components of a joint
replacement system. Bone cement particles may be particularly disastrous if they are left by the surgeon within the confines of the joint
capsule, where they lead to wear and generation of further particles. The physical properties of bone cement depend on its chemical
nature, the technique of use, and the development of a cement mantle of sufficient thickness. Problems with loosening or generation of
wearing particles in the periprosthetic tissues generally contribute to later problems. The same tissue reactions described for the other
polymers are also likely with polymethylmethacrylate particles.
Silicone Rubber
Silicone rubber is a relatively inert material, yet tissue reactions have been a cause of considerable concern. Many reports of complications
have dealt with these tissue reactions. Determining the cause and whether they are preventable will be the focus of this discussion.
Silicone devices, when implanted within the body, whether in bone or soft tissue, are sequestered by encapsulization. Collagen fibrils,
fibroblasts, and amorphous ground substance make up this reactive tissue. Swanson's concept of fixation by encapsulization is simply the
body's reparative response to surgical intervention and the introduction of the foreign material. Silicone in large pieces is encapsulated,
whereas particulate silicone approximately 10 to 100 μm in diameter may stimulate multinucleate foreign body giant cell and inflammatory
reactions. Aptekar and Cattell described detritic synovitis with chronic inflammation and foreign body giant cell response to shards of
silicone rubber in a patient with rheumatoid arthritis 3 years after a fractured finger implant (96 ). Since this initial report, Christie et al.
(97 ) and many others have further delineated the soft tissue reaction to silicone particles. A chronic inflammatory response is the rule,
with
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silicone lying both intracellularly and extracellularly (Fig. 15 ). The synovial tissue shows various degrees of hyperplasia and fibrosis.
Occasionally, aggressive reaction to silicone has been observed, including detritic synovitis, osteitis, and foreign body reaction with
granuloma.
FIG. 15. Host response to silicone rubber. A: Within medullary canals, mesothelial tissue usually reveals some particulate silicone
(arrows) but little tissue reaction. B: Synovial response is one of hyperplasia, with a variable inflammatory all response. C: Shards of
silicone (arrows) from subdermal silicone carving elicited an exuberant inflammatory response (a). (From Vanore J, O'Keefe R,
Pikscher I. Complications of silicone implants in foot surgery. Clin Podiatry 1984;1:175-198, with permission.)
These aggressive host reactions have yet to be fully understood. The term rejection has often been mentioned, although little evidence
and few clinical studies have shown this to occur. Kossovsky et al. did propose that the chronic inflammatory reaction observed in the
reports of various silicone implant complications does indeed represent a cell-mediated immunologically directed antisilicone or anti-
silicone-protein complex reaction (98 ).
Silicone in large pieces is well tolerated. The silicone implant is stabilized through the reactive periarticular capsular fibrosis, although it is
a pale imitation of the normal capsuleligament structures.
Microfragmentation of silicone implants does occur and may be the result of pistoning within the medullary canal, deformation or fracture
of the implant, or abrasion by a degenerative articular surface (1 ,12 ). Erosion and shedding resulting from normal wear or a tight joint
have also been suggested. Worsing and associates cautioned against the use of hemiimplant arthroplasty in patients with degenerative
irregular joint surfaces in that it probably leads to abrasion of silicone rubber and the potential for soft tissue or bony disease (99 ).
Detritic synovitis and tissue-bone reactions are complications of silicone arthroplasty and are discussed in greater detail in a later section
of this chapter.
The response of bone to silicone implants requires considerations of both biologic and physical compatibility. Like the response of the soft
tissues to silicone, a mesothelial lining also develops within the medullary canal of the implanted stem that walls off the nonporous
silicone material from the adjacent bone (100 ,101 ). New bone formation develops around the fibrotic mesothelial lining of the medullary
canal in 1 to 3 months. This is noted on postoperative radiographs as sclerosis around the medullary stem of the implant. The sclerosis
reflects bony remodeling as a result of increased mechanical loading through the stem (102 ).
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Silicone detritus within bone may also be seen and can elicit an inflammatory reaction within the substance of the bone itself
(1 ,12 ,103 ,104 ). I recognize this as osteitis and believe that it may be related to some of the resorptive changes observed within the
bone. Other changes may occur in the bone that have been associated with both biologic phenomena and dissimilarities of the physical
properties between the implant and bone or the implant and articular surface. These include fibroosseous encroachment, radiolucencies
within the subchondral bone (1 ,12 ,105 ), degenerative changes of the adjacent articular surface (106 ,107 ), adjacent avascular necrosis
of bone (108 ), and a potentially invasive fibrous hyperplasia occurring within the bone holding the implant stem (1 ). These are all
considered pathologic events and are discussed in the section of this chapter on complications.
Despite the abundant histologic evidence of host-implant reaction, the significance of chronic inflammatory reaction to wear particles and
dissolution products of polymers and metals is indeterminate. For the most part, materials are used for their inertness, but some tissue
response is unavoidable. Preferably, this tissue reaction will not interfere with the implantation, and most of the situations discussed
cannot be wholly related to failure of the surgical procedure.
Implantation is performed for broader indications and in younger patients. The host response to the joint implant is paramount and may
determine the ultimate success or failure of a particular implant. Host response encompasses not only the biologic reaction with regard to
compatibility but also the physical interaction of the implant or implants on a mechanical basis. These biologic and physical relationships
should be nondetrimental to both the host and the implant for the remaining lifetime of the patient.
INDICATIONS FOR IMPLANT ARTHROPLASTY

The general indications for implant arthroplasty (Table 2 ) have changed little over the past 3 decades, but patient selection has become
more stringent (2 ,109 ,110 ). Whether it is an interpositional or a joint replacement implant arthroplasty procedure, the joint is destroyed
(8 ). As such, it is recommended that each patient be assessed for alternatives (Table 3 ) to implant arthroplasty with efforts directed
toward joint preservation whenever possible, particularly in younger, more active patients.
TABLE 2. Indications for implant arthroplasty

Hallux rigidus: late stage III, stage IV
Hallux valgus with degenerative arthritis
Revisionary first metatarsophalangeal joint surgery with joint arthrosis or osseous deficit
TABLE 3. Alternatives to implant arthroplasty

Osteotomy with or without chondroplasty
Resection arthroplasty: phalanx, metatarsal
Arthrodesis
Cheilectomy
SURGICAL TECHNIQUE
The following description is of our general recommendations for the Swanson double-stem implant arthroplasty with titanium grommets.
Most recently, the Futura hinged implant, the Primus, has become available for use with protective grommets. These are clearly important
adjuncts to the longevity and success of the procedure. Other implants are available, from the hinged silicone to the metallic hemiimplant
to the component total joint systems. This general technique is offered, but it obviously requires modification depending on the joint
system chosen because each possesses specific instrumentation and technique developed for that system.
Approach
The most convenient surgical approach to the first metatarsophalangeal joint is through a dorsomedial incision medial to the tendon of the
extensor hallucis longus. The incision extends from the midpoint of the first metatarsal to the midpoint of the hallucal proximal phalanx.
This incision affords simple exposure to the metatarsophalangeal joint and to the articular and periarticular structures that will allow
adequate bone resection and soft tissue capsule tendon balance. An alternative incision from a direct medial approach has been advocated
for its cosmesis (9 ), and it is simply a matter of the surgeon's choice.
The length of the incision may vary depending on the need for basal osteotomy. The dorsomedial approach avoids disruption of the medial
proper digital nerve and associated vessels. As in hallux abducto valgus surgery, anatomic dissection of the skin and subcutaneous tissues
from the medial joint capsule is recommended if capsular correction is part of the repair. In cases of a rectus toe, as in hallux rigidus, only
limited underscoring of the medial skin and subcutaneous tissues is necessary. This is also recommended in cases of revision in which soft
tissue coverage may be tenuous.
Capsulotomy
A linear or lenticular capsular approach between the tendons of the extensor hallucis longus and the extensor hallucis capsularis has
proven adequate. Alternate capsulotomies include the inverted L, which can be extended into a T for exposure of the proximal phalanx.
The capsular incision begins proximally at the metatarsal neck, but it is carried distally onto the proximal phalanx only as needed for
resection of the base of the proximal phalanx. Articular exposure begins
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with subperiosteal dissection dorsally on the first metatarsal and proximal phalanx. Medial or lateral release may be necessary to alleviate
deforming influences. Dissection of the plantar attachments of the phalanx is best accomplished after the osteotomy for base resection.
Bone Resection
Removal of the base of the proximal phalanx usually accomplishes relaxation of the first metatarsophalangeal joint, although in cases of
long-standing or senile hallux valgus, a fibular sesamoidectomy may also be necessary to allow the articular relationship of the proximal
phalanx to be restored. Correction of deformity and restoration of motion are often accomplished, with soft tissue relaxation achieved
through joint decompression and bone resection. Sesamoidectomy is easily accomplished from an intracapsular approach after bone
resection.
Initial bone resection should generally begin at the phalanx and varies in the amount and angle of resection, depending on which implant
system is chosen. Many of the joint implants provide templates for both the amount and the direction of bone resection. Approximately
one-quarter to one-third of the proximal phalanx is resected through an osteotomy perpendicular to the desired final long axis of the
hallux. This must include an assessment of the degree of interphalangeus present. The transverse plane orientation of the osteotomy
usually parallels the eponychial nail fold.
The phalangeal osteotomy should just perforate the plantar cortex to avoid laceration of the long flexor tendon. From this point, careful
dissection of the soft tissues from the bone helps to maintain integrity of the plantar capsule and the aponeurotic insertions of the flexor
tendons. Actually, after removal of the base, there should be no violation of the plantar tissues, that is, the long flexor should not be
exposed.
The degree of degenerative osteophytosis and the size of the medial eminence help to determine the need for peripheral metatarsal head
remodeling. This becomes extremely important in cases of double-stem hinge arthroplasty in osteoporotic bone. The cortical margins of
the first metatarsal head are best maintained to give the greatest amount of support to the metaphyseal trabeculae.
Although the medullary canal may be reamed directly through the articular surface in cases of hinged silicone implant arthroplasty, it is
recommended that the articular surface be resected (Fig. 16 ). With the use of Sutter and Futura implants, flat surfaces opposing the hinge
portion of the implant are encouraged because of the design of the implant hinge.
Of course, if a hemiimplant is used, then no resection of the first metatarsal is performed. To give additional stability to the joint
reconstruction, the integrity of the lateral capsule should be maintained whenever possible with a hemiimplant. With use of the Biopro and
Futura hemiimplants, generally only minimal resection of the phalangeal base is required.
The articular surface of the first metatarsal is best resected closer to a perpendicular to the ground, rather than a perpendicular to the
long axis or declination of the first metatarsal. This aids in placement of the implant high in the metatarsal and maintains the plantar
condyles for their articulation with the sesamoids. This approach should also allow for distal excursion of the sesamoids on the metatarsal
head with dorsiflexion or extension of the joint.
A consequence of implant arthroplasty is that maintenance of the weight-bearing potential of the medial column is often diminished. In an
attempt to avoid lateral metatarsalgia associated with inadequate first metatarsal stability, bony resection of the first metatarsal is kept
to a minimum. A surgical dilemma arises because limited bone resection is believed to minimize the biomechanical faults of the procedure,
yet inadequate bone resection is probably the single most common cause of postoperative malalignment and recurrence of deformity. The
bone resection may occur on either the metatarsal or the phalangeal side of the joint. Excessive reduction of the phalangeal base releases
the intrinsics and may make fitting and secure placement of the phalangeal implant tenuous.
Bone resection with the two component joint systems is variable, and generally templates are supplied. The exact amount of bone
resected and the angle of resection depend on the implant. Surgeons who choose to use these implants should be familiar with the
recommended protocol and supplied instrumentation.
The exception to minimizing first metatarsal head resection with a hinged silicone implant is with forefoot arthroplasty, that is, the
Hoffmann-Clayton type operation. Forefoot reconstruction of the rheumatoid foot involves total head resection of the lateral metatarsal
heads to achieve a normalized bony parabola. As a result, some degree of resection of the first metatarsal is also necessary; this usually
involves at least one half of the first metatarsal head. This bone resection is also helpful in reducing both large degrees of hallux abductus
and metatarsus primus varus.
Canal Preparation
Canal preparation varies, depending on the implant chosen. Most implant systems today have reamers or rasps that allow the surgeon to
prepare the canal as a reflection of the implant stem. The angle of the canal may also vary, and the surgeon is referred to the surgical
technique guide provided by the manufacturer. Generally, implant sizers are used to determine the extent of canal preparation necessary,
although with the two-component systems, the stems are the same size, whereas the actual articular components may vary in size. One of
the features of the Biopro hemiimplant is that the stem does not require reaming and the trial implant with a smaller stem may simply be
impacted.
Implant Grommets
Titanium grommets were introduced for the Swanson double-stem implant and were later adapted by Futura for their
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Primus implant. These grommets are recommended because only beneficial consequences can be anticipated. Each size Swanson implant
has a corresponding pair of grommets. These are press fit into the medullary canals of the metatarsal and proximal phalanx. It is not
usually necessary to enlarge the medullary canals for fit of the grommet. In most patients with hallux valgus who are undergoing implant
arthroplasty, the bone density is soft, and the grommet can easily be press fit with the grommet inserter. In cases of hallux rigidus and
degenerative joint disease in which the bone is dense and sclerotic, it is necessary to round the margins of the medullary canals similar to
the contour of the grommet. The use of a grommet rasp is helpful.
FIG. 16. First metatarsal head resection. Line drawing (A) and intraoperative photograph (B) illustrating usual bone resection for
Swanson hinge implant. Bone resection varies, depending on the implant used. C: Illustrates the angular resection for insertion of a
Lawrence implant.
Implant Insertion
Once the canals are prepared to their exact size, copious irrigation is performed to remove all bone debris. In the case of a double-stem
silicone implant, the medullary stem of the first metatarsal is inserted first. Plantarflexion of the hallux then allows insertion of the distal
stem into the proximal phalanx. Insertion of the implant should be performed without the implant's touching the skin and possible
contamination with Staphylococcus epidermidis, a potential cause of latent foreign body-centered infections (93 ,111 ).
Insertion of a metallic hemiimplant generally also requires the use of an impactor to press fit the implant within the proximal phalanx.
Most of the two-component systems also supply impactors that allow the surgeon to press fit the implant securely without the use of bone
cement.
Capsular Repair
Capsular closure is performed with the surgeon's preference of absorbable materials. The medial margin of the extensor hood is also
incorporated into the capsular closure. This accomplishes an important function of medializing or maintaining the vector of pull of the
tendon of extensor hallucis
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longus. Bowstringing of this tendon laterally may destroy the stability of the joint reconstruction and may yield transverse and frontal
plane deformities postoperatively.
Soft tissue repair may be initiated before insertion of the implant system. In cases of significant bone resection, tethering the long and
short flexors to each other with an intracapsular suture helps to stabilize the hallux. Some surgeons have also found it useful to reattach
the short flexor tendons to the phalangeal base, as recommended by Kalish and McGlamry with reattachment of the intrinsic musculature
with suture through drill holes in the proximal phalanx (112 ).
In cases of significant hallux abductus, additional medial capsular repair is recommended. A capsulorrhaphy may be accomplished to give
additional transverse plane stability. This involves modification of the original linear or lenticular capsulotomy just before insertion of the
implant usually with the implant sizer in place. A vertical incision is made in the distal extent of the medial capsule, and a capsulotomy is
then performed. This capsular flap may then be advanced distally.
Closure and Postoperative Course

Subcutaneous and skin closures are left to the surgeon's preference. A compression dressing is used postoperatively to splint the toe in a
rectus position while maintaining it in a plantarflexed position to aid in postoperative toe purchase.
Ambulation is allowed immediately postoperatively with a surgical shoe. In cases of isolated interpositional implant arthroplasty,
ambulation in a flexible-soled shoe may sometimes be begun as early as 3 weeks postoperatively without any other form of toe splinting.
This actually helps to increase range of motion and to minimize edema. Severe and long-standing preoperative deformities should be
splinted in a rectus position for a longer length of time. Moderation in activity is emphasized early on, and the patient is followed with
serial postoperative visits and radiographic examinations.
RADIOLOGY
Surgical intervention for orthopedic disease is often predicated on radiographic findings. So too in the assessment of a surgical procedure,
postoperative radiographic studies offer vital information. It is true that bone may respond in only so many ways, although the radiographic
findings may be unique to or must be interpreted in light of the surgical procedure, in this case implant arthroplasty (1 ,12 ).
Besides obtaining preoperative films, radiographic examination is usually performed immediately postoperatively, at 6 weeks, at 3 months,
and at various intervals postoperatively whenever deemed necessary. The immediate postoperative examination (Fig. 17 ) is important
because it allows initial assessment of the surgical procedure, such as bone resection, reaming of the medullary canal, seating of the
implant, joint alignment, and overall correction of the preoperative deformity.
Postoperatively, periodic radiographic examination allows the surgeon to determine maintenance of correction and evaluation of the bone
implant interface. Most often, implants are press fit, and radiographic findings such as lucency may require further evaluation particularly
in the face of patient symptoms, such as unexplained pain. Radiolucency generally is indicative of loosening, be it a mechanical
phenomenon or osteolysis secondary to implant debris or infection. Osteolysis can be a troublesome problem leading to chronic pain and
instability of the implant within bony confines. Implant movement generally leads to further resorption and gross instability. Cystic
erosions have occurred and may be the result of bone resorption as a reaction to particulate debris.
Soft tissue margins and contours can also be indicators of local or regional swelling and inflammation. The soft tissues are a reflection of
both soft tissue and bone disorders. Chronic swelling of the soft tissues may be consistent with detritic synovitis, infection, or simply
instability of the implant. Abnormal soft tissue contours may reflect abnormal implant position or dislocation. If malalignment of the
implant or of joint segments is noted initially, surgical technique is probably to blame. Malalignment or joint instability does not tend to
improve, but it certainly may worsen. Consideration of pathologic loading or stressing of the implant must be acknowledged. Eccentric
loading may result in deformation, fatigue fracture, and microfragmentation and the osseous and soft tissue disease associated with it
(1 ,12 ). Malalignment of a total joint system may lead to wear of the softer component, generally titanium or polyethylene, with resulting
detritus in the tissues and possible tissue reactions.
Postoperatively, joint alignment must be assessed. Besides recognizing whether the stem or stems may be well seated, the joint alignment
in the frontal, transverse, and sagittal planes is evaluated regardless of the type or specific implant used. On the anteroposterior
projection, transverse plane alignment of the hallux and first metatarsal, as well as frontal plane position of the toe and the implant, may
be readily evaluated. These implants may be prominent after the initial postoperative swelling has resolved because the subcutaneous
tissues are thin, and excessive medial overhang of the implant itself or grommet may be responsible.
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FIG. 17. Preoperative and postoperative radiographs should be evaluated for reduction of deformity and alignment of joint and
implant. A: A patient with failed prior hallux valgus correction followed by revision (B) to a Swanson hinge implant with grommets.
Preoperative radiographs (C,D) and postoperative radiographs (E,F) of Futura metallic hemiimplant in a patient with hallux rigidus.
(Courtesy of Bruce Lawrence, Riverside, CA.)
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FIG. 18. Radiology: ectopic bone formation. This case of revision of previous hemiimplant arthroplasty with double-stem silicone
hinge arthroplasty illustrates progressive development of ectopic bone (arrows) along the dorsal surface of a resected phalangeal
base. A: Preoperative radiograph at 6 years after the hemiimplant. Postoperative radiographs: 2 weeks (B), 3 months (C), and 9
months (D). (From Vanore J, O'Keefe R, Pikscher I. Silastic implant arthroplasty. Complications and their classification. J Am Podiatry
Assoc 1984;74:423-433, with permission.)
Sesamoid position, particularly the absence of proximal retraction, indicates maintenance of the insertion of the plantar intrinsic muscles.
Between 6 and 12 months postoperatively, radiographic examination is helpful in demonstrating hallux purchase and sagittal plane position
of the first metatarsal on the weight-bearing lateral projections.
Serial radiographs can reveal evidence of osseous disorders as well as soft tissue disease. For example, the radiographs from 3 months to 1
year postoperatively may show a gradual development of ectopic bone (Fig. 18 ). New bone formation at either side of the resected bone
surfaces is common. Excessive bony proliferation is associated clinically with limitation of motion. Ectopic bone is noted as early as 3
months postoperatively and is well formed by 9 to 12 months. Our experience has shown a tendency to little further proliferation beyond 1
year postoperatively (1 ,12 ,105 , 107 ,113 ).
Before 3 months postoperatively, an aseptic periosteal reaction has been noted, predominantly along the metatarsal and associated with
periosteal bone formation after surgical dissection. Clinically, these patients usually possess a limited range of motion as well as induration
in the area. The induration gradually dissipates, but over a long period of time, often 6 to 12 months, although a limited range of motion
may persist.
Postoperatively, between 6 and 12 months, the radiograph shows a peripheral sclerosis surrounding the perimeter of the stems within the
medullary canals (Fig. 19 ). This is a consistent finding and is believed to be physiologic versus pathologic (102 ). I propose that the bone
internally now represents a load-bearing surface, and the sclerosis is actually new bone laid down in accordance with functional demand
(114 ).
Serial radiographic examination is particularly important given that implant arthroplasty of 10-, 20-, and 30-year follow-up on any series of
patients is yet to be reported. Serial radiographs beyond 1 year are also helpful in evaluating implant failure caused by deformation and
fatigue fracture because earlier failure is uncommon. The soft tissue may reflect synovitis, capsular hypertrophy, and granuloma formation.
These conditions are also not common before 1 year postoperatively and should not be confused with postsurgical edema.
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FIG. 19. Radiology: intramedullary remodeling. Postoperative radiographs of double-stem arthroplasty taken at 3 weeks (A), 2
months (B), 6 months (C), and 13 months (D). Note the progressive development of bony sclerosis along the perimeter of the implant
stems with an absence of resorption and osteolysis.
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Osseous disease is categorized in the section of this chapter on complications. Early in the postsurgical phase, pathologic features may
include osteomyelitis or resorption adjacent to the medullary stems as in fibrous hyperplasia. This may be associated with pathologic
fracture. The latter are difficult to appreciate without serial examinations or late-stage findings (107 ,115 , 116 , 117 , 118 , 119 ).
Proliferation of a fibrous tissue interface is seen to some degree in most cases of silicone implant arthroplasty (12 ,120 ,121 ).
Bone cysts associated with hemisilicone implants are first noted by 6 months postoperatively and grow to maturity by 3 years
postoperatively (1 ,12 ,122 ). These usually remain asymptomatic and are rarely associated with pathologic fracture or limitation of motion.
Usually, along the margins of the stems within the medullary canal, sclerosis develops along the perimeter, as previously described.
COMPLICATIONS
A classification was formulated for the complications of first metatarsophalangeal implant arthroplasty (12 ), particularly relative to the
problems noted with patients who had undergone hemisilicone arthroplasty. Since that time, implant arthroplasty has broadened, and
some modifications in the classification system have been made. The complications remain grouped into five main categories: implant
failure, postoperative joint alignment abnormalities, abnormalities of the bone, abnormalities of soft tissue, and biomechanical joint
complications.
Biomaterial Failure
The biomaterials used for the construction of implants are required to resist mechanical failure during normal use for an indefinite period.
Metals, various polymers, and carbon materials have all been used as joint implants. The physical properties of these materials should
reflect the types and degree of forces that would be compatible with long-term successful use of the implant (44 ,47 ,86 ).
An artificial division has been proposed with a distinction between intrinsic and extrinsic implant or material failure (12 ). Intrinsic failure
refers to problems encountered when in vivo physiologic or pathologic forces exceed the limits intended for normal use of the implant. The
physical properties of the device are defined both by the material as well as its structural configuration. Extrinsic failure is the result of
tampering with the implant or artificially creating defects within its structure and thus negatively influencing the physical properties of the
device.
Intrinsic implant failure includes deformation, fatigue fracture, and microfragmentation or wear debris. Deformation may occur when
loading forces exceed the elastic limit of the material or when repetitive cyclic loading adversely affects the physical properties of the
material. Deformation is identified as observable plastic changes in the topography of the implant. This can occur with numerous
biomaterials including silicone and UHMW polyethylene. Erosion or wear is also a problem, particularly when considering the articulating
implant systems, or total joint replacements. Wear implies the loss of material and generation of particles as a result of friction movement
between opposing surfaces (123 ). It also encompasses the phenomenon of particles that become trapped between bearing surfaces. Wear,
by definition, requires an interface between materials, biologic or otherwise, whereby they act on each other.
The physical properties of implant materials are generally dissimilar to those of the tissues they replace. Most metals possess elastic
moduli of much greater magnitude than cartilage or bone. This is associated with deformation of the articular surface and bone resorption
in cases of hemiimplantation (9 ,101 ,124 , 125 , 126 ). Bone resorption or loosening of implants has predominantly been a result of the
generation of particle debris. Wear produces particles in the periprosthetic tissues that may initiate a biologic response that has been
centered around macrophages, fibroblasts, and osteoblasts, as well as cell products including cytokines and lysosomal enzymes (123 ).
Small joint problems have resulted mainly from wear debris of silicone that produces soft tissue inflammation and granulomas as well as
osteolysis.
Initially, surgeons chose to reexamine surgical technique as a cause of implant material problems. Inadequate bone resection or soft tissue
release was believed to lead to problems of deformation and fatigue with either the hemiimplant or double-stem silicone implant. Implant
arthroplasty is an adjunct to resection arthroplasty, and the reconstruction requires joint release generally accomplished through bone
resection. Laxity of the joint arthroplasty is critical; a tight implant cannot maintain proper anatomic alignment. Instability in one or more
of the cardinal body planes can develop and can result in plastic deformation through the entire stressed implant.
With abnormal loading, long-term plastic deformations develop and usually precede fatigue fractures (Fig. 20 ). Repetitive loading may
also weaken the material or may introduce a flaw into the substance of the implant. This may then go on to complete fracture of the
implant into two or more pieces (127 ). Not all medical-grade silicones are equally stress resistant, and implant design may also influence
the dispersion of forces and strain. In vitro testing of the material is usually performed by the manufacturers using standard tests of the
American Society for Testing and Materials (47 ,127 ). These in vitro tests are generally considered a good indication of a material's ability
to avoid failure.
Microfragmentation or generation of particles is a result of wear debris from the joint interface, medullary shearing, corrosion or fretting,
or breakdown of a prosthetic material. Many reports regarding microfragmentation of silicone implants have been cited
(1 ,12 ,96 ,103 ,115 ,116 ,128 , 129 , 130 ). Silicone particles may be found adjacent to the prosthesis, in
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the surrounding synovium, and in bone, as well as at a distance from the implantation site. Christie and associates were the first to imply
migration of particulate debris by lymphatic channels (97 ), and this was stated more conclusively later by Gordon and Bullough (103 ). Our
own clinical findings suggest that some silicone debris can frequently be identified, but rarely does it become clinically significant (1 ,12 ).
FIG. 20. Complications with silicone implants included plastic deformation and fracture. A: Hemiimplant. B: Hinge implant. Wear is a
problem with total joint systems as well as with polymer devices. C,D: An intraoperative view of a total joint that showed erosion of
the titanium phalangeal tray resulting from postoperative malalignment with resultant titanium debris throughout the first
metatarsophalangeal joint area.
Microfragmentation of metal implants also occurs, particularly with titanium. Titanium is softer than cobalt chrome, and if abnormal
loading or abutment occurs, then titanium debris is generated and is deposited throughout the adjacent tissues as a black adherent
infiltrate. Wear of metals is usually easy to identify because the tissues are discolored or “blackened.”
Metal particles may undergo corrosion with the production of ions. Metallic ions combine with proteins and cell surfaces and can be carried
to other parts of the body. Modern metals are alloys that may combine many individual elements in an effort to produce materials with
particular characteristics.
Cobalt chrome alloys contain nickel and molybdenum, which are rapidly transported and eliminated in the urine, as is cobalt, but more
slowly. Chromium is handled in a similar manner, but it may accumulate in the tissues. Aluminum is normally found in the body and has
little impact. Vanadium from titanium alloys is rapidly excreted in the urine, whereas most titanium remains in the periprosthetic tissues
(29 ,92 ,123 ,131 ).
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Extrinsic implant failure implies a material defect associated with failure of the prosthesis. The surgeon may tamper with the physical
structure of the implant in an attempt at remodeling and may cause inadvertent laceration in a polymer or surface flaw with a resultant
stress riser. This may propagate a fracture in vivo without appreciable plastic deformation (12 ). Under some circumstances, surgeons have
placed a suture through the substance of a silicone implant. This introduces a defect or stress riser in the implant and may lead to
premature failure and fracture of the device.
Alignment Abnormalities
Alignment abnormalities develop if inadequate joint reconstruction accompanies the arthroplasty (1 ), and they are usually the result of
errors in surgical judgment or technique. They also make up the majority of cases of revision surgery.
Transverse plane instability gives rise to medial or lateral deviation of the hallux and may occur with either interpositional implants or
total joint replacement. This was common in the 1970s when the hemiimplant was used for the correction of severe or long-standing hallux
valgus or hallux varus. A hemiimplant functions as a nonconstrained spacer. The double-stem hinged implant is a fully constrained device,
but it is no substitute for adequate joint reconstruction. The implant may impart some transverse plane stability, but it should not be
relied on for such.
The original Swanson great toe hemiimplant possessed a large radius of curvature that did not conform to the metatarsal head. As a result,
the metatarsal head articulated with only a small surface area of the implant. Even when the hemigreat toe prosthesis was placed in
rectus alignment, settling of the implant articular surface may have led to lateral instability and recurrent deformity. The lateral gap sign
has been described as the radiographic appearance of a straight toe and implant with a laterally deviated articular surface (12 ). Weil
redesigned the standard hemiimplant to accommodate up to 15 degrees of the lateral deviation of the first metatarsal head articular
surface (132 ). In addition, the Weil modification possessed an implant base with a smaller radius of curvature.
Transverse plane stability of the double-stemmed prosthesis depends on its correct alignment (geometric reaming of the medullary canal)
in the frontal plane and avoidance of axial rotation. Use of a double-stemmed implant without reduction of an elevated metatarsus primus
varus may place excessive stress on the hinge of the implant and result in mechanical fatigue or deformity of the implant and joint
reconstruction.
Sagittal plane instability may be seen as dorsal or plantar subluxation of the first metatarsophalangeal joint. Hallux extensus or dorsal
subluxation is more frequently encountered and may occur with either the double-stem device or the hemidesign. Once again, the
importance of joint relaxation without creating excessive instability through disruption of the plantar intrinsics must be stressed. This is an
important feature of the Futura joint implants because bone resection guides are supplied that attempt estimation of the proper amount
of bone to be removed with the resection of the articular surfaces.
Axial rotation of the hallux is often associated with severe hallux valgus deformity of the great toe and metatarsophalangeal joint. Residual
axial rotation was often apparent on follow-up of hemijoint replacement in the presence of the soft tissue contractures of long-standing
hallux valgus. The double-stem implant imparts greater stability, although release of soft tissue contractures and reduction of an excessive
intermetatarsal angle are necessary. Axial rotation of the hallux has been associated with a large intermetatarsal angle and long-standing
deformity.
Adjacent Bone Abnormalities

Aseptic or ischemic necrosis of bone was first reported by Arenson and Weil involving the proximal phalanx (108 ). This abnormality is
believed to occur secondary to concomitant subperiosteal dissection and excessive reaming of the medullary canals. Often, these patients
remain asymptomatic, although serial radiographic examinations reveal findings consistent with aseptic necrosis (Fig. 21 ). The most
common radiographic abnormality involves the disintegration of the proximal phalanx and its subsequent remodeling. Our contention is
that the radiographic abnormality of so-called “engulfment” of the implant results from osseous collapse of the surrounding bone. As
repair occurs, the radiographic appearance may be one of complete osseous encapsulation of the implant. Sorto and Weil have attributed
this to so-called “bulldozing” by the harder material (9 ,133 ).
Ectopic bone or bony proliferation at the margins of the resected bone is a common finding and probably occurs to some extent in every
case (1 ,12 ). This and periarticular fibrosis are probably responsible for limitation of joint motion. Although uncommon, ectopic bone can
bridge a joint arthroplasty and can completely limit motion (12 ,106 ).
Ectopic bone can usually be observed by 3 months postoperatively and generally matures by 12 months. The use of titanium grommets with
the Dow Corning double-stem implant may be useful in limiting the degree of heterotopic bone (2 ,134 ,135 ). As a result, the range of
motion postoperatively is often greater than without the use of grommets.
Bone detritus or the presence of particulate foreign material in bone has been noted (1 ,99 ,103 ), particularly with polymers. It has been
implicated as the cause of chronic inflammatory reactions or of osteitis within the substance of the bone itself.
Bone cysts have been noted with some degree of frequency after arthroplasty. These appear as radiolucencies in trabecular bone that
progress to definitive osteolytic cavitation (1 ,12 ,106 ,136 ). These bone cysts are usually asymptomatic, although occasionally pathologic
fracture through the articular surface and subchondral bone may occur in the case of hemiimplant use. Cysts may represent an erosive
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phenomenon secondary to osteitis resulting from bone detritus, polymer, or metallic debris within the adjacent bone. A pannuslike tissue
initiated by detritic pathology invading periarticular bone has also been considered. These were first noted in the foot after hemisilicone
arthroplasty but now have been seen with most implants and materials.
FIG. 21. A: Phalangeal aseptic necrosis appears as sclerotic nontrabeculated hypertrophic bone that often obscures implant. Ectopic
bone is frequently observed at phalangeal resection (B), and occasionally it occurs along the periphery of first metatarsal head (C).
D: Bone detritus is the histologic observation of silicone debris (arrows) within bone substance and may be seen with osteitis or
synovitis. bt, bony trabeculae. E: Bone cysts, although noted as incidental findings, occur frequently within first metatarsal head
with hemiimplants. F: Fibrous hyperplasia of bone appears invasive as an expansile lesion of bone. (Courtesy of J. Kriger. F from
Vanore J, O'Keefe R, Pikscher I. Complications of silicone implants in foot surgery. Clin Podiatry 1984;1:175-198, with permission.)
Similar bony resorption has been seen both within the medullary canals of the proximal phalanx and in first metatarsal adjacent to the
implant stems. Benign, although at sometimes invasive, osteolysis has been noted. This has yielded pathologic fractures as well as
ballooning and a soap bubble appearance to the remaining bone (1 ). The magnitude of this bone resorption may be concerning, and
careful evaluation and follow-up of the patient are recommended.
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Erosions of the articular surface opposite the hemiinterpositional arthroplasties may also be encountered (12 ). The articulation of a
hemiarthroplasty is one of hyaline cartilage with a foreign surface, generally one of a much greater modulus of elasticity. Under these
conditions, it is not illogical to expect that the hyaline cartilage that remains would undergo degeneration and sequential pathologic
changes. Tracking or erosion of the articular surface by the implant has been demonstrated. Joint disorganization has been noted, and this
may be the result of disruption of normal joint dynamics in its nutritive role for the articular surface, that is, “stressdependent metabolic
homeostasis” (50 ). Cartilage breakdown may thus be a consequence of hemiinterpositional arthroplasty. I have previously identified the
syndrome of silicone hemijoint arthroplasty (12 ), which was postulated to explain the observations of articular disorganization, erosions,
cyst formation, and proliferative bone changes.
Soft Tissue Abnormalities

Pathologic host response in the soft tissues has also occurred with various implant arthroplasties. These host tissue reactions may occur in
the form of reactive or detritic synovitis, foreign body reaction with granuloma formation, and a reactive fibrous hyperplasia (130 ,131 ).
When implanted in the body, silicone or any inert foreign body, whether in bone or soft tissue, is followed by a process of fibrous tissue
encapsulization. In large pieces, the material usually becomes encapsulated and does not elicit much in the way of inflammatory response
by the body (41 ,45 ,99 , 120 ,137 ). Microscopic fragments or debris may incite a host tissue response (Fig. 22 ).
Wear of all implant materials has been observed. These may lead to both soft tissue and osseous diseases and may be related to the
concentration of debris, its rate of production, and particle size, as well as being a more specific biologic reaction. Problems are
encountered when large amounts of debris are produced, for example, in a hemiimplant articulating with a degenerated metatarsal head.
Large amounts of debris may be associated with implant fractures. In either situation, tissue reactions have been associated with cellular
events of phagocytosis and an inability to digest the particulate material followed by release of mediators of inflammation after cell death.
Material detritus is greatest in the periprosthetic tissues, and hypertrophy of the joint capsule is not uncommon and is not considered a
pathologic event. Occasionally, a significant foreign body reaction or soft tissue granuloma may form within the confines of a joint
reconstruction or at some extracapsular location (1 ,12 ,138 ). Several reports document the migration of implant debris, likely through
lymphatic channels (97 ,139 ,140 ).
Inflammatory reactions unrelated to material detritus have been noted. Certainly, infection must be considered. Postoperative wound
infections occur with a statistical frequency whether or not an implant is used. Generally, immediate postoperative wound infections are
not a diagnostic dilemma, but foreign bodies are associated with latent infections. Gristina and Webb termed these delayed foreign body
centered infections and identifies that often nonpathogenic bacteria, for example, S. epidermidis, is the causative organism (93 ,111 ).
The bacteria may have been sequestered on the surface of the prosthesis during implantation. At some later point, a latent low-grade
inflammation or infection presents that appears to respond to antibiotics. Problems persist, because the bacteria remain on the surface of
the foreign material. Generally, removal of the material is curative.
Superficial infections seen in the immediate postoperative phase have responded to appropriate treatment without the need for removal of
the implant. Deep infections usually require removal of the implant to allow drainage of the wound and to avoid chronic osteomyelitis
(133 ,136 ).
Biomechanical Joint Failure

Several biomechanical problems associated with implant arthroplasty or joint replacement procedures have been identified. Some are
inherent to the procedure, whereas others may be traced to technical error.
Surgical judgments and indications of usage are a consideration. The surgeon must recognize that implant arthroplasty is a joint-
destructive procedure, and in the younger and more active patient, the surgeon should use alternatives to implant arthroplasty whenever
possible. Implant arthroplasty may improve cosmesis and function of the foot compared with resection arthroplasty. However, even with
the best of surgical results, normal biomechanics cannot be attained. There is a disruption of the intrinsic muscle stability of the great toe
and dynamic toe purchase as a result of phalangeal bone resection. Along with this, first metatarsal stability is diminished (58 ), as well as
the reciprocal motion between the first metatarsal and the phalanx. Functional elevation of the first metatarsal occurs, with resultant
lesser metatarsalgia. These are all considered biomechanical inadequacies associated with almost any implant arthroplasty, and certainly
some techniques may minimize these problems. Alternative procedures need be examined for appropriateness to the specific patient and
his or her functional requirements.
Design of the implant is also important, but whether specific design parameters incorporated into an implant system will provide better
functional and cosmetic results is yet to be realized (6 ). Technical errors are responsible for some problems associated with function of an
implant arthroplasty. Lesser metatarsalgia often follows with loss of function of the first metatarsal sesamoidal complex (141 , 142 , 143 ).
Therefore, joint arthroplasty is best accomplished with the minimum amount of osseous resection necessary to alleviate tension and
deformity at the first metatarsophalangeal joint. The only exception to this is with a modified Hoffmann-Clayton procedure for the
rheumatoid foot in which the patient has an apropulsive gait and resection of the first metatarsophalangeal joint is accompanied by
excision of the lesser metatarsal heads.
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FIG. 22. Detritic synovitis is inflammatory response to particulate debris, in this case silicone rubber. A: Synovial biopsy specimen
revealing large amounts of granular silicone debris (s) and concomitant fibroplasia (f) of synovium. B: Foreign body giant cell (g)
often forms and may be found to be engulfing silicone fragments. C: Foreign body granuloma is result of chronic tissue reaction. D:
Patient reported chronic discomfort and swelling at the implanted first metatarsophalangeal joint. Inflammatory reactions have also
been noted without implication of silicone debris. E: Giant cell formation, although no silicone could be demonstrated.
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REVISION OF FAILED IMPLANT ARTHROPLASTY

As in any problematic surgery, the surgeon should give considerable thought to why the original arthroplasty failed, what is the present
problem, both from the patient's point of view and from the surgeon's own perception, and what is most likely to provide the patient with
a pain-free and durable revision. Revision and the surgeon's choices of repair certainly vary both with experience and willingness of the
patient to comply with surgical procedures and postoperative disability.
Revision of Failed Interpositional Implant

Revision of an interpositional implant may vary from the simple to the complex, and this is an important determinant for success. Implant
revision may be necessary because of chronic pain, recurrent deformity, or various soft tissue or bony reactions, such as detritic synovitis
or osteolysis.
The patient may be experiencing chronic joint pain and swelling, deformity, or lateral metatarsalgia (12 ,144 ). Radiographically, the
quality of the remaining bone, the presence of osteolysis, or cystic erosions may influence the revising surgeons choice of procedure.
Potential solutions may include (a) revision to another joint implant (4 ,84 ), (b) removal of the present implant to leave it as a resection
arthroplasty (144 ,145 ), and (c) revision to a joint fusion (21 ). Revision to another joint implant should probably be reserved for the
patient without significant host reaction to any of the prior implanted biomaterials. A situation encountered in the past was that of the
failed silicone hemiimplant. The length of the proximal phalanx, the integrity of the flexor apparatus, and the quality of bone stock often
determine the most appropriate reconstruction.
FIG. 23. A: This 34-year-old woman was initially treated with a silicone hemiimplant in the late 1970s. She developed joint pain and
in 1981 was revised to a silicone hinge implant (B). Today, revisional surgery would probably consist of an arthrodesis.
Many times, surgeons hope that revision with a double-stem implant will provide a satisfactory reconstruction. This is generally a
straightforward procedure as long as integrity of the soft tissues is present, but probably the better choice is simply leaving it as a
resection arthroplasty or converting it to a first metatarsophalangeal joint fusion, which may require a bone graft with internal or external
fixation.
Difficulties may be encountered in the presence of flexion at the hallux interphalangeal joint. In this case, fusion of the hallux
interphalangeal joint combined with removal of the first metatarsophalangeal joint implant would likely be the recommended procedure of
choice. Probably, the best alternative is to remove the old implant, to fill the osseous defect with a bone substitute or graft, and to
stabilize the reconstruction with internal or external fixation until sufficient healing has progressed.
Case 1: Detritic Synovitis With Silicone Hemiimplant Treated With Revision Implant
This was not an uncommon situation in the late 1970s through 1980s; the hemisilicone implant was no longer in
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common use much after the later 1980s. Actually, many patients with these implants had good results with excellent range of motion.
Problems occurred with this implant because many of these devices were used in a broad range of patients.
Figure 23 illustrates revision surgery in a 34-year-old white woman who probably should not have received an implant originally. Five years
postoperatively, she complained of periarticular pain with chronic swelling and joint stiffness. In 1981, she underwent revision to a double-
stem hinged silicone implant. Her immediate postoperative course was unremarkable, but on a long-term basis, she developed limitation of
first metatarsophalangeal joint motion and lesser metatarsalgia that required orthotic devices for relief. She also sustained permanent
limitation of activities and work capabilities.
FIG. 24. A,B: This 60-year-old woman with diabetes had a silicone hinge implant and developed a plantar exostosis below the distal
first metatarsal. C-F: The implant was removed. The medullary canals were packed with interpore bone graft substitute and were
stabilized with a Kirschner wire for 5 weeks. A good interval was maintained postoperatively, but this eventually went on to full bony
consolidation (G).
Case 2: Ankylosis With Double-Stem Hinged Implant Treated With Removal of the Implant
Some of the most satisfied patients with a double-stem hinged implant had limited motion at the first metatarsophalangeal joint. Because
of joint ankylosis, these patients actually had a stable reconstruction and rarely had problems with recurrent deformity. The case of Fig.
24 depicts the situation of postoperative ankylosis in a patient with diabetes that
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led to ulceration. Actually, this patient also suffered from proliferative exostosis inferior to the metatarsal head that led to the pressure
ulcer. After initial management of the ulceration, revision of the implant arthroplasty was performed. No infection or detritic host
reactions occurred.
FIG. 24. Continued.
Case 3: Chronic Pain With Hemimetallic Implant Treated With Implant Removal
At times, patients may experience complications for varied reasons. This case illustrates a problem resulting from the hard subcutaneous
nature of the implant. Generally, surgeons are careful to avoid overhang of the implant medially because this is the most common
problematic area (Fig. 25 ).
Revision of Failed Total Joint System

Problems with total joint systems are not that much different from those encountered with the interpositional devices, except bone loss is
generally greater and the muscle-tendon imbalances are magnified. Reconstruction of failed total joint arthroplasty is often complicated
by instability of the great toe and loss of osseous length. Generally, insertion and subsequent removal of any of the total joint systems
result in significant bone loss and requirement for bone grafting during revision.
Each case must be analyzed and treatment individualized. Obvious to the success to each case is that the patient has an immense part to
play as the central participant.
FIG. 25. This 40-year-old woman was initially treated with a cheilectomy for hallux limitus and then later a Keller procedure. She
underwent revision to a Biopro hemiimplant but had local pain because of minor overhang of the device that required removal. In
most patients, this probably would not have caused any difficulty, but she was extremely slender with little subcutaneous fat.
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One of the problems seen with greater frequency with total joint arthroplasty versus interpositional implant arthroplasty is that of
infection. Infection may come in the form of an immediate postoperative infection, either superficial or deep, with the latter usually
requiring removal of the joint implant. An additional problem may also be encountered with a foreign body-centered infection. In this type
of infection, the implant sequesters bacteria in a glycoprotein that generally does not respond to systemic antibiotics. The treatment of
this type of infection usually requires removal of the implant. Reconstruction after a deep infection definitely complicates the process.
Case 4: Chronic Pain From Foreign Body-Centered Infection Treated With Revision Fusion
This is an example of a failed total joint system resulting from a foreign body-centered infection. This 52-year-old white woman presented
6 months after hallux rigidus repair with an Osteomed total joint arthroplasty with low-grade periarticular pain and swelling (Fig. 26 ). No
erythema or acute inflammation was ever apparent, and no significant increase in sedimentation rate or white count was noted.
Radiographs showed a radiolucency around the stem of the phalangeal component. The patient did experience lesser metatarsalgia.
Loosening of implant components may be a mechanical phenomenon, occurring secondary to failure of the cement mantle, osteolysis from
foreign body reaction, or of course, infection.
Implant removal and fusion were recommended, but on opening the joint capsule, a seropurulent exudate was evident. The implant was
removed, and cultures were obtained. The wound was closed over gentamicin-impregnated polymethylmethacrylate beads, and the patient
began receiving intravenous antibiotics. She developed allergies to the vancomycin and completed a 6-week course of clindamycin.
The patient then underwent removal of the antibiotic beads and reconstruction of the defect with a bone graft fusion. An iliac crest bone
graft was inserted with maxillofacial straight plate fixation (7-hole, 2.4-mm plate). The patient was kept non-weight bearing for 8 weeks
and had good wound healing without evidence of infection or resorption of the graft. At 16 weeks postoperatively, she was walking and
suffered a fracture of the plate and fusion.
Case 5: Chronic Pain Total Joint Replacement Treated With Implant Removal
This patient underwent a KMI total joint replacement and postoperatively suffered gradual hallux instability and deformity (Fig. 27 ). She
presented with significant osteolysis of the proximal phalanx with malleus deformity. The metatarsal component was prominent dorsally
and caused pain. She also suffered with lesser metatarsalgia. Revisionary arthrodesis was recommended, but the patient was a 50-year-old
woman who played golf and was concerned about retaining movement. Because of the almost complete dissolution of the proximal phalanx,
revision with bone graft was performed to reconstruct the proximal phalanx with fusion of the interphalangeal joint and external fixation
to stabilize the reconstruction.
This patient was compliant and cooperative with the postoperative regimen and went on to unremarkable healing. The external fixation
frame was removed at 8 weeks postoperatively, and gradual return to activities was allowed. She patient recovered well, with resolution
of preoperative symptoms including the metatarsalgia. She was maintained in orthotic devices for several years postoperatively.
Implant arthroplasty of the first metatarsophalangeal joint actually created a whole new milieu of pathologic situations. Already discussed
were the biomaterial and host response problems. However, one of the most preventable problems with implant arthroplasty is related to
biomechanical faults. Implant arthroplasty should be avoided in young patients. This group is most likely to experience biomechanical
problems because of their functional demands. In nonsalvageable joints, particularly in younger patients, joint fusion is a strong
consideration.
Initially, sporadic disclosures of unanticipated complications appeared in the literature. Detritic synovitis was identified as a cause of late
inflammatory events (96 ,128 ,138 ,146 ). Material fatigue and detritus were being discovered with revision surgery by gross observation
and histopathologic examination (88 ,147 ).
Long-term serial radiography revealed further apparent sequelae, with heterotopic bone and subchondral cyst formation being the most
common findings and subchondral cyst formation closely related to hemiimplantation in particular (12 ,120 ,138 ). Although poorly
understood, these long-term findings could not be ignored, and further study led to their categorization and clearly acknowledged them as
complications (12 ).
Not long after the general use of the hemiimplant, a double-stem hinge variety comparable to those in use for the metacarpophalangeal
joint was also introduced (148 ,149 ). A barrel double-stem implant with a polyester jacket was developed by Cutter Biomedical, and then
Dow Corning's Swanson design became available. These devices were initially recommended for a greater degree of arthrosis in which the
hemiimplant simply would not be adequate. At one time, use of a hemiimplant was conceived as a more conservative procedure that could
always be revised to a total implant. Over the years, a considerable portion of published reports concerning hemisilicone implants in the
foot discussed their associated complications (1 ,4 ,12 ,104 ,117 ,128 , 130 ,145 ,150 , 151 , 152 ).
Investigators have also identified that detritic phenomena would be most prevalent with the use of a hemiimplant in cases of irregular,
degenerative first metatarsal heads. Although the proximal articular surface is usually the site of greater damage, the hemiimplant was
initially used to replace the phalangeal base. Subsequently, the eroded metatarsal head was acknowledged as a contributing etiologic
factor to wear debris (12 ,99 ,132 ).
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FIG. 26. A,B: This 52-year-old woman presented 6 months after total joint replacement with localized pain and swelling but no
erythema. Radiographs show resorptive charges around the phalangeal stem. The implant was removed, and purulence was noted; a
diagnosis of foreign body centered infection was made. C,D: The implant was removed, and antibiotic-impregnated beads were
inserted. E: This was later revised to an arthrodesis with autogenous bone graft and plate fixation.
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FIG. 27. This 50-year-old woman with hallux limitus was initially treated with a KMI total joint but underwent progressive instability
with deformity of both the metatarsophalangeal and interphalangeal joints (A-D) with osteolysis of the proximal phalanx. The implant
was removed, the interphalangeal joint was fused with an autogenous corticocancellous graft with stabilization with external fixation
for 6 weeks (E). Postoperatively, the metatarsophalangeal joint space was maintained (F), as well as hallux position (G).
Several double-stem implants are available for use, each with unique design characteristics. The tendency appears to continue design
modifications to improve function (20 ,79 ,80 ).
Indications that are particularly applicable for the double-stem implant are those involving transverse plane deformities. In cases of hallux
valgus and hallux varus with associated arthrosis, the constrained design offers improved stability for the reconstruction. This has been
used almost to extreme in cases of senile hallux valgus. If, during the reconstruction, complete relaxation at the first metatarsophalangeal
joint is accomplished, then reduction of intermetatarsal angle is also possible. This approach allows avoidance of osteotomy in patients
with poor bone stock and in whom rapid rehabilitation is most desirable (153 ).
Initial reports may have misled surgeons into believing that implantation regardless of deformity would secure a pain-free postoperative
state. In the late 1970s, this led to overuse of the procedure in cases in which the joint should not have been sacrificed. Today, surgeons
are aware of the potential for various complications and how to avoid such problems. Implant arthroplasty revision rates appear
comparable to those of other first metatarsophalangeal joint procedures.
Advances such as the titanium grommets may increase the life span of the implant arthroplasty and may help to limit complications
(135 ,144 ). Continued improvements in surgical techniques and development of specialized instrumentation for insertion allow more
predictable results among various surgeons.
Silicone implant arthroplasty is certainly a viable clinical option in many disorders. There have been continual advances in biomaterials and
implant design to produce devices that are both functional and well tolerated. The high level
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of patient satisfaction and rapid rehabilitation achieved with implant arthroplasty are testimony to the success of the procedure
(78 ,135 ,154 , 155 , 156 ).
FIG. 27. Continued.
RESULTS
Initially, reports by surgeons were enthusiastic because short-term results were successful. Albin and Weil reported virtually no
complications in more than 1,000 cases of hemiimplant arthroplasty (65 ), although the average patient follow-up was only 12.5 months,
whereas Kalish and McGlamry reported good results in 243 cases of the Swanson hemiimplant used for hallux valgus and hallux rigidus
(112 ). A third report appeared in the 1970s from LaPorta et al. on a large number of Swanson hemiimplants (109 ). The conclusion of these
early studies was that implant arthroplasty, using the Swanson great toe hemiimplant, was superior to the standard Keller or Mayo-type
arthroplasty of the first metatarsophalangeal joint with regard to function and cosmesis. Some insight was shown by Kravette and Baker in
their 1978 article in which they noted improvement with respect to pain relief and cosmesis, but the authors acknowledged
disappointment with function and identified possible implant failures in active patients (157 ).
Swanson and Swanson's own reports of their use of the hemiimplant reveal a longer follow-up than the previous studies, and most of the
procedures were performed for rheumatoid arthritis (74 ,149 ). They also identified several complications not previously reported, for
example, nonspecific inflammatory reactions, implant damage, avascular necrosis of the first metatarsal head, and heterotopic bone
although with a small incidence. Swanson found a few cases of cystic erosion of the first metatarsal head but attributed it to preexisting
disease, for example, rheumatoid arthritis.
A retrospective study published by Weil and Goller in 1984 reported on 484 implant procedures in 311 patients with an average follow-up of
3.1 years (9 ). Only 18 of the 484 procedures required revision: 3 from implant failure, 6 from infection, and 9 from persistent pain. The
patient population in this study was older, and each patient presented with joint pain. These investigators reported 70% good to excellent
results in 484 patients with an average age of 61 years.
These results compared with Kampner's 12-year experience with the Cutter and Sutter barrel-stem designs (40 ); 103 implants were placed
in 71 patients with a follow-up of 7.4 years (minimum of 12 months). He separated cosmesis from pain relief and noted 70% good to
excellent results for cosmesis and 80% for pain relief. Laird reviewed 228 double-stemmed implants over 8 years and reported a rate of 83%
for pain relief and 88.5% for satisfaction with cosmesis (155 ). He had two patients who experienced mild synovitis and no cases of implant
failure. Shankar and Asaad described experiences with 89 feet that underwent 106 implant procedures. Nearly 90% of patients were rated
with excellent or
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satisfactory results (158 ). Long-term morbidity was low, and no cases of silicone synovitis were observed.
Little question exists that surgeons became cautious with regard to silicone implants because of the silicone breast implant crisis of late
1980s. To criticize the use of silicone became fashionable, and all problems with the arthroplasty were blamed on the material. In some
instances, the patient should not have been a candidate for silicone arthroplasty, but the published article lacked insight or chose to
ignore reason.
Generally, published articles dealing with larger numbers of patients reported good results. Mondul et al. published a study looking at a
combined 88 feet with both hemiimplants and double-stem silicone implants (141 ). Follow-up averaged 6.3 years for the hemiimplants and
2.1 years for the double-stem arthroplasties.
Cracchiolo et al. reported on 66 patients with a total of 86 double-stem silicone implants in patients with hallux valgus, hallux rigidus, and
revision bunionectomies, as well as a group with rheumatoid arthritis (156 ). These investigators recommended careful patient selection
and found good results, better than 80%, in both groups of patients. They noted a group of dissatisfied patients, all of whom had prior
failed bunion operations but who were younger than the average age of the remaining patients. These investigators also noted a small
percentage of fractured implants but believed that there was no need for revision surgery unless the patient experienced untoward
symptoms. This is much the same conclusion of Moeckel et al. (154 ).
My experience and that of O'Keefe and Pikscher, the authors of this chapter in the previous edition of this textbook, had combined more
than 1,000 implant procedures, with approximately 20% implanted with grommets. The revision rate was less than 2%, and although the
incidence of ectopic bone, malalignment, and limited motion was not uncommon, these developments did not generally require additional
surgical procedures or affect patient satisfaction. This was the same conclusion of Grandberry et al. in 1991, who reviewed their series of
Sutter double-stem implants and found a significant percentage with implant deformation and fracture, although most patients were
satisfied with the procedure (159 ). These investigators calculated that half the implants would fail by 4 years postoperatively. Because of
concerns over durability, this group of surgeons abandoned this procedure.
Patient selection is paramount to a successful outcome. The current philosophy is that alternative procedures be employed for younger
patients and for those with limited arthrosis. The use of protective grommets with the hinged silicone implant has led numerous authors to
suggest that durability of the reconstruction with a reduction in implant deformation, fracture, and associated complications should
diminish (2 ,14 ,78 ,134 ,135 ,144 ,156 ).
A Mayo Clinic report on survivorship analysis of 93 implants performed on 79 patients over a 21-year-period identified age as a major
consideration of longevity of the arthroplasty (160 ). The overall probability that the implant would not be removed was 86% at 10 years
and 82% at 15 years.
Sebold and Cracchiolo reported on 32 patients, 47 feet, with an average age of 51 months and all with silicone hinged implants and
titanium grommets (135 ). They did not observe any implant fractures and concluded that the grommets provide a protective function and
improve the longevity of the arthroplasty.
Initially, the major fear with regard to postoperative complication was of wound infection. In no report involving any meaningful number of
cases have postoperative wound infections occurred with any significant frequency. The series of reports previously mentioned involving
more than 2,000 implant arthroplasties has a startling absence of postoperative wound infections (65 ,109 ,112 ). Even to this date,
implant arthroplasty has not been associated with an increased frequency of infections compared with other surgical procedures of the
first metatarsophalangeal joint regardless of antibiotic usage (161 , 162 , 163 ). The 1987 Kern Hospital study revealed an infection rate of
0.38% in 265 cases of isolated implant arthroplasty over a 5-year period (164 ). During this time, prophylactic antibiotics were administered
to only 17 patients of the total 265. The rationale was that because the infection rate was so low, only those patients with multiple risk
factors received perioperative antibiosis. The use of a silicone implant alone was considered insufficient.
A deep wound infection is a catastrophic event for implant arthroplasty (133 ). Deep wound infection usually requires removal of the
implant and failure of the procedure (165 ,166 ). This makes potential infection probably the major indication for antibiotic prophylaxis.
In general, prophylactic antibiotics are administered perioperatively in patients receiving implants (164 ,166 , 167 , 168 ). The usual
preference is cefazolin because of its well-documented impressive tissue and bone levels after intravenous administration (169 , 170 , 171 ).
One dose preoperatively is sufficient (167 ,172 ). The use of wound lavage with dilute antibiotic solution may be indicated, although its
efficacy is not well documented. Intraoperative lavage with a good volume of almost any physiologic solution and atraumatic surgical
technique are the primary deterrents to potential bacterial colonization.
First metatarsophalangeal joint implant arthroplasty is a viable option, preferably in older patients with significant arthrosis. In cases of
lesser degrees of arthrosis, a non-destructive joint reconstruction is clearly the better choice, but clinical results do show good success,
particularly with double-stem silicone implants used with protective grommets. A German study of 592 procedures in 430 patients showed
80% pain relief and better than 90% patient satisfaction (173 ). There is still a lack of large-scale studies to verify the clinical use of other
joint systems, although Townley's metallic implant has shown good long-term results for its inventor surgeon (17 ).
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CONCLUSIONS
Implant arthroplasty has provided patients and surgeons with another alternative for the surgical management of joint arthrosis of the first metatarsophalangeal joint. Most surgeons admit that
joint implants were overused through the 1970s. Even through most of the 1980s, surgeons continued to refine their criteria of patient selection, which is probably the more important clinical
parameter leading to successful joint reconstruction. Two leading investigators have recommended even more stringent criteria for total joint replacement implants (6 ).
During work on solutions for painful hallux rigidus, the use of joint-preservation techniques and alternatives to implant arthroplasty became better defined. Techniques of osteotomy,
cheilectomy, and chrondroplasty allowed for salvage of joints with degenerative arthritis that not much earlier would have been destined for implant arthroplasty. These joint-preservation
techniques have become important in the younger patient population in whom more functional and durable alternatives are required. As joint implants are designed to achieve or preserve a
more normal range of motion at the first metatarsophalangeal joint, it has been hoped that they will be more successful in younger patients with greater functional demands. This is yet to be
achieved. Just when, from a biomechanical basis, the total joint replacement systems were anticipated to be superior to a hinged design, Gerbert and Chang cited several complications after
their implantation including lack of hallux purchase, pain with limited first metatarsophalangeal joint range of motion, and metatarsalgia (6 ).
The choice of joint implant is not straightforward because no perfect implant exists. There is no perfect biomaterial. Much work in the area of analysis of what we are doing as clinicians is
necessary. A renewed interest in hemireplacement of the phalangeal base has been seen with metallic implants. Some good results have been reported, but wellconducted clinical studies
documenting patient outcomes are still lacking.
What are current recommendations in light of all that has transpired? Conservatism is the best rule. One should assess each patient for alternative procedures. Total joint replacement and
interpositional arthroplasty have their places in surgical treatment. They should be applied with caution and used in patients who meet specific criteria. The patients should be those in whom
other alternatives are less likely to yield a successful reconstruction.
ACKNOWLEDGMENT
This chapter is dedicated to the memory of Irving Pikscher, who contributed so much to our work on first metatarsophalangeal joint implants and to my life. I would also like to acknowledge
the contributions of prior collaborating authors: Robert O'Keefe, Maria Bidny, and, of course, Irving Pikscher.
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Chapter 5
Introduction and Evaluation of Hallux Abducto Valgus
Dennis E. Martin
Jane Pontious
Deformities of the first ray account for significant numbers of patient visits to foot and ankle specialists. The combination of structural
changes within the first metatarsal and faulty mechanics within the foot often result in common yet complex symptoms of the great toe
joint. Deformities of the great toe, specifically hallux abducto valgus, commonly referred to as a bunion deformity, have been the subject
of interest and debate for many generations. Despite the common occurrence of these problems, differences in opinion exist on a wide
variety of issues ranging from the incidence and etiology, to the proper treatment protocol, and the use and indications for specific
technical procedures.
EVOLUTION OF THE DEFORMITY

The documented incidence of hallux abducto valgus was as high as approximately 50% in one study of South Africans (1 ) and as low as 2%
in one study of a barefoot population (2 ). Female patients have been found to have a much higher incidence of the deformity (2 , 3 , 4 ).
Whether these studies indicate a true increased incidence of hallux abducto valgus in the female population or merely represent a
reflection of the effects different shoe gear remains an unsettled issue.
Controversy exists regarding the effects of heredity and shoe gear on the development of a bunion deformity. Shine cited faulty shoe gear
as a contributing factor in the progression of deformity (2 ). Sin-Fook and Hodgson found a 31% greater incidence of hallux valgus in a
Chinese population who wore shoes versus those who did not (5 ). In the Japanese population, an anecdotal increase in the number of
bunion deformities was noted after the 1970s when Western-influenced shoe gear began to replace the traditional “clog” (6 ). On the
contrary, Root and associates countered that no evidence indicates that shoes can cause this deformity in a foot that functions normally
(7 ). However, even if shoes do not play a direct role in the development of a bunion, they certainly can act as an aggravating factor in the
symptoms and possibly serve to enhance progression of deformity.
Heredity and genetic factors undoubtedly play a role in the formation of a bunion. The exact type and extent of involvement are unknown.
A positive family history of 63% (3 ) and 68% (8 ) was noted in two studies involving hallux abducto valgus deformity. Juvenile bunion
deformities do seem to have a higher familial tendency. Johnston went as far as to say that the condition was transferred as an autosomal
dominant trait with incomplete penetration (9 ). In one study, 94% of children with juvenile hallux valgus had mothers who also had the
deformity (10 ).
Aside from the tendency to inherit a bunion deformity, genetics can also play a role in the overall structure and function of the foot. A
person may have a genetically induced structural deformity that results in functional instability along the medial column and thus increases
the risk of developing hallux abducto valgus. Genetic disorders such as Down's syndrome, Ehlers-Danlos syndrome, and Marfan's syndrome
can lead to ligamentous laxity and subsequent poor mechanics. This laxity has been shown to lead to increased intermetatarsal and hallux
abductus angles (11 ,12 ).
Root and associates described four types of conditions that may lead to a hallux valgus deformity (7 ): biomechanical abnormalities,
arthritic conditions, neuromuscular disease, and traumatic compromise. A suggested causative factor in the formation of bunions is
excessive pronation throughout the stance phase of gait. Sgarlato and Root et al. adequately defined the biomechanical relationships and
functional sequences that can result in first ray disorders (7 ,13 ). Functional aberrations include compensated forefoot and rearfoot varus,
pes valgus deformity, hypermobile first ray, pronation secondary to equinus (osseous or soft tissue), torsional malalignments, and
rotational deformities of the lower extremity. All these disorders, and any other condition that results in an excessive amount of pronatory
motion, can predispose one to develop bunions.
Hypermobility of the medial column can also lead to the development of a hallux abducto valgus deformity. Although it is difficult to
quantify, the oblique axis of motion about the first ray typically allows for motion in the dorsal medial
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to plantar lateral direction. When hypermobility is present, abnormal amounts of motion at this joint can produce more complex symptom
patterns. First ray hypermobility not only can cause increased motion and friction between shoe gear and the first metatarsal head, but
also can result in stress transfer to the adjacent second metatarsal. This added pressure can produce a variety of pathologic conditions
about the second metatarsophalangeal joint, including callus formation, capsulitis, flexor plate disruption, hammer toe formation, and
metatarsal stress fractures.
The association between pes valgus and hallux abducto valgus deformities has been appreciated for years. McGlamry and Full believed that
the influence of equinus and pes valgus can be detrimental and can negatively affect outcomes after bunion repair (14 ). Inman noted a
close relationship between pronated feet and bunion deformities (15 ), and other investigators have predicted failure of hallux valgus
repair in feet that had coexistent severe pes valgo planus deformity with or without a tight heel cord (16 ,17 ). Hodman delivered the most
absolute opinion when he asserted that hallux valgus was always combined with pes planus (18 ). Electromyographic studies have
demonstrated that dynamic imbalance of the intrinsic musculature about the first ray is involved in the evolution of hallux valgus
deformities (19 ). This imbalance was believed to be secondary to structural change and pronated function of the hindfoot. Radiographs of
juvenile patients with hallux abducto valgus have demonstrated a much higher incidence of pes valgus deformity than would otherwise be
anticipated (20 ). However, some difference of opinion does exist regarding this relationship. In a study involving adults with acquired pes
valgus deformity secondary to posterior tibial tendon dysfunction, no increase in hallux valgus was noted (21 ). However, this would not
appear to represent an accurate corollary with a patient who has possessed pes valgus deformity for their entire life. Others have
concluded that the incidence of pes planus in the normal population and in those with a hallux valgus deformity was essentially the same
(22 ), although pes planus is not necessarily a pathologic condition as compared with pes valgus deformity.
The terminology regarding pes valgus deformity and simple pes planus has not been well delineated in some instances. Therefore, these
studies may be evaluating patients with an entirely different condition. Two studies found no correlation between pes planus and the
success rate of hallux valgus repair (22 ,23 ). However, simple measurements of arch height do not adequately denote the type of foot or
the biomechanical imbalances that are present.
Neuromuscular diseases such as cerebral palsy can also result in muscle imbalance with possible structural changes in the foot, including
hallux abducto valgus. Arthritic disease, specifically the inflammatory arthritides, can also produce secondary structural changes in the
foot with pathomechanical consequences. Biomechanical control may be particularly important in these patients both preoperatively and
postoperatively.
Traumatic conditions around the first metatarsophalangeal joint have been associated with the development of symptoms, notably hallux
limitus and hallux rigidus. These injuries range from crush injuries with intraarticular damage to soft tissue sprains and dislocations that
damage the periarticular structures. These latter impairments can lead to progressive muscle-tendon imbalance at the first
metatarsophalangeal and eventual structural adaptation of the metatarsal and phalanx. Injuries such as Lisfranc's fracture-dislocation can
result in residual instability along the medial column that increases the potential for bunion formation (24 ).
The simultaneous presence of hallux abducto valgus and metatarsus primus varus has been noted (3 ,25 ). Hardy and Clapham reported a
correlation between the degree of hallux valgus and the size of the intermetatarsal angle (3 ). Hardy and Clapham believed that
metatarsus primus varus is secondary to the hallux valgus deformity (3 ), whereas Truslow believed that when metatarsus primus varus
existed, hallux valgus was inevitable (26 ). The question of which condition develops initially, the hallux abductus or the metatarsus primus
varus, is still unanswered. Metatarsus adductus is another factor that has been associated with an increasing degree of hallux abductus
(27 ), and it is recognized as a predisposing factor to the development of hallux abducto valgus deformity (28 ,29 ).
Although the exact sequence of events that occur in the development of a bunion deformity continues to be debated, a few points are
understood and agreed on by most authorities. In cases of hallux valgus, as the great toe deviates laterally, the once stabilizing forces of
the adductor hallucis and flexor hallucis brevis become deforming forces as their pull now lies lateral to the long axis of the
metatarsophalangeal joint. With progression of the deformity, the soft tissue structures along the lateral side of the joint become
contracted, whereas those medially become weakened. This process may eventually result in loss of the medial buttressing effect of the
soft tissues and may allow for progressive medial displacement of the first metatarsal head. With continued movement of the metatarsal
medially and lateral deviation of the sesamoid apparatus, the integrity of the cristae may be jeopardized by the altered articulation
between the sesamoids and the metatarsal head, with resulting permanent articular damage. The combination of dynamic and structural
disorders makes treatment of symptomatic hallux valgus deformities challenging to even the most skilled surgeon.
EVALUATION AND DIAGNOSTIC CONSIDERATIONS
History
Management of a hallux abducto valgus deformity begins with a history and clinical evaluation of the patient. Patients primarily present
with either pain in the area of deformity or concerns over the appearance of the foot. In other circum-stances,
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the chief complaint may be a painful overlapping second toe, an interdigital heloma, or lesser metatarsalgia resulting from lateral weight
transfer. Therefore, pain specific to the bunion is not required for a hallux abducto valgus deformity to be problematic.
When symptoms related to the bunion are present, patients may report a dull ache located over the medial eminence of the first
metatarsal head. A burning character may indicate an adventitious bursa, whereas numbness and tingling may be found with irritation of
the first proper digital nerve. Joint symptoms may be present if the patient has degenerative arthrosis or an associated hallux limitus. Pain
plantar to the joint may be present with sesamoid deviation, especially when the tibial sesamoid is positioned directly under the crista.
Pain that is present even when the patient is barefoot suggests degenerative joint changes.
The degree of symptoms experienced with different shoes and activities may be helpful in correlating the extent of symptoms. The
duration of the symptoms in many instances may be relatively brief when compared with the length of time the bunion has been present.
Usually once symptoms develop, they are progressive. Collectively, these factors provide one with an appreciation of the extent of the
deformity and the degree of disability the patient is experiencing.
Clinical Examination
Physical examination may begin with an inspection of the overall foot type, to appreciate any obvious deformities such as pathologic
features in the rearfoot and midfoot that may contribute to the development of symptoms and deformities distally.
Local Deformity
Specific attention is directed to the first ray, and the degree of lateral deviation of the hallux or hallux abductus is appreciated. The
extent of the medial eminence or bunion deformity along with any other associated conditions such as plantar lesions, hammer toes, or
heloma molle may be helpful in assessing the overall status of the foot. Most bunions present at the dorsal medial corner of the first
metatarsal head. Osseous prominence that is also present directly over the dorsal aspect of the joint may reflect an associated hallux
limitus. Pain may be reproduced with range-of-motion examination of the first metatarsophalangeal joint and may indicate acute and or
chronic inflammation in the joint or degenerative changes. In the former setting, the likely cause is a concomitant structural or functional
hallux limitus. Pain with palpation of the dorsal medial eminence may be due to irritation of the medial dorsal cutaneous nerve or to an
inflamed bursa.
The position of the second toe is also an important consideration. If the toe is contracted, overriding, or deviated in the transverse plane,
then it may not be able to act as an adequate lateral buttress. Instability of the second toe may allow a more rapid progression of hallux
abducto valgus or may increase the risk of recurrent deformity postoperatively. These general observations enhance the clinical evaluation
of the deformity and help to identify any etiologic or contributory problems.
The mobility of the first ray may also be assessed. This may be important in the selection of the surgical procedure because a distal
osteotomy is less likely to provide adequate repair of a significant hallux abducto valgus deformity unless adequate mobility is present in
the first ray.
Hallux Abductus
Lateral deviation of the great toe may be the result of subluxation within the metatarsophalangeal joint, or it may be caused by the
structure of the hallux itself. One should attempt to develop a clinical impression about the actual location of this lateral deviation.
Deviation within the hallux may require additional procedures such as the Akin osteotomy to obtain an acceptable structural alignment of
the ray. An exaggerated distal articular set angle (DASA) or the presence of hallux abductus interphalangeus may be a significant part of
the deformity. A medial pinch callus, gross enlargement of the medial aspect of the hallux interphalangeal joint, and lateral deviation of
the nail plate may be indications of hallux deformity, as well as deformity of the metatarsophalangeal joint.
Range of Motion
The normal range of motion of the first metatarsophalangeal joint includes approximately 70 to 90 degrees of dorsiflexion and
approximately 30 degrees of plantarflexion (7 ). During this evaluation, there should be no medial or lateral deviation of the hallux from
the sagittal plane. Reduced joint mobility may indicate intraarticular degeneration, osteophytic lipping, or contracture of periarticular
structures.
One may attempt to reduce the transverse plane deformity of the hallux and to move the base of the proximal phalanx through a full range
of motion on the metatarsal head. In hallux abducto valgus, one usually notes a distinct lateral restraint of the hallux as it moves through
dorsiflexion. This is created by contracture of plantar lateral joint structures. The degree of resistance indicates the extent of contracture
present. Occasionally, the hallux loses its entire range of dorsiflexion if it is held in a rectus position, yet it possesses complete dorsiflexion
when it is in the position of deformity. This clinical finding has been described as a track-bound joint and supposedly is caused by an
adaptive lateral deviation of the articular surface of the metatarsal head. Traditionally, the track-bound joint has been treated by
osteotomy to realign the joint surface. The techniques of anatomic dissection have provided a new appreciation of the plantar lateral
structures of the first metatarsophalangeal joint and of the dynamic force of the laterally displaced sesamoids. In many
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cases of track-bound joints, a thorough release of these structures and osteotomy, with or without transfer of the adductor tendon,
eliminate the laterally deviated range of motion of the hallux. Furthermore, the lateral plantar release may allow full and unrestricted
motion in a rectus position (Fig. 1 ). When lateral release and relocation of the sesamoids have been employed and true lateral deviation
of the joint exists, then an osteotomy such as the Reverdin or Austin modification may be required to realign the articular cartilage.
FIG. 1. A: Preoperatively, the hallux cannot be reduced into a rectus position, a finding indicative of a track-bound joint. B:
Intraoperatively, after release of the lateral joint contractures, the hallux may be easily reduced. Most cases of a track-bound joint
result from soft tissue constraint, as opposed to joint adaptation.
The quality of motion may also indicate the extent of deterioration of the articular surfaces of the metatarsophalangeal joint. Limitation
of motion, crepitus, and pain with joint motion are associated with advanced degeneration of the joint surfaces.
General Biomechanical Examination

The biomechanical examination is an important component in the evaluation of hallux abducto valgus. Ankle equinus, metatarsus adductus,
pes valgus deformity, hypermobility of the first ray, and any factors responsible for excessive pronation are all common causes of hallux
abducto valgus. In some instances, the success of the surgical repair may be compromised if the underlying cause of the problem is not
addressed. Additional surgical procedures in other regions of the foot and leg may be required for the successful repair of hallux abducto
valgus.
Radiographic Examination
General Factors
Radiographic evaluation of hallux abducto valgus follows traditional guidelines, with the addition of several specific observations and
measurements. The soft tissues are evaluated for evidence of edema, bursae, calcification, or other signs of chronic irritation and
inflammatory changes. The osseous structures are then evaluated for general radiographic appearance. Bone density, cortical thickness,
and trabecular patterns are noted. Bone that demonstrates significant osteopenia may present more of a challenge as the surgeon executes
and fixes the osteotomy. In some cases, alternatives to osteotomy may need to be entertained by the physician. In addition, any cystic
erosion within the metatarsal head should be noted. Cystic changes, subchondral sclerosis, general hypertrophy, and osteophytic lipping in
and around the joint are evaluated. Narrowing of the joint space is a significant finding relative to the status of the articular surface. All
these observations are helpful in selecting a surgical procedure.
Also of note is that the true size of the osseous prominence or “bunion” may not be reflected on the standard dorsal plantar and lateral
radiographs. Because the bunion is located at the dorsal medial corner of the first metatarsal head, full appreciation of the distinct
prominence may be noted on only an oblique view (Fig. 2 ).
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FIG. 2. A: Dorsal plantar radiograph of a patient with hallux abducto valgus deformity and a large bunion. B: Because of the location
of the bunion at the dorsal medial corner of the first metatarsal, the osseous prominence will be more clearly evident on an oblique
view.
Structural and Positional Relationships

Many measurements, positions, shapes, and relationships have been described for the evaluation of hallux abducto valgus deformity. Many
of these values may be helpful in understanding the nature of the deformity and the selection of appropriate surgical procedures. Others
are only interesting observations. The astute surgeon must balance the significance of many of these radiographic findings with clinical and
surgical circumstances to develop a successful approach to hallux abducto valgus surgery. Radiographic findings and relationships are
meant as aids and guidelines, not as rigid surgical criteria.
Hallux Abductus Angle

On the dorsal plantar radiograph, the angle formed by the intersection of the bisection of the first metatarsal and the bisection of the
proximal phalanx is referred to as the hallux abductus angle (Fig. 3 ). In a normal foot, this angle is reported to be less than 15 degrees
(30 ,31 ). Piggot stated that abduction of the hallux may result from lateral deviation of the articular cartilage on the first metatarsal head
(30 ). In this circumstance, the joint remains congruous, and the deformity is more accurately defined as structural. This situation forces
the surgeon to assess two other angular relationships, the proximal articular set angle (PASA) and the DASA. The first relationship involves
the hallux itself. The
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angle formed between the longitudinal bisection of the proximal phalanx of the hallux and the perpendicular of its articular surface is
known as the DASA (Fig. 4 ). Normal values for DASA range from 0 to 8 degrees (32 ). Relationships in excess of this range represent lateral
deviation within the hallux and result in an increase in the overall abduction deformity of the hallux. Lateral deviation within the hallux
may also occur more distally with the deformity of hallux abductus interphalangeus and asymmetry of the proximal phalanx. Significant
deformity within the hallux has traditionally been addressed with procedures such as the Akin-type osteotomy.
FIG. 3. The hallux abductus angle represents the amount of lateral deviation of the hallux.
FIG. 4. The distal articular set angle is determined by the angle formed by the line bisecting the proximal phalanx relative to a line
perpendicular to the articular surface of the base.
A congruous metatarsophalangeal joint may also demonstrate an abnormally high degree of hallux abductus by significant structural
deviation of the articular surface of the metatarsal head, or PASA (Fig. 5 ). This relationship represents the angle formed by a line marking
the articular margins of the head of the metatarsal and a line representing the long axis of the metatarsal shaft. Normal values for PASA
range from 0 to 8 degrees (32 ). When the angle is excessive, true structural adaptation at the joint may be present. However, final
judgment should be reserved until intraoperative visualization is performed. The accuracy of this measurement and its reproducibility
(both intraexaminer and interexaminer) have been a subject of debate. Two separate studies have demonstrated that the intraoperative
and radiographic assessments of the PASA do not correlate well (33 ,34 ). True lateral adaptation involves subchondral bone, as well as
articular cartilage. If true lateral adaptation is noted intraoperatively, it may be addressed as part of the surgical correction. Many
techniques, including the Reverdin and Austin-type osteotomies, can accomplish derotation of the articular surface of the metatarsal head.
FIG. 5. The proximal articular set angle is formed by the intersection of a line bisecting the first metatarsal and a line parallel to the
articular cartilage of the metatarsal head.
Metatarsophalangeal Joint Position

Piggot noted that hallux abduction could also result from lateral joint displacement, with the relationship of the articular surfaces
remaining normal (30 ). In this instance, the joint becomes either deviated or subluxed, as opposed to remaining congruous (Fig. 6 ).
Therefore, a positional deformity of the joint is created. This is a significant factor in most hallux abducto valgus deformities. The
presence of positional deviation implies the need for repair, with relocation of the digit, release of lateral contracture, plication of medial
tissues, and reduction of the intermetatarsal angle as applicable. Significant hallux abductus with a congruous joint implies the need for
structural correction with an appropriate osteotomy of the proximal phalanx or head of the metatarsal. A deviated joint indicates the need
for soft tissue correction.
Sesamoid Position
The anatomic relationships around the first metatarsophalangeal joint are unique and specialized because of the presence of the sesamoid
apparatus. Structurally, the underside of the first metatarsal has two longitudinally oriented
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grooves lined with articular cartilage to accommodate the tibial and fibular sesamoid bones. In a normal relationship, the sesamoids glide
distally and proximally within the grooves by a combination of active and passive forces. A longitudinal ridge, the crista, separates the two
grooves. In the pathologic hallux abducto valgus, the crista is often eroded as a result of the laterally deviated position of the sesamoids,
such that the tibial sesamoid may lie on the crista and may thus enhance joint symptoms and plantar pressure beneath the first metatarsal
and possibly may create degenerative changes in the joint.
FIG. 6. First metatarsophalangeal joint position. A: Congruous joint. The effective articular cartilage of the metatarsal head and the
phalangeal base are parallel. B: A deviated joint. The lines representing the effective articular cartilage of the joint now intersect,
but outside the confines of the joint. C: A subluxed joint. The lines of the articular surfaces now intersect within the confines of the
joint.
The positional and structural adaptations of the sesamoid apparatus are important considerations when evaluating hallux valgus
deformities. The lateral position of the sesamoid apparatus renders a mechanical advantage to the fibular sesamoid and the plantar lateral
joint structures. As the shift continues, these structures become primary deforming influences encouraging the abducted position of the
hallux. Haas presented a classification scheme to quantify the degree of lateral movement of the sesamoid apparatus (31 ) (Fig. 7 ). When
the tibial sesamoid was in position 4 or greater, removal of the fibular sesamoid was recommended. As alternative techniques were
developed, such as specific release of the plantar lateral structures and the adductor tendon transfer, the need for removal of the fibular
sesamoid dramatically diminished. Today, the decision whether to remove the fibular sesamoid is based on whether or not lateral joint
contracture can be adequately released by addressing the capsular and tendinous structures in the area or after osteotomy. If this proves
insufficient, and lateral contracture persists, then removal of the fibular sesamoid may greatly enhance the overall result. If the fibular
sesamoid is enlarged or arthritic, the crista is eroded, or the lateral joint has adapted to the deformed alignment of the fibular sesamoid,
then restoration of the sesamoid-metatarsal articulation to a more anatomic relationship may not be possible, or it could lead to later
symptoms. Removal of the fibular sesamoid may also be indicated when extensive osteotomy techniques are inadvisable (i.e., elderly or
debilitated patients) or in other unique circumstances.
FIG. 7. The tibial sesamoid position is determined by the location of the tibial sesamoid relative to the bisection of the first
metatarsal.
More specific information regarding the status of the sesamoids or articulation with the metatarsal may be obtained with a sesamoid axial
radiograph. However, this projection is not routinely obtained.
First Intermetatarsal Angle

The angle formed by the intersection of the longitudinal bisection of the first metatarsal and the longitudinal bisection of the second
metatarsal on the dorsal plantar radiograph is referred to as the intermetatarsal angle. This represents one of the more important
relationships in an evaluation of patients with hallux abducto valgus deformities (Fig. 8 ).
A normal range is 8 to 12 degrees in a rectus foot and 8 to 10 degrees in an adductus foot type (32 ). However, significant hallux abducto
valgus deformity may exist with an intermetatarsal angle of 8 degrees to 12 degrees, and this relationship can be a major cause of
recurrence of deformity after surgical repair. Substantial deformity may be present with relatively small intermetatarsal values in the
adductus foot type.
Congenital metatarsus primus adductus is identified as a primary cause of many cases of hallux abducto valgus. The value of the
intermetatarsal angle has been described as a
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guide for determining the severity and progression of the deformity. The presence of metatarsus primus adductus, for whatever reason,
significantly compounds the severity of the deformity and the difficulty of surgical correction.
FIG. 8. The first intermetatarsal angle is determined by the intersection of lines bisecting the first and second metatarsals.
Metatarsus Adductus Angle

The metatarsus adductus angle is a measurement used to calculate a structural relationship between the lesser tarsus and the metatarsals
(Fig. 9 ). Normal values are considered to be less than 14 degrees (29 ,35 ). An increase in this angle is thought to predispose the foot to
the development of hallux abducto valgus and other foot deformities. LaReaux and Lee noted a coexisting metatarsus adductus in 38% of
their patients with hallux abducto valgus (28 ). They also concluded that children with metatarsus adductus had a 3.6 times greater chance
of developing hallux valgus. In another study, approximately two-thirds of patients less than 20 years of age who presented for repair of
hallux abducto valgus deformities possessed metatarsus adductus (29 ). The clinician should be aware that the intermetatarsal angle in
patients with hallux abducto valgus with a coexisting metatarsus adductus deformity is relatively low and may lead one to underestimate
this complex combination of deformities (36 ).
Shape of the Metatarsal Head

The structural contour of the metatarsal head may also affect the development and progression of a hallux valgus deformity. The shape of
the metatarsal head and articular surface can vary from round to flat. Investigators generally believe that greater transverse plane
stability exist in joints that have a more flattened metatarsal articular component. When other predisposing factors exist, a round
metatarsal head has been believed to offer little resistance to the development of a hallux abducto valgus rotation (32 ) (Fig. 10 ).
However, no objective study has proven this relationship.
FIG. 9. The metatarsus adductus angle is determined by measuring the medial and lateral margins of the lesser tarsus. A bisector is
drawn, and a perpendicular is constructed to this line. This intersects with the longitudinal axis of the second metatarsal and
provides the degree of metatarsus adductus.
Hallux Abductus Interphalangeus Angle

This angular relationship is formed between the longitudinal bisections of both the proximal and distal phalanges (Fig. 11 ). According to
Palladino, normal values are less than 10 degrees (32 ). In a separate study, Sorto et al. found normal values to be less than 13.4 degrees
(37 ). Although it increases the overall abductus appearance of the great toe, an increased hallux abductus interphalangeus angle more
specifically identifies deformity at the interphalangeal joint.
Other Characteristics of the First Ray

A long first metatarsal has been identified as a potential etiologic factor in hallux abducto valgus and even hallux limitus and rigidus. The
relative length and position of the first metatarsal may be ascertained clinically and radiographically
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(Fig. 12 ). However, the radiographic views may represent apparent relationships and may not consistently correlate with clinical
impressions. The selection of surgical procedures must be made not solely by radiographic appearance but also by correlating these views
with the clinical presentation.
FIG. 10. Different shapes of the first metatarsal head. A: Round metatarsal heads are usually most prone to develop hallux abducto
valgus, but they are also the most reducible. B: Oblique metatarsal head. C: A square metatarsal head with a ridge is more commonly
associated with a hallux limitus.
Generally, the first metatarsal should be approximately 2 mm shorter than the adjacent second metatarsal (32 ,38 ). The metatarsal
protrusion distance is another measurement used to estimate the length of the first metatarsal compared with the second metatarsal (32 ).
The distance is found by bisecting the first and second metatarsals, by placing a compass on the proximal point of intersection of two lines.
From the intersection of these lines, one measures the distance to the distal aspect of the first and second metatarsals. The normal range
is of values for the metatarsal protrusion distance is either more or less than 2 mm. Any significant shortening of the first metatarsal
relative to the second metatarsal may need to be taken into account when one plans the corrective procedure.
FIG. 11. The amount of hallux abductus interphalangeus may be measured by the angle formed from the intersection of the lines
bisecting the proximal and distal phalanges.
The sagittal plane alignment of the first metatarsal may also be evaluated on the weight-bearing lateral radiograph. Normally, the dorsal
cortex of the first and second metatarsals should be parallel regardless of whether the foot is pronated or supinated (39 ,40 ). This
relationship is not affected by tube head position, magnification, or distortion (Fig. 13 ). Should there be a deviation in this relationship,
then one
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may presume that the first metatarsal is either elevated or plantarflexed. This condition may result from problems within the metatarsal itself, that is, previous
fracture or surgery, versus deformity extrinsic to the metatarsal (39 ).
FIG. 12. The relative length of the first metatarsal is FIG. 13. On the weight-bearing lateral radiograph, the dorsal cortex
normally about 2 mm shorter than the adjacent of the first and second metatarsals should remain parallel.
second metatarsal on the dorsal plantar radiograph.
TREATMENT CONSIDERATIONS
Treatment options for hallux abducto valgus deformities can be roughly broken down into one of three types: observation, conservative care, and surgical management.
Factors that may help to guide the physician in this decision process may include the presence or absence of symptoms, the severity and duration of symptoms, the
presence of secondary deformities (i.e., hammer toe second digit), joint adaptation, the presence or absence of degenerative joint changes, the anticipated
progression of the deformity, the expectations of the patient, the general health of the patient, and the likelihood of response to conservative care.
Observation
Observation may be employed for those patients with few if any symptoms and without secondary deformities, joint degeneration, or joint adaptation. Surgical
intervention in patients who present for cosmetic reasons remains a controversial issue and must be negotiated individually by each surgeon. Yearly or biyearly follow-
up examinations may allow the physician to monitor the progression of the deformity and to note the development of symptoms. Employing orthotics may be useful at
this stage.
Conservative Care
Conservative care typically falls into one of two categories, biomechanical or palliative. Biomechanical modalities such as orthosis or supportive shoes can assist in
controlling the pronatory forces within the foot. Specific devices are available that are designed to address first ray instability and to improve function at the hallux.
Dananberg described the relationship between hallux limitus and gait efficiency (41 ). He believed that, with proper biomechanical control, motion at the great toe
joint could be improved, with a resulting overall improved gait. This may be performed with the use of first ray cutouts on the orthotic itself to improve motion at the
first metatarsophalangeal joint (42 ). The development of forefoot deformities has been noted to be delayed in patients with rheumatoid arthritis when functional
orthotic devices have been employed, but to date no other definitive studies have been conducted (43 ). Nonetheless, orthotic management may be a helpful means of
conservative management.
Palliative forms of conservative management include the variety of pads, shields, spacers, and splints that are commercially available. Shoes may be purchased with
greater width or space or softer materials. These modalities occasionally supply a degree of symptomatic relief, but they offer no real ability to correct the deformity.
Surgical Management
The ability to repair surgically the various soft tissue and osseous anomalies associated with hallux abducto valgus deformities has improved significantly over the past
several decades. Various bone and soft tissue procedures currently exist that allow the surgeon to address even the severest deformities. The indications,
contraindications, pros, and cons for each of these categories are reviewed in Chapters 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 and 15 .
The following features of surgical repair may prove advantageous for successful correction of these conditions:
• The establishment of a congruous first metatarsophalangeal joint

• Reduction of the intermetatarsal angle to normal parameters
• Realignment of the sesamoid bones beneath the metatarsal head
• Restoration of weight-bearing function of the first ray
• Maintenance of first metatarsophalangeal joint range of motion
• Repositioning of the hallux in a rectus alignment
• Control or correction of the factors that led to the development of the deformity
SUMMARY
Hallux abducto valgus is a complex deformity, as evidenced by the large number of procedures designed for its surgical repair. The factors discussed in this chapter by
no means constitute a complete guide for this condition but should provide a basis for further study. Critical assessment of the patient preoperatively, intraoperatively,
and postoperatively enhances the effectiveness of individual techniques and overall success.
REFERENCES
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4. Coughlin MJ. Hallux valgus in men: effect of the distal metatarsal articular angle on hallux valgus correction. Foot Ankle Int 1997;18: 463-470.
5. Sin-Fook L, Hodgson A. A comparison of foot forms among the nonshoe wearing Chinese population. J Bone Joint Surg Am 1958;40: 1058-1062.
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7. Root ML, Orien WP, Weed JH. Forefoot deformity caused by abnormal subtalar joint pronation. In: Normal and abnormal function of the foot and ankle: clinical biomechanics, vol 2.
Los Angeles: Clinical Biomechanics, 1977:349-462.
8. Glynn MK, Dunlop JB, Fitzpatrick D. The Mitchell distal metatarsal osteotomy for hallux valgus. J Bone Joint Surg Br 1980;67:188-191.
9. Johnston O. Further studies of the inheritance of hand and foot anomalies. Clin Orthop 1956;8:146-160.
10. Coughlin MJ. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int 1995;16:682-697.
11. McNerney JE, Johnston WB. Generalized ligamentous laxity: hallux abducto valgus and the first metatarsocuneiform joint. J Am Podiatry Assoc 1979;69:69-82.
12. Caputo PJ, Walter JH. Osteogenesis imperfecta. J Am Podiatry Assoc 1983;73:456-460.
13. Sgarlato TE. A compendium of podiatric biomechanics. San Francisco: California College of Podiatric Medicine, 1971.
14. Full MJ. Surgical approaches in equinus deformities. In: McGlamry ED, ed. Reconstructive surgery of the foot and leg. New York: Intercontinental Medical Book, 1974:275-282.
15. Inman VT. Hallux valgus: a review of etiologic factors. Orthop Clin North Am 1974;5:59-66.
16. Mann RA. Hallux valgus. In: Frankel VH, ed. American Academy of Orthopedic Surgeons: instructional course lectures. St. Louis: CV Mosby, 1982:181-183.
17. Coughlin MJ. Hallux valgus: causes, evaluation, and treatment. Postgrad Med 1984;75:174-187.
18. Hodman G. Der Hallux valgus und die uebrigen Zchenverkrucrnmungen. Ergeb Chir Orthop 1925;18:308-348.
19. Shimazaki K, Takebe K. Investigations on the origin and prevention of certain foot defects. BMJ 1953;2:749.
20. Kalen V, Brecher A. Relationship between adolescent bunions and flatfeet. Foot Ankle 1988;8:331-336.
21. Mann RA, Mann JA, Prieskorn DW, et al. Operative management of posterior tibial tendon dysfunction. (In press.)
22. Kilmartin TE, Wallace WA. The significance of pes planus in juvenile hallux valgus. Foot Ankle 1992;13:53-56.
23. Canale P, Aronsonsson D, Lamont R, et al. The Mitchell procedure for the treatment of adolescent hallux valgus. J Bone Joint Surg Am 1993;75:16-18.
24. Bohay DR, Johnson KD, Manoli A 2nd. The traumatic bunion. Foot Ankle Int 1996;17:383-387.
25. Craigmile DA. Incidence, origin, and prevention of certain foot defects. BMJ 1953;2:749.
26. Truslow W. Metatarsus primus varus or hallux valgus? J Bone Joint Surg 1925;7:98.
27. Griffiths TA, Palladino SJ. Metatarsus adductus and selected radiographic measurements of the first ray in normal feet. J Am Podiatr Med Assoc 1992;82:616-622.
28. LaReaux D, Lee R. Metatarsus adductus and hallux abducto valgus: their correlation. J Foot Surg 1987;26:104-108.
29. Banks AS, Hsu YS, Mariash S, et al. Juvenile hallux abducto valgus association with metatarsus adductus. J Am Podiatry Assoc 1994;84: 219-224.
30. Piggot H. Natural history of hallux valgus in adolescent and early life. J Bone Joint Surg Br 1960;42:749-760.
31. Haas M. Radiographic and biomechanic considerations of bunion surgery. In: Gerbert J, ed. Textbook of bunion surgery. Mt. Kisco, NY: Futura, 1981:23-62.
32. Palladino SJ. Preoperative evaluation of the bunion patient: etiology, biomechanics, clinical and radiographic assessment. In: Gerbert J, ed. Textbook of bunion surgery, 2nd ed. Mt.
Kisco, NY: Futura, 1991: 1-88.
33. Martin DE. Preoperative radiographic evaluation in HAV surgery: a critical analysis of PASA and other soft tissue adaptations. In: Camasta CA, Vickers NS, Ruch JA, eds.
Reconstructive surgery of the foot and leg: update ′93. Tucker, GA: Podiatry Institute, 1993.
34. Sullivan ET, Robinson JB, Palladino SJ. Inter-evaluator variability in the measurement of the proximal articular angle. J Foot Surg 1988; 27:466-468.
35. Weissman SD. Biomechanically acquired foot types. In: Weissman SD, ed. Radiology of the foot, 2nd ed. Baltimore: Williams & Wilkins, 1989:66-90.
36. Yu GV, DiNapoli DR. Surgical management of hallux abducto valgus with concurrent metatarsus adductus. In: McGlamry ED, ed. Reconstructive surgery of the foot and leg: update
′89. Tucker, GA: Podiatry Institute, 1989:262-268.
37. Sorto LA, Balding MG, Weil LS, et al. Hallux abductus interphalangeus. J Am Podiatry Assoc 1976;66:384-395.
38. Shaw AH. The biomechanics of hallux valgus in pronated feet. J Am Podiatry Assoc 1974;64:193-201.
39. Camasta CA. Radiographic evaluation and classification of metatarsus primus elevatus. In: Camasta CA, Vickers NS, Ruch JR, eds. Reconstructive surgery of the foot and leg: update
40. Seiberg M, Felson S, Colson JP, et al. Closing base wedge versus Austin bunionectomies for metatarsus primus adductus. J Am Podiatr Med Assoc 1994;84:548-563.
41. Dananberg HJ. Functional hallux limitus and its relationship to gait efficiency. J Am Podiatr Med Assoc 1986;76:648-652.
42. Dinapoli DR. Gait analysis based on first MTPJ function: the functional hallux limitus concept. In: Camasta CA, Vickers NS, Ruch JA, eds. Reconstructive surgery of the foot and leg:
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43. Budiman-Mak E, Conrad JK, Roach KE, et al. Can foot orthoses prevent hallux valgus deformity in rheumatoid arthritis? A randomized clinical trial. J Clin Rheumatol 1995;1:313-321.
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Chapter 6
Anatomic Dissection of the First Metatarsophalangeal Joint for
Hallux Valgus Surgery
John A. Ruch
Charles F. Peebles
Claire A. Sun
Repair of hallux valgus is a fundamental and time-honored area of foot surgery. Over the last 100 years, literally 100 or more
different surgical procedures have been described for the correction of this basic foot deformity (1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 ,
10 , 11 , 12 , 13 , 14 , 15 , 16 ). Each author has attempted to present a unique insight into the condition and to demonstrate a
novel method of correction. Despite the multitude of techniques and procedures that have been promoted, one common
denominator in the repair of hallux abducto valgus deformity remains: anatomy. The specific anatomy of the first
metatarsophalangeal joint and these fundamental relationships provide a degree of commonality to all techniques and
approaches for the surgical repair of the bunion deformity.
Although each patient must be evaluated individually, common elements contribute to the malalignment of the first
metatarsophalangeal joint. A systematic dissection technique provides a method for assessment of the individual anatomic
components of the first metatarsophalangeal joint and their contribution to the deformity of hallux abducto valgus. The
technique of anatomic dissection provides a cornerstone for the intraoperative assessment and repair of the deformity.
RATIONALE
Although the term anatomic dissection is commonly accepted as a surgical philosophy for most podiatric surgeons, it actually
encompasses all aspects of the surgical technique from incision placement to wound closure. The primary objectives of an
anatomic approach in hallux valgus surgery include the surgeon's ability to execute the procedure with control and consistency
in the wide variety of anatomic variations encountered, to reduce complications, and to be able to identify and manage unique
problems that may require special skills or techniques for a successful surgical repair.
An anatomic approach is employed in all key areas of the surgical technique:
• Anatomic dissection
o Incision placement
o Tissue plane dissection
o Preservation of blood and nerve supply, viability
• Exposure
o Individual anatomy assessment versus pathologic anatomy
o Individual anatomic release and manipulation
o Structural techniques, repair (osseous)
o Muscle-tendon balance, soft tissue repair and periarticular balance
PRINCIPLES OF ANATOMIC DISSECTION

The underlying concept of anatomic dissection is the preservation of blood supply (and innervation) to the soft tissues during
surgery. The incision placement is oriented parallel to and between any critical structures. The dissection of the subcutaneous
tissues is the fundamental basis of anatomic dissection. The superficial soft tissues (those external to the deep fascia) must be
reflected in a manner that preserves the skin and subcutaneous layers and avoids disruption of the laminar contact of these two
layers and the linear structures they contain. This approach not only maintains the viability and healing potential of these
tissues, but it also serves as the primary mechanism of establishing hemostasis of the surgical wound, whether the procedure is
performed with or without a tourniquet. The primary control of bleeding both during and after the surgical procedure is most
effectively accomplished with the anatomic dissection technique. This is key to reducing bleeding, hematoma, and edema. In
addition to improved soft tissue healing, tissue plane dissection maintains a distinct separation of the superficial and deep
tissues even after the healing process has occurred. Minimal scar and adhesion between the layers enhance delamination of
tissue planes should revisional surgery become necessary.
Another critical function of the surgical dissection is exposure.

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Whereas adequate exposure is usually related to the length of the incision, the exposure provided with anatomic dissection
creates full visualization of all aspects of joint anatomy without excessive retraction or tension on the surrounding soft tissues.
The “universal” dorsal medial incision allows for direct visualization of both medial and lateral aspects of the joint and their
related components without the need for excessive retraction or a second incision.
Full surgical exposure allows for critical evaluation of normal as well as pathologic anatomy around the first
metatarsophalangeal joint. Direct visualization of the key anatomic components of the joint, especially within the
intermetatarsal space, allows the surgeon to assess the structures influencing joint motion and facilitates the release, resection,
or other manipulations of each of these structures.
The initial goals of the anatomic dissection process are to provide access to the surgical area, to establish hemostasis, to
identify and release any significant soft tissue contracture, and to prepare for the “osseous” aspect of the surgical process.
Once the structural aspect of hallux valgus repair has been performed, the procedure is completed with a repair and balancing
of the periarticular soft tissue components. This includes refined capsulorrhaphy and tendon transfer techniques performed to
establish a balance of function around the first metatarsophalangeal joint axis. This final repair process and the osseous
realignment of the first ray are the keys to a successful and long-lasting surgical result.
PERIOPERATIVE ANESTHESIA
Before the actual incision, the perioperative area may be infiltrated with a local anesthetic agent. Hemostasis may be achieved
without the use of a tourniquet by the addition of epinephrine to the solution. A common technique is to combine a short-acting
and long-acting local anesthetic, usually equal volumes of lidocaine with epinephrine (1:100,000) and bupivacaine. This
technique may be performed whether the patient is maintained under general anesthesia or with intravenous sedation. In
addition to the augmentation of anesthesia, the epinephrine provides hemostasis through reduced capillary bleeding. Local
infiltration of epinephrine-containing solutions has been shown to be safely used in combination with most modern general
anesthetic techniques (17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ). This approach, along with the primary hemostasis established
with anatomic dissection, allows the procedure to be performed without a tourniquet.
However, tourniquets represent an effective means of achieving hemostasis and are favored by many surgeons. Ankle, calf, and
midthigh devices can be used safely when they are employed within commonly recognized guidelines (26 , 27 , 28 , 29 ).
Although complications may arise from the use of tourniquets, the incidence is low (30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 ,
40 , 41 , 42 , 43 ).
Complete anesthesia at the surgery site with the infiltration of local anesthetic also allows the patient to be maintained with a
lower level of intravenous sedation or general anesthesia. This approach may reduce potential side effects from the narcotic
and neuroleptic agents used in sedative and general anesthesia. Investigators have suggested that a preemptive effect may be
obtained that would improve the patient's postoperative course by decreasing pain (44 ,45 ).
INCISION
Strategic placement of the surgical incision can greatly enhance the surgeon's ability to access adequately critical aspects or
regions of the first metatarsophalangeal joint. Although the first metatarsophalangeal joint can be exposed through many
different surgical approaches (46 , 47 , 48 , 49 , 50 , 51 , 52 ), a universal incision for hallux valgus surgery can be oriented
along the dorsal medial aspect of the metatarsophalangeal joint and follows the angle of the primary deformity. The incision
begins proximally about the midshaft level of the dorsal medial aspect of the metatarsal, extends distally to the dorsal medial
aspect of the metatarsal head and ends just proximal to the hallux interphalangeal joint, medial to the extensor hallucis longus
tendon. This primary incision should extend equidistant from the center of the metatarsal head to allow for ease of retraction in
exposure of both the medial and lateral aspects of the metatarsophalangeal region. The incision usually lies between the
extensor hallucis longus tendon and the dorsal medial neurovascular structures. The incision technique is usually controlled
depth, to allow for separation of the dermis without violation of underlying subcutaneous vessels.
SUBCUTANEOUS DISSECTION
Manipulation of the subcutaneous layer is the key step in anatomic dissection. The subcutaneous layer is initially divided in the
line of the primary skin incision and then is separated from the surface of the deep fascia around the dorsal, medial, and lateral
aspects of the metatarsophalangeal joint. This enhances surgical hemostasis, preserves the viability of the surrounding tissues,
and minimizes the risk of postoperative edema, hematoma, and other wound complications.
The subcutaneous layer, or superficial fascia, is actually composed of two tissue layers between which the cutaneous vessels
and nerves traverse. The outer fatty layer, or panniculus adiposus, contains the venous tributaries and is attached to the deep
fascia by a thin, membrane-like film (53 ). This membrane attachment creates the dissection plane to be followed when
separating the superficial fascia from the deep fascia in anatomic dissection or tissue plane separation. Accurate and clean
separation of the superficial fascia from the deep fascia preserves the cutaneous neurovascular structures.
Technique
With separation of the wound edges through the initial dermal incision, the subcutaneous tissues are visualized. Superficial
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veins that cross the line of incision are clamped, cut, tied, or coagulated with electrocautery.
The technique of tissue plane dissection around the first metatarsophalangeal joint is best initiated over the dorsal aspect of
the shaft of the proximal phalanx. At this point, the subcutaneous tissues are easily separated from the deep fascia or extensor
retinaculum overlying the extensor hallucis tendon. It is not necessary to separate the subcutaneous layer throughout the entire
length of the incision at this time.
The subcutaneous layer is separated down to the level of the deep fascia from the distal end of the incision proximally to the
base of the proximal phalanx. A surgical sponge can be used to peel the subcutaneous tissues away from the medial and lateral
aspects of the proximal phalanx without violation of the delicate deep fascial layer. This initial technique creates the primary
division of the tissue layers, preserves the critical neurovascular structures within the subcutaneous tissues, and provides the
“pocket” through which the rest of the dissection is performed.
Medial Subcutaneous Reflection

Reflection over the medial aspect of the joint capsule is initiated with insertion of the blunt end of the knife handle into the
pocket at the medial aspect of the proximal phalanx. The knife handle is passed proximally between the tissue layers to
separate the subcutaneous layer cleanly from the deep fascia and capsule over the medial aspect of the joint and more
proximally along the shaft of the metatarsal. Dorsal attachments of the subcutaneous layer to the deep fascia may be released
with scissors or a sharp knife, with care taken to avoid laceration of the linear course of the medial nerve and vascular
structures.
Increased exposure of the plantar medial aspect of the joint capsule is usually accomplished with a side-to-side brushing stroke
of the surgical knife that peels the subcutaneous tissues away from the inferior margins of the joint capsule and the course of
the abductor hallucis tendon. Care must be taken to avoid laceration of the plantar medial neurovascular structures and the
perforating capsular vein at the proximal and inferior aspect of the metatarsal neck. The clean separation of subcutaneous
tissues from the deep fascia allows this surgical procedure to be performed with minimal bleeding even without the use of a
tourniquet.
Lateral Subcutaneous Reflection

Dissection into the intermetatarsal space is initiated with a similar reflection of subcutaneous tissues away from the deep fascia
over the lateral aspect of the metatarsophalangeal joint. A surgical sponge is again used to peel the superior level of
subcutaneous tissues away from the deep fascia along the course of the extensor tendons. A deep pocket is initiated along the
lateral aspect of the proximal phalanx with finger dissection. The surgeon can easily separate the subcutaneous tissues down to
the inferior edge of the proximal phalanx and then palpate the fascial expansions that cross the proximal intermetatarsal space.
FIG. 1. Universal incision for hallux valgus repair: dorsal medial incision with subcutaneous reflection medially and
laterally.
Proximal dissection into the interspace is carried along the fascial plane to separate the subcutaneous tissues from lateral
aspect of the metatarsophalangeal joint capsule (Fig. 1 ). A Weitlaner retractor is helpful for maintaining retraction.
Metzenbaum scissors or another form of controlled dissection is used to separate the subcutaneous tissues gently from the
lateral fascial surface. The subcutaneous dissection is carried to the floor of the intermetatarsal space, which is composed of a
transverse structure consisting of either communicating fibers of the dorsal extensor retinaculi from the first and second
metatarsophalangeal joint or a superficial portion of the deep transverse intermetatarsal ligament (54 ). This communicating
expansion needs to be transected to expose the adductor tendon and other deep plantar lateral structures for manipulation or
release. The deep portion of the transverse intermetatarsal ligament is preserved to maintain the sling mechanism and to
stabilize the first ray segment (55 ).
Tissue plane dissection is made more difficult in patients who have undergone previous surgical procedures. In these instances,
extension of the primary incision proximal or distal to the surgical scar allows one to initiate tissue plane dissection, which can
be extended into the wound to restore normal tissue plane relationships.
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FIRST INTERSPACE DISSECTION
Sequential Release of Plantar Lateral Contracture

Contracture of the plantar lateral structures of the metatarsophalangeal joint is one of the primary deforming forces of the
great toe joint in hallux abducto valgus deformity and is largely responsible for the progressive nature of the condition. Failure
to release this area of contracture adequately can lead to recurrence of deformity after surgical intervention. Therefore, the
release of plantar lateral joint contracture is a primary component of hallux valgus correction.
Release of plantar lateral contracture can be accomplished by different surgical approaches (46 , 47 , 48 , 49 , 50 , 51 , 52 ).
Weil (personal communication) addressed the lateral structures through an intraarticular technique consisting of tenotomy of
the adductor tendon and sectioning of the lateral sesamoidal ligament. Tenotomy of the lateral head of the short flexor as well
as release of the lateral collateral ligament may also be performed through this approach as needed. The advantage of this
technique is that it avoids additional dissection into the intermetatarsal space.
Release of plantar lateral contracture by dissection into the intermetatarsal space provides direct exposure of the anatomic
structures affected, the ability to perform tendon transfer techniques, and access for removal of the fibular sesamoid if
necessary. The first objective of dissection in the intermetatarsal space is to provide direct visualization and specific
identification of the individual anatomic structures of the deep intermetatarsal space. Joint motion is evaluated before and
after release of individual anatomic structures in a controlled and sequential manner. The dissection is terminated once a free
and congruous motion of the metatarsophalangeal joint is created.
The specific sequence of release to be performed in the first intermetatarsal space is as follows:
 Adductor hallucis tendon

 Fibular sesamoidal ligament
 Tenotomy of the lateral head of the flexor hallucis brevis
 Excision of the fibular sesamoid
The technique begins with release of the adductor tendon but progresses only as needed to release the contracture effectively
and to allow unrestricted sagittal range of motion of the metatarsophalangeal joint. With each additional step in the release
process is an increased potential for lateral instability. However, without these steps or other appropriate measures, lateral
contracture may persist and may encourage recurrence of the hallux abducto valgus deformity. Therefore, the surgeon is
attempting to recreate a more normal balance of the soft tissues at the joint level.
Release of the Adductor Tendon

The adductor tendon is the first of the deforming structures to be evaluated and released. Adequate exposure and an
understanding of the anatomy allow the surgeon to perform the dissection in a deliberate manner without compromising the
neurovascular or joint structures (56 ). Although some authors have questioned the safety of interspace dissection (57 , 58 , 59 ,
60 ), more current evidence supports the concept that this maneuver can be safely performed without significant disruption of
vital blood supply (61 , 62 , 63 , 64 , 65 , 66 ).
The motion of the first metatarsophalangeal joint should first be evaluated, and the hallux should be held in a relatively rectus
position. Dorsiflexion of the hallux usually demonstrates a significant lateral deviation of the great toe and is a direct reflection
of the lateral displacement of the fibular sesamoid as the proximal phalanx dorsiflexes on the metatarsal head. At the same
time, one sees an increased medial deviation of the metatarsal head with retrograde pressure of the abducted proximal phalanx.
Release of the adductor tendon from its insertion into the proximal phalanx along with proximal stripping of the tendon from its
lateral attachment to the fibular sesamoid will essentially negate the deforming influence of the adductor tendon on the motion
of the first metatarsophalangeal joint. Once the tendon has been released, the surgeon can repeat the manipulation of the
hallux and may begin to appreciate the improvement in motion of the first metatarsophalangeal joint.
Technique
As previously described, exposure of the deep structures of the first intermetatarsal space begins with sectioning of the
transverse expansion or dorsal intermetatarsal ligament. Release of this expansion opens the adductor canal dorsally and reveals
the oblique orientation of the adductor hallucis tendon as it courses proximally from its insertion at the plantar lateral aspect of
the base of the proximal phalanx into the depth of the intermetatarsal space.
The adductor tendon is visualized within the adductor canal and is freed along its inferior surface from the subcutaneous tissues,
which include an extensive venous network of the plantar fat. This approach allows visualization of the conjoined tendon as it
courses proximally from the base of the proximal phalanx along the lateral surface of the fibular sesamoid and further into the
intermetatarsal space (Fig. 2 ).
The conjoined adductor tendon is clamped at the level of the metatarsophalangeal joint and is sharply released from its
insertion into the base of the proximal phalanx (Fig. 3 ). Distal tension is maintained on the tendon as a coaxial dissection
technique is used to strip the tendon from its attachments along the lateral surface of the fibular sesamoid and to release the
lateral or transverse head of the adductor tendon deep in the intermetatarsal space. The tendon is tagged for possible later
transfer. Motion of the first metatarsophalangeal joint should then be evaluated. If significant lateral deviation of the hallux
remains, additional interspace dissection will be necessary.
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FIG. 2. Identification of the conjoined adductor tendon. The adductor tendon is identified within the intermetatarsal
space, and the initial incision is made to begin release of the tendon.
Release of the Fibular Sesamoidal (Suspensory) Ligament

Lateral displacement of the fibular sesamoid can be maintained by contracture of the fibular sesamoidal ligament. Repositioning
of the fibular sesamoid beneath the metatarsal head or the ability to move the metatarsal head back over the fibular sesamoid
may require release or sectioning of the contracted sesamoidal ligament and the capsular tissues.
The maneuver is easily accomplished by inserting the blade of a Freer elevator through the capsulotomy created with the initial
incision for the release the adductor tendon. The blade of the Freer elevator is then passed between the plantar condyle of the
metatarsal head and the articular surface of the fibular sesamoid (Fig. 4 ), to suspend the lateral capsular tissues, including the
vertically oriented sesamoidal ligament. The suspended soft tissues are then sectioned and are reflected inferiorly to expose the
articular surface of the fibular sesamoid (Fig. 5 ). The lateral capsular tissues should be released completely from the posterior
surface of the sesamoid and proximal condylar aspect of the metatarsal head to the distal junction of the sesamoid and base of
the proximal phalanx.
Once complete release of the fibular sesamoidal ligament has been performed, motion of the metatarsophalangeal joint should
be reevaluated to determine the extent of residual
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contracture (Fig. 6 ). If no contracture is appreciated and if unrestricted sagittal plane motion of the joint is present, no further release of anatomic structures will be necessary (Fig. 7 ). However, if significant lateral deviation of
the hallux remains as the great toe is dorsiflexed, then the dissection sequence of the interspace will continue with release of the lateral head of the flexor hallucis brevis.
FIG. 3. The adductor tendon detached from its insertion into the proximal phalanx.
FIG. 4. Demonstration of the fibular sesamoidal ligament with the adductor tendon retracted.
FIG. 5. Freeing of the fibular sesamoid after release of the fibular sesamoidal ligament.
Tenotomy of the Lateral Head of the Flexor Hallucis Brevis Tendon

Significant contracture of the lateral head of the flexor hallucis brevis muscle can occur in moderate to severe hallux abducto valgus deformities and will perpetuate the deviation of the proximal phalanx (67 ). Tenotomy of the
lateral head of the flexor hallucis brevis tendon is performed by sectioning the tendon between the anterior edge of the fibular sesamoid and the plantar lateral aspect of the base of the proximal phalanx (Fig. 8 ). The maneuver is
performed while the surgical assistant maintains an adductory pull on the hallux to create tension of the fibers of the flexor hallucis brevis tendon. The knife should section a few millimeters of tendon at a time until adequate
release of the lateral contracture is accomplished. Complete sectioning of the tendon may not be necessary to accomplish the desired result. Once this tendon is released, a noticeable change in sagittal plane motion of the hallux is
usually appreciated.
If significant contracture remains after complete sectioning of the lateral head of the flexor hallucis brevis tendon, then the fibular sesamoid is most likely influencing the joint motion. In this circumstance, the shape of the
sesamoid or its articulation with the metatarsal head may prevent the repositioning of the sesamoid beneath the metatarsal head. Osteophytic lipping or enlargement of the sesamoid, loss of the lateral sesamoid groove or lateral
condyle, and flattening of the crista may create a situation in which the fibular sesamoid will only function on the lateral surface of the metatarsal head. In these circumstances, removal of the fibular sesamoid may be necessary to
allow unrestricted sagittal plane motion of the congruously aligned hallux on the metatarsal head.
FIG. 6. Evaluation of the first metatarsophalangeal joint range of motion after the release of intermetatarsal structures. The intermetatarsal angle is reduced manually, and the proximal phalanx is placed in a rectus
position on the metatarsal head.
Removal of the Fibular Sesamoid

Excision of the fibular sesamoid is the final and consummate maneuver used to eliminate lateral contracture of the periarticular structures that influence motion of the first metatarsophalangeal joint. This step is reserved for those
deformities characterized by persistent lateral deviation of the hallux in dorsiflexion when the first metatarsophalangeal joint is placed in a congruous position, despite the complete sequence of soft tissue release. It may also be
necessary when
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the sesamoid is arthritic or enlarged. Smooth, gliding motion between the sesamoids and the first metatarsal head is required
for normal joint function. A deformed sesamoid may prevent this mobility.
FIG. 7. Dorsiflexion of the hallux reflects the release of contracture involving the sesamoid apparatus. If the hallux moves
freely in the sagittal plane, an adequate intermetatarsal release has been performed. If the hallux deviates laterally with
dorsiflexion, residual contracture at the plantar lateral aspect of the joint remains, necessitating further release.
Although preoperative radiographs may give some indication of the need for removal of the fibular sesamoid, the final decision
should be based on the intraoperative assessment of metatarsophalangeal joint motion. The need for removal of the fibular
sesamoid is seen in a significant minority of cases, and the routine removal of the fibular sesamoid should be avoided because of
the increased risk of hallux varus (68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 ).
Removal of the fibular sesamoid may be performed more frequently in nonosteotomy procedures (78 , 79 , 80 ). In geriatric
patients with hallux abducto valgus and in other patients with decreased bone density, the use of modern osteotomy techniques
may be contraindicated. In these cases, a viable compromise to structural correction of deformity can be accomplished with
greater positional manipulation that can be accomplished after removal of the fibular sesamoid. The obvious caution against
hallux varus remains and close attention to muscle-tendon rebalancing and capsulorrhaphy techniques must be employed.
FIG. 8. Tenotomy of the lateral head of the flexor hallucis brevis is performed at the anterior edge of the fibular sesamoid
if lateral contracture remains after release of the fibular sesamoidal ligament.
Technique
Removal of the fibular sesamoid can be a challenging experience if the patient has significant hypertrophy, osteophytic lipping,
or ossification of the intersesamoidal ligament (8 ,81 , 82 , 83 , 84 , 85 , 86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 , 94 ). The technique
requires release of all attachments to the fibular sesamoid including the distal attachment to the base of the proximal phalanx,
release of the intersesamoidal ligament, and reflection of the tendinous plantar fibers and the proximal muscle investment into
the posterior surface of the sesamoid bone. Care must be taken in the sectioning of the intersesamoidal ligament to prevent the
laceration of the flexor hallucis longus tendon, which lies in the fibroosseous canal between the tibial and fibular sesamoids.
With removal of the fibular sesamoid, motion of the loaded metatarsophalangeal joint should be evaluated closely. Primary
controlling elements of the transverse plane alignment of the metatarsophalangeal joint then become the position and function
of the tibial sesamoid. In the absence of the fibular sesamoid, osteotomy techniques for reduction of the intermetatarsal angle
and periarticular realignment of capsular structures become more effective. Overcorrection or subtle medial imbalance can
more easily place the tibial sesamoid in a medial position and can possibly lead to a hallux varus deformity.
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Lateral Collateral Ligament of the First Metatarsophalangeal Joint

At this point in the sequential release of lateral plantar contracture of the metatarsophalangeal joint, the only remaining intact
anatomic structures are the lateral collateral ligament and the associated joint capsule. It has been common practice in hallux
valgus surgery to manipulate or rupture these lateral soft tissues or to section them with the surgical knife. Rarely is there such
significant contracture of these lateral structures that it precludes realignment of the metatarsophalangeal joint. A general
recommendation would leave these tissues intact, with the exception of the most extreme deformities of the great toe joint.
MEDIAL CAPSULOTOMY
Capsular and Periosteal Reflection

Exposure of the metatarsal head in hallux valgus surgery can be accomplished by many different incision techniques. Primary
considerations for incision and reflection of capsular tissues include adequate exposure for osseous techniques and preservation
of primary blood supply to the distal end of the metatarsal bone.
The blood supply to the head of the first metatarsal has been described in detail (95 ), and it includes primary nutrient vessels
in the dorsal, plantar, and lateral aspects of the metaphyseal region of the bone. Significant blood supply is also provided by the
periosteal tissues that cover the osseous surfaces of the head and neck of the metatarsal.
Incision placement is guided by the need for exposure. Capsular reflection and periosteal reflection also provide exposure but
should be controlled in an attempt to preserve adequate blood supply to the capital fragment of the metatarsal specifically
when metaphyseal osteotomies are performed.
Primary Capsular Incision and Reflection

A universal approach to the metatarsal head can be made through a longitudinal incision along the dorsal medial aspect of the
metatarsophalangeal joint from the neck of the metatarsal distally across the joint line and onto the base of the proximal
phalanx. Elevation of the dorsal capsular tissues at the joint line, with slight distal reflection from the dorsal aspect of the
phalangeal base (Fig. 9 ), provides clear appreciation of the contours of the metatarsal head, yet it preserves the capsular and
synovial attachments over the dorsal aspect of the metatarsal head. Preservation of this tissue reduces intraarticular fibrosis
and adhesions in the postoperative healing phase.
Reflection of the capsule from the medial aspect of the metatarsal head may be initiated with a vertical incision at the joint
line (Fig. 10 ). An appreciation of actual capsular attachment to the epicondyle aspect of the metatarsal head facilitates the
sharp dissection and reflection the medial capsular flap from the surface of the bone. Meticulous dissection is necessary when
one reflects the medial capsule from the metatarsal head to avoid buttonholing the capsular flap as dissection is carried over
the metaphyseal flare onto the shaft of the metatarsal.
FIG. 9. Reflection of the dorsal capsule of the first metatarsal joint reveals the contour of the metatarsal head and
articulation with the proximal phalanx.
The primary capsular dissection necessary for the ostectomy or simple bunionectomy requires only reflection of the medial
capsular flap. If the hallux valgus procedure involves a distal osteotomy technique, then a more involved soft tissue dissection
technique is required to provide exposure for the osteotomy and fixation techniques.
FIG. 10. A vertical incision is made at the medial aspect of the joint line. This incision sections the medial collateral
ligament and prepares for reflection of the medial capsule from the metatarsal head.
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MEDIAL EMINENCE
The dissection and reflection of the medial soft tissue structures allow for maximum exposure to the medial eminence with
minimal disruption of blood supply. A Seeburger or Sayer retractor may be placed medially beneath the metatarsal head to
provide full visualization of the medial eminence for resection of the prominence.
Modern hallux valgus techniques rely on structural correction of the deformity and require only minimal resection of the dorsal
medial eminence (96 ). Resection of the dorsal medial prominence should preserve both the sesamoidal groove and its extension
as the sagittal groove. Preservation of the plantar medial condyle and of the sagittal groove enhances a stable congruous
articulation of the base of the proximal phalanx on the head of the metatarsal and resists medial luxation and the progression of
a hallux varus deformity.
CAPSULAR CONSIDERATIONS FOR THE AUSTIN BUNIONECTOMY

The Austin bunionectomy and other distal metaphyseal osteotomies have been criticized for the theoretic potential for
disruption of the intraosseous blood supply to the head of the first metatarsal. Varying degrees of purported avascular necrosis
have been described. However, Jones et al. described the “safe zones” for performing the Austin osteotomy by carefully
maintaining these soft tissue attachments and minimizing periosteal reflection for distal osteotomy techniques (63 ).
Preservation of soft tissue attachments over the dorsal, lateral, and plantar aspects of the metatarsal head is accomplished with
a subperiosteal dissection technique around the neck of the first metatarsal.
A Freer elevator is used to create a tunnel across the dorsal aspect of the metatarsal neck (Fig. 11 ), to maintain the capital and
metaphyseal arteries that supply the metatarsal head and neck. The same technique is used plantarly just proximal to the
synovial sesamoidal fold (Fig. 12 ). This preserves the plantar blood supply and integrity of the plantar capsular folds. The dorsal
and plantar tunnels are connected along the lateral aspect of the metatarsal neck to create a subperiosteal collar around the
neck of the metatarsal.
FIG. 11. Reflection of dorsal periosteum from the neck of the metatarsal in preparation for a metaphyseal osteotomy.
FIG. 12. Reflection of plantar periosteum from the neck of the metatarsal in preparation for the plantar cut of a chevron
osteotomy.
The subperiosteal envelope serves multiple purposes:
 It maintains the periosteal and articular blood supply to improve healing and consolidation of the osteotomy.
 It maintains normal intraarticular synovial relationships to decrease adhesions and fibrosis during postoperative healing.
 It creates an extraarticular osteotomy that additionally enhances recovery of postoperative motion.
 The stability of the capital fragment is maintained through the plantar tether, which resists dorsiflexion of the capital
fragment with weight bearing.
MUSCLE-TENDON BALANCING AND SOFT TISSUE PROCEDURES IN HALLUX VALGUS

CORRECTION
Realignment and congruous function of the first metatarsophalangeal joint (Fig. 13 ) is accomplished by release of lateral
contracture, correction of osseous deformity (Fig. 14 ), and reestablishment of the normal balance with the periarticular soft
tissues. Muscle-tendon balance around the metatarsophalangeal joint can be accomplished by a combination of techniques,
including the adductor tendon transfer and various manipulations of the joint capsule.
Adductor Tendon Transfer

Restoration of sesamoid apparatus beneath the head of the metatarsal is accomplished by the combination of release of
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lateral soft tissue contracture and osseous realignment of the metatarsal head over the sesamoids by an osteotomy technique.
The adductor tendon transfer is used primarily to maintain derotation of the capsular tissues around the metatarsal head and to
enhance medial capsular integrity. Caution must be exercised not to overtighten the adductor tendon transfer, to avoid medial
luxation of the tibial sesamoid and the precipitation of a hallux varus deformity (97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 ).
FIG. 13. Congruous realignment of the metatarsal phalangeal joint. The base of the proximal phalanx is placed in the
sagittal groove of the metatarsal head. If adequate plantar lateral release has been performed, the proximal phalanx will
articulate and function in a rectus position.
FIG. 14. Execution of a distal chevron osteotomy with the dorsal and plantar arms of the osteotomy exiting within the
periosteal tunnels and preservation of dorsal, lateral, and plantar capsular attachments maintained on the metatarsal
head.
Medial Capsulorrhaphy
Closure of the medial capsule is the final step in reestablishing balance around the first metatarsophalangeal joint (106 , 107 ,
108 , 109 , 110 , 111 ). The joint should initially be placed in a rectus position with the medial base of the proximal phalanx
resting within the sagittal groove. The medial capsule can then be thoroughly evaluated, and an appropriate section can be
removed to eliminate any redundancy of this tissue layer and to provide for apposition and repair of the medial aspect of the
joint. The dorsal capsule is reapproximated to maintain alignment of the extensor hallucis longus tendon (112 , 113 , 114 , 115 ,
116 , 117 , 118 ).
SUMMARY
Anatomic dissection of the first metatarsophalangeal joint in the repair of hallux abducto valgus deformity is a fundamental
concept that allows the surgeon to evaluate the various components of the deformity and to execute the appropriate maneuvers
and procedures necessary to accomplish a consistent repair of the deformity. In addition, one notes a reduction in the incidence
of surgical and postoperative complications.
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Chapter 7
Distal Metaphyseal Osteotomies in Hallux Abducto Valgus Surgery
Thomas J. Chang
As early as 1881, Reverdin introduced the concept of addressing hallux abducto valgus deformity at the level of the metatarsal head (1 ).
Over time, the distal osteotomies have become the most commonly performed type of bunionectomy, most likely for several reasons. First,
most of the procedures afford immediate or early return to functional weight bearing because of the inherent stability of the osteotomy.
This basic tenet simplifies the postoperative management period and may reduce the risks associated with patient noncompliance
compared with other osteotomy designs. Second, modifications in the techniques allow for multiplanar correction to address various levels
of deformity in the transverse, sagittal, and frontal planes, as well as the metatarsal length.
Historically, distal metaphyseal osteotomies have been considered in patients with mild to moderate hallux valgus deformity with an
intermetatarsal (IM) angle up to 15 degrees. However, some investigators have reported the ability of certain distal osteotomies to correct
IM angles of up to 20 degrees (2 , 3 , 4 , 5 ). In addition, distal osteotomies may be employed to correct deviations in the proximal articular
set angle (PASA). Concomitant hallux limitus can also be addressed with several of the osteotomy designs.
Because of the significant benefits to the distal metaphyseal osteotomies, many investigators have considered these osteotomies as
“universal” procedures. As a general statement, the distal procedures are considered technically easier to perform than the more
proximally oriented procedures. However, patients with significant deformity, metatarsus adductus, or other conditions are still well
served with proximal repair procedures.
TECHNIQUE: APICAL AXIS GUIDE

The axis guide concept was first introduced by The Podiatry Institute in 1980 (3 ). The guide is simply a Kirschner wire (K-wire) used for
reconstructive surgery of the foot and ankle to help guide the angles and planes of the osteotomy being performed. Once the guide is in
place, the surgeon simply needs to maintain the saw blade parallel to the axis guide for a well-executed cut. A Reese osteotomy guide
placed on the axis guide can also be employed to assist in the execution of the osteotomy, but it is not necessary. The Reese osteotomy
guide also relies on the concept of proper axis guide placement to work properly (Fig. 1 ). In hallux valgus correction, use of the axis guide
can assist the surgeon in manipulating and executing an accurate osteotomy. This concept allows a K-wire to be placed from medial to
lateral through the metatarsal head to help plan the actual direction of the capital fragment before the osteotomy is cut (6 ). The most
common planes of manipulation are the sagittal and transverse planes (Fig. 2 ). Simple placement of the axis guide readily assists in
manipulation of the (a) sagittal plane placement (plantarflexion) and (b) metatarsal length.
FIG. 1. Example of the use of the apical axis guide for execution of an Austin osteotomy. If the axis guide is placed appropriately,
then the surgeon will only need to keep the saw blade parallel to the guide to create a perfectly aligned osteotomy.
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FIG. 2. Frontal plane orientation of the Kirschner wire used as an apical axis guide. A: When the wire is directed dorsally, the
metatarsal head dorsiflexes as it is displaced laterally. B: If the wire is directed parallel to the weight-bearing surface, then the
metatarsal head will remain in its current weight-bearing position. C: If the Kirschner wire is directed plantarly, then plantarflexion
of the metatarsal head will occur as the metatarsal head is displaced laterally.
The apex of the osteotomy is usually selected as the central point of the metatarsal head medially after resection of the medial eminence.
Depending on the angular manipulations desired, it is recommended to expand the cuts from the central point when necessary to create
even segments of bone both above and below the apex (Fig. 3 ). This is most important in sagittal plane manipulations. For example,
plantarflexion of the capital fragment is commonly selected for hallux valgus correction. Therefore, the axis guide is directed from dorsal
medial to plantar lateral. If the wire enters centrally on the medial side of the metatarsal, then the osteotomy will exit the lateral cortex
at a more plantar oriented position. Consequently, depending on the amount of plantarflexion desired, one may adjust the axis guide to
enter the medial head above the central point. If dorsiflexion of the capital fragment is desired, then the medial entry of the pin may be
below the midpoint medially and may exit above the midpoint laterally.
Manipulation of the metatarsal length can also be achieved using an apical axis guide pin (Fig. 4 ). Usually, the metatarsal is either
shortened slightly or the length is maintained. Actually, the width of the power saw and normal bone resorption during healing result in
some shortening of the bone. The relative length of the first metatarsal is usually measured with respect to the second metatarsal;
similarly, the K-wire is delivered with respect to the second metatarsal as a reference. Again, the midpoint of the head is estimated, and
the wire is driven from medial to lateral. To maintain length, the wire is driven perpendicular to the second metatarsal shaft. If shortening
is desired, then the K-wire is directed in a slightly proximal position.
The foregoing comments apply well to an Austin-type

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osteotomy, but the general concepts can also apply to most other distal osteotomies. The surgeon performs the osteotomy with the saw
blade parallel to the axis guide. Any deviation of the blade from the pin causes the osteotomies to converge or diverge laterally and may
compromise proper seating of the capital fragment.
FIG. 3. Diagram to illustrate the importance of placing the medial side of the osteotomy more dorsally to allow for a more central
exit laterally. A: Example of a plantarflexory axis that exists too plantarly if the apex is started central on the medial side. B:
Example of even surfaces of the capital fragment both above and below the apex by starting more dorsally on the medial side.
FIG. 4. Transverse plane orientation of the Kirschner wire used as an apical axis guide. A: When the axis is directed proximally, the
metatarsal shortens as the capital fragment is displaced laterally. B: If the axis is oriented perpendicular to the second metatarsal,
then no change in length will occur. C: To lengthen the metatarsal after osteotomy, the axis should be oriented distally.
AUSTIN BUNIONECTOMY
Austin first performed this procedure in 1962 (Fig. 5 ) (7 ). The Austin bunionectomy is described as being inherently stable with the ability
to correct an IM angle of up to 15 degrees, although authors have reported the ability to correct IM angles up to 22 degrees (2 , 3 , 4 ). The
osteotomy is “V” shaped and is oriented from medial to lateral with the apex distally and two arms of the osteotomy exiting the proximal
cortex. The apex is usually considered to be the central point of the medial metatarsal head. This point can be estimated by visualizing a
line from the proximal extent of the dorsal cartilage to the proximal extent of the plantar articular surface. The midpoint of this line often
provides a good location for the apex of the osteotomy. If the apex is positioned too proximally, then the osteotomy will be located within
the diaphyseal portion of the metatarsal, more closely approximating the offset-V procedure. If the apex is placed too far distally, it will
increase the chance of an intraarticular fracture (Fig. 6 ). The osteotomy is usually performed with an
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angle of approximately 60 degrees between the dorsal and plantar segments.
FIG. 5. Traditional Austin osteotomy angulated at 60 degrees. The inherent stability of the osteotomy results from the weight-bearing
compression across the plantar arm.
FIG. 6. Determining proper site for apex of Austin osteotomy. The midpoint of imagery line (A) connecting the dorsal and plantar
edges of the articular cartilage is usually ideal. An osteotomy placed too far proximally (B) increases the risk of dorsal displacement.
If the apex is placed too far distally (C), then the metatarsal head may fracture after impaction.
After the osteotomy is completed, lateral transposition of the capital fragment is executed. When the position of the capital fragment is
deemed to be acceptable, impaction of the fragment provides early stability before fixation is introduced. This maneuver is performed by
applying even proximal pressure against the entire width of the metatarsal head with one hand while stabilizing the metatarsal shaft with
the other. When mild PASA deviations may exist, this can be addressed by more direct impaction on the medial half of the capital fragment
to derotate the articular surface. This approach is helpful in repositioning the capital fragment with the articular surface directed in a
more rectus or medial position. After initial stability is imparted to the capital fragment, then fixation may be introduced.
Results
Austin first performed this procedure in 1962 and reported his results in 1965 on 300 patients (7 ). In his early review, he reported 10% of
recurrence of the bunion and only a few cases of hallux varus. When Austin and Leventen presented their “new” osteotomy in 1981, they
had performed more than 1,200 procedures (7 ). An interspace release was performed from an intracapsular approach, and these
investigators believed that impaction of the capital fragment provided enough stability to the osteotomy site without fixation.
Johnson et al. described their experience with a similar chevron osteotomy at the Mayo Clinic starting in 1976, with an article on their
follow-up on 18 patients published in 1979 (8 ). Their approach was identical to that of Austin and Leventen, but it also included an
occasional bone peg fashioned from the resection of the medial metatarsal shaft across the osteotomy site for added stability. Johnson et
al. reported a 7-degree average decrease in the IM angle and an average of 12-degree correction of the hallux abductus angle.
In 1993, Hetherington et al. reported a follow-up study on the Austin bunionectomy to address the following issues: (a) long-term results of
the Austin for hallux abducto valgus correction; (b) reproducibility of these results; (c) efficiency of capsular reefing to enhance results;
and (d) comparison of fixated versus nonfixated osteotomies (9 ). They compared several groups of patients in four categories. The first
two categories were a follow-up of 18 nonfixated Austin osteotomies performed by one of the primary authors. Group 3 procedures were
performed with capsular reefing, and group 4 procedures were performed with K-wire fixation. Their conclusions were as follows: (a) long-
term results appeared to be good and reproducible; (b) capsular reefing did not appear to improve results—an increase in joint stiffness
and metatarsalgia was noted in this group; and (c) no difference was noted among the fixation techniques used.
Modifications
Since its introduction, certain modifications have been made to the original Austin design in an attempt to use this osteotomy as a
universal procedure for correction of many conditions involving the first metatarsal. The modifications have allowed more dynamic
manipulations in the transverse and sagittal planes to emphasize different aspects of correction or fixation.
Long Dorsal Arm

A longer dorsal arm was employed under the premise that this would provide more stability to the capital fragment and would obviate the
need for fixation. The more acute angulation of the osteotomy necessary to create the longer dorsal arm was reported to reduce some of
the problems seen with the traditional design. This difference provided shorter postoperative immobilization and more rapid return to
normal footwear (10 ). Some investigators have described favorable results with the modification (11 , 12 , 13 , 14 ), although fixation is
typically employed by most surgeons, in contrast to the original report (Fig. 7 ). In fact, the longer dorsal arm provided an excellent means
of stabilizing the osteotomy with two dorsally to plantarly oriented screws (11 ). Two points of fixation are important in providing
transverse plane rotational stability to the capital fragment. With these new modifications, surgeons began to extend the limits of the
traditional Austin osteotomy to more aggressive levels. The modified osteotomy has been reported as successful in addressing patients with
IM angles of 20 to 22 degrees (2 ) (Fig. 8 ). The screw fixation techniques also allow the capital fragment to be translocated up to one-half
of the metatarsal width.
The dissection for the longer dorsal arm is slightly different, owing to the forms of fixation most commonly employed for stabilization. The
dorsal synovial fold is typically dissected from the metatarsal head. Fixation of the long arm osteotomy is usually achieved with two
parallel screws oriented perpendicular to the osteotomy site. In some instances,
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threaded K-wires have also proven suitable. Two 2.7-mm AO screws are most commonly used, or sometimes a 2.0-mm screw is employed as
the proximal anchor. A 0.045-inch K-wire is used for temporary fixation across the extremely distal portion of the dorsal arm of the
osteotomy, directed from dorsal distal to plantar proximal, exiting proximal to the plantar arm of the osteotomy. The guide pin may also
be used as a reference for the orientation of the screws (Fig. 9 ). The initial holes for the screws are on the dorsal cortex of the capital
fragment and are often created with a 0.062-inch K-wire. Smith described identifying the dorsal position of the screws with either a
marker or drill holes before making the osteotomy to ensure adequate bone surface for fixation (15 ). With the temporary fixation pin in
place, a 0.062-inch K-wire is introduced in the location of the proximal screw and is driven parallel to the temporary fixation wire. With
these two wires in place, the distal screw is inserted across the osteotomy site, parallel to the two K-wires (Fig. 10 ).
FIG. 7. Modified osteotomy (Kalish modification) with the angle measuring 55 degrees. This facilitates bicortical screw fixation across
the dorsal arm of the osteotomy.
FIG. 8. A: Preoperative radiograph of a patient with a 21 -degree intermetatarsal angle. B: Postoperative radiograph at 1 year after
the Kalish procedure, with good alignment noted.
The two points of temporary fixation provide rotational stability to the capital fragment while the first screw is applied. After the first
screw is secure, then the proximal wire is removed, and the second screw is placed into this hole. Again, two points of stability are
provided by the temporary 0.045-inch wire and the first distal screw. With the oblique direction of the screws, it is possible for the screws
to slide proximally along the plantar cortex of the metatarsal and to compromise stable fixation across the osteotomy (Fig. 11 ).
Complications have been noted infrequently and have most often consisted of hallux varus (3%), fracture of the dorsal arm (2%), and stress
reaction of the lesser metatarsals resulting from weight transfer (1%) (13 ,14 ).
Long Plantar Arm

A long plantar arm modification of the Austin osteotomy has also been described (16 ). The angle approaches 55 degrees, with the plantar
arm exiting more proximally. Fixation is most often accomplished with two points of fixation across the plantar arm. Two 2.7- or 2.0-mm
screws are usually employed. In addition, resection of a medially based wedge for PASA correction may be performed if necessary. One
needs to ensure that the proximal extent of the plantar arm of the osteotomy is sufficiently long to avoid compromise of the sesamoid
articulation with the fixation. Good results have been reported with this modification with few complications (16 ,17 ).
Youngswick Modification
Youngswick first described a modified osteotomy for addressing hallux valgus or hallux limitus (18 ). The procedure consists of the
resection of a rectangular wedge of bone from the dorsal arm of the traditional Austin osteotomy. Removal of this segment of bone causes
the capital fragment to seat more proximally on the first metatarsal shaft and to shift plantarly along the plantar arm of the osteotomy
(Fig. 12 ). The amount of plantarflexion can be adjusted by varying the orientation of the plantar arm. A more vertically oriented plantar
arm results in more plantarflexion of the capital fragment, but it also reduces stability as the angle of the osteotomy increases. A
significant benefit of the procedure is the decompression of the first metatarsophalangeal joint, which should improve outcomes in
patients with hallux limitus with or without concomitant hallux abducto valgus deformities. Lateral transposition of the capital fragment
can simultaneously correct the transverse plane deformity.
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FIG. 9. A: Preoperative radiograph of a patient with mild to moderate hallux valgus deformity. Five-year anteroposterior view (B) and
stress lateral view (C) of the postoperative result. Note the parallel position of the screws in both the anteroposterior and lateral
radiographs.
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FIG. 10. Note the parallel position of the temporary fixation and the screws. The temporary fixation helps to guide the proper
direction of the screws. There are always at least two points of fixation across the osteotomy to prevent rotational motion while
fixation is being applied.
Bicorrectional and Tricorrectional Osteotomies

The Austin osteotomy can also be modified to correct for deviations of the PASA (19 ,20 ). The procedure involves removal of a medially
based wedge of bone from proximal aspect of both the dorsal and plantar segments to realign the articular surface. This procedure is
technically more difficult because of the obliquity of the dorsal and plantar cuts. Successful fitting of the osteotomy is facilitated by
initially cutting across only 80% across the osteotomy site to remove the wedges that are required. This maneuver provides stability to the
capital fragment before the surgeon cuts through the lateral cortex (20 ). Lateral transposition of the capital fragment may then be
performed to achieve reduction of the IM angle.
FIG. 11. A: Diagram showing the ideal position of the two cortical screws in fixation of a long dorsal arm modification. B: The
proximal screw may have a tendency to migrate proximally and ride up the shaft of the plantar cortex. The result can be gapping of
the proximal osteotomy site.
FIG. 12. Template of a Youngswick-Austin modification. Note the ability to decompress the first metatarsophalangeal joint while also
achieving plantarflexion of the capital fragment.
A “tricorrectional” bunionectomy has also been described (21 ). The V osteotomy is made through the metatarsal head from a dorsomedial
to a plantar lateral direction.
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Then a second V osteotomy is performed on the proximal segment removing a medially based wedge to reduce the PASA. The metatarsal
head is then transposed laterally. Thus, the correction occurs in the transverse and sagittal planes as well as addressing the PASA. A 4.0-
mm cancellous screw is used for fixation. K-wire fixation has been reported as successful in the same form of osteotomy (22 ). Good results
have been reported in each study.
Fixation of the Austin Procedure

Various fixation techniques have been recommended for the Austin bunionectomy. They are as varied as the modifications to the
procedure, and each new modification is often described with recommendations for new fixation techniques.
When it was first described, the Austin osteotomy was stabilized by simple impaction of the capital fragment onto the proximal metatarsal
shaft. Numerous reports have noted good to excellent results in patients with nonfixated Austin bunionectomies. Feit et al. reviewed 100
procedures, with 90 of the cases requiring a fibular sesamoidectomy (23 ). Average IM reduction was measured at 5.27 degrees, and only a
single case required reoperation from a postoperative fracture. However, external forces acting on the metatarsal head during the
postoperative period can result in rotation of the metatarsal head, dorsal malposition, and displacement of the capital fragment altogether
(Fig. 13 ). Since the late 1980s, the preference for most surgeons has slowly shifted to employing some form of fixation for the procedure.
However, as noted by the successes seen in the early studies, good results may be achieved without fixation.
FIG. 13. Complete dislocation of the capital fragment of a nonfixated Austin osteotomy into the interspace 24 hours postoperatively.
FIG. 14. Diagram illustrating a 0.062-inch Kirschner wire oriented medial proximal to distal lateral across the plantar arm of the
osteotomy. The direction of the wire is usually directed toward the crista or lateral portion of the metatarsal head.
Many different forms of fixation have been advocated for the standard Austin procedure. K-wires are the simplest form of stabilization and
have been used successfully for years. The most common technique is to direct the wire from dorsal proximal medial across the plantar
arm of the osteotomy to enter the capital fragment plantar distal lateral. The wire may be left percutaneously or bent, cut, and turned to
lie against the metatarsal shaft (Fig. 14 ). Care is taken to avoid protrusion of the K-wire into the joint space. A helpful technique is to
visualize the wire within the joint and then to slowly move the wire in retrograde fashion until the tip lies just beneath the subchondral
bone (24 ). Care should also be employed with percutaneous K-wires to avoid exiting along the dorsal margin of the joint, where it may
restrict dorsiflexory mobilization.
Yu and Malay described an “intramedullary” locking K-wire technique in an effort to enhance the stability of K-wire fixation (25 ). The wire
is introduced in a manner as described earlier. The wire is cut, leaving a small segment that is rotated from a medial to a dorsal position
onto the top of the metatarsal shaft. If the angle of the bent wire is sufficiently acute, then the wire will need to be forced onto the dorsal
cortex with pliers. Doing so results in a bending moment that is transferred to the portion of the K-wire inside
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the metatarsal head. The key to locking the internal portion of the wire within the osteotomy successfully is to create a bend in the K-wire
that is slightly more acute than the angle created by the exiting K-wire and the dorsal cortex of the metatarsal. This bending moment is
analogous to intramedullary locking techniques for fixation of long bone fractures. When this is locked properly, it is extremely difficult to
pull the K-wire free until it is rotated back medially and is “unlocked” from this position (Fig. 15 ).
FIG. 15. Diagram of the intramedullary locking Kirschner wire (K-wire) technique. A,B: The proximal portion of the K-wire is rotated
onto the dorsal shaft of the metatarsal to create a bending moment within the K-wire that crosses the osteotomy site. Radiographs
show this technique. Note the subtle bending of the Kwire within the capital fragment on the anteroposterior (C) and lateral (D)
views.
Some surgeons have employed threaded K-wires directed in a similar manner as the smooth counterpart. The threaded wire may then be
cut flush with the bone. Several authors have described staple fixation for the osteotomy (26 ), one dorsally (27 ) and another medially
(28 ). Absorbable pins and rods have also been employed with success (29 ,30 ). Allofix (Musculoskeletal Transplant Foundation, Edison, NJ)
cortical bone allograft pins have been introduced and appear to provide good stability in the early follow-up period.
Screw fixation can also be used across the plantar arm of the Austin bunionectomy. Partially threaded screws are often considered in this
technique. Because of standard screw design, it may be difficult to ensure that all the threads of a particular screw cross the osteotomy
site. When possible, it is helpful to select a screw with a short thread pattern like the AO cannulated screws. The short thread pattern is
one-third the length of the screw, in contrast to the standard half-length (Fig. 16 ). To assist in allowing more threads of the screw to cross
the osteotomy site, it may be helpful to shift the apex of the osteotomy slightly more dorsally. In this fashion, the plantar arm exits
further proximally along the plantar shaft of the metatarsal and provides a larger area of metatarsal head in which the screw can purchase.
When a drill is used to prepare the direction of screw placement, it is helpful to drill into the joint space plantarly. After the measurement
is taken, a screw length 2 to 3 mm shorter is selected to avoid intraarticular encroachment of the screw (Fig. 17 ). Any partially threaded
screw can be used in this fashion, including the Herbert bone screw (31 , 32 , 33 ). Fully
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threaded screws can also be used with proper preparation of the screw hole to achieve interfragmentary compression.
FIG. 16. Diagram of a partially threaded screw across the plantar arm of the osteotomy. This is similar to the direction of the
Kirschner wire discussed earlier.
Several authors have recommended adjusting the angle of the osteotomy to create a longer dorsal arm for screw fixation. The theory is
that this approach allows the surgeon to translocate the capital fragment more aggressively. Fixation is often achieved with one or two
screws or threaded K-wires. Specifically, this has involved one 2.7-mm cortical screw (34 , 35 , 36 ), two 2.7-mm cortical screws (13 ,37 ),
or one 2.7-mm screw distally with a 2.0-mm screw proximally (2 ,3 ). It is ideal to place the fixation from the central portion of the dorsal
fragment to the central portion of the plantar fragment. With this in mind, the fixation is oriented from dorsal lateral to proximal medial.
The surgeon must make sure that the plantar exit point of the most distal is proximal to the plantar arm of the osteotomy. This approach
secures stable cortical fixation to the osteotomy site. It is possible to aim too far laterally and for the screw to miss the plantar segment of
the metatarsal altogether. If the angle of the screw is too oblique, the screw may fail to exit the plantar cortex and may slide along the
plantar aspect of the medullary canal. In this instance, the screw may tighten, but less than optimal stabilization is achieved (Fig. 18 ).
FIG. 17. The drill for screw placement can be visualized entering the plantar aspect of the joint space. After this length is measured,
a screw 2 to 3 mm shorter is selected to keep screw threads from penetrating the joint.
Techniques that provide fixation across the plantar arm of the Austin osteotomy are more mechanically stable when compared with
techniques that leave the plantar arm free. When the plantar arm is not fixated, excessive forces to the metatarsal head result in shear
across the plantar surface, dorsal rotation of the capital fragment around its apex, and, ultimately, fracture of the capital fragment at the
most distal fixation device. Models that were fixated with a cancellous screw across the plantar arm failed only through middiaphyseal
fracture, without exhibiting any shift or failure at the osteotomy site. These examples clearly show the enhanced stability of fixation
across the plantar arm of the osteotomy (38 ).
FIG. 18. An example of fixation screws that were directed too far laterally and missed the plantar cortex of the osteotomy.
Orientation of the screws should be directed in a medial fashion, to engage in the central portion of the metatarsal shaft solidly.
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The fixation devices simply augment the inherent stability of the osteotomy design and prevent the shear moment seen at this interface
when this surface is left unfixated. Although these studies are interesting in the in vitro situation, one should appreciate their clinical
applications. Little if any correlation may exist between the measurements achieved in laboratory studies assessing stability of the fixation
for the Austin procedure and the ability of the fixation to produce adequate stabilization in the clinical setting. Each of these measures
may prove adequate and suitable in actual patients. Clearly, most Austin bunionectomies do not dislocate. Often, the patient is
apropulsive after surgery and places only minimal pressure on the surgery site because of discomfort and the presence of a bulky dressing.
Patients rarely place enough force through their surgical site to cause failure of the osteotomies. Gentle weight-bearing pressure also
provides compression forces across any plantar arm design of the osteotomy and offers stability to the healing bone.
REVERDIN BUNIONECTOMY
In 1881, Reverdin described a medially based incomplete wedge resection of the metatarsal head (1 ). After his original article, the next
mention in the literature did not occur until more than 90 years later (39 ,40 ). The location of this vertical osteotomy is proximal to the
articular cartilage and usually distal to the sesamoid apparatus. The osteotomy can directly correct an abnormal articular set angle and
can also reduce the IM angle if the first ray is flexible (41 ). Two divergent cuts are made within the metaphyseal portion of the metatarsal
head. Because of the intraarticular location of this shortening osteotomy, there is a direct relaxation of the periarticular structures that
also enhances postoperative range of motion, although one sees little if any change in the functional weight-bearing length of the
metatarsal. The distal cut is oriented parallel to the articular cartilage, and the proximal cut is oriented perpendicular to the long axis of
the metatarsal (Fig. 19 ). When the surgeon removes a triangular wedge of bone from within these two cuts, structural correction is
achieved by alignment of the joint surface perpendicular to the metatarsal shaft. Ideally, an intact lateral cortical hinge is preserved. This
provides significant stability to the remainder of the osteotomy.
Fenton and McGlamry introduced the concept of reverse buckling to describe how a distal osteotomy without lateral transposition could
reduce the IM angle in patients with a flexible first ray (42 ). As described, the PASA was reduced to 0 degrees or to a slightly negative
value. This reoriented the vectors of force exerted by the musculotendinous structures from lateral predominance, as seen in hallux
abducto valgus, to rectus or slightly medial. Thus, the buckling forces exerted by the abducted hallux were reversed, so the retrograde
forces acting on the first metatarsophalangeal joint would force the first metatarsal laterally and thereby reduce the IM angle. Studies
have shown that an average reduction of the IM angle of 3.5 degrees may be seen (42 ). This would also tend to maintain apposition of the
osteotomy without any fixation devices. These authors discussed the analogy of the patient with hallux varus, in whom a negative IM angle
is typically noted. The Reverdin procedure produced a controlled application of these forces.
FIG. 19. Proper cuts for a Reverdin-type osteotomy to reduce the proximal articular set angle to 0 degrees. The distal cut is made
parallel to the residual articular cartilage of the first metatarsal head. The proximal cut is made perpendicular to the long axis of the
first metatarsal.
The prerequisite for success with the Reverdin osteotomy in this situation was a flexible first ray. Redirecting the forces at the first
metatarsophalangeal joint would fail to reduce the IM angle in a rigid condition. Although it is difficult to assess the mobility of the first
ray in the transverse plane, it is presumed that a direct correlation exists with mobility in the sagittal plane. Therefore, the transverse
plane mobility may be inferred by assessing sagittal plane motion.
Although the reverse buckling helped to maintain apposition of the osteotomy, other authors preferred to provide some form of fixation.
Beck employed a 2-0 absorbable suture across the osteotomy (40 ), whereas Cavaliere used three Orthosorb pins (43 ). Common forms of
fixation today include K-wires, monofilament wires, absorbable pins and rods, and cortical bone pins (Fig. 20 ). Because of the orientation
of the osteotomy and the narrow configuration of the capital fragment, it is difficult to use a screw to achieve interfragmental
compression. With stable fixation across the osteotomy, postoperative weight bearing is permitted.
Several modifications to the design of the Reverdin osteotomy have been described. Green advocated an oblique plantar arm similar to the
Austin procedure, to avoid disruption of the articular surface between the first metatarsal and the sesamoids (44 ) (Fig. 21 ). With the
plantar arm described by Green, it is much easier to use screw fixation when desired, although this is certainly not required (Fig. 22 ).
Laird et al., employing the Reverdin-Green configuration, noted that lateral transposition of the osteotomy could also be performed
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once the osteotomy was completed through the lateral cortical hinge (45 ). Thus, one could accomplish correction of the PASA as well as
reduce the IM angle. This modification is commonly referred to as a Reverdin-Green-Laird procedure. Good results have been reported in a
large series of patients with this approach (46 ).
FIG. 20. Preoperative (A) and 1-year postoperative (B) radiographs of a Reverdin bunionectomy with monofilament fixation. Note the
minimal shortening that results from this type of capital osteotomy. The second metatarsal and digit were also addressed.
Postoperatively, weight bearing is allowed with a surgical shoe. When it is used for the purposes of reverse buckling, some form of
splintage is commonly employed for the hallux for up to 3 months. This approach helps to maintain the hallux in mild adductus and assists
in osteotomy healing.
The Reverdin bunionectomy is still a popular option for patients with hallux valgus. It is ideal to incorporate the Reverdin design in
corrective procedures in patients with a significant PASA. The Reverdin procedure is also part of the “double” osteotomy or Logroscino
approach to hallux
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valgus correction (Fig. 23 ). The Logroscino approach is classically described as a proximal rotational osteotomy in conjunction with a
Reverdin procedure at the metatarsal head (47 ). Theoretically, any proximal rotational osteotomies of the first metatarsal, that is, a base
wedge osteotomy or a crescentic osteotomy, tend to increase a true PASA deviation as the metatarsal rotates laterally. The practical
significance of this finding appears to be of little importance in most patients. However, in some patients, realignment of the articular
cartilage through a Reverdin type of procedure may provide an adjunct to correction. Mahan stated that his preference in the order of
procedures was to perform the proximal osteotomy first, to evaluate the alignment of the hallux better before the distal procedure (47 ),
although the opposite approach may prove equally valid.
FIG. 21. Reverdin-Green modification. A: Medial view of the Green modification of the Reverdin osteotomy with a plantar shelf
designed to protect the sesamoids. B: Dorsal view.
FIG. 22. Three-month follow-up after a Reverdin-Green-Laird procedure with cancellous screw fixation. The Green modification
makes this an inherently stable osteotomy.
FIG. 23. Preoperative (A) and postoperative (B) radiographs of a Reverdin bunionectomy in conjunction with a closing base wedge
osteotomy.
MITCHELL BUNIONECTOMY
This procedure was described by two earlier authors (48 ,49 ), yet in 1952, after Mitchell and colleagues reported on the results of more
than 400 such osteotomies, the procedure started to bear his name (50 ). This technique involves a distal metaphyseal osteotomy with the
removal of a rectangular block of bone and preservation of a lateral cortical “spur” of bone. The width of the lateral bone spur depended
on the degree of metatarsus primus varus. Mitchell et al. recommended a range from one-sixth to one-third of the metatarsal width
corresponding to the amount of correction required. As the metatarsal was transposed, the lateral spur of bone would overhang the lateral
cortex of the metatarsal shaft (Figs. 24 and 25 ). Mitchell et al. advocated a dorsal suture through drill holes to secure the osteotomy site
and allowed weight bearing in a walking cast for the first 4 weeks. In the initial results, a secondary metatarsalgia was noted and was
attributed to a lack of plantar displacement of the capital fragment, rather than to shortening of the metatarsal. Mitchell et al. supported
their conclusions by quoting Harris and Beath, who stated that “a short first metatarsal
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seldom, if ever, is the cause of foot disability” (51 ). Mitchell et al. did note, however, that when the amount of metatarsal shortening was
greater than or equal to 6.2 mm, the presence of transfer metatarsalgia became significant.
FIG. 24. A,B: The Mitchell osteotomy.
FIG. 25. Preoperative (A) and postoperative (B) radiographs of a Mitchell osteotomy with Kirschner wire fixation. Note the shortening
that results in the metatarsal. (Courtesy of Gerard V. Yu, D.P.M.)
Additional authors also shared their experiences with this osteotomy (52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 ), and most of them reported
similar findings of postoperative transfer metatarsalgia. These investigators attributed this finding to the shortening inherent within the
design of the procedure as well as the instability of suture fixation techniques. They also cautioned against using this
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osteotomy in a patient with a short first metatarsal or one of normal length. Additional complications described included restriction of
motion and recurrence of deformity (60 ).
FIG. 26. The Roux modification of the Mitchell osteotomy that also corrects for a proximal articular set angle deviation. A: Diagram
illustrating this osteotomy. B: Intraoperative photograph showing the different cuts for both shortening and angulation correction of
the capital fragment. (Courtesy of Gerard V. Yu, D.P.M.)
The fixation for the Mitchell osteotomy has also been modified to provide more predictable healing for this inherently unstable construct.
Various techniques that have been described include an oblique 1-mm K-wire (61 ), an oblique Steinmann pin (62 ), two crossing 0.062-
inch K-wires (63 ), pneumatically driven staples (64 ), and a Herbert bone screw (52 ).
Other modifications have been described as well. Wu recommended an oblique orientation in the sagittal plane of the osteotomy to
increase the surface area of bone contact and to minimize the chance of dorsal angulation (65 ). The osteotomy extended from dorsal
distal to slightly plantar lateral. Plantar transposition of the capital fragment compensated for the shortening of the first metatarsal,
which averaged 4.9 mm. In selecting 100 patients for follow-up, Wu found 85% with good to excellent results (65 ). Weiner et al. proposed
resection of a trapezoidal wedge of bone with the medial border shorter than the lateral border (66 ). The purpose was to minimize the
shortening seen along the medial edge of the bone. Fixation was also employed with a K-wire. These simple changes increased the good to
excellent results in this study to 91%. Roux presented a variation on the distal osteotomy to account for an abnormal PASA (67 ). The
wedge that was resected was trapezoidal, but it had a wider medial border, which provided correction of an abnormal PASA once the
capital fragment was transposed (Fig. 26 ).
FIG. 27. Postoperative radiographs of a Mitchell bunionectomy with Herbert bone screw fixation. Anteroposterior (A) and lateral (B)
views are shown. (Courtesy of Gerard V. Yu, D.P.M.)
Current indications for the Mitchell bunionectomy include a mild to moderate hallux abducto valgus deformity with a normal to long first
metatarsal. Shortening accomplished by the Mitchell procedure is predictable and is easier to perform than with other distal procedures.
Plantarflexion of the capital fragment is also considered. Stable internal fixation consistently minimizes unwanted movement of the
osteotomy during the healing period (Fig. 27 ). Non-weight bearing is typically employed until healing has occurred, to prevent
displacement of the osteotomy.
HOHMANN BUNIONECTOMY
Hohmann first described his osteotomy technique in 1921 (68 ). The procedure was executed at the neck of the first metatarsal and
consisted of the removal of a medial wedge of bone, to realign the hallux in a more rectus position. The capital fragment was also
transposed laterally. This concept is similar to a Reverdin type of osteotomy, yet with sectioning of the lateral cortical hinge and
subsequent lateral transposition of the metatarsal head. Because the procedure is performed at the surgical neck of the first metatarsal,
any potential for sesamoid irritation is avoided (Figs. 28 and 29 ).
The procedure was modified to accommodate screw fixation by angulating the osteotomy from distal medial to proximal lateral within the
transverse plane (69 ). Plantar transposition was also recommended. Doing so resulted in an average reduction in the hallux abductus angle
of 8.7 degrees
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and a reduction in the IM angle of 4.8 degrees. The average amount of shortening was seen at 4.1 mm.
FIG. 28. A,B: The Hohmann osteotomy.
Several authors have reported long-term studies of the Hohmann procedure. Christensen and Hansen presented a 52-month average follow-
up in 159 patients who underwent a modified Hohmann technique (70 ). The dissection, osteotomy, and fixation were usually performed
without entering the joint capsule. The postoperative IM angle was 1 degree larger than the preoperative measurement. Although the
hallux abductus angle reduced 10 degrees on the average, the postoperative hallux abductus angle still measured 21.4 degrees. Other
investigators have noted a high incidence of recurrence (71 ). If the hallux is not realigned into a rectus position at the time of the surgical
procedure, then the flexor structures will remain in a laterally deviated position and will tend to perpetuate the deformity. Because the
procedure is performed in an extraarticular manner, this complication may be common unless additional measures are performed at the
joint level.
FIG. 29. Example of a Hohmann bunionectomy. A: Osteotomy and wedge performed at the level of the metatarsal neck before wedge
removal and lateral transposition. B: Immediate postoperative radiograph of the correction. There is suture fixation of the osteotomy
site. C: Two-year follow-up anteroposterior radiograph showing significant shortening as well as callus formation. D: Lateral
radiograph also showing elevation and bone callus at the osteotomy site.
WILSON BUNIONECTOMY
In 1963, Wilson described an oblique osteotomy of the distal first metatarsal for addressing hallux abducto valgus deformity (72 ). The
osteotomy was oriented perpendicular to the sagittal plane and 45 degrees to the transverse plane
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of the metatarsal in a distal medial to proximal lateral direction (Fig. 30 ). Accordingly, the metatarsal shortened with lateral transposition.
The capsule of the joint was rarely opened, and the osteotomy essentially remained extraarticular. Fixation was recommended with a
suture technique to anchor the medial capsule to the medial metatarsal shaft. The hallux was bandaged in 5 degrees of varus. Because of
the inherent instability of the osteotomy design, metatarsal malposition in both the sagittal and transverse planes was a frequent
occurrence. The shortening and elevation of the capital fragment resulted in significant lesser metatarsalgia.
FIG. 30. A,B: The Wilson osteotomy.
Several modifications to the original technique deserve mention. Helal oriented the osteotomy 45 degrees from the sagittal plane, from
dorsal distal to plantar proximal (73 ). This change was believed to prevent dorsiflexion of the capital fragment. A secondary benefit was
the ability to plantarflex the metatarsal head during translocation in hopes of overcoming some of the adverse effects from excess
shortening of the metatarsal. Other authors advocated plantar manipulation of the metatarsal head to overcome this problem (74 ,75 ).
However, not until later were rigid internal fixation techniques recommended to stabilize the procedure (76 ). The addition of rigid
internal fixation significantly reduced the possibility of positional loss during healing of the osteotomy. Removal of a medially based wedge
of bone was also performed in patients who had abnormal PASAs. In one study, good stabilization was achieved with a 3.5-mm cancellous
screw technique from dorsal medial proximal to plantar lateral distal (77 ). In 115 feet with a 10-year follow-up, 80% of patients reported
good to excellent results with minimal problems related to the position of the metatarsal head. In addition, crossed K-wire fixation has
been shown to reduce the amount of shortening by 50% when compared with a single K-wire or no fixation (78 ).
Most of the original authors advocated forefoot plaster casting for a 6- to 8-week period to ensure proper healing, although a later study
suggested no significant difference on functional outcome with either a 3-week or a 6-week course of plaster casting (79 ). Even with the
addition of rigid screw fixation, other authors still recommend cast immobilization for their patients for a 4-week period (80 ).
Shortening of the first metatarsal and lesser metatarsalgia have been the main complications reported with this technique. Schemitsch and
Horne reported a 20% to 25% occurrence of secondary metatarsalgia and concluded that if the preoperative length of the metatarsal was
less than 82% of the length of the second metatarsal, then the chance of secondary metatarsalgia was increased to 50% (81 ). Grace found
the average shortening with a Wilson osteotomy to be 7.3 mm (82 ). Another report noted that when when the first metatarsal was
shortened more that 6 mm, the hallux lost its purchase power (77 ). Because of these reports, a straight lateral transverse osteotomy was
proposed to minimize shortening of the metatarsal (83 ). In addition, the metatarsal was displaced plantarly to enhance weight bearing,
and crossed 0.062-inch K-wire fixation was employed for stability. Later, using screw fixation, surgeons began to see more predictable
postoperative results that often correlated with increased patient satisfaction.
Another consistent finding with this procedure has been recurrence of the deformity or loss of correction. As noted previously, early
authors avoided entering the capsule, and most did not perform a lateral release. One of the main reasons was their fear of potential
avascular necrosis with overzealous dissection of the joint capsule. Schemitsch and Horne reported that one-third of their postoperative
patients still showed hallux abutment against the second toe (81 ). Pouliart et al. also showed a significant recurrence of the deformity
when evaluating their patients 2 years postoperatively versus at 2 to 3 months postoperatively (78 ). If lateral contractures are maintained
within the joint complex in conjunction with a lateral position of the sesamoid complex, then continued retrograde buckling is present,
and the recurrence of the deformity is far more likely.
COMPARATIVE STUDIES
Several comparative studies have been published that compare radiographic and clinical findings among different distal metaphyseal
osteotomies. However, evaluating these studies is difficult because of the different technique employed for each procedure by various
surgeons, variations in postoperative care, and a lack of standardized criteria for evaluation. Nonetheless, several are presented here for
the basis of discussion.
Grace et al. compared patients who had undergone both the Wilson and Hohmann procedures and found no subjective differences between
the patient groups (84 ). Both these procedures were performed as originally described, except the Hohmann osteotomy was fixed with a
K-wire. Using pedobarograph studies, the patterns for toe contact times were identical, with more excessive lateral loading noted for the
Wilson group. Patients undergoing the Hohmann procedure
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demonstrated significant radiographic changes of the metatarsophalangeal joint, and this was attributed to the proximity of the osteotomy
to the joint space. These investigators also found a direct correlation of the patient's age with this occurrence and cautioned against the
use of the Hohmann procedure in older age groups. Overall, the satisfaction rate with both these osteotomies was found to be 77% and was
almost identical in each group.
Seven popular types of hallux valgus procedures were compared in another study (82 ), five of which were distal metaphyseal osteotomies
and two involved the proximal metatarsal. Several parameters were evaluated, including incidence of nonunion, incidence of avascular
necrosis, average shortening of the first metatarsal, technical difficulty, and satisfactory results. The incidence of avascular necrosis and
of nonunion was negligible in all groups, and the greatest amount of shortening was found to be 7.3 mm with the Wilson procedure. A
review of literature revealed the satisfaction with all techniques to be in the upper 80% level and higher. Overall, only 10% of all bunions
were actually congruous, so most feet required soft tissue realignment. Therefore, it was believed the chevron, Mitchell, and Wilson
approaches were the most practical.
Klosok et al. evaluated and compared the results of the chevron procedure with those of the Wilson bunionectomy (85 ). Both operations
were performed without internal fixation, with an average follow-up of 38 months. The average shortening noted in the Wilson group was
10 mm compared with 6 mm in the Austin group. This finding did not correlate directly with postoperative metatarsalgia because plantar
displacement was more readily available with the double Wilson osteotomy technique. Because of this design, only five patients
complained of transfer metatarsalgia versus ten for the Austin group. The Wilson group also showed a better maintenance of the reduced
hallux abductus angle correction at long-term follow-up.
The Austin and Mitchell osteotomies were compared in another series of patients (57 ). Patients undergoing the Mitchell procedure
demonstrated a better correction of the IM angle by almost 3 degrees, whereas there was a tendency for the chevron to lose IM angle
correction during the healing period. The authors attributed this difference to lack of fixation at the osteotomy site. Metatarsal shortening
was found to be 3 to 4 mm and was equivalent in both groups. Although patient satisfaction was generally considered acceptable and
similar in both groups, 40% of patients reported some degree of transfer metatarsalgia to the central rays. These investigators stressed the
importance of load-bearing considerations in procedural selection in all hallux valgus surgery.
In a retrospective review of the literature regarding the Austin, Mitchell, and Wilson-type bunionectomies, Loretz et al. noted largely
excellent to good results in the majority of cases (46 ). A direct comparison was difficult to make because no standardized criteria were
available to compare results of treatment. There were 542 Austin procedures performed, resulting in 73% to 97% good to excellent results.
The findings were similar for the Mitchell and Wilson bunionectomies, yet the incidence of displacement or angulation and metatarsalgia
was higher with these two procedures than with the Austin procedure. Delayed and nonunions occurred after the Mitchell and Wilson
procedures, with a 0% incidence in the Austin population.
POSTOPERATIVE MANAGEMENT
Management of the distal osteotomies for hallux abducto valgus repair is dictated by the inherent stability of the individual osteotomy
design. Dressings used at the time of the surgery and on subsequent postoperative visits can be applied to supply corrective forces on the
realigned first metatarsophalangeal joint, such as derotation, plantarflexion, and adduction. Additional mild compression can help to
reduce postsurgical swelling.
Most often, patients are allowed to begin weight bearing from the first day postoperatively with a surgical shoe if the osteotomy design
and fixation allow. Postoperative radiographs are obtained at intervals to evaluate healing and the maintenance of correction. Once
dressings are removed, splintage may be employed to maintain the hallux in a rectus alignment for an additional period while the soft
tissues continue to remodel. Range-of-motion exercises may be helpful in reducing periarticular scarring, which may lead to subsequent
loss of mobility. In procedures that are inherently unstable, non-weight bearing is typically employed for the first 6 to 8 weeks.
COMPLICATIONS
Avascular Necrosis
The literature contains extensive discussion of this issue, with specific emphasis on distal first metatarsal osteotomies. The incidence of
avascular necrosis that has been reported has varied greatly. The variability may be attributed in part to the various radiographic and
clinical findings that are thought to represent the process. These findings include degenerative arthrosis, hallux limitus, subchondral cysts,
and changes in radiodensity (86 , 87 , 88 , 89 , 90 , 91 , 92 , 93 ). However, Banks described how each of these findings could be just as
easily and more logically explained by other events that do not involve disruption of the blood supply, including hyperemia, which would
be anticipated to follow any osteotomy, decortication of bone after bunionectomy, the changes in mechanical forces about the first
metatarsophalangeal joint after repair of the hallux abducto valgus deformity, thermal damage created during the osteotomy, and hallux
limitus (94 ). Other investigators noted that these findings could all be accounted for in other ways, including unstable fixation, bone
compaction with subsequent sclerosis, and remodeling of the metatarsal head (90 ). Most studies failed to describe the preoperative
appearance of the first metatarsal head, so there is a
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lack of sequential evaluation that would be anticipated in assessing patients for this condition. In the one study in which preoperative
radiographic assessment was incorporated into the assessment, the authors concluded that the findings noted postoperatively—irregular
subchondral margins, small cysts, and asymmetric joint narrowing—were all present preoperatively. Even though more recent studies have
noted some of these radiographic changes in patients at follow-up, these changes are now believed to be benign (88 ,90 ,93 ,95 ).
Magnetic resonance imaging studies would have appeared to be a good means of assessing potential avascular necrosis after capital
osteotomies, but they have failed to provide sufficient evidence. In two initial studies, magnetic resonance imaging findings in patients
evaluated after Austin osteotomies were believed to be representative of avascular necrosis (88 ,96 ). However, the criteria used for
evaluation could have also been related to hemorrhage, edema, and inflammation of the osteotomy (91 ,94 ). A subsequent study
employing gadolinium-enhanced magnetic resonance imaging demonstrated that the first metatarsal head was well perfused despite the
presence of cysts (97 ). Preoperative scans were not performed in any of these studies; therefore, it is entirely possible cystic change could
have preceded the surgical procedure.
Historically, investigators suggested that the soft tissue dissection required to perform the Austin procedure or the osteotomy itself
rendered the metatarsal head more susceptible to avascular necrosis, particularly if interspace dissection was performed. However,
anatomic studies have demonstrated that the adductor hallucis tendon is not immediately adjacent to the primary vascular structures of
the first metatarsal head (90 ,93 ,98 ) Jones et al. mapped the blood supply to the first metatarsal head and recommended “safe zones”
within the metatarsophalangeal joint complex for the distal osteotomy and the lateral release (98 ).
FIG. 31. Radiographs of a patient preoperatively (A) and immediately after (B) an Austin osteotomy with Kirschner wire fixation. C:
Three weeks later, note the mild medial rotation of the capital fragment.
Christenson and Jones presented a unique case in which the capital fragment was completely dissected free and actually fell onto the floor
(99 ). After antibiotic treatment for the fragment, the head was placed back onto the metatarsal shaft and was fixed with a K-wire. No
evidence of avascular necrosis or infection was noted with up to 20 months of postoperative follow-up.
In summary, avascular necrosis of the first metatarsal head may develop in rare circumstances in patients undergoing distal osteotomies.
However, the incidence has been overstated, in large measure because of the differences in interpretation of radiographic and imaging
findings and an underappreciation of local anatomy and other factors.
Sagittal and Transverse Plane Deviations

Hallux varus may result after any procedure for the repair of hallux abducto valgus. However, of interest is the reverse
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Austin procedure that has been employed to address this condition. This is the same osteotomy as previously described, but it involves a
medial translocation of the capital fragment in an attempt to increase the IM angle. Multiple modifications have also been recommended
for the “reverse” procedure (100 ,101 ).
Aggressive plantarflexion of the capital fragment can result in pain or keratosis under the first metatarsal head. When mobility of the first
metatarsocuneiform joint is adequate, compensation in the sagittal plane for a plantarflexed capital fragment is possible, but this is
limited and in some patients may eventually create arthrosis in this joint. Hallux extensus may also occur because the change in the
structure of the first metatarsal favors the extensor tendons such that they may overpower the plantar structures. Hallux extensus may
also result if there is excessive shortening of the first metatarsal shortening or dorsal joint adhesions.
FIG. 32. A: Radiograph of a patient immediately after an Austin osteotomy. B,C: Two weeks postoperatively, with an impaction
fracture of the first metatarsal head. The patient was non-weight bearing, and the osteotomy healed, although in a shortened
position. D,E: Radiographs at 9 weeks postoperatively.
Limitation of Joint Motion

Postoperative limitation of joint motion can be found with any surgery around a joint. Weight-bearing joints also have a tendency to
develop a greater degree of edema, which can also increase the amount of scar tissue around the joint capsule. Preservation of the dorsal
and plantar synovial folds during soft tissue dissection and range-of-motion exercises in the postoperative setting may enhance the amount
of motion available.
Patients with significant limitation of motion in the postoperative period can be placed into an aggressive physical therapy regimen.
Anesthetic blocks about the joint may be helpful to disrupt adhesions surrounding the joint capsule. Once the motion is recaptured, the
patient is encouraged to maintain this range of motion by continuing home exercises daily. In some patients, external splintage or motion
devices may also be employed with success.
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FIG. 32. Continued.
Displacement of the Osteotomy

Despite the use of fixation for the distal osteotomies, one may on occasion witness some displacement of the surgical site. When this is
evident, it most often consists of a rotational change in the alignment of the capital segment. In some instances, this complication may be
due to collapse of an underlying segment of bone, typically on the proximal side of the osteotomy. If the problem is noted early and is
believed to be significant, then relocation may be considered. However, if significant time has elapsed since the operation, it may be
preferable to allow for osseous healing and consolidation before one attempts relocation through a revisional osteotomy (Fig. 31 ).
In some patients, the capital fragment has become impacted into the proximal segment of the osteotomy (Fig. 32 ). Provided the joint
alignment is satisfactory, it may be best to allow the metatarsal to heal, then to lengthen the bone. Alternatively, an immediate reduction
could be performed, but grafting would likely be required and maintaining the correction may prove difficult.
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Chapter 8
Proximal Procedures of the First Ray
PART 1 Osteotomies of the First Metatarsal Base

Robb A. Mothershed
Metatarsus primus adductus, or an increase of the first intermetatarsal angle, has long been recognized as a major contributing
factor in the deformity of hallux abducto valgus. This component of hallux abducto valgus has been addressed by proximal
osteotomies for decades. A transverse plane osteotomy of the first metatarsal base for the repair of hallux abducto valgus
deformity was first described in 1901 by Loison (1 ), and it was performed in 1903 by Balacescu (2 ). However, not until the late
1960s and early 1970s did the base wedge osteotomy became popular and widely used. Over the intervening years, this
particular procedure has been performed with less frequency because of several factors. First, certain complications were
believed to be inherent to the procedure, including first metatarsal elevatus, shortening of the metatarsal, failure of the
fixation, and delayed union (3 , 4 , 5 , 6 , 7 ). However, surgeons subsequently began to appreciate that most of these problems
resulted from surgical technique, inadequate fixation, and insufficient postoperative protection, as opposed to a deficiency of
the procedure itself. The perceived complications associated with the closing base wedge osteotomy also led surgeons to
consider other forms of proximal osteotomies such as the crescentic and chevron configurations. In addition, other surgeons
have employed more distal procedures for the correction of hallux abducto valgus deformity such as the Austin or Scarf
osteotomies whenever possible. These latter procedures may prove technically easier to perform, and the patient can remain
weight bearing during the postoperative period. However, the proximal osteotomies still are effective, particularly in patients
with severe deformities and in patients with high intermetatarsal angles. The technical advances in surgical technique, rigid
internal fixation, and the institution of a non-weight-bearing interval in the postoperative recovery have demonstrated that
these procedures can provide consistently good results.
INDICATIONS
Large Intermetatarsal Angles

The traditional indication for a transverse plane base osteotomy of the first metatarsal was a hallux abducto valgus deformity
with a high intermetatarsal angle, typically exceeding 15 degrees. This is still a reasonable criterion for employing this type of
procedure, although in some instances adequate correction of severe deformities can be accomplished with other approaches as
well.
The base wedge procedure may be more effective in reducing a high intermetatarsal angle than a distal procedure, particularly
in rigid deformities, because of the geometric principles of placement of the osteotomy (8 ). The oblique orientation of the base
wedge osteotomy is angled from proximal-medial to distal-lateral. This design allows the axis and hinge of the osteotomy to be
placed in close proximity to the base of the first metatarsal. The effect creates the longest distance possible between the hinge
and the distal end of the bone while keeping the osteotomy within the first metatarsal. This distance is the radius arm. A longer
radius arm creates greater lateral movement at the end of the arm for each degree of rotation around the arc of the circle.
Therefore, the base wedge osteotomy allows greater lateral movement of the head of the metatarsal for every degree of wedge
resected and thereby provides a more effective procedure.
In addition, the more proximal the apex of the osteotomy,

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the more lateral is the axis of rotation in relation to the position of the second metatarsal. Therefore, a more proximal hinge
provides a more lateral overall position of the first metatarsal head once the distal segment has been reduced into a parallel
relationship with the second metatarsal. In effect, the more proximal hinge allows the first metatarsal head to come closer to
the second metatarsal without creating a negative intermetatarsal angle in the distal segment of the bone (8 ).
The crescentic osteotomy also offers a more proximal location for rotation of the metatarsal. Although the proximal chevron
procedure is typically transposed, it may also be rotated to enhance the reduction of the intermetatarsal angle. In each instance,
more effective correction of large intermetatarsal angles may be obtained as compared with distal osteotomies.
Rigid First Ray

Flexibility of the first ray is an important factor to consider when evaluating the patient with hallux abducto valgus deformity.
The success of a distal metatarsal osteotomy in the repair of hallux abducto valgus deformity associated with high
intermetatarsal angles requires good transverse plane flexibility. This feature may be evaluated preoperatively by assessing the
sagittal plane mobility of the first ray. If the first ray demonstrates good mobility in the sagittal plane, then it will almost
always have good mobility in the transverse plane as well. In addition, one may assess the flexibility by applying medial to
lateral compression to the first metatarsal head. However, if the sesamoids are significantly displaced within the first
intermetatarsal space, then lateral shift of the metatarsal head may be difficult to accomplish.
FIG. 1. A: Preoperative radiograph of a patient with severe hallux abducto valgus and a rigid first ray secondary to the
articular relationship of the first and second metatarsal bases. B: Postoperative appearance 15 months after a closing base
wedge osteotomy and fibular sesamoidectomy.
Radiographic evaluation may also render helpful information. Some patients may actually have an enlarged articular facet
between the metatarsal bases and a rudimentary os intermetatarsia, both of which are typically associated with less mobility of
the first ray (Fig. 1 ). When distal osteotomies are employed for the correction of greater degrees of hallux abducto valgus
deformity, the correction is accomplished by a combination of the release of soft tissue tension about the first metatarsal
phalangeal joint and the translocation of the metatarsal head. If a distal osteotomy is performed in a rigid deformity, then the
release of the soft tissues at the first metatarsophalangeal joint will generally result in little if any ability to reduce the
intermetatarsal splay significantly. As such, it becomes more difficult to achieve a desirable permanent correction with a distal
procedure. Therefore, a proximal osteotomy may be appropriate for correction of the hallux abducto valgus deformity in
patients with reduced mobility of the first ray with only moderate amounts of intermetatarsal splay.
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Sagittal Plane Abnormalities of the First Ray

Proximal osteotomies may also be helpful in addressing significant sagittal plane deformity or disease in patients with hallux
abducto valgus deformity. The presence of a callus or pain plantar to the second metatarsal head generally indicates a
hypermobile first ray, and patients may benefit from simultaneous plantarflexion of the metatarsal with reduction of the
intermetatarsal angle. Proximal osteotomies are well suited to correction of this type of combined deformity.
An abnormally large sagittal plane deviation of the metatarsal can be more effectively corrected with an osteotomy of the first
metatarsal base. An elevated first metatarsal may be effectively addressed at the base of the metatarsal because there will be
more effective plantarflexion of the metatarsal as the resection of a small amount of bone wedge at the base translates into a
larger amount of plantar deflection of the metatarsal when compared with resection of a distal wedge of bone. If a similar
amount of plantarflexion could be achieved with a distal metatarsal osteotomy, it would more abruptly change the vectors of
the flexor and extensor tendons crossing the joint. This change in vectors would potentially have a greater disruption of the
muscular balance of the first metatarsal phalangeal joint, which could lead to a nonpurchasing or cock-up hallux.
FIG. 2. A: A preoperative radiograph of a patient with hallux valgus deformity with concomitant metatarsus adductus. B: A
closing base wedge osteotomy was performed to reduce the first intermetatarsal space.
Hallux Abducto Valgus with Metatarsus Adductus

Some investigators have described the association of hallux abducto valgus with metatarsus adductus. LaReaux and Lee found
that 35% of their patients with hallux abducto valgus had a metatarsus adductus deformity, compared with only 13% in a control
group (9 ). Measurements of radiographs in 115 feet without evidence of hallux abducto valgus demonstrated a statistically
significant and direct relationship between an increasing metatarsus adductus angle and an increasing hallux abductus angle
(10 ). Banks et al. noted, in their series of patients with juvenile hallux abducto valgus, that 48 of the 72 cases had a metatarsus
adductus angle greater than 15 degrees (11 ). Furthermore, an association was noted between an increasing metatarsus
adductus angle and increasing amounts of hallux abductus.
The initial radiographic evaluation of hallux abducto valgus in patients with a concomitant metatarsus adductus is often
misleading. Significant abduction of the hallux may be noted, yet with little intermetatarsal splay (Fig. 2 ). However, one must
consider that the generalized adductus of the forefoot results in a greater functional value of the intermetatarsal angle. In this
situation, the true intermetatarsal angle may best be estimated by the following formula (12 ):
True intermetatarsal angle = (Metatarsus adductus angle − 15 degrees) + Intermetatarsal angle

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This formula provides a better determination of the actual intermetatarsal angle being treated.
When repairing a hallux abducto valgus deformity in a patient with metatarsus adductus, the surgeon should reduce the
intermetatarsal angle to 0 degrees or a slightly negative value to minimize the chance of recurrence of hallux abducto valgus
(12 ). Despite excellent correction, the hallux may not remain perfectly rectus, but it may resume a slightly abducted alignment
postoperatively. The longer radius for correction with a proximal osteotomy is well suited to achieve the degree of correction
that is desirable.
Juvenile Hallux Abducto Valgus Deformity

The development of a hallux abducto valgus deformity in young patients represents significant deforming forces acting on the
foot. Patients with juvenile hallux abducto valgus often present with other significant deformities. Banks et al. found that 66.7%
of their patients with juvenile hallux abducto valgus deformity possessed a metatarsus adductus angle greater than 15 degrees
(11 ). Pes valgus deformity and ankle equinus have also been associated with juvenile hallux abducto valgus (12 , 13 , 14 , 15 ).
In the younger patient, correction of hallux abducto valgus deformity must be maintained over decades. Studies have shown
that the incidence of recurrence of the deformity is higher in young patients undergoing a soft tissue procedure or distal
osteotomy (16 , 17 , 18 ). The intermetatarsal angle in juvenile and adolescent patients is best reduced to 0 degrees or closely
approximating that value to minimize the possibility of recurrence. In most patients, this goal can be more effectively
accomplished with a proximal osteotomy.
FIG. 3. A: Preoperative radiograph of a patient after a simple Silver bunionectomy with narrowing of the metatarsal head.
This may preclude the use of a capital osteotomy for subsequent repair. B: Radiograph after a closing base wedge
osteotomy.
Iatrogenic Deformities
Correction of a recurrent hallux abducto valgus deformity often represents a difficult challenge. The metatarsal head is typically
narrowed from the previous surgical procedure, and this configuration may make the use of a capital osteotomy difficult for the
degree of correction required (Fig. 3 ). Furthermore, the presence of any retained fixation devices may compromise the
integrity of the bone, so additional osteotomies at this level may pose more of a risk relative to fixation. In these instances, a
proximal osteotomy may prove the best alternative, even if the intermetatarsal angle is low.
ANATOMIC CONSIDERATIONS
The choice of incisions for proximal osteotomies has been debated, but an effective incision may be placed dorsally
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along the first ray slightly medial to the extensor hallucis longus tendon. The incision commences proximal to the first
metatarsocuneiform joint and extends distally to the proximal phalanx. Typically, the distal segment of the incision is initiated
and the metatarsophalangeal joint is released, and then the incision is extended proximally to provide access for the osteotomy
(Fig. 4 ). The single-incision approach has been employed for decades without deleterious sequelae (8 ).
FIG. 4. Once the first metatarsophalangeal joint dissection has been accomplished, the skin incision is extended proximally
for execution of the base osteotomy.
Once the skin incision is completed, dissection is carried through the relatively thin subcutaneous tissues. The previously
defined tissue planes may be followed from the more distal aspect of the wound into the proximal metatarsal area. At the
proximal aspect of the incision, one typically encounters a branch of the medial dorsal cutaneous nerve. This nerve is easily
retracted into the medial subcutaneous tissues. Once the superficial fascia has been cleared from the deeper structures, the
deep fascia is incised along the medial aspect of the extensor hallucis longus tendon. This provides for effective retraction of
the tendon and better exposure of the base and shaft of the metatarsal. The periosteum is then incised and reflected from the
base of the metatarsal. Additional dissection of this layer may be required both medially and laterally to allow satisfactory
clearance for the saw blade during the performance of the osteotomy as well as the insertion of internal fixation.
FIG. 5. The transverse closing base wedge osteotomy.
TECHNIQUES
Closing Base Wedge Osteotomy

The closing wedge osteotomy has been the standard technique for base procedures for many years. Traditionally, the procedure
was performed in a transverse orientation, and fixation was provided by Kirschner wires (K-wires), intraosseous wire loops, or
other methods (Fig. 5 ). The transverse wedge osteotomy was modified to an oblique orientation to accommodate screw fixation
(8 ) (Fig. 6 ). In addition, the oblique orientation allows the surgeon to place the apex of the osteotomy further proximally, thus
providing a longer radius arm for correction. More freedom was obtained in
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maneuvering the oscillating saw for performance of the procedure. With this technique, the handle of the saw is directed
medially away from the foot and is free from the interference and contact of the foot itself. Therefore, the surgeon need not
worry that the saw may be misdirected during the osteotomy.
FIG. 6. The oblique closing base wedge osteotomy.
FIG. 7. Traditional axis of the base wedge osteotomy. If the osteotomy is made perpendicular to the metatarsal,
subsequent lateral displacement of the distal metatarsal will result in sagittal plane dorsiflexion as well. Such may be the
cause of a short first metatarsal.
Regardless of which orientation is employed, the use of an axis guide may facilitate the performance of the osteotomy. The axis
guide also provides an accurate means of assessing and implementing concomitant dorsiflexion or plantarflexion of the distal
metatarsal with closure of the osteotomy. During the base wedge osteotomy of the first metatarsal, an intact cortical hinge acts
as an axis of rotation (8 ). The traditionally perceived axis for a hinged osteotomy of the first metatarsal was perpendicular to
the long axis of the bone. Because of the anatomic declination of the first metatarsal in the human foot, rotation of the distal
segment of the first metatarsal around this axis after a closing base wedge osteotomy would tend to create elevation of the
metatarsal head from the weight-bearing surface (Fig. 7 ). However, designing the osteotomy so the axis is perpendicular to the
weight-bearing surface allows for full rotation of the distal segment of the metatarsal without elevating or plantarflexing the
metatarsal head in relation to the weight-bearing plane (Fig. 8 ).
The previous description of the sagittal plane orientation of the axis is based on the given relationship that the axis is
perpendicular to the transverse plane when viewed in the frontal projection. Logically, manipulation of the axis in the frontal
plane may influence the ultimate position of the metatarsal head in relation to the weight-bearing surface. Manipulation of the
axis in the frontal plane is based on the presumption that the axis remains perpendicular to the weight-bearing surface in the
sagittal plane.
With the axis perpendicular to the weight-bearing surface in the frontal plane, lateral rotation of the distal metatarsal segment
maintains the metatarsal head on the weight-bearing surface (Fig. 9 ). When the superior pole of the axis is tilted laterally, a
dorsomedial hinge is created, and plantarflexion of the distal segment of the metatarsal occurs with lateral rotation or closing
of the wedge osteotomy (Fig. 10 ). Conversely, when the superior pole of the axis is tilted medially, a plantar medial hinge is
created, and dorsiflexion of the distal segment occurs with closing of the wedge osteotomy (Fig. 11 ).
FIG. 8. If the osteotomy is made perpendicular to the weight-bearing surface, then lateral displacement of the distal
metatarsal will not dorsiflex or plantarflex the metatarsal head, and it should remain parallel with the weight-bearing
surface.
The concept of the axis relationship just described may be directly applied to the actual execution of the closing base wedge
osteotomy of the first metatarsal. A 0.045-inch K-wire
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can be drilled through the base of the first metatarsal to represent the functional hinge of the intended osteotomy. The K-wire
should penetrate the dorsal cortex just short of the apex of the intended osteotomy, to allow for additional feathering of the
hinge. The wire is then drilled to penetrate the metatarsal at the appropriate angle, which affects manipulation of the distal
metatarsal as required for each individual case.
FIG. 9. Proper frontal plane orientation must be observed as well. Same perpendicular relationship of the axis is essential
if the distal segment is to remain on the weight-bearing surface after closure of the osteotomy.
FIG. 10. Altering the position of the axis may be used to the surgeon's advantage. If the axis is tilted laterally, then a
dorsomedial hinge is created. When the osteotomy is closed, plantarflexion of distal segment occurs.
With the K-wire in place, the relationship of the axis with the weight-bearing surface is evaluated from a medial and frontal
perspective. The position of the axis may easily be changed before the osteotomy by simply removing and reinserting the K-wire.
The wedge osteotomy is then cut by keeping the plane of the saw blade in line with the axis guide so the planes of the two cuts
converge at the K-wire. The medial cortex of the metatarsal remains intact as a physical hinge that coincides with the axis and
planes of the intersecting wedge osteotomies. The osteotomy may be feathered to create a flexible yet intact hinge that bends
but does not fracture with manual reduction. Christensen et al. showed that the intact medial hinge provides stability to the
osteotomy and functions as another point of fixation (19 ). If the hinge fractures, the stability of the osteotomy will be reduced,
and fixation may prove more difficult.
FIG. 11. Should dorsiflexion of the distal segment be necessary, then the axis should be tilted medially.
Various forms of fixation have been employed with the closing base wedge osteotomy, and studies have been conducted in an
attempt to determine which form of fixation is more stable (20 ,21 ). An important factor for a successful closing base wedge
osteotomy is the presence of two points of fixation. An intact medial cortical hinge may be considered one point of fixation. The
transverse wedge osteotomy is more commonly stabilized with crossed K-wires or cerclage wire. Evidence seems to indicate that
when a K-wire is used, the osteotomy is more stable if the wire crosses the metatarsal-cuneiform joint (21 ). Cerclage wire
appears to provide the most stability when it is applied at the plantar aspect of the metatarsal, such that it prevents disruption
by the weight-bearing forces (20 ).
Although K-wires and cerclage wire are commonly used for fixation, the technique I favor is the use of two 4.0-mm partially
threaded cancellous screws to secure the osteotomy. This has provided effective fixation and a high rate of success. The first
screw is placed distal to the medial hinge and is oriented perpendicular to the metatarsal. The second screw is positioned distal
to the first and is oriented perpendicular to the osteotomy (Fig. 12 ). Alternatively, crossed-screw fixation of the base wedge
has been described, with favorable results (22 ). The cancellous screws are employed more often because they provide rigid
fixation of the osteotomy, regardless of the integrity of the bone. However, provided non-weight-bearing is instituted after
surgery, both crossed 0.062 K-wires and a single screw may provide good results that are comparable (23 ). Cortical bone screws
also provide good stabilization.
The closing base wedge osteotomy has always been an effective means of reducing the intermetatarsal angle, although early
reviews noted that shortening of the first metatarsal was a common occurrence after a transverse base wedge osteotomy (3 , 4 ,
5 , 6 , 7 ). As a consequence, metatarsalgia, painful plantar callosities, and stress fractures of the lesser metatarsals developed
in some patients. However, the base wedge osteotomy was not totally abandoned because it provided a much needed
alternative in patients with severe deformities with high intermetatarsal angles. A few workers persisted in the investigation of
the procedure (24 ), and the technical aspects were further advanced by the application of rigid internal fixation across
angulated osteotomies. However, elevation of the first metatarsal continued to develop even with the use of the new fixation
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techniques. Although some authors proposed that the change in metatarsal declination was related to the removal of excessive
amounts of bone from the dorsal aspect of the osteotomy (6 ), Schuberth et al. attributed this phenomenon to weight bearing in
the postoperative period before osseous healing had occurred, as opposed to its being a primary complication of the procedure
itself (7 ). Furthermore, the radiographic appearance of a shortened metatarsal could largely be explained by the elevation of
the distal fragment, which could be overcome by geometrically correct osteotomy and an appropriate interval of non-weight-
bearing during the healing process (8 ). Later investigators proved that the shortening associated with the oblique base wedge
osteotomy was less than actually perceived. Using both mathematic and bone models, investigators determined that the average
oblique base wedge osteotomy would result in less than 2 mm of shortening, comparable to most other osteotomies (25 ).
Therefore, elevation of the first metatarsal would be a primary means of creating the appearance of a “shortened” metatarsal
on dorsoplantar radiographs. Other investigators noted that early weight bearing in the postoperative period either contributed
to or directly caused failure of the fixation (26 ).
FIG. 12. Two-screw fixation for the oblique closing base wedge osteotomy. A: The anchor screw is oriented perpendicular
to the medial cortex or long axis of first metatarsal. B: Compression screw perpendicular to the plane of the osteotomy. C:
Medial orientation of the two-screw technique. D: Compression and anchor screws.
However, later authors who instituted at least 6 weeks of non-weight bearing after the closing base wedge osteotomy continued
to find evidence of first metatarsal elevatus, although of far less magnitude and with few associated problems (19 ,27 ,28 ).
Nonetheless, patient satisfaction rates were high, and evaluations of the results by the investigators were similar. The problems
of transfer lesions or other symptoms related to the alignment of the first ray were minimal. In one study, 44% of patients
admitted to premature weight bearing on the extremity (28 ). Whether this is a consistent finding in other patient groups or
whether this accounts for the small degree of metatarsal elevation is unknown. In addition, an inconsistency is noted in the
means by which first metatarsal elevation has been measured on radiographs, and
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at times the values could have been affected by the position of the foot. Therefore, it appears that at the current levels of
elevation noted with non-weight bearing in the postoperative setting, this phenomenon is clinically inconsequential. Good
correction can be achieved with restoration of function.
FIG. 13. A,B: The crescentic first metatarsal osteotomy. A notch may be made on each side of the osteotomy before
rotation to help assess the amount of correction achieved.
Crescentic Osteotomy
The crescentic osteotomy is another popular technique for achieving reduction of the intermetatarsal angle at the proximal
aspect of the first metatarsal. This procedure may provide correction of deformity in all three planes (Fig. 13 ). Because no
bone is resected, this procedure theoretically produces little shortening (29 ), so it may be a good alternative in the patient who
has a significantly short first metatarsal. However, the performance of any osteotomy creates some amount of shortening,
typically in the range of 1 to 2 mm. The osteotomy has been modified to include a plantar shelf in an attempt to provide more
stability (30 ).
A special crescentic blade is necessary to perform the procedure. The saw blade is oriented with the concavity directed
proximally, so there is more excursion of the bone segments to allow for correction of the intermetatarsal angle. This also
allows for better bone contact once the osteotomy is rotated (31 ). Cohen et al. and Kay et al. demonstrated how the
orientation of the blade directs the correction in each plane (29 ,30 ). As in the closing base wedge osteotomy, the cut should
be oriented so the saw is perpendicular to the weight-bearing surface to prevent dorsiflexion of the distal metatarsal with
lateral rotation. If the blade is oriented laterally, then plantarflexion of the distal segment will occur, with reduction of the
intermetatarsal angle. If the blade is oriented medially, then dorsiflexion will occur with translation of the osteotomy.
The osteotomy is best performed distal to the plantar flare of the metatarsal; otherwise, the cut will be difficult to complete. A
small notch may be made at the intended osteotomy site, to provide a better determination of the amount of correction that is
achieved with rotation of the distal segment (Fig. 14 ). However, care must be taken not to produce significant plantarflexion
and inversion during correction of more severe deformities. It appears that the best correction of the intermetatarsal angle may
be achieved when the saw diameter is larger than the diameter of the osteotomy site (31 ).
Although the crescentic osteotomy does provide good correction, it has some disadvantages. Because there is no fixed hinge, the
osteotomy is unstable, and this feature may make it difficult to achieve solid, reliable fixation across the osteotomy site. The
cannulated screw system has facilitated this process (32 ). Fixation may consist of one screw (33 ,34 ), two screws (32 ), one
screw and one K-wire (35 ), crossed K-wires, or Steinmann pins. The screws can become prominent at a later time and may
require removal (33 ).
Cohen et al. described a modification of the crescentic procedure that incorporated a plantar shelf to enhance overall stability
(30 ). A K-wire was introduced medially at the apex of the osteotomy, and the plantar shelf was created initially with a sagittal
saw. The dorsal crescentic cut was then performed. Good results were noted without sagittal plane deviation of the first
metatarsal. Later studies comparing the crescentic shelf and standard crescentic procedures indicated that, by using the shelf
procedure, one could produce slightly greater reductions in the intermetatarsal angle and enhanced plantarflexion of the distal
metatarsal, although the differences were not statistically significant. Overall, both procedures possessed similar mechanical
properties, although investigators believed that the shelf osteotomy may be easier to fixate (36 ).
Favorable results have generally been reported with the procedure (30 ,32 , 33 , 34 , 35 ,37 ). Although the crescentic
osteotomy may tend to resist sagittal plane disruptive forces more effectively than a base wedge osteotomy (38 ), weight
bearing cannot be recommended before osseous consolidation. Unrestricted weight bearing has been associated with metatarsal
elevation (33 , 34 , 35 ), although most authors have apparently not altered their postoperative regimen to prevent this
potential problem.
Chevron Osteotomy
The procedure was first described by Kotzenberg in 1929 as a horizontal “V” in Schotte's article (39 ). The osteotomy is
performed 1 to 1.5 cm from the metatarsal cuneiform joint. The apex of the osteotomy can be oriented either distally or
proximally, although most surgeons appear to favor a distal apex. In either instance, care should be taken to avoid compromise
of the first metatarsal cuneiform joint (Fig. 15 ). The same axis guide techniques described for osteotomies of the metatarsal
head may be incorporated into the proximal procedure to shorten, lengthen, dorsiflex, or plantarflex the distal metatarsal with
lateral transposition. However, because the osteotomy is primarily transpositional, it does not appear to provide any advantage
over the more distally based Austin procedure. Regardless of the location of the osteotomy, similar amounts of lateral shift
result in similar reductions in the intermetatarsal angle. Improved correction may be achieved with the proximal chevron
procedure if the distal segment is swiveled laterally before fixation. The design of the osteotomy affords good stability in the
sagittal plane.
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FIG. 14. A: The crescentic osteotomy is performed with the concavity directed proximally. B: A crescentic osteotomy is
temporarily fixated with a guidewire for a cannulated screw. C: A preoperative radiograph of a patient with a high
intermetatarsal angle. D: After the crescentic osteotomy and fixation with two cannulated screws. (Courtesy of Ira Fox,
D.P.M.)
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FIG. 15. A,B: The proximal chevron osteotomy.
One may experience some difficulty in securing fixation. The V-osteotomy may be stabilized with one (40 ) or two screws, or a
single (34 ) or crossed K-wires (35 ). In some instances, the screw may have to traverse the tarsometatarsal joint to achieve
adequate stability (40 ).
Favorable experiences have been reported with the procedure, and few complications have been noted (34 ,40 ). Dorsal
angulation of the first metatarsal has been noted in some patients (34 ). Although weight bearing has been allowed in the
postoperative setting, it cannot be recommended.
Opening Base Wedge Osteotomy

The opening base wedge osteotomy is seldom performed today because of the increased technical demands of the procedure. A
primary indication is an excessively short first metatarsal resulting from iatrogenic or congenital causes. The hinge is laterally
based, and a bone graft is placed in the osteotomy site to achieve correction by expanding the medial side of the metatarsal
(Figs. 16 and 17 ). Graft can be harvested from many possible donor sites in the foot, leg, or hip. The medial eminence from the
metatarsal head is often used because it is readily accessible (41 ). However, in some instances, the quality of bone from this
area is not optimal and has been associated with loss of correction with time (42 ).
FIG. 16. The opening wedge osteotomy. A laterally based hinge is necessary for this procedure.
The opening base wedge osteotomy has an increased healing time because of the time required for the graft to incorporate into
the metatarsal. The use of a graft also increases the risk of delayed union or nonunion. Furthermore, at times one may note a
delayed shift in the alignment of the distal metatarsal. Fixation may be provided with crossed K-wires, cerclage wire, plates and
screws, staples (41 ), or external fixation (43 ), although originally this osteotomy was not fixated (44 ), and other surgeons have
allowed weight bearing in a cast without fixation (42 ). Youngswick recommended that the osteotomy be performed, the
metatarsal rotated to the corrected position, and staple fixation applied prior to the insertion of the bone graft (41 ).
The purpose of the opening wedge osteotomy is either to lengthen or to prevent shortening of the metatarsal, although this may
predispose the patient to developing a hallux limitus or hallux rigidus deformity by increasing tension at the
metatarsophalangeal joint. Curiously, few studies have actually evaluated the change in length after the procedure, although
one series noted no significant change in the relative lengths of the first and second metatarsals at postoperative follow-up (42 ).
If this finding is accurate, then it would appear to obviate the specific indication for the opening wedge osteotomy compared
with other proximal procedures, especially considering the additional risks and complexities of the former.
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FIG. 17. A: A patient with recurrent hallux abducto valgus deformity and a short first metatarsal. B: After an opening base
wedge osteotomy. Stabilization was achieved with a plate and screw.
FIG. 18. A,B: Elevation of the first metatarsal may develop after any proximal first metatarsal if weight bearing is allowed
before healing.
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FIG. 19. A,B: Nonunion of the first metatarsal base resulting in part from early weight bearing. C: The nonunion was
resected, and a bone graft was obtained from the patient's iliac crest to preserve length to the metatarsal.
POSTOPERATIVE COURSE
Proximal osteotomies must be protected against the disruptive forces of weight bearing, regardless of the procedure or fixation.
Although most distal osteotomy designs can withstand the forces of weight bearing, the base osteotomy can be easily disrupted
by the forces transmitted through the longer lever arm (Fig. 18 ). Once the internal fixation is compromised, instability of the
osteotomy will occur, producing motion and ultimately elevation of the first metatarsal. If the disruptive forces continue across
the osteotomy site, a delayed union or nonunion can develop (Fig. 19 ). Non-weight bearing is maintained for a minimum of 6
weeks and until evidence of bone healing is sufficient. The patient is placed in a below-knee non-weight-bearing cast, and
ambulation is assisted with crutches, walker, or a knee walker. Early passive range of motion of the first metatarsal phalangeal
joint can begin even during the casting period. The range-of-motion exercises can also be performed at the lesser metatarsal
phalangeal joints and the knee. After 6 weeks, the patient can usually progress to protective weight bearing, provided the
patient has radiographic evidence of osseous healing and satisfactory clinical evaluation.
SUMMARY
Base osteotomy of the first metatarsal can be a successful and rewarding component of hallux valgus surgery. Many advances
have been made in the technical aspects of these procedures, such as precise resection of bone and stable fixation techniques
that have accounted for fewer complications and improved results. The use of the hinge-axis concept can aid in the proper
orientation of the osteotomy. Once the osteotomy is temporarily fixated, one should evaluate the patient's foot to ensure that
the proper amount of correction
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has been achieved. It appears that subsequent elevation of the first metatarsal has been noted with all these procedures, although the outcomes achieved would lead one to believe that this is not a functional
problem with the amount of displacement currently observed.
In all osteotomies of the first metatarsal base, stable fixation is important to ensure a successful result. Although studies may indicate that one form of fixation is superior to another for any given procedure, in
actual clinical practice, these differences often prove insignificant, provided good correction is achieved and appropriate measures are instituted after surgery. Regardless of which procedure is performed, the
patient must remain non-weight bearing for a minimum of 6 weeks and until bone healing is sufficient. Osteotomy of the first metatarsal base provides predictable long-term results in a reliable manner in the
compliant patient, especially when careful attention is paid to the technical aspects of its execution.
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36. Earll M, Wayne J, Caldwell P, et al. Comparison of two proximal osteotomies for the treatment of hallux valgus. Foot Ankle Int 1998;19:425-429.
37. Thordarson DB, Leventen EO. Hallux valgus correction with proximal metatarsal osteotomy: two-year follow-up. Foot Ankle 1992;13:321-326.
38. Fillinger EB, McGuire JW, Hesse DF, et al. Inherent stability of proximal first metatarsal osteotomies: a comparative analysis. J Foot Ankle Surg 1998;37:292-302.
39. Schotte M. Zur operativen Korrektur des Hallux valgus im Sinne Ludloffs. Klin Wach 1929;50:2333-2334.
40. Sammarco GJ, Brainard BJ, Sammarco VJ. Bunion correction using proximal chevron osteotomy. Foot Ankle 1993;14:8-14.
41. Youngswick FD. Opening abductory wedge osteotomy of the first metatarsal base. In: Gerbert J, ed. Textbook of bunion surgery. Mt. Kisco, NY: Futura, 1991:395-408.
42. Limbird TJ, DaSilva RM, Green NE. Osteotomy of the first metatarsal base for metatarsus primus varus. Foot Ankle 1989;9:158-162.
43. Amarnek DL, Juda EJ, Oloff LA, et al. Opening base wedge osteotomy of the first metatarsal utilizing rigid external fixation. J Foot Ankle Surg 1986;25:321-326.
44. Trethowan J. Hallux valgus. In: Choyce CC, ed. A system of surgery. New York: PB Hoeber, 1923:1046-1049.
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Reconstructive surgery of the foot and leg: update ′97. Tucker, GA: The Podiatry Institute, 1997:27-31.
Bar-David T, Trepal MJ. A retrospective analysis of distal chevron and basilar osteotomies of the first metatarsal for correction of intermetatarsal
angles in the range of 13 to 16 degrees. J Foot Surg 1991;30:450-456.
Bonney G, Macnab I. Hallux valgus and hallux rigidus. J Bone Joint Surg Br 1952;34:366-385.
Borton DC, Stephens MM. Basal metatarsal osteotomy for hallux valgus. J Bone Joint Surg Br 1994;76:204-209.
Bruyn JM. Chevron closing base wedge bunionectomy. J Foot Ankle Surg 1993;32:382-389.
Cedell CA, Astrom M. Proximal metatarsal osteotomy in hallux valgus. Acta Orthop Scand 1982;53:1013-1018.
Christenson C, Jones RO, Basque M, et al. Comparison of oblique closing base wedge osteotomies of the first metatarsal: stripping versus
nonstripping of the periosteum. J Foot Surg 1991;30:107-113.
Cicchinelli LD, San Juan MG, Testa JA. Absorbable screw fixation. In: Camasta CA, Vickers NS, Carter SR, eds. Reconstructive surgery of the foot
and leg: update ′95. Tucker, GA: The Podiatry Institute, 1995:59-65.
Cicchinelli LD, San Juan MG, Testa JA. Clinical uses of absorbable screws in foot and ankle surgery. In: Miller SJ, Mahan KT, Yu GV, et al., eds.
Reconstructive surgery of the foot and leg: update ′96. Tucker, GA: The Podiatry Institute, 1996:85-89.
Coughlin M. Juvenile hallux valgus: etiology and treatment. Foot Ankle Int 1995;16:682-697.
Coughlin M. Juvenile hallux valgus. In: Coughlin MJ, Mann RA, eds. Surgery of the foot and ankle, 7th ed. St. Louis: CV Mosby, 1999:270-319.
Davies GF. Plantarflexory base wedge osteotomy in the treatment of functional and structural metatarsus primus elevatus. Clin Podiatr Med Surg
1989;6:93-102.
Doll PJ, Esposito FJ. Angular analysis of wedge-type osteotomies. J Am Podiatry Assoc 1984;74:587-595.
Dreeban S, Mann RA. Advanced hallux valgus deformity: long term results utilizing the distal soft tissue procedure and proximal metatarsal
osteotomy. Foot Ankle 1996;17:142-144.
Haapaniemi TM, Manninenn MJ, Arajarvi EJ. Proximal osteotomy in hallux valgus, long-term results of 167 operated feet. Arch Orthop Trauma Surg
1997;116:376-378.
Harper MC. Dorsal closing wedge metatarsal osteotomy: a trigonometric analysis. Foot Ankle 1990;10:303-305.
Jay RM, Schoenhaus HD, Donohue CM. Modified crescentic osteotomy in children. J Foot Ankle Surg 1990;29:417-420.
Kay DB, Njus G, Parrish W, et al. Basilar crescentic osteotomy. Orthop Clin North Am 1989;20:571-582.
Kempe SA, Grapel D, Hovanec P. A mathematical approach to closing base wedge osteotomy. J Am Podiatry Assoc 1984;74:601-604.
Kummer FJ. Mathematical analysis of first metatarsal osteotomies. Foot Ankle 1989;9:281-289.
Lavery LA, Higgins KR, Ashry HR, et al. Mechanical characteristics of poly-L-lactic acid absorbable screws and stainless steel screws in basilar
osteotomies of the first metatarsal. J Foot Ankle Surg 1994;33:249-254.
Lavery LA, Higgins KR, Ashry HR, et al. Stability of absorbable fixation in basilar first metatarsal osteotomies. J Am Podiatr Med Assoc 1993;83:557-
562.
Lian GJ, Markoff K, Cracchiolo A. Strength of fixation constructs for basilar osteotomies of the first metatarsal. Foot Ankle 1992;13:509-514.
Luthe P. Long-term results of proximal metatarsal osteotomy in hallux valgus. J Am Podiatr Med Assoc 1990;80:304-306.
McCluskey LC, Johnson JE, Wynarsky GT, et al. Comparison of stability of proximal crescentic metatarsal osteotomy and proximal horizontal “V”
osteotomy. Foot Ankle 1994;15:263-270.
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osteotomies. J Foot Surg 1982;21:247-249.
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Kisco, NY: Futura, 1991:321-394.
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Sammarco GJ, Conti SF. Proximal chevron metatarsal osteotomy: single incision technique. Foot Ankle 1993;14:44-47.
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Shereff MJ, Sobel MA, Kummer FJ. The stability of fixation of first metatarsal osteotomies. Foot Ankle 1991;11:208-211.
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Doctors Hospital, Podiatry Institute, 1983:66-68.
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PART 2 Metatarsal Cuneiform Procedures

Alan R. Catanzariti
Edwin L. Blitch IV
FIRST METATARSOCUNEIFORM ARTHRODESIS

Procedures involving the first metatarsocuneiform joint have been advocated since the earliest stages of hallux valgus repair.
The initial impetus for surgical intervention at this site was based on what was believed to be the primary cause of hallux
abducto valgus (1 , 2 , 3 ). Truslow described hallux abducto valgus as secondary to a “metatarsus primus varus,” which would
need to be addressed for surgical treatment to be successful. To accomplish this purpose, he favored a wedge resection from
the first metatarsocuneiform joint (2 ). Kleinberg believed that the most remarkable finding on a dorsoplantar radiograph in
patients with hallux abducto valgus was the adduction of the first metatarsal. He noted that whereas the remaining
tarsometatarsal joints were transverse, the first metatarsocuneiform joint was oriented in a more oblique manner. To correct
the primary cause of the hallux abducto valgus, Kleinberg believed that one would be required to address the tarsometatarsal
joint. Truslow's procedure was thought inadequate to reduce the deformity, and Kleinberg proposed a double wedge resection
of the joint that would allow the first and second metatarsals to be oriented parallel to one another (3 ). Later, Lapidus
described metatarsus primus varus as an atavistic foot type that had not fully developed over previous phylogenetic forms. Again,
this increased separation between the first and second metatarsals was deemed the most frequent cause of hallux abducto
valgus, and resection of the first metatarsocuneiform joint was advocated (4 ).
As the decades passed, the philosophies regarding the origin of hallux abducto valgus changed, yet resection of the first
metatarsocuneiform joint remained an accepted procedure, albeit with a different perspective. Other indications have evolved,
so arthrodesis of the first metatarsocuneiform joint remains a viable option in patients with hallux abducto valgus (Fig. 20 ).
Indications
In numerous instances, arthrodesis of the first metatarsocuneiform joint may prove an acceptable choice in the repair of hallux
abducto valgus. Correction of large intermetatarsal angles may be readily accomplished; an intermetatarsal angle greater than
15 degrees has been an arbitrary level at which the procedure was deemed appropriate (5 , 6 , 7 ). However, the procedure may
also be employed in patients with lower intermetatarsal angles and concomitant metatarsus adductus or a long first metatarsal,
to enhance first ray stability, in cases of revisional surgery, or in patients with degenerative change or symptoms at the first
metatarsocuneiform joint. Arthrodesis at this level may also be helpful in addressing hallux rigidus secondary to metatarsus
primus elevatus. The procedure permits repositioning of the first metatarsal in the sagittal plane and is particularly effective if
the first metatarsal is long.
A common use that has evolved for the procedure has been in conjunction with a hypermobile first ray or in patients with
ligamentous laxity. Hypermobility of the first ray has classically been noted as a precursor to hallux abducto valgus deformity
(8 ). However, exactly what constitutes abnormal motion within the medial column has not been firmly established. First ray
motion involves two distinct joints: the medial naviculocuneiform joint and the first metatarsocuneiform joint. The primary
source of motion in a normal first ray is at the medial naviculocuneiform joint (9 ,10 ). Specifically, an average of 12.3 degrees
of motion has been noted at the medial naviculocuneiform joint and 5 degrees at the first metatarsocuneiform joint (10 ).
Gellman et al. found that the first metatarsal itself could dorsiflex about 5.0 degrees (11 ). Wanivenhaus and Pretterdklieber
described the dorsal shift from neutral at the base of the first metatarsal as measuring about 2.6 mm (12 ). Furthermore, the
actual shape of the first metatarsocuneiform joint has been proposed to have an influence on the range of motion as well
(13 ,14 ). However, the contribution of each component joint to the total range of first ray motion and the amount of motion
available as a whole will vary, in some instances to a significant degree (10 ,15 ).
Clinical studies have appeared to support the values derived from the laboratory and have demonstrated that patients with
hallux abducto valgus deformity may possess a greater degree of first ray mobility compared with control patients (16 ).
Additional studies have shown an association between a hypermobile first ray and generalized ligamentous laxity. An evaluation
of 50 patients presenting with various foot problems revealed a marked increase in the intermetatarsal and hallux abductus
angles when hypermobility was present (17 ). Hyperflexibility of the thumb has been associated with first ray hypermobility, yet
no correlation was found between first ray motion and sex, age, intermetatarsal angle, size, skin stretch, hyperextension of the
knee, or shape
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of the distal cuneiform (14 ). In female patients with symptomatic hallux abducto valgus, a statistically significant correlation
was found with mild generalized hypermobility when compared with a similar control patient group (18 ).
FIG. 20. A,B: The first metatarsocuneiform arthrodesis for correction of hallux abducto valgus deformity.
Radiographic features associated with hypermobility are difficult to assess and are generally nonspecific. Most radiographic
findings are secondary to structural changes that develop over time. A modified Coleman block test has been recommended to
produce maximum dorsiflexion and plantarflexion of the first ray to assess motion at the first metatarsocuneiform joint with a
lateral radiograph. Although this test may demonstrate the motion available at the joint, no objective studies have been
conducted to demonstrate its reliability (19 ). Cortical thickening of the second and possibly third metatarsals on an
anteroposterior radiograph may provide indirect evidence of a hypermobile first ray.
Hallux abducto valgus deformity resulting from hypermobility of the first ray has been described as a prime indication for
arthrodesis of the first metatarsocuneiform joint (5 ,20 , 21 , 22 , 23 , 24 , 25 ). This procedure can indirectly restore functional
stability to the medial column by allowing the peroneus longus muscle to have a greater mechanical advantage at the medial
naviculocuneiform joint, where the majority of first ray motion occurs. Furthermore, this procedure has also been
recommended in patients with concomitant hallux abducto valgus deformity associated with a hypermobile flatfoot (24 ,25 ).
However, a hypermobile first ray is a relative, but not an absolute, indication for first metatarsocuneiform arthrodesis.
Numerous procedures have proven successful in the repair of bunion deformities, many in patients who undoubtedly possessed a
hypermobile first ray. Most first ray mobility occurs at the naviculocuneiform level (9 ). Although arthrodesis at the more distal
joint may enhance stability, other methods such as a modified Young procedure or naviculocuneiform joint arthrodesis may also
prove suitable. Furthermore, orthotic devices may be employed to address medial column instability postoperatively. The actual
selection of the procedure is based on the knowledge, skill, training, and experience of the surgeon and on the specific clinical
findings and concerns unique to the patient. Numerous options may be suitable for any given situation.
First metatarsocuneiform arthrodesis has also been recommended for adolescents with hallux abducto valgus deformity. Several
studies in this patient population have demonstrated good results (21 ,24 ). Although this procedure has been recommended for
adolescents with a closed epiphysis, the procedure may be used in adolescents with an open growth plate with no complications.
Smooth wires or pins are used for fixation in this setting. Temporary use of smooth pins has not been found to damage an open
growth plate (5 ,26 ). However, because growth plate damage may develop secondary to periosteal dissection (7 ), one must be
careful to avoid unnecessary stripping of the soft tissues away from the physis. Myerson et al. found that in adolescents with a
hypermobile first ray, realignment could be accomplished with a first metatarsocuneiform arthrodesis without distal soft tissue
release or exostectomy (24 ). Avoiding surgery at the metatarsophalangeal joint may be an option in juvenile or adolescent
patients who have no joint adaptation, but once lateral contracture has developed, then release of the joint appears prudent.
Salvage of previously failed hallux abducto valgus surgery with recurrent or residual metatarsus primus adductus is another
indication for first metatarsocuneiform arthrodesis, especially if recurrence is secondary to hypermobility or ligamentous laxity.
However, in many instances, the previous operation may have shortened the first metatarsal, so a bone graft may be necessary
to prevent any additional shortening or to restore more functional length.
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Arthrodesis of the first metatarsophalangeal joint has been recommended when the first metatarsocuneiform angle is medially
deviated more than 30 degrees (26 ). However, variations in the angular relationships at this level have been found based on the
position of the foot in addition to the orientation of the x-ray beam (17 ,27 ). Furthermore, ligamentous laxity was noted to
have little to no effect on the metatarsocuneiform angles (17 ). This finding suggests that angular deviation should not be used
as a sole criterion for tarsometatarsal arthrodesis. In some instances, a lateral weight-bearing radiograph may demonstrate
sagittal plane subluxation with plantar gaping of the metatarsocuneiform joint.
Surgical Technique
The surgical incision is placed dorsally or medially over the first metatarsocuneiform joint. This may be a proximal extension
from the incision used for exposure of the first metatarsophalangeal joint or a separate second incision. The medial dorsal
cutaneous nerve is usually encountered in the subcutaneous tissue and should be retracted. Once the deep fascia is incised, the
extensor hallucis longus is easily retracted to access the dorsal aspect of the joint. Medially, the tibialis anterior is freed from
its distal fascial investments, so the tendon may be retracted dorsally to access the plantar aspect of the joint better and to
facilitate fixation when a medial plate is used. The location of the joint may then be identified.
A linear incision is then made over the capsule and periosteum, which are carefully reflected. Caution is warranted during
dissection of the lateral portion of the joint in an effort to avoid damage to the deep peroneal nerve and the first perforating
branch of the dorsalis pedis artery. Plantarly, one needs to release the thick tarsometatarsal ligaments. Attachments of the
posterior tibial and peroneus longus tendons, as well as Lisfranc's ligament, frequently hinder removal of the joint surfaces
because of their extensive attachments in this location. Full joint mobilization facilitates later débridement of the cartilaginous
surfaces. Dissection is generally extended distally to the junction of the proximal and middle third of the first metatarsal.
Exposure of the thick cortical bone along this area is important when compression screw fixation is used. The thick cortical bone
in this area is an excellent area for screw head contact to aid in compression across the arthrodesis site. Additionally, screw and
wire placement becomes technically easier when one begins from a more distal site. When a dorsal or medial plate is used, then
dissection needs to be extended to expose most of the metatarsal shaft distally and to identify the naviculocuneiform joint
proximally. If more proximal dissection is done, care must be taken to avoid inadvertent damage to the saphenous nerve.
The joint may be resected using the technique preferred by the surgeon. When power saws are employed, the first metatarsal
may be manually reduced to the desired position. Care should be taken to align the first metatarsal in both sagittal and
transverse planes. This alignment often places the osseous structures in such a position that any wedging will tend to occur by
default, as opposed to any freehand wedge resection that may be required otherwise. Osseous resection should proceed with
care to avoid penetration of the second metatarsal. This occurs most often when the lateral aspect of the joint is not well
visualized. If difficulty is encountered during transposition of the first metatarsal, the lateral proximal condyle at the base of
the first metatarsal may also require resection.
Hand instruments may also be used to resect the joint surfaces. An osteotome and mallet is generally employed to begin the
process, with curettes useful in some instances. A power bur may be helpful in reducing any remaining portions of cartilage or
subchondral bone. With this technique, the surgeon is better able to preserve the normal contours of the joint and to achieve a
good fit, generally with less bone resection. Therefore, when hand instruments are used, the correction of deformity is based on
the ability to realign the joint about its normal articular shape.
Transverse plane correction may be achieved using a combination of wedge resections and simple repositioning, which is readily
facilitated once the joint has been freed of the surrounding soft tissue. By using a power saw, the technique of reciprocal
planing may be employed to remove areas of incongruity gradually until a good fit is achieved. However, in patients with more
significant deformity, intentional wedge resections will likely be required. A laterally based wedge is preferably resected from
the medial cuneiform because the distal articular surface of this bone typically exhibits some degree of deviation from the long
axis of the first ray. Therefore, one is simply using the normal alignment to best advantage in reducing the intermetatarsal
angle. In addition, wedge resection of the medial cuneiform preserves a large cancellous portion of bone for apposition.
Sagittal plane alignment of the first ray may be influenced by displacement of the first metatarsal dorsally or plantarly. This
maneuver requires less bone resection, is technically simple, and avoids any additional shortening (5 ,25 ). If the metatarsal is
shifted plantarly, a small ledge of bone at the dorsal joint level may be present that will require remodeling once the fixation
has been applied. However, wedge removal, either dorsally or plantarly based, is an effective means of achieving greater
degrees of correction. In some patients, a combination of both elements may be employed to achieve the desired position (Figs.
21 , 22 and 23 ).
Once the preferred alignment is achieved, and before the joint surfaces are approximated, a small drill or Kirschner wire may
be used to fenestrate the medial cuneiform and first metatarsal base in an effort to facilitate arthrodesis. The first metatarsal
and medial cuneiform are then repositioned, and provisional fixation is applied.
Bone Grafting
Supplemental bone grafts may also be employed with arthrodesis of the first metatarsocuneiform joint in several situations.
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This approach may prove helpful in patients in whom shortening of the first ray would not be tolerated, in patients requiring
greater degrees of wedge resection for correction, or when significant changes in sagittal plane alignment are necessary. The
graft source may include autogenous or allogenous bone. However, some authors have recommended that allogeneic bone be
avoided when rigid internal fixation cannot be obtained (28 ). When a nonunion or pseudarthrosis of a failed
metatarsocuneiform joint arthrodesis is repaired, autogenous bone is preferred (29 ). Tricortical iliac crest graft is ideal for this
procedure because the graft provides three cortical surfaces for excellent stability dorsally, plantarly, and medially. The
cortical bone provides and maintains positional correction and allows the use of rigid internal compression across the arthrodesis
site. The cancellous bone provides a lattice network for osteoconduction throughout the healing process.
FIG. 21. During first metatarsocuneiform fusion, the sagittal plane position of the first metatarsal may be adjusted by
shifting the metatarsal base dorsally (A) or plantarly (B) without resecting additional bone.
FIG. 22. A,B: A greater degree of plantarflexion of the first metatarsal may be achieved by resecting a plantar wedge from
the joint area.
Modifications
Several authors have proposed several modifications to the basic technique described. The exostosis removed from the medial
first metatarsal head has been used as a graft in the arthrodesis site to limit first metatarsal shortening (30 ). However, in most
patients, the amount of bone resected is too small to have any meaningful effect on first metatarsal length. Other investigators
have suggested that less aggressive resection of the joint may be adequate to provide suitable fusion. In some instances,
cartilage has been removed to expose only the subchondral bone (22 ). When the joint is wedged for correction of the
metatarsus primus adductus, several authors have resected bone from the lateral aspect of the joint, to leave the cartilage
intact medially (22 ,24 ). Mauldin and associates released the joint, adjusted the position of the metatarsal, then applied the
fixation. A medial trough was created in the medial first metatarsocuneiform joint, and an onlay graft was applied (23 ).
Fixation
Because of the relatively transverse orientation of the first metatarsocuneiform joint, numerous options are suitable for
stabilizing the area. Kirschner wires or Steinmann pins provide good fixation and are quick and easy to use. Generally, two wires
are preferred, to reduce any potential for rotation and to create additional stability. Pins may prove advantageous in patients
with osteopenia and in pediatric patients with an open growth plate. Another advantage of using wires is that dissection may be
more limited than when screws or plates are employed.
Compression screw fixation provides excellent stability and was first employed by Rutherford (20 ). Devices used to date most
commonly consist of 3.5- or 4.0-mm fully or partially threaded cortical or cancellous screws inserted in lag fashion. These
screws may be introduced in several orientations. Exposure along the proximal one-third of the metatarsal base is important, to
ensure that the appropriate-length screw is used and that adequate compression is obtained by the screw head making contact
with the thick cortical bone in this area. A common error is to begin screw placement too close to the arthrodesis site. The bone
content here is more cancellous, and compression may be less effective. A key step with osteosynthesis in this area is adequate
countersinking. This facilitates appropriate screw orientation into the plantar portion of the cuneiform, enhances optimal
compression, prevents stress risers along the dorsal cortex of the metatarsal, and reduces the prominence of the screw head.
Screws that cross the intercuneiform joints have not been noted to create any functional or symptomatic problem (22 ).
Certainly, a combination of screws and wires may be used as well.
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FIG. 23. Arthrodesis of the first metatarsocuneiform joint may also be used to alleviate metatarsus primus elevatus
associated with a dorsal bunion. A,B: Preoperative clinical and radiographic appearance. C,D: Postoperative clinical and
radiographic appearance.
FIG. 24. A,B: Plate fixation may also be employed with or without the addition of an interfragmental screw. In many
patients, the additional bulk of the plate proves problematic and requires subsequent removal.
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FIG. 25. A medial plate works well when a large graft is incorporated into the arthrodesis site.
Cannulated screws have also proved useful for osteosynthesis. However, with some products, the screw head is large, and often
this feature limits the ability to insert two screws in the area. The screws are placed in the same fashion as previously
mentioned. The first step is to countersink. If desired, a rotary bur may be used for this purpose. Initial countersinking allows
appropriate placement of the guide pin. The guide pin is then visualized through the metatarsal segment. At that point, the
metatarsal is placed in the appropriate alignment, and the guide pin is then driven into the cuneiform segment.
Plate fixation is also an option for the modified Lapidus arthrodesis and is particularly useful when bone graft is used (Figs. 24
and 25 ). The technique may be employed in other situations when additional stability is preferred. However, the plate and
screws are often prominent postoperatively after complete healing and create a source of irritation for many patients.
Therefore, they often require subsequent removal, thus necessitating an additional surgery. Plate fixation has been described
for the procedure in both dorsal and medial positions (25 ,31 ). Eccentric drilling can be used to afford compression across the
arthrodesis site as the screws are inserted into the plate. The addition of a plantar interfragmentary screw was also noted to
enhance stability further (31 ) (Fig. 26 ). However, when osteopenia is present and compression fixation is difficult to achieve,
large-diameter Steinmann pins may be adequate. Burying the pins may prove helpful in eliminating pin tract irritation and
loosening of the wires within the cast.
Chang and Ruch undertook a study to determine the effectiveness of different fixation methods for the first metatarsocuneiform
fusion. A medial five-hole plate with a plantar screw was noted to resist disruptive forces to the greatest degree. Other forms of
fixation that were tested are listed in order of decreasing strength: crossed 4.0-mm screws, medial five-hole plate, and crossed
Kirschner wires (31 ). However, this finding does not imply that any of these methods of fixation are inferior; it simply provides
the surgeon with a means of assessing the available options. Each form of fixation has its own advantages and disadvantages,
and any of these methods may be adequate for stabilizing the fusion site, provided patient compliance is good.
The patient is maintained non-weight bearing for 6 to 10 weeks or until radiographic evidence of an osseous union is noted. If
bone grafting is performed, this non-weight-bearing period will be extended, typically for a minimum 12 weeks. Postoperative
radiographs may be obtained at regular intervals to evaluate joint consolidation.
Ancillary procedures may be required for complete reduction of the hallux abducto valgus deformity. The release of deformity
at the first metatarsophalangeal joint should be considered an integral part of surgical treatment. When the effective articular
surface of the first metatarsal head is laterally deviated, a distal metaphyseal osteotomy may be necessary for cartilaginous
realignment.
Results
Overall, the results obtained with first metatarsocuneiform fusion for the repair of hallux abducto valgus have been good (Fig.
27 ). Rutherford reported good results in more than 120 feet. Minor keratoses were said to develop beneath the second and
third metatarsal heads in some patients, presumably from shortening of the first metatarsal. Otherwise, no specific problems
were noted (20 ). Using the medial eminence of the first metatarsal head as a graft, Butson reported excellent or good results in
110 of 119 feet (92%) in patients evaluated between 2 and 16 years postoperatively. No cases of nonunion were reported.
Fixation consisted of two Kirschner wires inserted between the shafts of the first and second metatarsals (30 ).
Clark and colleagues reported on 20 adolescent patients representing a total of 32 procedures. Good correction of deformity was
noted, in addition to alleviation of the medial column hypermobility, which was noted in 93% of the feet preoperatively. Two
patients sustained problems related to lesser metatarsalgia (21 ).
A thorough report was provided by Saffo et al., who evaluated patients undergoing 54 procedures between 1 and 5 years earlier.
Of these patients, 82% reported good or excellent results. However, several problems were identified. Transfer lesions were
found in 14% of the patients, although symptoms were experienced by only 4%. An asymptomatic pseudarthrosis was found in
12% of their patients. The first metatarsal was 6 mm shorter compared with the second metatarsal, but the authors believed
that this was readily overcome by the plantarflexion introduced in the medial column at the time of surgery (5 ).
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FIG. 26. A,B: Preoperative clinical and radiographic appearance of a patient with hallux abducto valgus deformity,
metatarsus adductus, and joint space narrowing at the medial first metatarsocuneiform joint. C,D: Immediate
postoperative results. E: Radiographic appearance 10 weeks postoperatively. F: Clinical appearance 6 months
postoperatively.
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FIG. 27. A,B: Preoperative and postoperative radiographs 1 year after repair of hallux abducto valgus deformity with first
metatarsocuneiform fusion.
A 10% nonunion rate was also present in the series of patients reviewed by Sangeorzan and Hansen, although all the patients
with nonunion in their series were symptomatic. In patients in whom bone grafting was not used, an average shortening of 5 mm
was reported. Overall, only 75% of patients achieved a successful result (22 ).
Using an inlay graft technique, Mauldin and colleagues found satisfactory or very satisfactory results in 90% of 51 feet in patients
undergoing surgical procedures. However, trabecular bridging at the fusion site was noted in only 25% of the cases. Despite this
finding, no correlation was found between the radiographic evidence of fusion and patient satisfaction. The intermetatarsal
angle was reduced from an average preoperative value of 14.6 degrees to a postoperative value of only 8.7 degrees (23 ). This
finding leads one to question whether better correction of the metatarsus primus adductus deformity could have been achieved
with a more traditional joint resection.
Myerson et al. reported on 67 cases; 77% of their patients were judged to have achieved total resolution of their preoperative
symptoms, and 15% achieved partial relief. Five dorsal bunions were noted at follow-up. Seven nonunions occurred, only one of
which was symptomatic. Three neuromas of the deep peroneal nerve were noted (24 ). Moreover, patients were allowed to bear
weight fully during the recovery period. This could be one possible explanation for the demonstration of dorsal prominence of
the metatarsal head.
Complications
Fortunately, major complications associated with the first metatarsocuneiform arthrodesis are not common. Because part of the
motion of the first ray is eliminated, deviations in the sagittal plane may not be as well tolerated. Although some degree of
plantarflexion of the metatarsal is desirable, excessive plantarflexion may result in sesamoiditis. Accommodative padding or
orthoses may frequently resolve symptoms related to the plantar pressure. When conservative treatment fails, surgical
treatment may include tibial or fibular sesamoid planning, tibial or fibular sesamoidectomy, or dorsiflexory wedge osteotomy of
the first metatarsal in severe cases. A metatarsal resting in a more dorsal position could lead to additional pronation within the
foot and is typically more difficult to accommodate.
Previous authors noted significant amounts of shortening of the first metatarsal in some instances (5 ,22 ). Excessive shortening
of the first metatarsal has the potential to cause complications including transfer lesions, less effective hallux purchase, and
metatarsalgia. Although one may compensate for shortening to some extent with plantarflexion of the first metatarsal, the
amount of shortening that may be overcome is limited. Furthermore, significant plantarflexion
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alters the loading of the plantar joint structures and encourages less effective purchase of the hallux, a problem that is
compounded by shortening of the metatarsal. Such difficulties are more likely to occur in patients who require significant wedge
resections to achieve the desired correction. The use of a bone graft may reduce the risks of this type of complication, but it
also adds another level of complexity to the procedure and a more prolonged recovery process.
Neuritic symptoms have also been described in some patients (21 ,24 ). The medial dorsal cutaneous nerve will almost certainly
be encountered during the dissection process, and if more proximal dissection is done, the saphenous nerve will often be
visualized. The deep peroneal nerve may also be susceptible to disruption in the first interspace area. Proper tissue handling
minimizes the risk of nerve entrapment. However, the normal scarring process that is part of healing may create nerve
entrapment even in the best circumstances.
FIG. 28. A,B: Preoperative and immediate postoperative radiographs of a patient with recurrent hallux abducto valgus
deformity with an associated hypermobile first ray. C,D: Radiographic appearance 3 months postoperatively demonstrating
a delayed union that is asymptomatic. E,F: Despite continued immobilization and an external bone stimulator, the patient
developed an asymptomatic nonunion at the first metatarsocuneiform fusion site. This has been noted in several studies.
Hallux limitus is not a common complication, but it may be encountered as a consequence of any first metatarsophalangeal joint
repair. Hallux limitus is more likely when the first metatarsal is lengthened with a graft as part of the fusion or when the
arthrodesis heals with the first metatarsal in an elevated position.
Failure to achieve radiographic union of the arthrodesis site has been seen in about 10% of cases in several studies (5 ,22 ,24 ).
Although this complication has generally been noted to be asymptomatic, painful nonunions have developed that have required
subsequent surgical treatment (22 ) (Fig. 28 ).
Arthrodesis of the first metatarsocuneiform joint is a versatile procedure that may be employed in a variety of situations.
Overall results have been suitable. Numerous forms of fixation are applicable and work well. Patients are best maintained non-
weight bearing until healing of the osteotomy is achieved.
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FIG. 28. Continued.
CUNEIFORM OSTEOTOMIES
Several authors have discussed cuneiform osteotomies for the correction of certain foot deformities. Cotton recommended an
opening wedge osteotomy of the medial cuneiform with allogeneic femoral graft to correct sagittal plane deformity in collapsed
pes valgus (32 ). Other investigators have used an opening wedge cuneiform osteotomy for correction of residual forefoot
adductus in the treatment of clubfoot deformity (33 ,34 ). Joplin performed an opening wedge osteotomy for repair of splay foot
deformity associated with hallux abducto valgus (35 ) (Fig. 29 ). Graver recommended a similar procedure for the correction of
metatarsus primus adductus and used a triangular piece of bone from the resected medial eminence of the first metatarsal (36 ).
Hara and associates employed a completely different approach, by resecting a closing abductory wedge from the medial
cuneiform to reduce intermetatarsal splay for hallux abducto valgus (37 ) (Fig. 30 ).
Indications
Perhaps the primary indication for an opening cuneiform osteotomy is in conjunction with a repair of metatarsus adductus with
and without hallux abducto valgus. In this case, the opening wedge cuneiform osteotomy is generally combined with a closing
wedge osteotomy of the cuboid. The wedge of bone removed from the cuboid may then be used to augment the material
inserted into the medial cuneiform (38 ). Other investigators have noted that cuneiform osteotomies may be employed in
patients with hallux abducto valgus who have increased obliquity of the first metatarsocuneiform joint (37 ,39 ). However,
questions have been raised
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regarding the reliability of this measurement on standard radiographs (17 ,27 ).
FIG. 29. The opening cuneiform osteotomy with graft for reduction of the intermetatarsal angle associated with hallux
abducto valgus deformity.
FIG. 30. A,B: The closing cuneiform osteotomy for repair of intermetatarsal splay associated with hallux abducto valgus
deformity.
Bacardi and Frankel employed a biplane opening cuneiform osteotomy for surgical repair of juvenile hallux abducto valgus (40 ).
Lynch noted that juvenile hallux valgus was often associated with metatarsus adductus deformity, so this procedure is a logical
choice in these patients or in patients with forefoot adductus. In addition to making an oblique osteotomy, wedging of the graft
may be helpful in plantarflexing the medial column to address sagittal plane deformity or hypermobility (39 ). Ganley and
Ganley noted that the procedure would be useful in correcting metatarsus primus adductus in patients after a failed closed base
wedge osteotomy with residual dorsiflexion (38 ).
A general contraindication for these procedures has been in patients less than 6 years old because they have inadequate
consolidation of the osseous structures (39 ). Furthermore, the procedure may need to be avoided if the bases of the first and
second metatarsals articulate with each other (38 ). Graver noted that the procedure was not as effective in reducing larger
intermetatarsal angles of 20 degrees or more (36 ). Relative to the closing wedge osteotomy of the cuneiform, Hara et al.
reported that general contraindications were osteoporosis, bone blockage between the first and second metatarsals, or a rigid
foot (37 ).
Surgical Technique
The opening wedge procedure is performed through a linear incision along the dorsal medial or medial aspect of the midfoot.
The primary anatomic structures encountered are the extensor hallucis longus and tibialis anterior tendons and the medial
dorsal cutaneous and saphenous nerves. The fascia surrounding the tibialis anterior will need to be released to mobilize the
tendon and obtain better access to the cuneiform. A linear periosteal incision is performed in the same orientation as the skin
incision, and the tissue is freed. A power saw is used to create an osteotomy approximately 7 to 10 mm proximal to the
metatarsocuneiform joint. The lateral cortex is initially maintained intact, but in most cases it fractures as the osteotomy is
opened. A lamina spreader may be placed in the osteotomy to separate the two segments and to better determine the
appropriate amount of bone graft that is necessary. Intraoperative radiographs may be obtained before insertion of the graft to
assess reduction in the intermetatarsal angle.
Tricortical iliac crest allogenic bone graft is well suited for this procedure. Autogenous graft from the calcaneus has also been
used with success (39 ). Fixation is not always necessary, but when it is employed, staples, pins, and wires are all appropriate.
Postoperative management includes a 6-to 10-week period of non-weight bearing or longer until radiographs demonstrate
consolidation at the host-graft interface.
Results
Graver reported having performed 23 cases of opening wedge cuneiform osteotomy with the medial eminence of the first
metatarsal head as the donor graft. No specifics were provided for the group as a whole. Advantages of the procedure were said
to be the ease of execution, rapid healing, and the lack of need for no internal fixation. He noted that the procedure could be
used in patients with intermetatarsal angles of up to 20 degrees and that the first metatarsal should not be long (36 ).
Lynch provided the most comprehensive review on the use of the opening wedge osteotomy for the repair of hallux abducto
valgus deformity. He described good results in 48 feet of adolescent patients. In addition, he noted that the procedure also
provided stabilization of the medial column. Calcaneal allograft was employed, and staple fixation was applied. Capital
osteotomies were often required to reduce a deviated proximal articular set angle (39 ) (Fig. 31 ).
Hara et al. recommended a different approach consisting of a first cuneiform closing wedge abductory osteotomy for reduction
of metatarsus primus adductus in patients with intermetatarsal angles greater than 15 degrees and with pronounced obliquity of
the first metatarsocuneiform joint. The procedure was said to be ideal in patients with space at the first intercuneiform joint
and the opposing bases of the first and second metatarsals. Steinmann pins were used for fixation, and the patient was
maintained non-weight bearing for 6 weeks. In 51 cases, no patients had delayed union or nonunion of the osteotomy. Arthrosis
involving the intercuneiform joints did not develop (37 ).
Complications may include nonunion, graft displacement, and malunion if the graft is not fashioned appropriately. The ability to
control precise levels of correction is not as certain
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as with other procedures, and in some cases inadequate correction has been noted.
FIG. 31. Preoperative and postoperative radiographs of a patient after opening wedge cuneiform osteotomy with graft for
repair of hallux abducto valgus deformity. (From Lynch FR. Applications of the opening wedge cuneiform osteotomy in the
surgical repair of juvenile hallux abducto valgus. J Foot Ankle Surg 1995;34:103-123, with permission.)
Osteotomies of the cuneiform for the repair of hallux abducto valgus deformity are not commonly employed by most surgeons,
but they may have merit. The proposed advantages of this approach include avoiding the growth plate at the base of the first
metatarsal in the pediatric patient, the long radius arm that theoretically requires less wedging to gain correction when
compared with distal osteotomies, and the ability to provide biplane correction. However, for most patients, other techniques
have been better accepted and have proven successful, so determining specific indications for this approach remains difficult.
REFERENCES
1. Albrecht GH. The pathology and treatment of hallux valgus (Russian). Russk Vrach 1911;10:14-19.
2. Truslow W. Metatarsus primus varus or hallux valgus. J Bone Joint Surg 1925;7:98-108.
3. Kleinberg S. Hallux valgus and bunions. Med J Surg 1932;15:75-81.
4. Lapidus PW. Operative correction of the metatarsus varus primus in hallux valgus. J Surg Gynecol Obstet 1930;58:183-
191.
5. Saffo G, Wooster M, Stevens M, et al. First metatarsocuneiform joint arthrodesis: a five-year retrospective analysis. J
Foot Surg 1989;28:459-465.
6. Bacardi BE, Boysen TJ. Considerations for the Lapidus operation. J Foot Surg 1986;25:133-138.
7. Myerson M. Metatarsocuneiform arthrodesis for treatment of hallux valgus and metatarsus primus varus. In: Myerson M,
ed. Current therapy in foot and ankle surgery. St. Louis: Mosby-Yearbook, 1993.
8. Root ML, Orien WP, Weed JH. Muscle function of the foot during locomotion. In: Root ML, O'Rien WP, Weed JH, eds.
Clinical biomechanics, vol 2. Los Angeles: Clinical Biomechanics Corporation, 1977.
9. Phillips RD, Law EA, Ward ED. Functional motion of the medial column joints of the foot during propulsion. J Am Podiatr
Med Assoc 1996;86:474-486.
10. Ouzounian, TJ, Shereff MJ. In vitro determination of midfoot motion. Foot Ankle 1989;10:140-146.
11. Gellman H, Lenihan M, Halikis N, et al. Selective tarsal arthrodesis: an in vitro analysis of the effect on foot motion.
Foot Ankle 1987;8:127-133.
12. Wanivenhaus A, Pretterdklieber M. First tarsometatarsal joint: anatomical biomechanical study. Foot Ankle
1989;9:153-157.
13. Hirsch BE. Structural biomechanics of the foot bones. J Am Podiatr Med Assoc 1991;81:338-343.
14. Fritz GR, Prieskorn D. First metatarsocuneiform motion: a radiographic and statistical analysis. Foot Ankle Int
1995;16:117-123.
15. Ebisu JM. The first ray axis and the first metatarsophalangeal joint. J Am Podiatry Assoc 1968;58:160-167.
16. Klaue K, Hansen ST, Masquelet AC. Clinical, quantitative assessment of first tarsometatarsal mobility in the sagittal
plane and its relation to hallux valgus deformity. Foot Ankle 1994;15:9-13.
17. McNerney JE, Johnston WB. Generalized ligamentous laxity, hallux abducto valgus and the first metatarsocuneiform
joint. J Am Podiatry Assoc 1979;69:69-82.
18. Carl A, Ross S, Evanski P, et al. Hypermobility in hallux valgus. Foot Ankle 1988;8:264-270.
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19. Prieskorn DW, Mann RA, Fritz G. Radiographic assessment of the second metatarsal: measure of first ray hypermobility.
Foot Ankle Int 1996;17:331-333.
20. Rutherford RL. The Lapidus procedure for primus metatarsus adductus. J Am Podiatry Assoc 1974;64:581-584.
21. Clark HR, Veith RG, Hansen ST. Adolescent bunions treated by modified Lapidus procedure. Bull Hosp Jt Dis Orthop
Inst 1987;47:109-122.
22. Sangeorzan BJ, Hansen ST Jr. Modified Lapidus procedure for hallux valgus. Foot Ankle 1989;9:262-266.
23. Mauldin DM, Sanders M, Whitmer WW. Correction of hallux valgus with metatarsocuneiform stabilization. Foot Ankle
1990;11:59-66.
24. Myerson M, Allon S, McGarvey W. Metatarsocuneiform arthrodesis for management of hallux valgus and metatarsus
primus varus. Foot Ankle 1992;13:107-115.
25. Catanzariti AR. First metatarsocuneiform joint arthrodesis. In: Marcinko DE, ed. Comprehensive textbook of hallux
abducto valgus reconstruction. St. Louis: Mosby-Yearbook, 1992.
26. Goldner JL, Gaines R. Adult and juvenile hallux valgus: analysis and treatment. Orthop Clin North Am 1976;7:863-887.
27. Brage ME, Holmes JR, Sangeorzan BJ. The influence of x-ray orientation on the first metatarsocuneiform joint angle.
Foot Ankle Int 1994;15:495-497.
28. Catanzariti AR. Graft-enhanced arthrodesis. J Foot Ankle Surg 1996;35:463-473.
29. Catanzariti A, Karlock L. The application of allograft bone in foot and ankle surgery. J Foot Ankle Surg 1996;35:440-451.
30. Butson ARC. A modification of the Lapidus operation for hallux valgus. J Bone Joint Surg Br 1980;62:350-352.
31. Chang TJ, Ruch JA. Lapidus arthrodesis: a different perspective. J Am Podiatr Med Assoc 1994;84:281-288.
32. Cotton FJ. Foot statistics in surgery. N Engl Surg Soc 1935;18:181-187.
33. Fowler B, Brooks AL, Parrish TF. The cavovarus foot. J Bone Joint Surg Am 1959;41:757-764.
34. Hoffman AA, Constine RM, McBride GG, et al. Osteotomy of the first cuneiform as treatment of residual adduction of
the forepart of the foot in clubfoot. J Bone Joint Surg Am 1984;66:985-990.
35. Joplin RJ. Some common foot disorder amenable to surgery. Am Acad Orthop Surg 1958;15:144-149.
36. Graver HH. Cuneiform osteotomy in correction of metatarsus primus adductus. J Am Podiatry Assoc 1978;68:111-116.
37. Hara B, Beck JC, Woo RA. First cuneiform closing abductory osteotomy for reduction of metatarsus primus adductus. J
Foot Surg 1992;31:434-439.
38. Ganley JV, Ganley TJ. Metatarsus adductus deformity. In: McGlamry ED, Banks AS, Downey MS, eds. Comprehensive
textbook of foot surgery, 2nd ed. Baltimore: Williams & Wilkins, 1992:829-852.
39. Lynch FR. Applications of the opening wedge cuneiform osteotomy in the surgical repair of juvenile hallux abducto
valgus. J Foot Ankle Surg 1995;34:103-123.
40. Bacardi BE, Frankel JP. Biplane cuneiform osteotomy for juvenile metatarsus primus varus. J Foot Surg 1986;25:472-
478.
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Chapter 9
Osteotomies of the First Metatarsal Shaft in Hallux Abducto Valgus
PART 1 Offset-V Osteotomy

Gary R. Bauer
Harold W. Vogler
Shaft osteotomies may be employed in the repair of hallux abducto valgus deformities in some patients as an alternative to proximal
procedures. The offset-V osteotomy is one type of shaft osteotomy and represents a modification of the Ludloff procedure (1 ). The
procedure was first performed by Vogler in 1983 (2 , 3 , 4 ). The apex of the osteotomy is located at the distal metaphyseal-diaphyseal
junction of the first metatarsal (Fig. 1 ). This zone, referred to as transitional bone, represents the junction between primarily cortical
and cancellous bone (2 ). Compared with a base osteotomy, the procedure is performed at a more distal location with a shorter lever arm,
and it allows protected weight-bearing ambulation in the immediate postoperative course. It has therefore been characterized as a
“compromise osteotomy”(2 ). The procedure is useful in patients with cystic erosion of the metatarsal head that may make performance
and stabilization of a metaphyseal type osteotomy difficult.
The intrinsic stability of the offset-V osteotomy is conferred by its geometry, with long dorsal and short plantar legs. The procedure is
versatile and allows for reduction of intermetatarsal angles up to 18 degrees and proximal articular set angle deviation (PASA) in excess of
40 degrees. The reduction of the intermetatarsal angle is achieved through lateral translation of the capital fragment.
TECHNIQUE
Because of the diaphyseal location of the osteotomy and the degree of displacement of the capital fragment that is often achieved,
surgical dissection is usually minimized to maintain the vascular supply to the osseous segments (5 , 6 , 7 , 8 , 9 ). The skin approach is
through the classic dorsomedial linear incision. After incision of the superficial fascia, a limited dissection interval is developed between
the superficial and deep fascia along the dorsomedial first metatarsal. The capsular and periosteal incision is curvilinear and commences
over the proximal third of the metatarsal in line with the medial margin of the extensor hallucis longus tendon. It then curves medial to
the level of the metatarsal insertion of the medial collateral ligamentous complex and ends in the midline dorsally on the phalangeal base.
The periosteal-capsular plane is raised medially to expose the metatarsal. Care is taken to preserve the integrity of the capsular tissues for
subsequent closure.
The tissues in the first intermetatarsal space may then be released, and the medial eminence of the metatarsal head is resected. We have
often employed a percutaneous approach for the former maneuver. A 0.045-inch Kirschner wire is positioned at the anticipated apex of the
offset-V osteotomy as an axis guide and is oriented to accomplish the desired displacement plane of the distal fragment. Factors that
influence pin orientation include relative length of the first metatarsal, metatarsus primus elevatus, sub-second metatarsalgia, and PASA
deviation.
The geometry of the offset-V osteotomy varies depending on the size and shape of the metatarsal and the magnitude of the deformity. The
typical divergence of the wings of the osteotomy is 40 to 45 degrees. The length of the dorsal wing depends on the size of the metatarsal
and the degree of PASA to be addressed, but it usually extends 50% to 75% of the length of the bone. Significant swivel of the capital
fragment requires a shorter dorsal cut to prevent the juxtaposition of the proximal wing against the second metatarsal.
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FIG. 1. The offset-V osteotomy.
The legs of the offset-V osteotomy are scored onto the medial metatarsal with the saw blade directed perpendicular to the osseous surface.
The dorsal cut is accomplished first and begins distally. This maneuver facilitates the saw blade orientation through the medial cortex in
line with the axis guide. Stability afforded by the intact plantar leg facilitates completion of the longer proximal wing. After completion of
the plantar cut, a lateral shift of the capital fragment frequently occurs spontaneously. Distal traction on the hallux creates gapping across
the entire osteotomy and confirms that the osteotomy is complete.
Lateral translation of the capital fragment reduces the intermetatarsal angle and is facilitated by placing a curved mosquito hemostat
proximal to the apex of the osteotomy into the first metatarsal interspace just lateral to the extensor hallucis longus tendon. The tip of
the instrument engages the lateral cortex of the proximal segment. The hallux is distracted, and the capital fragment is forced laterally
with direct pressure while the hemostat pushes the proximal metatarsal fragment medially (Fig. 2 ). Resistance to shift most commonly is
the result of incomplete transection of the metatarsal
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at either the proximal cortex of the dorsal wing or the osteotomy apex distally. Occasionally, a significantly displaced fibular sesamoid may
act as an obstacle to lateral transposition and requires blunt manipulation with the aid of the hemostat. The typical amount of lateral
translation approaches 50% to 75% of the shaft width (Fig. 3 ).
FIG. 3. A: Preoperative radiograph of a 63-year-old woman with hallux abducto valgus and metatarsus primus varus. The
intermetatarsal angle is 18 degrees. B: Postoperative appearance.
FIG. 2. Lateral translation of the capital fragment to reduce the intermetatarsal angle. Note the hemostat that is levered against the
proximal segment of the first metatarsal shaft within the interspace to facilitate the maneuver.
FIG. 4. After lateral transposition, one may swivel the capital fragment to achieve reduction of the proximal articular set angle.
Resection of any redundant bone medially may then be accomplished.
After lateral displacement, the distal fragment may be rotated to effect reduction of the PASA. The hemostat is repositioned medial to the
proximal portion of the dorsal wing and lateral to the lateral cortical wall of the proximal fragment. This serves as a fulcrum around which
the swivel maneuver may be used to correct the proximal articular set angle (Figs. 4 and 5 ). The cancellous substance of the metatarsal
head is impacted medially into the medullary canal of the shaft as the pivot occurs around the lateral cortical apex spike of the proximal
segment. “Troughing” is possible with this maneuver because of the cortical location of the procedure. The orientation of the osteotomy
dictates that the capital fragment plantarflex should troughing develop. This added plantarflexion of the metatarsal may be beneficial in
reducing lesser metatarsalgia. This is in contrast to iatrogenic primus elevatus that can occur with “troughing” in the Scarf Z-procedure
(10 ,11 ).
The redundant medial cortical overhang is then resected. This triangular fragment may be reversed from anterior to posterior and may be
inserted as a wedge into the intramedullary canal between the remaining medial cortex of the proximal fragment and the medial border of
the dorsal wing of the capital fragment (Fig. 6 ). This serves as an autogenous bone graft to enhance healing and fills the void in the
medullary canal.
FIG. 5. Note the swivel of the capital fragment in this patient to address the deviated proximal articular set angle.
Osteosynthesis is then accomplished. In patients with high intermetatarsal angles and PASA components, the reduced bone contact may
limit the fixation to one obliquely driven Kirschner wire. When the displacement contact area is sufficient, two cortical screws are
commonly used for fixation (Fig. 7 ). One well-positioned 0.062-inch Kirschner wire provides stable fixation for this osteotomy even in the
presence of significant displacement and limited bony contact (Fig. 8 ). Experimental study has demonstrated the importance of the pin
orientation. Enhanced stability can be achieved by delivering fixation from dorsal proximal medial to plantar distal lateral, crossing the
plantar wing of the osteotomy (12 ,13 ). The pin may be left percutaneously or used as temporary fixation while screws are inserted.
Closure is accomplished in layered fashion and may be enhanced with two to three obliquely oriented “load sutures” in the capsule using 2-
0 absorbable suture incorporating the thickened medial capsule and medial collateral ligament. These load sutures are directed obliquely
from plantar distal to proximal dorsal. The hallux is held in corrected alignment with slight adduction and plantarflexion at
metatarsophalangeal joint level.
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FIG. 6. Resection of the medial overhang with autogenous bone graft translocation. A: The medial overhang redundancy is resected
colinear to the plane of the medial eminence. The resected fragment is rotated front to back 180 degrees. B: The rotated fragment is
positioned into the intramedullary canal between the medial cortex of the proximal metatarsal segment and the medial border of the
dorsal wing of the capital segment. This bone graft functions to stabilize the osteotomy after the swivel maneuver.
FIG. 7. The osteotomy may be fixated with two 2.0- or 2.7- mm screws.
FIG. 8. Radiograph after fixation with Kirschner wire and a bone graft wedge.
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FIG. 9. Postoperative synostosis between the first and second metatarsals. A: Focal synostosis that was asymptomatic 3 years
postoperatively. Note the well-maintained alignment and sesamoid position. B: Another case with more extensive bridging.
A compression bandage is applied, and the patient is allowed to bear weight with either a surgical shoe or a slipper cast, depending on the
surgeon's preference. Immobilization varies from 4 to 6 weeks, depending on the magnitude of osseous displacement and other patient
factors. Early active and passive range-of-motion exercises are encouraged, to maintain first metatarsophalangeal joint flexibility during
the immediate postsurgical phase, although bandaging impedes this process to some extent. After cast or bandage removal, the patient
may resume wearing closed shoes as tolerated. Most commonly, a supportive athletic style shoe is initially employed until postoperative
swelling is reduced and joint mobility is restored. Serial radiographs are used to monitor consolidation and remodeling. Generally, no
significant external bone callus develops other than along the proximal aspect of the dorsal wing segment. The displaced lateral wing
undergoes remodeling with resorption, blunting, and new bone formation. This process is complete at about 8 months postoperatively and
provides a more rectus first ray appearance radiographically.
COMPLICATIONS
The procedure has proven to be predictable and rewarding in resolving painful hallux valgus conditions associated with moderate to severe
deformity. Age presents no barrier to the performance of this procedure, provided the patient's circulatory status is sufficient. Reduced
bone stock or poor quality can result in telescoping and additional shortening of the first ray segment. As with all reconstructive
procedures for hallux abducto valgus, patients may experience some reduction in the total range of motion of the first
Significant PASA correction accomplished with the swivel maneuver performed along a plantar laterally declinated axis guide plane
produces apparent elevatus of the metatarsal head with plantar migration of the dorsal wing. Although this condition presents more of an
adverse radiographic appearance than a functional detriment, this situation is generally avoided. Infrequently, a synostosis may develop
between the second metatarsal and the dorsal wing, without causing subjective complaints or any untoward clinical consequences (Fig. 9 ).
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scintigraphy. Foot Ankle 1992;13:137-142.
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the first metatarsal head. J Bone Joint Surg Am 1995;77:197-204.
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12. Gonda E, Bauer GR, Hillstrom HJ, et al. Stability of the offset V osteotomy: test jig development and saw bone model assessment.
J Am Podiatr Med Assoc (submitted).
13. Dalton SK, Bauer GR, Lamm BM, et al. Stability of the offset V osteotomy: effects of fixation and surgical translocation in saw
bone and preserved cadaver specimens. Presented at the 57th American College of Foot and Ankle Surgeons symposium, 1999.
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PART 2 Scarf Z-Osteotomy

Charles J. Gudas
HISTORICAL REVIEW
As surgeons became interested in reevaluating osteotomies of the first metatarsal shaft for the repair of hallux abducto valgus deformity,
Zygmunt and Gudas devised a procedure that become known as the Scarf osteotomy. A similarly configured osteotomy had been previously
described by Meyer, but with the bone cuts performed in the sagittal versus the transverse plane (1 ). Like the Mau procedure, the Scarf
osteotomy, which is also known as the Zosteotomy, is performed in the midshaft of the first metatarsal. However, the Scarf procedure is
inherently more stable than the Mau procedure because of the interlocking segments at each end of the osteotomy that allow for early
postoperative weight bearing (Fig. 10 ). Various modifications of the Scarf osteotomy were offered shortly after the procedure became
popular, so some form of this procedure is commonly employed for the repair of hallux abducto valgus.
INDICATIONS
Initially, investigators believed that the Z-osteotomy would be well suited for the repair of hallux abducto valgus deformities with mild to
moderate intermetatarsal angles. Some authors noted that this would offer the surgeon the opportunity for an “in between” procedure for
those patients whose metatarsus primus adductus deformities were believed to be too great for an Austin or capital osteotomy, yet one
desired to avoid the non-weight-bearing protocol required with a base wedge procedure (2 ). However, as with the capital osteotomies,
time and experience have demonstrated that the Scarf procedure may be employed for patients with larger intermetatarsal angles than
had initially been appreciated (3 ). One may also obtain simultaneous correction of a deviated proximal articular set angle by derotating
the capital fragment. However, this maneuver tends to counteract and limit the reduction of the intermetatarsal angle that is attained (4 ).
Patients who have a first metatarsal of average or greater width also seem to derive greater potential benefit from this procedure,
especially when larger intermetatarsal angles are encountered.
The Scarf procedure has also been advocated for patients with a short first metatarsal based on the premise that little if any shortening
occurs with the osteotomy (5 ). However, shortening occurs with most any procedure that transects the bone, so preservation of
metatarsal length should not be considered a unique property of the procedure. However, as with the capital osteotomies, the axis of the
Z-osteotomy can be modified to lengthen or shorten the first metatarsal when required.
CONTRAINDICATIONS
Because of the complexity and length of the osteotomy, these procedures are best employed in patients with good bone quality and
without significant osteopenia (4 ). In patients with reduced bone quality, the ability to stabilize the osteotomy adequately after rotation
or transposition is limited. Surgeons may also want to exercise care when they contemplate performing the procedure in obese patients if
these patients are to be fully weight bearing postoperatively.
SURGICAL CONSIDERATIONS
Surgical Technique
The incision is generally placed over the medial or dorsomedial aspect of the first ray, and it extends from the midshaft or proximal region
of the first metatarsal to the base of the proximal phalanx of the hallux. Dissection within the interspace and the medial exposure of the
metatarsal head is conducted as preferred by the surgeon. The periosteum needs to be incised along the course of the incision, with a
greater length usually required for reduction of larger intermetatarsal angles. The periosteum needs to be freed from the metatarsal to
execute the osteotomy and to provide adequate visualization for the fixation process. The medial eminence may be removed before or
after the osteotomy, and this segment of bone may be used as a subsequent graft for a variety of purposes.
The osteotomy consists of a longitudinal cut through the midshaft of the first metatarsal with additional cuts proximally and distally to
transect the plantar and dorsal cortices, respectively. The horizontal portion of the osteotomy typically measures 3 to 4 cm. This cut is
placed at the junction of the upper two-thirds of the first metatarsal and the lower one-third of the first metatarsal to provide a stronger
dorsal wing to resist weight-bearing forces. A sharp, thin, broad saw blade is preferred for the horizontal cut, which is initiated
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from medially to laterally, and it may be directed slightly plantarward to enhance the weight-bearing position of the metatarsal
postoperatively. The distal and proximal cuts of the Z-osteotomy are made 60 to 80 degrees from the perpendicular (Fig. 11 ). Care should
be taken so the distal and proximal cuts do not extend beyond the longitudinal osteotomy of the metatarsal shaft; otherwise, the bone will
be weakened, possibly leading to later stress fracture. One way to help prevent this overcutting of the bone is to use a small osteotome to
perform the final portion of the transection.
FIG. 10. The Scarf osteotomy.
Although not required, axis guides, which are typically smooth Kirschner wires (K-wires), may help the surgeon to perform this procedure
with greater precision (5 ,6 ) (Fig. 12 ). This may be particularly helpful when attempting to alter either the sagittal plane alignment or
length of the first metatarsal with transposition of the osteotomy. As with other procedures, altering the plane of the osteotomy may help
the surgeon to accomplish the change in position of the first metatarsal that is desired. However, transposition will be more difficult if the
proximal and distal cuts are oriented perpendicular to the first metatarsal or if lengthening is attempted.
Translocation of the osteotomy may be facilitated by distracting the hallux and employing a small osteotome to free up any remaining
osseous attachments plantar laterally. The capital fragment is displaced approximately one-third of the width of the metatarsal shaft and
is initially stabilized with a bone clamp. Intraoperative radiographs may be used at this point to assess the osteotomy and the degree of
correction. Furthermore, one should note whether the distal aspect of the osteotomy is approximated, because the juxtaposition at this
level enhances overall stability. The osteotomy may also be pivoted to reduce deviation of the proximal articular set angle (Fig. 13 ). The
medial corticocancellous overhang is removed with a sharp bone saw and may be used as a graft.
FIG. 11. Intraoperative view after completion of the Scarf procedure and before transposition. Note the saw blade typically used to
perform the osteotomy.
Fixation
Satisfactory stabilization of the osteotomy may be performed with various devices including screws (2 ,4 ,5 ,7 ,8 ), threaded K-wires (6 ,9 ),
smooth K-wires (10 ), and absorbable pins (11 ). Two fixation devices are preferred to provide the best stability with the longer form of the
osteotomy (Fig. 14 ). However, shorter forms of the Z-osteotomy may be adequately stabilized with only one fixation device (10 ,12 ).
In some situations, secondary fixation may become necessary if there is instability at the osteotomy site, if only one screw or wire can be
properly positioned, or if significant osteopenia is present. Secondary stabilization of the osteotomy may include the use of smooth K-wires
oriented from proximal and medial to the osteotomy and directed distally into the metatarsal head. A second K-wire can be driven from
the head of the metatarsal proximally. The wires may be buried or left percutaneously, in which case they are removed after 4 to 6 weeks.
In these circumstances, the patient is usually maintained in a non-weight-bearing status. Throughout the fixation process, care must be
taken not to compromise the dorsal cortex with multiple drill sites, or further failure may occur.
Postoperative Care
The specifics of the postoperative care depend on the stability obtained during surgery, the quality of the bone, the weight of the patient,
and the patient's ability to comprehend and follow postoperative instructions. Younger, healthy patients with good bone stock and a
comparatively normalsized first metatarsal are allowed to bear weight in a surgical shoe for 3 to 4 weeks. After this period, the patient
may begin use of a wide-toe running shoe as tolerated. Otherwise, when instability or other factors may lead to compromise with weight
bearing, patients may be maintained in a non-weight-bearing status until healing has occurred, or they may be allowed to bear weight with
a cast or other assistive device. Consolidation of the osteotomy usually occurs 6 to 8 weeks postoperatively. Progress is monitored with
serial radiographs (Fig. 15 ).
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FIG. 12. A,B: As with the Austin procedure, axis guides may be used at the proximal and distal apices of the Scarf osteotomy to
enhance execution of the procedure. The plane of the axis guides may be altered to provide shortening or lengthening and
plantarflexion or dorsiflexion of the metatarsal with lateral transposition. In this instance, the axis wires are oriented so
plantarflexion will be achieved with lateral translocation. The axis guides must be parallel to one another to achieve an accurate cut.
FIG. 13. A: Lateral transposition of the Scarf procedure corrects the intermetatarsal angle. B: By pivoting or swiveling the osteotomy,
one may also correct a deviated proximal articular set angle.
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FIG. 14. A-C: In some instances, the fixation devices may not provide adequate stability in a parallel orientation. Therefore,
different orientations may be employed for the internal fixation devices to maintain alignment.
Modifications
Numerous modifications of the original Scarf procedure have been described and used with success. Shorter versions of the osteotomy have
been used (8 ,10 ,12 ). Although these modifications appear to offer no specific advantage over the Austin or modified Austin procedures,
the procedures may be employed successfully based on the surgeon's preference.
Originally, the longitudinal portion of the Scarf osteotomy was made at the junction of the dorsal two-thirds and the plantar one-third of
the metatarsal shaft in an attempt to protect the proximal cut from stress fracture (Fig. 10 ). With this configuration, the distal fragment
was subjected to high stress loads, and the result was an occasional distal metatarsal fracture. Because of this problem, different bone
cuts evolved to help protect the proximal and distal portions of the osteotomy from potential fracture. One popular technique is to place
the distal apex in the upper two-thirds of the distal metaphysis and the proximal apex at the lower two-thirds of the midshaft or
metaphysis of the bone (Fig. 16 ). A 1.5- or 2.0-mm drill may be used to predrill the cortex at each end to avoid any cross-hatching that
may occur during the osteotomy. However, this technique may not be practical if axis guides are used to help create the osteotomy.
FIG. 15. Preoperative (A) and postoperative (B) radiographs of a patient undergoing a Scarf procedure. Two parallel forms of fixation
are typically employed from dorsal to plantar to provide stabilization.
Some authors have described the resection of segments of bone from the distal or proximal aspects of the osteotomy to facilitate the
reduction of a deviated proximal articular set angle. This technique tends to enhance the apposition of the distal aspect of the osteotomy
after the swivel or pivot of the first metatarsal head. Kramer et al. proposed altering the distal portion of the osteotomy to a 90-degree
relationship with the longitudinal cut (5 ). This technique was believed to facilitate accurate resection of a medially based wedge from the
metatarsal head. Other investigators noted that this relationship allows for greater ease of insertion of
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bone grafts to fill any deficits after transposition of the osteotomy (13 ).
FIG. 16. In an attempt to provide a stronger osteotomy, one may alter the configuration of the Scarf procedure so the distal cut is
made in the dorsal one-third of the metatarsal and the proximal cut is made in the plantar one-third of the metatarsal.
Traditionally, the Scarf procedure was considered a transpositional osteotomy. However, some investigators have proposed that better
correction may be achieved by proximal rotation, similar to the Mau procedure (2 ,13 ). These authors believe that rotating the distal
fragment leads to better bone overlap along the course of the osteotomy and allows one to provide for greater degrees of intermetatarsal
angle correction (Fig. 17 ).
Perhaps the most significant change from the original Scarf procedure has been the development of the inverted Scarf or inverted Z-
osteotomy (Fig. 18 ). The impetus for evaluating this configuration came from research that demonstrated that the inverted osteotomy
provided greater resistance to disruption from weight-bearing forces. In studies using plastic bone models, as well as fresh-frozen cadaver
limbs, consistent fracture patterns were produced with each osteotomy, but significantly greater quantitative force was required to create
disruption of the inverted Z-osteotomy (14 ,15 ). In the traditional Scarf configuration, a fracture or stress riser was noted extending from
the proximal aspect of the osteotomy through the dorsal metatarsal. With the inverted Z-osteotomy, most specimens demonstrated a
fragmentary type of fracture from the proximal cut of the osteotomy through the plantar metatarsal shaft. Furthermore, the inverted Z
configuration was noted to be approximately 1.6 times stronger than the traditional Scarf osteotomy. However, either configuration is
sufficiently stable to resist the normal forces of weight bearing for most patients (15 ), and these experiments do not necessarily recreate
actual stresses experienced by a patient during weight bearing. Therefore, extrapolating the experimental data to clinical practice is not
always proportional or accurate.
FIG. 17. In a rotational Scarf procedure, the distal metatarsal is rotated about the proximal segment to provide reduction of the
intermetatarsal angle.
FIG. 18. The inverted Scarf procedure.
RESULTS
Overall, surgeons have reported good results with the Scarf procedure, with few problems encountered (Fig. 19 ). Evaluation at significant
intervals after surgery has demonstrated 85% to 90% patient satisfaction (3 ,4 ). Furthermore, average intermetatarsal angles have been
reduced 6 to 11 degrees (3 ,5 ,7 ,12 ,16 ). Although the location of the osteotomy may be of concern to some surgeons, primary bone
healing was noted in 95% of patients in a review evaluating 230 Scarf procedures (9 ).
Zygmunt et al. evaluated 39 patients having undergone 66 procedures with an average follow-up period of 29 months (4 ). Good reduction
of deformity and good range of motion at the first metatarsophalangeal joint were appreciated. Intermetatarsal angles were reduced from
an average preoperative value of 16 degrees to an average postoperative measurement of 8 degrees. Minimal shortening was noted in the
first metatarsal. The surgeons rated 79% of the feet as satisfactory, 12% as mostly satisfactory, and 9% as unsatisfactory. The last category
was composed of 2 feet with hallux varus, 2 feet with first metatarsal fractures, and 2 feet with recurrent hallux abducto valgus.
Schoen and colleagues performed an extensive evaluation on 31 patients with an average follow-up of 5 to 9 years (3 ). Objectively,
patients demonstrated a mean postoperative range of motion of 75 degrees, and a sesamoid position of 2.8. The first metatarsal was found
to have shortened by an average of 1.64 mm, and the average postoperative intermetatarsal angle was reduced to 7.1 degrees. No patients
studied had pain or crepitus on range of motion of the first metatarsophalangeal joint, and no lateral metatarsalgia was noted. Avascular
necrosis was identified in a single patient, but it was asymptomatic. A mild hallux varus or hallux adductus was the most frequently
encountered complication and was noted in 20% of their patients.
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FIG. 19. Preoperative radiographs (A,B), postoperative radiographs (C,D), and 3-year follow-up radiograph after a Scarf osteotomy
(E). (Courtesy of Norman Kornblatt, D.P.M.)
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FIG. 19. Continued.
FIG. 20. A: Troughing of the first metatarsal may occur with the shaft type of osteotomies as the metatarsal segments are shifted. In
this situation, the stronger cortical bone may be impacted into the more porous cancellous bone to create a shift in the alignment of
the osteotomy. B,C: This may be overcome by inserting a bone graft from the medial eminence of the first metatarsal head into the
osteotomy.
Kelikian evaluated 35 patients representing a total of 50 surgical procedures and found good reduction of deformity and patient
satisfaction (7 ). The intermetatarsal angle was reduced an average of 11 degrees. The only problems noted were a single patient with an
asymptomatic fibrous union and 2 patients with screw irritation.
In one study, a comparison of patients undergoing the Scarf and modified Austin procedures was conducted (16 ). These investigators noted
that intermetatarsal angles were adequately reduced in both groups without any appreciable difference in postoperative complications.
However, the modified Austin procedure did appear to provide greater alleviation of symptoms than the Scarf osteotomy. However, there
was no real standardization of multiple parameters. In particular, multiple forms of fixation were used for both procedures.
In yet another study, although satisfactory results were reported in patients undergoing a shorter version of the Scarf osteotomy, in 7 of
the 50 procedures, patients developed fractures of the first metatarsal (12 ). Furthermore, the average amount of intermetataral angle
correction was 6.3 degrees, which is less than that reported with the more traditional form of the procedure.
COMPLICATIONS
Troughing along the first metatarsal is a problem that is more commonly noted with shaft osteotomies such as the Scarf (6 ,13 ). This
condition may develop as the osteotomy is translocated laterally to where the cortical margins of the first metatarsal are now opposed
with the open medullary canal. This harder cortical bone may then compress into the shaft of the metatarsal and may create instability or
malposition. Most often, this is recognized as the surgeon begins to fixate the osteotomy, particularly if compression fixation is achieved
(Figs. 20A and 21 ). Troughing tends to be less problematic in younger patients or in patients with little osteopenia. Duke noted that
troughing was more frequent in
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patients older than 50 years of age (13 ). He also noted that troughing is more likely to develop if the distal aspect of the osteotomy is
placed beyond the confines of the metaphyseal bone into a more proximal position.
FIG. 21. In this patient, troughing resulted in dorsiflexion of the distal fragment of the metatarsal.
Using a bone graft from the previously resected medial eminence or medial overhang may be one measure that may be considered to resist
troughing (3 ,13 ). The graft is typically placed in the plantar proximal portion of the medullary canal. Alternatively, cancellous graft from
the medial eminence may be inserted into the distal plantar canal abutting the distal apex of the osteotomy (Figs. 20B and C and 22 ).
After the bone grafts have been positioned, one should inspect the dorsal distal aspect of the osteotomy to ensure that good apposition
remains. If some distal slippage tends to develop once stabilization has been performed, then the osteotomy and grafts may be
repositioned, and a 0.062-inch K-wire may be inserted across the osteotomy to prevent distal movement when the bone clamp is applied.
Another technique to resist troughing is to use fixation devices that maintain the position of the fragments, but do not actually provide
compression. Threaded K-wires or cortical bone screws that are inserted without overdrilling (i.e., not in lag fashion) may be reasonable
alternatives.
FIG. 22. Intraoperative appearance of the osteotomy graft to eliminate troughing.
FIG. 23. Fracture through the proximal metatarsal after a Scarf osteotomy. Conservative measures are usually adequate to allow
uneventful healing.
Fractures of the metatarsal have also been noted in a small number of cases (4 ,13 ). Distal fractures have been noted to occur acutely in
some instances, whereas proximal fractures are often not noted until 2 to 3 weeks into the postoperative period. Because distal fractures
may involve the first metatarsophalangeal joint, surgical reduction may be required. Distal fractures may also be seen at the interface of
the most distal screw, yet without joint compromise (13 ). Proximal fractures may be treated successfully in a conservative manner
provided displacement is not significant, but one must carefully monitor the healing process and the patient's compliance because
elevation of the metatarsal has been noted after such fractures (4 ) (Fig. 23 ).
Zygmunt et al. noted two patients who sustained fractures through the dorsal cortex of the first metatarsal at the proximal portion of the
osteotomy (4 ). This complication was attributed to an osteotomy that was positioned too far dorsally within the first metatarsal shaft.
However, later authors demonstrated that this was a consistent site and means of failure in metatarsals that were stressed to the point of
fracture and therefore probably was not as dependent on the sagittal plane position of the osteotomy as originally thought (15 ). The
greatest number of patients who sustained a fracture of the osteotomy was reported after a shorter version of the Scarf procedure (12 ).
As a means of attempting to overcome the risk of postoperative fracture, the surgeon may choose to alter the configuration of the
osteotomy. As previously mentioned, one technique is to place the distal apex in the upper two-thirds of the distal metaphysis and the
proximal apex at the lower two-thirds of the midshaft or metaphysis of the bone (Fig. 16 ). Alternatively, one may consider an inverted-Z
osteotomy. However, the risk of significant fracture appears to be low, and no studies have confirmed any greater degree of efficacy with
either modification.
Dorsiflexion of the capital fragment was noted in a significant number of patients undergoing the short Z-bunionectomy. This problem was
evident in 30% of the patients
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whose osteotomies were fixated with absorbable pins, yet in 60% of patients undergoing screw fixation. Overt dislocation of the osteotomy
occurred in 2 of 29 patients in whom absorbable pins were used. Modifying the dorsal cut to a more acute angle approximating 45 degrees
appeared to prevent dislocation of the capital fragment in subsequent patients with absorbable fixation (11 ).
SUMMARY
The Scarf or Z-osteotomy is an effective, yet complex procedure that has been used in the correction of hallux abducto valgus. In most
instances, the procedure is best suited for patients with intermetatarsal angles between 12 and 18 degrees in a rectus foot type, and
therefore, it may be an alternative to more traditional proximal osteotomies. Studies have indicated that good long-term reduction of the
deformity can be maintained, with few postoperative complications.
REFERENCES
1. Vogler H, Smith M. Osteotomy of the first metatarsal shaft in hallux abducto valgus surgery. In: McGlamry ED, Banks AS, Downey MS,
eds. Comprehensive textbook of foot surgery. Baltimore: Williams & Wilkins, 1992:523-532.
2. Gerbert J, Palladino SJ. The double osteotomy and the Scarf procedure of the first metatarsal. In: Gerbert J, ed. Textbook of
bunion surgery. Mt. Kisco, NY: Futura, 1991:409-438.
3. Schoen NS, Zygmunt K, Gudas C. Z-bunionectomy: retrospective long-term study. J Foot Ankle Surg 1996;35:312-317.
4. Zygmunt K, Gudas C, Laros G. Z-Bunionectomy with internal fixation. J Am Podiatr Med Assoc 1989;79:322-329.
5. Kramer J, Barry LD, Helfman DN, et al. The modified Scarf bunionectomy. J Foot Surg 1992;31:360-367.
6. Shaffer M. The Meyer-Scarf midshaft osteotomy. In: Marcinko D, ed. Comprehensive textbook of hallux abducto valgus. St. Louis:
CV Mosby, 1992:139-146.
7. Kelikian A. The surgical treatment of hallux valgus using the modified Z-osteotomy. Clin Sports Med 1988;7:61-74.
8. Gill PW. Modification of the Scarf bunionectomy. J Am Podiatr Med Assoc 1988;78:187-189.
9. Schwartz N, Groves ER. Long-term follow-up of internal threaded Kirschner-wire fixation of the scarf bunionectomy. J Foot Surg
1987; 26:313-316.
10. Glickman S, Zahari D. Short “Z” bunionectomy. J Foot Surg 1986; 25:304-306.
11. Friend G, Grace K, Stone H. Cortical screws versus absorbable pins for fixation of the short Z-bunionectomy. J Foot Ankle Surg
1994;33: 411-418.
12. Pollack R, Bellacosa R, Higgins K, et al. Critical evaluation of the short “Z” bunionectomy. J Foot Surg 1989;28:158-161.
13. Duke HF. Rotational scarf (Z) osteotomy bunionectomy for correction of high intermetatarsal angles. J Am Podiatr Med Assoc
1992;82: 352-360.
14. Chang T, Yu G, Ruch J. The inverted Scarf bunionectomy. In: Ruch J, Vickers N, eds. Reconstructive surgery of the foot and leg:
update ‘92. Tucker, GA: Podiatry Institute, 1992:265-270.
15. Miller JM, Stuck R, Sartori M, et al. The inverted Z bunionectomy: quantitative analysis of the scarf and inverted scarf
bunionectomy osteotomies in fresh cadaveric matched pair specimens. J Foot Ankle Surg 1994;33:455-462.
16. Day MR, White SL, DeJesus JM. The “Z” osteotomy versus the Kalish osteotomy for the correction of hallux abducto valgus
deformities: a retrospective analysis. J Foot Ankle Surg 1997;36:44-50.
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PART 3 Mau and Ludloff Osteotomies

Tzvi Bar-David
Paul M. Greenberg
HISTORY
In 1913 and again in 1918, Ludloff described an oblique first metatarsal osteotomy oriented from dorsal proximal to plantar distal for the
correction of metatarsus primus adductus associated with hallux abducto valgus deformity (1 ,2 ). In 1926, Mau challenged the stability of
the Ludloff procedure and described the reverse osteotomy oriented from plantar proximal to dorsal distal, thereby creating a dorsal shelf
to resist weight-bearing forces (3 ) (Figs. 24 and 25 ). As originally described, fixation was not applied to these osteotomies, despite their
inherent instability. The middiaphyseal location of each procedure was also a potential concern relative to bone healing. Therefore, both
these osteotomies were largely rejected for several decades. However, partly because of technical modifications and the advent of stable
forms of fixation, these procedures have gained popularity and are most commonly employed as alternatives to closing base wedge
osteotomies (4 , 5 , 6 , 7 , 8 ).
At first glance, these procedures may appear to be almost identical. However, to appreciate the difference between each osteotomy fully,
it is important to discuss the concept of planes of motion. Conceptually, two types of osteotomies provide correction of an increased
intermetatarsal angle: wedge resection and plane-of-motion osteotomies.
In a wedge resection procedure such as the closing base wedge osteotomy, the hinge axis influences the direction of motion (9 ). In a
plane-of-motion osteotomy, there is no hinge; therefore, the direction of motion is influenced by the plane or orientation of the osteotomy
(10 ). Plane-of-motion osteotomies may be either transpositional or rotational. In a transpositional osteotomy, such as the Ludloff
procedure, one bone fragment is slid on the other, to create areas without bone-to-bone contact. Other examples include the Austin,
offset-V, and Scarf procedures. In a rotational osteotomy, such as the Mau procedure, the distal portion of the metatarsal is rotated or is
pivoted around a relatively fixed axis. Therefore, the essential differences between the Mau and Ludloff procedures are the orientation of
the osteotomy and the means by which correction is achieved (Fig. 26 ).
FIG. 24. The Ludloff osteotomy. Lateral view of the first metatarsal.
FIG. 25. The Mau osteotomy. Lateral view of the first metatarsal.
INDICATIONS
Both the Ludloff and Mau procedures are indicated for correction of hallux abducto valgus deformities with intermetatarsal angles greater
than 13 degree and are alternatives to a closing base wedge osteotomy (8 ,11 ). Generally speaking, correction may be achieved with
relatively little shortening of the first metatarsal (4 ). Therefore, these procedures may be useful in patients with a short first ray. There
are no age limits, and each procedure has been performed on patients in their seventh decade. As with any proximal osteotomy, one must
be cautious in children with open growth plates. The average intermetatarsal angle reduction has been reported between 6.5 and 10.5
degrees (4 , 5 , 6 ), but good correction of deformity has been noted even in patients with first intermetatarsal angles up to 20 degrees
(4 ,6 ). Important factors are the quality of the bone and the ability of the patient to remain non-weight bearing postoperatively. The
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osteotomies are simple to perform, versatile, and easily adjusted intraoperatively.
FIG. 26. A: The Mau procedure is a rotational osteotomy, and the fragments are rotated. B: The Ludloff procedure is a
transpositional osteotomy, and the fragments slide on each other.
Because the Mau is a rotational osteotomy and bone-to-bone contact is maintained proximally, troughing and accompanying instability are
not common problems. Troughing may be more likely with the Ludloff procedure because the operation is transpositional. However, there
may be a significant area of cortical overlap at the proximal and distal aspects of the osteotomy to promote stability.
OPERATIVE TECHNIQUE
Mau Osteotomy
A dorsolinear incision the length of the first metatarsal is placed medial and parallel to the extensor hallucis longus tendon. The incision is
deepened bluntly to the periosteum, and the capsule of the first metatarsophalangeal joint is released. The periosteal incision is then
extended proximally, and the metatarsocuneiform joint is identified. The periosteum is reflected dorsally and plantarly, and the plantar
flare of the base of the metatarsal is visualized. Care is taken not to disrupt the plantar first metatarsocuneiform ligament because this
provides sagittal plane stability to the first ray (12 ) (Fig. 27 ).
The foot is rotated laterally to enhance the visualization of the dorsal, medial, and plantar surfaces of the metatarsal. A power saw is used
to perform the osteotomy, which is oriented from distal dorsal to proximal plantar. The cut extends from approximately 1 to 1.5 cm
proximal to the metatarsophalangeal joint to approximately 1 to 1.5 cm distal to the metatarsocuneiform joint. The entire length of
medial cortical bone is osteotomized first, and the medial cortex is then used as a guide for cutting the lateral cortex.
The osteotomy is stabilized with a bone clamp before any manipulation. A 0.045-inch Kirschner wire is then drilled perpendicular to the
osteotomy from dorsal to plantar in the proximal aspect of the metatarsal. The purpose of the wire is to act as an axis of rotation for the
osteotomy. Once the Kirschner wire is inserted, the bone clamp is removed, and the distal fragment is rotated laterally to reduce the
intermetatarsal angle. The bone clamp is then reapplied to stabilize the osteotomy in its corrected position (Fig. 28 ).
The intermetatarsal angle is evaluated before fixation to determine the amount of reduction. One may use the juxtaposition between the
first and second metatarsal heads as a general guide to gauge the degree of correction. If insufficient or excessive correction is deemed to
have occurred, then the bone clamp may be removed and the osteotomy realigned into a better position. The osteotomy is fixated, and
the medial overhang of bone is removed (Figs. 29 and 30 ).
FIG. 27. Intraoperative photograph demonstrating the exposure required to effect the Mau osteotomy.
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FIG. 28. A: Preoperative radiograph of a patient with hallux abducto valgus deformity. B: Intraoperative radiograph after the Mau
osteotomy. Note the Kirschner wire, used as an axis for rotation. C: The osteotomy after fixation.
FIG. 29. A: Preoperative radiograph of a patient with hallux abducto valgus deformity. B,C: Postoperative dorsal plantar and lateral
radiographs.
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FIG. 30. Preoperative (A) postoperative (B) radiographs of a patient after a healed Mau osteotomy and after removal of fixation.
Ludloff Osteotomy
The dissection for the Ludloff procedure is the same as that for the Mau procedure. Once the patient's foot is positioned, the osteotomy is
performed from medial to lateral with an orientation from dorsal proximal to plantar distal. The osteotomy extends from 1.5 cm distal to
the metatarsocuneiform joint to proximal to the sesamoid apparatus. The distal fragment is transposed laterally to reduce the
intermetatarsal angle. The osteotomy is stabilized with a bone clamp, and correction is evaluated before fixation. The osteotomy is fixated,
and the medial overhang of bone is removed.
Modifications
As originally described, both the Mau and Ludloff procedures were shorter, midshaft osteotomies. Neese and colleagues introduced a
longer modified Mau procedure, as just described (4 ). This makes good, stable, internal fixation easier and also tends to leave the
osteotomy closer to parallel relative to the supporting surface, thereby enhancing later resistance to weight-bearing forces. This
modification appears to be a preferred approach compared with the original procedure.
The Mau and Ludloff osteotomies are versatile procedures that allow additional adjustments to realign the first metatarsal in addition to
reducing the intermetatarsal angle (Figs. 31 and 32 ). If the osteotomy is oriented from medial dorsal to lateral plantar, then
plantarflexion can be achieved when the intermetatarsal angle is reduced. Conversely, if the osteotomy is oriented from medial plantar to
lateral dorsal, then dorsiflexion will occur when the osteotomy is shifted. The distal fragments may be shifted distally or proximally,
affecting the length of the metatarsal. If the longitudinal orientation of the osteotomy deviates from the weight-bearing surface, then
translation in the proximal or distal direction may also affect the sagittal plane position of the first metatarsal. In the traditional
orientation of the Ludloff procedure, if the metatarsal is shifted distally, then lengthening and plantarflexion will occur. With the Mau
procedure, distal shift of the metatarsal produces lengthening and dorsiflexion. If each osteotomy is shifted proximally, then the reverse
effects will be noted. However, if the plane of the osteotomy is perpendicular to the weight-bearing surface, then pure lengthening or
shortening may be accomplished without any sagittal plane effect.
An abnormal proximal articular set angle may also be addressed with either procedure. With a Ludloff osteotomy, the distal segment may
be swivelled medially to reduce the proximal articular set angle. However, the amount of correction of the proximal articular angle that
can be achieved is limited by the ultimate abutment of the proximal segment of the osteotomy against the second metatarsal. In addition,
as more rotation is introduced to compensate for a deviated proximal articular set angle, the amount of available intermetatarsal angle
correction is reduced (4 ) (Fig. 33 ). A larger deviation of the proximal articular set angle is more easily addressed with the Mau procedure
in combination with a capital osteotomy such as the Reverdin procedure.
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FIG. 31. The sagittal plane of the first metatarsal is influenced by the plane of the Mau osteotomy. A: If the plane of the osteotomy
is close to parallel with the weight-bearing surface, then the metatarsal head will neither dorsiflex nor plantarflex with rotation. B:
Orienting the plane of the osteotomy from dorsal medial to plantar lateral creates plantarflexion of the capital fragment with lateral
movement. C: A plantar medial to dorsal lateral plane creates dorsiflexion with lateral movement of the capital fragment.
FIG. 32. When the Mau osteotomy is performed, sliding of the fragments distally or proximally influences the length of the first
metatarsal. Little sagittal plane deviation will be noted if the osteotomy is oriented close to parallel with the weight-bearing surface.
A: Mau osteotomy with the capital fragment distracted distally, thereby elongating the first metatarsal. B: Mau osteotomy with the
capital fragment shifted proximally, thereby shortening the first metatarsal. C: Ludloff osteotomy with the capital fragment
distracted distally. Note the elongation and plantarflexion of the first metatarsal. D: Ludloff osteotomy with the capital fragment
shifted proximally. Note the shortening and dorsiflexion of the first metatarsal.
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FIG. 33. Proximal articular set angle correction with the Ludloff osteotomy. After the fragment is transposed, the proximal segment
is rotated laterally to shift the orientation of the articular surface.
Fixation
Fixation of the Ludloff and Mau osteotomies is relatively easy. Two screws are preferred to prevent rotation and slippage. One of the
screws is typically oriented perpendicular to the osteotomy. Cortical screws up to 3.5 mm are commonly employed (5 ,8 ,11 ), although
2.0-mm cortical screws have also been used successfully (4 ). The screws are positioned in the proximal and midpoint areas along the
length of the osteotomy. If the screws are placed too far distally or proximally, then a stress riser of the dorsal or plantar cortices may
occur. A third screw can be used if necessary and if the length of the osteotomy permits.
Postoperative Considerations
The postoperative course for both these procedures is varied. Immobilization in a non-weight-bearing cast or splint has been used for
periods ranging from 12 days to 6 weeks (4 ,5 ,13 ). Studies show that patients may be able to ambulate safely at 3 weeks postoperatively
(5 ,6 ). Vogler recommended a slipper cast for 4 to 6 weeks (11 ).
RESULTS
Few reports in the English literature have documented the success achieved with either of these osteotomies. Neese et al. noted good
results in 21 cases with the modified Mau procedure (4 ). The average intermetatarsal angle preoperatively measured 13.6 degrees and was
reduced to an average of 4.38 degrees postoperatively. The average amount of first metatarsal shortening was 1.37 mm, with a range of
0.82 to 2.24 mm. Intermetatarsal angles up to 20 degrees were said to have been effectively addressed with the modified Mau osteotomy.
Bar-David and Greenberg noted 95% success in 22 cases of hallux abducto valgus in which the Mau procedure was used to repair the
deformity (6 ). The average reduction in the intermetatarsal angle was 10.5 degrees. Eight patients had preoperative intermetatarsal
angles measuring between 18 and 21 degrees. A Reverdin-Green procedure was employed in 18 of the cases to reduce the deviation in the
proximal articular set angle.
Experiences with the Ludloff procedure were documented by Saxena and McCammon (5 ). In 14 cases, the average preoperative
intermetatarsal angle of 15.9 degrees was reduced to 9.4 degrees. Patients were maintained non-weight bearing for 3 weeks and were
allowed to ambulate with a surgical shoe for the next 2 to 3 weeks before they resumed wearing a tennis shoe. Complications consisted of
a single delayed union, a patient with recurrent hallux abducto valgus deformity, and a patient with pain beneath the second metatarsal
head.
Anecdotal experience has shown that the incidence of delayed bone healing is not increased in either of these procedures when rigid
internal fixation is used. Complications encountered with these procedures may include fracture of the dorsal or plantar shelf. This may
occur intraoperatively or when weight bearing begins. Therefore, patients who are allowed to bear weight before the osteotomy heals
should be carefully monitored (Fig. 34 ). Elevation of the capital fragment can occur and may lead to lesser metatarsalgia, stress fracture
of the lesser metatarsals, or hallux limitus.
The Mau-Ludloff shaft osteotomies are alternative procedures to first metatarsal basal procedures when addressing hallux abducto valgus
deformity with high intermetatarsal angles. Outcomes are usually reliable, and complications are few. Problematic or delayed bone healing
does not appear to be a concern.
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FIG. 34. A,B: Dorsal plantar and lateral radiographs, 6 weeks after Mau osteotomy, with the presence of a dorsal shelf fracture
resulting from ground reaction forces. C,D: At 10 months postoperatively, note the complete healing and dorsiflexion of the capital
fragment.
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REFERENCES
1. Ludloff K. Hallux valgus operation. Zentralbl Chir 1913; 40:306.
2. Ludloff K. Die Beseitigung des hallux valgus durch die schrage plantadorsale Osteotomie des Metatarsus I. Arch Klin Chir 1918;110:
364-387.
3. Mau C, Lauber HT. Die operative behandlung des hallux valgus (Nachuntersuchungen). Dtsch Z Chir 1926;197:361-375.
4. Neese DJ, Zelichowski JE, Patton GW. Mau osteotomy: an alternative procedure to the closing abductory base wedge osteotomy. J
Foot Surg 1989;28:352-362.
5. Saxena A, McCammon D. The Ludloff osteotomy: a critical analysis. J Foot Ankle Surg 1997;36:100-105.
6. Bar-David T, Greenberg P. Retrospective analysis of the Mau osteotomy and effect of a fibular sesamoidectomy. J Foot Ankle Surg
1998; 37:212-216.
7. Martin DE, Blitch EL. Alternatives to the closing base wedge osteotomy. Clin Podiatr Med Surg 1996;13:515-531.
8. Vogler HW, Smith ME. Osteotomy of the first metatarsal shaft in hallux abducto valgus surgery. In: McGlamry ED, Banks AS, Downey
MS, eds. Comprehensive textbook of foot surgery, 2nd ed. Baltimore: Williams & Wilkins, 1992:523-532.
9. Ruch JA. Base wedge osteotomies of the first metatarsal. In: McGlamry ED, Banks AS, Downey MS, eds. Comprehensive textbook of
foot surgery, 2nd ed. Baltimore: Williams & Wilkins, 1992:504-522.
10. Patton GW, Zelichowski JE. Middiaphyseal osteotomies. In: Hetherington VJ, ed. Hallux valgus and forefoot surgery. New York:
Churchill Livingstone, 1994:215-225.
11. Vogler HW. Shaft osteotomies in hallux valgus reduction. Clin Podiatr Med Surg 1989;6:47-69.
12. Mizel MS. The role of the plantar first metatarsal first cuneiform ligament in weightbearing on the first metatarsal. Foot Ankle
1993;14:82-84.
13. Cisar J, Holz U, Jenninger W, et al. Die Osteotomie nach Ludloff bei der hallux-valgus-Operation. Aktuelle Traumatol
1983;13:247-249.
SELECTED READING
Blatter G, Magerl F. Osteotomien des ersten strahls zur Behandlung des Hallux valgus. Ther Umsch 1991;48:803-811.
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Chapter 10
Arthrodesis of the First Metatarsophalangeal Joint
Gerard V. Yu
Jeffrey E. Shook
Procedures designed to treat disorders involving the first metatarsophalangeal joint may be categorized as soft tissue or muscle-
tendon balance, exostectomy or cheilectomy, osteotomy, resection arthroplasty, implant arthroplasty, or arthrodesis. Within
the orthopedic community, first metatarsophalangeal fusion is a time-honored procedure for the treatment of hallux rigidus and
geriatric hallux valgus. Until recently, this procedure was not favored among podiatric physicians. This was largely because of
interest in resection and implant arthroplasty and a lack of familiarity with arthrodesis. The concept of eliminating motion at
the first metatarsophalangeal joint has been viewed as unacceptable because hallux limitus or rigidus creates distinct
mechanisms of compensation that may lead to other symptoms in some patients. In addition, investigators believed that normal
function and motion at the first metatarsophalangeal joint were necessary to provide a stable medial column for propulsion and
a normal heel-to-toe gait cycle. However, greater appreciation for the complications associated with resection or implant
arthroplasty has fueled interest in first metatarsophalangeal joint arthrodesis.
Until 1990, only two publications concerning first metatarsophalangeal arthrodesis can be identified in the podiatric literature
(1 ,2 ). Since 1990, multiple publications have been released from the podiatric community (3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ).
Increased interest and improved technique have expanded the accepted indications for this procedure because of predictable
results. Arthrodesis is an effective and powerful procedure for addressing a multitude of disorders affecting the first
metatarsophalangeal joint. When performed correctly in the appropriate patient population, this procedure stabilizes the
forefoot and increases the function of the medial column, and it often produces a pain-free gait.
Fusion of the first metatarsophalangeal joint was first described by Broca in 1852 (13 ). Subsequently, in 1894, Clutton reported
on seven procedures performed on four patients. The procedure rendered excellent results even in a postal worker. Clutton
surmised that “anchylosis” of the joint in the “ideal position” would produce the most permanent and satisfactory correction for
a hallux valgus deformity (14 ). Although little was published concerning this procedure for the next 50 years, Clutton's
sentiments have been reiterated by a resurgence in the popularity of arthrodesis of the first metatarsophalangeal joint evinced
by multiple studies of this procedure from 1940 to the present (1-60).
Early interest in this procedure evolved from serendipitous findings after ankylosis at the first metatarsophalangeal joint was
produced after an infectious process (40 ,48 ). In 1941, McKeever encountered a successful fusion of the first
metatarsophalangeal joint after a complication of a bilateral bunionectomy. Infection produced a functional arthrodesis on one
foot. This side had a better result, both subjectively and objectively, than the nonfused, contralateral bunionectomy.
Specifically, metatarsus primus varus was noted to be greater after the standard bunionectomy. Subsequently, McKeever
performed this procedure on military personnel and was so impressed with the results that he adopted this procedure for all
cases of hallux valgus, hallux rigidus, and metatarsus primus varus (40 ).
Since McKeever's original article, 29 separate studies involving 10 or more surgical procedures have been published in the English
language literature (Table 1 ). The position of fusion is the most critical aspect of the operation. Unfortunately, for some
authors, the focus of the procedure has been oriented toward resection techniques and fixation modalities implemented to
ensure arthrodesis, rather than the position of fusion.
Along with advances in technique has been expansion in the indications commonly used for fusion of the great toe joint.
Traditionally, this procedure was performed for cases of hallux rigidus and geriatric hallux valgus. Currently, arthrodesis of the
first metatarsophalangeal joint is used in cases of inflammatory or septic arthritis, traumatic arthritis, hallux varus or recurrent
hallux valgus, failed resection or implant arthroplasty, and neuromuscular instability or spasticity. Despite the technical
advances and greater use of the procedure, fusion rates have not been significantly altered over the years. Regardless of the
specific approach to joint preparation or the type and method of fixation, the result of the fusion most closely mirrors the
success or failure in positioning of the hallux. This is best illustrated by the uniformity of good results with appropriate position
in almost every type of technique described for the performance of arthrodesis of the first metatarsophalangeal joint since over
the past century.
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TABLE 1. Synopsis of studies

Male-to-female
Author, year Patients/feet ratio Indications Age Follow-up Fixation Results
Harrison and 66/72 Not given HAV (6) 46 yr Not Brockman (43) 32/43 fusion
Harvey, 1963 HR (5) given Charnley clamp 100% fusion
(29)
Wilson, 1967 23/31 Not given HR (26) Not Not Cerclage wire 30/31 fusion
HAV (5) given given
Moynihan, 108/158 Not given HAV (136) 4-6 ½ Peg-in-hole (54) 87% fusion
1967 HR (22) deca over Screw (104) 137/158
des 5 yr
Marin, 1968 100 Not given HAV (90) Not 2-4 yr Screw 98% fusion
feet HR (10) given 95%
good/excelle
nt results
Fitzgerald, 69/100 15:85 HAV 46 yr 12 yr Inlay graft 97% fusion

1969 HR 10-17
yr
Raymaker et 25/30 3:22 HAV (25) 55 yr 3½ yr Screw (29) 29/30 fusion

al., 1971 25
excellent/go
od results
Wilkinson, 68/85 20:48 HR (61) 44 yr 5 mo- Cerclage wire 83/85 fusion

1978 HAV (16) (M) 20 yr
47 yr
(F)
Gemple, 1978 23/35 1:22 HAV 60 yr 28 mo Cross K-wire 27/35 fusion

Hallux 80%
varus good/excelle
nt results
Humbert et 18/34 5:13 HAV (34) 54.8 42 mo Tongue/trough 24/34 fusion

al., 1979 yr 29/34
good/excelle
nt results
von Soglio, 35/48 4:31 HAV (28) 39.8 3-32 Dorsal plate 46/48 fusion
1979 HR (6) yr mo 33/48 very
(M) good
49.5
yr (F)
Mann and 28/41 2:26 HAV/RA Not 35 mo Threaded 39/41 fusion

Oates, 1980 (14) given Steinmann pin × 2
Failed HAV
(17)
Riggs and 156/206 29:127 HAV (75%) 53 yr 15 yr Single screw 187/206

Johnson, 1983 HR (20%) fusion
86%
satisfactory
with
reservation
Johannson 51/60 18:33 HAV (34) 55 yr 39 mo One screw 58/60 fusion

and HR (17) 2/51 unhappy
Barrington,
1984
Chana et al., 64/87 13:74 HAV (76) Not 6 yr Chromic catgut 78/87 fusion
1984 HR (11) given 94%
good/excelle
nt results
Beauchamp et 21/34 Primarily RA 53.6 28 mo Oblique screw 29/34 fusion

al., 1984 female yr
Mann and 11/18 All RA 59 yr 4.1 2 Steinmann pins 17/18 fusion

Thompson, female yr,
1984 avera
ge
Sussman et 8/12 1:7 HAV 60.7 17.6 K-wire, cerclage 11/12 fusion
al., 1986 yr mo wire 9 excellent
3 good
Phillips and 43/51 11:32 HAV (17) 56 yr Not K-wire, cerclage 49/51 fusion
Hooper, 1986 HR (34) given wire
Turan and 20/20 2:18 HR/DJD 59 yr 12 mo 2.7-mm screws × 2 20/20 fusion

Lindgren, DJD
1987
Loughlin, 1987 11/16 All Failed 60.3 29 mo IM Steinmann pin × 16/16 fusion
female Keller (16) yr 2
Mann and 32:47 Not given RA (22) 61 yr 8 mo IM threaded 47/47 fusion

Katcherian, HAV (7) Steinmann pin
1989 Failed HAV
(15)
Gregory et 25/32 24:1 HAV 54.8 31.5 Screw × 2 (9), 29/32 fusion
al., 1990 HR yr mo 0.062 K-wires × 2
(23)
Coughlin, 30/35 3:27 RA (14) 63.9 24.7 Dorsal plate +/− K- 35/35 fusion
1990 Failed HAV yr mo wire
(10)
O'Doherry et 37/50 5:32 HV (43) 59 yr 31.5 K-wire, cerclage 38/50 fusion

al., 1990 HR (7) mo wire
Lampe et al., 56/61 16:40 Not given 47-50 Not Rush nail, cross K- 53/61 fusion
1991 yr given wire
Hughes et al., 18/34 1:17 RA 56 yr 4 yr McKeever 18/34 fusion

1991
Niskanen et 39/39 10:29 RA 52-58 Not Cross K-wire, 34/39 fusion

al., 1993 yr given biodegradable
rods
Wu, 1993 >100 Not given HV Not Not Screws, Herbert 3 nonunions
Failed HAV given given
Hecht et al., 13/15 4:9 Failed 54 yr 55 mo Screw/plate IM 14/15 fusion

1997 implant threaded
arthroplas Steinmann pins
ty
DJD, degenerative joint disease; HAV, hallux abducto valgus; HR, hallux rigidus; HV, hallux valgus; IM, intramedullary; K-wire, Kirschner wire; RA, rheumatoid arthritis.
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CLINICAL EVALUATION
A good sense of the patient's expectations is important in an evaluation for first metatarsophalangeal joint arthrodesis. This is
especially true with regard to activity level, occupation, and desired shoe gear. Patients who run or play racquet sports such as
tennis and racquetball may function well after first metatarsophalangeal arthrodesis, whereas a bowler may have great
difficulty. A person whose occupation requires a greater than normal need for squatting, such as a plumber, may be at a great
disadvantage with first metatarsophalangeal joint arthrodesis or may require a greater than average amount of dorsiflexion at
the time of fusion. Thus, patients need to understand the implications of first metatarsophalangeal joint fusion with respect to
activities of daily living, participation in sports or other strenuous types of occupations or activities, and limitations with shoe
gear. In cases of revisional surgery, awareness of patient goals with respect to pain relief, cosmesis, and function may direct the
physician toward arthrodesis and away from extraarticular reconstruction.
An apropulsive or antalgic gait, in which minimal or no motion is seen through the first metatarsophalangeal joint, may be a
good indicator that the patient is likely to do well with an arthrodesis. Other concomitant pedal deformities such as contracted
digits, hallux extensus or malleus, metatarsus adductus, and collapsing pes valgo planus may be important in the overall
management of the foot. Another particular concern is appreciation for the sagittal and transverse plane position of the first
metatarsal. An apparent metatarsus primus varus or elevatus may be a result of retrograde forces at the first
metatarsophalangeal joint. Restoring the hallux to a more anatomic position may reduce these secondary deformities and may
preclude the need for a proximal osteotomy or proximal arthrodesis. When a previous osteotomy has been preformed on the
first metatarsal, the need for additional proximal procedures should be studied further and may become necessary to
reestablish the weight-bearing capacity of the medial column. Evaluation for proximal pathologic features helps to ensure a
good functional result after fusion. Specific problems, such as an equinus deformity or limb length discrepancy, may affect the
position of arthrodesis or an ancillary procedure selection.
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FIG. 1. A,B: Acquired hallux varus deformity in an adult patient with no underlying neuromuscular disease or prior surgical
procedures. This condition is difficult to repair, and correction is difficult to maintain using joint salvage techniques.
INDICATIONS
The primary indications for arthrodesis for the first metatarsophalangeal joint have not changed dramatically in the last 50 years;
however, the frequency of use of fusion for these conditions has increased significantly. Arthrodesis of the first
metatarsophalangeal joint should be considered in two specific instances, regardless of any other contributing factors:
significant degenerative changes at the first metatarsophalangeal joint and clinical and radiographic evidence of instability at
the first metatarsophalangeal joint (Fig. 1 ). Often, osteoarticular damage and periarticular instability are seen concomitantly
and should not be considered mutually exclusive. Although the overall indications are vast, a common finding with each specific
entity may be intraarticular damage of the first metatarsophalangeal joint (including sesamoidal apparatus) or joint instability.
Current indications for arthrodesis of the first metatarsophalangeal joint are provided in Table 2 ; however, this list is not
meant to be totally inclusive and does not imply that other surgical procedures are not appropriate for some of the same
conditions (12 ,61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 ).
The most common indications for first metatarsophalangeal joint arthrodesis have been geriatric hallux valgus deformity and
hallux limitus or hallux rigidus deformities. These two entities account for an overwhelming majority of the clinical indications
found throughout the literature (9 ). Advances in the understanding of the origin of these two deformities, coupled with
improved surgical techniques, have limited the use of fusion as the primary treatment of either hallux valgus or hallux limitus or
rigidus among many surgeons. Numerous other procedures may be considered first. However, in specific instances, arthrodesis
may present a more favorable and predictable outcome compared with reconstructive-type procedures.
Gross instability of the first metatarsophalangeal joint may be a primary indication for fusion regardless of the quality of the
joint. We believe that fusion should be considered a primary procedure for correcting an initial hallux valgus deformity in
patients with an underlying neuromuscular disease (71 ,74 ), severe ligamentous laxity or hypermobility, or severe residual
metatarsus adductus (not to be corrected). In these instances, the chance for failure is greater with restoration of
musculotendinous balancing around the first metatarsophalangeal joint. Fusion corrects positional deformity and improves
function. This is especially true in patients with spastic neuromuscular conditions such as cerebral palsy (Fig. 2 ).
Renshaw et al. reviewed 14 procedures in 11 patients with cerebral palsy and severe bunion deformities. Soft tissue releases and
extraarticular osteotomies demonstrated a propensity for recurrence at long-term follow-up. Arthrodesis of the first
metatarsophalangeal joint was recommended as the procedure of choice in this patient population to prevent recurrence (75 ).
The clinician should identify and address
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any periarticular spasticity or contracture, to decrease the incidence of malunion or nonunion (70 ). One of the most common causes of nonunion in our experience is underlying neurologic disease and
associated spasticity.
TABLE 2. Current indications for arthrodesis of the first metatarsophalangeal joint
Previously failed bunion procedures

Failed implant arthroplasty (hemiarthroplasty or total arthroplasty)
Neuromuscular disease
Cerebral palsy
Previous poliomyelitis
Cerebrovascular accident
Chronic gouty arthritis

Inflammatory arthritis
Psoriatic arthritis
Charcot's neuroarthropathy
Infection/septic arthritis
Ligamentous laxity
Congenital
Down's syndrome
Ehlers-Danlos syndrome
Marfan's syndrome
Hallux abducto valgus deformity

Severe hallux valgus deformity
Moderate hallux valgus deformity with sub-second metatarsal lesion/metatarsalgia
Hallux abducto valgus with concomitant metatarsus adductus
Failed Keller procedure or other resection arthroplasty

Loss of extensor or flexor function
Hallux varus
Congenital
Iatrogenic
Trauma
Joint proper (first metatarsal head and phalangeal base)
Sesamoidal apparatus
Hallux limitus/hallux rigidus
Fusion obviates the need for additional structural correction often required to produce a good, long-standing result in cases of severe hallux abducto valgus deformity. Because of the severity of the bunion
deformity associated in patients with disorders such as Down's syndrome and spastic cerebral palsy, arthrodesis of the first metatarsophalangeal joint represents an excellent choice (71 ). Although some
surgeons prefer arthrodesis of the first metatarsocuneiform joint, we favor fusion at the metatarsophalangeal joint level. These patients may have difficulty in remaining non-weight bearing for 6 weeks after a
closing base wedge osteotomy. Early ambulation on an arthrodesis of the first metatarsophalangeal joint is much better tolerated. Alteration of fixation methods (plate application) also enhances the fusion rate
with the proper position when early weight bearing is anticipated. This same flexibility does not exist with any basilar osteotomy or proximal fusion needed to correct the significant deformity seen in this
patient population.
Patients with ligamentous laxity present a difficult challenge when one attempts to repair a hallux abducto valgus deformity. It is not uncommon to see a postoperative hallux varus after a reconstructive
surgical procedure. In fact, many of these patients experience several deviations in hallux position throughout a traditional treatment course. Successful arthrodesis allows for permanent correction and provides
enhanced stability to the medial column and perhaps to the rearfoot complex.
Congenital hallux varus, hallux flexus, and hallux malleus deformities, as well as the flail toe, are also indications for fusion of the first metatarsophalangeal joint. Such conditions are commonly reported in
patients with underlying neuromuscular disease of paralytic origin, such as poliomyelitis, or after previous surgical procedures of the first ray. An inability to control the hallux with conventional tendon
balancing procedures is a primary indication for arthrodesis in most of these situations.
We have found fusion to be a satisfactory procedure for the correction of hallux abducto valgus in patients with moderate to severe residual metatarsus adductus. This is particularly true in older patients,
especially if their gait is relatively apropulsive and their activity level is low. In such cases, our experience has been that the conventional hallux valgus procedure often produces less than optimal long-term
results. In skeletally mature patients with residual metatarsus adductus, it is often difficult to justify cutting the lateral four metatarsals to provide space for repositioning the first ray, especially when
symptoms and clinical findings are isolated to the first ray complex. Arthrodesis of the first metatarsophalangeal joint obtains a permanent position of the hallux. Although the true first intermetatarsal angle
does not reduce as much as desired, patient satisfaction is usually obtained. Fusion of the first metatarsophalangeal joint has also greatly improved the alignment of the lesser toes, regardless of whether
surgical procedures were performed at the level of the lesser metatarsophalangeal joint and the digits.
Specific attention must be given to the position of fusion in patients with residual metatarsus adductus. One should understand and appreciate the amount of lateral deviation of the lesser digits. Placement of
the great toe in what would normally be considered an optimal position may result in a foot with a large space between the hallux and the lesser toes. This can occur in spite of performing soft tissue releases on
the lateral aspect of the lesser metatarsophalangeal joints with or without concomitant medial joint plication. Ultimately, the surgeon must determine where the lesser digits will rest after all forefoot
procedures have performed.
In dealing with the fully mature adult foot, reconstructive surgery for metatarsus adductus is usually not recommended. Conversely, when dealing with children and residual metatarsus adductus in which there
is usually little lesser digit abduction, we have found more conventional procedures, with or without correction of the underlying metatarsus adductus, to be beneficial. In more severe cases, metatarsus
adductus is corrected by way of osteotomies of the first through third metatarsals or, more commonly, osteotomies of all five metatarsals. We do not in any way wish to convey that fusion is an appropriate
procedure in the child or juvenile patient with metatarsus adductus.
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FIG. 2. A-C: Severe spastic hallux abducto valgus deformity secondary to underlying severe cerebral palsy. This is another
primary indication for arthrodesis of the first metatarsophalangeal joint.
The treatment of iatrogenic and postoperative complications of first ray procedures is another strong indication for first
metatarsophalangeal arthrodesis (76 ). When surgically treating iatrogenic hallux varus or recurrent hallux abducto valgus
deformity, periarticular soft tissue balance cannot be predictably restored in many instances. Moreover, degenerative changes
may affect the joint or the sesamoid apparatus. When joint instability and intraarticular damage coexist, a joint-destructive
type of procedure is preferred. Revisional surgery requires a slightly different approach than with primary hallux abducto valgus
surgery. Some emphasis must be placed on selecting a definitive procedure even if this involves joint destruction in a younger
patient. Experience proves to be the most important factor in the decision-making process; however, too many times we have
seen multiple attempts at joint preservation when this was not realistic. In many of these instances, fusion was not considered
because of a lack of familiarity with the procedure, because of an inability to perform the procedure, or simply because the
patient was “too young.” With each subsequent attempt atjoint preservation surgery, many patients invariably end up with an
increasing amount of stiffness to the first metatarsophalangeal joint, which may prove extremely painful and nonfunctional.
Consequently, even if an appropriate clinical appearance is achieved, the failure to restore motion to the great toe joint results
in increased functional disability. Resection or implant arthroplasty may be considered in revisional surgery or iatrogenic
deformities, but these procedures do not give the same functional result as fusion and often necessitate another revisional
operation. Arthrodesis of the first metatarsophalangeal joint consistently corrects multiplanar deformities and proves to be a
reliable procedure to reestablish function of the first ray complex.
Common clinical problems with elements of intraarticular damage are controversial with respect to arthrodesis of the first
metatarsophalangeal joint. Specifically, hallux limitus and hallux rigidus are entities with a wide disparity in treatment
philosophy among surgeons. Many physicians believe
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that preservation or re-creation of motion by extraarticular osteotomy or implant arthroplasty is essential in treating hallux
limitus and hallux rigidus, respectively. Resection arthroplasty may also be successfully employed in these types of cases.
However, arthrodesis should also merit significant consideration in this patient population, especially because this procedure
has repeatedly provided consistent, long-term results in these patients. Resection arthroplasty is a viable option and may be
more desirable in patients who cannot tolerate the postoperative course after a fusion or who do not want a fusion.
In patients with true metatarsus primus elevatus, the joint should be thoroughly inspected before osteotomy of the first ray.
Often, an apparent elevatus spontaneously reduces with periarticular soft tissue release and appropriate joint positioning. If
clinical evidence of elevatus persists after arthrodesis, then a plantarflexory closing base wedge osteotomy may be needed,
although this is rarely necessary.
In cases of hallux limitus associated with significant structural abnormalities of the first metatarsal (metatarsus primus elevatus,
excessively long first metatarsal), consideration should be given to shortening or plantarflexory osteotomies of the first
metatarsal. These may include modifications of the Austin bunionectomy, midshaft osteotomies such as the sagittal plane “Z,”
and basilar osteotomies. These osteotomies would be done in conjunction with arthroplasty of the first metatarsophalangeal
joint and present alternatives to arthrodesis of the first metatarsophalangeal joint. The decision to preserve the joint is usually
based on intraarticular damage, the surgeon's preference, and the patient's expectations. We are not suggesting that every
patient with hallux limitus undergo arthrodesis.
In cases of failed resection arthroplasty or failed implant arthroplasty, fusion may prove beneficial. Hecht et al. reviewed 15
cases of first metatarsophalangeal arthrodesis for salvage of failed total implant arthroplasty. Bone grafting was used in every
case, and fixation was achieved by intramedullary Steinmann pins or dorsal plate with interfragmentary screw. The average
follow-up was 55 months, and every patient showed significant improvement with respect to pain tolerance, ability to wear
shoes, ability to walk, and appearance of the foot. Overall satisfaction was graded at 4.79 (scale: 5 is normal and 0 is severely
affected) (77 ).
Excessive bone loss has been attributed to poor results. With new advances in callus distraction, this problem may be overcome,
but with a certain degree of additional inconvenience on the part of the patient because of the additional recovery time. Bone
loss from the metatarsal side of the joint is more significant and of greater consequence than isolated bone loss from a failed
resection arthroplasty using a hemiimplant. In cases of bone loss from just the phalangeal component of the joint, good results
can often be obtained by simply fusing the remainder of the great toe to the first metatarsal head in spite of the appearance of
a slightly shortened hallux. Clearly, a failed total implant arthroplasty is a more difficult problem to address than a failed
hemiimplant arthroplasty. In spite of implant removal, bone grafting, and successful arthrodesis, chronic pain may still be
experienced. The precise cause of the persistent pain in some cases is not clearly understood. Although some investigators
attribute it to the fusion procedure itself, we believe it to be more reflective of underlying chronic and persistent synovitis or a
foreign body type of reaction to the implant.
Inflammatory arthritis is one of the most common indications for arthrodesis of the first metatarsophalangeal joint. Most
notably, arthrodesis has become a standard in the reconstruction of the forefoot in rheumatoid arthritis. Excellent results have
been reported in patients with symptomatic rheumatoid arthritis (78 ). Arthrodesis of the first metatarsophalangeal joint is
effective in treating any metabolic process that attacks the periarticular soft tissue structures as well as the articular surfaces
(68 ). Arthrodesis has also been effective in treating patients with psoriatic arthritis, gouty arthritis, septic arthritis, and
Charcot neuroarthropathy.
Fusion of the great toe joint is an excellent procedure selection in many geriatric patients with severe hallux abducto valgus
deformities. Many of these patients have a significant amount of intraarticular degeneration resulting from the long-standing
nature and severity of the deformity. More important, because of the significant reduction of the intermetatarsal angle seen in
patients after fusion of the great toe, the need for a basilar procedure is obviated. It is more common in the geriatric
population to perform a fibular sesamoidectomy to obtain proper alignment of the hallux before fusion.
CONTRAINDICATIONS
The presence of degenerative arthritis of the interphalangeal joint may be a relative contraindication, especially if it is ignored
or untreated. Authors have expressed concern over limited motion or the lack of motion altogether at this joint because
excessive strain may be placed on the interphalangeal joint after fusion at the metatarsophalangeal level (23 ,51 ,52 ). The
stress placed on the interphalangeal joint probably reflects the position of fusion of the metatarsophalangeal joint. Inadequate
dorsiflexion at the metatarsophalangeal joint is certain to increase stress on the interphalangeal joint, as is severe malposition
in either the transverse plane or the frontal plane. We believe that proper dorsiflexion with slight abduction, so the hallux aligns
itself parallel with the lesser toes, especially the second digit, will produce the best results. Frontal plane valgus rotation is not
necessary; the nail should be facing dorsally. With proper positioning, stress at the interphalangeal joint is minimized. If
significant degenerative arthritis, hypermobility, or subluxation already exists at the interphalangeal joint, simultaneous fusion
or, less commonly, arthroplasty of this joint may be considered.
Osteoporosis has also been reported as a contraindication to fusion of the metatarsophalangeal joint. The precise reason for this
is not known, but it is presumably related to the misconception that fusion is difficult to achieve. We do not agree with this
concept. Excellent fusion has been obtained consistently in patients with osteopenia on preoperative radiographs,
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most notably in patients with rheumatoid arthritis. Bone density problems have a more profound influence on the type of
fixation than on the type of procedure.
Perhaps the most significant relative contraindication is the patient who fails to comprehend the implications of the procedure
itself. Patients must understand the intent of the procedure and its implications. Patients should realize that motion will be
eliminated, and certain activities, such as squatting, kneeling, and the like, may be more difficult, if not altogether impossible.
The position of fusion indisputably determines the type and style of shoes that may be worn postoperatively. Patients, especially
women, who desire to wear higher-heeled shoes, will require a greater degree of dorsiflexion when the metatarsophalangeal
joint is fused. The increased dorsiflexion may be unacceptable or unsightly when patients are standing without shoes and may
preclude patients from wearing shoes with no or minimal heel height. Patients who wish to wear narrow or pointed shoes will
require increased abduction at the fusion site, which may result in crowding of the lesser toes with subsequent deformity and
possible subluxation. We strongly discourage positioning of the great toe in excessive dorsiflexion or abduction to accommodate
shoe gear; in such cases, alternative procedures should be considered.
Finally, a rigid metatarsus primus adductus may be a relative contraindication to fusion alone. An abnormally shaped
articulation or severe degenerative arthritis at the metatarsocuneiform joint or an excessively large and rigid intermetatarsal
angle may indicate the need for additional procedures to reduce the splaying in conjunction with fusion. As a practical matter,
this is rarely necessary.
To date, we have appreciated the need for concomitant osteotomy of the first metatarsal in patients who underwent prior
procedures with a resultant poor outcome. In many cases, a structural increase in the intermetatarsal angle or metatarsus
primus elevatus has occurred as a result of failure of a proximal osteotomy or arthrodesis (especially with opening wedge
osteotomy and bone grafting). Both these iatrogenic deformities may require procedures at either the first metatarsal base or
the first metatarsocuneiform joint to reduce the structural deformity of the first metatarsal. In addition, a proximal osteotomy
with distraction osteogenesis may be necessary when first metatarsophalangeal arthrodesis is performed to salvage nonunion of
a distal metaphyseal osteotomy in the presence of significant shortening of the first ray.
One may achieve a significant reduction of the intermetatarsal angle by arthrodesis of the first metatarsophalangeal joint alone,
even when the clinical or radiographic evaluation suggested otherwise. In some cases, although a persistent splaying may be
seen on radiographs after fusion, the clinical appearance does not correlate with the radiographic appearance and is considered
excellent by both patient and physician.
SURGICAL TECHNIQUE
Skin Incision and Exposure

A medial or dorsomedial incision is generally used to provide complete exposure from the midshaft area of the first metatarsal
to the level of the hallux interphalangeal joint. Anatomic dissection techniques are employed to minimize postoperative
adhesion and scar tissue formation. In cases of revisional surgery, extension of the incision more proximally and distally helps to
establish the normal tissue planes initially. In some cases, it may be necessary to carry the skin incision down to the level of
bone and to raise the periosteum, deep fascia, subcutaneous tissue, and skin as one layer. Although this is not ideal, it may be
necessary to avoid wound complications caused by excessive scar from multiple prior surgical procedures.
Before periosteal and capsular dissection, two structures should be evaluated to ensure proper positioning of the hallux. In cases
of failed implant arthroplasty or resection arthroplasty and neuromuscular disorders, the extensor hallucis longus (EHL) tendon
may require Z-plasty lengthening. This is usually not performed until joint preparation is complete. In cases of failed joint-
destructive procedures, the apparent shortening of the EHL tendon is negated by osteocartilaginous or implant removal.
Removal of cartilage and subchondral bone indirectly lengthens the EHL tendon by shortening the first ray. Inappropriate tendon
lengthening in conjunction with bone removal may weaken the EHL tendon and may adversely affect ankle and hallux
interphalangeal joint function. We rarely lengthen the EHL tendon in the absence of neuromuscular disease. In these situations,
if the EHL tendon is not weakened, a forefoot varus could be produced because of the increased lever arm provided by a fused
first metatarsophalangeal joint. In some situations, transfer of the lateral half of the EHL tendon to the lateral part of the foot
is necessary to avoid frontal plane deformity postoperatively. The presence of a spastic EHL tendon may also predispose to
nonunion or malunion.
The second structure that should be evaluated is the sesamoid apparatus. The approach depends on the contracted side of the
joint, medial for hallux varus and lateral for hallux valgus. The goal is to produce a congruous joint by soft tissue release with,
or preferably without, sesamoidectomy. This process facilitates positioning of the hallux before fixation. A standard
intermetatarsal release is performed in cases of severe or recurrent hallux abducto valgus, and a fibular sesamoidectomy is
performed at times to free the lateral side of the first metatarsophalangeal joint. Most articles do not address periarticular
release during first metatarsophalangeal arthrodesis. Some authors intentionally avoid this and state that an intact adductor
tendon and lateral head of the flexor brevus muscle will provide a dynamic reduction of the first intermetatarsal space
postoperatively after successful arthrodesis. We believe that postoperative reduction of the intermetatarsal angle results from
restoration of a congruous joint and elimination of retrograde force of the hallux on the first metatarsal head. Reduction of the
intermetatarsal angle does not depend on the pull of the adductor and short flexor muscles. First intermetatarsal dissection and
reduction have been routinely performed, followed by consistent and significant reduction of the first intermetatarsal angle. In
cases of severe hallux valgus, an intact adductor tendon may predispose to a malunion or nonunion because of relative
shortening
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of the adductor tendon from a long-standing and severe deformity (Davis law).
The abductor tendon and the medial head of the short flexor are approached in similar fashion in cases of iatrogenic and
congenital hallux varus. Again, the tibial sesamoid may need to be removed to reduce the first metatarsophalangeal joint in
severe cases of hallux varus.
The deep fascial, capsular, and periosteal structures are incised in longitudinal fashion. Circumferential dissection is performed
with the goal of exposing the entire head of the first metatarsal, the base of the proximal phalanx, and the sesamoid apparatus.
One must preserve this layer to ensure adequate closure over fixation and augmentation of blood supply to the fusion site.
Technically, this is easier to achieve if the periosteal dissection is started at the diaphyseal level of the first metatarsal shaft
and proximal phalanx. Both layers of the periosteum are easily dissected free from the bone because of weaker attachments at
the diaphyseal level as compared with the metaphyseal area of bone. Once the joint has been identified and the diaphyseal
periosteum has been dissected, it is not difficult to deglove the entire first metatarsophalangeal joint and to maintain an intact
layer for closure. In general, we favor making a vertical caspsulotomy and converting the linear, deep fascial incision to an
inverted Ltype or T-type incision. This approach enables the surgeon to inspect the sesamoid apparatus and to denude the
plantar cartilage from the metatarsal head if appropriate. More important, the vertical capsular incision relieves tension from
the medial side of the deep fascial layer and facilitates placement of temporary and permanent fixation.
If necessary, one or both of the sesamoid bones could be removed through the incision approach described previously. Although
rare exceptions exist in which excision of both sesamoids may be indicated, we discourage excision of both these structures.
Postoperatively, the patient may develop tendinitis of the flexor hallucis longus, or lesser metatarsalgia may be induced or
exaggerated because of a decrease in the weight-bearing function of the first ray. Preservation of the sesamoid apparatus, even
when these bones are fused to the underside of the metatarsal, encourages weight-bearing function. Bouche and Adad
recommended either a plantarflexory first metatarsal osteotomy or fusion of the sesamoids to the plantar aspect of the
metatarsal for this reason (8 ). A fusion of the sesamoids to the plantar aspect of the metatarsal, although not necessary, is
favored over removal of both sesamoids. This approach maintains protection of the flexor hallucis longus tendon and does not
disrupt the weight-bearing relationship between the first metatarsal and lesser metatarsal segments.
Joint Resection
The first metatarsal head and the phalangeal base should be inspected before any osseous or cartilaginous resection. Often,
during previous surgical procedures, the metatarsal head was staked from overzealous resection. In this instance, the surgeon
should refrain from further eminence resection medially because this may cause malposition when a wellopposed arthrodesis is
achieved in the presence of iatrogenically created lateral deviation of the metatarsal cartilage. This relationship must be
appreciated to position the hallux appropriately. In this situation, it is not uncommon for the medial aspect of the phalangeal
base to overhang the medial aspect of the remainder of the metatarsal head. Although it is tempting to resect the medial
portion of the base of the proximal phalanx, this should be avoided. The medial overhang creates a natural peg-in-hole fit,
increases stability of the fusion site, and provides a buttress for the head of an interfragmentary compression screw.
Removal of an exostosis or proliferative bone before cartilage resection may be preferable. This process allows true
appreciation of the joint surface and prevents misconception with regard to positioning. A large dorsal exostosis may cause
inadvertent plantarflexion of the hallux when temporary fixation is inserted. The goal during this portion of the procedure is to
recreate normal architectural configuration before osteocartilaginous resection.
An aggressive medial eminence resection may be performed in many instances, because no reason exists to fear hallux varus.
However, if crossing screw fixation is desired, the plantar aspect of the medial eminence may be preserved, to allow for greater
purchase of the screw head and greater latitude of screw placement. Because more of the plantar aspect of the medial
eminence is removed, the plantar proximal screw must be placed in a longitudinal fashion. This placement may prevent the
screw from exiting the lateral cortex of the proximal phalanx and reduces interfragmentary compression. Alternatively, one may
elect to place the proximal screw dorsally; however, because of medial resection, the screw must be placed further proximally
on the metatarsal shaft at the diaphyseal metaphyseal flare. This naturally directs the screw longitudinally and creates the
same potential problem previously described. If other fixation modalities are used, such as Kirschner wires (K-wires), Steinmann
pins, staples, monofilament wire, isolated plate, and external fixation devices, then the entire medial eminence may be
sacrificed without comprising quality or ease of fixation.
Various techniques have been described for surgical resection of the joint surfaces. Some surgeons prefer to use a curettage-
type joint resection because it preserves length of the first ray segment and the ball-and-socket joint configuration, which
facilitates joint positioning. Removal of cartilage is accomplished primarily with hand instrumentation—scalpel, curette, and
rongeur. The subchondral bone is left intact. The risk of this type of joint resection is a greater chance of nonunion. However,
we have observed nonunion to occur with the curettage technique more frequently when one attempts to fuse one or multiple
joints of the greater tarsus or ankle areas as compared with Lisfranc's or metatarsophalangeal joint areas. To prevent nonunion
resulting from inadequate joint resection, one may use a high-speed power burr to remove and contour cartilage anatomically
down to bleeding bone (Fig. 3 ). Copious lavage helps to avoid thermal necrosis. One may also use a power drill bit to perforate
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both surfaces, theoretically to increase bleeding at the arthrodesis site and to promote rapid revascularization of the site.
Multiple holes are placed on both sides of the joint. The most important aspect of this process is maintenance of the normal
convexity of the first metatarsal head and concavity of the phalangeal base. This allows easy and accurate positioning and
increases arthrodesis rates by providing a concentric fit and enhanced stability at the arthrodesis site. Accurate contouring
ensures the best reciprocal fit.
FIG. 3. Removal of the cartilaginous surfaces and contouring with a power burr result in minimal shortening of the segment
and provide a good raw bone surface for fusion.
FIG. 4. Use of crescentic saw blade to resect the joint surfaces when shortening is necessary or desired. Phalangeal (A)
and metatarsal (B) resection. C: Fragments after excision.
Alternatively, the joint may be resected with power instrumentation, which should provide an even, flush surface for fusion.
The power saw is particularly useful when specific osseous shortening is desired. A crescentic blade may help to maintain the
convex and concave relationship at the arthrodesis site (Fig. 4 ). The crescentic saw is used from side to side (base of saw held
dorsally) when one treats a transverse plane deformity such as hallux valgus or hallux varus. The base of the saw is angled
toward the leg to effect sagittal plane positioning. For sagittal plane deformities, the joint surfaces are cut from plantar to
dorsal (base of the saw is held medially). Transverse plane positioning must be kept
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in mind, and the base of the saw must be placed perpendicular to the desired position of the hallux in the transverse plane. This
is useful when treating cases of hallux limitus and hallux rigidus when shortening is desired. This technique is also employed
during a concomitant panmetatarsal head resection.
The metatarsal parabola and segmental osseous length should be considered before joint resection. This is especially important
when a panmetatarsal head resection is performed in conjunction with a first metatarsophalangeal arthrodesis. The combination
of these two procedures has proven to produce good long-term results; however, if the first metatarsal length is not taken into
consideration, the result can be less than optimal. This is especially true if rheumatoid nodules surround the first metatarsal. In
general, most of the first metatarsal head should be resected to create a parabola in which the fusion site is just slightly shorter
or equal to the remaining second metatarsal shaft. It is beneficial to perform the panmetatarsal head resection before the first
metatarsophalangeal arthrodesis.
In general, bone resection is dictated by the pathologic process at the first metatarsophalangeal joint. When the first metatarsal
is relatively long, most osseous resection should be directed toward the first metatarsal. This includes cases in which a
panmetatarsal head resection is performed in conjunction with a first metatarsophalangeal joint fusion or in cases of failed
resection arthroplasty (Keller-Brandes arthroplasty) with or without a hemiimplant. Failed Keller bunionectomy or failed
hemiimplant arthroplasty usually leaves the phalangeal component short, and joint resection is typically focused at the
metatarsal portion of the joint or pseudoarticulation. In contrast, failed hallux abducto valgus surgery with prior osteotomy
shortens the metatarsal segment. Often, excessive shortening of the first metatarsal accounts for the failure. In these situations,
if formal joint resection is desired, it is usually focused at the phalangeal component of the joint.
Where bone loss is significant, bone grafting may be necessary. This frequently occurs with failed total implant arthroplasty,
septic arthritis, crush or open fractures, gunshot injuries, and avascular necrosis of the first metatarsal head. The two best
options for replacing bone are autogenous bone graft and segmental lengthening of bone by callus distraction or bone transport.
If one needs only 1 to 2 cm of length, then bone graft harvest from the calcaneus, distal medial tibia, or iliac crest will suffice.
If significant shortening or overall bone loss has taken place, then callus distraction is an alternative to replace bone and
possibly to avoid panmetatarsal head resection or hallux amputation. This can be achieved in two ways. Direct fusion of the
remainder of the first metatarsophalangeal joint followed by corticotomy of the proximal metaphysis of the first metatarsal will
provide length and fusion. This approach is recommended when the overall bone loss does not exceed 2 to 3 cm. If overall bone
loss is greater than 3 cm, then consideration should be given to staging the procedures. The proximal corticotomy is performed
first, followed by appropriate callus distraction. Once desired length is obtained and consolidation has taken place, then a
second, docking-type procedure is performed. The actual arthrodesis is performed during this second phase. This procedure is
especially attractive as a salvage procedure in younger, active patients (Fig. 5 ).
Throughout the literature, multiple types of reamers or joint resection systems have been described. The main goal of these
systems is to provide a perfect reciprocal fit at the arthrodesis site. Currently, power reamers are favored by some authors
because of mechanical stability and increased contact area at the fusion site with this type of joint preparation. Fixation studies
have shown this type of relationship at the fusion site to be more inherently stable than a simple planar relationship. Curtis et al.
compared four types of fixation techniques. In only one of the four groups was a conical reamer system applied. In this group,
fixation was with an interfragmentary screw. This particular fixation technique failed at higher loads than planar excision with
crossed Kwires, planar excision with dorsal plate and screws, and planar excision with interfragmentary screw fixation (79 ).
Despite these advantages, we do not favor or advocate the use of conical reamer systems during arthrodesis of the first
metatarsophalangeal joint. These systems give only one chance for positioning the hallux. Bone contact and stability are more
than adequate with other resection techniques, followed by appropriate fixation. The increased possibility of a malpositioned
fusion with a reamer system far outweighs the advantages of increased contact at the fusion site and enhanced stability. It is
not uncommon to perform joint resection, temporarily fixate the fusion, and then reposition multiple times before desired
position is obtained. Repositioning the fusion is difficult, if not impossible, when using a conical reamer system.
Position of Fusion
The most critical portion of a first metatarsophalangeal arthrodesis is achieving proper position. Excessive deviation of the
hallux in any cardinal plane may cause failure of the procedure and may require further surgical intervention. Once fusion has
been achieved, it is often difficult to rectify a malunion from a conservative or surgical standpoint. The final position of fusion
of the great toe is clearly more important than the method or technique by which it is achieved. The goal of arthrodesis of the
first metatarsophalangeal joint is to create a sound fusion that imparts freedom from pain, a high level of functional efficiency,
and minimal complications. When possible, the goal is to provide a result that is cosmetically pleasing to the patient that should
allow conventional shoes to be worn with minimal restrictions. To date, most authors have recommended that the great toe be
fused in approximately 15 to 25 degrees of dorsiflexion in the sagittal plane and 15 to 20 degrees of valgus or abduction in the
transverse plane. However, recommendations have ranged from as low as 0 degrees to as high as 40 degrees in both planes (1-
60). Unfortunately, these numbers may be difficult to interpret unless one understands the appropriate plane of reference from
which to determine the final position of fusion. However, frontal plane rotation (valgus or varus) in any direction clearly should
be avoided.
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FIG. 5. A: Patient with two previously failed surgical procedures for hallux limitus with severe shortening and loss of
functional purchase of the hallux. B: Dorsoplantar radiograph. C: Oblique radiograph after distraction osteogenesis to
attain restoration of length before arthrodesis of the joint. D: Final radiograph after arthrodesis of the first
metatarsophalangeal joint and osteotomy of the first metatarsal to correct for first ray malalignment. Complete resolution
of symptoms was achieved as a result of this two-stage reconstructive surgery. E: Final clinical appearance and outcome of
surgery.
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Clinically, the hallux is typically placed parallel to the lesser digits with respect to the transverse plane. The hallux should not
collide, overlap, or underlap the second digit, nor should excessive space exist between the hallux and the second digit. The
final position of the hallux may vary greatly from the preoperative position or little, depending on the original cause. In patients
with hallux limitus or hallux rigidus, there is usually little transverse plane repositioning. In fact, the tendency may be to place
the hallux in more of an abducted position to accommodate shoe gear and to avoid postoperative symptoms at the hallux
interphalangeal joint. During the correction of a severe hallux valgus deformity or recurrent bunion deformity, care is taken to
obtain 15 to 20 degrees of abduction while maintaining an appropriate relationship with the second digit. In cases of transverse
plane instability and malalignment at the second metatarsophalangeal joint, this deformity may need to be reduced and
realigned to achieve proper hallux position. Often, the second ray is used as a reference point unless metatarsus adductus is
significant.
Obtaining optimal sagittal plane position is more difficult. When the forefoot is loaded in an off-weight-bearing attitude, the
metatarsophalangeal joints approximate 15 to 25 degrees of dorsiflexion. Intraoperatively, once the joint is disarticulated and
all periarticular contractures are reduced, the hallux tends to sit in the proper position when the forefoot is loaded. With
respect to sagittal plane position, the tip of the hallux should be elevated 10 to 15 mm from the weight-bearing surface. This
can be evaluated by inserting temporary fixation in the desired position and evaluating position after loading the foot with a flat
sterile instrument (Fig. 6 ). Minimal dorsiflexion is necessary to achieve a satisfactory and functional position; approximately 10
degrees from the plantar weight-bearing plane of the foot should be sufficient. With increasing experience with first
metatarsophalangeal fusions, we have found that excellent function is readily achieved with minimal dorsiflexion; a
plantarflexed hallux, on the other hand, is likely to be met with failure.
FIG. 6. Intraoperative confirmation of proper alignment in the sagittal plane can be enhanced by placing the foot on a flat
surface and assessing the hallux position. In this case, toe-off is simulated by maximum dorsiflexion of the distal pulp of
the toe. Part of the apparent dorsiflexion position of fusion is coming from interphalangeal joint extension.
In long-standing, severe hallux abducto valgus deformities, an unappreciated hallux deformity (hallux interphalangeus) can be
uncovered by correction of the hallux abducto valgus deformity at the level of the first metatarsophalangeal joint. If this is not
recognized during surgery, the hallux could be adducted too far at the level of the first metatarsophalangeal joint to avoid
abutment of the first and second digits. In this situation, an Akin osteotomy may be necessary to provide parallel relationship
between the first and second digits while appropriate abduction is maintained at the level of the first metatarsophalangeal joint.
Care must be taken with respect to the sagittal plane position when one uses a longitudinal pin for temporary fixation. If the
hallux interphalangeus is hyperextended when the first metatarsophalangeal joint is temporarily fixated in a retrograde fashion,
then the digit may appear too dorsiflexed. If the hallux is repositioned to accommodate the tip of the hallux with no
appreciation of the proximal phalangeal base, then the entire hallucal segment will not be dorsiflexed enough once the
temporary fixation is removed across the hallux interphalangeal and first metatarsophalangeal joints. One must focus on the
base of the proximal phalanx of the hallux with respect to transverse and sagittal plane positioning. This approach helps to
provide a proper perspective to the tip of the hallux and helps to avoid a malunion resulting from perceived or real deformities
at the hallux interphalangeal joint.
Many other contributory factors affect placement of the hallux. Strict measurement of numbers or angles ultimately leads to
problems and failure. Emphasis should be placed on observed relationships among the phalanges, metatarsals,
metatarsophalangeal joints, and the forefoot to rearfoot, ankle, and leg. Many authors have devised schemes and intraoperative
techniques to guarantee correct placement of the hallux. Simply put, proper positioning is more of an art than a science.
Intraoperative radiographs are helpful but will not replace clinical judgment.
Fixation
Numerous methods of fixation have been described since Clutton's publication in 1884, in which he reported using an ivory peg
for fixation of the first metatarsophalangeal joint. Methods have ranged from chromic gut to screws to external fixators and
compression plates (4 ,19 ,21 ,55 ,80 ). Fusion does not depend on any one technique or method. One author reported successful
fusion even without internal fixation in a small series of cases. As previously stated, the success of arthrodesis of the first
metatarsophalangeal joint is highly dependent on the final position. A preoccupation
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or obsession with a particular method of fixation may be of little benefit to the overall result. However, in certain situations,
fixation may be a critical part of the procedure.
FIG. 7. Single Kirschner wire or Steinmann pin employed for fixation. Note the excellent apposition of the fusion surfaces.
FIG. 8. A: Multiple Kirschner wire technique for fusion of first metatarsophalangeal joint is commonly used during
simultaneousfusion of the hallux interphalangeal joint. B: Two parallel Kirschner wires or Steinmann pins provide enhanced
fixation and eliminate potential rotation of the fusion site in the frontal plane.
Pin or Wire Fixation

The use of stainless steel cerclage wire alone or in combination with obliquely inserted K-wires has been reported by several
authors and appears to be an acceptable method of fixation (2 ,24 ,28 ,44 ,46 ,52 ,53 ). The stainless steel wire should be
inserted by either a horizontally or vertically oriented cerclage technique, or a combination of the two, and should be of
sufficient gauge to provide axial compression and stability. A 22 to 25 gauge wire is recommended. The cortical bone should be
of sufficient quality to prevent failure when the wire is twisted and tightened. The use of an obliquely placed K-wire will assist
in preventing rotation of the fusion site and improve overall stability. Emphasis is placed on maintaining hallux position while
the wire is tightened. Stainless steel wire may also be used in conjunction with K-wires in a tension band wiring technique; a
technique which has proven useful when other fixation methods have failed due to technical difficulty.
The placement of threaded or smooth K-wires or Steinmann pins has been the most popular fixation technique reported to date
(1 ,9 ,20 ,23 ,27 ,37 ,38 ,47 ). Wire and pin sizes have ranged from 0.062 inches to 7/64 inches and differ in the manner and
direction of placement. When they are placed
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in an appropriate fashion, excellent stability at the fusion site can be achieved. This type of fixation works well when an
excellent reciprocal fit exists between the two components of the arthrodesis site (Fig. 7 ). The most common method using
pins or wires has been the intramedullary technique with two or more parallel threaded or smooth wires or pins crossing both
the interphalangeal joint and the metatarsophalangeal joint.
Good fusion rates have been reported (23 ), but some concern exists about transverse plane positioning of the hallux.
Intramedullary pins oriented from the tip of the hallux to the base of the first metatarsal may limit the amount of abduction of
the hallux that may be achieved. Furthermore, a high incidence of radiographic and clinical evidence of interphalangeal arthritis
was reported in one study (38 ). We believe that this is caused by two problems associated with this fixation technique. First,
large Steinmann pins are driven across the interphalangeal joint. Second, if an appropriate position cannot be achieved in the
transverse plane, excessive pressure may be placed on the hallux interphalangeal joint. Nonetheless, this technique remains
viable, particularly when one performs simultaneous fusion of the first metatarsophalangeal and hallux interphalangeal joints
(Fig. 8 ). This form of fixation may also prove advantageous in patients with extensus deformity at the interphalangeal joint that
does not require fusion, yet enhanced alignment may be maintained if the joint is transfixed in the desired position while
awaiting fusion of the first metatarsophalangeal joint. On occasion, we have employed a single 5/64-inch Steinmann pin inserted
in a retrograde manner crossing both the interphalangeal and metatarsophalangeal joints. This technique is particularly useful in
those clinical situations in which deformity exists at both joint levels but in which only fusion of the metatarsophalangeal joint
will be performed. A typical situation involves hallux varus with simultaneous hallux flexus or hallux malleus deformity. In these
situations, correction of the metatarsophalangeal joint contracture alone allows manipulative reduction of the interphalangeal
joint deformity; the single K-wire or Steinmann pin provides fixation at the metatarsophalangeal joint level while simultaneously
maintaining the interphalangeal joint in its correct position, whether or not the joint is fused.
If additional stability or fixation is needed because of frontal plane rotatory instability, a 0.062-inch K-wire is inserted obliquely
across the first metatarsophalangeal joint; thus, two-point fixation is achieved (Fig. 9 ). It may cross in a distal medial to
proximal lateral direction or, more commonly, in a proximal medial to distal lateral direction. The wire may be inserted
percutaneously or buried beneath the skin or the capsular and periosteal tissues. These techniques have been effective in
patients who have previously undergone a resection-type of arthroplasty procedure resulting in loss of one-third or even one-
half of the proximal phalanx. Unfortunately, this technique may promote degenerative arthritis at the interphalangeal joint.
Although this arthritis may be of only minimal or even no clinical significance, it is readily identifiable on postoperative
radiographs.
FIG. 9. Double Kirschner wire technique. The axial wire controls the sagittal plane position, and the oblique wire prevents
rotation in frontal plane.
To prevent the problems with positioning, the pins or wires may be driven distally through the hallux in parallel fashion. The
fusion site should be placed in an appropriate position, and then the wires or pins are directed across the fusion site and into
the first metatarsal. The fixation is parallel to the hallux and oblique to the metatarsal. Stress fractures of the first metatarsal
have been reported when the Steinmann pin has traversed the plantar cortex (15 ).
Another common technique is that of crossing K-wires or pins placed either external or cut off and buried beneath the skin. One
pin is typically inserted from dorsal medial proximal to plantar lateral distal, and a second pin is placed either from dorsal distal
medial to plantar proximal lateral or from dorsal proximal lateral to distal plantar medial. Intraoperative fluoroscopy may be
extremely beneficial in evaluating the pins with respect to placement and length.
We emphasize that these techniques, although they provide excellent overall stability to the fusion site, furnish little in terms
of axial compression. At best, they may maintain the compression achieved during surgery by manual compression or the use of
an ancillary device such as a miniature fixator. However, use of cerclage wire, K-wire, and Steinmann pin fixation is often
preferable in cases of severe osteopenia most commonly associated with rheumatoid arthritis.
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These fixation methods are also used as alternative modalities when other techniques have failed.
FIG. 10. Technique of fusion with isolated cortex bone screw. This technique is dependable, provided excellent-quality
bone stock is available for screw purchase.
Screw Fixation
The use of cortical or cancellous screws has gained in popularity and is commonly employed today (Fig. 10 ). The technique of
screw fixation today generally involves placement of two small cortical or cancellous screws obliquely across the
metatarsophalangeal joint (Fig. 11 ). The cannulated screws have facilitated proper and accurate placement. At times, a single
screw may be employed with the addition of a crossed K-wire to reduce rotatory stress (Fig. 12 ).
The first screw typically enters the dorsomedial aspect of the first metatarsal at the diaphyseal-metaphyseal junction and is
directed in a plantar lateral direction across the fusion site. A second screw enters the proximal phalanx at its medial aspect
and is directed in a proximal lateral direction across the joint. A K-wire should be placed at the second screw site to maintain
position during instrumentation and placement of the first screw. Ultimately, the hole from the K-wire will serve as the pilot
hole for the second screw. It can be technically difficult to avoid hitting the first screw while placing the second screw. Ideally,
screws should exit the cortex to provide the best compression and stability.
In addition to the smaller cortical and cancellous screws, we have employed the Herbert bone screw in a similar manner. The
advantage of the Herbert bone screw is the lack of prominence of the screw head seen with traditional cortical and cancellous
screws. The prominence of the screw heads is a common reason for subsequent removal because of symptoms related to soft
tissue irritation. However, Herbert bone screws do not provide the same amount of compression in comparison with
conventional cortical or cancellous screws.
One of the more common problems with screw fixation is the need to removal of these devices because of irritation
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of the overlying soft tissue structures (41 ). Washers have been employed in some instances with screws, particularly over the
medial flange of the proximal phalanx (35 ,81 ,82 ). Care should be taken to contour and place the washer flush against the
overhang of the medial proximal phalanx to help avoid prominence. We have noted failure of the medial portion of the proximal
phalanx when compression screws are placed from distal medial to proximal lateral (second screw placement of a two-screw
technique). However, we do not typically use washers.
FIG. 11. Common technique of fusion employing cannulated cancellous bone screws. This technique can provide excellent
rigid internal fixation.
FIG. 12. A,B: Combined technique employing a single screw with a secondary Kirschner wire to enhance overall stability
and to prevent any tendency for frontal plane rotation.
If the screws heads are placed in the metaphyseal flare of the distal metatarsal and the proximal phalanx, then the need for
subsequent removal should be diminished. Use of small screw heads with adequate countersinking allows for good protection of
the screw heads and decreases the likelihood of stress risers. The other end of the screw can also become a problem that
necessitates subsequent removal. This is especially true of a screw that runs from proximal medial dorsal to distal lateral
plantar. Care should be taken to avoid excessive dorsal to plantar angulation because this may lead to symptoms resulting from
direct pressure from the weight-bearing surface or from impingement involving the plantar lateral neurovascular bundle.
Arthrodesis with screws is a more difficult and time-consuming technique. We generally reserve this technique for situations in
which few or no additional procedures will be performed or in which axial compression is deemed critical to successful fusion.
This would include some revisional cases if adequate bone stock is present to support the screws and cases involving repair of a
nonunion or pseudoarthrosis from a previous attempt at fusion.
Plate Fixation
The use of dorsal plates for arthrodesis of the first metatarsophalangeal joint has been a popular technique in the orthopedic
community (Fig. 13 ). Various plate configurations have been used including, semitubular, one-fourth tubular, one-third tubular,
dynamic compression, and limited contact plates. Multiple studies have demonstrated the superior stability and rigidity
achieved with the application of a dorsal plate (21 ,22 ,29 ,81 ,82 ). Traditionally, stainless steel plates have been favored
because of their increased rigidity; however,
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titanium has been employed at times as a result of its biologic compatibility and decreased stiffness. The stiffness of a titanium
plate is closer to that of bone when compared with stainless steel. This decreases the amount of stress shielding caused by the
fixation and may decrease potential postoperative complications such as fatigue or stress fracture on either side of the plate.
The use of more limited contact plating also reduces the risk of stress shielding and has become more popular. Smaller, more
malleable plates also allow for easier manipulation and enhanced ability to monitor bone healing postoperatively (Fig. 14 ).
Ultimately, the material used and the size of the plate are dictated by the clinical situation. When rigidity is the primary
concern, such as fusion with an interpositional bone graft, a stainless steel one-third tubular plate may be the best option.
FIG. 13. Technique using a single one-third tubular plate. Typical dorsoplantar radiograph of fusion with a single one-third
tubular plate. Visualization of the fusion site is significantly obscured with this size plate.
FIG. 14. A: Fusion with a smaller-profile titanium plate and an interfragmentary screw. These materials are more
compatible with the size of the bones at the first metatarsophalangeal joint and from a biologic perspective. B:
Dorsoplantar radiograph of same. Note enhanced visualization of the fusion site on the radiograph, which allows more
accurate assessment of bone healing.
Little question or debate exists on the stability achieved by this technique. However, the amount of compression achieved at
the fusion site may not be any greater than that achieved by the use of one or two cortical or cancellous screws. Compression at
the fusion site is accomplished by eccentric drilling at the time of screw insertion. Our opinion is that this technique should be
reserved primarily for those cases with minimal or no transverse plane deformity or when rigid stability is considered critical to
a successful outcome. The compression plates are particularly valuable when interpositional corticocancellous bone grafts will
be necessary to restore length to the segment. When a large intermetatarsal angle is present and significant transverse plane
deformity at the joint exists preoperatively, then the required contouring and positioning of the plate may make this technique
difficult. In comparison, application of a plate dorsally in the absence of transverse plane deformity is straightforward.
Ideally, concentric compression is produced when one attempts to produce axial compression with a plate at a fusion or fracture
site. To achieve concentric compression with a plate at a first metatarsophalangeal fusion site, the plate must be bent so the
convexity of the bend points dorsally. When axial compression is generated with eccentric screw application, the plantar
surfaces compress first, followed by the dorsal surfaces. By bending the plate in this fashion, the surgeon has no control of the
sagittal plane placement of the hallux; thus, ideal position is sacrificed for optimal compression. Union is achieved, but the
proximal phalanx may approximate the same declination as the first metatarsal and may render the medial column
nonfunctional during propulsion.
To use a plate for a first metatarsophalangeal arthrodesis, the surgeon must apply the plate so both fusion and desired position
are obtained. With a normal first metatarsal declination angle of 15 to 20 degrees and a desired phalangeal position of 10 to 20
degrees from the weight-bearing surface, the total angulation needed in the plate approaches 30 to 40 degrees.
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The obtuse angle formed by the dorsal surface of the plate approximates 140 to 150 degrees, whereas the two acute angles
formed between the plate and the weight-bearing surface measure 15 to 20 degrees each. The proximal acute angle depends on
the first metatarsal declination angle, and the distal acute angle depends on the sagittal plane displacement of the hallux away
from the weight-bearing surface.
When applying a plate in this fashion, we use three different screw application techniques. The first technique involves bending
the plate, as described earlier, and securing the plate to the metatarsal and proximal phalanx with concentrically placed screws.
This technique would be ideal in patients with severe hallux rigidus and in whom the first metatarsophalangeal joint appears to
have nearly autofused. The plate's primary function is to neutralize the mechanical stress surrounding the first
metatarsophalangeal joint. If compression is desired, one or two screws closest to the fusion site can be drilled eccentrically
(screw technique No. 2). This would provide some degree of compression; however, the compression would be eccentric and
dorsally focused. A dorsal plate with eccentric screws is ideal when one uses a bone graft to replace an osseous deficit. An
eccentric screw on either side of the bone graft provides compression at each bone graft-host interface. Another method to
obtain compression on either side of the bone graft (screw technique No. 3) would be to place a dorsal plate and concentrically
placed screws with an interfragmentary screw spanning the bone graft or fusion site (Fig. 15 ). The interfragmentary screw
could be contained within the plate, but more likely it would be outside the plate. This would be determined by the angle of
the screw, the desired sagittal plane angulation of the arthrodesis site, and the size of the metatarsal and the phalanx. The
interfragmentary screw is most commonly placed from distal medial in the phalangeal base to proximal lateral in the metatarsal.
To place an interfragmentary screw within a plate and across a bone graft at the first metatarsophalangeal joint is technically
demanding and often is not feasible or practical.
The length of the plate is also important. Ideally, at least two screws should be inserted from dorsal to plantar through the
plate into the phalanx. Optimally, three screws should be inserted on the proximal portion of the plate and should pass through
both the dorsal and plantar cortices of the metatarsal. This technique then necessitate, at minimum, a five-hole, if not a six-
hole, plate. When a six-hole tubular plate is used, the third hole is placed over the fusion site. Before securing the plate to the
first metatarsal, it is bent to the appropriate angle to ensure adequate dorsiflexion at the fusion site. In some cases, the plate
may be prebent, based on the preoperative radiographs; one must take into consideration the first metatarsal declination angle.
The hole closest to the fusion site is eccentrically drilled to achieve some compression at the fusion site.
After the screw has been inserted, the second hole is drilled. This hole may be drilled either concentrically or eccentrically to
achieve additional compression and to maximize rigid stability. If it is drilled eccentrically, the first screw is loosened before
insertion of the second screw. Once the second screw has been securely inserted, the first screw is tightened. The technique of
eccentrically drilling the first two holes, theoretically, provides increased compression at the fusion site as compared with the
technique of eccentrically drilling only the first hole. Finally, the third hole is drilled, and the screws of choice are inserted.
Traditionally, 2.7- or 3.5-mm cortical screws have been used with a plate from the mini and small fragment sets, respectively.
However, with the advent of smaller plates from the hand modular, distal radius, or oral maxillofacial sets, screw sizes for plate
application have decreased. This feature allows for easier placement and application of the plate along with enhanced
visualization of the fusion site on radiographs.
FIG. 15. The same technique with use of an interfragmentary screw to enhance compression at the fusion interfaces. The
isolated tubular plate may not provide significant compression at the site.
When several fusions have been performed previously, or a hemiimplant or total implant arthroplasty was performed, an
interpositional corticocancellous graft will usually be necessary to restore length. In these situations, one screw should securely
fix the plate to the graft itself. Eccentric drilling is then performed both distal and proximal to the graft, to achieve
compression at the graft-host interfaces. This technique provides the greatest rigidity and stability to both fusion sites on
opposite sides of the graft, and it is the procedure of choice when interpositional bone grafts are necessary (Fig. 16 ).
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FIG. 16. A: Preoperative radiograph of a patient with a severely painful first metatarsophalangeal joint secondary to
previously failed hallux abducto valgus surgery. No infection was present. B: Same patient intraoperatively after joint
resection, insertion of tricortical autogenous bone graft, and plate fixation. C: Dorsoplantar radiograph several months
postoperatively. D: Dorsoplantar radiograph 4 years later at the time of plate removal.
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FIG. 17. A,B: Salvage technique for fusion of first metatarsophalangeal joint using figure-of-eight tension band principles.
Other Forms of Fixation

Various other techniques of fixation have been reported but offer little advantage over those previously described (Fig. 17 ).
Although some surgeons may have entertained devices such as absorbable pins or rods synthesized from polyglycolic acid, these
do not appear to have any significant value. In fact, because of the incidence of sterile abscess formation, this type of fixation
may represent a significant consideration with respect to potential complications of the procedure. However, absorbable
fixation made of poly-Llactide seems to produce a significant decrease in the incidence of associated soft tissue complications.
The use of allogeneic cortical bone screws or wires may have some advantages and implications in the future. Current trial
studies are being established.
External devices probably provide the greatest degree of compression to the fusion site. In addition, they allow for adjustment
to increase or decrease compression at the fusion site without the need for a return to the operating room. Perhaps the greatest
advantage is their ability to maintain distraction of the area before final fusion. This may be desired in cases of infection in
which extensive incision, and drainage, and débridement of necrotic bone have been performed but a delay of several weeks
may be necessary before the definitive fusion procedure. As with compression plating and screw fixation, non-weight bearing is
required until consolidation at the fusion site is achieved (Fig. 18 ).
Ancillary Procedures
Ancillary procedures clearly deserve discussion. The nature and frequency of these procedures vary with the nature and severity
of deformity of both the metatarsophalangeal and interphalangeal joints. The most common procedure in our experience is a
lengthening of the EHL tendon. This procedure is frequently necessary in patients with severe hallux malleus or hallux extensus
deformity, conditions seen
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alone or in combination with hallux adduction or hallux varus deformity. A word of caution is in order. Excessive lengthening
may encourage drooping of the hallux at the interphalangeal level or a hallux flexus deformity that may adversely affect gait as
a result of dropped hallux.
FIG. 18. Lateral radiograph with an external fixator applied dorsally to maintain temporary distraction of the site until one
is ready for fusion after incision and drainage for osteomyelitis of the joint.
FIG. 19. Preoperative (A) and postoperative (B) dorsoplantar radiographs demonstrating excellent reduction of the
intermetatarsal angle with establishment of a congruous first metatarsophalangeal joint without the need for additional
procedures on the first metatarsal. Simultaneous fusion of the second digit was performed to eliminate retrograde
pressure of a hammer toe deformity causing lesser metatarsalgia.
FIG. 20. Preoperative (A) and postoperative (B) lateral radiographs demonstrating reduction of the metatarsus primus
elevatus deformity as a result of more proper positioning of the great toe. The change in alignment of the hallux has
eliminated the retrograde pressure to the first metatarsal that resulted in dorsal migration. C: Demonstrating simulated
push-off in weight bearing. Note the amount of heel elevation, which can be achieved, with minimal dorsal angulation of
the great toe.
A tibial sesamoidectomy or release of the abductor tendon may be necessary in cases of severe transverse plane malalignment,
such as hallux varus or hallux adductus deformity. Although realignment and fusion of the metatarsophalangeal joint could be
accomplished without these procedures, theoretically
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they are necessary to prevent medial drifting and pull of the entire first ray by the abductor tendon after fusion.
Release of the plantar lateral structure, including the adductor tendon, is generally reserved for cases in which severe
subluxation or dislocation of the metatarsophalangeal joint is present. Some authors have advised that, when possible, the
adductor tendon should be left intact because this approach helps to reduce the intermetatarsal angle after restoration of
alignment at the metatarsophalangeal joint level (21 ,36 ,61 ). We appreciate this argument but do not subscribe to this theory.
A standard plantar lateral release, with or without fibular sesamoidectomy, is sometimes essential to allow for proper alignment
of the first metatarsophalangeal joint before arthrodesis.
Significant deformity or degenerative arthritic changes at the interphalangeal joint may warrant consideration for concomitant
fusion of the joint along with fusion of the metatarsophalangeal joint. This procedure should only be contemplated if the
patient has significant clinical correlation of degenerative joint disease at the interphalangeal joint. Often, degeneration or
malalignment on radiographic findings proves to be clinically asymptomatic. If arthrodesis is indicated clinically, this may be
accomplished with the use of single or, more commonly, two parallel K-wires or Steinmann pins crossing both joints.
Alternatives are cross K-wire fixation of the interphalangeal joint and cancellous screw fixation with crossing K-wires and other
similar techniques at the metatarsophalangeal joint level. In some cases, a single longitudinally oriented K-wire or Steinmann
pin may be sufficient to provide external immobilization when a cast is also employed. With a single axial fixation technique
(screw, Kwire, or Steinmann pin), rotation may occur at one or both of the fusion sites, an obviously undesirable outcome.
FIG. 21. Postoperative dorsoplantar (A) and lateral (B) radiographs after first metatarsophalangeal joint fusion with
panmetatarsal head resection for rheumatoid arthritis.
The routine excision of the tibial or fibular sesamoid is not recommended. As previously discussed, this operation is performed
in cases of severe hypertrophy or degenerative arthritic changes of the bone or when the sesamoid bone is believed to be a
hindrance to realignment and fusion of the great toe. It may be helpful and necessary to remove the fibular sesamoid to achieve
a greater reduction in the intermetatarsal angle.
In cases of severe splaying between the first and second metatarsals with a tendency toward subluxation at the
metatarsocuneiform joint, closing base wedge osteotomy or metatarsocuneiform joint fusion may be necessary. However, fusion
of the first metatarsophalangeal joint has been reported to reduce the intermetatarsal angle successfully without either of
these procedures (Fig. 19 ). Mann and Katcherian demonstrated that spontaneous reduction of the first intermetatarsal angle
occurred after a successfully positioned fusion of the first metatarsophalangeal joint. In fact, this effect was magnified as the
first intermetatarsal angle increased (83 ). Concomitant osteotomy of the first metatarsal is rarely needed for reduction of an
elevated intermetatarsal angle or a flexible metatarsus primus elevatus (Fig. 20 ). However, proximal procedures are required in
some patients to correct severe iatrogenic malalignment of the first ray.
Ancillary procedures on the adjacent rays are performed in

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patients with rheumatoid arthritis or other major deformities. The most common procedures include panmetatarsal head
resection, digital arthroplasty, and arthrodesis with appropriate soft tissue release. In patients with mild to moderate hammer
toe deformities, some authors have recommended no treatment, because a spontaneous reduction of the deformity may be seen
after successful fusion of the great toe. We have noted spontaneous reduction of the lesser metatarsophalangeal joints after
arthrodesis of the first metatarsophalangeal joint in our patients. In general, if the lesser metatarsophalangeal and lesser digital
deformities are flexible and reducible, surgical treatment of the digits may not be warranted. This may be seen with or without
a concomitant panmetatarsal head resection. When performing a panmetatarsal head resection, the surgeon should resect the
first metatarsal head to establish an acceptable parabola and should then recontour the bone to fit congruously with the
preserved architecture of the proximal phalangeal base (Fig. 21 ).
Most authors advocate immediate postoperative weight bearing regardless of the type of fixation. Typically, protected weight
bearing is recommended, ranging from a surgical shoe to a short leg cast (20 ,32 ,33 ,35 ,37 ,42 ,47 ,79 ). Few articles in the
orthopedic literature recommend a non-weight-bearing status postoperatively. We suggest that the outcome may be enhanced
and the complications minimized by non-weight bearing for the first 4 to 6 weeks postoperatively, followed by protective weight
bearing until clinical signs and radiographic evidence show consolidation of the arthrodesis site. Certain types of fixation are
more amenable to weight bearing than others. In patients who have undergone bone grafting or revisional procedures, non-
weight bearing for a minimum of 8 weeks is optimal. The forces of early weight bearing are detrimental to bone graft healing
and incorporation. Serial radiographs confirming incorporation and bone graft consolidation are critical.
Regardless of weight-bearing status postoperatively, weight-bearing radiographs are important to monitor and assess the bone
healing process. Should radiographs indicate a disturbed union process, then a modification of postoperative care should be
considered.
FIG. 22. Clinical (A) and radiographic (B) appearance of a patient with mild hallux flexus contracture resulting from the
dorsiflexed position of the fusion at the first metatarsophalangeal joint. Minimal dorsiflexion at the fusion site is
recommended to enhance cosmesis and to prevent such a deformity.
External fixation devices, such as K-wires or Steinmann pins, are usually left in place for 6 to 8 weeks. Other forms of fixation
are generally left in place unless they become symptomatic because of incompatibility with shoe gear or irritation of the
overlying soft tissues, especially the cutaneous nerves.
Most conventional shoe gear is well tolerated. Incompatibility with shoe gear generally indicates poor position of arthrodesis. In
patients with excessive dorsiflexion at the fusion site, pain beneath the first metatarsal head and sesamoid apparatus may occur
and may necessitate the use of an accommodative type of orthotic devise. In patients with inadequate weight-bearing and
propulsive function of the first ray, a Morton extension may be necessary. Excessive dorsiflexion at the first
metatarsophalangeal joint after arthrodesis may result in compensatory plantarflexion at the interphalangeal joint. Persistent
pressure in this area may cause preulcerative or hyperkeratotic areas. This condition is easily treated with a digital pads and
conventional shoe gear or shoe gear with an increased toe box height.
COMPLICATIONS
Attainment of proper position at the time of fusion is the most critical element to the success of first metatarsophalangeal
arthrodesis: the most significant postoperative complications are those related to poor positioning. They include difficulty with
ambulation resulting from excessive or inadequate dorsiflexion, excessive abduction, or excessive adduction making
conventional shoe gear intolerable (Fig. 22 ). Various lesions may result because of malposition, including lateral or medial
ingrown nail deformities with or without paronychia, painful callus, or corn formation resulting from excessive pressure. Lesser
metatarsalgia may also develop because of improper positioning including the formation of severe plantar callosities as a result
of compensatory supination of the foot that leads to lateral column overload.
The most common complications reported to date pertain to the interphalangeal joint of the great toe. The radiographic
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appearance of degenerative arthritis, usually asymptomatic, is the most frequent complication reported. Lateral or dorsal
subluxation of the distal phalanx is a not infrequent occurrence and is usually a sequela of malpositioning of the
metatarsophalangeal joint. The arthritic process is also accelerated by the use of multiple internal fixation devices across the
joint. Should symptoms develop at the interphalangeal joint, arthrodesis will probably be required, either alone or in
combination with revisional arthrodesis, at the level of the metatarsophalangeal joint, to resolve the problem definitively.
Stress fractures of the metatarsal shaft or proximal phalanx have been reported but are rare. They have been suggested to
occur as a result of removal of an excessive amount of the cortical bone at the diaphyseal metaphyseal area. Stress fractures
may conceivably result from malalignment of the fusion site. Although inadequate dorsiflexion places stress at the fusion site
itself, excessive dorsiflexion may cause excessive loading of the first metatarsal that results in a stress fracture. Stress fractures
may also occur in the adjacent metatarsals as a result of excessive loading from malalignment of the arthrodesis site.
Complications associated with internal fixation devices depend on the type of fixation employed. Whereas external K-wires and
Steinmann pins are associated with pin tract irritation or infection, cortical and cancellous screws may be problematic because
of excessive loosening, protrusion, or prominence of the screw head or because of irritation of the overlying soft tissue
structures, especially the cutaneous nerves. Failure resulting from fracture of internal fixation devices has also been reported.
Although newer means of internal fixation, such as the Herbert bone screw, reduce the incidence of complications attributable
to the screw head itself, the removal of these devices may be difficult, should that become necessary. Excessive length of
screws may cause soft tissue irritation or plantar pain resulting from direct pressure. In these instances, screw removal is
mandated after osseous consolidation.
FIG. 23. Nonunion after first metatarsophalangeal joint fusion with Herbert bone screws (A) and conventional 4.0-mm
cancellous bone screws (B).
Bone healing complications such as delayed unions, nonunions, and pseudoarthrosis have all been reported. Fibrous unions are
likely to cause minimal symptoms: in some cases, they may be asymptomatic altogether. Delayed unions and nonunions
seemingly occur more frequently when arthrodesis has been performed after failure of previous surgical procedures such as
resection arthroplasty or implant arthroplasty. The use of interpositional bone graft may also increase the likelihood of bone
healing complications. Certain patients seem to be at higher risk of developing bone healing complications. These patients
include those with a previous history of infection, avascular necrosis from previous metatarsal head osteotomy, previous implant
arthroplasty, and neuromuscular disease (Fig. 23 ).
Disability or deformity attributable to complications at the metatarsocuneiform joint is rare. We are is aware of only one
reported case involving symptoms attributed to changes at the metatarsocuneiform joint. However, this finding was reported in
a patient who had previously undergone triple arthrodesis. Several authors have reported the absence of subluxation or
degenerative arthritic changes at this joint after the first metatarsophalangeal joint fusion, even when a large intermetatarsal
angle was not corrected by a separate
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procedure. Should subluxation, dislocation, or degenerative arthritis develop later, then fusion is recommended.
Overall morbidity associated with first metatarsophalangeal joint arthrodesis is clearly low. First metatarsophalangeal joint arthrodesis is a time-honored, effective, and predictable procedure. Complications
are best avoided by attainment of the proper position at the time of fusion and by selection of an appropriate method of fixation to ensure consolidation. In a compliant patient, excellent functional and
cosmetic results can be expected.
Patients who fail to understand the implications of the procedure are more inclined to be dissatisfied with the surgical outcome. Patients must clearly recognize and appreciate the implications of complete loss
of motion of the first metatarsophalangeal joint. Certain maneuvers, such as squatting and kneeling, may become more difficult. This change may have significant impact on an patient's employment if it is not
explained in detail before the surgical procedure. Complaints attributable to shoe gear are often more reflective of malpositioning. Patients who desire to wear both high-heeled and low-heeled shoes are
certainly not good candidates for first metatarsophalangeal arthrodesis.
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2. Sussman RE, Russo CL, Marquit H, et al. Arthrodesis of the first metatarsophalangeal joint. J Am Podiatr Med Assoc 1986;76:631-635.
3. Gregory JL, Childers R, Higgins KR, et al. Arthrodesis of the first metatarsophalangeal joint: a review of the literature and long-term retrospective analysis. J Foot Surg 1990;29:369-374.
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35. Lipscomb PR. Arthrodesis of the first metatarsophalangeal joint for severe bunions and hallux rigidus. Clin Orthop 1979;142:48-54.
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Chapter 11
Juvenile Hallux Abducto Valgus Deformity
Luke D. Cicchinelli
Aprajita Nakra
Juvenile hallux abducto valgus is a commonly encountered complex deformity. This condition has also been referred to as adolescent
bunion, metatarsus primus varus, and metatarsus primus adductus. Specific criteria for defining juvenile or adolescent hallux abducto
valgus deformity are lacking, although some investigators have classified the condition as occurring in a person aged 20 years or less
because of the relatively plastic nature of the components of the deformity (1 ). Other investigators have referred to the deformity as
manifesting during the formative years of life, roughly from 11 to 19 years of age (2 , 3 , 4 , 5 ).
The origin of hallux abducto valgus is multifactorial. In 1895, Boniface categorized the various etiologies into four groups: mechanical,
muscular, diathetic, and anatomic (6 ). Root et al. described the primary etiologic factors for development of hallux abducto valgus as
hypermobility of the first ray, rheumatic inflammatory disease, neuromuscular diseases, and postsurgical malfunction (7 ). Schwitalle et al.
devised a classification that was more specific for children, including congenital, neurogenic, and idiopathic types (8 ). Congenital hallux
valgus is almost always associated with other deformities such as polydactyly, cleft foot, and tumors, especially enchondroma. Some
congenital cases may represent a limb bud deficiency or an actual developmental anomaly (1 ). Neurogenic hallux valgus is the result of
spastic or paralytic palsy with a muscular imbalance that typically affects the foot as a whole. As such, the clinical and radiographic
evaluation may reveal some of the pathologic entities affecting the overall alignment of the first metatarsophalangeal joint (9 ). However,
in other patients, the cause is less certain.
Hereditary factors are perhaps the most commonly cited cause of juvenile hallux abducto valgus deformity. A positive family history for
the condition has been noted in 68% (10 ) to 80% (11 ) of patients. The factor predisposing to the evolution of a hallux valgus may be
transmitted by an autosomal dominant trait showing incomplete penetrance. Full penetrance may result in a much earlier onset and a
more severe deformity.
Although tight or poorly fitted shoes are often blamed by patients for the presence of hallux abducto valgus deformity, the role of shoes in
the creation of this condition is likely overstated. However, the incidence of juvenile hallux valgus has been shown to be higher in the shod
population than among those who walk barefoot (12 ,13 ). Poorly fitted shoes have been proposed as a contributing factor in the
progression of the juvenile hallux valgus deformity (14 ), although the association of tight shoes with juvenile hallux valgus has not been
examined (15 ). Shoes should be viewed as more of an aggravating factor once the condition is evident than a primary cause.
Juvenile hallux valgus is usually a manifestation of abnormal biomechanical function of the lower extremity that is related to anatomic
variations in structures and acquired changes resulting from external forces. With the exception of congenital anomalies or inflammatory
diseases, the progression of hallux abducto valgus in the juvenile patient is usually related to the severity of biomechanical disorder (16 ).
According to Piggott, a congruous metatarsophalangeal joint is stable and does not progress to significant hallux abducto valgus deformity
(5 ). However, once the joint has begun to sublux, it is at significant risk for progressive deformity.
Numerous anatomic and biomechanical conditions have been proposed as leading to the development of juvenile hallux valgus (17 ). This
diversity is probably a result of the different emphasis placed on each entity by different investigators, and it also reflects an inconsistent
interpretation of the relationship between potential causes and effects (8 ). Furthermore, many conditions may be responsible for the
development of juvenile hallux abducto valgus, and the origin may be multifactorial.
Truslow described an oblique position of the first metatarsal bone as the initial deforming influence in the creation of metatarsus primus
varus (18 ). This divergence was interpreted as an anatomic variation and not an acquired deformity. Lapidus believed that the atavistic
cuneiform, similar
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to the prehensile great toe of higher primates, accounted for the increased medial deviation of the first metatarsal (19 ). He believed that
an inherent instability in the medial column of the foot predisposed it to the formation and propagation of a bunion deformity. Other
anatomic variants that have been purported to predispose a young patient to hallux valgus include a round first metatarsal base, long and
short first metatarsal, oblique positioning of the first metatarsocuneiform joint, and the presence of a lateral exostosis or an os
intermetatarsia at the base of the first metatarsal (16 ,20 ). However, definitive scientific evidence to confirm the influence of these
factors in the development of juvenile hallux valgus is still lacking.
In staging the progression of hallux abducto valgus, some authors considered that the abduction of the hallux preceded the development of
metatarsus primus adductus (7 ,21 ,22 ). Piggott found that subluxation of the first metatarsophalangeal joint occurred with
intermetatarsal angles as small as 7 degrees (5 ). Kalen and Brecher also showed that metatarsus primus varus was nearly absent in
adolescents with hallux abducto valgus deformity, yet the hallux was almost always abducted (23 ). The opposite view, that an increased
intermetatarsal angle is the initial abnormality associated with hallux abducto valgus, has been explained by authors such as Truslow and
Lapidus, as described previously.
Many investigators agree that any factor that causes abnormal subtalar joint pronation and a subsequent hypermobile first ray enhances
the progression of juvenile bunions (24 ). Although they are seldom the reason for seeking professional care, metatarsus adductus, pes
valgus deformity, ankle equinus, and suprastructural deformities such as medial femoral or tibial torsion may directly influence the bunion
deformity (25 ,26 ). Yu et al. recommended that the hallux valgus deformity should be regarded as a sign or symptom of another
underlying deformity rather than as an isolated condition (27 ).
Pontious et al. proposed a classification system based on the belief in two distinct types of patients with juvenile hallux abducto valgus
deformity (28 ). The first group (type I) consists of a patient with significant metatarsus adductus, more severe deforming forces (equinus
and flatfoot), a strong familial history, and an earlier onset. The second group (type II) is composed of patients with moderate deformity, a
more rectus foot type, controllable deforming forces, or later onset with slower progression of deformity (28 ).
CLINICAL FEATURES
The typical patient with juvenile hallux abducto valgus presents between the ages of 10 and 16 years. Pain is not as common a complaint
as in the adult, but the primary concern may be the appearance of the deformity. However, girls may describe an inability to wear a
certain style of shoes, discomfort from activity-specific shoes, and increased concerns regarding self-image and perception of their bodies.
Adolescent boys may be less concerned with appearance, but they frequently have questions regarding discomfort in sport shoes. There
may be a family history of the condition, and therefore the patient or parents may express concerns regarding the progression of the
deformity, a desire to explore treatment options that may control or prevent further development of the deformity, or a need to
understand surgical options and timing. The patient's ability to participate in physical activities may help to determine the level of
disability in those patients reticent to complain. A family history of hallux abducto valgus deformity may assist in determining the
likelihood of further progression.
Clinical evaluation of the affected side reveals the amount of transverse and sagittal plane deviation. Juvenile hallux valgus differs
significantly from the adult bunion in that the deviation of the toe is less pronounced, the medial eminence is smaller, bursal thickening is
rare, and a rotation deformity of the hallux is present only in patients who have a more pronounced condition. Degenerative changes at
the metatarsophalangeal joint are minimal, and the phalangeal and metatarsal epiphyses may have yet to close (29 ).
The presence of digital deformities or plantar callosities may also help in determining the overall nature of the condition. The range of
motion of the first metatarsophalangeal joint may be assessed in both the resting position and under manual reduction. Lack of ability to
reduce the hallux passively is referred to as “a track bound joint” and historically was believed to indicate deviation of the affected
articular cartilage, but it more likely represents displacement of the sesamoid apparatus and contracture of the soft tissues (26 ,28 ).
However, in patients with juvenile hallux abducto valgus deformity, a higher degree of proximal articular set angle deviation has been
observed (28 ).
Examination of the alignment of the foot and the motions therein may be helpful in identifying potential influences in the formation of
juvenile hallux valgus deformity. Ankle equinus can have a profound effect on midfoot stability by unlocking the midtarsal joint with
resultant distal hypermobility and juvenile hallux valgus. Pes valgus deformity and metatarsus adductus can potentially compromise the
repair of juvenile hallux valgus and may need to be considered in the surgical approach to the patient.
Progression of the deformity may lead to secondary problems such as digital contractures and plantar callosities. Painful degenerative
hallux valgus in an adult is often the result of untreated deformities in the growing adolescent. Appropriate and timely treatment of
juvenile hallux valgus is helpful in avoiding the more pronounced and permanent ligamentous, articular, and osseous changes that ensue
over time.
The treatment protocol for juvenile hallux valgus remains controversial. Many factors must be taken into consideration (27 ), including the
following:
 The age of the patient and the status of the growth plate (open or closed)
 The flexibility of the deformity
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 The onset and progression of the deformity

 The coexisting etiologic factors
 The presence of a coexisting deformity
 Family history
 The degree of symptoms
 The patient's and parents' expectations
RADIOGRAPHIC EVALUATION
Radiographs are an important part of the evaluation of a patient with juvenile hallux abducto valgus. In most instances, this evaluation
includes the assessment of weight-bearing dorsal plantar and lateral views. Sesamoid axial and oblique views may also be of benefit in
some instances. Neutral-position lateral and dorsal plantar views have been recommended in some instances to help reveal compensated
deformity such as metatarsus adductus (25 ). However, this is seldom necessary. The relationships that appear to be of primary importance
are the intermetatarsal angle, the metatarsus adductus and hallux abductus angles, and the sesamoid position. Other features that may be
evaluated are the amount of hallux abductus interphalangeus, the overall shape of the first metatarsal head, the presence of any accessory
bones between the first and second metatarsal bases, and the length of the first metatarsal. A relatively low intermetatarsal angle or a
long first metatarsal may belie an underlying metatarsus adductus deformity (27 ) (Figs. 1 and 2 ). Proximally, other features to observe
are the growth plate and any apparent obliquity of the first metatarsocuneiform joint.
FIG. 1. Although the intermetatarsal angle is low, early bunion deformity is appreciated in association with a substantial metatarsus
adductus deformity.
FIG. 2. Note the appearance of a long first metatarsal in the presence of metatarsus adductus as a result of the transverse plane
adduction of the forefoot on the midfoot.
Of particular note is the lateral displacement of the sesamoid bones. Deviation of these structures is evidence of a mechanical advantage
of the lateral soft tissue structures and flexor hallucis longus. If the condition is allowed to persist, these soft tissue structures will
increase the likelihood of further progression of the deformity (27 ).
Attempts to assess the proximal articular set angle radiographically are unreliable, and this relationship is best assessed intraoperatively
(28 ). Historically, the shape of the first metatarsal head was believed to be important in determining the transverse plane stability of the
metatarsophalangeal joint. A round metatarsal head was purportedly associated with a greater amount of joint instability and a greater
tendency toward hallux abducto valgus, whereas a square head was considered more likely to resist abductory forces at the first
metatarsophalangeal joint. However, screening of 6,000 school children between the ages of 9 and 10 years for hallux abducto valgus
deformity revealed only a weak relationship between the shape of the metatarsal head and the degree of hallux abducto valgus (30 ).
Assessment of the rearfoot and midfoot joints may reveal positional or structural abnormalities that may influence the forefoot and the
formation of juvenile hallux valgus deformity. This is particularly pertinent in patients with suprastructural deformities or collapsing pes
valgus conditions. Yu et al. proposed that juvenile hallux valgus deformity may
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be classified radiographically as either static or dynamic (27 ). The dynamic form results primarily from hypermobility of the forefoot
secondary to biomechanical abnormalities, with the first metatarsophalangeal joint the primary site of deformity. In these cases, the
extent of lateral deviation of the great toe is more likely to create a retrograde buckling force on the metatarsal head and therefore to
increase the splaying between the first and second metatarsals. In addition, the eccentric loading of the metatarsophalangeal joint may
cause lateral articular cartilage deviation and abduction.
The static form of juvenile hallux abducto valgus primarily presents as a deformity of the metatarsal itself or of the metatarsal cuneiform
joint. The hallmark of the dynamic deformity is abduction of the hallux and an increased intermetatarsal angle. However, patients with
the static deformity present with or without abduction of the great toe, yet with a high intermetatarsal angle. A rhomboidal shape of the
metatarsal may result from an abnormally wide and hypoplastic lateral epiphyseal growth plate. Deviation may also arise from the
articular surface of the medial cuneiform (27 ). Investigators have suggested that an increase in obliquity of the distal articular facet of the
medial cuneiform indicates a hyperadduction of the first ray (26 ).
ASSOCIATED DEFORMITIES
Deformities associated with juvenile hallux abducto valgus may be those that contribute to the origin of the condition or those that are
produced as byproducts of the early onset of hallux valgus. As previously discussed, predisposing conditions such as torsional deformities,
pes valgus deformity, and ankle equinus may affect the long-term success of correction of juvenile hallux valgus. A significant contributing
factor to juvenile hallux valgus is metatarsus adductus. The association of metatarsus adductus with juvenile or adolescent hallux valgus
deformity has been recognized by several authors (17 ,28 ,31 ,32 ). Greater levels of metatarsus adductus have been associated with
greater amounts of hallux abductus in adult patients (32 ). A statistically significant association has been identified between increasing
metatarsus adductus angle and hallux abducto valgus in adolescent patients undergoing surgery (17 ). Pontious et al. also noted a 75%
incidence of metatarsus adductus in adolescent patients with hallux abducto valgus (28 ). Furthermore, significantly higher rates of
recurrence of deformity were noted in juvenile and adolescent patients because of an unappreciated metatarsus adductus deformity.
Metatarsus adductus has also been noted to be more prevalent in adult patients with hallux abductus (31 ).
A low intermetatarsal angle may not accurately reflect the amount of true structural deformity in the presence of an increased metatarsus
adductus. With greater degrees of metatarsus adductus, one typically sees a significant increase in the amount of hallux abduction, yet
with a relatively small intermetatarsal angle. Accordingly, Yu and DiNapoli proposed an equation that will help in more accurately
assessing the true or functional intermetatarsal angle in patients with a concomitant metatarsus adductus (33 ). The true intermetatarsal
angle in these cases is most appropriately assessed as follows:
IMA + (MAA − 15) = true IMA
Where IMA is the intermetatarsal angle and MAA is the metatarsus adductus angle.
Yu and DiNapoli's recommendations for treatment of hallux abducto valgus associated with metatarsus adductus were based on the severity
of the latter condition. They arbitrarily graded metatarsus adductus as follows:
Normal: 0 to 15 degrees
Mild: 16 to 20 degrees
Moderate: 21 to 25 degrees
Severe: more than 25 degrees
Studies with patients undergoing surgery for adolescent hallux abducto valgus have confirmed that the 14-degree mark is the threshold at
which metatarsus adductus deformity appears to become problematic.
When surgical procedures are selected without an appreciation for an underlying metatarsus adductus, the true or effective
intermetatarsal angle will likely not be appreciated (33 ). This factor could lead to an underuse of proximal osteotomies. Pontious et al.
found that the closing base wedge osteotomy provided superior correction of the intermetatarsal angle in adolescent patients with hallux
abducto valgus deformity (28 ).
In most cases of hallux abducto valgus deformity with a concomitant metatarsus adductus, repair of the hallux abducto valgus alone may
be suitable. However, in patients with more significant levels of midfoot deformity, correction of the metatarsus adductus may need to be
entertained because of a greater potential for recurrence of deformity at the first metatarsophalangeal joint (25 ). In general, this
correction consists of osteotomies of the first through fifth metatarsals.
Collapsing pes valgus deformity is another condition frequently seen in conjunction with juvenile hallux valgus. Hohmann stated: “Hallux
valgus is always combined with pes planus and pes planus is always the predisposing factor in hallux valgus” (34 ). Although this statement
is not entirely accurate, an association clearly exists between these two conditions in some individuals. Root et al. suggested that
excessive pronation of the subtalar joint, manifesting clinically as pes valgus, rendered the first ray hypermobile and susceptible to the
deforming forces of ground reaction (7 ). Radiographic measurements in adolescent patients with bunions have demonstrated that these
patients have an incidence of flatfeet that is 8 to 24 times higher than expected (23 ). Furthermore, substantial pes valgus deformity may
increase the risk of recurrence of hallux abducto valgus in juvenile patients undergoing surgical repair of the bunion. Ancillary procedures
for stabilization of the pronated foot in the presence of juvenile hallux abducto valgus may merit
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consideration (35 ). Alternatively, one may institute orthotic management postoperatively to counter the biomechanical aberrations that
may lead to juvenile hallux abducto valgus.
Suprastructural deformities such as limb length disparities, genu varum and genu valgum, and axial deviations in the tibial or femoral
segments may cause additional stress to be exerted on the first metatarsophalangeal joint (33 ). Many of these particular deformities are
associated with hyperpronation and may create instability through the forefoot and first metatarsophalangeal joint, with a resulting higher
incidence of hallux abducto valgus (7 ). Evaluation of the patient both during weight bearing and in gait may help to correlate the
differences between open kinetic and closed kinetic chain function and appearance of the lower extremity.
The progression of juvenile hallux abducto valgus may lead to secondary deformity such as hammer toes, transverse plane abduction of
lesser toes, and plantar skin lesions. If these conditions are present when a patient first seeks treatment for juvenile hallux valgus
deformity, surgical intervention may be considered to address these other problems at the same time.
TREATMENT
Conservative Care
The conservative treatment options for patients with juvenile hallux abducto valgus are limited, and these have traditionally consisted of
splints, bunion shields, wider shoes, and orthoses. If the condition is mild and there is no gross instability within the foot, then these
measures may provide symptomatic relief. However, simply splinting the hallux, using pads, or prescribing shoe modifications will typically
fail to alter the progression of deformity. Naturally, if the deformity is more advanced, or if the patient has other significant concomitant
conditions, it may be a disservice to the patient and family to indicate that conservative measures will reduce the bunion deformity.
Furthermore, although various splints and bunion shields are available, adolescents are unlikely to persist with the use of these devices and
will perceive them to be unattractive. Orthoses may prove helpful in reducing symptoms in mild to moderate conditions until such time as
more definitive therapy can be instituted. The intent of such devices is to control or limit excessive pronation of the foot and therefore to
reduce hypermobility of the medial column. However, orthotic devices in this circumstance should be considered more as a means of
attempting to resist further deformity than as being corrective. Biomechanical control may be considered to have greater applications in
the postoperative stages of treatment to reduce deforming forces and to protect the surgical correction. In fact, some investigators
believe that failure to institute postoperative supportive measures is a direct cause of recurrent juvenile hallux abducto valgus (36 ).
Essentially, conservative measures in the treatment of juvenile hallux valgus deformity represent a symptomatic approach to the
management of the condition (27 ). Further abduction of the hallux likely develops over time. Long-term conservative treatment may not
be optimal, particularly in patients with a strong family history. However, in a younger patient, educating the family and postponing
surgical intervention until the osseous structures mature is a popular approach.
Surgical Treatment
The indications for surgical intervention include pain, progression of deformity, adaptive contracture of the first metatarsophalangeal joint,
the development of additional forefoot deformities such as hammer toes, failure of conservative therapy, contributory forces that are
poorly controlled or controllable, and cosmetic concerns. The goal of surgical treatment is to relieve pain, to arrest progression of the
deformity, to improve function of the first metatarsophalangeal joint, and to improve the cosmetic appearance (27 ). The presence of pain
itself should not be considered an absolute or strict prerequisite for surgical management. Absolute deferral of surgery in patients without
substantial symptomatic complaints poses the risk of allowing significant deterioration in the alignment and function of the first
metatarsophalangeal joint over time (27 ). However, in some circumstances, watchful waiting is appropriate. The effective correction of
juvenile hallux abducto valgus deformity involves the release of lateral joint contracture, reduction of the intermetatarsal angle,
preservation of the first metatarsal length and weight-bearing capacity, and neutralization of concomitant deformities when indicated.
Historically, opinion has been divergent regarding the timing of surgery. Advocates of a more conservative school of thought have
recommended delaying surgery until skeletal maturity, as evidenced by closure of the growth plate. Although this approach may seem
prudent, the progressive nature of the condition may lead to continued adaptive changes around the metatarsophalangeal joint. Simmons
and Menelaus noted that the best surgical results were achieved in patients who were treated before the foot was fully mature, usually in
the age range of 11 to 15 years (37 ). Surgical intervention may be delayed in patients with less advanced deformities that are relatively
static until after skeletal maturity.
A more timely approach to surgical correction is based on an evaluation of all the factors that affect the hallux abducto valgus deformity
and the overall foot structure. The primary tenet of this concept is that surgical correction of the deformity is preferred before abductory
changes have created permanent alterations of joint anatomy and function (4 ,38 ).
It appears prudent not to delay surgery for a prolonged period in the presence of painful or progressive deformity. The mere presence of a
juvenile or adolescent hallux abducto valgus deformity indicates a significant functional or structural disorder. Its persistence may result in
a more serious
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deformity with physical and psychological sequela (27 ). The ultimate decision on surgery requires considerate and thoughtful attention to
parental concerns, the patient's primary complaint, an understanding of concomitant deformities that will affect the progression of the
present condition, and an appreciation that adolescents have many years of active life ahead of them.
As noted previously, Pontious et al. proposed two distinct types of adolescent hallux abducto valgus (28 ). Those patients presenting with
type I findings with an earlier onset of deformity, a stronger familial history, significant metatarsus adductus, or more severe deforming
forces such as equinus and pes valgus may be better served with earlier surgical intervention. The alternate group, composed of patients
with moderate deformity such as mild intermetatarsal angle, hallux adductus angle and more rectus foot type, controllable deforming
forces or later onset with less progression of the deformity, may be candidates for deferral of surgical intervention until skeletal maturity.
Perhaps more important than the chronologic age of the patient is the skeletal age. In children less than 6 years old, at least 40% to 50% of
the total metatarsal growth remains (39 ). The metatarsal is immature and small, features that potentially limit the effectiveness of
surgical correction. Fortunately, surgical intervention in this age group is rarely warranted. As children approach 6 to 10 years of age, 60%
to 80% of the metatarsal length has been attained, and the overall size and shape of the first metatarsal resemble those in an adult, so the
condition lends itself more readily to surgical procedures if the deformity is advanced and progressive (40 ). If surgery is undertaken in this
age group, proximal osteotomies will be located in close proximity to the growth plate. However, an open growth plate should not be
viewed as a contraindication to surgery, but it requires greater care during the performance of the procedure. Perhaps the best period for
surgical intervention is between the age of 10 and 16 years; 90% of the normal metatarsal length has been obtained in most boys by the
age of 12 years and 95% in girls of the same age (40 ). At this time frame, the bone structures are significantly matured, and the ability to
execute osseous procedures accurately and the opportunity to repair an adaptation are ideal.
Surgical Procedures
More than 100 procedures have been described for the surgical correction of hallux abducto valgus deformity. The techniques used to
repair adolescent hallux abducto valgus can be divided into the following categories:
 Soft tissue and capsule-tendon balance procedures

 Distal first metatarsal osteotomies
 Proximal first metatarsal osteotomies
 Metatarsal cuneiform joint procedures
 Epiphysiodesis
 Phalangeal procedures

Soft tissue procedures have a limited role as isolated treatment measures for juvenile hallux abducto valgus deformity. Soft tissue
procedures alone do little to correct intermetatarsal splay, address medial column instability, or provide any lasting effect. In one study,
the highest failure rate, almost 75%, was in children in whom the McBride procedure was performed (36 ). However, soft tissue capsule and
tendon balancing procedures do play an integral part in the repair of juvenile hallux abducto valgus in conjunction with osteotomies.
The techniques of anatomic dissection and muscle tendon balance are probably even more important in the juvenile condition than in the
adult deformity. Although weakening and stretching of the medial capsule occur, the capsule is rarely hypertrophied as in the adult.
Nonetheless, the lateral displacement of the sesamoids can be equally severe. With development of the juvenile hallux abducto valgus
deformity, one sees a medial drift of the first metatarsal head with the relative displacement of the sesamoids laterally. As displacement
progresses, the lateral intrinsic musculature contracts and gains functional advantage over the weakened medial soft tissue structures.
Relocation of the sesamoid apparatus to an appropriate position beneath the metatarsal head is helpful in providing lasting correction of
the juvenile bunion deformity. When the procedure is performed effectively, relocation of the sesamoids encourages a more centralized
effect of the long flexor tendon beneath the metatarsal head and thereby assists in a more rectus motion of the hallux during sagittal
plane excursion. Fibular sesamoidectomy is seldom, if ever, indicated in the juvenile or adolescent patient.
The reduction of a medial eminence is often not necessary or is indicated only to a mild degree. When it is performed, preservation of the
sagittal groove is advised for smooth tracking of the base of the proximal phalanx and the avoidance of subluxation of the tibial sesamoid
medially. Lengthening of the extensor tendons is rarely, if ever, required in this patient population.
Distal Osteotomies of the First Metatarsal

Many of the distal osteotomies employed for the repair of adult hallux abducto valgus deformity are also employed in the juvenile
counterpart. These procedures are primarily indicated for mild to moderate deformity and may also allow for some correction of proximal
articular set deviation. The procedures used most commonly are the Mitchell, Wilson, and Austin osteotomies. Patients undergoing the
Mitchell and Wilson procedures have experienced several complications including shortening and elevatus of the first metatarsal, transfer
lesions, and lesser metatarsalgia (10 ,41 , 42 , 43 ). However, good results have been reported by other investigators (8 ,44 ).
Nonetheless, it appears that many of these complications

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could be avoided. The Austin procedure and its variations are well suited for maintaining the length of the metatarsal and provide for more
controlled manipulation of the capital fragment in the sagittal plane. Overall good results have been noted, with fewer postoperative
complications (15 ,24 ).
In patients with significant deviations of the proximal articular set angle, the Reverdin osteotomy and its modifications may be effective in
restoring a normal alignment of the articular cartilage on the metatarsal head. However, preoperative radiographic assessment does not
accurately reflect a true increase in the proximal articular set angle. Final determination of the extent of deviation is reserved for
intraoperative evaluation (28 ).
Proximal Osteotomies of the First Metatarsal

Osteotomies of the first metatarsal base are indicated for the correction of metatarsus primus adductus and offer the most accurate
structural correction of this component of deformity. The goal of the procedure is to create a parallel relationship between the first and
second metatarsals without damage to an open physeal plate, if present (27 ). In adults, these procedures have typically been
recommended in patients with intermetatarsal angles of 15 degrees or greater. However, this approach is valid in juvenile or adolescent
patients with lesser degrees of deformity, considering the profound nature of the forces that have resulted in hallux abducto valgus at such
an early age. Proximal osteotomies are typically favored in patients with metatarsus adductus deformity. In this setting, reduction of the
intermetatarsal angle to 0 degrees or to a slightly negative value is helpful in optimizing the correction (23 ,30 ,31 ,33 , 34 , 35 ,45 ,46 ).
The osteotomy may be performed in a variety of fashions including a transverse base wedge, oblique closing base wedge, opening base
wedge, or crescentic or dome-type osteotomies. Opening wedge osteotomy of the first metatarsal may be considered when the patient has
a short metatarsal with significant intermetatarsal deviation. However, as with any procedure that lengthens the first metatarsal, this may
create stiffness at the metatarsophalangeal joint because of an increase in intraarticular pressure and soft tissue tension at the joint level.
In addition, the opening osteotomy requires an alternative surgical site for procurement of bone graft. The addition of the bone graft adds
another element of complexity to the repair that needs to be considered in light of the increased potential risks.
The crescentic osteotomy of the base of the metatarsal is a popular procedure and creates a minimal degree of shortening, but fixation
may prove difficult, particularly if the patient has an open growth plate (47 ). The closing base wedge osteotomy and its modifications
have been employed successfully in the correction of juvenile hallux abducto valgus deformity. The same principles of osteotomy design,
hinge axis concept, and internal fixation techniques are employed in the juvenile patient as in the adult (Figs. 3 and 4 ). Base wedge
osteotomies work well in combination with distal procedures such as the Reverdin osteotomy (48 ). A 92% rate of good and excellent results
has been reported in an 11-year retrospective study of 60 feet with juvenile hallux valgus treated by a multiprocedural approach that
included proximal osteotomies (15 ).
FIG. 3. Closing oblique base wedge osteotomy with single screw fixation in the presence of an open epiphyseal plate. The apex of the
osteotomy is distal to the epiphyseal complex, yet it still provides good reduction of the intermetatarsal angle.
Metatarsocuneiform Joint Arthrodesis and Cuneiform Osteotomy

Correction of juvenile hallux abducto valgus deformity may also be performed by fusion at the first metatarsocuneiform joint or by
osteotomy for reorientation of the distal articular surface of the medial cuneiform. Indications for fusion include severe juvenile hallux
abducto valgus deformity or deformities associated with instability of the first ray, particularly as seen in neuromuscular diseases or
genetic conditions such as Down's syndrome. Caution must be employed in patients with an open growth plate. Shortening with this
procedure may be offset by corticocancellous grafting and, to a lesser extent, by plantarflexion of the first metatarsal. Smooth Kirschner
wires are used for fixation if the devices cross an open growth plate.
Lynch advocated use of an opening wedge cuneiform osteotomy in the surgical repair of juvenile hallux abducto valgus deformity (26 ). The
indication described for this procedure is a severe structural increase in the first intermetatarsal angle in association with an atavistic
cuneiform, manifested as an increase in the obliquity of the distal articular set angle of the medial cuneiform. Proponents of the
procedure
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embrace the concept that the deformity of metatarsus primus adductus is generally a result of underdevelopment of the medial aspect of
the first cuneiform. The osteotomy is a combination of the Cotton procedure, a plantarflexory cuneiform osteotomy that affords sagittal
plane correction, and the Fowler procedure, which is an abductory osteotomy providing transverse plane correction (49 ,50 ). An
osteotomy is created in the substance of the medial cuneiform that leaves a lateral cortical hinge intact. A wedge-shaped bone graft,
typically freeze-dried corticocancellous bone, is inserted and is fixed with a staple or Kirschner wire. When excessive obliquity of the
metatarsal cuneiform joint exists, this procedure may be an attractive component of the correction. A distal first metatarsal osteotomy is
frequently required as well to gain further intermetatarsal angle reduction and to correct for deviations in the proximal articular set angle,
if warranted.
FIG. 4. Closing oblique base wedge osteotomy with two-screw fixation in the presence of an open epiphyseal plate. Preoperative (A)
and postoperative (B) anteroposterior views. Note the placement of the osteotomy and two screws distal to the epiphyseal complex.
The intermetatarsal angle has been reduced to 0 degrees.
However, the oblique orientation of the first metatarsocuneiform joint may vary, depending on the position of the foot during the
radiographic examination. Furthermore, even when present, this condition is not a contraindication to a proximal metatarsal osteotomy or
arthrodesis.
Epiphysiodesis
Epiphysiodesis is a unique appoach for correction of juvenile hallux abducto valgus. The basic concept of epiphysiodesis involves controlling
the final position of the first metatarsal and intermetatarsal angle by selectively arresting growth on the lateral aspect of the physis at the
first metatarsal base (39 ,51 ). This has been accomplished by the use of cancellous allograft or staple fixation (39 ,52 ,53 ). Proponents of
this procedure have suggested that it is more logical to use the body's growth potential to aid correction at the first metatarsal and to
avoid the recovery necessitated by elective osteotomies (52 ). Seiberg et al. preferred epiphyseal stapling because of the reversibility and
simplicity of the procedure (52 ). Epiphysiodesis by bone graft is irreversible, and timing of the procedure must be optimal to gain the
maximal correction depending on residual bone growth. In general, the procedure can be performed at a younger age in girls and at an
older age in boys because of different timing in the respective adolescent growth patterns. Nelson evaluated the average adolescent
growth sequence and found the majority of growth occurred between the ages of 10 and 12 years for girls and between 12 and 14 years for
boys (40 ).
Preoperative planning in the performance of epiphysiodesis requires a consideration of how much correction of the intermetatarsal angle is
required, a determination of the skeletal age and remaining growth potential of the first metatarsal, and a decision whether concomitant
procedures will need to be performed, such as in the presence of proximal articular set deviation. Sieberg et al. noted that the timing of
an epiphysiodesis procedure must include (a) medial growth necessary at the physis for correction as determined by templates, (b) skeletal
maturity as estimated by using a standard radiographic atlas, (c) percentage of growth remaining in the first metatarsal, (d) estimated
amount of growth remaining in
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the medial physis, and (e) medial growth needed for correction, which is then compared with the estimated amount of growth remaining in
the medial physis (52 ).
FIG. 5. A: Staple fixation for epiphysiodesis showing a longer proximal arm and shorter distal arm to allow for complete dorsal to
plantar fixation of the epiphyseal complex. B: Stapling should be performed in the lateral 25% of the epiphyseal complex and should
completely bridge the physis.
Epiphyseal stapling has been favored by some surgeons because growth may be restored if necessary by removal of the fixation. Therefore,
the procedure is more forgiving than when growth arrest is achieved with bone grafts. Staple fixation should cross the growth plate within
the lateral 25% of the physeal complex and should extend completely from the dorsal to the plantar cortex. Failure to cross the plantar
cortex could result in continued bone growth at the plantar metatarsal and could possibly lead to a metatarsus primus elevatus deformity.
Care must be taken to avoid the first metatarsal cuneiform joint as well as the actual physeal plate. An offset staple fashioned from with a
0.62-inch Kirschner wire is ideal for this procedure (Fig. 5 ). Placement of the staples deep to the periosteum is advised, to reduce the
possibility of extrusion. In a review of 15 feet undergoing this procedure with an average follow-up of 3.9 years, the intermetatarsal angle
was reduced an average of 6.6 degrees, and the hallux abductus angle was reduced 19.6 degrees (52 ).
Epiphyseal stapling is not typically performed as an isolated procedure. Often, a distal soft tissue procedure is performed concurrently.
The orientation of articular cartilage and soft tissue contracture of the first metatarsophalangeal joint will need to be evaluated carefully
because of uncertainty regarding the overall results when the procedure is performed as an isolated technique (Fig. 6 ). Patients may still
require additional corrective surgery if epiphysiodesis has not provided adequate reduction of the intermetatarsal splay (Fig. 7 ).
FIG. 6. A: Lateral postoperative radiograph. Note the purchase of the plantar cortex by staple (arrows) and placement distal to
metatarsocuneiform joint.
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FIG. 6. Continued. B: Preoperative and 4-year postoperative follow-up distal plantar views. Note 4 degrees reduction in the
intermetatarsal angle. Also note that a modified McBride procedure was performed distally. C: Clinical 4-year postoperative view of
the same patient after epiphysiodesis. (Courtesy of Donald F. Green, D.P.M.)
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FIG. 7. A: Radiographic appearance of a left foot in a 5-year-old patient. B: Subtle abduction of the hallux is appreciated 2 years
later in the same patient. C: Continued progression of deformity at the age of 9 years. D: Epiphysiodesis performed at the age of 11
years. E: Moderate intermetatarsal increase noted in the presence of epiphyseal stapling and subluxation of the sesamoids now
radiographically apparent. F: Persistent hallux abducto valgus with an intermetatarsal angle increase in this patient, now 15 years
old. G: Eventual intermetatarsal angle reduction and correction of the juvenile hallux abducto valgus deformity by distal metaphyseal
osteotomy. (Courtesy of John A. Ruch, D.P.M.)
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FIG. 7. Continued.
Phalangeal Osteotomies
Phalangeal osteotomies are rarely indicated in the correction of juvenile hallux abducto valgus deformity. Significant deviation of the proximal articular surface of the proximal phalanx, as identified by the distal articular set angle, is most common in
the mature adult hallux abducto valgus deformity. The Akin procedure may be appropriate in patients with excessive abduction at the interphalangeal joint. A transverse or oblique wedge osteotomy is appropriate to reduce juxtaposition of the hallux
against the second digit. On occasion, an excessively long hallux secondary to an elongated proximal phalanx may be a component of juvenile hallux abducto valgus deformity. A cylindric or trapezoidal osteotomy may be appropriate when an
extremely long hallux may abut the shoe and may result in significant abductory forces that may compromise the alignment of the first metatarsophalangeal joint. Phalangeal osteotomies are best used only after positional and structural corrections
have been achieved with more proximal osseous correction and soft tissue rebalancing.
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SELECTED READINGS
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Kilmartin TE, Burlington RL, Wallace WA. A controlled perspective trial of a foot orthosis for juvenile hallux valgus. J Bone Joint Surg
Br 1994; 76:210-214.
Manninen MJ, Paivarinta U, Taurio R, et al. Polylactide screws in the fixation of the olecranon osteotomies: a mechanical study in
sheep. Acta Orthop Scand 1992;63:437-442.
Muller E, Allegower M, Schneider R, et al. Manual of external fixation: techniques recommended by the AO group, 2nd ed. New York:
Springer, 1979.
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Chapter 12
Traditional Procedures for the Repair of Hallux Abducto Valgus
Bradley D. Castellano
Joe T. Southerland
In the early history of surgical treatment for hallux abducto valgus deformity, the procedures consisted primarily of osseous resection of
the medial aspect of the metatarsal head or the proximal phalangeal base with or without associated soft tissue repair or soft tissue
correction alone. Although repair of the condition has become more sophisticated, some of these procedures remain suitable repair
techniques. In particular, the simpler approaches have been deemed preferable in older patients, in whom osteotomies may pose a higher
degree of risk. However, the indications for these procedures are certainly broader than just in the elderly, and their use may be
appropriate in patients with a wide age range.
EARLY PROCEDURES
The early means of surgical treatment for hallux abducto valgus deformity often consisted of soft tissue procedures that preceded true
bunionectomy. Surgical excision of the bursa overlying the head of the first metatarsal was advocated (1 ), but in the early to mid-1800s,
controversy existed about whether bursectomy should be combined with exostectomy of the metatarsal head.
Reverdin described exostectomy of the first metatarsophalangeal joint (2 ), and in 1881 he reported on two cases in which he used a
wedge osteotomy of the first metatarsal head. Sagittal plane resection of the medial eminence of bone of the first metatarsal head was
then made popular by Moeller, who described the surgical procedure performed by Max Shede between 1884 and 1892 (3 ). Shede's simple
exostectomy was performed on the medial first metatarsal head, and an elliptic skin resection was used to aid in relocation of the hallux.
Forceful manipulation of the toe was performed intraoperatively to release the shortened lateral structures of the joint. Although Bromeis
noted that correction of an abducted hallux was rarely obtained using simple exostectomy (4 ), he nonetheless reported satisfactory results
in 87% of his cases using Shede's procedure.
SILVER BUNIONECTOMY
In 1923, Silver described his method of capsulorrhaphy of the first metatarsophalangeal joint for hallux valgus repair (5 ). Silver was
probably influenced by Fuld, an ophthalmic surgeon, who proposed abductor hallucis tendon transfer for the repair of hallux abducto
valgus (6 ). Furthermore, the philosophy of joint preservation may have been a reaction to the earlier arthroplasty procedures, which
Silver found to be indiscriminate and nonspecific. Later, prominent surgeons such as McBride (7 ), Lapidus (8 ), and Mitchell et al. (9 )
noted and used Silver's technique to supplement their own procedures. The technique was remarkable because medial exostectomy or at
least decortication of the medial head of the first metatarsal was performed. Supplemental to this, the medial joint capsule was
reinforced with the abductor hallucis tendon and the inferior capsular attachments by relocating the tendon insertion to a more dorsal
position on the proximal phalangeal base. Fuld detached all the structures attached to the abductor tendon before its transfer (6 ). Silver
noted the significance of the lateral position of the sesamoid apparatus and attempted its relocation by maintaining the attachment of the
flexor plate to the abductor tendon. Finally, the tendon of adductor hallucis and the lateral joint capsule were sectioned with a U-shaped
capsulotomy.
Silver immobilized patients for prolonged periods in an attempt to maintain the correction obtained with this primarily soft tissue
procedure. However, this prolonged period of immobilization is not necessary today because numerous different types of splints are
available to help maintain the hallux in the corrected position. Extended splinting may be helpful in allowing the capsular tissues to adapt
to the new position, but it may also contribute to joint stiffness.
Indications
The Silver bunionectomy procedure, or a slight modification thereof, is frequently combined with osteotomies of the first metatarsal or
proximal phalanx of the hallux. As an
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isolated procedure, it is best used in the presence of a true dorsomedial or medial prominence of the first metatarsal head with little
hallux valgus or increase in the first intermetatarsal angle. Less than favorable results occur in most other situations. Patients undergoing
Silver bunionectomy should be warned that cosmetic results are generally poor because the hallux position is unaffected or is sometimes
made worse if the medial capsule is weakened by the procedure (Fig. 1 ). The Silver bunionectomy provides few advantages over other,
slightly more involved techniques.
FIG. 1. A: A 73-year-old man with chronic pain and occasional ulceration over the medial first metatarsophalangeal joint. A simple
exostosis (Silver-type) procedure was performed. B: Postoperative radiograph showing the reduction of the prominence but continued
positional deformity of the hallux.
MCBRIDE BUNIONECTOMY
In 1928, McBride described a procedure similar to the Silver bunionectomy, but he added a transfer of the conjoined tendon of the
adductor hallucis and the fibular head of the flexor hallucis brevis to the dorsum of the first metatarsal head. The fibular sesamoid was
removed on occasion as well, and, if it was not excised, the lateral head of the flexor hallucis brevis was tenotomized (7 ,10 ). McBride
believed that eliminating the lateral joint contracture was essential to allow the first metatarsal to resume a more rectus alignment.
During this time, much attention was paid to the tendon transfer described by McBride. Although some surgeons may have interpreted this
maneuver as a means of attempting to reduce the intermetatarsal angle, McBride himself stated that its purpose was to ensure that the
lateral tendinous structures would not serve as a potential deforming force in the future (11 ).
Modification of the McBride bunionectomy has generally been concerned with the method of adductor tendon transfer and the
performance or omission of fibular sesamoidectomy. In a later publication, McBride indicated that the adductor tendon was sutured into
the lateral aspect of the first metatarsal, as opposed to dorsally (11 ). DuVries modified the procedure by suturing the adductor hallucis
tendon to the adjacent capsular structures of the first and second metatarsophalangeal joints (12 ). McGlamry and Feldman discussed the
transfer of the adductor hallucis across the dorsum of the metatarsal (13 ). The tendon was then sutured into the medial joint capsule to
aid in repositioning the sesamoid apparatus.
Removal of the fibular sesamoid has been widely discussed. The proponents of fibular sesamoidectomy argue that this method provides
effective release of the lateral contracture of the first metatarsophalangeal joint, even in advanced deformity. In contrast, fibular
sesamoidectomy has been shown to be a risk factor for hallux varus when the procedure is combined with a rounded first metatarsal head
(14 ). The evolution of anatomic dissection techniques has provided the surgeon with a means by which the lateral joint contracture may
be released without indiscriminate removal of the fibular sesamoid. Nonetheless, excision of the fibular sesamoid may be required when
the standard soft tissue release is inadequate to alleviate lateral joint contracture and when the fibular sesamoid is deformed or arthritic.
Because removal of the sesamoid does result in a significant alleviation of joint tension and contracture, this technique may also
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be important in some older or compromised patients, in whom avoiding an osteotomy may be preferable.
Indications
In general, the McBride procedure is usually discussed with regard to whether or not the fibular sesamoid should be excised. Lateral
release without excision of the sesamoid is often referred to as a modified McBride procedure. As an isolated procedure, this approach
may be used in patients of any age with a painful bunion deformity, who have little hallux abducto valgus and normal to mild increase in
the intermetatarsal angle. Otherwise, the procedure is most commonly employed as a step in joint release in conjunction with metatarsal
osteotomy procedures.
The true McBride procedure, consisting of removal of the fibular sesamoid, may be an option for older patients who may be at greater risk
for complications with an osteotomy because of poor bone stock, unstable gait, previous osteomyelitis of the metatarsal head, or other
special situations. The key to determining whether the McBride procedure would be potentially successful for any given deformity is the
flexibility of the first ray. The ability of the surgeon to reduce the intermetatarsal angle with a soft tissue release alone is predicated on
the first ray's being flexible and reducible. If the first ray possesses a limited range of motion, then success is less likely. Flexibility is
usually assessed by evaluating the sagittal plane mobility of the first ray. Should good motion be available in this plane, then the patient
will most likely possess adequate mobility in the transverse plane to allow reverse buckling at the first metatarsophalangeal joint and
reduction of the intermetatarsal angle. However, if the first ray is rigid, then one can anticipate a limited degree of reduction of the
intermetatarsal angle and generally a disappointing correction (Fig. 2 ).
FIG. 2. A,B: Preoperative clinical and radiographic appearance of a patient with hallux abducto valgus deformity. C,D: Clinical and
radiographic appearance 15 years after a true McBride procedure with removal of the fibular sesamoid.
In younger patients, the modified McBride procedure results in reduced healing time and a quicker return to function, as compared with
more frequently used osteotomy procedures, although the procedure may not always result in muscle tendon balancing about the first
metatarsophalangeal joint, and a recurrence of deformity may be noted (Fig. 3 ). This thought has persuaded some surgeons that the
modified McBride procedure is not well suited in younger patients (14 ,15 ). A capital osteotomy with a small degree of transposition may
be considered as an alternative. However, it would be difficult to argue against using the modified McBride procedure when the
intermetatarsal angle is normal, yet a problematic bunion is present.
Technique
Both the medial and lateral sides of the first metatarsophalangeal joint are easily approached from a single dorsolinear incision made just
medial to the extensor hallucis longus tendon. The dissection approach is a standard technique that is employed by many surgeons and is
discussed in the section on anatomic dissection of the first ray (see Chapter 7 ). Several important points should be considered in the
process. One needs to ensure that the adductor tendon is completely released and is not tethered to the proximal aspect of the fibular
sesamoid. The fibular sesamoidal ligament needs to be transected to relieve lateral contracture completely and to allow the flexor
apparatus to relocate beneath the first metatarsal head. If continued lateral contracture persists, then the segment of the flexor hallucis
brevis between the fibular sesamoid and the proximal phalanx may be sectioned. Persistent contracture indicates a need to consider
removal of the fibular sesamoid. A judicious resection of the dorsomedial eminence should be performed. If significant prominence persists
after exostectomy, then an osteotomy may be indicated. Transfer of the adductor tendon may enhance the overall repair and the balance
of the tissues about the first metatarsophalangeal joint.
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FIG. 2. Continued.
FIG. 3. A: Radiographic appearance of a patient with a painful irritated bunion, but with little intermetatarsal splay. B: Appearance
after a modified McBride procedure. C: Appearance 18 months later. Notice the recurrent abduction of the hallux and the prominent
bone at the medial joint margin despite the good initial result and the even resection of bone.
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Complications
Removal of the fibular sesamoid has often been considered a predisposing factor for the development of hallux varus. However, the
incidence of this complication is probably not as great as imagined. Pfeffinger reported an 8% hallux varus rate in 72 McBride procedures
(16 ), although Feinstein and Brown found only 10 cases of hallux varus in 878 cases (17 ). Nine of the 10 cases were the result of McBride
bunionectomies. Unfortunately, most studies do not compare the rate of complications with those achieved with osteotomy techniques,
thereby making an absolute determination of the influence of fibular sesamoidectomy with hallux varus less certain.
Other complications of fibular sesamoidectomy may include subsequent tibial sesamoiditis or the development of a plantar hyperkeratosis
beneath the tibial sesamoid. Usually, these problems are well managed with accommodative insole devices.
Recurrence of the hallux abducto valgus deformity may be seen regardless of whether the fibular sesamoid was removed. In younger
patients undergoing the modified McBride procedure, the medial capsular tissues may not provide enough stability to resist lateral
deviation of the hallux in later years. When the true McBride technique is employed, patients generally have a greater degree of deformity
present preoperatively that one is attempting to correct by redirecting the vectors of force across the first metatarsophalangeal joint with
soft tissue alone. In this instance, an element of persistent instability may be noted that may not be present in other procedures when an
osteotomy is performed.
KELLER JOINT RESECTION ARTHROPLASTY

Joint resection procedures were first performed in the early 1800s. Fricke described a complete arthrectomy with resection of both sides
of the first metatarsophalangeal joint along with the sesamoids (18 ). This operation was reported to be a perfect success. In 1877, Hueter
described a procedure in which the first metatarsal head was resected for hallux valgus deformity (19 ). Keller believed that the resection
of the proximal phalangeal base was a less destructive approach to hallux valgus repair (20 ), because complete resection of the first
metatarsophalangeal joint created complications such as metatarsalgia and flail hallux. Furthermore, he believed that weight was
primarily borne by the heel and the first and fifth metatarsal heads, hence the impetus to preserve the metatarsal head. The Keller
procedure initially entailed resection of the proximal half of the proximal phalanx of the hallux. Brandes subsequently reported a more
significant two-thirds resection of the proximal end of the phalanx (21 ). Resectional arthroplasty was supplemented with implantation of
durillium and then silicone joint prostheses in later years. With the addition of numerous modifications, the resectional arthroplasty often
bears little resemblance to the original Keller procedure, except for the removal of the base of the proximal phalanx.
Opinion varies regarding the success and utility of the resection arthroplasty, probably more so than with any other procedure for the
repair of hallux abducto valgus deformity. Much of this controversy results from some of the complications encountered with the procedure.
These complications may be real, but they are probably overemphasized and the incidence overstated, particularly with the modifications
in technique that are available. Today, one may perform the procedure with greater reliability, and most of the historical problems
witnessed with this approach can be minimized. The modifications of the procedure can make a significant difference in the success or
failure of the procedure.
Indications
The indications for resection arthroplasty are not exclusively based on the patient's age. However, the significant indications based on
degenerative joint disease and osteopenia may be more frequently encountered in the older patient. More recently, the procedure has
been considered as a primary means of addressing the “geriatric bunion.” This term conjures the image of an older patient who may be
less stable or propulsive in ambulation, who may have osteopenic bone or cystic degeneration of the metatarsal head, who may present
with significant deformity, and in whom an osteotomy may create too great a risk in the perioperative and postoperative periods. In such
patients, resection arthroplasty provides a viable means of safely repairing the deformity and providing a lasting correction. The
advantages of the procedure include avoidance of an osteotomy, avoidance of a joint prosthesis, reduction in convalescence, and ablation
of arthritic or hypertrophic bone. Several studies have reported a greater than 75% satisfaction rate with the Keller resection arthroplasty.
In these particular studies, the average age has ranged from 43 to 66 years (22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 ).
The Keller bunionectomy has been successfully employed for the repair of hallux abducto valgus of varying severity. Much of the success of
the procedure is based on the degree of flexibility of the first ray, the release of plantar lateral joint contracture, and the ability of the
new hallux position to effect reverse buckling at the first metatarsophalangeal joint. Fenton and McGlamry reported an average reduction
in the intermetatarsal angle of 5.5 degrees with the procedure (31 ), although other investigators noted a lesser degree of correction
(32 ,33 ). In one study, the amount of reduction in
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the intermetatarsal angle was directly proportional to the preoperative measurement; greater correction was noted in patients with larger
preoperative splay (32 ). Greater decreases in intermetatarsal angles were reported when the procedure was combined with additional soft
tissue maneuvers, such as tendon transfers, capsular tightening, and sesamoidectomies (34 , 35 , 36 , 37 ). The amount of reduction
achieved also depends on the technique and the individual patient. However, in patients with a more rigid first ray, additional procedures
may need to be considered to assist in reducing intermetatarsal splay, or the surgeon will need to recognize that the result may not be
optimal.
In younger patients, the primary application of this procedure is in patients with significant arthritic degradation of the first
metatarsophalangeal joint for whom the surgeon is searching for an alternative to joint fusion that will provide for continued mobility
without an implant. In such instances, the status of the joint is the primary consideration for resection arthroplasty, rather than the
patient's age. Although in most circumstances it is preferable to restore motion by cheilectomy or osteotomy, in some instances the joint is
sufficiently deteriorated to preclude reasonable function with this more conservative approach. In other patients, the primary
degeneration may occur at the sesamoid-metatarsal articulation, thereby eliminating the normal gliding function of these structures. Even
with a lesser degree of degeneration at the metatarsophalangeal joint, if gliding function cannot be restored to the sesamoids, then
resection arthroplasty is a more reliable means of enhancing motion and alleviating symptoms. In addition, the procedure may also restore
a more anatomic length to the ray in patients with a long hallux or first metatarsal and one that may be associated with a hallux rigidus or
limitus.
Another indication for resection arthroplasty is the presence of peripheral neuropathy. Although osteotomy is not contraindicated in these
patients, it may present a greater degree of risk in the presence of insensitivity (Fig. 4 ). Resection arthroplasty may also be a suitable
means of treating patients with iatrogenic complications such as hallux varus. If the first metatarsal head has been “staked,” then
restoring normal function to the first metatarsophalangeal joint may be difficult with other procedures. The procedure may also be
suitable for patients who have suffered joint compromise as a result of infection or gout.
Results
The results reported with resection arthroplasty have varied greatly. In part, this divergence results from the different modifications of the
procedure employed by many of the surgeons, a situation that makes assessment of results across a spectrum of time or in multiple sets of
patients difficult. However, the diversity in technique has helped to define certain modifications of the procedure that may prove
beneficial while also identifying circumstances that may need to be avoided.
After resection of the proximal phalangeal base, some surgeons have devised capsular flaps to cover the metatarsal head and to act as a
spacer for fear of the development of a painful joint interface (30 ,38 ,39 ). Other surgeons have sutured the capsule in a pursestring
manner in an attempt to the capsule into the joint more effectively draw (39 ,40 ). Although the basic Keller procedure does destroy the
joint, over time a coating of fibrous cartilage forms over the remainder of the base of the proximal phalanx. Histologic evaluation has
revealed that the structure of the tissue is similar to that of an articulation, yet without hyaline cartilage. This tissue is found to preserve
a sufficient gliding surface between the two bone ends that results in optimal limitation of the natural wear process (41 ), without having
to interpose capsule. Furthermore, capsular interposition may prevent the surgeon from using this tissue as a medial stabilizing structure
to enhance function and help to maintain correction.
A floating or nonpurchasing hallux has been historically associated with the Keller procedure. With the traditional approach, the dissection
process disrupts the insertion of the heads of the flexor hallucis brevis tendon and the attachment of the medial strand of the plantar
fascia from the base of the proximal phalanx and eliminates an important stabilizing force for the hallux. However, several mitigating
circumstances should be considered.
Gait studies have demonstrated little weight-bearing function within the hallux in patients with hallux abducto valgus deformity (42 ).
Furthermore, one sees a significant loading of the lesser metatarsals in these persons. Therefore, in many of these patients, the
preoperative function of the flexor structures is less than optimal. With that in mind, one may then view the classic resection arthroplasty
as a procedure that does not primarily disrupt hallux stability, but rather may fail to reestablish hallux stability. This complication has
been seen more frequently when a larger amount of bone has been resected. With this in mind, surgeons have lengthened the extensor
hallucis longus tendon as a means of attempting to balance some of the muscular forces about the joint. This technique tends to overcome
the tendency for the hallux to elevate, although it does not restore flexor function.
Another potential source for poor flexor function postoperatively is that, in patients with hallux abducto valgus, the flexor hallucis longus
tends to be laterally displaced. The position of the sesamoids indicates the position of the long flexor. If the sesamoids remain well within
the first interspace after surgery, then the only remaining stabilizing force on the flexor side, the flexor hallucis longus, will similarly
remain in the laterally deviated position. This leaves the long flexor poorly positioned to provide any meaningful stabilization of the hallux.
Realigning this tendon along with the flexor plate to a more central location beneath the metatarsal head tends to enhance overall
function and alignment of the hallux.
Excessive resection of the phalanx has also been implicated in flail deformity of the hallux (23 ,26 ,43 , 44 , 45 ). The recommendations
regarding the amount of osseous resection have varied significantly, from one-half to two-thirds, and often have been subjective, with
some investigators suggesting that the surgeon should be able to place his or her finger into the remaining space after joint resection (26 ).
Obviously, resection of too great a segment of bone would itself tend to lead to a flail hallux. Resection of too small of a segment of bone
would possibly lead to jamming at the joint interface and would result in a hallux malleus deformity. Therefore, the surgeon needs to
determine the amount of bone resection that is necessary to decompress the joint and to allow for correction of deformity without
creating subsequent problems with hallux function. Patients undergoing resection of more than one-third of the proximal phalanx are most
likely to sustain this type of problem (23 ,26 ,44 ,45 ). Instability of the first metatarsophalangeal joint may also develop because of the
difficulty of adequately splinting the hallux while awaiting healing and consolidation of tissue planes.
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FIG. 4. A,B: Preoperative appearance of a 72-year-old man with hallux abducto valgus, hallux limitus, peripheral diabetic
neuropathy, and recurrent ulceration at the plantar medial hallux. C,D: Clinical and radiographic appearance 3½ years after
resectional arthroplasty. Good function is noted, and no further ulcers developed.
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Modifications
Experience has shown that the problems associated with the resection arthroplasty may be overcome, and later function of the hallux and
first metatarsophalangeal joint may be enhanced. Although implementation of specific modifications may vary, depending on the surgeon's
preference and the patient's needs, the following protocol is a good basis from which one may begin the process.
Dissection
Often, surgeons failed to release the plantar lateral joint contracture during resection arthroplasty for repair of hallux abducto valgus
because the soft tissue relaxation achieved with joint resection and detachment of the short flexor tendon was believed to be adequate to
eliminate the influence of the laterally deviated structures. However, release of these structures is important in allowing one to relocate
the sesamoid apparatus and, with it, the long flexor tendon beneath the first metatarsal head after the surgical repair. This may not be
necessary in patients with hallux limitus or rigidus, in whom the sesamoids are bound to the plantar aspect of the metatarsal head.
On the medial side of the joint, various different capsular flaps and incisions have been proposed. In many instances, the design of the flap
has been based on the method of capsular interposition preferred by the surgeon. However, because the new joint interface will resurface
with a functional fibrous tissue, capsular interposition may be viewed as not mandatory for pain-free function. If this is the case, the
surgeon may alternatively use the capsule as an effective stabilizing structure in the overall repair.
The configuration of the capsular flap does not appear to be as important as is the preservation of this tissue layer, so the flap may later
be reattached to the base of the proximal phalanx to provide stability. McGlamry et al. described a Ushaped flap that accomplishes this
function well (46 ,47 ). Toward this end, a long dorsolinear incision may be made into the capsule and periosteal tissues medial to the
extensor tendon. A vertical incision is then made on the base of the proximal phalanx close to the site of the anticipated bone resection. A
plantar arm is then extended proximally to the metatarsophalangeal joint, and the flap is then dissected proximally until the joint and
metatarsal head are exposed (Fig. 5 ). Once the capsular-periosteal flap is dissected free from the base of the proximal phalanx, the first
metatarsal head is exposed, and the remaining soft tissue is freed from the base of the proximal phalanx. The exostectomy is also
performed at the first metatarsal head at this stage.
Osseous Resection
As noted earlier, the amount of phalangeal base resected may have a profound influence on later function. As a general rule, for patients
with hallux abducto valgus deformity, approximately one-third of the base of the proximal phalanx is removed. However, the surgeon
should be prepared to adjust the amount of bone resection intraoperatively to achieve the necessary relaxation of the tissues. A slightly
greater amount may be required to decompress the joint adequately in patients with hallux limitus. The saw is usually oriented so the cut
is parallel to the proximal nail fold of the hallux. This technique tends to leave a more rectus appearance of the hallux postoperatively,
although this may need to be adjusted in patients with a significant degree of hallux abductus interphalangeus. In this latter circumstance,
a concomitant arthrodesis of the hallux interphalangeal joint may be required to provide a rectus alignment of the hallux.
Flexor Tendon and Capsular Reattachment

Once the base of the proximal phalanx is resected, the overall stability may be enhanced by the reattachment of the either the flexor
hallucis brevis or flexor hallucis longus tendon and the medial capsular flap into the remaining base of the phalanx (46 ,47 ). Three drill
holes are made into the phalangeal base: one plantar central, one plantar medial, and one dorsomedial (Fig. 6 ). Using nonabsorbable
suture, the surgeon anchors the flexor tendon into the plantar central drill hole on the base of the phalanx (Fig. 7 ). Reattaching the short
flexor may prevent retraction of the sesamoids. However, one must ensure good mobility at the sesamoid metatarsal articulation;
otherwise, dorsiflexion will be limited. Reattaching the long flexor tendon may create less potential for jamming on the joint
postoperatively. The actual tendon used may vary, depending on the patient and the preference of the surgeon, but in either circumstance
the hallux should be held distracted during this maneuver to ensure that too much tension is not placed on the tendon during reattachment.
Once the tendon is reattached, the medial capsular flap is then tagged to the phalanx through the two remaining drill holes (Fig. 8 ). The
suture may be secured, or if Kirschner wire splinting is to be used, then the suture is secured after insertion of the wire. This latter step
was originally advocated on the premise that joint distraction would allow for the ingrowth of fibrous tissue to maintain a greater degree
of separation for the joint interface (48 ). Although later investigators noted that using a wire temporarily across the joint did not result in
any greater degree of osseous separation (49 ), this technique does provide a helpful stabilizing influence during the early postoperative
period. In addition, the use of Kirschner wire stabilization has greatly reduced the incidence of lesser metatarsalgia (23 ). The wire is
introduced into the base of the proximal phalanx of the hallux and is directed distally through the tip of the toe. The wire is then directed
in retrograde fashion across the first metatarsophalangeal space and into the metatarsal head and shaft. In patients with hallux abducto
valgus deformity, the metatarsals can be pressed together by an assistant before the wire is driven into the metatarsal head, so healing
occurs with the intermetatarsal angle reduced. In flexible conditions, the correction is usually well maintained. Furthermore, the desired
position of the hallux is stabilized, more than would be possible with a bandage alone.
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FIG. 5. A: The U-shaped medial capsular flap for the resection arthroplasty. B: Good plantar separation of the superficial and deep
fascia at the medial side of the first metatarsophalangeal joint is required to create a large effective medial flap for resection
arthroplasty. C: The vertical incision is created on the base of the proximal phalanx at the site of the anticipated bone resection. D:
Appearance of the medial flap once dissected free. E: Diagrammatic representation of the medial flap after dissection.
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FIG. 6. Three drill holes are created in the remaining base of the proximal phalanx after bone resection. One drill hole is made
plantar centrally for reattachment of the flexor tendon. Drill holes are then created plantar medially and dorsomedially for
reattachment of the medial capsular flap.
FIG. 7. A: In this patient, the medial tendinous slip of the flexor hallucis brevis is tagged into the central drill hole in the base of the
proximal phalanx. B: Diagrammatic representation.
FIG. 8. Method of suturing the medial capsular flap into the proximal phalanx.
Once the Kirschner wire has been inserted, the medial capsular flap may be advanced and secured to further enhance stability (Fig. 9 ).
The adductor tendon may then be transferred and sutured into the medial joint capsule to aid in maintaining derotation of the sesamoids
and in relocating the flexor hallucis longus to a more central position beneath the first metatarsal head.
Postoperatively, one may note that the hallux tends to telescope down the Kirschner wire to abut the metatarsal head. Generally, this
phenomenon is not a problem because
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it is not anticipated that all the space will be maintained indefinitely. However, in patients with hallux limitus, the temporary distraction
may be helpful in preserving future motion. An additional wire is often placed obliquely across the joint to maintain separation at the joint
interface in this circumstance (Figs. 10 and 11 ).
FIG. 9. A: A Kirschner wire may be used across the joint space to provide stability. B: Once inserted, the medial capsular flap is
advanced and closed with a nonabsorbable suture.
FIG. 10. A: Preoperative appearance of a patient with hallux rigidus and degenerative joint disease. B: In this instance, an additional
crossed wire was employed to maintain joint distraction for several weeks.
The wire may be maintained for up to 6 weeks in patients with a flexible hallux abducto valgus deformity. However, in patients with hallux
limitus, when fear of joint adhesion exists, or when the hallux has telescoped proximally to abut the metatarsal head, the wire is usually
removed after 2 to 3 weeks. While the wire is in use, a padded surgical shoe is helpful in reducing bending forces across the first ray that
could otherwise result in a bent or broken wire or could encourage pin tract infection. Additional splinting may be used after wire removal,
depending on the needs of the patient.
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FIG. 11. Preoperative clinical (A) and radiographic (B) appearance of an older patient with severe hallux abducto valgus deformity
and hammer toe contracture. C: Radiographic appearance immediately postoperatively. Clinical (D) and radiographic (E) appearance
2 years after surgery. The correction has been well maintained, and the intermetatarsal angle is reduced even at this stage.
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Additional Modifications
Z-plasty lengthening of the extensor hallucis longus tendon is typically not required if the flexor structures are reattached to the proximal
phalanx or in patients with hallux limitus. However, the technique is still widely employed and in some instances may help to prevent a
cock-up hallux, although reattachment of the flexor tendon is usually more effective in preventing the deformity. Ganley et al. were
proponents of extensor tendon lengthening. They also used the medial capsular flap to cover the first metatarsal head and then took a
segment of the extensor hallucis brevis to reinforce the medial aspect of the joint (30 ) (Fig. 12 ). Alternatively, pursestring closure of the
capsule is still a popular technique even though capsular interposition is not required to provide asymptomatic function (Fig. 13 ).
FIG. 12. Capsular interposition may still be employed by some surgeons. A: In this instance, the medial capsular flap has been divided
into superior and inferior portions. B: The inferior portion of the medial capsular flap as it is sutured to the lateral joint capsule. C:
Finally, the superior arm of the capsulotomy is sutured to the phalangeal base using the drill holes previously created.
A technique used to aid sesamoid realignment is transfer of the extensor hallucis brevis tendon into the tibial sesamoidal ligament medially.
The tendon is transferred beneath the extensor hallucis longus to the medial capsular thickening superior to the tibial sesamoid. This
technique has been reported to result in a more sustained correction of the deformity (34 ).
Contraindications
Relative contraindications for the Keller procedure are the presence of significant lesser metatarsalgia preoperatively without coexistent
digital deformities and significant hallux instability. In these cases, osteotomy of the lesser ray or arthrodesis of the first
metatarsophalangeal joint may be considered. If the lesser metatarsalgia can be attributed to retrograde plantar pressure resulting from
digital contracture,
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then digital stabilization should be combined with the repair of the hallux abducto valgus deformity to prevent continuance or worsening of the condition. However, reduction of the hallux
abducto valgus deformity should improve first ray function, and with modifications, resection arthroplasty may work well even in cases of mild to moderate lesser metatarsalgia. As noted
previously, a flexible first ray is required to achieve the maximum reduction of deformity when one performs the procedure in a patient with hallux abducto valgus deformity.
FIG. 13. Pursestring closure of the capsule after resectional arthroplasty.
Complications
Because bone is resected from the base of the proximal phalanx, some degree of shortening of the toe is anticipated. Other than appearance, the shortened hallux is rarely an inherent problem.
With a judicious excision of bone, this should not be a significant problem and certainly not one that creates functional difficulties. Ganley et al. noted that the shortening was well tolerated
because a long hallux was present preoperatively in 85% of their patients undergoing resection arthroplasty (30 ).
Lesser metatarsalgia has been reported as problematic in patients postoperatively (22 ,33 ,44 ). However, some authors have reported that the procedure did not appear to increase the
incidence of lesser metatarsalgia or hyperkeratoses (24 ,26 ,30 ,45 ). The actual incidence of lesser metatarsalgia after resection arthroplasty is difficult to determine because of the different
techniques employed by previous authors. In one study, in patients with lesser metatarsal complaints postoperatively, the problems were found to be directly related to the amount of osseous
resection and subsequent purchase of the hallux (44 ). Other investigators have noted that the incidence of lesser metatarsalgia is simply a matter of perspective. Because many of these
patients present with similar complaints preoperatively, the Keller procedure should not be viewed as creating the problem, but simply as not improving the condition (45 ).
Ganley et al. believed that if lesser metatarsalgia developed, it more than likely resulted from the retraction of the sesamoids. In patients with a preexisting problem with the second
metatarsal, osteotomy at this level was recommended to reduce any potential for future problems (30 ). Reattachment of the short flexor tendon may also prevent retraction of the sesamoids
and thus avoid lesser metatarsalgia.
As discussed previously, specific measures are available to counter the tendency to develop a nonpurchasing hallux. Relocation of the sesamoids beneath the first metatarsal head should
effectively resist any tendency for recurrent hallux abducto valgus.
CONCLUSION
A role for the resection arthroplasty and for the McBride or Silver bunionectomy still exists in modern foot surgery. The indications are not strictly limited or dictated by the age of the patient,
but rather by the specifics of the disorder.
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3. Moeller F. Bietrag zur operativen Behandlung des Hallux valgus. Jahrb Hamb Staatskrankenanst 1894;3:306-338.
4. Bromeis H. Unsere Erfahrungen mit der Hallus valgus: Operation nach M. Shede. Chirurg 1931;3:465-471.
5. Silver D. The operative treatment of hallux valgus. J Bone Joint Surg 1923;5:225-232.
6. Fuld JE. Transplantation of the abductor hallucis tendon in the surgical treatment of hallux valgus. Surg Gynecol Obstet 1916;23:626-628.
7. McBride ED. A conservative operation for bunions. J Bone Joint Surg 1928;10:735-739.
8. Lapidus PW. The operative correction of the matatarsus varus primus in hallux valgus. Surg Gynecol Obstet 1934;58:183-191.
9. Mitchell LS, Fleming JL, Allen R, et al. Osteotomy-bunionectomy for hallux valgus. J Bone Joint Surg 1958;40:41-60.
10. McBride ED. The conservative operation for “bunions”: end results and refinement of technic. JAMA 1935;105:1164-1168.
11. McBride ED. Hallux valgus, bunion deformity: its treatment in mild, moderate and severe stages. J Int Coll Surg 1954;21:99-105.
12. DuVries HL. Surgery of the foot. St. Louis: CV Mosby, 1959:381.
13. McGlamry ED, Feldman MH. A treatise on the McBride procedure. J Am Podiatry Assoc 1971;61:161-173.
14. Martin WJ, Mandraccia VJ, Aiken S. A preliminary analysis of fibular sesamoidectomy in the McBride bunionectomy. J Am Podiatry Assoc 1983;73:577-580.
15. Hsu CY, Cheng YM, Law CL, et al. Hallux valgus: Soft tissue procedure versus bony procedure. Kao Hsiung I Hsueh Ko Hsueh Tsa Chih 1994;10:624-631.
16. Pfeffinger LL. Etiology and treatment of hallux valgus: the modified McBride procedure. Orthopedics 1990;13:979-984.
17. Feinstein MH, Brown HN. Hallux adductus as a surgical complication. J Foot Surg 1980;19:207-211.
18. Fricke JL. Exostosis of the ball of the foot: Dr. Fricke's report on the Hamburg Hospital for the first quarter of 1836. Dublin J Med Sci 1837; 11:497-504.
19. Hueter C. Klinik der Gelenkkrankheiten. Leipzig: FCW Vogel, 1877: 339-351.
20. Keller WL. The surgical treatment of bunions and hallux valgus. N Y Med J 1904;80:741-742.
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21. Brandes M. Zur operativen Therapie des Hallus valgus. Zentralbl Chir 1929;56:2434-2440.
22. Majkowski RS, Gallaoway S. Excision arthroplasty for hallux valgus in the elderly: a comparison between the Keller and modified
Mayo operations. Foot Ankle 1992;13:317-320.
23. Vallier GT, Peterson SA, LaGrone MO. The Keller resection: a 13-year experience. Foot Ankle 1991;11:187-194.
24. O'Doherty DP, Lowrie IG, Magnussen PA, et al. The management of the painful first metatarsophalangeal joint in the older patient:
arthrodesis or Keller's arthroplasty? J Bone Joint Surg Br 1990;72:839-842.
25. Kitaoka HB, Patzer GL. Arthrodesis versus resection arthroplasty for failed hallux valgus operations. Clin Orthop 1998;347:208-214.
26. Love TR, Whynot AS, Farine I, et al. Keller arthroplasty: a prospective review. Foot Ankle 1987;8:46-54.
27. Broughton NS, Winson IG. Keller's arthroplasty and Mitchell osteotomy: a comparison with first metatarsal osteotomy of the long-
term results for hallux valgus deformity in the younger female. Foot Ankle 1990;10:201-205.
28. Rankin ME, Rankin EA. Experience with the Keller bunionectomy. J Nat Med Assoc 1996;88:33-35.
29. Richardson EG. Etiology and treatment of hallux valgus: Keller resection arthroplasty. Orthopedics 1990;13:1049-1053.
30. Ganley JV, Lynch FR, Darrigan RD. Keller bunionectomy with fascia and tendon graft. J Am Podiatr Med Assoc 1986;76:602-610.
31. Fenton CF, McGlamry ED. Reverse buckling to reduce metatarsus primus varus. J Am Podiatry Assoc 1982;72:342-346.
32. Kissel CG, Mistretta RP, Morse RL. Reduction of intermetatarsal angle following Keller arthroplasty. J Foot Ankle Surg
1993;32:193-196.
33. Turnbull T, Grange W. A comparison of Keller's arthroplasty and distal metatarsal osteotomy in the treatment of adult hallux
valgus. J Bone Joint Surg Br 1986;68:132-137.
34. Capasso G, Testa V, Maffulli N, et al. Molded arthroplasty and transfer of the extensor hallucis brevis tendon: a modification of
the Keller-Lelievre operation. Clin Orthop 1994;308:43-49.
35. Vitek M, Steinbock G. Value of cerclage fibreux for the Keller-Brandes procedure. Arch Orthop Trauma Surg 1989;108:104-106.
36. McCain LR, Nuzzo JJ. The sesamoidal ligament and its employ in the suturing of the Keller bunionectomy procedure. J Am
Podiatry Assoc 1969;59:479-480.
37. Fielding MD. Surgical treatment of hallux abducto valgus and allied deformities. Mt. Kisco, NY: Futura, 1973.
38. Cosentino GL. The Cosentino modification for interpositional arthroplasty. J Foot Ankle Surg 1995;34:501-508.
39. McDonough MW. Geriatric hallux valgus deformity. In: McGlamry ED, Banks AS, Downey MS, eds. Comprehensive textbook of foot
surgery, 2nd ed. Baltimore: Williams & Wilkins, 1992:578-586.
40. Kaplan EG, Kaplan GS. The Keller procedure. J Am Podiatry Assoc 1974;64:603-609.
41. De Palma L, Tulli A, Sabetta SP. Histological study of the phalangeal articular side following Keller procedure for hallux valgus. J
Foot Surg 1992;31:355-359.
42. Dhanendran M, Pollard JP, Hutton WC. Mechanics of the hallux valgus foot and the effect of Keller's operation. Acta Orthop Scand
1980;51: 1007-1012.
43. Axt M, Wilder M, Reichelt A. Late results of the Keller-Brandes operation for hallux valgus. Arch Orthop Trauma Surg
1993;112:266-269.
44. Henry APJ, Waugh W, Wood H. The use of footprints in assessing the results of operations for hallux valgus: a comparison of
Keller's operation and arthrodesis. J Bone Joint Surg Br 1975;57:478-481.
45. Wrighton JD. A ten year review of Keller's operation. Clin Orthop 1972;89:207-214.
46. McGlamry ED, Kitting RW, Butlin WE. Keller bunionectomy and hallux valgus correction: further modifications. J Am Podiatry
Assoc 1973; 63:237-246.
47. McGlamry ED. Arthroplastic technique for repair of the first metatarsophalangeal joint. J Amer Podiatry Assoc 1974;64:611-616.
48. Fitzgerald W. Hallux valgus. J Bone Joint Surg Br 1950;32:139.
49. McLaughlin EK, Fish C. Keller arthroplasty: is distraction a useful technique? A retrospective study. J Foot Surg 1990;29:223-225.
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Chapter 13
Surgical Procedures of the Hallux
Albert E. Burns
HALLUX OSTEOTOMIES
Osteotomy of the hallux for the correction of hallux abducto valgus was first proposed by Akin in 1925 (1 ). The original procedure included
resection of the medial eminence of the first metatarsal head, resection of the proximal medial base of the proximal phalanx, and
cuneiform osteotomy of the phalanx (Fig. 1 ). No specific criteria were provided for use of the procedure. Experience has shown that this is
not a primary procedure to be used for the repair of hallux abducto valgus deformity because the hallux osteotomy does not directly
address an increased intermetatarsal angle or proximal articular set angle (PASA) (2 ,3 ).
More important, the inappropriate use of the classic Akin procedure for the repair of hallux abducto valgus deformity may result in further
lateral displacement of the first metatarsophalangeal joint and recurrence of the deformity (2 , 3 , 4 , 5 , 6 , 7 ). Although the clinical
alignment of the hallux may appear improved, if a significant increase in the intermetatarsal angle or PASA is not addressed, then the
functional center of the first metatarsophalangeal joint will be lateral to the midline of the first ray. In the presence of this structural and
musculotendinous imbalance, one may anticipate an even greater lateral subluxation or luxation of the first metatarsophalangeal joint that
leads to a rapid recurrence of the original condition (Fig. 2 ).
Therefore, the Akin osteotomy is considered an adjunctive procedure that is usually performed concomitantly with a first metatarsal
osteotomy and, occasionally, with a tendoncapsule balancing hallux valgus repair. Clinical experience has shown that this is a useful
technique for straightening the hallux. Some surgeons may employ the procedure to realign the long flexor and extensor tendons into a
more central location over the hallux and first metatarsophalangeal joint. Theoretically, this would reduce the retrograde forces that may
otherwise tend to result in further lateral stress at the first metatarsophalangeal joint. However, if the intermetatarsal angle is reduced
and joint congruity is restored, then it appears that the additional Akin osteotomy would have a negligible effect.
Evaluating the need for an Akin osteotomy may best be performed intraoperatively once the primary surgical procedures have been
completed. Should lateral deviation of the hallux persist in spite of a congruous joint and reduction of more proximal structural
deformities, then one must consider that further deformity persists within the hallux itself (2 ,3 ,8 ). Most commonly, this condition is a
result of a hallux abductus interphalangeus or an increased distal articular set angle (DASA). It may be further appreciated when the
medial side of the proximal phalanx is longer than the lateral side. Although capital osteotomies are classically indicated for the correction
of PASA deformities, in some patients osteotomy in the first metatarsal head may be impeded by bone cysts, iatrogenic deformity, or the
need to perform multiple procedures. In this instance, an Akin procedure may be used to assist in compensating for the PASA. Although it is
not at the apex of the deformity, the hallux osteotomy may be close enough to provide a satisfactory clinical and functional result (2 ).
Dissection
The surgical approach used most often for an Akin procedure is a dorsomedial linear incision, which may be an extension of the
dorsomedial incision used for the bunionectomy. A medial longitudinal incision at the juncture of the dorsal and plantar skin is also a
popular approach. Other modifications of the incisional approach may be employed to facilitate exposure and to create better wound
relaxation. Two others include a serpentine incision at the hallux interphalangeal joint and the addition of a transverse segment to the
dorsomedial linear incision over the interphalangeal joint simply to create an L-shaped configuration (9 ) (Fig. 3 ). To some degree, the
incision selection may be based on the type of osteotomy to be performed and the fixation that the surgeon anticipates will be required to
stabilize the bone adequately for optimal healing.
Sharp and blunt dissection techniques are used to continue the dissection through the superficial fascia, with care taken
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to avoid the dorsomedial and lateral neurovascular structures. Once the deep fascia or extensor hood fibers are identified, then separation
of the superficial fascia is extended medially and laterally to provide a clear definition of the deep fascia and periosteum over the
proximal phalanx. At this stage, several different methods may be employed for the additional steps in the dissection process. The deep
fascia and periosteum may be incised linearly just medial to the extensor tendon. Dissection is usually facilitated by a Freer elevator,
except at the metaphyseal area of the phalanx,
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where a scalpel is typically required because of the adherence of ligamentous and capsular fibers.
FIG. 1. The traditional Akin osteotomy.
FIG. 2. The Akin procedure is not effective as a primary approach for the repair of hallux abducto valgus deformity. Although the clinical alignment of the hallux may be improved from
the preoperative state (A), the relative deformity at the joint remains (B). C: Because the intermetatarsal angle is not reduced with this technique, the surgeon may resect too much
bone from the metatarsal head in an attempt to reduce the bunion.
FIG. 3. Several incisional approaches may be used for the Akin osteotomy. Most frequently, the dorsomedial incision from the bunionectomy is extended distally. This may be converted
to a serpentine incision, which crosses transversely at the hallux interphalangeal joint, or an L-shaped incision.
Alternatively, the periosteum may be incised transversely at the level of the anticipated osteotomy. In this manner, less periosteum needs to be reflected to perform the surgery, but additional
freeing and retraction of the long extensor tendon are required. Although the traditional approach is to reflect the periosteum, this layer is thin at this level, and reflecting the tissue as one
unit may be difficult. Therefore, one may elect to leave the periosteum intact during the osteotomy.
Proximal Akin Osteotomies

As commonly performed, the Akin osteotomy is a medially based transverse wedge resection located at the base of the proximal phalanx. Ideally, the cuts are located in metaphyseal bone,
where the bone is wider, the lateral cortical hinge is less likely to fracture, and the overall bone quality is superior. As a general guide, the osteotomy is located between 0.5 and 1.0 cm distal
to the articular surface (7 ,10 ,11 ), with the specific distance influenced by the type of fixation to be employed. Typically, the lateral cortex is left intact to function as a hinge for rotation.
This also imparts an added measure of stability to the osteotomy.
The axis of the osteotomy may be altered to achieve different forms of correction with the procedure. If the axis is perpendicular to the weight-bearing surface, then closure of the osteotomy
will maintain the alignment of the phalanx in the weight-bearing plane. An axis that is tilted laterally may result in elevation of the distal portion of the bone as the osteotomy is closed. This
feature may be advantageous in patients with some element of hallux limitus. Tilting the axis distally, while maintaining neutrality in the frontal plane, reduces valgus rotation of the hallux as
the osteotomy is closed.
Numerous methods exist for determining the amount of bone that should be resected. As a general guideline, attempts are made to reduce the distal articular set angle to 0 degrees.
Conceptually, enough wedge is being removed to make the two articular surfaces of the proximal phalanx parallel to each other. During a transverse type of osteotomy, the surgeons wants to
orient the proximal cut so it is parallel to the joint surface. Then a better estimate may be derived regarding the amount of bone to resect when the distal cut is performed. Some investigators
have suggested that constructing a preoperative template on the radiograph may be one way to estimate the amount of wedge necessary to achieve the desired correction (8 ). Another method
is to measure the medial and lateral length of the proximal phalanx and to determine how much wedge removal is necessary, taking the base from the long side, to create a parallel relationship
between the proximal and distal articular surfaces of the phalanx (12 ) (Fig. 4 ).
Distal Akin Osteotomies

Excessive abduction of the hallux may result from a primary deformity within the head of the proximal phalanx, the interphalangeal region, or a general asymmetry of the proximal phalanx.
This last source of abductus is more common than a deviated DASA. In these patients, an osteotomy performed at the distal aspect of the phalanx, closer to the apex of maximum deformity,
proves more effective in providing correction. Daw described an opening wedge osteotomy to correct the deformity at this level (13 ). However, most surgeons prefer to perform a closing
wedge osteotomy at the distal metaphysis of the phalanx.
FIG. 4. The amount of wedge to be removed can be determined by measuring the lateral length of the proximal phalanx (CD) and subtracting it from the measured medial length of the
proximal phalanx (AB).
The distal Akin procedure may also be used to correct lateral deviation of the hallux arising proximally. Because the distal metaphysis of the proximal phalanx corresponds to the digital sulcus,
adduction at this level provides a hallux that appears straight clinically, although radiographically the hallux may appear skewed (2 ) (Fig. 5 ).
On the other hand, some surgeons would argue that the end result of both the proximal and distal procedures is to realign the two articular surfaces of the proximal phalanx parallel to each
other. For this reason, the proximal Akin procedure has been advocated for the correction of both an increased DASA and an increased hallux abductus interphalangeus (6 ,10 ,14 ,15 ). Although
the proximal Akin procedure realigns the distal and proximal articular surfaces in the latter condition, it creates a slight Z shape of the proximal phalanx, which may not be as accurate in
realigning the extensor and flexor tendons as a distal Akin procedure.
Performing a distal Akin osteotomy may offer some potential advantages over the proximal counterpart. The distal Akin procedure involves a shorter lever arm, which results in the transmission
of less weight-bearing force across the osteotomy and is associated with less potential for disruption.
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Performing the procedure at a more distant site from the metatarsophalangeal joint may also enhance the performance of range-of-motion
exercises because there will be less tendency to disrupt the osteotomy at the more distal level with the application of this type of stress.
FIG. 5. The apex of the distal Akin osteotomy approximates the level of the digital sulcus. As a consequence, the distal osteotomy
may provide functional correction of more proximal deformity such as an enlarged distal articular set angle.
The prototypical procedure is a transverse wedge osteotomy in the distal metaphyseal bone 0.5 to 1.0 cm proximal to the hallux
interphalangeal joint (Fig. 6 ). The wedge osteotomy has its apex laterally and its base medially, and the amount of bone to be removed
may be determined using similar methods described for the proximal Akin osteotomy. Clinically, one may make the distal portion of the
osteotomy parallel to the interphalangeal joint or to the proximal nail fold. The proximal cut may then be performed perpendicular to the
long axis of the proximal phalanx. The axis guide concepts apply here also, and it is more common to use the axis guide to address any
valgus rotation of the hallux at this level than with the proximal Akin osteotomy.
Modifications of the Akin Osteotomy

The main modification that has been described for the proximal Akin osteotomy is to perform the wedge resection in an oblique manner to
use screw fixation (3 ,9 ). For a proximal Akin procedure, instead of placement of the osteotomy transversely, it is angled from proximal
lateral to distal medial (Fig. 7 ). To provide adequate space for wedge removal and to accommodate screw fixation, the osteotomy usually
traverses most of the length of the proximal phalanx. For this reason, some authorities have advocated this procedure for the correction of
both an abnormal DASA and an abnormal hallux abductus interphalangeus (6 ,14 , 15 , 16 ). An axis guide pin may be used in the same
fashion as a traditional
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proximal Akin osteotomy. The distal Akin procedure may also be modified in an oblique fashion to facilitate screw fixation. The osteotomy
is angled from distal lateral to proximal medial with the apex on the lateral side approximately 0.5 cm from the hallux interphalangeal
joint (Fig. 8 ).
FIG. 6. Intraoperative appearance of the traditional distal Akin osteotomy.
FIG. 7. The oblique proximal Akin osteotomy.
FIG. 8. The oblique distal Akin osteotomy.
FIG. 9. A: Patient with an excessively long proximal phalanx of the hallux. B: Postoperative radiograph after resection of a cylindrical
segment of bone. Fixation has been provided with two wires in a four-cortex technique from dorsal to plantar. C: Postoperative
lateral radiograph.
An excessively long hallux may be treated by removing a cylinder of bone from the proximal phalanx (3 ,6 ,8 ,17 ) (Fig. 9 ). When this is
accomplished, it is referred to as a cylindric Akin procedure. This is most commonly used in patients with hallux limitus or when the hallux
is so long relative to the adjacent digits that it creates a problem with shoe wear. Ideally, enough bone is removed so the hallux is of equal
length or is slightly shorter than the second digit. Realignment of the articular surfaces of the proximal phalanx may be simultaneously
accomplished by the removal of a trapezoidal wedge of bone. Alternatively, one may choose to use matching chevron osteotomies to
perform the shortening. This technique provides locking segments that may enhance the overall stability of the procedure (Fig. 10A and B ).
A shortening sagittal Z-osteotomy has also been described, particularly as an alternative to the enclavement procedure at the phalangeal
base. Investigators proposed that shortening of an otherwise long hallux would tend to reduce excessive retrograde forces at the first
metatarsal head and would thereby enhance motion. Screw fixation was used to stabilize the osteotomy (18 ) (Fig. 10C ).
The complete transverse osteotomy without wedge or bone resection may also be employed to provide for derotation of significant
deformity within the hallux. Because these types of procedures are complete through-and-through osteotomies, adequate fixation is
important. Correction of valgus rotation of the hallux can also be accomplished by changing the direction of the axis guide of the hinge of
the osteotomy
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(19 ,20 ). The closer the axis guide of the hinge comes to lying within the transverse plane, the more frontal plane correction can be
accomplished. By angulating the axis guide of the osteotomy hinge in the lateral cortex from dorsodistal to plantar proximal, the closure of
the osteotomy will reduce the valgus rotation of the hallux. This technique results in both cosmetic and functional benefits. Derotation of
the hallux may also be accomplished by sacrificing the lateral cortical hinge, aligning the hallux in the desired position, and applying two
points of fixation.
FIG. 10. A: A long hallux may be shortened with the removal of a cylinder of bone. Alternatively, one may resect the bone by using
two chevron cuts (B) or by a sagittal Z-osteotomy to provide interlocking segments that will enhance stability (C).
Fixation
Akin did not use internal fixation, but simply splinted the hallux with a tongue depressor (1 ). However, the use of fixation optimizes bone
healing and postoperative rehabilitation, as well as reducing the incidence of hinge fracture, potential osteotomy displacement, and
possible loss of correction. The transverse form of the osteotomy is inherently more stable, simply based on the orientation of the
osteotomy itself. The fragments will not shorten or shift even if the lateral cortex fractures. An oblique osteotomy has an inherent
instability should the lateral cortex fracture whereby the fragments can easily shift and shorten along the plane of the osteotomy.
Two points of fixation are helpful in maintaining alignment and apposition of the osteotomy segments and in preventing disruption of the
fixation. The intact lateral cortex is usually considered to be one point of fixation, and the fixation device is considered to be the second.
Should the lateral cortex fracture intraoperatively, then a second point of fixation is considered.
Kirschner Wire Fixation

Either smooth or threaded Kirschner wires (K-wires) may be used to stabilize the osteotomy. If the cortical hinge is intact, a single K-wire,
either 0.045 or 0.062 inch, may be appropriate. The pins are typically passed obliquely through the distal cortex, across the osteotomy,
and exit the proximal cortex without violating either the hallux interphalangeal joint or the first metatarsophalangeal joint. By inserting
the wires in this manner, one avoids displacement of the less stable distal fragment. The wire may be inserted from either the medial or
lateral approach. It is preferable for the wire to penetrate the cortex on each side to provide the best stability (Fig. 11 ).
Should some element of instability exist, or should the hinge fracture, then greater security would be afforded with the use of two K-wires.
If two pins are used, they are typically advanced in opposite directions crossing each other. By stacking the wires in the sagittal plane, one
may avoid a single pivot point within the osteotomy and thus provide greater stabilization (Fig. 12 ).
It may be easier to insert the pins percutaneously rather than attempting to incorporate them into the surgical incision,
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but in some situations, the orientation of the incision lends itself well to this latter circumstance. The patient is allowed to be weight
bearing because the propulsive forces that would tend to disrupt the osteotomy are usually neutralized by the use of the commercially
available postoperative shoes.
FIG. 11. A single Kirschner wire may provide good stabilization of the Akin osteotomy if the lateral cortical hinge is intact.
Stainless Steel Wire Fixation

Traditionally, dorsal cortical wire loops were employed when surgeons first began to apply internal fixation for the Akin procedure (21 ,22 ).
Although it is simple to perform, this technique adds little stability to the osteotomy site. Even small amounts of weight-bearing stress can
result in plantar gapping at the osteotomy. In addition, one may note fracture of the cortical hinge with possible displacement or rotation
of the osteotomy about the fixation site. However, this technique may be employed if there is a significant control of weight-bearing
forces across the hallux (Fig. 13 ).
A more secure way of using wire loop fixation is to pass the wire through four cortices. Two configurations may be employed. The most
secure form of wire loop fixation is accomplished with a vertical loop perpendicular to the plane of the osteotomy. A drill hole is placed
from dorsal to plantar, close to the medial cortical wall on either side of the osteotomy. A strand of monofilament wire is folded in half,
and the closed end is passed from dorsal to plantar through both sets of drill holes. The ends are then grasped with a hemostat, and the
wire is delivered into the wound. The closed end of the distal wire is threaded through the loop
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in the proximal wire. The proximal wire is now pulled upward, to thread the distal wire through all four cortices (Fig. 14 ). Care must be taken to stabilize the osteotomy adequately during this
manipulation to avoid fracture of the lateral cortical hinge. The osteotomy is held in a reduced attitude, and the wire loop is twisted carefully to provide firm apposition of the opposing
cortical surfaces. The wire is then cut shorter, and the end may be twisted or tucked into one of the drill holes to reduce any potential prominence.
FIG. 12. If the lateral cortical hinge of the osteotomy should fracture, then a second Kirschner wire may be employed to provide better stability.
FIG. 13. A: A dorsal wire loop was used for fixation in this Akin osteotomy. B: Weight bearing tends to disrupt the osteotomy when this loop is used and may create a plantar gap.
FIG. 14. The vertical wire loop fixation technique for the Akin osteotomy.
A horizontal wire loop may also be used to stabilize the osteotomy, but this technique generally requires a greater degree of exposure and soft tissue dissection. Two drill holes are made from
medial to lateral, one proximal and one distal to the osteotomy site. The wire is then passed through on the transverse plane, to encircle the osteotomy site (Fig. 15 ). The wire is twisted to
coapt the osteotomy surface and to provide compression as in the vertical loop fixation. Both these techniques are stable, and the wires tend to resist displacement of the osteotomy with hinge
fracture. The selection of the best wire gauge for fixation is based on a balance between flexibility and strength and the relative density and stability of the osseous segments to be fixated. A
26- or 28-gauge monofilament wire is commonly employed. The wire may also be folded and twisted to provide a double strand for additional strength.
FIG. 15. The horizontal wire loop fixation technique for the Akin osteotomy.
Staple Fixation
Staple fixation with numerous types of devices has been reported with success (23 , 24 , 25 , 26 ). Although good stability may be achieved with staple fixation, certain precautions are
necessary. Because of the curved surface of the proximal phalanx, it is difficult to achieve a flush fit of the staple to the cortical surface. Special care must be taken to make sure that, on
insertion, the staple does not violate the joint. Additionally, the force required to insert a staple, especially using the pneumatic stapler, would more easily fracture the hinge or displace the
osteotomy.
Screw Fixation
The use of screws provides good stability for both the proximal and the distal Akin procedures (9 ). A modification of the Akin osteotomy is necessary to allow fixation by a cortical lag screw.
The osteotomy must be oblique, with the apex of the wedge and the intact lateral cortex at the proximal lateral aspect of the base of the proximal phalanx. The osteotomy is angulated
approximately 45 degrees to the longitudinal axis of the proximal phalanx, and the base of the wedge is approximately midshaft at the medial aspect of the bone.
The osteotomy is fixed in a routine fashion with a lag technique, usually using a 2.7-mm cortical screw (Fig. 16 ). Because soft tissue coverage is minimal, good countersinking is important to
minimize the prominence of the screw head. A single screw is most often used for fixation. Cannulated screws may also be employed and may be helpful in this more confined area where the
space for additional instruments may be limited (Fig. 17 ). Absorbable screws are another alternative, and the screws manufactured from polylactic acid have thus far demonstrated the
necessary stability and rigidity without the sinus reaction problem associated with other polyesters. Countersinking is unnecessary because of the small size of the screw head (Fig. 18 ).
The disadvantage of screw fixation is that the oblique osteotomy is not as inherently stable as the transverse configuration. Therefore, should hinge fracture occur, salvage of the procedure
may be more difficult.
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FIG. 16. A 2.7-mm lag screw used for fixation for the proximal Akin osteotomy.
FIG. 17. A 2.7-mm cannulated screw used to fix an oblique distal Akin osteotomy.
FIG. 18. Postoperative radiograph illustrating fixation of an oblique proximal Akin osteotomy with an absorbable screw.
Protected weight bearing is allowed with a postoperative shoe, provided other procedures have not been performed that would require
non-weight bearing. If any concern exists over the stability of the osteotomy, then some additional form of external splinting may be
provided. Periodic radiographs may be used to monitor healing of the osteotomy. Progression to normal shoes is based on the type of
fixation employed and the patient's symptomatic progress, which, again, may be dictated by the primary surgical procedure.
Complications
Significant complications are rarely encountered with the Akin osteotomy. Most of the potential complications are related to excessive
bending forces that overcome the fixation of the osteotomy. Perhaps the most common problem is fracture of the lateral cortical hinge.
This complication is usually managed well with the use of additional fixation devices. Should this develop postoperatively, then external
splinting or other forms of immobilization should allow uneventful healing. If displacement develops at the osteotomy, then angular
deviation of the distal hallux may result. Nonunion may occur, but it is rare. Poor osteotomy techniques and lack of appropriate fixation
may also lead to painful nonunion (Fig. 19 ).
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FIG. 19. Nonunion of each proximal phalanx 2 years after hallux osteotomies with an osteotripsy technique. No fixation was
employed.
HALLUX INTERPHALANGEAL JOINT ARTHRODESIS

Fusion of the hallux interphalangeal joint is primarily indicated for structural deformity that exists at the interphalangeal joint or for
when intrinsic muscle function has been compromised and interphalangeal and metatarsophalangeal joint stability is lacking (27 , 28 , 29 ,
30 , 31 ). The most common structural deformity is a flexion contracture, commonly seen in a cavus foot deformity. Other structural
deformities may also be treated by this procedure such as an extensus deformity at the interphalangeal joint that has resulted from a
hallux limitus. There may also be transverse and frontal plane deformities that occur with hallux abducto valgus and hallux varus that may
be best corrected with an arthrodesis. Instability of the first metatarsophalangeal joint occurs whenever function of the flexor hallucis
brevis is lost, as occurs with simultaneous excision of the tibial and fibular sesamoids. Hallux instability contracture also is seen in the
cavus foot or in certain muscle-tendon imbalances such as postpolio syndrome. Arthrodesis of the interphalangeal joint is further indicated
any time a patient has pain in the joint as a result of traumatic arthritis. The degenerative changes in the joint could occur as a result of
any of the aforementioned deformities or as a result of trauma.
The goal of arthrodesis is to correct structural deformity, to alleviate symptoms, and to restore musculotendinous balance. Fusion of the
interphalangeal joint creates a rigid lever on which the long extensor and flexor may function and restores sagittal plane stability to the
Dissection
Various skin incisions may be used to provide adequate exposure for the procedure (27 ,29 ,30 ). Two transverse semielliptic incisions
centered over the interphalangeal joint provide adequate exposure in addition to removing redundant skin that may be present in a hallux
malleus condition (Fig. 20 ). Further relaxation of the wound margins may be afforded by adding a central linear component extending
proximally to provide a T shape. Another popular approach is the use of a serpentine incision that runs along the dorsomedial aspect of the
proximal phalanx, crosses the joint transversely, then extends distally along the lateral nail fold. The serpentine incision could also be
done in reverse, starting dorsolaterally and ending distal medially. Another incision is an L-shaped approach overlying the interphalangeal
joint. The decision regarding which incisional approach to use is in large part predicated on the planned fixation and on whether the
incision is an extension of that used for concomitant procedures.
The dissection is carried through the subcutaneous tissue

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to the level of the extensor hallucis longus tendon. Care should be taken to protect the two dorsal neurovascular bundles. The extensor
hallucis longus is incised transversely at the interphalangeal joint and is reflected proximally. The capsule and supporting ligaments of the
joint are released, thereby delivering the head of the proximal phalanx into the wound.
FIG. 20. The transverse elliptic incision is commonly employed for arthrodesis of the hallux interphalangeal joint. This allows the
removal of otherwise redundant skin that would remain after correction when significant contracture is present preoperatively.
The articular surfaces of the hallux interphalangeal joint may be resected with a power saw or with hand instruments. If little angular
change is required, then hand instruments will leave a rougher bone surface that may enhance earlier arthrodesis. Typically, a rongeur is
used to remove the cartilage from the distal phalanx, and double-action bone-cutting forceps are employed for the head of the proximal
phalanx. However, if significant angular change needs to be performed, then power instruments may be more effective. The bone is cut so
no residual angular deviation is present in the transverse or sagittal plane. Whatever angular correction is desired is usually achieved by
the resection of bone from the head of the proximal phalanx.
Fixation
Fixation of the arthrodesis site is possible and effective with numerous different modalities including K-wires, stainless steel wire, staples
and bone screws (2 ,27 , 28 , 29 , 30 , 31 , 32 ). K-wires are a simple and effective way of providing stability. A 0.045- or 0.062-inch K-wire
is placed in the medial aspect of the base of the distal phalanx and is advanced distally out the lateral aspect of the hallux. A second wire
is placed on the lateral aspect and is advanced medially. The phalanges are now placed in apposition, and the wires are placed in
retrograde fashion across the osteotomy into the cortex of the proximal phalanx (Fig. 21 ).
FIG. 21. Crossed Kirschner wires used to stabilize the hallux interphalangeal fusion.
Monofilament wire may also be employed for fixation, but it is less stable and is more easily disrupted with weight bearing. K-wires and
stainless steel wire can also be used in combination. Ministaples or small, pneumatically driven staples may also be used.
Screws have also been a popular means of fixation for hallux interphalangeal joint fusion. This procedure is most commonly accomplished
with either a 4.0-mm cancellous lag screw or a 3.5-mm fully threaded cancellous screw. When using the 4.0-mm cancellous screw, a drill
hole is made through the distal phalanx with a 2.0-mm drill bit from proximal to distal. A small stab incision is made at the tip of the
hallux to allow the drill bit to exit. The drill bit is removed, the resected joint surfaces are held flush, and the 2.0-mm drill bit is
reinserted through the distal phalanx from distal to proximal and is used as a guide to create a drill hole into the proximal phalangeal shaft.
The tuft of the distal phalanx should be countersunk to help prevent microfracturing and to reduce the prominence of the head of the
screw. After tapping, the screw is advanced through the distal phalanx until it starts to emerge at the proximal end of that bone. Tapping
of the proximal phalanx is optional. The tip of the screw is then aligned with the guide hole in the proximal phalanx, and the screw is
advanced until the fusion site is compressed (Fig. 22 ).
At times, the bone threads created by a 4-mm cancellous screw may become stripped in the soft intramedullary canal
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at the base of the proximal phalanx. Should this occur, the fixation screw will be no more effective than a single intramedullary K-wire.
The situation can still be salvaged by removal of the cancellous screw and insertion of a 3.5-mm cortical screw. The distal phalanx must be
overdrilled with a 3.5-mm bit to create the gliding hole, and the cortical screw can then be inserted. The threads of the screw usually
purchase the denser intramedullary bone in the region of the head of the proximal phalanx and midshaft section. Solid interfragmental
compression results, and consistent arthrodesis is seen. The use of the 3.5-mm cortical screw inserted in a lag technique may also be
considered a primary fixation technique (Fig. 23 ). Another alternative is to use a 4.0-mm cannulated cancellous screw, in which a guide
pin is driven in first for temporary fixation, and the screw is passed right over the pin.
FIG. 22. Hallux interphalangeal arthrodesis with 4.0-mm screw fixation.
FIG. 23. A 3.5-mm cortical screw inserted in lag fashion for arthrodesis of the hallux interphalangeal joint.
Other methods of screw fixation have been described using smaller lag screws. A 2.0-mm lag screw passed from proximal medially to distal
laterally in the transverse plane with bone cuts done in the traditional fashion (27 ), and a 2.7-mm lag screw is passed from
dorsoproximally to plantar distally with a modified osteotomy (28 ). These have both been described as alternative methods of fixation.
However, these modifications are more tenuous and do not lend themselves to the same degree of rigidity, stability, and compression
accomplished with the 4.0- and 3.5-mm screws. Additionally, in patients with osteopenic bone, the best alternative is probably to use
crossed K-wires.
Arthrodesis of the hallux can be managed postoperatively in a weight-bearing fashion as long as bending forces are controlled. Because
rotation can occur about a single screw, the toe should be kept bandaged or splinted with the toenail facing upward for 2 to 3 weeks. The
aftercare is similar to that in the Akin osteotomy and requires a minimum of 6 weeks of postoperative splinting.
HALLUX INTERPHALANGEAL SESAMOID MANAGEMENT

The hallux interphalangeal sesamoid is located at the plantar aspect of the interphalangeal joint. This accessory bone articulates with the
head of the proximal phalanx and is invested within the capsule of the interphalangeal joint. Its stated frequency has ranged from 30% to
60%, and it is almost always bilateral (33 , 34 , 35 ). The size can range from 0.05 to 1.0 cm in diameter, and its shape can vary from
elliptic to circular (Fig. 24 ). Some investigators have debated whether this is a sesamoid bone or simply an accessory bone (34 ,36 ).
McCarthy et al. identified a tendon that they named the flexor hallucis capsularis interphalangeus; it is associated with the deep surface of
the flexor hallucis longus that arises at the level of the separation of the tibial and fibular bipennate fibers of the flexor hallucis brevis at
the base of the proximal phalanx (36 ). This tendon passes distally to invest the sesamoid and to blend with the interphalangeal joint
capsule. By definition, a sesamoid is invested in a tendon, so one could conclude that this ossicle is a sesamoid bone (Fig. 25 ).
This ossicle may result in the development of a painful hyperkeratotic lesion inferior to the interphalangeal joint of the hallux
(33 ,34 ,36 ,37 ) (Fig. 26 ). In patients with diabetes, this lesion can degenerate into a neurotrophic ulcer. The lesion may be either
directly plantar to the proximal phalanx head or plantar and slightly medially. In some patients, the relatively large size of the sesamoid
may be the source of the hyperkeratotic lesion. Because the presence of hallux
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limitus may result in the formation of the same type of lesion and hyperextension of the interphalangeal joint, the presence of the
interphalangeal sesamoid cannot be assumed to be the sole cause of the symptoms. However, investigators have proposed that the
presence of a hyperextended hallux interphalangeal joint without a concomitant hallux limitus is a direct clinical indicator of the presence
of the interphalangeal sesamoid (38 ).
FIG. 24. Dorsoplantar (A) and lateral (B) radiographs of a patient with a hallux interphalangeal sesamoid.
Radiographs are generally reliable in demonstrating the presence of the sesamoid. Investigators have recommended that the lateral view
be performed with the hallux elevated to enhance the likelihood of visualization. Otherwise, the dorsoplantar and medial oblique views
prove most effective (39 ). However, the sesamoid possibly may be fibrous or cartilaginous, and therefore, it may not be evident on
radiographs (36 ,39 ,40 ).
FIG. 25. Cross section of a cadaver demonstrating the interphalangeal joint sesamoid bone superior to the flexor hallucis longus and
plantar to the joint itself. (From Yu GV, Nagle CJ. Hallux interphalangeal joint sesamoidectomy. J Am Podiatr Med Assoc
1996;86:105-111, with permission.)
Procedure
Numerous surgical approaches have been described, including a medial, dorsal transverse, plantar linear, plantar U-shaped flap, and
plantar transverse incision (33 ,37 ,39 ,41 ,42 ).
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In the dorsal transverse approach, an incision is made transversely or in a curvilinear manner over the interphalangeal joint. The extensor
hallucis longus is transected to achieve access to the plantar tissue (42 ). The sesamoid is then excised from within the joint. A plantar
linear incision, with or without an elliptic excision of the hyperkeratotic lesion, and a plantar U-shaped flap with the apex proximal provide
excellent exposure to the sesamoid (41 ).
FIG. 26. A typical lesion on the plantar aspect of the hallux caused by a hallux interphalangeal sesamoid. (From Yu GV, Nagle CJ.
Hallux interphalangeal joint sesamoidectomy. J Am Podiatr Med Assoc 1996;86:105-111, with permission.)
FIG. 27. A: Medial approach for excision of the interphalangeal sesamoid. B: Intraoperative exposure. The interphalangeal joint is
dorsally, and the sesamoid plantarly.
The medial, slightly curvilinear incision has proven to be an effective approach, especially if plantar scarring is a concern. The incision is
centered over the head of the proximal phalanx and is made at the juncture of the dorsal and plantar skin (Fig. 27 ). The incision is
deepened by sharp and blunt dissection through the subcutaneous tissue to the level of the joint capsule. An artificial plane is created
plantarly between the capsule and fascia by blunt dissection, and the tendon sheath of the flexor hallucis longus is identified. The deep
fascia is then incised, and subcapsular and subperiosteal
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dissection performed while the flexor hallucis longus tendon is retracted plantarly. The sesamoid is commonly found in the joint capsule, in a pad beneath the joint, or within the superior
aspect of the flexor tendon. Once it is identified, the sesamoid is grasped and extirpated by sharp dissection. Adequate lavage is performed, and the flexor tendon and joint are evaluated to
ensure the integrity of these structures.
FIG. 28. A: The plantar transverse incisional approach with proximal and distal extensions to enhance exposure. B: The flexor hallucis longus tendon has been split to allow retraction
and access to the sesamoid. C: Excision of the sesamoid. (From Yu GV, Nagle CJ. Hallux interphalangeal joint sesamoidectomy. J Am Podiatr Med Assoc 1996;86:105-111, with
permission.)
The plantar transverse incision is also a popular technique. This is actually a serpentine approach with the proximal arm of the incision commencing medially, curving transversely across the
plantar aspect of the interphalangeal joint, and then curving distally at the lateral side of the hallux (39 ). Care must be exercised to avoid damage to the plantar neurovascular structures on
the medial and lateral aspects of the incision. One may combine this approach with an elliptic excision of a painful plantar lesion. In some instances, only the proximal medial extension is
incorporated into the transverse segment of the incision. Dissection is then directed plantarly to the long flexor tendon, which may be split longitudinally, or else an incision is made medial to
the tendon. In either instance, retraction of the flexor provides access to the underlying sesamoid bone (Fig. 28 ).
Occasionally, if the sesamoid appears small or the head of the phalanx is enlarged, a plantar condylectomy may need to be performed to ensure a satisfactory result. If one is concerned over
the stability of the joint or the long flexor tendon, then a K-wire may be introduced for several weeks in the postoperative period (39 ).
The patient is placed in a postoperative shoe and is allowed to ambulate. The patient is seen 1 week later for a dressing change and to evaluate for infection, and the patient returns at 2 weeks
postoperatively for suture removal. The patient may then be progressed to normal shoes as tolerated and continues to use a type of compressive wrap for the next couple of weeks.
HALLUX EXOSTECTOMY
A medial pinch callus is a common condition affecting the great toe. The development of this lesion almost universally is caused by a structural or functional disorder that results in excessive
pressure applied to the medial aspect of the hallux during propulsion. Hallux valgus, hallux abductus interphalangeus, pes valgus deformity, external limb position, and an abducted gait pattern
all can create a line of progression that falls medial to the foot and hallux. This medial roll-off of the great toe creates undue pressure over the prominent contour of the interphalangeal joint.
In some instances, this callus can be solely caused by the presence of an exostosis of the medial aspect of the head proximal phalanx, but occasionally such an exostosis exists concomitantly
with another disorder, which may also account for the symptomatic callus.
Although the primary cause of this condition is usually biomechanical or functional, surgical intervention may be of benefit if conservative methods alone appear inadequate to relieve the
patient's symptoms. A simple condylectomy involving the plantar medial condyle of the head of the proximal phalanx and the base of the distal phalanx can significantly reduce any bony
prominence that leads to the irritation of this area. Primary procedures for correction of major deformity (e.g., hallux valgus, pes valgus) may themselves provide the functional or structural
correction needed. However, the condylectomy may be considered an adjunctive procedure as necessary or a primary procedure if major reconstruction is not indicated or feasible.
Exposure may be gained through extension of an incision used to address the first metatarsophalangeal joint, or a medial incision centered over the hallux interphalangeal joint may be used.
The dissection is performed in the previously described fashion for a medial approach, and the exostosis may be reduced as the surgeon chooses. The postoperative management is dictated by
the primary procedures.
REFERENCES
1. Akin OF. The treatment of hallux valgus: a new operative procedure and its results. Med Sentinel 1925;33:678-679.
2. Boberg J. Surgical procedures of the hallux. In: McGlamry ED, Banks AS, Downey MS, eds. Comprehensive textbook of foot surgery. Baltimore: Williams & Wilkins, 1992:533-544.
3. Springer KR. The role of the Akin osteotomy in the surgical management of hallux abducto valgus. Clin Podiatr Med Surg 1989;6: 115-130.
4. Brahms MA. Hallux valgus: the Akin procedure. Clin Orthop 1981; 157:47-49.
5. Goldberg I, Bahar A, Yosipovitch Z. Late results after correction of hallux valgus deformity by basilar phalangeal osteotomy. J Bone Joint Surg Am 1987;69:64-67.
6. Plattner PF, VanManen JW. Etiology and treatment of hallux valgus: results of Akin type proximal phalangeal osteotomy for correction of hallux valgus deformity. Orthopedics
1990;13:989-996.
7. McDonald KC, Drake R, Durrant MN, et al. Retrospective analysis of Akin-Austin bunionectomies on patients over fifty years of age. J Foot Surg 1988;6:545-555.
8. Clark JR. Akin-type procedure. In: Gerbert J, ed. Textbook of bunion surgery. Mt. Kisco, NY: Futura, 1991:143-166.
9. Boberg JS, Menn JJ, Brown WL. The distal Akin osteotomy: a new approach. J Foot Surg 1991;30:431-436.
10. Segel DS. Proximal and distal akin procedures. J Foot Surg 1977;16: 57-58.
11. Purvis CG, Brown JH, Kaplan EG, et al. Combination Bonney-Kessel and modified Akin procedure for hallux limitus associated with hallux abductus. J Am Podiatry Assoc 1977;67:236-
240.
12. Gohil P, Cavolo DJ. A simplified preoperative evaluation for Akin osteotomy. J Am Podiatry Assoc 1982;72:44-45.
13. Daw SW. An unusual type of hallux valgus (two cases). BMJ 1935; 2:580.
14. Mitchell LA, Baxter DE. A chevron-Akin double osteotomy for correction of hallux valgus. Foot Ankle 1991;12:7-14.
15. Tollison ME, Baxter DE. Combination chevron plus Akin osteotomy for hallux valgus: should age be a limiting factor? Foot Ankle 1997; 18:477-481.
16. Mann RA. The great toe. Orthop Clin North Am 1989;20:519-533.
17. McGlamry ED, Kitting RM, Butlin WE. Hallux valgus with correction of coexisting long hallux. J Am Podiatry Assoc 1970;60:86-90.
18. Hodor L, Hess T. Shortening Z-osteotomy for the proximal phalanx of the hallux using axial guides. J Am Podiatr Med Assoc 1995;85: 249-254.
19. Schwartz NH, Iannuzzi PJ, Thurber NB. Derotational Akin osteotomy. J Foot Surg 1986;25:479-483.
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20. Schwartz N, Hurley JP. Derotational akin osteotomy: further modification. J Foot Surg 1987;26:419-421.
21. Colloff B, Weitz EM. Proximal phalangeal osteotomy in hallux valgus. Clin Orthop 1967;54:105-113.
22. Gerbert J, Melillo T. A modified Akin procedure for the correction of hallux valgus. J Am Podiatry Assoc 1971;61:132-136.
23. Barouk LS. Osteotomies of the great toe. J Foot Surg 1992;31: 388-399.
24. Barca F, Busa R. Resorbable poly-L-lactic acid mini-staples for the fixation of Akin osteotomies. J Foot Ankle Surg 1997;36:106-
111.
25. Green AH, Bosta SD. Akin osteotomy of the hallux proximal phalanx utilizing Richards mini staple fixation. J Foot Surg
1986;25:386-389.
26. Levitsky DR. Percutaneous osteoclasp fixation of akin osteotomy: an alternative fixation technique. J Foot Surg 1981;20:163-166.
27. Franke JP, Turf R, Tirone M. Arthrodesis of the hallux interphalangeal joint using a diagonally placed 2-mm cortical bone screw. J
Foot Surg 1989;28:466-470.
28. Gerbert J. Digital arthrodesis. Clin Podiatr 1985;2:81-94.
29. Langford J, Fenton CF. Hallux interphalangeal arthrodesis. J Am Podiatry Assoc 1982;72:155-157.
30. Shives TC, Johnson KA. Arthrodesis of the interphalangeal joint of the great toe: an improved technique. Foot Ankle 1980;1:26-29.
31. DeSteiger RN, Menelaus MB. Hallux interphalangeal extensus. J Pediatr Orthop 1993;13:797-798.
32. Ritt MJP, Bos KE. Proximal interphalangeal joint arthrodesis using powered staple fixation. Clin Orthop 1993;292:172-176.
33. Roukis TS, Hurless JS. The hallucal interphalangeal sesamoid. J Foot Ankle Surg 1996;35:303-308.
34. Sharon SM. Interphalangeal joint hallux ossicle. J Foot Surg 1977;16: 69-72.
35. Yanklowitz BAD, Jaworek TA. The frequency of the interphalangeal sesamoid of the hallux. J Am Podiatry Assoc 1975;65:1058-
1063.
36. McCarthy DJ, Reed T, Abell N. The hallucal interphalangeal sesamoid. J Am Podiatr Med Assoc 1986;76:311-319.
37. Miller WA, Love BP. Cartilaginous sesamoid or nodule of the interphalangeal joint of the big toe. Foot Ankle 1982;2:291-293.
38. Genakos JJ. Clinical sign consistent with the hallucal interphalangeal sesamoid. J Am Podiatr Med Assoc 1993;83:696-697.
39. Yu GV, Nagle CJ. Hallux interphalangeal sesamoidectomy. J Am Podiatr Med Assoc 1996;86:105-111.
40. Burman MS, Lapidus PW. The functional disturbances caused by the inconsistent bones and sesamoids of the foot. Arch Surg
1931;22:936.
41. Gosselin RE, Toyzi MA, Gohil P. Interphalangeal joint hallux ossicle resection: a simplified approach. J Foot Surg 1982;21:132-135.
42. Hill JH. Ostectomy of supernumerary sesamoid in flexor hallucis longus tendon. J Am Podiatry Assoc 1970;60:237-238.
SELECTED READINGS
Frey C, Jahss M, Kummer FJ. The Akin procedure: an analysis of results. Foot Ankle 1991;12:1-6.
Kinnard P, Cantin S. The Akin procedure in hallux valgus. Can J Surg 1991;34:491-493.
McGarvey SR. Internal fixation of the Akin osteotomy. Foot Ankle Int 1995;16:172-173.
Murphy JS, Mozena JD, Walker RE. J-wire technique for fixation of the akin osteotomy. J Am Podiatr Med Assoc 1989;79:291-293.
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Chapter 14
Complications of Hallux Abducto Valgus Surgery
Gerard V. Yu
Molly Schnirring-Judge
Jeffrey E. Shook
Surgical correction of hallux abducto valgus and related deformities is commonly performed. Unfortunately, complications of
hallux abducto valgus surgery may develop, many of which are unpredictable. Common complications of hallux valgus surgery
include recurrence of the deformity, hallux varus, and complications of bone healing, such as delayed union, nonunion, or
malunion. The purpose of this chapter is to provide an overview of and insight into the diagnosis and treatment of some of the
more common complications of hallux abducto valgus surgery.
RECURRENCE OF DEFORMITY
Definition, Incidence, and Etiology

Experience has shown that even when strict criteria are followed for the repair of hallux abducto valgus deformity, the
condition can recur. Generally, patients with recurrent hallux abducto valgus may be divided into two groups: those patients
who manifest with hallux abducto valgus early in the postoperative period, perhaps in the first few months to 1 year, and those
patients who present some time later with recurrent deformity. Although one or two factors may play a dominant role in the
development of recurrent deformity, others may also be involved to a lesser degree.
Early Recurrent Deformity

In general, early recurrence of the deformity may be attributed to one of several different factors: (a) an error in judgment in
the selection of procedures; (b) inadequate execution of the procedure; (c) events during the postoperative care, including
patient noncompliance; and (d) failure to recognize or to address concomitant deformities such as metatarsus adductus.
Most cases of hallux abducto valgus deformity are caused by a combination of dynamic soft tissue factors as well as structural
factors. Although some bunion deformities have a more dynamic cause, others have a structural component as the primary
etiologic factor.
The degree and extent of displacement of the sesamoidal apparatus may be strong indicators of the dynamic component of the
bunion deformity. Failure to release the plantar lateral soft tissues of the first metatarsophalangeal joint can increase the
incidence of recurrence after hallux valgus correction. With contracture of adductor hallucis muscle and other periarticular
structures, the sesamoid apparatus displaces in a lateral direction relative to the first metatarsal head and contributes to
further progression of the deformity. The failure of the surgeon to release these lateral soft tissue structures properly, a failure
that inhibits relocation of the sesamoidal apparatus beneath the first metatarsal head, significantly increases the risk of
recurrence. Even in cases with an adequate release of the plantar lateral structures, the surgeon may find that the sesamoid
apparatus is not adequately mobilized, and consequently fibular sesamoidectomy may be necessary.
Kitaoka et al. studied 49 feet that underwent simple bunionectomy for hallux valgus deformity. The primary reason for
treatment failure was recurrence, and 14% of these patients underwent revisional surgery as a result. Patients who had a lateral
capsulotomy had less likelihood of experiencing recurrence of the deformity (1 ).
Restoring integrity to the medial joint capsule is helpful in maintaining rectus hallux alignment. As such, a deliberate
reinforcement or medial joint capsulorrhaphy is sometimes performed to restrain the tendency for recurrent valgus drift of the
hallux. In a cadaveric study, Kura et al. investigated the functional significance of the medial capsule and the transverse
metatarsal ligament in hallux valgus deformity. A three-dimensional imaging technique was used to track the effect of
sectioning these structures to assess their influence in deformity about the first metatarsophalangeal joint. No significant
deformity was noted when the transverse metatarsal ligament was sectioned. Valgus deformity of the hallux increased an
average of 22 degrees when the medial
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capsule was sectioned, a finding that underlines the contribution of this structure to joint stabilization. However, this does not
imply that medial capsulorrhaphy is the critical aspect of the soft tissue procedure responsible for maintenance of correction
(2 ), although it is an adjunctive measure that may assist in restoring overall balance to the joint. The study does indicate the
concern for addressing lateral joint contractures, because compromise of the medial joint structures is required to alleviate the
bunion prominence.
FIG. 1. A: Preoperative dorsoplantar radiograph of a patient with hallux abducto valgus deformity. B: Initial early
postoperative radiograph after a distal metaphyseal osteotomy with soft tissue release. C: Recurrence of deformity 2½
years postoperatively, resulting from inadequate correction of the intermetatarsal angle.
Perhaps the most common cause of recurrence is an error in judgment in the selection of the surgical procedure for the
correction of a hallux valgus deformity (Fig. 1 ) (3 ,4 ). Typically, a capital osteotomy was employed, yet it proved inadequate
to provide full correction of the intermetatarsal
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angle (Fig. 2 ). Often, this is not so much a recurrent deformity as a residual hallux abducto valgus that was not fully corrected
with the original procedure.
FIG. 2. A: Preoperative dorsoplantar radiograph of previously failed hallux abducto valgus surgery, which consisted of an
offset-V osteotomy. The patient complained of an excessively wide forefoot incompatible with conventional shoes. B:
Follow-up radiograph 4 months postoperatively. Procedures consisted of muscle-tendon balancing as well as an oblique
closing base wedge osteotomy of the first metatarsal and a distal oblique closing wedge osteotomy of the fifth metatarsal.
Excellent correction of the deformity was achieved. C: Stressed dorsiflexion lateral showing excellent range of motion in
spite of apparent joint space narrowing.
The recurrence rate after distal metaphyseal osteotomies has been proposed to involve approximately 10% of patients
undergoing these surgical procedures (3 ). Historically, distal metaphyseal osteotomies have been indicated for the correction of
mild to moderate bunion deformities with an intermetatarsal angle of 12 to 15 degrees (4 , 5 , 6 , 7 ), although surgeons
commonly employ these types of procedures in patients with larger intermetatarsal angles if the deformity is flexible. Meier and
Kenzora found that 94% of the patients undergoing distal metaphyseal osteotomies with a preoperative intermetatarsal angle of
less than 12 degrees had a satisfactory result, compared with 74% of the patients with an intermetatarsal angle greater than 12
degrees (8 ).
Clearly, in some cases, a proximal osteotomy is far more effective in reducing the intermetatarsal angle than a distal
metaphyseal osteotomy. Historically, procedures may have been selected based on radiographic findings alone, such as the
intermetatarsal or hallux abductus angle. However, strict radiographic criteria should not serve as the sole basis for the
selection of a procedure. Appreciation of the intermetatarsal angle can be better assessed intraoperatively after a complete
release of the periarticular structures.
Inadequate postoperative care may also encourage the development of a recurrent bunion. Immediate postoperative bandaging
should be employed to help maintain the great toe in a rectus position. When the toe is not splinted properly during first several
weeks after surgery, the likelihood of recurrence of the deformity is increased. Inadequate splinting and poor maintenance of
alignment allow the medial
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capsular structures to undergo stretching, whereas the lateral structures attempt to recontract and shorten, with a resulting
recurrence of the deformity in the earlier stages after bunion surgery (3 ). Obviously, the cooperation of the patient is essential
during this period, to ensure the best possible result.
Delayed Recurrence of Deformity

Failure to address concomitant deformities associated with hallux valgus deformity has also been associated with recurrence of
the deformity over time (3 ,4 ,9 ,10 ). Hypermobility of the first ray may contribute to recurrence of the deformity if it is not
addressed either surgically or postoperatively with orthotic control or other measures. Other deformities and conditions
associated with recurrent hallux valgus may include ankle equinus, collapsing pes valgo planus deformity, metatarsus adductus,
spasticity, or hyperelasticity or ligamentous laxity, such as in Ehlers-Danlos syndrome (3 ,4 ,9 ,10 ).
In particular, patients with concomitant hallux abducto valgus and metatarsus adductus present a challenging problem. Failure
to recognize the existence of metatarsus adductus before surgical intervention is apt to result in a less than a satisfactory
outcome. Recurrence and undercorrection are common and vary depending on the severity of the underlying metatarsus
adductus and digital abduction (Fig. 3 ).
FIG. 3. A: Preoperative dorsoplantar radiograph of an adult patient who had undergone two previous bunionectomy
procedures without success. Note the structural residual metatarsus adductus deformity, as well as the lesser digital
abduction. B: Correction of the deformity postoperatively by aggressive reduction of the intermetatarsal angle by an
oblique closing base wedge osteotomy and internal screw fixation. Note the reduction of the intermetatarsal angle to 0
degrees with restoration of a congruous first metatarsophalangeal joint. Revision arthrodesis of the lesser toes was also
performed.
In radiographic evaluation of such feet, the intermetatarsal angle must be considered to be significantly greater than that
determined by actual measurement (11 , 12 , 13 , 14 ). It is not uncommon to strive to obtain a reduction of the intermetatarsal
angle intraoperatively, to 0 to - 2 or - 3 degrees. In some cases, an opening wedge osteotomy of the first metatarsal or medial
cuneiform may be an appropriate procedure, although we have not found this approach necessary (15 ).
Clinical experience shows that even when the intermetatarsal angle has been reduced to a slightly negative value, an increased
separation between the first and second metatarsals may be seen later when full weight-bearing function has been restored to
the foot. This ultimately results in a final intermetatarsal angle of approximately 0 to 5 degrees.
Patients who undergo surgical correction of a hallux abducto valgus deformity in the presence of a structural metatarsus
deformity frequently have a residual bunion deformity, or clinical hallux abducto valgus deformity, without any radiographic
evidence of such. In many cases, the surgeon may identify full correction and normal values of most radiographic parameters.
The degree to which the clinical appearance of a residual bunion and hallux abducto valgus deformity occurs is proportional to
the degree of metatarsus adductus deformity and the degree of compensation present (10 ,16 , 17 , 18 , 19 , 20 , 21 ). The
greater the metatarsus adductus deformity,
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the greater is the abduction of the hallux and lesser digits on their adjacent metatarsal (10 ,16 ,22 , 23 ).
Clinical and Radiographic Evaluation

The clinical and radiographic findings associated with a recurrent hallux abducto valgus deformity are usually not different from
those seen before the first surgical procedure, with one exception: they are usually worse. Both the type and the intensity of
the pain as well as the clinical deformity are more extreme than the original presentation. Patients may also complain of a
“tingling, numbness, or pins and needles” sensation suggestive of an entrapment neuropathy of the medial proper digital branch
of the medial dorsal cutaneous nerve or the terminal branches of the saphenous nerve. A sharp focal area of pain may be caused
by a residual osseous prominence. Pain along the plantar aspect of the joint, especially at the medial portion, may indicate an
abnormal articulation between the sesamoid and the first metatarsal head.
The hallux may underride or overlap the second digit, a feature that may not have been present with the original deformity. The
bunion prominence is typically larger even though aggressive resection of bone may have already been performed. Lateral
bowstringing of the extensor hallucis longus tendon may be seen. Although the original deformity may be purely transverse,
increased valgus rotation of the hallux is often seen in patients with a recurrent deformity.
Of significance is the degree to which the deformity is reducible and the joint range of motion is maintained while in the
corrected position. A patient with a limited range of motion associated with pain and crepitation may require a joint-destructive
procedure regardless of the radiographic findings. An assessment of the reducibility and flexibility of the deformity not only is
helpful in identifying the most appropriate procedure, but also it may signify the propensity or likelihood that a transverse plane
hallux varus deformity will develop. An inability to reduce the deformity strongly suggests tight plantar lateral structures, most
notably the adductor hallucis and secondarily the lateral head of the flexor hallucis brevis muscles.
Patients should also be observed while they are in a relaxed stance position. It is not uncommon to see an exacerbation of the
deformity when the foot is fully loaded. In addition, one gains a much greater appreciation of the plane of the deformity (i.e.,
purely transverse versus a combination of transverse and frontal). Clinical observations are then correlated with the
radiographic findings.
Finally, the presence of concomitant deformities is assessed. Emphasis is placed on the presence of metatarsus adductus, as
well as any pronatory changes in the foot consistent with severe collapsing pes valgo planus deformity that could require
treatment to ensure correction of the recurrent hallux abducto valgus deformity, especially in the juvenile or adolescent patient.
Treatment Considerations
Most patients with symptomatic recurrent hallux abducto valgus deformity do not respond well to conservative treatment
modalities. The surgical correction of a recurrent deformity is more challenging than that of the original condition. Although the
goals of the revisional operation should be to establish a congruous, pain-free, functional first metatarsophalangeal joint, this
cannot always be achieved. Joint-salvage procedures can only be employed when the patient has sufficient bone and stable
architecture at the first metatarsophalangeal joint. Patients who have had excessive resection of the medial eminence may not
have adequate bone stock to support a traditional distal metaphyseal procedure. In such cases, proximal osteotomies may be
necessary despite a relatively low intermetatarsal angle. In cases of significant arthrosis, joint compromise, or instability, a
resection arthroplasty, implant arthroplasty, or arthrodesis may be required. Joint-preservation procedures are preferred
whenever possible.
Meticulous surgical technique is critical to achieving the desired outcome. In most cases, a dorsomedial skin incision is employed.
Every attempt is made to separate the skin and subcutaneous tissues from the deep fascial layer, to prepare for anatomic
closure. One must be cautious to avoid the dorsal cutaneous nerves and pertinent vascular structures. In patients with clinical
evidence of nerve entrapment, the nerve is carefully explored, and any surrounding scar tissue is released; when necessary,
nerve resection may be performed.
Unless the fibular sesamoid has been previously excised, attention is directed to the first interspace. Complete release of the
plantar lateral structures is performed. In most cases, this operation involves release of the adductor hallucis tendon and fibular
sesamoidal ligament. In more severe cases, release of the lateral head of the flexor hallucis brevis muscle may also be necessary.
If adequate immobilization of the sesamoid apparatus cannot be achieved, then considerations should be given to removal of the
fibular sesamoid.
After release of the intermetatarsal space, the deformity must be reassessed. When a recurrent contracture of the plantar
lateral structures has occurred, or an inadequate release was performed initially, a significant improvement in the alignment of
the hallux on the first metatarsal is generally seen. After plantar lateral release, one can more readily appreciate the true
structural components of the deformity and decide on the need for additional procedures to achieve adequate joint congruity
and position.
Various medial capsular approaches can be employed for exposure of the joint. The choice depends on the experience and
preference of the surgeon. The first metatarsal head and phalangeal base are inspected. The orientation of the articular
cartilage on the first metatarsal head is inspected and should be compared in position with the long axis of the metatarsal shaft.
Although some contouring of the dorsal and medial aspects

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of the first metatarsal head may be necessary, aggressive resection of the metatarsal head should not be performed. Further
“staking” of the metatarsal head only compromises function.
FIG. 4. A: Recurrent hallux abducto valgus deformity in a patient who had undergone a prior modified bunionectomy with
osteotomy at the proximal diaphyseal area. A resection of the metatarsal head has left the remaining articular cartilage in
a laterally deviated position. B: Postoperative correction, 1½ years postoperatively, after a base wedge osteotomy with a
Reverdin osteotomy for realignment of the articular cartilage. Excellent correction was achieved.
If excessive resection of bone was not performed in the initial surgical procedure, then a distal metaphyseal osteotomy may be
appropriate for correction of any residual splaying between the first and second metatarsal. The type of osteotomy performed
depends on several factors. In patients with significant deviation of the articular cartilage on the first metatarsal head, a
Reverdin-type osteotomy may be used to reposition the articular surface properly. This form of osteotomy may also be
considered to rotate the remaining cartilage into a more effective position when the first metatarsal head has been staked. Any
remaining intermetatarsal splay is corrected by a more proximally oriented procedure (Fig. 4 ).
Structural splaying between the first and second metatarsal is usually addressed by a proximal procedure. The most common
procedure is a closing base wedge osteotomy, not only to reduce the intermetatarsal angle, but also to minimize the amount of
shortening. When postoperative elevatus has occurred in conjunction with recurrence of the deformity, the osteotomy may be
modified to achieve both reduction of the intermetatarsal angle and simultaneous plantarflexion of the distal fragment. In some
cases, a first metatarsocuneiform arthrodesis or opening wedge osteotomy of the metatarsal base or cuneiform may be
appropriate, especially when restoration of length is an important consideration. Lengthening of the first ray segment may
create tension at the first metatarsophalangeal joint and may possibly lead to limitation of motion, with or without symptoms.
In cases of recurrent juvenile or adolescent hallux abducto valgus deformity, careful consideration must be given to the surgical
correction of concomitant deformities. In patients with a significant ankle equinus, a tendo Achillis lengthening or
gastrocnemius recession may be performed. Patients with severe collapsing pes valgo planus deformity may also need surgical
correction if they cannot be treated effectively with an appropriate orthotic device or shoe modifications. Finally, the influence
of metatarsus adductus deformity cannot be overemphasized. Residual metatarsus adductus can have a profound influence on
first ray disorders. Although it is rare to attempt full correction of the deformity in an adult, it may be important in obtaining
the best correction of a juvenile or adolescent suffering with a painful hallux valgus deformity.
HALLUX VARUS
Definition, Incidence, and Etiology

Hallux varus is classified as either a congenital or an acquired deformity and has been a subject of study for many
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years (1 ,3 ,4 ). Although acquired hallux varus may have several causes (i.e., postsurgical, trauma, rheumatoid arthritis), this
discussion focuses on those cases noted after surgical correction of hallux abducto valgus or related deformities. Regardless of
whether a hallux varus deformity is congenital or acquired, common denominators exist. In virtually all cases, one appreciates a
muscle imbalance in which the abductor hallucis muscle gains a significant mechanical advantage over its antagonistic muscle,
the adductor hallucis. In a postsurgical hallux varus, the abductor hallucis muscle usually is responsible for deformity, although
in some cases the deformity may occur primarily as a result of structural alterations of the first metatarsal, proximal phalanx, or
both.
We use the term hallux varus (or hallux adductus) to describe purely transverse plane, medial deviation of the great toe with
the apex of deformity at the metatarsophalangeal joint. This condition is readily identified both radiographically and clinically.
The term hallux malleus is used to describe a great toe with an extension contracture at the metatarsophalangeal joint and
concomitant flexion contracture at the interphalangeal joint. When the conditions occur simultaneously, we refer to the
condition as hallux varus with a concomitant hallux malleus deformity (Fig. 5 ). Regardless of the terminology, one must be
aware of the apex of deformity and the presence of combination deformities to ensure adequate surgical selection and
treatment.
The combination of the transverse and sagittal plane deformities usually represents the end point of the deformity. The rate of
progression and the ultimate severity of the condition depend on several factors, including inherent flexibility, the time elapsed
since the surgical procedure, the degree of musculotendinous imbalance, the amount of structural malalignment, and other
underlying concomitant disorders such as neuromuscular or connective tissue diseases.
Iatrogenic hallux varus alone or in combination with a hallux malleus deformity can be more painful, disfiguring, and disabling
than the original hallux valgus condition. Cosmetic complaints are rare when the varus deformity is less than 10 degrees (24 ).
Pain associated with the deformity is often coincident with significant joint incongruity or degenerative joint disease.
FIG. 5. Hallux varus deformity with concomitant hallux malleus.
McBride first described the complication of hallux varus in the follow-up study of his procedure and reported an incidence of
5.1% (25 ). The incidence of postoperative hallux varus reported by other authors approximates 1% (26 , 27 , 28 ). In a review of
878 first metatarsophalangeal joint procedures, Feinstein and Brown reported 10 cases of hallux varus, with an overall incidence
of 1.13%. This study involved procedures for the correction of hallux abducto valgus and hallux limitus. Other studies, which
reviewed procedures performed only for the correction of hallux abducto valgus, cited a similar incidence of postoperative
hallux varus. Combining two separate reviews, 21 cases of hallux varus were discovered in 1,400 postoperative cases for an
overall incidence of 1.5% (26 ,27 ).
In more recent literature, the reported range is from 2% to 17% (29 , 30 , 31 ). The length of the first metatarsal has been
purported to predispose to the development of hallux varus (28 ). Janis and Donick found 18 cases of hallux varus in a review of
1,110 bunion operations. These investigators concluded that all but 2 cases were in patients with a long first metatarsal and
deduced that this feature was influential in the development of a hallux varus deformity. However, considering that the normal
metatarsal protrusion with respect to the first and second metatarsals is plus or minus 2 mm, with scrutiny of the results, one
finds that the first metatarsal was abnormally long in only 50% (9 of 18) of these cases. In another study of 10 cases of hallux
varus, the first metatarsal measured more than 2 mm longer than the second in only 2 cases. In the remaining 8 cases, the
length pattern of the first metatarsal was not considered a significant cause (26 ). Therefore, it appears that the length of the
metatarsal may not predispose a patient to hallux varus, as was once suspected.
The shape of the first metatarsal head, specifically a round first metatarsal head, has also been implicated as a factor leading to
the formation of hallux varus after bunion operations (28 ,31 ). A round metatarsal head seemingly implies an absence of the
sagittal groove or plantar, medial condyle. Although the morphology of the sagittal groove and plantar medial condyle may vary
from patient to patient, we have yet to perform an initial bunion operation and find these structures to be absent. Furthermore,
no reports exist in the literature that correlate the architecture and shape of the first metatarsal noted intraoperatively with
the preoperative radiographs. The concept of a round first metatarsal head as a contributory factor to hallux varus is strictly a
supposition based on retrospective radiographic analysis and clinical experience. The apparent shape of the first metatarsal
head is easily altered by positional changes of the foot or by changing the tube head angle in x-ray acquisitions. Therefore, the
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validity of a round metatarsal head as a contributory factor to the development of iatrogenic hallux varus deformity should be
questioned.
The flexibility of the first ray may certainly be a contributory factor in the development of postoperative hallux varus
deformities (32 ). A foot that is extremely mobile and has an excessive sagittal plane range of motion may be more susceptible
to postoperative deformity. It seems logical that patients with an excessive range of motion of the first metatarsophalangeal
joint (90 to 100 degrees or greater) and first ray will tend to be flexible in the transverse plane as well.
Certain connective tissue disorders (i.e., Marfan's syndrome and Ehlers-Danlos syndrome) are associated with an inherent joint
laxity that predisposes the patient to recurrent deformity or hallux varus. In addition, patients with disorders such as Down's
syndrome or other neuromuscular diseases such as cerebral palsy may also be predisposed to developing a postoperative hallux
varus condition.
Historically, the development of an hallux varus deformity has been largely attributed to a McBride-type procedure. Hawkins
stressed the importance of maintaining either the adductor tendon or the lateral head of the flexor hallucis brevis tendon. In
Hawkins' study of 300 cases of McBride bunionectomies, all 3 cases of hallux varus were attributed to the removal of the fibular
sesamoid or sectioning of the lateral head of the flexor hallucis brevis tendon (27 ). However, at that time, correction of hallux
abducto valgus deformity was largely performed without the benefit of an osteotomy. Therefore, much of the risk involved with
the McBride procedure may have resulted from attempts to reduce significant deformity with soft tissue procedures alone, as
opposed to the sesamoidectomy.
Although the lateral head of the short flexor tendon does not actively abduct the great toe, it does provide some passive
restraint against adductory forces because it is lateral to the midline of the first metatarsal. Many true McBride procedures have
been performed without the development of subsequent hallux varus deformity. This finding highlights the importance of a
stepwise approach to the lateral release performed for hallux abducto valgus deformities. A properly performed interspace
release establishes a rectus or congruous joint; however, significant compromise to the integrity of the plantar lateral soft
tissues may be necessary to achieve the desired result. Most cases of hallux abducto valgus require at least the release of the
adductor tendon and the fibular sesamoidal ligament (33 ). Although empiric removal of the fibular sesamoid may unnecessarily
disrupt the plantar lateral support of the first metatarsophalangeal joint (27 ,34 ), this may still be required to provide full
correction of the hallux abducto valgus deformity in some patients.
Obviously, other factors contribute to the articular and periarticular instability at the first metatarsophalangeal joint and lead
to the development of an iatrogenic hallux varus. In most cases of hallux varus, one of the following must be present in
conjunction with a plantar lateral release: (a) staking of the first metatarsal head, (b) overcorrection of structural deformities,
and (c) excessive tightening of the medial capsular structures (22 ,32 ,35 ,36 ).
Many surgeons have recognized the concept of staking the first metatarsal head. The sagittal groove represents the articular
confine for the medial aspect of the base of the proximal phalanx. The bone medial to the sagittal groove acts as a buttress and
provides support to help prevent the phalanx from drifting medially. The plantar medial aspect of the first metatarsal head also
provides medial stability and is essential to the normal function of the tibial sesamoid. Loss of the medial condyle allows the
tibial sesamoid to sublux medially. This significantly alters the function of both the abductor hallucis muscle and the medial
head of the flexor hallucis brevis. Both muscles then become primary transverse plane deforming forces.
Unfortunately, some surgeons still improperly use the sagittal groove as a landmark for resection of the medial exostosis during
the “bunionectomy” or exostectomy portion of hallux abducto valgus correction procedures. This results in removal of all the
bone medial to the sagittal groove. Perhaps this aspect of the surgical correction has resulted in the claim of a “round
metatarsal” as a significant factor in the development of a hallux varus deformity. Clearly, the loss of articular stability and
alteration of the muscle-tendon function favors the development of a hallux varus or hallux malleus deformity.
The creation of a negative intermetatarsal angle may also be a significant contributing factor to the cause of a hallux varus
deformity. Youngswick reviewed 40 cases of hallux varus deformity and concluded that a negative intermetatarsal angle was a
significant factor in most cases (37 ). Although this may be true, slight overcorrection of this radiographic-anatomic parameter
may not be a significant factor in hallux varus if the integrity of the joint surface has been preserved and other factors known to
be contributory are absent. In patients with a considerable degree of metatarsus adductus, we routinely reduce the
intermetatarsal angle to a slightly negative value without a subsequent increase in the risk of developing a hallux varus
deformity.
The physician should understand that what appears to be the intermetatarsal angle on conventional radiographs is actually a
combination of a structural relationship between the first and second metatarsals and the positional effect of the hallux on the
first metatarsal as a result of retrograde forces. Just as a lateral deviation of the great toe results in an increase in the
intermetatarsal angle, so a negative intermetatarsal angle in a hallux varus deformity may simply be the result of retrograde
forces as the hallux deviates medially on the metatarsal head. In some cases, the identification of a negative intermetatarsal
angle on conventional radiographs is the result of an osteotomy either at the head or at the base of the first metatarsal.
Excessive displacement of a capital osteotomy, or resection of too large a wedge from the base of the first metatarsal, may
result in a true negative angular relationship between the first and second metatarsals. In such
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cases, muscle-tendon balancing about the joint is unlikely to resist hallux varus deformity.
Significant alteration of first metatarsophalangeal joint congruity may be associated with the development of hallux varus, but
it is unlikely to be the direct cause of the deformity. The creation of a negative proximal articular set angle is not likely to
result in a hallux varus deformity unless other contributing factors are realized.
Overtightening of the medial capsule in conjunction with either a plantar lateral release or an aggressive osteotomy is likely to
contribute to the propagation and development of a hallux varus deformity. In some cases, the surgeons may have chosen to use
a medial soft tissue plication in lieu of correcting an underlying osseous deformity. In some cases, an osseous deformity may be
underappreciated, and an aggressive capsulorrhaphy may be used in isolation to correct the deformity.
An underlying deformity of the hallux (increased distal articular set angle or hallux interphalangeus) that increases the degree of
hallux abduction may provide the appearance of joint abduction even though the joint is congruous. In this situation, the
surgeon may continue to tighten the medial capsule to provide a rectus hallux. However, because the residual deformity resides
in the toe as opposed to the joint, the base of the hallux may displace medially and may result in hallux varus (35 ). In this
situation, an osteotomy of the proximal phalanx is indicated.
FIG. 6. A: Clinical photograph of a patient with postoperative hallux adductus deformity. Because of the flexibility of the
deformity, revisional surgery was not required. B: Dorsoplantar radiograph of the same patient.

It is important to understand the chief complaint of the patient, to identify appropriate care and treatment. Although the
patient may present with a severe, rigid hallux varus and hallux malleus deformity, the only complaint may be irritation with
formation of a dorsal callus on the dorsal medial aspect of the hallux interphalangeal joint, which is painful with shoe gear. In
such cases, complete correction of the deformity may not be necessary. This is particularly true in any patient who has already
lived with the condition for many years. Understanding the patient's complaint and expectations is helpful in determining the
most appropriate procedure to correct the deformity. This information should be correlated with the clinical observations and
radiographic findings (Fig. 6 ).
An exaggeration of the deformity with weight bearing suggests an increased role of muscle-tendon imbalance. This applies not
only to the transverse plane adduction deformity, but also to the sagittal plane contracture and loss of appropriate toe purchase
with the ground-supporting surface.
Integrity and preservation of function of the intrinsic musculature are evidenced by a hallux that purchases the ground-
supporting surface with weight bearing; a floating toe or hallux malleus deformity suggests partial or complete loss of intrinsic
function responsible for stabilization of the proximal phalanx. An ability to flex the interphalangeal joint of the great toe
actively against resistance suggests integrity
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and function of the flexor hallucis longus tendon; the inability to plantarflex the proximal phalanx at the metatarsophalangeal
joint against resistance suggests dysfunction of the flexor hallucis brevis muscle. It is easier to assess the function of the
extensor hallucis longus tendon. Although active contracture of this tendon may not result in extension of the interphalangeal
joint in cases of severe hallux malleus, visual confirmation of tendon function aids in the assessment. Manipulation of the great
toe in the transverse plane provides the surgeon with an appreciation of the amount of contracture and contribution of the
abductor hallucis muscle to the hallux varus deformity. Tautness of the tendon is readily appreciated on digital palpation of the
medial border of the foot.
Other clinical factors to assess are the reducibility of the deformity and the presence or absence of degenerative joint disease
at both the metatarsophalangeal and interphalangeal joints. The quality and quantity of motion, as well as the ability to reduce
the deformity, are important factors in determining whether muscle-tendon balancing procedures or more aggressive osseous
procedures may be needed to achieve correction. A deformity that is flexible, and therefore reducible, without evidence of
crepitation or restriction of joint range of motion, suggests that the deformity will be amenable to tendinous rebalancing and
joint preservation procedures. In contrast, a nonreducible deformity causing pain and crepitation on range of motion may
indicate the need for some type of joint-destructive procedure.
The dorsoplantar radiograph provides information regarding the severity of the transverse plane hallux deviation, the condition
of the joint surfaces, the alignment of the first metatarsal segment, and the presence or absence of each sesamoid bone. The
alignment of the tibial sesamoid may also provide some measure of the severity of the condition. The intermetatarsal angle may
be assessed by determining the true bisector of the first metatarsal (12 ), measured from the shaft of the metatarsal to a point
just proximal to the previous osteotomy, as well as the bisector through the cartilage of the metatarsal head and the base of
the metatarsal. These two lines are distinctly different. An evaluation of the two may provide insight into the extent of osseous
malalignment of the first metatarsal from previous osteotomy.
Additional views may be useful for further assessing the metatarsal and interphalangeal joints. Findings on these views should
confirm clinical observations. The forefoot axial view may provide information on the congruence of the crista and sesamoids as
well as further evaluation of the condition of the metatarsal head. The extent of preservation or destruction of the sagittal
groove and plantar medial articulation for the tibial sesamoid can also be appreciated.
Finally, if clinical findings are equivocal, obtaining a dorsoplantar radiograph while the patient's great toe is manipulated into a
corrected position will provide a more definitive image showing the flexibility and reducibility of the deformity. When the
deformity can be reduced, the intermetatarsal angle can be further assessed to determine whether the deformity is more likely
secondary to medial retrograde pressure from the phalangeal base or whether it is perhaps more structural, as a result of the
previous procedure.
Multiple procedures have been described for the surgical management of a hallux varus deformity (3 ,4 ,22 ,32 ,35 , 38 , 39 , 40 ,
41 , 42 , 43 , 44 ). The basic principles used in the correction of an hallux varus deformity are often similar to those applied in
hallux abducto valgus surgery.
A standard dorsomedial approach is usually employed. This approach provides adequate exposure of all aspects of the joint. The
operation is often performed using a tourniquet to enhance visualization. Sharp and blunt dissection techniques are used to
separate the skin and subcutaneous tissues from the overlying deep fascia and capsular tissues on both the medial and lateral
sides.
Various deep fascial, periosteal, and capsular incisional approaches can be employed. Most commonly, a modified capsular
approach is necessary to facilitate effective lengthening of the abductor hallucis and medial capsular tissues. Our most common
approach is an inverted-L capsulotomy similar to that used in conventional hallux valgus surgery, except the vertical portion of
the incision is placed proximal to the joint at the level of the metaphyseal-diaphyseal junction. Subcapsular dissection is
performed to expose the first metatarsal head. The abductor hallucis is readily identified at the plantar medial aspect of the
joint and can be transected, or a section of the tendon can be excised if desired. Further dissection and release provide
identification of the tibial sesamoid. If the tibial sesamoid is significantly displaced from beneath the medial aspect of the joint,
every attempt is made to relocate the tibial sesamoid beneath the metatarsal head. If this cannot be achieved, consideration is
given to excision of the tibial sesamoid. However, this procedure should be performed with great caution, especially when the
fibular sesamoid has already been excised. Additional excision of the tibial sesamoid may induce or further accelerate a hallux
malleus deformity. The inability to relocate the tibial sesamoid beneath the first metatarsal head may result from a structural
deformity, such as overcorrection of the intermetatarsal angle by either a proximal or a distal osteotomy or excessive staking of
the sagittal groove.
Scarring and fibrosis of the deep transverse intermetatarsal ligament or structures within the first intermetatarsal space may
prevent the first metatarsal from returning to its more normal position even after the retrograde forces of the hallux have been
released. Therefore, dissection and release of scar tissue in this region should be considered before the execution of an
osteotomy or removal of the tibial sesamoid. This approach helps to identify the true structural position of the first metatarsal.
Increased medial displacement (adduction) of the metatarsal head may occur in a flexible first ray after release of the deep
transverse intermetatarsal ligament and appropriate soft tissue release medially (35 ).
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If the deformity is not completely reduced after proper soft tissue balancing techniques and the joint does not have any
significant degenerative changes, the intermetatarsal angle may have to be corrected. The deformity can be addressed by
reverse Austin, Reverdin, or modified Reverdin procedures or by a reverse closing base wedge osteotomy (Fig. 7 ).
FIG. 7. A: Preoperative appearance of a patient with hallux varus deformity with concomitant hallux malleus. B:
Radiographic appearance. C: Incision of the lateral capsule in an inverted-L fashion to facilitate later tightening. D:
Release of the medial capsular tissues including the abductor hallucis tendon. E: Intraoperative appearance before closure.
Procedures consisted of a reverse Reverdin-Green osteotomy and arthrodesis of the hallux interphalangeal joint. F:
Radiograph 6 weeks postoperatively. G: Clinical appearance 4 months postoperatively.
When the joint cannot be salvaged, three options have been advocated: (a) resection arthroplasty, (b) resection arthroplasty
with implant, and (c) arthrodesis. A joint-destructive
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procedure should be considered under the following conditions: (a) a rigid, nonreducible deformity; (b) clinical and radiographic
evidence of degenerative joint disease; (c) an excessively staked first metatarsal head; (d) the presence of disorders that
produce joint laxity; and (e) the presence of an underlying neuromuscular disorder involving spasticity.
FIG. 7. Continued.
Occasionally, significant compromise of the quality and architecture of the bone may have left the metatarsal unfit to
accommodate an implant. In addition, the use of a hemiimplant may not be a good choice because the remaining metatarsal
head may not be an acceptable “receptor site” for an implant (35 ). Implants are also likely to fail when arthritic changes are
present at the tibial sesamoid-first metatarsal articulation. Finally, restoration of a normal intermetatarsal angle is also a
prerequisite for the successful use of a resection arthroplasty or implant arthroplasty procedure. If arthrodesis is selected in lieu
of implant arthroplasty, correction of the deformity can usually be achieved without the need for correction of the
intermetatarsal angle. This is in accordance with the premise that relief from retrograde force on the metatarsal head allows
for adequate reduction of deformity.
Additional adjunctive soft tissue measures have also been described. In some cases, the abductor hallucis tendon is freed from
its insertion into the base of the proximal phalanx and is dissected proximally. This is done in a manner similar to release of the
adductor tendon in correction of a bunion deformity. The abductor tendon can then be passed subperiostally over the
metatarsal and sutured onto the lateral capsular tissues to assist in derotation and relocation of the sesamoid apparatus.
Alternatively, one may pass the abductor tendon beneath the metatarsal head.
The lateral component of muscle-tendon rebalancing consists of a lateral capsulorrhaphy. This is usually performed by the use of
over-and-over sutures using 2-0 absorbable or a braided polyester suture. An overly aggressive lateral capsulorrhaphy may result
in a recurrent hallux valgus deformity.
Complete reapproximation of the medial capsular tissues is not necessary. The small amount of bone that is exposed on the
medial side is not of concern. If the surgeon is compelled to have complete coverage of the first metatarsal, then a V-to-Y
capsulotomy may be performed. The surgeon must not retighten the medial capsular tissues because this is likely to encourage a
recurrence of the hallux varus deformity. It is better simply to lay the capsule in place than to suture the capsule in a manner
that tends to adduct or rotate the hallux into a varus position.
In patients with a concomitant hallux malleus deformity, strong consideration should be given to arthrodesis of the hallux
interphalangeal joint of the great toe. Lengthening of the extensor hallucis longus tendon and an extensor hood recession may
be necessary to realign the great toe in the sagittal plane.
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BONE HEALING COMPLICATIONS OF THE FIRST METATARSAL
Malunion of the First Metatarsal
Definition, Incidence, and Causes

A malunion is referred to as a consolidated fracture (osteotomy) site that has healed with an angular or rotatory deviation, in
one or more cardinal planes, in reference to the long axis of the bone (45 ). Other investigators have defined malunion of distal
metaphyseal osteotomies of the first metatarsal as any movement of the capital fragment or consolidation of the osteotomy in a
position other than that placed intraoperatively (46 ).
We propose a modified definition as follows: a malunion should be considered an angular or rotatory deviation, or excessive
shortening of the bone that is other than that achieved in surgery and has resulted in clinical symptoms. This includes deviations
in the sagittal, transverse, or frontal planes of the bone different from that position established at the time of osteotomy or
fusion. Patients who demonstrate angular, rotational, or shortening deformities, but who have no clinical sequelae, are
classified as having asymptomatic malalignment.
Malunion or malalignment after a distal metaphyseal osteotomy of the first metatarsal for the correction of hallux valgus surgery
can occur in any direction, but most commonly it manifests itself as a “dorsal tilting” of the capital fragment. In one study, up
to 14% of cases demonstrated tilting of the distal fragment (47 ). Conversely, Mancuso et al. reviewed 500 distal metaphyseal
osteotomies and reported an incidence of only 1.6% malunion in these patients. He indicated that “mild displacement” was of
no clinical significance, a philosophy similar to ours (46 ).
Elevatus after a basilar-type osteotomy of the first metatarsal is a well-known complication. This complication can be all but
eliminated by maintaining patients non-weight bearing after proximal osteotomies.

As previously stated, malalignment after hallux valgus surgery may not have any clinical significance. Some patients have only
minimal symptoms, and no significant conservative or surgical treatment is warranted or necessary. For example, Mann et al.
reported a 28% rate of radiographic elevatus and no new painful transfer lesions in 109 feet (48 ). These surgeons concluded that
because the first metatarsophalangeal joint was realigned adequately after hallux valgus surgery, the hallux continued to bear
weight in a normal manner, thereby compensating for any dorsiflexion that may have occurred. Broughton and Winson reported
that dorsal malunions of up to 10 degrees after Mitchell bunionectomy did not appear to influence the result or to cause
metatarsalgia (49 ).
In other cases, clinical symptoms may be significant. The most common sequela of sagittal plane malunion is the development of
lesser metatarsalgia. In some cases, this is associated with the development of plantar hyperkeratosis beneath one or more of
the metatarsal segments; in rare cases, a porokeratoma or nucleated hyperkeratotic lesion may develop. Patients may complain
of a feeling of imbalance because of the off-loading of the first ray segment. As weight is transferred to the lesser metatarsal
segments, other clinical symptoms may develop, such as a neuroma or hammer toe contractures. Some patients may complain
that the medial column of the foot has minimal contact with the ground-supporting surface.
If the metatarsus primus elevatus is significant, a hallux limitus deformity may develop. In such cases, patients may report pain
and limitation of motion. In severe cases, patients may complain of a dorsal “bump” that is aggravated by conventional shoe
gear.
Although sagittal plane malalignment or malunion of the osteotomy is perhaps the most common complication (Figs. 8 and 9 ),
other planal deformities may also develop. Significant transverse plane deviation of an osteotomy may result in clinical
overcorrection or undercorrection of the original hallux valgus deformity. Transverse or frontal plane malalignments may affect
the overall quality and quantity of motion present at the first metatarsophalangeal joint.
The dorsoplantar view demonstrates any evidence of medial or lateral translocation of the metatarsal. Metatarsus primus
elevatus is appreciated best on a lateral film. A forefoot axial view may also aid the surgeon in assessing elevation of the first
metatarsal. Camasta studied metatarsus primus elevatus radiographically and classified it as either extrinsic (positional) or
intrinsic (structural). Extrinsic metatarsus elevatus is noted when the architecture of the first metatarsal is normal and there is
divergence between the first and second metatarsals. Intrinsic metatarsus elevatus occurs with divergence between the first
and second metatarsals and evidence of a structural abnormality within the first metatarsal. This is most commonly seen
postoperatively after a proximal
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or distal procedure for the correction of a hallux valgus deformity (50 ).
FIG. 8. Malunion after a previous closing base wedge osteotomy with sagittal plane elevation. In most instances, this
complication results from premature weight bearing.
FIG. 9. A,B: Dorsoplantar and lateral radiographs of a patient with a postoperative hallux varus deformity compounded by
a bone healing complication. Note the excessive callus formation and the shortening and elevation of the first metatarsal
head, in spite of the screw fixation.
Frontal plane malalignment may be difficult to evaluate. The forefoot axial view may reveal rotation of the metatarsal head.
Clinical correlation is essential to understanding this complex problem fully.
Conservative treatment modalities consist of shoe modifications, orthotic devices, and possibly alterations in activity. A balance
mold orthotic device may prove to be the most beneficial. A Morton extension on any type of orthotic device helps to increase
weight bearing to the first ray segment.
The surgical management of malunion deformities has two basic approaches. The first is geared toward recognition of the cause
of the problem with a goal of restoring normal architectural alignment, and thus function, of the first ray. In other cases, this
approach may not be realistic, and consequently a symptomatic approach may be appropriate. This section focuses primarily on
sagittal plane malunion. The reader is referred to the remainder of the chapter for transverse plane malunion deformities that
contribute to the recurrence of a hallux valgus or hallux varus deformity.
Any significant aberration in the length of the first metatarsal is appreciated, along with sagittal plane malunion. The excessive
shortening in combination with a metatarsus primus elevatus is more commonly seen after procedures performed in the
proximal portion of the first ray (base wedge osteotomy, first metatarsocuneiform arthrodesis, or first metatarsocuneiform
osteotomy). When excessive shortening is seen after a procedure that was not intended to accomplish this goal, it usually results
from a disturbance of the bone healing process. When reviewing postoperative radiographs to assess alignment and position, one
should also evaluate whether the osteotomy has progressed to a successful union. The presence of a radiolucent line, excessive
osteoporosis, or bone callus proliferation may suggest the need for further evaluation of the bone healing process.
Dorsal angulation may be seen after distal metaphyseal osteotomies; subtle transverse or frontal plane malalignment may also
be seen with the dorsal angulation. This problem may be treated by performing a plantarflexory osteotomy in the distal
metaphyseal area of the first metatarsal by using an opening wedge osteotomy with the apex plantar and the base dorsal, with
the insertion of a corticocancellous bone graft. An alternative is a closing plantarflexory osteotomy (base plantar, apex dorsal);
this effectively accomplishes plantargrade realignment of the capital fragment. The surgeon may also perform a V osteotomy in
a dorsal to plantar direction that also allows plantar displacement of the metatarsal head. The decision regarding which
osteotomy is more appropriate should be based on the surgeon's preference, on the amount of shortening of the first metatarsal,
and on the ability to restore normal range of motion and to avoid “jamming” of the joint with the procedure. In some cases, it is
simply not realistic to attempt correction if the deformation is severe. Alternative approaches including panmetatarsal
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head resection may unfortunately be necessary, depending on the individual patient.
Historically, postoperative metatarsus primus elevatus has been seen after a proximal osteotomy. Many of these cases are seen
in combination with a disturbed union process that eventually goes on to heal with a significantly shortened first metatarsal
segment. As previously mentioned, the primary goal of surgical treatment is the restoration of weight bearing to the first
metatarsal with preservation of the range of motion at the first metatarsophalangeal joint. Length may also need to be restored,
but one must be more careful in correcting this component of the deformity because lengthening beyond a certain point creates
jamming at the first metatarsophalangeal joint.
Once the base osteotomy has undergone complete healing from the first operation, revisional surgical treatment can be
attempted. Plantarflexion of the first metatarsal can be accomplished by several different means. One technique is a closing,
oblique plantarflexory osteotomy of the first metatarsal. A proximal dorsal cortical hinge is preserved. The base of the
osteotomy is plantar distal. One or two small cortical or, more commonly, cancellous bone screws may be effective for fixation
of the osteotomy.
A plantarflexory osteotomy oriented in a perpendicular relationship with the first metatarsal can also be performed at the base.
The apex is be dorsal and the base is plantar. Because of the architectural configuration of the first metatarsal base area,
adequate exposure can be difficult. Complete subperiosteal stripping around the entire proximal metaphyseal area of the bone
is necessary to execute this osteotomy in the proper location. The more proximal the location of the cortical hinge (for either
this osteotomy or the oblique osteotomy), the more effective is the radius-arm concept. Fixation of this type of osteotomy is
also more difficult. Crossing 0.062-inch Kirschner wires, small Steinmann pins, horizontal stainless steel cerclage wire, or staples
can be used for fixation.
In patients with excessive shortening of the first metatarsal segment and preservation of the range of motion at the first
metatarsophalangeal joint, an opening wedge osteotomy can be performed. This osteotomy requires a corticocancellous bone
graft. We recommend the use of autogenous bone. This may be procured from the body of the calcaneus for this procedure. This
approach provides cortical bone to prevent the osteotomy from collapsing and excellent cancellous bone to facilitate bone
healing. Autogenous calcaneal bone graft for reconstructive foot surgery has proved efficacious in a variety of settings (51 ).
An alternative to a plantarflexory osteotomy, which requires the preservation of a cortical hinge, is to reosteotomize the bone
through the original oblique osteotomy. The metatarsal is then rotated within the plane of the osteotomy itself and then
undergoes fixation. This technique is less technically demanding and can employ the principles of the hinge-axis concept to
resolve metatarsus primus elevatus successfully. In addition, the procedure can be modified to accomplish some restoration of
length as weight bearing is restored. If one needs to reduce the intermetatarsal angle, a wedge of bone can be removed in the
more traditional manner, the hinge can be sacrificed, and then the osteotomy can be rotated to correct for the elevatus
deformity.
A versatile means of addressing both sagittal plane and length problems of the first ray is with the sagittal Z osteotomy (52 ).
Because this is a through-and-through osteotomy, no hinge needs to be protected or preserved. This feature allows the surgeon
the opportunity to stabilize the osteotomy temporarily and to assess the overall position and alignment, then to readjust as
deemed necessary before the fixation process without compromising the osteotomy. The distal segment may be distracted to
restore length.
In some cases, a symptomatic approach may be appropriate. This is particularly true when one or more lesser metatarsal
osteotomies may have already been performed. For example, if the patient has had a previous second or third metatarsal
osteotomy, then it may be appropriate to treat the isolated transfer lesion by way of a lesser metatarsal osteotomy directed
toward relieving pressure under the prominent area. Other patients may have marked distortion of the entire transverse weight-
bearing arch of the forefoot, so panmetatarsal head resection may be the treatment of choice. Although this approach seems
aggressive, in some cases it is the most appropriate and efficient way to achieve resolution of symptoms and to salvage foot
function.
Delayed Unions and Nonunions
Definition, Incidence, and Causes

The definition of a delayed union, as opposed to a nonunion, is not without controversy. Taylor stated that the difference is
mostly in degree, and the time to unite a fracture site cannot be set arbitrarily. He further stated that union is delayed when
healing has not advanced at the average rate for the location and type of fracture (53 ,54 ). Mayer and Evarts referred to a
delayed union as one in which repair is not complete, spaces between the fracture are filled with granulation tissue (not scar
tissue), and clinical evidence indicates that healing is taking place. Rosen defined a nonunion as a failure to heal in 6 to 8
months and a delayed union as an absence of complete healing in 2 to 6 months (55 ). The Arbeitsgemeinschaft for
Osteosynthesefragen/Association for the Study of Internal Fixation (AO/ASIF) group classified a delayed union as a fracture that
is not united by 4 to 5 months from the time of injury (53 ).
Nonunion, conversely, was once defined by the United States Food and Drug Administration for the purposes of testing bone
healing devices. This diagnosis was established when a minimum of 9 months had elapsed from the time of injury and the
fracture had shown no visible progressive signs of healing for 3 months (53 ). The definition has changed significantly over time.
At one time, these definitions were used to justify the expense of using electrical bone
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stimulator devices for the treatment of nonunions. Today, the definition by the Food and Drug Administration has become more
generalized; a nonunion is considered to be established when no signs of progressive healing are visible on plain radiographs;
most physicians would agree that this definition is more suitable.
Nonunions have been classified based on their ability to heal conservatively with local vascularity at the site. A hypertrophic
nonunion occurs when a proliferative, well-vascularized bone reaction occurs at the fracture site. Usually, the interposed
fibrous tissue calcifies, ossifies, and eventually maturates. Hypertrophic nonunions are considered viable and are reportedly
more common after closed reduction of fractures. In hypertrophic nonunions, electrical stimulation is beneficial in the
conservative plan (56 ).
This finding is in contrast to atrophic nonunion, in which no local bone reaction occurs and the site is not well vascularized. This
situation occurs primarily after open reduction and internal fixation of fracture or osteotomy (53 ).
The temporal sequence that distinguishes a delayed union of the first metatarsal is not universally accepted. Naimark et al.
defined an osteotomy that was not healed by 4 months as delayed union, whereas other surgeons use 6 months as the
differentiating time. Mancuso et al. defined delayed union as a prolongation of secondary bone healing. However, this definition
excludes osteotomies that are healing by primary intention but fail to unite completely in the time anticipated. The review by
Mancuso et al. of 500 distal metaphyseal osteotomies with Kirschner wire fixation revealed only a single delayed union and no
nonunions when delayed union was defined as a lack of clinical or radiographic consolidation by 8 weeks, but occurring by 8
months postoperatively (46 ).
We recommend the following definitions. A union should be considered delayed when clinical symptoms and radiographic
findings suggest a healing process slower than expected for the type and location of osteotomy performed. The presence of
inappropriate pain and swelling is usually the first sign of a delayed union. At this time, further radiographic investigation is
needed to substantiate the diagnosis. However, radiographic studies may be equivocal with respect to the clinical findings, and
clinical symptoms are more important than radiographic manifestations. With appropriate treatment, a delayed union may go on
to a successful osseous union. A nonunion with clinical symptoms and persistent radiographic evidence is consistent with an
improbability to heal. To distinguish a nonunion, at least 6 months should elapse from the initial surgical procedure, and in
general, the diagnosis is made between 8 and 12 months. However, the time to initiate therapy can be more expeditious, given
newer philosophies and definitions of nonunion in bone.
A delayed union or nonunion is considered asymptomatic when the clinical findings do not suggest a disturbance of the bone
healing process, but conventional radiographs show marked disturbance of the union process and findings consistent with a
nonhealing osteotomy. An asymptomatic nonunion may or may not require intervention.
Nonunions of the first metatarsal fortunately are not common. Jones et al. retrospectively reviewed more than 300 hallux
abducto valgus procedures and reported only 2 nonunions (41 ). Austin, in his original article, reported no nonunions of the
chevron osteotomy in which no fixation was employed. The review by Mancuso et al. revealed no nonunions in more than 500
procedures (46 ).
Basilar osteotomies are more commonly associated with malunion, but, once again, nonunion is rare overall. In Mann and
Coughlin's series of more than 250 crescentic osteotomies fixed by the use of Kirschner wires or screws, only a single nonunion
was reported (3 ). Other authors have indicated that the frequency of nonunions after a first metatarsal osteotomy is low, even
when there is no fixation and early weight bearing is permitted (57 ,58 ).
Certain factors contribute to the development of a delayed union or nonunion. Systemic factors including pregnancy, iron
deficiency anemia, diabetes mellitus, corticosteroids, and irradiation have been implicated. However, the primary cause
appears to arise from local factors (53 ). These factors include infection, interruption of blood supply, lack of contact between
bone ends, inadequate immobilization, and actual loss of bone substance. In addition, early aggressive ambulation, thermal
osteonecrosis, inadequate or improper fixation, disruption of the fixation, and soft tissue stripping at the osteotomy site may
also contribute to the development of a delayed union or nonunion process.
Although delayed union or nonunion can occur in any patient at any time without identification of any specific inciting event or
reason for the disturbed healing process, the overall incidence is still extremely low. Particular care should be placed on the
risks versus gains of weight bearing; it is common practice to maintain patients with a basilar osteotomy in a non-weight-bearing
attitude for approximately 6 to 7 weeks, whereas distal metaphyseal osteotomies can usually be weight bearing. Even then,
some distal metaphyseal osteotomies (Mitchell or Roux) are inherently more unstable by the nature of the osteotomy alone, and
consequently patients should be non-weight bearing unless the type of fixation is capable of supporting and withstanding the
stresses generated by weight bearing. Finally, monitoring of patients after surgery by clinical and radiographic assessment
further reduces the incidence of a bone healing complication.

Most surgeons would agree that a delayed union is associated with clinical symptoms. Nonunions, conversely, have varying
degrees of symptoms. Although some patients have profound clinical symptoms throughout the entire period of the disturbed
bone healing process, others are asymptomatic.
Investigators have estimated that up to 50% of nonunions involving the first metatarsal are asymptomatic (4 ). The clinical
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signs and symptoms may include pain and edema, induration, clinical motion, and instability at the osteotomy site. Increased
warmth may also be present. Patients may report difficulty with weight bearing, especially on the affected area, and they
consequently develop metatarsalgia resulting from a compensatory gait pattern. Difficulty with wearing conventional shoe gear
is not uncommon. In some cases, these clinical signs and symptoms may suggets an infectious process. If the physician is highly
suspicious of an infectious process associated with the bone healing complication, then further investigation by specialized
studies or, more appropriately, a bone biopsy may be necessary.
Serial radiographs usually identify a disturbed bone healing process. Evaluation is focused on subtle alterations and disturbances
of alignment and healing. Increased radiolucency or resorption at the osteotomy site, loosening and migration of internal
fixation devices, secondary bone callus formation, and increased soft tissue volume and density may be seen in early cases of a
delayed union or nonunion process. Subtle or overt changes in the alignment and position of the osteotomy indicate that
undesirable motion is taking place and contribute to a delayed union or a nonunion. In some cases, obvious failure of the
internal fixation device is seen; fracture of a screw or pin may only be seen on one of three views, a finding emphasizing the
need for careful evaluation of each view.
When an osteotomy has failed to go on to a successful union within a reasonable time after surgical treatment, then further
radiographic investigation may be considered. Radionuclide imaging studies are often used to help classify the type of disturbed
healing process (59 ). A conventional technetium bone scan helps in classifying the nonunion as hypertrophic or viable or as
atrophic and nonviable. In some cases, bone scan results are indeterminate. Radionuclide imaging studies or other ancillary
imaging should not be used as a substitute for clinical acumen or, when necessary, the current standard of bone biopsy.
Finally, a magnetic resonance imaging study or computed tomography scan may further help to delineate a nonunion process.
The presence of internal fixation devices may significantly alter the quality and reliability of such imaging studies. One should
also be aware of the lack of experience in the interpretation of lower extremity imaging by many radiologists.
Delayed union and nonunion of bone can be treated conservatively or surgically. The decision regarding the approach to
undertake depends on several factors. Although the viability of the bone, and thus the ability to treat a bone healing
complication by noninvasive means, may be readily ascertained from radiographs, this is only one factor in the clinical decision-
making process. More important than radiographic findings are the clinical implications of the bone healing process. If one notes
significant alteration in the alignment and position of the bone, then consideration should be given to a more aggressive
treatment approach. This may mean manipulation with administration of local or general anesthesia to restore the alignment
and position or surgical intervention to accomplish the same. It is an exercise in futility to spend up to 6 months with
conservative treatment modalities only to end up with a severe malunion. When the alignment and position are satisfactory,
then conservative treatment modalities are appropriate and should result in nearly full functional recovery.
Conservative treatment modalities consist primarily of immobilization and non-weight bearing, with or without the use of
noninvasive electrical bone stimulation. A severe delayed union may require as long as 4 to 6 months to respond to this
treatment approach.
When significant malunion is present, it is likely to result in a significant negative impact on foot function. Therefore, surgical
intervention should be considered. In cases of delayed union, the osteotomy should be repositioned and restabilized. When
possible, rigid internal compression fixation modalities should be employed. If the bone substance is tenuous, then stable
internal fixation may be achieved by conventional fixation techniques such as stainless steel wire, staples, or large Kirschner
wires or Steinmann pins. In some instances, external fixation may prove more efficacious if the bone segments are compromised
and cannot support internal fixation devices. If a small bone deficit exists, this may require grafting. Autogenous bone procured
from the calcaneus would be an excellent source, although the ileum and distal tibia are also good sources for autogenous
corticocancellous bone grafts. Demineralized bone matrix may also prove valuable.
The treatment of frank nonunion depends on the type and location, as well as the size of the involved nonunion fragments. In
some cases, excision of nonunion fragment may be the best and most realistic alternative treatment. An example is a distal
osteotomy (i.e., Reverdin-type procedure) that has developed a complete nonunion. These patients have insufficient viable
cartilage on the distal fragment to warrant repair of the defect. Excision of the fracture fragment alone or in combination with
arthrodesis or implant arthroplasty may be the best approach.
Most nonunions of the first metatarsal warrant preservation of the bone and repair of the nonunion site. Depending on the
amount of nonviable bone and the extent of shortening that has already occurred, bone grafting may or may not be necessary.
In all cases, the nonunion site should be resected. In some cases, this can be accomplished by simply passing the saw blade
through the original osteotomy site several times and planing the original osteotomy or nonunion site until viable bleeding bone
is visualized. If sufficient length of the metatarsal has been preserved, then the fragments can be placed in their desired
anatomic position, and appropriate fixation can be achieved.
Although resection of the nonunion itself with or without bone grafting is likely to result in healing at the nonunion
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site, this in and of itself does not ensure resolution of pain and restoration of function. A more normal alignment and position
may need to be restored as well. In some cases, malalignment is present in only one plane (sagittal plane or transverse plane),
whereas in other cases, an equal amount of deformity is present in two planes. Multiple planar deformities can be extremely
difficult to correct. In addition to resection of the nonunion of the nonunion site itself, the surgeon must devise a mechanism for
restoration of alignment. When a bone graft will be used, the surgeon often must spend considerable time fashioning the graft
to achieve multiplanar correction (Fig. 10 ). Intraoperative radiographs are helpful in such cases.
FIG. 10. A: Dorsoplantar radiograph of a patient with nonunion of the first metatarsal osteotomy. Note the callus
formation and radiolucency. Significant clinical symptoms were also present. B: Lateral radiograph of the same patient.
Note the severe metatarsus primus elevatus, as well as the malalignment of the first metatarsophalangeal joint. The distal
osteotomy of the first metatarsal healed. C: Intraoperative appearance after resection of the nonunion site. Note the
presence of sclerotic bone. Aggressive drilling was performed. The plantar cortex was preserved to provide some inherent
stability and to serve as a hinge for correction of the sagittal plane malalignment. The laminar spreader is maintaining in
plantarflexed position of the first metatarsal before insertion of the bone graft. D: Insertion of autogenous tricortical iliac
crest graft with fixation by Kirschner wire and one-third tubular plate with multiple screws. Postoperative dorsoplantar (E)
and lateral (F) radiographs after excellent healing and incorporation of bone graft. Correction of the metatarsus primus
elevatus was achieved as well as restoration of length. Dorsoplantar (G) and lateral (H) radiographs 3 years
postoperatively. Because of stress across the metatarsocuneiform joint, the plate failed and was subsequently removed.
The retained portion of the screw within the medial cuneiform remained asymptomatic.
In some cases, aggressive major resection of bone is necessary. These patients require autogenous bone grafting. The iliac crest
provides excellent tricorticocancellous grafts with a combination of stability and osteoinductive bone. More recently,
autogenous calcaneal bone has proven to be an excellent source of bone graft for repair of nonunions of the first metatarsal
(51 ,60 ). In some instances, callus distraction techniques may also be employed to restore length to the first metatarsal when
shortening is significant (Fig. 11 ).
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FIG. 10. Continued.

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FIG. 11. A: Clinical appearance after surgical procedures of the first ray and both feet. The patient's right foot developed
a severe nonunion with a severely dorsiflexed hallux resulting from proximal retraction. B: Dorsoplantar radiograph of the
same patient. Note the obvious frank nonunion of a previous distal metaphyseal osteotomy 1½ years later. C: Clinical
photograph showing the miniature external fixator that was used for distraction osteogenesis for the first stage of surgery.
D: Oblique radiograph of same after successful lengthening. Note the early callus formation. E: Dorsoplantar radiograph of
the same patient after removal of the internal fixator. F: Dorsoplantar radiograph showing angular deformity of the first
metatarsal resulting from weakness of the medial cortex after successful distraction osteogenesis. G: Stage II surgery
consisting of first metatarsophalangeal joint arthrodesis and stabilization of the first metatarsal using a one-third tubular
plate. The deformity of the first metatarsal is readily corrected by simply passing a surgical blade through the soft bone
area and applying a plate. Note restoration of length compared with the preoperative radiograph. H: Final clinical
appearance of the same patient 1½ years postoperatively.
In some cases, the surgical procedure can be augmented by the use of noninvasive or implantable electrical bone
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stimulation (61 ). The effects of electrical stimulation on bone healing are well known and proven, although their specific use
and success with respect to nonunion or delayed unions of osteotomy sites within the foot have not been reported.
FIG. 11. Continued.
Although some differences in the management of patients may depend on the type of surgical procedure performed, most
patients require a non-weight-bearing period of 8 to 12 weeks. The extent of non-weight bearing depends primarily on the
radiographic evidence of bone healing. This
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is particularly important when bone grafting procedures have been performed. When adequate radiographic consolidation is seen, patients are permitted partial weight bearing for a 1- to 2-week period. Patients then progress to
full weight bearing. Serial radiographs are taken throughout the postoperative course.
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16. Yu GV, Dinapoli DR. Surgical management of hallux abducto valgus with concomitant metatarsus adductus. In: McGlamry ED, ed. Reconstructive surgery of the foot and leg: update ′87. Tucker, GA: Podiatry Institute,
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21. Banks AS, Hsu Y, Mariash S, et al. Juvenile hallux abducto valgus association with metatarsus adductus. J Am Podiatr Med Assoc 1994;84:219-224.
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24. Richardson EG. Complications after hallux valgus surgery. Instr Course Lect 1999;48:331-342.
25. McBride ED. The conservative operation for “bunions”: end results and refinements of technique. JAMA 1935;105:1164-1168.
26. Feinstein MH, Brown HN. Hallux adductus as a surgical complication. J Foot Surg 1980;19:207-211.
27. Hawkins FB. Acquired hallux varus: cause, prevention and correction. Clin Orthop 1971;76:169-176.
28. Janis LR, Donick II. The etiology of hallux varus: a review. J Am Podiatr Med Assoc 1975;65:233-237.
29. Peterson DA, Zilberfarb JL, Greene MA, et al. Avascular necrosis of the first metatarsal head: incidence in distal osteotomy combined with lateral soft tissue release. Foot Ankle Int 1994;15:59-63.
30. Trnka HJ, Zetti R, Hungerford M, et al. Acquired hallux varus and clinical tolerability. Foot Ankle Int 1997;18:593-597.
31. Zinsmeister BJ, Griffin JM, Edelman R. A biomechanical approach to hallux varus. J Am Podiatr Med Assoc 1985;75:613-615.
32. Boike AM, Christin G. Hallux varus. In: Hetherington VJ, ed. Hallux valgus and forefoot surgery. New York: Churchill Livingstone, 1994:307-311.
33. Martin DE, Phillips AJ, Ruch JA. Intra-operative decision making in hallux valgus surgery. In: McGlamry ED, ed. Reconstructive surgery of the foot and leg: update ′89. Tucker, GA: Podiatry Institute, 1989:1-14.
34. Miller JW. Acquired hallux varus: a preventable and correctable disorder. J Bone Joint Surg Am 1975;57:183-188.
35. Banks AS, Ruch JA, Kalish SR. Surgical repair of hallux varus. J Am Podiatr Med Assoc 1988;78:339-347.
36. Edelman RD. Iatrogenically induced hallux varus. Clin Podiatr Med Surg 1991;8:367-382.
37. Youngswick FD. Iatrogenic hallux varus. In: Gerbert J, ed. Textbook of bunion surgery, 2nd ed. Mount Kisco, NY: Futura, 1991:493-508.
38. Bilotti MA, Capriola R, Testa J. Reverse Austin osteotomy for correction of hallux varus. J Foot Surg 1987;26:51-55.
39. Clark WD. Abductor hallucis tendon transfer for hallux varus. J Foot Surg 1984;23:146-148.
40. Greenfogel SI, Glubo S, Werner J, et al. Hallux varus: surgical correction and review of the literature. J Foot Surg 1984;23:46-50.
41. Jones KJ, Feiwell LA, Freedman EL, et al. The effects of chevron osteotomy with lateral capsular release on the blood supply to the first metatarsal head. J Bone Joint Surg Am 1995;77:197-204.
42. Kimizuka M, Miyanaga Y. The treatment of acquired hallux varus after the McBride procedure. J Foot Surg 1980;19:135-138.
43. Wood WA. Acquired hallux varus: a new corrective procedure. J Foot Surg 1981;20:194-197.
44. Rochwerger A, Curvale G, Groulier P. Application of bone graft to the medial side of the first metatarsal head in the treatment of hallux varus. J Bone Joint Surg Am 1999;81:1730-1735.
45. Randolph TJ, Vogler H. Nonunions, and delayed unions. J Foot Surg 1985;24:62-67.
46. Mancuso JE, Abramow SP, Bloom WB, et al. Smooth Kirschner (K) wire fixation of distal metaphyseal osteotomy bunionectomies: a 10-year retrospective survey. J Foot Surg 1992;31:276-284.
47. Grabe RP, deJongh AGV, Van Papaendorp D. The chevron osteotomy in the treatment of hallux valgus-scientic paper. J Bone Joint Surg Br 1990;72:744.
48. Mann RA, Rudicel S, Graves SC. Repair of hallux valgus with a distal soft tissue procedure and proximal metatarsal osteotomy. J Bone Joint Surg Am 1992;74:124-129.
49. Broughton NS, Winson IG. Keller's arthroplasty and Mitchell osteotomy: a comparison with first metatarsal osteotomy of the long-term results for hallux valgus deformity in the younger female. Foot Ankle Int
1990;10:201-205.
50. Camasta CA. Radiographic evaluation and classification of metatarsus primus elevatus. In: Camasta CA, Vickers NS, Ruch JA, eds. Reconstructive surgery of the foot and leg: update ′94. Tucker, GA: Podiatry Institute,
1994:122-127.
51. Mahan KT, Hillstrom HJ. Bone grafting in foot and ankle surgery: a review of 300 cases. J Am Podiatr Med Assoc 1998;88:109-118.
52. Cicchinelli LD, Camasta CA, McGlamry ED. Iatrogenic metatarsus primus elevatus: etiology, evaluation, and surgical management. J Am Podiatr Med Assoc 1997;87:165-177.
53. Mayer PJ, Evarts CM. Nonunion, delayed union, malunion, and avascular necrosis. In: Epps Jr CH, ed. Complications in orthopaedic surgery, vol 1, 2nd ed. Philadelphia: JB Lippincott, 1986.
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54. Taylor JC. Delayed union and nonunion in fractures. In: Crenshaw A, ed. Campbell's operative orthopedics, vol 2, 8th ed. St. Louis: CV Mosby,
1992.
55. Rosen H. Nonunion and malunion. In: Browner BD, Jupiter JB, Levine A, et al., eds. Skeletal trauma. Philadelphia: WB Saunders, 1992.
56. Donley BG. Current topic review: acquired hallux varus. Foot Ankle Int 1997;18:586-592.
57. Farham MJ. Distal metatarsal osteotomy for hallux valgus. Foot 1992;1:179-183.
58. Grace DL. Metatarsal osteotomies: which operation? J Foot Surg 1987;26:46-50.
59. Jacobs AM, Klein S, Oloff L, et al. Radionuclide evaluation of complications after metatarsal osteotomy and implant arthroplasty of the foot. J
Foot Surg 1984;23:86-96.
60. Mahan KT. Bone graft materials and perioperative management. In: Camasta CA, Vickers NS, Carter SR, eds. Reconstructive surgery of the foot
and leg: update ′95. Tucker, GA: Podiatry Institute, 1995:69-71.
61. Downey MS. Clinical application of an implantable direct current bone growth stimulator. In: Camasta CA, Vickers NS, Carter SR, eds.
Reconstructive surgery of the foot and leg: update ′95. Tucker, GA: Podiatry Institute, 1995:88-93.
SELECTED READINGS
Camasta CA, Pontious J, Boyd RB. Quantifying magnification in pedal radiographs. J Am Podiatr Med Assoc 1991;81:545-548.
Badeway TM, Dutkowsky JP, Graves SC, et al. An anatomical basis for the degree of displacement of the distal chevron osteotomy in the treatment
of hallux valgus. Foot Ankle Int 1997;18:213-215.
Bar-David T, Trepal MJ. A retrospective analysis of distal chevron and basilar osteotomies of the first metatarsal for correction of intermetatarsal
angles in the range of 13 to 16 degrees. J Foot Surg 1991;30:450-456.
Crenshaw A. Campbell's operative orthopedics, vol 1. St. Louis: CV Mosby, 1974:761.
Downey MS. First MTPJ arthrodesis for salvage of failed HAV surgery. In: Vickers NS et al., ed. Reconstructive surgery of the foot and leg: update
Farmer AW. Congenital hallux varus. Am J Surg 1958;95:274-278.
Freund EI. Capsular closure after hallux valgus surgery. Foot Ankle Int 1999;20:137.
Granberry WM, Hickey HC. Idiopathic adult hallux varus. Foot Ankle Int 1994;15:197-205.
Johnson KA, Spiegl PV. Extensor hallucis longus transfer for hallux varus deformity. J Bone Joint Surg Am 1984;66:681-686.
Joseph B, Jacob T, Verghese C. Hallux varus: a study of thirty cases. J Foot Surg 1984;23:392-397.
Joseph B, Vergnese C, Abraham T, et al. Pathomechanics of congenital and acquired hallux varus: a clinical and anatomical study. Foot Ankle Int
1987;8:137-143.
Kitaoka HB, Patzer RN. Salvage treatment of failed hallux valgus operations with proximal first metatarsal osteotomy and distal soft-tissue
reconstruction. Foot Ankle 1998;19:127-131.
Mahan KT. Management of delayed unions and nonunions. In: Camasta, CA, Vickers NS, Carter SR, eds. Reconstructive surgery of the foot and leg:
update ′95. Tucker, GA: Podiatry Institute, 1995:94-97.
McBride ED. The surgical treatment of hallux valgus bunions. Am J Orthop 1963:44-46.
Merkel KD, Katoh Y, Johnson EW, et al. Mitchell osteotomy for hallux valgus: long-term follow-up and gait analysis. Foot Ankle 1983;3:189-196.
Naimark A, Miller K, Segal D, et al. Nonunion. Skeletal Radiol 1978;6:21.
Resch S, Stenstrom A, Reynisson K, et al. Chevron osteotomy for hallus valgus not improved by additional adductor tenotomy: a prospective,
randomized study of 84 patients. Acta Orthop Scand 1994;65:541.
Talbot KD, Saltzman CL. Assessing sesamoid subluxation: how good is the AP radiograph? Foot Ankle Int 1998;19:547-554.
Thomson SA. Hallux varus and metatarsus varus: a five year study (1954-1958). Clin Orthop 1960;16:109-118.
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Chapter 15
Hallux Limitus and Hallux Rigidus
Thomas J. Chang
Craig A. Camasta
Hallux limitus and hallux rigidus are diagnostic terms that describe a painful, acquired, arthritic condition of the first
metatarsophalangeal joint that is characterized by inadequate sagittal plane mobility of the hallux. Aside from hallux valgus, no
other condition affecting this joint has received more attention in surgical journals and texts (1 ). Dorsal bunion (2 ), hallux
flexus (3 ), hallux equinus (4 ), hallux limitus (5 ), hallux rigidus (6 ), hallux dolorosus (7 ), and metatarsus primus elevatus (8 )
are all terms that have been used to describe this condition. The natural history appears to be multifactorial, and various
associated factors have been implicated in the origin, but repetitive trauma to the joint is a universally accepted causative
factor (3 ,9 , 10 , 11 , 12 ).
Hallux limitus and hallux rigidus are clinical terms that are vaguely differentiated, based on the degree of joint immobility and
arthritis, with no clearly defined clinical or diagnostic benchmark that separates the two terms. In general, hallux limitus is a
precursor state in the progression to hallux rigidus (11 ,13 ). Hallux rigidus is the end-stage form of arthritis that approaches
bony ankylosis of the first metatarsophalangeal joint. More specifically, the primary factor that differentiates hallux limitus
from hallux rigidus in most circumstances is sesamoid mobility. Hallux rigidus is most often characterized by functional ankylosis
of the sesamoids to the plantar surface of the first metatarsal.
Lapidus first categorized hallux rigidus based on four etiologic factors: hallux rigidus, paralytic deformities (flaccid and spastic),
congenital clubfoot, and severe congenital talipes planovalgus (2 ). Root et al. attributed hallux limitus to a long first metatarsal,
hypermobility of the first ray, immobilization of the first ray, metatarsus primus elevatus, degenerative joint disease, and
trauma (14 ). Nilsonne categorized primary hallux rigidus as developing in adolescent patients with localized degenerative
changes and characterized secondary hallux rigidus as a long-standing effect of osteoarthritis (15 ). Several authors have
proposed osteochondritis dissecans as a causative factor (16 ,17 ), whereas others believe that hallux limitus precedes
osteochondral damage (18 ).
Investigators have implied that normal gait requires 65 to 75 degrees of dorsiflexion at the first metatarsophalangeal joint
(14 ,19 ,20 ). This observation was based on studies of total range of motion, by measuring excursion limits of dorsiflexion and
plantarflexion (21 ). However, Hetherington et al. found that the mean range of motion of the first metatarsophalangeal joint
during the contact phase of gait was 31.54 degrees in 12 disease-free patients (22 ). This is less than half of what was previously
reported as “essential” for normal function. Therefore, some discrepancy may exist between the total range of motion at the
first metatarsophalangeal joint and the actual range required for normal ambulation. In addition, the required range of motion
is likely to vary among patients and with different activity patterns.
CLINICAL FEATURES
Pain is the most frequent symptom in patients with hallux limitus and hallux rigidus, although various compensatory findings
accompany arthritic symptoms of the first metatarsophalangeal joint. Whereas hallux valgus is often more painful with shoe
pressure, hallux limitus and hallux rigidus may be equally painful when the patient is unshod as well, although certain shoes may
create strain on the joint, depending on the patient's activity (1 ). Pain in the arthritic first metatarsophalangeal joint is
aggravated by activity and footwear that stress-loads and results in impingement of the dorsal aspect of the joint. The degree of
discomfort usually is correlated with the level of activity, and it progressively increases throughout the day. With time, a dorsal
exostosis typically develops at the first metatarsal head such that direct shoe pressure may exacerbate the pain or may lead to
hyperkeratosis. In addition, nerve impingement secondary to chronic pressure can result in paresthesias that radiate distally to
the dorsal hallux.
Stiffness of the great toe results in alteration of gait that can transfer load to adjacent joints and can thereby affect the
position and function of the foot. Therefore, some patients with hallux limitus may not initially complain of pain
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at the first metatarsophalangeal joint if compensatory mechanisms have developed to reduce stress at this level. Associated
findings may include pain or pressure-induced hyperkeratoses adjacent to bony prominences, second metatarsophalangeal joint
(11 ), lateral column (23 ), and plantar aspect of the hallux interphalangeal joint (Fig. 1 ). In particular, one may note a
hyperextension or increased dorsiflexion at the hallux interphalangeal joint as the body attempts to achieve the necessary
dorsiflexory motion at this level. The skin beneath the first metatarsophalangeal joint is usually spared weight-bearing pressure,
and it is often supple, with little evidence of hyperkeratosis (2 ).
FIG. 1. Pressure-induced hyperkeratosis (tyloma) of the plantar aspect of the hallux interphalangeal joint. This is a
common finding in patients with hallux limitus.
Dannanberg discussed several compensatory mechanisms seen with hallux limitus, including the following: “Lowering of the
medial longitudinal arch of the foot is related to the inability of the hallux to extend” (24 ). If dorsiflexion of the hallux is not
sufficient, then retrograde pressure may be directed along the medial osseous structures and soft tissues. Dorsally, compressive
forces predominate, whereas plantarly, distraction stresses are evident. Arthritic symptoms may develop at the
metatarsocuneiform level initially. Plantar joint pain, plantar fasciitis, or arch strain may be other associated complaints.
Conversely, these are conditions may possibly indicate an initial medial column instability, which leads to secondary hallux
limitus. Each of these conditions tends to perpetuate the other.
Gait variations have also been described in conjunction with hallux limitus (24 ). Forefoot inversion provides two potential
means of compensation. If sufficient weight-bearing stress to the first metatarsal is relieved, the peroneus longus may be able
to achieve a relative functional superiority and appropriately plantarflex and stabilize the metatarsal. Forefoot inversion may
also allow the patient to complete toe off by rolling weight off the lateral metatarsals and eliminating the medial column from
weight transfer. The same lateral transfer of weight may be accomplished by adducting the foot.
Depending on the degree of compensation required, the symptoms of hallux limitus may range from diffuse lesser metatarsalgia
to more discrete symptoms plantar to the fifth metatarsal head. At times, the hyperkeratosis may be located beneath the fourth
metatarsal head if the fifth ray is hypermobile. Other findings may include a heloma molle in the fourth web area or complaints
of lateral subtalar, lateral ankle, or lateral knee pain.
Another compensatory mechanism is premature lift off. The normal stance weight transfer from heel to metatarsal head to toes
is bypassed as the hallux automatically avoids dorsiflexion. Consequently, the toes are lifted off the ground before the
metatarsal heads, a process that disrupts efficient energy flow and contributes to digital contractures.
The final means of compensation for hallux limitus is seen most commonly in the geriatric population and consists of vertical toe
off with an apropulsive gait. This is an inefficient gait pattern, which results in increased muscular output, fatigue and an
increased ratio of double to single limb support.
Examination of the patient's shoes may reveal a distinct wear pattern that reflects the long-standing nature of this condition
(11 ). Because of restricted motion within the first metatarsophalangeal joint, pressure is transferred to the hallux
interphalangeal joint. The typical shoe wear pattern in patients with hallux limitus or rigidus may be concentrated beneath the
second metatarsophalangeal joint and hallux interphalangeal joint (Fig. 2 ). One may see an accentuated oblique angulation at
the shoe break that reflects the altered position of the foot in propulsion (3 ,11 ,23 ).
Numerous different means of assessing first metatarsophalangeal joint mobility have been described, and techniques may vary
among examiners. This situation makes comparison of data in studies and in the clinical setting difficult in some instances. Care
should be taken to assess the first metatarsophalangeal joint independent of the interphalangeal joint, which may be
hyperextended or mobile as a result of compensation for metatarsophalangeal immobility. Regardless of the technique
employed, evaluating the range of motion in both a relaxed and a loaded manner may prove helpful in more accurately assessing
the functional capacities of the first metatarsophalangeal joint. In some patients, limitation of joint mobility is noted only in
the loaded or functioning position, whereas the same evaluation in the relaxed position may demonstrate good range of motion.
This entity, termed functional hallux limitus (24 ), often precedes the fixed limitation of mobility or arthritic findings that
characterize the advanced forms of hallux limitus and rigidus. Symptoms with functional hallux limitus may be the same
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or similar to those in patients with more fixed limitation of motion. Therefore, if the patient possesses functional hallux limitus,
a cursory evaluation may lead the examiner to believe that mobility of the first metatarsophalangeal joint is adequate or normal,
when instead there is a problematic limitation of motion during gait.
FIG. 2. Shoe wear pattern in an asymptomatic patient with hallux limitus. Note the weight transfer from the second
metatarsophalangeal joint to the hallux interphalangeal joint.
Stance and gait observations may reveal several characteristic findings common to hallux limitus and hallux rigidus. In stance,
the hallux may be plantarflexed relative to the first metatarsal, thus accentuating the dorsal prominence of the first metatarsal
head (dorsal bunion) (Fig. 3 ). In gait, the point of ground contact through the first ray may be the interphalangeal joint of the
hallux, which hyperextends to accommodate propulsion (2 ,11 ).
FIG. 3. The dorsal bunion, which is a combination of a plantarflexed proximal phalanx and a dorsiflexed first metatarsal.
ETIOLOGY
Pes Valgus Deformity

The most commonly associated condition encountered with hallux limitus or rigidus is flexible pes planovalgus deformity
(8 ,25 ,26 ), which is characterized by hypermobility of the first ray (9 ). The flexible pes valgus undergoes compensation in all
planes of motion, and the predominant plane of compensation determine whether a patient will develop an associated hallux
valgus or hallux limitus or rigidus deformity. Transverse and frontal plane compensation predisposes to the development of a
hallux valgus deformity, whereas sagittal plane compensation predisposes to the development of a hallux limitus or rigidus
deformity. Repetitive contracture of the flexor hallucis brevis muscle, in an attempt to stabilize the medial column, leads to
plantarflexion of the proximal phalanx on the first metatarsal. In open-chain kinetics, range of motion of the first
metatarsophalangeal joint is initially unrestricted, whereas the “loaded” weight-bearing closed-chain kinetic motion is
restricted in the direction of dorsiflexion. Initially, the reduction in motion is appreciated only in the functional attitude, that
being with weight bearing or simulated weight bearing. If one evaluates the range of motion of the first metatarsophalangeal
joint at this stage in a non-weight-bearing, relaxed position, then full pain-free mobility is typically present. However, if the
foot is loaded and the motion is evaluated, a reduction in mobility will be noted, indicative of the early contracture of the
plantar tissues. This condition was termed functional hallux limitus by Dannanberg (24 ). Patients may present with symptoms
consistent with hallux limitus, yet without gross changes in the joint or surrounding osseous structures and with an apparently
normal range of motion on initial evaluation.
As the condition persists, adaptive changes occur within the joint, and arthrosis results from repetitive impingement of the two
adjacent articular surfaces. This observation has been termed flexor stabilization of the hallux and is analogous to a flexor
stabilization hammer toe, both of which can coexist in the same patient (27 ). In this description of hallux limitus or rigidus, the
distal phalanx is relatively dorsiflexed on the proximal phalanx, whereas the proximal phalanx is relatively plantarflexed on the
first metatarsal. Analogous osseous positions occur in a lesser digit hammer toe, with the proximal phalanx of the hallux
corresponding to the middle phalanx of a lesser digit and the first metatarsal corresponding to the proximal phalanx of a lesser
digit.
Length Pattern Aberrations

Several associations have been made between hallux limitus or rigidus and the length of the osseous segments that
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make up the first ray and its relation to the lesser tarsus. A long first metatarsal may lead to excessive loading of the joint and
eventual adaptive or degenerative changes (12 ,15 ,26 ,28 ). Paradoxically, a short first metatarsal may also serve as an indirect
source of hallux limitus (29 ,30 ). Patients with a short first metatarsal may experience lesser metatarsalgia and may “grip” the
ground with the hallux in an attempt to reduce the symptoms in the lateral forefoot. Over time, this hyperactivity of the flexor
hallucis brevis may lead to adaptive contracture and eventual loss of motion. Likewise, any condition that creates lesser
metatarsalgia may similarly lead to a hallux limitus regardless of the length of the first metatarsal. Retrograde pressure from a
long proximal phalanx against the first metatarsophalangeal joint has also been proposed as another cause of hallux limitus (31 ).
Uncompensated Varus Deformity

Uncompensated frontal plane inversion, regardless of the level of occurrence, prevents the forefoot from contacting the ground
in midstance and propulsion. Varus deformities can occur at any level, including the knee, leg, ankle, rearfoot, or forefoot.
Sagittal plane elevation of the medial column prevents the first metatarsal head from bearing full weight, and compensation
occurs within the first metatarsophalangeal joint through plantarflexion of the proximal phalanx on the first metatarsal (8 ). The
hallux thereby assumes a position of equinus (hallux equinus) relative to the first metatarsal (27 ). Contracture of the flexor
hallucis brevis muscle allows the hallux to contact the ground and to bear weight through the hallux interphalangeal joint (2 ).
Over time, the first metatarsophalangeal joint becomes fixed in equinus, and arthrosis follows, as previously described.
A varus deformity leading to hallux limitus or rigidus can occur in congenital conditions such as a forefoot varus, uncompensated
or partially compensated rearfoot varus, or residual clubfoot, in acquired conditions such as a tarsal coalition or peroneal
spastic flatfoot, or after a malpositioned proximal fusion, the most common of which includes ankle, pantalar, subtalar, or
triple arthrodesis (32 ).
Postsurgical Complications
Malunion of a first metatarsal osteotomy, most commonly seen after bunion surgery, can lead to sagittal plane elevation or
excessive shortening of the first metatarsal bone (33 ). This condition most commonly occurs after displacement of a proximal
metatarsal osteotomy (Fig. 4 ). However, it can also be observed in distal metaphyseal osteotomies (Fig. 5 ). In essence,
postoperative metatarsus primus elevatus is a localized form of forefoot varus that occurs within the architectural structure of
the first metatarsal bone.
Hallux limitus can also occur after hallux abducto valgus surgery. Limited motion may ensue after any reconstructive procedure
involving a joint, and limited dorsiflexion can occur after bunion surgery in the absence of any specific untoward events,
depending on the degree of capsular adhesions and scarring. Other factors that contribute to hallux limitus or rigidus formation
after bunion surgery may include infection, avascular necrosis, displacement or migration of the internal fixation, and various
host-dependent factors such as increased age, history of hypertrophic or keloid scar formation, or one of the many connective
tissue diseases.
FIG. 4. Malunion of a dorsally displaced proximal first metatarsal osteotomy with intrinsic metatarsus primus elevatus.
Trauma and Arthrosis

Injuries to the first metatarsal or first metatarsophalangeal joint can predispose to hallux limitus or rigidus. Malunited fractures
of the first metatarsal bone with sagittal plane elevatus lead to findings similar to those associated with the iatrogenic type of
metatarsus primus elevatus (Fig. 6 ), whereas intraarticular fracture-dislocations of the first metatarsophalangeal joint can
result in traumatic arthritis (Fig. 7 ). Bingold (11 ) described fragmentation and bony sclerosis of the basal epiphysis of the
proximal phalanx in adolescent patients with painful hallux rigidus and related this to stubbing or crushing injuries of the hallux
and poor fitting footwear. Various acquired arthritic conditions, including gout,
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psoriatic arthritis, and rheumatoid arthritis, have been implicated (34 ).
FIG. 5. Iatrogenic hallux limitus with intrinsic metatarsus primus elevatus after displacement of a distal metaphyseal
osteotomy.
FIG. 6. Traumatic intrinsic metatarsus primus elevatus after dorsally malunited fracture of the first metatarsal.
Osteochondritis Dissecans
Hallux limitus or rigidus has been associated with traumatic defects in the articular cartilage of the first metatarsophalangeal
joint. Adolescent hallux limitus or rigidus has been attributed to osteochondritis dissecans of the first metatarsal head
(16 ,17 ,35 ); however, adult cases of osteochondritis have been reported with and without a history of trauma (18 ,36 ).
Whether hallux limitus is a predisposing factor in osteochondral injury remains a topic of debate, although the presence of this
injury has been suggested to occur before the onset of pain (11 ,18 ).
FIG. 7. Traumatic arthritis of the first metatarsophalangeal joint after intraarticular fracture of the hallux.
Osteochondral Fractures
Osteochondral fractures of the first metatarsophalangeal joint occur most frequently on the dorsal distal central aspect of the
first metatarsal head, opposite the surface on the base of the proximal phalanx. Impingement of these two opposing joint
surfaces creates an impaction of the metatarsal head, and convergence of these forces leads to fracture of the subchondral
bone plate, which propagates into the subchondral bone. Disruption of the blood supply to this portion of bone leads to
avascular necrosis and subsequent arthrosis of the remainder of the joint. Pain occurs directly from edema within the bone and
secondarily throughout the joint from effusion of synovial fluid.
Paralytic Deformities
Lapidus identified three types of paralytic deformities (flaccid or spastic) in which muscular imbalance is accompanied by the
formation of a dorsal bunion (2 ). One such condition was defined as “weakness of the peronei with a strong tibialis anterior and
strong flexors of the big toe.” The description of this condition focused on the varus position of the foot and the inability of the
medial column to contact the ground. The tibialis anterior tendon maintains the varus position of the foot, whereas the flexors
of the hallux contract to purchase the weight-bearing surface. The varus position is the primary deforming force. Iatrogenic
dorsal bunions have been described as postoperative sequelae after transfer of the peroneus longus tendon into the tibialis
anterior in patients with poliomyelitis (37 ), a finding lending support to this theory.
The second condition was defined as “weak dorsiflexors of the foot and toes with strong plantarflexors of the big toe and strong
calf muscles.” This describes a situation whereby the forces of plantarflexion serve as the primary deforming force, with
dorsiflexion of the first metatarsal occurring secondarily to the effect of the hallux on the medial column of the foot. Dorsal
bunions have been described after transfer of the extensor hallucis longus into the distal first metatarsal head in which
weakening of the extensor tendon allowed the flexor tendons to predominate at the first metatarsophalangeal joint (38 ).
The third condition was defined as “calcaneus deformity with active plantarflexors of the big toe.” In this category of
deformities, the flexor hallucis longus is recruited as an accessory plantarflexor of the foot and thereby leads to hallux equinus
and a dorsal bunion.
Goldner described hallux flexus in cerebral palsy and paralytic
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patients that resulted from a weak extensor hallucis longus, overpowering tibialis anterior tendon, and spasticity of the flexor
hallucis longus or brevis tendon (38 ). This condition leads to an underlapping of the hallux, as compared with the overlapping
hallux that is a frequent component of hallux valgus.
Other Factors
The presence of a distal pseudoepiphysis at the first metatarsal head has also been associated with subsequent hallux limitus or
rigidus (31 ,39 ). Classically, a squared articular surface has also been believed to render a patient susceptible to hallux limitus
in the presence of mechanical imbalance (40 ).
ROLE OF THE PLANTAR STRUCTURES: THE NATURAL HISTORY OF ARTHROSIS

Several layers of structures within the plantar arch of the foot influence the function of the first metatarsophalangeal joint,
both directly and passively. The flexor hallucis longus has a passive but influential role on first metatarsophalangeal joint
function. Recruitment of long flexor function in weight bearing and propulsion locks the interphalangeal joint against ground
reactive forces and transfers tension to the proximal metatarsophalangeal joint. The effect on the metatarsophalangeal joint is
plantarflexory, with the proximal phalanx assuming an equinus position in relation to the first metatarsal. Plantarflexion of the
proximal phalanx creates a dorsiflexory effect on the first metatarsal through retrograde buckling (2 ). Therefore, forceful
contracture of the flexor hallucis longus leads to clawing of the hallux at both the interphalangeal and metatarsophalangeal
joints in open-chain kinetics and to true hammering in closed-chain kinetic function.
The plantar fascia has a passive role in restricting motion about the first metatarsophalangeal joint. The distal interdigitations
of the medial band of the plantar fascia insert into the base of the digits and create a windlass mechanism, such that
dorsiflexion of the digits creates tension on the plantar fascia. In addition to aiding in resupination of the rearfoot during
propulsion, the plantar fascia assists in loading the metatarsophalangeal joints. Secondary contracture of the plantar fascia can
occur in hallux limitus or rigidus, and it has been addressed surgically as an adjunct to other procedures for this condition (3 ).
The effect of plantar fascia release on first metatarsophalangeal joint mobility has been investigated. Measurements taken
before and after fasciotomy demonstrate that on average, dorsiflexion increases by 10 degrees, whereas plantarflexion is not
affected (Goecker R, Harton F. Effect of plantar fasciotomy on first metatarsophalangeal joint mobility. Personal
communication, 1999).
The flexor hallucis brevis muscle inserts into the sesamoid apparatus and is an important stabilizing influence on the first
metatarsophalangeal joint. Many authors have drawn attention to the role of this muscle in the development and propagation of
plantar contracture in hallux rigidus. Some have attributed spasm of the flexor hallucis brevis as a causative factor in the
development of this process (9 ,11 ,12 ,26 ), whereas others have recognized the late effects of contracture as a secondary
finding (2 ). Watson Jones advocated a surgical release of the plantar intrinsic musculature as an isolated early procedure in
selected cases devoid of significant arthrosis (41 ). Although controversy exists on the order of events in the natural history of
this condition, it is generally well accepted that contracture of the flexor hallucis brevis muscle compounds the degenerative
process within the first metatarsophalangeal joint.
Sesamoid degeneration and immobility have been recognized as associated findings in hallux limitus and hallux rigidus
(25 ,42 ,43 ). In hallux limitus, sesamoid immobility is less pronounced, and open-chain kinetic range of motion often reveals
near-normal joint mobility. However, the “loaded” or weight-bearing joint with hallux limitus typically demonstrates limited
dorsiflexion. With hallux rigidus, sesamoid immobility is more clinically significant, because of restriction in both dorsiflexion
and plantarflexion, both in open-chain and closed-chain kinetics.
Immobility of the sesamoids, through contracture of the flexor hallucis brevis muscle, prevents gliding of the metatarsal head
over the sesamoid apparatus in propulsion (11 ). The normal axis of rotation is changed from the central aspect of the first
metatarsal head (Fig. 8A ) to the plantarflexor plate and sesamoid apparatus (44 ). In this manner, the normal gliding motion is
converted to a hinge, with the axis of
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rotation occurring outside the joint (Fig. 8B ). Hetherington et al. identified four instant centers of rotation of the first
metatarsophalangeal joint that occur in closed-chain kinetics (22 ): “As dorsiflexion begins, there is a rolling initially followed by
a sliding, which accompanies first metatarsal plantarflexion. Compression occurs as the joint reaches its end range of motion”
and “The final center demonstrates a vector entering the proximal phalanx of the hallux, the characteristic of a compressive
force at the end range of motion.” These findings support the theory that sesamoid immobility influences the range of motion in
patients with hallux limitus such that they function entirely at the fourth instant center of rotation suggested by Hetherington
et al., a center characterized by compressive forces. The identified location of this center of rotation is dorsally, where
impingement occurs between the metatarsal head and phalangeal base. Thereafter, the dorsiflexory moment of action about
the first metatarsophalangeal joint results in dorsal impingement between the metatarsal head and proximal phalangeal base.
Repetitive dorsal impingement leads to an eccentric concentration of pressure on the dorsal articular cartilage, which gradually
erodes and fibrillates (17 ), thereby exposing the underlying subchondral bone plate. Loss of functional articular cartilage
initiates the cascade of changes that results in arthrosis (11 ).
FIG. 8. A: The normal axis of the range of motion of the first metatarsophalangeal joint is centrally located within the first
metatarsal head provides for gliding motion. B: With sesamoid immobility, the axis of rotation is converted to a plantar
hinge located at the level of the sesamoid phalangeal ligament. This leads to dorsal impingement of the proximal
phalangeal base on the metatarsal head.
Osseous impingement erodes the dorsal articular surfaces on the opposing sides of the metatarsophalangeal joint. Loss of
functional cartilage stimulates dorsal osteophyte formation in an attempt to increase the surface area of the joint and thereby
dissipates the same force over a larger contact surface. Pain can often occur as a late finding, after a significant degree of
articular degeneration has already occurred. Splinting and guarding of the joint secondary to pain lead to further adaptive
contracture of the plantar structures. Flattening of the joint surfaces further limits motion as the body attempts to restrict
painful motion within the joint. Bony ankylosis, the hallmark of hallux rigidus, is the end result of this cyclic cascade—restricted
motion, articular degeneration, osteophyte formation, pain, splinting and adaptive contracture, articular flattening, and finally
bony ankylosis. Watson Jones (41 ) proposed and Jack (9 ) supported this theory, having identified three sequential stages:
spasm of the short flexors, secondary contracture of plantar structures, and subsequent osteoarthritis. These investigators
believed that the arthrosis of hallux rigidus was identical to that occurring in any joint with osteoarthritis.
Clinical evidence of this theory of cyclic events is apparent through surgical dissection of an arthritic first metatarsophalangeal
joint. Synovial membrane thickening is most pronounced at the dorsal half of the joint. Articular erosion is more severe on the
dorsal surface of the joint (11 ,17 ), because the inferior one-half of the metatarsophalangeal joint is relatively spared early in
the arthritic process (9 ,45 ). Cupping of the proximal phalangeal base around the metatarsal head is common, as is furrowing of
the sagittal groove on the plantar metatarsal head where the sesamoids articulate. Flexor plate and sesamoid immobility is a
consistent surgical finding in hallux rigidus.
Microtrauma Versus Macrotrauma

Establishing a direct cause and effect between hallux limitus and arthrosis is difficult to document, because most asymptomatic
patients do not seek treatment. Once the cyclic cascade of events is under way, few will argue the relationship between joint
immobility and degenerative changes. Most authors agree that both acute trauma and chronic trauma are influential in the
development of hallux rigidus (9 ,17 ,45 ). Two distinct groups of patients appear to be afflicted with hallux rigidus: adolescents
and middle-aged patients. A higher correlation with osteochondral defects is noted in adolescent patients, whereas adults are
more likely to suffer from gradual progressive arthritis.
In effect, hallux rigidus appears to occur by two parallel methods. In both cases, a predisposition to hallux limitus exists,
typically in the form of pes planovalgus. In one instance, a macrotraumatic event (stubbing injury, rapidly increased demand)
exceeds the capacity of the osseous structures to accommodate dorsal compression, and a fatigue fracture occurs in the
metatarsal head (Fig. 9 ). This lesion is always on the side of the metatarsal head (not the proximal phalanx) because of
convergence of compressive forces on the convex surface (18 ,27 ) (Fig. 10 ). The second form of hallux rigidus occurs as a
gradual microtraumatic event, in
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which repetitive dorsal impingement erodes the dorsal articular surface, but the forces occur gradually so the subchondral bone
has a chance to hypertrophy instead of fracture. This is typically the case in the adult form of this condition, because
radiographic subchondral sclerosis and osteopetrotic bone are typically encountered at the time of surgery. Regardless of the
cause, the cyclic events of adaptive contracture and arthrosis occur in a similar fashion and are identical to osteoarthritis or
traumatic arthritis observed elsewhere throughout the body.
FIG. 9. Osteochondritis dissecans of the first metatarsal head occurs on the dorsal one-third of the articular surface,
centrally from medial to lateral.
FIG. 10. Diagrammatic representation of impaction of the phalangeal base on the metatarsal head, leading to an
osteochondral defect. These lesions typically occur on the convex surface of the joint (metatarsal head) as a result of
convergence of trabecular forces on the underlying bone.
Hallux Equinus Versus Metatarsus Primus Elevatus

Controversy exists regarding the order of events in the progression of hallux limitus to hallux rigidus. Elevation of the medial
column may be either primary or secondary to the influence of the hallux. Hallux equinus can occur primarily, or it may be
secondary to a forefoot or rearfoot varus deformity. With an uncompensated varus, metatarsus primus elevatus is present
initially, and hallux equinus occurs as a compensation (2 ). In the hypermobile flatfoot or spastic deformities, the hallux equinus
occurs first (9 ), and it secondarily elevates the first metatarsal in the sagittal plane (32 ). Clinical and radiologic examinations
help to determine whether the hallux equinus or metatarsus primus elevatus is the primary deformity.
Observation of stance and gait at times demonstrate the compensatory muscular contraction of the hallux in midstance and
propulsion. Range of motion of the subtalar, midtarsal, and tarsometatarsal joints reveals the level of hypermobility or joint
immobility, as well as each joint's neutral position. Manual loading of the forefoot through the first and fifth
metatarsophalangeal joints pronates the rearfoot and allows for observation of the sagittal position of the first ray in relation to
the lesser metatarsus. In a patient with a forefoot varus deformity, one will not be able to plantarflex the first ray to a plane
that is parallel to the fifth metatarsal. A forefoot supinatus deformity is characterized by the ability of the first ray to
plantarflex, but only through rearfoot pronation.
Another clinical method of assessing metatarsus primus elevatus is through use of a forefoot block test (27 ). In this test, the
patient bears weight while the digits are suspended off the weight-bearing surface. A step, book, or other platform serves to
allow the patient's entire foot to bear weight from the heel to the metatarsal heads, without the digits' contacting the ground.
The influence of the hallux on metatarsus primus elevatus is thus eliminated as the rearfoot and forefoot pronate and allow the
first ray to gain contact with the ground. If no difference in the sagittal position of the first metatarsal occurs when comparing
normal weight bearing with the forefoot block test, then the foot either has a varus deformity or the forefoot is being
maintained in an inverted position because of a long-standing contracture of the tibialis anterior tendon. If the tendon is in
spasm, the foot may resist pronation initially, but the spasm can be broken by volitional contraction of the peroneus longus
tendon.
Radiologic Examination
Standard pedal radiographic examination is used to help assess the type and severity of hallux limitus and hallux rigidus. Hallux
limitus or rigidus may appear radiographically similar to osteoarthritis or traumatic arthritis in other joints, depending on the
severity and stage of the process. However, specific findings are unique to the first metatarsophalangeal joint. Nonspecific
findings include joint space narrowing, osteophytic lipping, joint flattening, joint enlargement, sclerosis of the subchondral
bone plate, subchondral cyst formation, and intraarticular fragmentation (e.g., loose bodies, joint mice). Findings specific to
the first metatarsophalangeal joint include the following: accentuation of the sesamoidal grooves on the dorsoplantar
radiograph, actually a cupping of the metatarsal head around the base of the proximal phalanx; lateral and dorsal spurring;
metatarsalsesamoid arthrosis; sesamoid hypertrophy and elongation; and proximal sesamoid migration (27 ).
Classification systems for the radiographic findings have been described as a means to characterize the degree of deformity.
Although differences of opinion exist regarding treatment for each stage, the general consensus is that advanced degenerative
disease correlates with less satisfactory surgical outcomes regardless of the surgical procedure or grading system that was used
to assess the condition of the joint (46 , 47 , 48 , 49 ).
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Grading scales have been proposed to characterize the severity of deformity based on radiographic findings. Osteoarthritis may
be graded as follows (50 ):
Grade I: Small osteophytes
Grade II: Definite osteophytes in the presence of an unimpaired joint space.
Grade III: Extensive loss of joint space in the presence of sclerosis of subchondral bone.
Within the first metatarsophalangeal joint, Regnauld described the following (13 ):
Grade I: Functional limitation of dorsiflexion, mild dorsal spurring, pain derived from dorsal hypertrophy, no structural sesamoid
disease.
Grade II: Broadening and flattening of metatarsal head and base of proximal phalanx, joint space narrowing, structural first ray
elevatus, osteochondral defect, sesamoid hypertrophy.
Grade III: Severe loss of joint space, extensive dorsal, medial, and lateral spurring, osteochondral defects of metatarsal head
and/or proximal phalanx, with or without joint mice, extensive sesamoid hypertrophy and loss of joint space, near ankylosis.
Hanft et al. further characterized these findings, with subcategories to include osteochondral defects and subchondral cysts
(47 ):
Grade I: Metatarsus primus elevatus, mild dorsal spurring, and sclerosis.
Grade II: Elements of grade I, plus broadening and flattening of the joint, decreased joint space, dorsal and lateral osteophytes.
Grade IIB: Elements of grade II, plus osteochondral defect, loose bodies, and subchondral cyst formation.
Grade III: Elements of grade II, plus severe flattening of the joint, sesamoid hypertrophy, minimal joint space, severe dorsal and
lateral spurring, and osteophyte formation.
Grade IIIB: Elements of grade III, plus osteochondral defects, loose bodies, and subchondral cyst formation.
Sesamoid degeneration and elongation indicate sesamoid immobility and likewise correlate to the degree of arthrosis of the
metatarsophalangeal joint. Chronic traction and tension on the sesamoid apparatus from adaptive contracture of the intrinsic
muscles may lead to bony proliferation at the proximal and distal margins of the sesamoids (13 ,42 ), much like that of
insertional enthesiopathies seen elsewhere in the lower extremity (inferior and posterior calcaneal spur) (Fig. 11 ).
Proximal sesamoid migration may be observed on both dorsal plantar and lateral radiographs (Fig. 12 ). This may be the result of
a coincidental hallux equinus, in that as the flexor hallucis brevis contracts, the sesamoids retain a proximal position in relation
to the metatarsal head.
FIG. 11. Sesamoid elongation and hypertrophy secondary to chronic traction.
Metatarsophalangeal joint morphology has been used to contrast hallux valgus and hallux rigidus (51 ,52 ). Although distinct
differences exist between the two conditions, whether joint shape is a cause or effect of either condition is speculative. Hallux
rigidus radiographically exhibits a squarer metatarsal head, although flattening of opposing articular surfaces is common to any
arthritic joint.
Positional effects of hallux limitus or rigidus may be apparent when one assesses the lateral weight-bearing radiograph. In
patients with hallux equinus, the proximal phalanx assumes a position of plantarflexion in relation to the first metatarsal. In a
typical case, the hallux appears parallel to
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the first metatarsal. In severe cases, the hallux is plantarflexed in relation to the first metatarsal (Fig. 13 ). Although it is not a
true indicator of function during gait, this positional relationship can be used to characterize the severity of the deformity
further.
FIG. 12. Proximal sesamoid migration as a result of contracture of the flexor hallucis brevis muscle.
FIG. 13. Hallux equinus contracture, in which the hallux assumes a position that is plantarflexed in relation to the first
metatarsal.
Metatarsus Primus Elevatus

Assessing metatarsus primus elevatus with static radiographs may not represent the true functional position of the first ray.
Nonetheless, various means have been used in an attempt to distinguish this condition. Several authors attempted to described
an index of measurement from lateral weight-bearing radiographs that assesses the distance between the first and second
metatarsals (9 ,28 ,53 , 54 , 55 ). A comparison study failed to distinguish patients with hallux rigidus from controls and patients
with hallux valgus (53 ), and the researchers concluded that radiographic metatarsus primus elevatus is a normal variant in the
population. Several factors can adversely affect the ability to reproduce direct distance measurements accurately on pedal
radiographs. These may include radiographic magnification, distortion (elongation and foreshortening) (56 ), and variation with
tube head angular divergence and convergence (57 ). Therefore, a more accurate and reproducible method is to measure the
angular divergence of the dorsal cortical surfaces of the first and second metatarsals. This method assigns an angular
measurement that is not affected by tube head position, magnification, or distortion (57 ) (Fig. 14 ).
FIG. 15. A: Intrinsic metatarsus primus elevatus is present when the elevation of the first metatarsal is within the first
metatarsal itself. Note the elevation of the distal dorsal cortex of the first metatarsal above the predicted normal right-
angle relationship. B: Quantification of radiographic metatarsus primus elevatus. In this instance, the patient has 19
degrees of intrinsic metatarsus primus elevatus.
FIG. 14. The proper assessment of metatarsus primus elevatus is based on the divergence between the dorsal cortices of
the first and second metatarsals. Angulation of the x-ray tube head does not change this relationship. In this radiograph,
the tube head is angled at 10 degrees, yet there is no difference in the parallel relationship between the dorsal cortices of
the first and second metatarsals in this radiograph, and therefore, no metatarsal primus elevatus is present.
Seiberg et al. described a reproducible method of evaluating radiographic elevatus by using standard reference points (54 ).
They measured the difference between the dorsal cortices of the first and second metatarsal at 1.5 cm distal to the metatarsal-
cuneiform joint and then compared the difference 1.5 cm proximal to the first metatarsal head. If the distal
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number is greater than the proximal one, then a true elevation is present.
FIG. 16. A: Extrinsic metatarsus primus elevatus. In this circumstance, the bony architecture of the first metatarsal is
normal, but the first metatarsal is elevated above the second metatarsal. Note the normal right-angle relationship of the
articular base to the dorsal cortex of the first metatarsal. B: Quantification of radiographic metatarsus primus elevatus. In
this instance, the patient has 9.5 degrees of extrinsic elevatus.
First metatarsal morphology has also been assessed to determine the level of deformity leading to radiographically apparent
metatarsus primus elevatus. A normal first metatarsal has a right-angle relationship between the metatarsocuneiform joint and
the dorsal cortex of the first metatarsal (57 ). Violation of this normal relationship can provide radiographic evidence of
metatarsus primus elevatus, either from trauma or from previous surgery with a displaced metatarsal osteotomy. When the
radiographic metatarsus primus elevatus is within the bony architecture of the first metatarsal, then this is termed primary or
intrinsic metatarsus primus elevatus (Fig. 15 ). When there is a normal architectural alignment of the first metatarsal bone, but
with significant divergence of the angular relationship of the first and second metatarsals, then this is termed secondary or
extrinsic metatarsus primus elevatus (Fig. 16 ) (57 ).
CONSERVATIVE TREATMENT
The goal of conservative management of hallux limitus or rigidus is to alleviate pain by reducing inflammation through physical
and pharmacologic means and by altering the function of the first metatarsophalangeal joint. Shoes may be purchased with an
additional depth to eliminate pressure on the osteophytic spurring. Environmental modifications include the recognition and
avoidance of activities that stress the hallux into a dorsiflexed position, such as high-heeled shoes, steel-tip work boots, or
squatting or kneeling for extended periods of time. Nonsteroidal antiinflammatory drugs may be effective in the management of
acute and chronic pain associated with hallux limitus or rigidus. Intraarticular and periarticular infiltration of corticosteroids
may also effective in the management of an acutely inflamed first metatarsophalangeal joint. Physical therapeutic means of
treating painful hallux limitus are similar to those recommended for any arthritic joint. Manipulation of the first
metatarsophalangeal joint after periarticular infiltration of local anesthetic has also been recommended (58 ), in an effort to
alleviate the adaptive contractures associated with hallux limitus, although this is not possible in most cases.
Another modality in the conservative treatment of this deformity is orthotic therapy. The type of orthotic depends on both the
flexibility and the severity of the deformity. Depending on the evaluation of these important parameters, recommendations for
orthotic management can be made.
Orthotics are the most beneficial when patients have the ability to reposition the first metatarsal into a more functional
position, to allow a better mechanical environment at the level of the first metatarsophalangeal joint. In addition, patients with
a functional hallux limitus generally respond well to orthotic management. A first ray cutout may be incorporated into the
device to encourage further plantarflexion of the first metatarsal. One may also add a forefoot extension with the first
metatarsal head pocketed to allow further plantarflexion relative to the lesser rays. When the first metatarsal deformity is
essentially rigid or the patient presents with a structural hallux limitus, then functional foot orthotics may be used in an
attempt to support the deformity strictly. In patients with a structural metatarsus primus elevatus, the first ray elevation will
not reduce with subtalar inversion, and therefore, the patient will not benefit from the foregoing devices and modifications.
Patients in this category may benefit from a Morton extension in an effort essentially to immobilize the first
metatarsophalangeal joint. A metatarsal bar or a rocker-bottom sole may also alleviate some of the dorsiflexory
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stress to the joint and may reduce symptoms (Fig. 17 ).
FIG. 17. A: More traditional site of placement for rocker is at the metatarsophalangeal joint level. B: Sulcus marker is
represented by more distal mark. Placement of the rocker at the sulcus level provides more relief of dorsiflexion stress
than does the more proximal location.
SURGICAL TREATMENT
Joint Salvage and Preservation

Although conservative treatment may be helpful in the early stages of hallux limitus, many patients warrant surgical
intervention (59 ). Often, attention is directed solely toward the osseous deformity, to affect the overall alignment of the joint.
The soft tissues also play a vital role in limitation of joint motion.
The surgical approaches to joint preservation procedures are varied, but several goals are shared. Relief of excessive joint
tension is required (60 ). If excessive joint compression is present and is not alleviated, hallux limitus will return, often worse
than before. Structural correction of the first metatarsal often assists in achieving this goal. The second key principle is to
ensure that mobility of the plantar joint structures is adequate. In reality, one cannot ensure relief of joint tension without
providing mobility of the sesamoids and flexor apparatus. Preoperatively, sesamoid and flexor plate mobility may be evaluated
by pulling the plantar fat pad distally and placing a thumbnail against the distal margin of the sesamoid (60 ). With the surgeon's
thumb in that position, the hallux is passively dorsiflexed. The movement of the thumb indicates the degree of mobility of the
flexor plate. Finally, orthotic control may be necessary to provide a supportive environment for maintenance of joint function.
The approach to joint salvage focuses on the local deformity at the first metatarsophalangeal joint, with the understanding that
proximal deformities need to be adequately controlled. The proximal deformities that need to be addressed may require
procedures such as release of posterior equinus or medial column stabilization. At the level of the first metatarsophalangeal
joint, the approach begins with the initial soft tissue release and cheilectomy. Afterward, the first ray may then be further
evaluated to determine which, if any, additional measures will be required to provide the best correction.
Cheilectomy and Initial Soft Tissue Releases

Cheilectomy is the removal of the osteophytic proliferation about the metatarsal head or the proximal phalangeal base (Fig. 18 ).
This technique was first described by Nilsonne and served as only a temporary treatment at that time (15 ). This is the first step
in the repair of hallux limitus for most patients. The normal gliding function of the joint is absent in hallux limitus and is
replaced by a rocking motion that produces intermittent bone-on-bone impingement at the dorsal margins of the joint.
Hypertrophic bone formation and fragmentation result from this chronic microtrauma. This process eventually blocks
dorsiflexion and can become painful even without shoe pressure.
Cheilectomy may also be employed as a sole procedure in the repair of hallux limitus (Fig. 19 ). In general, favorable results
have been reported (46 ,48 ,61 ), although some authors have recommended resection of one-fourth to one-third of the
metatarsal head to avoid recurrence (45 ,46 ). Pontell and Gudas noted good to excellent results 5 years postoperatively in
patients with minimal joint change and no sesamoid degeneration (48 ). Mondul et al. reported similar results in their study (62 ).
Aggressive cheilectomies have been reported, characterized by removal of one-half to two-thirds of the dorsal aspect
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of the metatarsal head. After 56 months (30 to 100 months), the average improvement in joint range of motion was 20 degrees
(63 ). None of the patients require additional operative intervention. Removal of this large a segment of bone is beyond the
scope of cheilectomy, which serves to restore normal anatomy, and is more accurately termed an arthroplasty.
FIG. 18. A: First metatarsophalangeal joint cheilectomy. B: Removal of dorsal eminence. C: Intraoperative appearance of
the metatarsal head after cheilectomy. Note the rounded dorsal contour.
The applications of cheilectomy alone are limited. The patient should have only minimal erosive or degenerative changes within
the joint, and the central regions of the hyaline surfaces should be mostly intact. The etiologic factors involved in creating the
hallux limitus should be amenable to supportive measures postoperatively. Otherwise, the duration of improvement may be
relatively brief. Subsequent procedures are often required in patients with more advanced joint degeneration after cheilectomy
alone.
FIG. 19. A: Preoperative radiograph of a patient with dorsal exostosis and joint fragmentation. No metatarsal elevation is
present. A cheilectomy is effective in this case to restore better functional motion to the first metatarsophalangeal joint.
B: Postoperative radiograph shows restoration of the normal contour of the joint with good range of motion.
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FIG. 20. Technique of subchondral drilling in an attempt to encourage fibrocartilage regrowth into the cartilage defect.
The approach to the joint is generally through a dorsomedial incision. A rectus hallux does not require capsular modifications
that decrease joint volume. When the normal anatomy of the metatarsal head is altered, the hypertrophic bone should be
remodeled. The resection involves the dorsal, dorsomedial, and dorsolateral corners of the joint. True cheilectomy does nothing
more than reestablish normal anatomic contours to the osseous structures (64 ). Generally, the amount of proliferation seen
surgically is large compared with the appearance on radiographs, inasmuch as the outer portions of the exostosis may be largely
cartilaginous. The articular surfaces should be inspected for gross arthritic changes both on the metatarsal head and on the
proximal phalanx. A satisfactory quality of motion should be noted. When indicated, abrasion arthroplasty or subchondral
drilling techniques may be recommended to encourage fibrocartilage repair of defects (65 ) (Fig. 20 ).
After resection of the hypertrophic bone and treatment of eroded cartilage, the sesamoid apparatus should also be inspected.
Banks and McGlamry described the importance of the flexor plate in hallux limitus (60 ). If mobility of the sesamoids and flexor
plate is questionable, then the flexor plate may be freed by sharp dissection or by use of the McGlamry metatarsal elevator.
Sesamoid shape and position can also affect the mobility of the joint. Partial resection of a hypertrophic or proximally elongated
sesamoid often allows the metatarsal head to plantarflex more predictably and to maintain hallux motion. When severe
adhesions or arthritic changes of the sesamoids are present, a different surgical approach is indicated, possibly involving
removal of the arthritic sesamoid.
Some concern must be given to denuding bone on adjacent sides of a joint (i.e., from the metatarsal head as well as from the
phalangeal base). This should be avoided if possible. Our experience has been less favorable when both sides of this joint
require remodeling, although some authors have reported satisfactory results (66 ,67 ).
The range of motion should again be evaluated after capsular release, cheilectomy, and sesamoid release. If structural
deformity of the metatarsal is determined to be present or the range of motion after cheilectomy is still not adequate, then an
osteotomy should be considered.
Distal Osteotomies
Distal osteotomies are primarily used to help decompress the first metatarsophalangeal joint in hallux limitus or when the
patient appears to have minimal or mild metatarsal primus elevatus. The goals should include shortening and plantarflexion of
the capital fragment (60 ). Rotation of the capital fragment may also be considered when dorsal articular cartilage is absent. We
believe that the most important structural change is shortening of the metatarsal, a maneuver that effectively relaxes the
plantar structures and decompresses the joint space to provide for increased range of motion. This will produce an improved
mechanical environment for joint function. Most of the distal osteotomies are inherently stable in their design.
Watermann Osteotomy
The original Watermann procedure consisted of the removal of a trapezoidal wedge of bone from the first metatarsal head with
its base dorsally (Fig. 21 ), to redirect the effective motion of the joint to allow more dorsiflexion of the hallux (68 ). DeLauro
and Positano described this procedure as creating an “internal rocker” within the metatarsal head (69 ). Although not discussed
by the original author, a second important effect is produced as a result of the intracapsular nature of the osteotomy. The
internal cubic content within the joint is reduced, thereby relaxing capsular and periarticular soft tissues and permitting an
increase in joint motion, provided sesamoid mobility is adequate. When a dorsally based piece of bone is removed, the dorsal
cortex of the first metatarsal is also shortened. This tends to alleviate some of the jamming of the joint that occurs at the end
range of motion. No long-range studies of this procedure are available. Cavolo and associates reported satisfactory results in two
cases (70 ).
Several inherent problems are noted with the design of this osteotomy. Obviously, a complete osteotomy leaves the capital
fragment unstable. At Northlake Regional Medical Center a modification of the Watermann osteotomy is used (Fig. 22 ). A
triangular wedge of bone with the base oriented dorsally is removed from the distal metatarsal head, to leave a plantar hinge
and articular cartilage intact. Although internal fixation is not generally required, provided the osteotomy hinge has been
sufficiently weakened to allow easy closure of the interface, some form of fixation may allow for more predictable healing.
Absorbable pins and rods or even dorsal absorbable suture can adequately stabilize this osteotomy.
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Absorbable fixation may be directed through the articular cartilage into the shaft of the metatarsal. The sesamoids are carefully
evaluated for mobility. Marked arthritic changes must not be present. If this condition primarily involves only one of the
sesamoid bones, then removal may be required.
FIG. 21. A,B: Original Watermann osteotomy involved a dorsally based trapezoidal wedge osteotomy of the first metatarsal
head and neck area.
Weight bearing is permitted immediately in a surgical shoe. Gentle passive range-of-motion exercise is started early in the
postoperative phase. The hallux may be splinted in mild dorsiflexion until radiographic evidence of bone healing is present,
generally in 4 to 6 weeks. This approach facilitates compression at the osteotomy site. Our experience has been encouraging in
mild to moderate cases of hallux limitus. Because of its design, this osteotomy mildly decompresses the joint space but does not
correct any structural elevation within the metatarsal. However, the redirection of forces at the first metatarsophalangeal joint
may result in a buckling effect, so a flexible first metatarsal elevatus may be reduced to a suitable weight-bearing position.
FIG. 22. A,B: Modified Watermann osteotomy maintaining the integrity of the plantar cortex and cartilage.
Another indication for the Watermann procedure is when a double osteotomy is necessary. Most of the proximal plantarflexory
osteotomies employed in moderate to severe metatarsus elevatus result in rotation of the capital fragment in the sagittal plane.
This change places the final position of the articular cartilage in a slightly plantar position. Although the range of motion of the
first metatarsophalangeal joint may improve, the actual amount of functional cartilage available when the hallux purchases the
ground is decreased. A Watermann procedure may be helpful derotating the cartilage into a more functional position. This
theory is analogous to employing a double osteotomy (Logroscino) for a hallux valgus deformity (71 ). Several authors have
described the sagittal plane Logroscino technique. Cavolo et al. advocated a crescentic osteotomy at the metatarsal base with a
Watermann procedure distally (70 ). Drago et al. also described this technique by placing the wedge of bone from the
Watermann osteotomy into an opening wedge osteotomy at the base of the metatarsal (72 ).
Modified Green-Watermann Osteotomy

The Green-Watermann modification was devised after it became apparent that simple wedge osteotomy alone was often
inadequate to relieve joint tension. Although mobility appeared to increase, in some patients persistent binding was often noted
intraoperatively, especially at the end range of motion. The Green-Watermann osteotomy incorporates the removal of a small
section of bone, to provide more dramatic
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relaxation of the flexor apparatus (Fig. 23 ). Selner et al. described a tricorrectional osteotomy that is essentially the same
design (73 ). The procedure has been performed in conjunction with a Kessel-Bonney type of phalangeal osteotomy (74 ) (Fig.
24 ).
FIG. 23. A,B: Modified Green-Watermann procedure involves removal of a rectangular section of bone. Enlarging the angle
between the dorsal and plantar cuts results in further plantarflexion of the capital fragment for enhanced weight-bearing
function.
The goal of the procedure is twofold: to provide enough shortening of the bone to relieve all tension on flexor structures and at
the same time to displace the first metatarsal head plantarly to avoid the lesser metatarsal symptoms that can be associated
with first ray shortening. Because of the design of the osteotomy, it addresses two separate aspects of the hallux limitus
deformity.
The “Watermann” name can be misleading, because no actual rotation of the cartilage occurs, as seen in the traditional
Watermann osteotomy. The osteotomy is technically easy to perform and can be easily stabilized. After the initial cheilectomy
approach, the initial osteotomy is made from the central portion of the metatarsal head, to form the apex, to the dorsal cortex
and is oriented perpendicular to the long axis of the first metatarsal. The second cut is angulated similar to the plantar cut of
an Austin procedure. The second dorsal arm is parallel to the first and is performed to remove an appropriate section of bone to
create the desired amount of shortening. Critics may argue that the shortening also results in the loss of functional weight-
bearing length. However, by angulating the plantar cut toward the weight-bearing plane, plantar displacement of the
metatarsal head occurs as the osteotomy is closed. The angulation of the plantar arm to the weight-bearing surface determines
the amount of plantarflexion achieved (73 ,74 ). However, as the angle between the arms of the osteotomy increases, the
inherent stability of the design decreases. A plantar arm at 45 degrees to the weight-bearing surface will result in 1 mm of
plantarflexion for 1 mm of shortening (75 ). Any plantarflexion helps to offset the loss of length and secondarily enhances the
procedure by providing some of the benefits of more proximal plantarflexory procedures.
Laakman et al. reviewed 33 Green-Watermann procedures and reported good results in their patients (76 ). The patients
revealed an overall subjective decrease in pain and increase in range of motion. Although the average increase of range of
motion was only 6 degrees, the significant decrease in pain may have contributed to their perception of more increased motion.
Even with aggressive plantarflexion attempts in their osteotomies, the final resultant plantarflexion was deemed to be only 1
mm with respect to the preoperative position using the Seiberg index (54 ).
Fixation of the modified Green-Watermann is recommended and may consist of either absorbable or metallic fixation devices
such as Kirschner wires (K-wires), staples, or screws (Fig. 25 ). The angle between the arms is approximately 120 to 140 degrees
and does not provide the same stability of the osseous fragments seen with the usual 60-degree cut of an Austin procedure. If
absorbable pins are used, we recommend one point of fixation across the dorsal arm and a second point across the plantar arm.
This approach has provided good stable fixation with no documented evidence of postoperative complications. One device
across the plantar arm alone, however, does not appear to stabilize the vertical portion of the osteotomy adequately.
On the contrary, one metallic device across the plantar arm is usually adequate. Smooth or threaded 0.062-inch K-wires that are
bent or are cut flush with the dorsal cortex have been employed. When threaded K-wires are used, they can be driven distally
and plantarly until the tip of the wire is viewed at the distal end of the metatarsal head. The wire driver is reversed, and the
wire is retracted just beneath the cartilage. The Podiatry Institute Flush Pin Cutter (an instrument licensed by the Podiatry
Institute, Tucker, GA) may then be used to cut the wire down to a length of approximately one-fourth inch. The cutter is
repositioned, and the wire is then cut flush with the metatarsal. The threaded wires are left in place permanently. One wire
may be adequate, whereas two wires provide extremely secure fixation. Both solid and cannulated screws are also adequate;
however, the screw head may at times prove to be prominent and may require later removal. If screws are used, the surgeon
must be especially careful to avoid violating joint cartilage. The configuration of the osteotomy tends to have a self-seating
effect with weight bearing and further compresses the fragments.
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FIG. 24. Preoperative anteroposterior (A) and lateral (B) radiographs of a patient with hallux limitus. Note the joint space
narrowing, metatarsal elevation, and long proximal phalanx. Postoperative anteroposterior (C) and lateral (D) radiographs
after a Green-Watermann osteotomy in combination with a dorsiflexory rotational phalangeal osteotomy. (Courtesy of
Michael Miller, D.P.M.)
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FIG. 25. A: Preoperative radiograph depicting a mild to moderate metatarsus primus elevatus. Note the relative change
along the dorsal cortices of the metatarsal from proximal to distal. B: Postoperative radiograph after a Green-Watermann
osteotomy with absorbable pin fixation. Note the plantarflexion of the capital fragment with respect to the metatarsal
shaft. This plantarflexing and shortening type of osteotomy is effective in decompression of the joint space. C: Clinical
follow-up of 2 years with good functional motion noted.
Austin Osteotomy
Modifications of the Austin procedure have been described that provide shortening of the first metatarsal (77 ,78 ), with an end
result similar to that achieved with the modified Green-Watermann osteotomy. The best-known modification was described by
Youngswick, in which two parallel cuts are made dorsally to remove a segment of bone (78 ). The design of the 60-degree arms
provide more intrinsic stability among the osseous fragments than the Green-Watermann procedure (Fig. 26 ). A second
technique for removing a larger portion of bone from the dorsal osteotomy is to place two saw blades in the sagittal saw before
executing the cut. The dorsal arm can be reciprocally planed further to remove more bone. Again, the osteotomy design results
in shortening and plantarflexion of the capital fragment (Fig. 27 ). Fixation is similar to that of standard Austin fixation
techniques.
With the standard Austin procedure, correction in two

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planes may also be obtained by using the appropriate axis guide. The capital fragment may be plantarflexed or shortened in
conjunction with lateral transposition (79 ). This is ideal when hallux valgus exists in conjunction with hallux limitus. However,
in many cases of hallux limitus, the intermetatarsal angle is low enough to restrict lateral transposition of the capital fragment
severely unless the axis is at a high and impractical angle. In these situations, shortening achieved with the wedge techniques
described earlier is more practical.
FIG. 26. The Youngswick-Austin procedure.
FIG. 27. A,B: Intraoperative photograph of the Youngswick modification for hallux limitus. Joint decompression is achieved
with a rectangular wedge taken from the dorsal arm of the osteotomy. Inherent stability is imparted to the osteotomy by
maintaining the integrity of the plantar arm.
Oblique Head Osteotomies

Other distal osteotomies that provide joint decompression and metatarsal plantarflexion may also be used in patients with
hallux limitus. Although the Hohmann and Wilson osteotomy designs (80 , 81 , 82 ) are not as inherently stable as the Austin and
Watermann osteotomies, surgeons have used stable 3.5-mm screw fixation to provide as suitable stabilization for this construct.
Parallel cuts can be made in a dorsal distal to plantar proximal direction to help decompression of the capital fragment, and
plantar transposition is also achieved easily. Dorsal rotation of the cartilage can also be achieved by removing more bone from
the dorsal aspect of the metatarsal (Fig. 28 ).
Proximal Osteotomies
Proximal plantarflexory osteotomies of the first metatarsal are used to correct a moderate to significant structural first
metatarsal elevatus. Good results have been observed, particularly when the procedure is employed in younger patients. The
elevatus should be rigid or structural, as opposed to a result of pronatory tarsal malalignments (4 ). This procedure in theory
corrects a deformity that leads to hallux limitus or rigidus. It may be combined with a more distal procedure if necessary.
However, by plantarflexing the distal aspect of the metatarsal, the extensor tendons develop a more effective vector of force at
the first metatarsophalangeal joint, whereas the flexor apparatus is correspondingly more relaxed. These changes may negate
the need for additional soft tissue procedures to alleviate hallux limitus in younger patients.
Proximal plantarflexory osteotomies can take on several forms. The most common options include the Lambrinudi or
plantarflexory wedge osteotomy, the oblique base osteotomy with intentional compromise of the medial hinge (83 ), and the
sagittal Z osteotomy. The plantarflexory moment of the foregoing osteotomies occurs around an axis of rotation. Depending on
the procedure and location of the osteotomy, the surgeon should understand that the axis of rotation varies and affects the
amount of plantarflexion possible (Fig. 29 ).
Camasta described the concept of intrinsic versus extrinsic metatarsus primus elevatus. In intrinsic elevatus, the apex of the
deformity is within the metatarsal shaft (57 ). Extrinsic elevatus refers to the apex of deformity being proximal to the
metatarsal-cuneiform joint. Cases of intrinsic elevatus are usually seen in previous surgical patients secondary to either early
weight-bearing or elevational and rotational forces at the metatarsal head after a metatarsal osteotomy. This can occur with
both distal and proximal procedures in which the orientation of the cartilage has healed with dorsal angulation. Cases of
intrinsic elevatus are ideal for rotational-type osteotomies, to attempt to bring the metatarsal and the cartilage to a more
normal rectus position. However, the rotational osteotomies are often performed on patients with extrinsic elevatus. In this
case, the final position of the articular cartilage is slightly plantar declinated (84 ), and the available functional cartilage is
decreased. Therefore, a distal counterrotational osteotomy may be considered in conjunction with a rotational proximal
osteotomy. A Watermann type of procedure distally achieves this goal. This “double osteotomy” approach realigns the articular
surface into a
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more functional position. Double osteotomies are easily accomplished with the proximal wedge procedures because the shorter
oblique nature of these osteotomies minimizes their potential extension into the metatarsal head region. A sagittal Z procedure
can only be used if the distal arm does not extend into the metatarsal head, to interfere with the more distal Watermann
procedure.
FIG. 28. Preoperative anteroposterior (A) and postoperative (B,C) radiographs of an oblique distal osteotomy stabilized
with two cannulated screws across the “plantar” arm. There is significant potential for manipulation of the capital
fragment with the inherently unstable design of this osteotomy. (Courtesy of James Pelletier, D.P.M.)
In certain situations, structural correction from a sagittal Z or an oblique sagittal base procedure can be achieved by strict
plantar displacement of the metatarsal, rather than rotation around a proximal axis. This does not affect the final position of
the articular cartilage as greatly, and a distal osteotomy may be avoided. The trade-off is a higher chance of troughing into the
medullary canal because of the decrease in cortical overlap from medial to lateral. After the osteotomy is performed and fixed,
the range of motion of the first metatarsophalangeal joint is again reevaluated, to assess improvement.
Lambrinudi Osteotomy (Plantarflexory Wedge Osteotomy)

Proximal plantarflexory osteotomies with resection of an oblique wedge of bone have been used successfully for metatarsus
primus elevatus. Lambrinudi (8 ) first described this in 1938 and Davies (85 ) later favored this approach. An axis guide is helpful
to insure precise cuts. The apex is usually 1 cm distal to the metatarsal-cuneiform joint with the proximal cut at 45 degrees to
the joint line. Due to the design of the osteotomy the surgeon must be fairly exact with the amount of wedge resection to avoid
overzealous plantarflexion of the metatarsal. Fixation is most often achieved with either one or two 3.5-mm cortical or 4.0-mm
cancellous screw. The plantar flare of the proximal metatarsal base creates an oblique angle relative to the orientation of the
screw and at times makes it difficult to purchase good cortical bone. A 4.0 cancellous screw may work well, but using a fully
threaded screw may help guide the screw more effectively
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toward the plantar cortex without the same tendency for deviation in the metatarsal shaft.
FIG. 29. Illustrations of several types of plantarflexory basal osteotomies. A: Lambrinudi osteotomy. B: Oblique sagittal
base osteotomy and sagittal Z osteotomy. All these procedures result in a plantar rotation of the cartilage. This is ideal in
procedures in which “intrinsic” dorsal elevation is noted within the metatarsal head.
Although wedge resection requires a more exacting technique, the preservation of a dorsal cortical hinge may offer enhanced
stability compared to the sagittal plane procedures. Alternatively, an opening plantarflexory wedge osteotomy may be employed
with the use of an allogenic bone graft.
Oblique Sagittal Base and Sagittal Z Osteotomies

Sagittal plane osteotomies are a useful approach because one may readily adjust the position of first metatarsal plantarflexion
intraoperatively. We have found the sagittal Z design to be more versatile. In most cases of hallux limitus, the intermetatarsal
angle is often negligible. The Z design allows additional elongation or shortening along the metatarsal shaft without affecting
the intermetatarsal angle (Fig. 30 ). The arms of the osteotomy exit distal laterally and proximal medially. The plantar
repositioning of the metatarsal can be achieved either with pure transposition, rotation, or in combination (33 ). Because these
are diaphyseal osteotomies, the surgeon should be aware of the potential for troughing. Therefore, some rotation should be
incorporated into the distal fragment for cortical overlap from medial to lateral. In plantar rotation of this osteotomy, often
some gapping of the dorsal cortex occurs. When combining plantar rotation with elongation, if the gapping becomes significant,
the areas can be augmented with either allogenic or autogenous bone graft. If grafting is used, the pieces are most often fixed
with either small screws or K-wires. Although it may appear that grafting is necessary when any gapping occurs, many operations
have been performed without grafting, and no compromise has been noted relative to healing or long-term function (Fig. 31 ).
The sagittal base osteotomy is better suited to the patient with concomitant hallux abducto valgus. In this situation, the surgeon
may initially perform an oblique base wedge osteotomy with bone resection to reduce the intermetatarsal angle. Once adequate
correction of this component of the deformity has been achieved, the medial cortical hinge is transected, and the distal
segment of the bone is rotated into the desired position in the sagittal plane.
Our opinion is that the locking of the arms in the sagittal Z design provides more stability against dorsiflexory forces than the
oblique design. The application of internal screw fixation allows the patient to institute early range-of-motion therapy after
surgery. Banks described the sagittal Z osteotomy in 1995 (86 ), and Cicchinelli et al. recommended this as the procedure of
choice in patients with metatarsus primus elevatus associated with hallux limitus (33 ). Viegas reported his experience with 11
patients with 100% good to excellent results (55 ). Chang reported on 32 cases with 86% good
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results after a 2-year follow-up (87 ). When a proximal rotational osteotomy is selected, evaluation of the apex of deformity is
helpful. The plantarflexory osteotomy provides a more proximal axis of rotation as compared with the sagittal Z design. This
may be preferred when more dramatic plantarflexion is required. However, patients who have undergone previous surgical
procedures may have some shortening of the first metatarsal that may be addressed by simultaneous distraction and
plantarflexion of the distal segment of the sagittal Z procedure.
FIG. 30. Preoperative anteroposterior (A) and lateral (B) radiographs of 34-year-old patient with joint space narrowing and
metatarsal elevation. C: Intraoperative photograph of a joint mouse found within the first metatarsophalangeal joint. D:
The sagittal Z osteotomy provides for plantar rotation of the distal metatarsal. Stabilization is provided with two cortical
bone screws. E,F: Patient with apparent shortening of the first metatarsal resulting from plantarflexion of the distal
segment (E) on the anteroposterior radiograph and good sagittal alignment (F) noted on the lateral view. G: Range of
motion and function at 3 years are satisfactory.
Lapidus Arthrodesis
When hypermobility is noted at the metatarsal-cuneiform joint, a Lapidus fusion may be considered (88 ). Patients with
significant metatarsal elevatus can also achieve more dynamic correction when the deformity is addressed at this joint because
of the long lever arm effect. Curettage techniques or wedge resections can be used for metatarsal positioning. Care should be
taken when wedge resections are chosen, because minimal wedge resections of the joint space
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dramatically affect plantarflexion and shortening at the metatarsal head. Cain and Chang demonstrated that a 3-mm wedge
resection at the joint level produces 1 cm of plantarflexion at the metatarsal head (89 ).
FIG. 30. Continued.
In patients whose metatarsal protrusion distance is already short, consideration should be directed to a graft at the fusion site.
Although one may argue proper plantarflexion should adequately compensate for metatarsal shortening, active patients may still
present with subsequent sub-second metatarsal symptoms because the second metatarsal head bears increased stress during
heel off.
All the proximal procedures are managed differently from their distal counterparts in the postoperative period. Rigid fixation
allows early range-of-motion exercises. Serial radiographs are taken immediately postoperatively and at appropriate intervals.
The patient should be non-weight bearing for 6 to 8 weeks until both clinical and radiographic signs of healing are noted.
Hallux Procedures
Few indications exist for hallux osteotomy procedures. This approach is probably most useful in adolescent patients without
arthritic changes and metatarsus primus elevatus, although generally few adolescents are unresponsive to more conservative
treatment regimens (60 ).
Kessel-Bonney Osteotomy
The Kessel-Bonney procedure involves resection of a dorsally based wedge of bone from the base of the proximal
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phalanx of the hallux (32 ) (Fig. 32 ). Plantarflexory position of the hallux is redirected to a more favorable dorsal orientation.
Kessel and Bonney reported a good increase in motion with reduction in pain in their patients, who averaged 12.4 years of age.
However, only occasional case studies have been published since the original report (1 ,90 ), so the clinical experience with this
procedure is still largely unreported. Purvis et al. discussed this procedure in combination with an Akin osteotomy for
concomitant correction of hallux limitus and valgus (90 ). Unfortunately, their article only includes a case report.
FIG. 31. Postoperative anteroposterior (A) and lateral (B) radiographs of a sagittal Z osteotomy. Note the gapping on the
anteroposterior view as well as two areas of dorsal gapping on the lateral view. This is common when plantarflexion and
lengthening are desired. Although grafting of these areas is an option, pathologic stress fractures have not been observed
when the gapping was maintained, as shown here.
In most patients with hallux limitus, the deformity appears to reside in the metatarsal or more proximal areas of the foot.
Therefore, the Kessel-Bonney procedure would not appear to address the primary site of deformity.
FIG. 32. Kessell-Bonney procedure.
Regnauld, Vanore, and Sagittal Z Procedures

Regnauld has described a technique of removing the base of the proximal phalanx of the hallux, resecting a cylinder of bone,
and reimplanting the base as an osteocartilaginous graft (13 ). He originally advocated this approach for patients affected by
functional limitation of the joint with mild dorsal spurring, yet no sesamoid disease. By fashioning a proximal medullary plug to
seat into the phalangeal shaft, some degree of stability may be afforded, provided bone quality is adequate. Regnauld actually
described three different variations in the shape of the bone graft (hat shaped, cork shaped, and inverted), but they all serve
the same function. Essentially, one-third of the proximal phalanx is removed from the base of the joint.
In theory, enclavement serves to relieve joint tension by shortening the proximal phalanx. Although this may have some effect,
one should also recognize that more effective relaxation is gained by the sacrifice of the short flexor and adductor and abductor
attachments to the base of the phalanx. The medullary bone plug may be a tenuous form of stability for anyone with osteopenia.
Additional fixation may be required, and this may prove awkward.
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FIG. 33. Intraoperative photograph of an in situ cylindric graft taken for a decompression phalangeal osteotomy. Although
this technique decreases the length of the hallux, the tension inside the joint is not affected to the same degree.
(Courtesy of John Vanore, D.P.M.)
FIG. 34. Postoperative anteroposterior (A) and lateral (B) radiographs of the Regnauld procedure to decompress the joint
at the phalangeal level. Note the increase in joint space achieved after the phalangeal base is dissected free from the
joint and then replaced as an autograft. This effectively removes all soft tissue insertions onto the base of the proximal
phalanx. (Courtesy of John Vanore, D.P.M.)
Vanore and Corey recommended circumferential drilling of the graft to facilitate bleeding and more rapid revascularization (91 ).
Twenty-five to 30 drill holes are placed into the periphery of the graft, with care taken to avoid the cartilaginous surface (Figs.
33 and 34 ). These surgeons preferred a Herbert bone screw for fixation, inserted from proximal medial across the osteotomy
directed distal laterally to capture the lateral cortex. A 2.7-mm screw has also been employed oriented from medial to lateral
to capture the peg of the graft (92 ).
Despite the success achieved by Regnauld, little long-term experience exists with the procedure in the United States. Quinn et
al. detailed the success of this approach in 25 patients seen in follow-up 15 months or longer after surgery (93 ). Fixation was
afforded by absorbable suture between the osseous segments. Seventy percent of the patients experienced an average
increased range of motion of 35 degrees. Resorption of the graft was noted in several patients. Consistently better results were
obtained in patients who were less than 50 years old.
In situ decompression techniques have also been described, which avoid the potential devascularization of the bone that occurs
with complete extirpation of the phalangeal base. However, Vanore and Corey found more dramatic decompression of the joint
after complete removal of the osseous segments (91 ). This finding supports the role of the intrinsic muscle and soft tissue
release as a dramatic influence on the limitation of joint motion. Hanft et al. compared
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the standard hat-shaped graft with the inverted design, both in situ, and found minimal differences between the two techniques,
with an average increase in motion of 23 degrees at 2 years posteratively (47 ). In 1995, Kissel et al. described hallux
decompression by performing a shortening sagittal Z osteotomy within the body of the phalanx and fixation with two cortical
screws (94 ). Rotation of the distal phalanx on the proximal phalanx was performed to gain an added advantage similar to a
Kessel-Bonney procedure. This approach was combined with an aggressive cheilectomy and chondroplasty in 24 patients with
early encouraging results.
Soft Tissue Release

After the cheilectomy and osteotomy have been performed, joint motion should again be evaluated. In certain situations,
recognizable soft tissue tightness may be noted along the plantar aspect of the joint. Durrant and Siepert described several
characteristics of the soft tissue structures that would effectively restrict dorsiflexory motion at the first metatarsophalangeal
joint (95 ). The structures must cross and lie below the transverse axis of the joint, should exert a force that is parallel and lie
on both sides of the longitudinal axis of the joint, and should insert into the proximal phalanx. With these criteria in mind, the
medial band of the plantar fascia, the flexor hallucis brevis muscle with the sesamoid apparatus, and the plantar capsule may
be culprits in restricting joint motion (95 ). Theoretically, the tendons of the abductor hallucis, adductor hallucis, and flexor
hallucis longus fail to meet the foregoing criteria. However, clinical experience has demonstrated that release of the adductor
hallucis tendon as an initial stage in the soft tissue release of hallux limitus does have some favorable effects on dorsiflexory
motion. This is most likely mediated by the insertion into the sesamoid complex.
Evaluation of the sesamoids is vital. For proper joint motion to occur at the first metatarsophalangeal joint, the first metatarsal
head must have the ability to plantarflex and allow the sesamoids to glide distally. If the sesamoids are located too proximally,
are elongated, or are too thick, it is much more difficult for this gliding to occur. Partial or total excision of a hypertrophic or
elongated sesamoid bone often provides significant relaxation of plantar constriction.
FIG. 35. Diagrams illustrating the significant soft tissue relaxation achieved by removal of the proximal phalangeal base
and demonstrating force vectors before release (A) and after release (B). This shows why procedures that temporarily or
permanently remove the base of the phalanx such as the Keller arthroplasty and the Regnauld procedure can be so
successful. F.H.B., flexor hallucis brevis; F.H.L., flexor hallucis longus.
A much more dramatic increase in metatarsophalangeal motion would be seen if the short flexor tendons were resected from
the proximal phalanx. This is in essence the effect created by the Regnauld autograft procedure (13 ) (Fig. 35 ). As the base of
the proximal phalanx is removed from the joint, all soft tissue attachments are likewise removed, to allow the short flexor
tendons to retract proximally (96 ).
The distal insertion of the plantar fascia inserts into the flexor plates of the metatarsophalangeal joints through digitations.
These slips may also play a role in limiting the gliding motion of the sesamoids. Release of this medial band can provide a
noticeable increase in range of motion (Goecker R, Harton F. Effect of plantar fasciotomy on first metatarsophalangeal joint
mobility. Personal communication, 1999) (60 ). This is performed through a medial stab incision at the level of the metatarsal
shaft (Fig. 36 ). The tight fascial band is easily isolated at this location, safely away from the joint capsule. We have dissected
this area on cadaveric specimens and have clearly isolated the fascial band superficial to the deeper tendinous structures.
Although this release can also be carried out at a more proximal location, a more distal resection has less effect on rearfoot
stability. At this time, elongation procedures of the plantar capsule have not been described and appear to be difficult to
perform.
Joint-Destructive Techniques
Keller Arthroplasty
The Keller arthroplasty is a proven procedure for reduction of joint pain and has been a mainstay of hallux limitus and rigidus
surgery for many years (12 ,97 ,98 ). In the past, it was the procedure most often used in comparison studies (28 ,99 ). Although
this approach has had critics (28 ,100 ), good results have also been reported (101 , 102 , 103 ). The procedure is still useful and
effective in selected patients, particularly
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as an alternative to an implant in patients who desire to maintain some degree of motion at the first metatarsophalangeal joint.
FIG. 36. A: The hallux is dorsiflexed in this patient to illustrate the tightness of the medial band of the plantar fascia in
some patients presenting with hallux limitus. B: A small stab incision is made several centimeters proximal to the first
metatarsophalangeal joint, and the medial slip of the fascia is identified and transected. Care is taken to avoid the long
flexor tendon to the hallux. C: Improved dorsiflexion is noted.
The Keller arthroplasty may be considered primarily as a salvage procedure for iatrogenic complications or arthritic joints. In
addition, the Keller arthroplasty may be the procedure of choice in neuropathic patients with hallux limitus. Many such patients
manifest with ulcerations under the hallux that recur unless hallux limitus is recognized as a contributing factor and is addressed.
Daniels achieved a good increase in hallux dorsiflexion and no recurrent ulcerations in ten patients with diabetes (104 ).
If implant spacers are not used, and when the procedure is employed for the repair of hallux limitus, we prefer to direct a
0.062-inch K-wire across the joint for approximately 2 to 4 weeks to allow better organization of scar tissue at the new joint
interface. The wire is then removed, and range-of-motion exercises are instituted. Although it may seem unusual to pin across a
joint that has previously exhibited a limitation of motion, the functional result does not appear to suffer, and greater stability is
achieved. In addition, the flexor hallucis longus tendon is attached to the base of the phalanx with a nonabsorbable suture to
maintain plantar purchase of the hallux (105 ).
Mayo-Stone and Valenti Arthroplasty

Resection arthroplasty techniques have also been described for the metatarsal head. The Mayo-Stone procedure involves an
angular resection of bone from the metatarsal
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head, whereas the Valenti procedure involves angular resection from both the metatarsal head and the proximal phalanx. The
angles usually are cut at 45 degrees from the dorsal cortex to the plantar joint space. As a result, short flexor insertion is
usually maintained. Both these procedures represent an attempt to maintain alignment of the great toe and restore pain-free
range of motion to the first metatarsophalangeal joint. The Mayo-Stone approach has generally fallen from favor and is not
commonly performed. However, the Valenti procedure is performed by some surgeons.
The results of the Valenti procedure have been mixed. Grady and Axe (106 ) and Saxena (107 ) recommended this procedure in
grade II and III cases with clear intraarticular damage, yet Grady and Axe stated that the procedure should be considered
“temporary and not curative.” The most common complication was sesamoiditis, which was found to be self-limiting.
Continued debate exists on the specific criteria for a Valenti procedure, the ability to revise a failed procedure, and patient
function. Weil has advocated capsular interposition to minimize abutment of raw bone edges and has stated revision, when
necessary, has not been difficult (108 ). Vanore and Corey have discussed a U-shaped capsular approach that is eventually
interposed into the joint from dorsal to plantar and is sutured into the plantar structures (91 ).
Implant Arthroplasty
Implant arthroplasty has played a major role in the advancement of surgery for painful arthritic joints. Implants for the first
metatarsophalangeal joint have provided thousands of patients with the opportunity to ambulate with a pain-free functional
first ray. Some authors have applauded the versatility and effectiveness of implants, especially for hallux rigidus (48 ,61 ,109 ).
It is regrettable that the technique may be overused. Mild to moderate erosion of the articular cartilage alone fails to constitute
a suitable criterion for joint-destructive procedures, provided the subchondral bone plate is intact (60 ). If tension is adequately
relieved and early motion is instituted, then primary joint salvage procedures as already described can be successful.
Implants may be considered in patients who would otherwise be poor candidates for osteotomy because of questionable bone
stock, in whom suitable shortening cannot be accomplished by osteotomy, or in instances of arthritic involvement of the
sesamoidal complex. If smooth motion of the sesamoids cannot be restored, then a procedure will be required that eliminates
these structures from interfering with joint function. Resection arthroplasty, with or without a prosthesis, accomplishes this
goal (see Chapter 4 ).
The profession has evolved from the introduction of hemiimplants to total joint implants. Forette and Thul reported on 18 cases
of Swanson hemiimplants in 1983 and found that 66.7% of the patients had a good to excellent result (110 ). LaPorta et al. and
Sethu et al. reported similar findings with much larger patient populations using a total Silastic implant (109 ,111 ). Mondul et al.
reported one-third the incidence of transfer metatarsalgia from hemiimplantation versus total implantation (62 ). These
investigators attributed this finding to the maintenance of the metatarsal head versus partial resection (62 ). Bonet et al.
reported the results of the total Silastic implant with a follow-up as long as 21 years; 27 patients with 40 implants were
evaluated biomechanically and radiographically at an average of 8.25 years. Ninety-six percent stated they would undergo the
procedure a second time. Although 52% stated that they were “completely satisfied,” 22.5% reported second metatarsalgia, and
47.5% lacked hallux purchase (112 ).
Because the properties of the Silastic and metallic materials differ from those of bone, all materials are either much harder or
softer than the metatarsal head. Therefore, the formation of silicone particles or degenerative bone is inevitable. Both these
events may result in an inflammatory process within the joint. The mechanical demands of the first metatarsophalangeal joint
also place tremendous stress and wear on a single hinge axis, as found in the total silicone joint implants. The introduction of
the titanium grommets to the design probably provides more protection and separation of the softer implant from the denser
surrounding bone rather than serving to impede osseous proliferation into the joint space. This improvement has been found to
increase the life of the Silastic implants.
Along with the popular use of Silastic joint implants has been a reevolution of two-component prostheses. The nonconstrained
design of these devices allows the two components essentially to function independently of each other. Because of the
migratory axis of the first metatarsophalangeal joint, the mechanical advantage of this design is a theoretic benefit. Several of
the implant manufacturers have recommended a more aggressive resection of bone from the base of the proximal phalanx. This
technique serves to reduce tension and jamming of the implant during range of motion. Reattachment of the long flexor tendon
is again recommended to maintain hallux purchase. Koenig and Horwitz reported a 83.5% rate of excellent results with the
Koenig Biomet two-component implant, with a 5-year follow-up (113 ). However, Boberg reported a much lower percentage of
patient satisfaction during an evaluation of the same population (114 ).
One of the first clinical outcomes studies was reported by Gerbert and Chang in 1995 (115 ). They reviewed the results of
patients undergoing implantation with 20 Acumed and 10 Bioaction implants and reported on clinical complications seen over a
2-year follow-up (Fig. 37 ). More than one-third of the patients reported complications, which included flexor tendinitis,
metatarsalgia, sesamoid disorders, metallosis, limitation of joint motion, and pain (Fig. 38 ). Gerbert et al. continued to follow
up these patients and reported further findings in a 4- to 5-year follow-up (116 ). Although the
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clinical range of motion was not ideal, subjective evaluation was overall satisfactory because most patients related minimal pain
at follow-up. Most surgeons have come to realize that whereas objective assessment using these types of implants is at time
equivocal, the subjective experiences voiced by the patients are generally more favorable. However, further study and
evaluation are needed.
FIG. 37. Radiograph of a Kinetikos total joint implant with a 18-month follow-up. Note the angulation within the proximal
stem of the metatarsal component. Good alignment is noted, and motion has been improved and maintained at this follow-
up.
FIG. 38. Intraoperative view of circumferential scar tissue around and between the two components of the implant. This
patient related symptoms of deep joint pain as well as chronic swelling. The patient had only 5 degrees of available total
motion preoperatively.
FIG. 39. Deviation noted within the distal component of the implant. This phenomenon has been noted with impaction of
the metallic components because these materials are much stiffer than the surrounding bone.
Early reports of first metatarsophalangeal joint two-component implants are inconclusive, but many of these devices have
required removal because of both technical error and implant migration (115 ). Inflammatory reactions to the metallic
components have also been noted. It will be important to continue reporting long-term clinical follow-up of the two-component
devices as time progresses. In the early 1990s, five implant designs were on the market. At the time of this writing, only three
are still available.
Renewed interest has also be shown in hemiimplants. The previous designs were either too soft or hard and eventually caused
moderate pain or destruction at the joint (Fig. 39 ). The new designs attempt to use a more biocompatible material to maintain
the life of the joint. The future of these new designs is in question.
During the implant arthroplasty procedures, first metatarsal position should again be evaluated. If a structural metatarsal
elevatus is present, this should also be addressed during arthroplasty techniques. Patients with moderate to severe metatarsus
elevatus may require a proximal osteotomy to realign the joint (Fig. 40 ). When this situation is not recognized, considerably
more stress is applied to the implant, and that, in turn, limits joint motion and decreases the life expectancy of the implant
itself.
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FIG. 40. A,B: Structural realignment of the metatarsal in combination with joint replacement surgery. Realignment of the
metatarsal minimizes abnormal tension on the joint and provides a longer life expectancy to the implant. A plantarflexing
oblique sagittal base osteotomy was performed.
Arthrodesis
Arthrodesis of the first metatarsophalangeal joint has been advocated by several authors as a treatment for hallux limitus
(117 ,118 ). Arthrodesis has been compared with the Keller arthroplasty and in many instances was judged superior
(99 ,101 ,117 ,119 ), because the incidence of postoperative lateral metatarsalgia was lower.
The advocates of arthrodesis have traditionally excluded the younger population, the persons commonly affected by hallux
limitus (120 ,121 ). They give no alternative treatments. Young patients are seen with increasing frequency in the early stages of
disease, not end-stage rigidus. In older, extremely active patients, other types of repair, including cheilectomy and joint
realignment osteotomies, should be considered as primary procedures. Patients with apropulsive gait patterns are more suitable
candidates for arthrodesis because the full range of metatarsophalangeal joint motion is not required for ambulation. Shortening
of the great toe by one-half inch or more makes arthrodesis of the first metatarsophalangeal joint far more tolerable and much
less prone to secondary degenerative changes at the interphalangeal joint. The reader is referred to Chapter 10 for a detailed
discussion of arthrodesis of the first metatarsophalangeal joint.
First metatarsal joint arthrodesis is an appropriate option in cases of moderate to severe joint disease (122 ). The procedure
provides predictable functional stability to the first metatarsal and hallux complex.
In many ways, the postoperative care after hallux limitus surgery is much the same as that for hallux abducto valgus. Weight
bearing may be allowed after the modified Watermann, Green-Watermann, Austin, Keller, or implant procedures. Non-weight
bearing is recommended for at least 6 weeks after proximal osteotomies and may prove advantageous in arthrodeses.
An important factor in the postoperative care is the institution of early range-of-motion exercises for the first
metatarsophalangeal joint. Failure to begin early motion may encourage postoperative adhesions that will serve to restrict
mobility. The patient is taught to place the ankle and foot in plantarflexion and to grasp the first ray with one hand and the
proximal phalanx of the hallux with the opposite hand. The hallux is moved to maximum dorsiflexion and then is stressed
slightly while the first ray is stabilized with the opposite hand. The patient carries out several repetitions of the motion and is
encouraged to repeat the exercise several times daily. This is especially important if the sesamoid apparatus-flexor plate
required an aggressive surgical release. Obviously, a large part of the aftercare process depends on patient compliance.
Patients may need to monitor range of motion of the joint for up to 6 months postoperatively. In some instances, range-of-
motion exercises may be continued for that long. Regardless, early attempts at joint mobilization are important to the
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overall success of these joint salvage procedures. However, the visible range of motion achieved intraoperatively is not fully
maintained during the healing period. Because of capsular adhesions and fibrosis, the patient usually loses at least 10 degrees of
final motion during the healing period. Modalities such as continuous passive motion or Dynasplint may be employed if the loss
of motion is significant.
Once the patient resumes weight bearing in normal shoe gear, orthotic control may be indicated if the primary deforming force
was not addressed surgically. Stuck et al. noted that patients who underwent implant arthroplasty sustained a longer, more
effective hallux purchase in stance when orthotics were used postoperatively (123 ). The addition of accommodative forefoot
padding may also help to alleviate any transient metatarsalgia that develops. After decompression procedures, patients may
occasionally notice a slight decrease in hallux purchase. This relaxation is a result of the shortening of the osseous structures
that, in turn, relaxes the tendons and plantar fascia and acts on the plantar aspect of the first metatarsophalangeal joint.
SURGICAL COMPLICATIONS
Complications of hallux limitus surgery are general as well as specific to each procedure. The most common specific
complication noted is persistent limitation of motion at the first metatarsophalangeal joint. This most often results from
postoperative scarring during the healing process, particularly if good motion was achieved at the time of surgery. In particular,
failure of the sesamoids to maintain a smooth gliding function precludes good function. In other instances, this complication
may be due to the inability to realign the first metatarsal or medial column adequately into a functional position. However, in
many patients, the lack of mobility seen in the postoperative setting does not appear to be symptomatic. The decompression of
the joint associated with numerous repair procedures appears to alleviate joint tension and jamming despite the subsequent
periarticular scarring.
Excessive plantar displacement of the metatarsal head may result in a floating hallux or a hallux extensus. The latter deformity
is followed by adaptive plantarflexion deformity at the hallux interphalangeal joint. Chronic sesamoiditis may also result from
excessive plantar position of the first metatarsal head with any of the osteotomy techniques. Lesser metatarsalgia may occur on
occasion with the shortening of the first metatarsal that is incorporated into the distal osteotomies, and, if present, it is usually
transient.
SUMMARY
Because of the multiple procedures and approaches to hallux limitus, it is easy to discern that the ideal means of repairing this
condition has yet to be discovered. Considerable overlap exists in the indications for some of the procedures, and there may be
more than one suitable option for any given deformity. Nonetheless, progress has been made, particularly in understanding the
factors that lead to limited mobility of the first metatarsophalangeal joint. Current philosophy regarding the surgical
management of hallux limitus or rigidus is based on whether the joint is salvageable from the onset. When joint salvage is
possible, joint decompression by shortening and plantarflexory osteotomies have proven successful. The results are a better
structural environment and relaxation of periarticular soft tissues. Joint-destructive procedures have provided pain relief, but
often at the cost of joint function. In a patient who presents with hallux limitus with mobile sesamoids, most surgeons prefer to
employ a sequential dissection and repair approach to address the periarticular contractures and to improve metatarsal position,
joint function, and range of motion. In general, distal osteotomies are primarily indicated for joint decompression, whereas
proximal osteotomies primarily address a structural elevatus.
Although there are no absolutes regarding procedural selection, older patients, those with neuropathy, osteopenia, immobile
sesamoids, and patients with significant joint deterioration may respond well to the use of a Keller arthroplasty with or without
an implant. Patients with a neurologic component to the deformity, failed implant surgery, or significant joint deterioration
with hallux rigidus are good candidates for arthrodesis. Physiologic age and activity requirements also influence procedural
selection.
Implant arthroplasty, although a viable option for hallux rigidus, provides variable degrees of success. In addition, the implant
has a potentially limited life expectancy, and additional revisional surgery may be needed later. The likelihood that any of the
currently available implants will withstand or survive the requirements of a young patient is doubtful.
Other options may be available in the future. More research has been directed at replacing diseased cartilage in arthritic joints.
The fibrous and hyaline-like cartilage that is produced by subchondral drilling and abrasion techniques has been shown to
degenerate after a few years. The arena of cartilage grafting is continually evolving, and these concepts have also been
considered within the first metatarsophalangeal joint. Early experimental studies have shown that periosteum possesses a
chondrogenic potential when it is placed into a chondrotrophic (mobile) environment (124 ). Mobilization is the key in the
differentiation of periosteum into cartilage rather than bone. Ritsila et al. reported on six periosteal grafts from the anterior
tibia to treat hallux rigidus and Freiberg's disease (125 ). Promising techniques include autogenous osteochondral grafts or
mosaicplasty and autologous chondrocyte transplantation. These techniques of perichondral grafting and more current research
on autologous cartilage grafting are exciting frontiers to explore in joint salvage and, one hopes, will provide the foot and ankle
surgeon with another viable option in the treatment of hallux limitus.
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76. Laakman G, Green RM, Green DR. The modified Watermann procedure: a preliminary retrospective study. In: Vicker NS, ed. Reconstructive surgery of the foot and leg: update '96. Tucker, GA: Podiatry Institute,
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77. Brahm S, Gerbert J. A potential cause of hallux adductus in bicorrectional Austin bunionectomies. J Am Podiatry Assoc 1983;73:155-157.
78. Youngswick F. Modifications of the Austin bunionectomy for treatment of metatarsus primus elevatus associated with hallux limitus. J Foot Surg 1982;21:114.
79. Boberg J, Ruch JA, Banks AS. Distal metaphyseal osteotomies in hallux abducto valgus surgery. In: McGlamry ED, ed. Textbook of foot surgery. Baltimore: Williams & Wilkins, 1987:173-184.
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92. Cohen M, Roman A, Liessner P. A modification of the Regnauld procedure for hallux limitus. J Foot Ankle Surg 1992;31:498-503.
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95. Durrant MN, Siepert KK. Role of soft tissue structures as an etiology of hallux limitus. J Am Podiatr Med Assoc 1993;83:173-180.
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Chapter 16
Metatarsus Adductus and Allied Disorders
Patrick S. Agnew
NOMENCLATURE
The term metatarsus adductus was described by Ganley and Ganley as being the least cumbersome and most accurate description of the
shared component (adduction of the metatarsal bones) present in a group of disorders (1 ). Extensive controversy surrounds the subject of
metatarsus adductus. This controversy persists because no study has provided complete answers to some basic questions. These questions
include the etiology, prognosis, and treatment of this condition.
Even the terminology is debatable (2 ). Some authors prefer the terminology used in ancient anatomic dissections of a fresh cadaver
executed by hanging, in which the foot is in a varus position (3 ). The more practical approach is to describe the condition in terms of the
functional anatomy (i.e., the appearance of the weight-bearing foot). The issue of terminology is further complicated by the existence of
several major variations of metatarsus adductus and countless shades of penetrance. The basic list of foot deformities that possess
metatarsus adductus as an obvious characteristic includes metatarsus adductus, metatarsus adducto varus, cavoadducto varus,
cavometatarsus adductus (also known as serpentine or “Z” foot), and talipes equinovarus (4 ). Talipes equinovarus often includes
metatarsus adductus as a component, along with forefoot adducutus.
Metatarsus adductus as an isolated deformity is characterized by a uniplanar, adducted metatarsus. It may be differentiated from other
complex deformities such as talipes equinovarus by the absence of rearfoot deformity associated with the metatarsus adductus deformity
(Fig. 1 ). However, the apex of the metatarsus adductus deformity may vary from the metatarsal diaphysis to the rear area of the
midtarsus. Isolated metatarsus primus adductus may also present similarly, but it lacks the prominence of the styloid process of the fifth
metatarsal.
Metatarsus varus includes varying amounts of metatarsus adductus but also demonstrates forefoot varus in the open kinetic chain (5 ). The
rearfoot is normal, at least until weight bearing is initiated, and produces either uncompensated, partially compensated, or compensated
forefoot varus (6 ). In the case of the latter (fully compensated forefoot varus), the rearfoot must pronate.
Cavoadducto varus includes metatarsus adductus and rearfoot varus. This condition is more commonly acquired from neuromuscular
disease (7 ) (Fig. 2 ).
The compensated metatarsus adductus foot occurs when metatarsus adductus is accompanied by varying amounts of rearfoot pronation. In
a fully compensated metatarsus adductus deformity, the foot may appear almost normal (Fig. 3 ). Subdivisions of compensated metatarsus
adductus have been described by Berg (8 ), who detailed the apexes of the deformity. Forefoot and midfoot deformity is termed
cavometatarsus adductus. Forefoot and hindfoot deformity is termed skewfoot. Complex skewfoot includes extensive deformity throughout
the foot.
Other terms used have included parrot foot, pigeon toe, ding foot, C-foot, and hooked foot (5 ). Standardized terminology is preferred and
is necessary to facilitate intercultural and international communication.
INCIDENCE AND ETIOLOGY

The overall incidence of deformities that are primarily characterized as metatarsus adductus has been reported at 1 per 1,000 live births.
This is about 10 times more frequent than talipes equinovarus (9 ). Kite was the first to recognize an apparent modern increase in the
incidence (3 ). Whether this trend is a result of better recognition or other possible causes is unclear. Other potential causes for the
increased incidence include a wider distribution of infant care manuals that encourage belly sleeping (in this position, babies often sleep
on the feet and effectively splint the lower legs and feet in a position of medial rotation and adduction), increasing birth weight with
better prenatal nutrition, broader intervals between sibling births, and older maternal age at birth.
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A large-number comparison of the incidence of metatarsus adductus in developed countries versus developing countries may help to clarify
whether any of these postulated causes has merit.
FIG. 1. Neonate with metatarsus adductus as part of a talipes equinovarus deformity. Note the abnormal rearfoot positioning with
rearfoot varus and ankle equinus.
FIG. 2. Cavoadducto varus deformity. The ability of the patient to assume a plantigrade stance indicates the absence of equinus
deformity and helps to to differentiate this deformity from talipes equinovarus.
Many theories on the origin of metatarsus adductus exist. These may be grossly classified as “packaging” defects or “manufacturing”
defects (10 ). It is also conceivable that either mechanism could produce the same clinical appearance. Although the cause is academically
interesting, I am unaware of any evidence demonstrating that the prognosis for resolution of an inherited disorder is any worse than that of
an acquired defect.
Evidence of intrauterine pressure, or a “packaging” defect, as a cause includes the prevalence of left-sided over right-sided deformity
(11 ). The left leg is more often positioned against the firmer spine than against the abdomen in utero. Ponseti and Becker also noted a
higher incidence in first pregnancies, when presumably the womb is less stretched (12 ). Preterm and multiple fetus births also have a
higher incidence of metatarsus adductus (13 ).
Wynne-Davies noted an increased appearance of metatarsus adductus in siblings, a finding possibly indicating a genetic or “manufacturing”
defect (9 ). However, because an inheritance pattern is not clear, multigenic inheritance with variable penetrance is a possible mechanism.
Abnormalities in the mother's anatomy could also explain higher sibling involvement. A later work by Wynne-Davies and associates failed to
demonstrate support for this premise (14 ).
Absence of the medial cuneiform has been cited as one possible cause of metatarsus varus (15 ). This cause has not been supported by
other studies. However, abnormal growth of the medial cuneiform is a likely cause of persistent metatarsus
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adductus. This condition has been illustrated in histologic sections (16 ).
FIG. 3. Compensated metatarsus adductus deformity exhibiting valgus of the heel and medial prominence of the talonavicular joint.
This indicates excessive rearfoot pronation and almost makes the patient's right foot appear normal.
Abnormal muscle positions have also been suggested. Ghali et al. reported an exaggerated plantar insertion of the tibialis anterior tendon
(17 ), although another study was unable to demonstrate this abnormality in cadaveric specimens (18 ). Browne and Paton suspected
contraction of the posterior tibial tendon as a cause of metatarsus adductus (19 ). An abnormal insertion of the abductor hallucis has been
noted by Sgarlato (20 ). Thompson and Simons theorized that hyperactivity of the abductor hallucis could produce metatarsus adductus
deformity or at least mimic it and resist its correction (21 ).
Tax and Albright suspected that an arrest of normal ontologic rotation of the foot resulted in persistent metatarsus adductus (22 ).
Metatarsus adductus is a normal position of the foot in early fetal development (Fig. 4 ).
Many congenital syndromes include metatarsus adductus as a component. Deformation sequences may also terminate in metatarsus
adductus. A higher index of suspicion may lead the foot and ankle physician to suspect a comorbid disease. In infants, the “hard tissue”
(bone) is soft cartilage analog, and the “soft tissue” (ligament) is normally strong or hard. The fetus with ligamentous laxity is unable to
resist the deforming forces of the primigravida womb, and metatarsus adductus may be induced (23 ) (Figs. 5 and 6 ).
FIG. 4. Ultrasonogram of the foot of a third trimester fetus with mild metatarsus adductus.
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FIG. 5. Laxity of ligaments in individuals with Ehlers-Danlos syndrome may leave bones unprotected from intrauterine forces.
FIG. 6. Metatarsus adductus and early secondary digital deformities afflict this patient who has Ehlers-Danlos syndrome.
CLINICAL EVALUATION
Presentation
Metatarsus adductus presents as six distinct forms:
1. Simple metatarsus adductus is characterized by an abnormal forefoot to rearfoot relationship, with the metarsals abducted on the
transverse plane at Lisfranc's articulation. Pure adduction occurs on a plane parallel to the ground.
2. Metatarsus adducto varus is present when the adducted metatarsals have an additional frontal plane varus component. Therefore, the
deformity exists on two planes, that is, adduction (transverse) and varus (frontal).
3. Metatarsus primus adductus exists when only the first metatarsal is adducted and the intermetatarsal angle is greater than 15 degrees.
4. Complex metatarsus adductus is present when a valgus deformity of the rearfoot coexists. In this instance, the calcaneus, cuboid, and
navicular are all rotated laterally beneath the talus. This is referred to as the serpentine foot or Z-foot, in which the navicular is
articulating on the lateral side of the talar head. Normally, the talus, navicular, and the first metatarsal form a straight line, but in this
foot, a line drawn through the long axis of the talus deviates laterally through the navicular and then deviates medially through the first
metatarsal to form a Z. This foot is identified in the neonate with a large increase in the talocalcaneal angle because the navicular shadow
cannot be seen on radiograph. Berg further subdivided the complex metatarsus adductus deformity according to pathologic findings in
three foot segments: forefoot, midfoot, and hindfoot (8 ). The first condition, complex metatarsus adductus, is a deformity of the forefoot
and midfoot. Its characteristics are (a) an adducted forefoot, (b) lateral translation of the midfoot, and (c) a normal hindfoot. The second
category is skewfoot, a deformity of the forefoot and hindfoot, which consists of (a) an adducted forefoot, (b) a normal midfoot, and (c)
hindfoot valgus. In the third condition, complex skewfoot, all three components are deformed, resulting in (a) an adducted forefoot, (b)
lateral translation of the midfoot, and (c) hindfoot valgus. The key to the lateral translation of the midfoot is that the calcaneal midline
intersects the medial one-third of the cuboid. Normally, the cuboid is directly in front of the calcaneus.
5. Talipes equinovarus is the classic clubfoot, with adducted metatarsals as one of the three basic components, the other two being
rearfoot varus and equinus. Equinus is the key factor that differentiates this condition from metatarsus adductus. Equinus is invariably the
more difficult component to correct.
6. Cavoadducto varus is a deformity in which the metatarsals are adducted and the rearfoot is in varus (7 ). It differs from the classic
clubfoot (No. 5) in that equinus is absent. It differs from metatarsus varus (No. 2) in that the first metatarsal is plantarflexed (frontal plane
valgus). This deformity is seldom seen in the infant and usually appears during the early teens, a finding suggesting a possible neurologic
cause.
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FIG. 7. Evaluation of the position of an infant's feet in all three cardinal planes is necessary. Comparison of the lateral border of the
foot to a straight edge may highlight deformity.
FIG. 8. Simulated weight bearing may demonstrate dynamic deformity.
Physical Examination
The ARM method of physical examination described by Ganley facilitates immediate appreciation of the metatarsus adductus deformity
(24 ). ARM stands for the components of the pediatric evaluation: attitude, relationship, and movement. The resting “attitude” of the foot
in the non-weight-bearing neonate with metatarsus adductus is pointing medially, unless more proximal deformity negates this appearance.
Therefore, appreciation of the “relationship” of the forefoot to the rearfoot in all three cardinal planes is necessary (Fig. 7 ). In all
deformities that exhibit metatarsus adductus, the forefoot is adducted toward the body's midline relative to the rearfoot. Deformity in the
hindfoot, leg, knee, thigh, or hip may, however, produce an overall rectus or laterally rotated attitude. “Movement” of the forefoot
relative to the rearfoot may be possible in varying amounts. Simply stimulating the primitive reflexes of the lower extremity may
spontaneously reduce the deformity in some patients temporarily, whereas firm laterally directed force may not in other patients.
Apparent changes may occur rapidly in infancy. Positional abnormalities present at birth may spontaneously resolve as the effect of
maternal hormones diminishes. Mild-appearing deformities may become much worse when weight bearing begins. Thus, even mild flexible
deformities must be frequently reexamined, and weight bearing should at least be simulated at each visit (2 ,17 ) (Fig. 8 ).
Other deformities have been associated with metatarsus adductus (14 ). Tibial torsion and femoral torsion are frequently observed
comorbid conditions with metatarsus adductus (25 ). Developmental dysplasia of the hip has also been reported as more common with
metatarsus adductus; however, this claim has been disputed by Wynn-Davies et al. (14 ). Appropriate physical examination for these
conditions
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should be included in the lower extremity examination of any infant. Suspicious hip movement or sounds should be assessed or referred for
appropriate management.
FIG. 9. Flexibility test. A,B: Severity of deformity is tested by attempts at manual correction. In this instance, the foot can be
corrected but only with force; thus, the deformity is moderate.
Prognostic Classification
With the patient supine, the examiner can lift the patient's foot by the toes. Bestard and associates considered the results positive when
the deformity persisted in this position (26 ). Berg employed a bisection of the plantar heel to estimate the severity of the deformity, but
he admitted that his method could not predict outcomes (8 ).
Ganley and Ganley preferred a simple flexibility test, which is reproducible and uncomplicated (1 ) (Fig. 9 ). If the foot is manually
correctable without force, this is considered a mild deformity. If the deformity is only correctable with force, it is classified as moderate.
A severe case is not manually reducible. Although this method has been suggested as a good prognostic test for the success of treatment,
no published studies have substantiated this claim. In addition, although three levels of severity are described, only two basic treatment
protocols are recommended. These are treatment or no treatment. A system that fails to provide treatment guidance is of little use to
clinicians.
I am unaware of any system that can correctly predict the outcome of any form of metatarsus adductus. Therefore, I do not rely on any
specific tests to predict outcomes.
DIAGNOSTIC IMAGING
Several roentgenographic methods measuring the amount of metatarsus adductus have been described. Regrettably, most of these
methods are useful only in a fully ossified skeleton. This problem was addressed by Ganley and Ganley, who used the calcaneus as a
reference point (1 ). They recognized that the metatarsals are the most obvious component involved and show varying degrees of
deformity. The lesser tarsal bones in a neonate, however, are not measurable and are radiographically silent. In many types of metatarsus
adductus, the talocalcaneal relationship may be abnormal. These investigators went on to state that it is axiomatic that a variable is best
measured against a fixed reference point.
In the clinical examination of the infant, a preferred method is to use the more proximal anatomy as the fixed point against which the
distal parts are measured with respect to attitude and range of motion (24 ). To be consistent, the examiner should consider a correlative
method regarding the radiographic study. The tibia is ideal for recording foot position when it is viewed laterally inasmuch as the foot and
leg are on the same plane. However, in the dorsoplantar view of the foot, the leg is at a right angle to the x-ray film, and the tibia
becomes less than an ideal reference point. Recognizing this problem, Ganley and Ganley stated that the talus is the foot structure with
the most constant and normal relationship with the leg (1 ). This is especially true in metatarsus adductus deformity because equinus and
dorsiflexion do not enter into the problem. The talus moves on the sagittal plane but is relatively fixed in the other two planes in the ankle
mortise. No one has suggested an abnormal talotibial position in metatarsus adductus. Possibly, severe adduction deformity could influence
the angle between the talar head and body, but for the most part, the central axis of the talus represents an extension of the leg and is
the
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best starting point to measure metatarsus adductus deformity. Therefore, Ganley and Ganley preferred the talocalcaneal angle of
divergence, or Kite's angle, as the first recommended measurement to determine the presence of rearfoot abnormality (1 ). This angle is
normally 20 to 25 degrees. If the talocalcaneal angle is within normal limits, then a rearfoot abnormality can be ruled out, and the talar-
first metatarsal angle (i.e., the angle formed by the long axis of the talus and the long axis of the first metatarsal) should determine the
degree of metatarsus adductus. Simons showed that in the infant, the talar-first metatarsal angle is normally 0 to −20 degrees (27 ).
FIG. 10. The talocalcaneal angle is normally 20 to 25 degrees. If this is normal, as illustrated, then the first metatarsal talar angle
will give a reasonable assessment of forefoot adduction. The second metatarsal calcaneal angle provides a valid assessment of
metatarsus adductus regardless of the rearfoot status.
The calcaneal-second metatarsal angle (i.e., the angle formed between the long axis of the calcaneus and the bisection of the long axis of
the second metatarsal) is probably the best method for measuring forefoot adduction (Fig. 10 ). The central axis of the calcaneus is
parallel to the lateral border, and because the lateral border of the calcaneus is often easily visualized on a radiograph, the calcaneal-
second metatarsal angle is often measured between the lateral border of the calcaneus and the long axis of the second metatarsal. The
calcaneal-fifth metatarsal angle is normally 0 degrees (12 ). The central axis of the calcaneus bisects the fourth metatarsal (28 ). Ganley
and Ganley found that the normal calcaneal-second metatarsal angle is 15 degrees, plus or minus 3 degrees (1 ).
Therefore, dorsoplantar foot radiographs are used to determine the degree of rearfoot abnormality using the talocalcaneal angle. The
talar-first metatarsal angle may be useful in this regard, although it is valid only if simple metatarsus adductus exists. A laterally
translated cuboid, or an increased calcaneal-cuboid abduction angle, may indicate a midfoot abnormality. The calcaneal-second
metatarsal angle (after subtracting 15 degrees) is the most constant determinant of the deformity, according to Ganley and Ganley (1 ).
Metatarsus adductus does not present any distinguishing characteristics on a lateral radiograph. However, assessment of the forefoot to
rearfoot relationships, and the degree of compensation in the rearfoot, can be accomplished. A foot that demonstrates significant subtalar
joint pronation has a smaller sinus tarsi and an anteriorly broken cyma line, and the talar bisection falls below the first metatarsal. The
calcaneal inclination angle often is also decreased. The lateral talocalcaneal angle is normally between 25 and 45 degrees. In the presence
of excess pronation in the rearfoot, this angle may be greater. In the foot with a lack of adequate pronation and showing little rearfoot
compensation, the calcaneal inclination angle is increased. One may also see a “bullet-hole” appearance of the sinus tarsi and a
posteriorly broken cyma line. The lateral talocalcaneal angle is typically decreased and is less than 25 degrees.
The traditional method used for measuring the deformity has been to compare the lesser tarsus axis with that of the longitudinal axis of
the metatarsals (29 ) (Figs. 11 and 12 ). Yu and Dinapoli considered 15 to 20 degrees a mild metatarsus adductus deformity, 21 to 25
degrees a moderate deformity, and greater than 25 degrees a severe deformity (30 ) (Fig. 13 ). Weissman considered the normal
metatarsus adductus angle to be up to 12 to 14 degrees (31 ). Heatherington and associates considered an angle greater than 14 to 16
degrees to be abnormal (32 ). The navicular-first metatarsal angle has been used to assess residual forefoot adduction in clubfoot, and this
requires that one outline the base of the navicular bone (33 ). However, this technique is not possible during the first year of life. Engel et
al. used simple and convenient measurement of the longitudinal axis of the second cunieform as the alignment of the lesser tarsus (34 )
(Fig. 14 ). This approach alleviated the often difficult plotting of the medial and lateral points of the lesser tarsus used in the more
traditional method. These authors used 571 radiographs to arrive at a normal value of 24 degrees, whereas the value using the traditional
method was 21 degrees. This method, however, is also difficult in the infant.
Lepow and others combined the arcs of a circle centered about the base of the first and fifth metatarsals to measure metatarsus adductus
(35 ). The juncture of the arcs forms a central line against which the long axis of the second metatarsal is measured. The problem with this
method is that the measurement records the inner relationships of the metatarsals to each other. It is in effect measuring a deformity
against itself. It does not relate the more proximal (normal) parts.
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FIG. 11. A: Diagram demonstrating critical points plotted for determination of longitudinal bisection of lesser tarsus. B: Shows lesser
tarsal axis (LTAx), which represents a perpendicular to the bisection of lesser tarsus. Points E and F are midpoints between A and B
and C and D, respectively, and line EF is the bisection of the lesser tarsus. Dotted line G represents bisection of the second
cuneiform.
FIG. 12. Diagrammatic representation of metatarsus adductus angle (C) formed by the longitudinal axis of the second metatarsal (line
A) and the longitudinal axis of the lesser tarsus (line B).
FIG. 13. Dorsoplantar radiographic view of patient with moderate metatarsus adductus deformity. Line ABD represents the
longitudinal axis of the lesser tarsus. Line BC is the longitudinal axis of the second metatarsal. Angle ABC is the resultant metatarsus
adductus angle.
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FIG. 14. Alternative method of determining metatarsus adductus angle employing the longitudinal axis of the middle cuneiform (C')
(rather than the longitudinal axis of the lesser tarsus) in relationship to the longitudinal axis of the second metatarsal (A'). This is
referred to as Engel's angle (B').
Thompson and Simons stated that roentgenograms are not needed to evaluate or track most cases of metatarsus adductus (21 ). Accurate
measurements may also be difficult to reproduce (36 ). Radiographs may help to confirm a complex deformity when such is suspected, and
this may alter treatment techniques. For example, the manipulation of the calcaneus is entirely different in treating metatarsus cavovarus
than it is for simple metatarsus adductus or complex metatarsus adductus. Banks and associates showed a significantly increased risk of
juvenile hallux abductovalgus when the metatarsus adductus angle was greater than or equal to 14 degrees (37 ). This may be another use
for roentgenograms in attempting to provide a prognosis.
Photographs and, more recently, photocopies have been used to document metatarsus adductus. These have even been used in research.
Regrettably, erroneous conclusions may be drawn with these techniques, because although the overall external appearance of the foot
may improve spontaneously, the actual positioning of the bones may be abnormal (10 ).
Magnetic resonance imaging and computed tomography scans can produce detailed images in the incompletely ossified infant or child's foot
with metatarsus adductus. However, unless this approach is essential to planning invasive treatment, the need for deep sedation to permit
such time-consuming studies seems unnecessarily risky. Although magnetic resonance imaging can demonstrate the unossified structures of
the tarsus, radiographs are the most efficient means of evaluating the talocalcaneal and talar-first metatarsal relationships (38 ).
TREATMENT
In the absence of a reliable prognostic indicator or test, the decision whether to treat and how to treat a patient with metatarsus adductus
remains more of an art than a science. Many disorders have been associated with uncorrected metatarsus adductus including difficulty in
wearing shoes and bunion formation (39 , 40 , 41 ). Many different treatment methods have been proposed, often focusing on the patient's
age. This approach is practical, although unfortunate. The method is practical because most practitioners encounter uncorrected cases at
every age level (42 ). The approach is unfortunate because so many uncorrected cases result from a lack of uniformity in recognition and
treatment.
The natural history of metatarsus adductus is controversial (43 ). Treatment methods also lack satisfactory outcomes data. This situation
has led some investigators to recommend observation in the hopes of spontaneous resolution (10 ). However, few clinicians disagree with
the conclusion that earlier treatment is safer and easier than later treatment (21 ,44 , 45 , 46 , 47 ). Moreover, few parents are interested
in how often the deformity spontaneously improves (or apparently resolves), but instead they simply want to know whether their child will
be all right. Because accurate prognostication is not possible, treatment in most cases is indicated.
Conservative Therapy
Because maternal hormones are present for several months in the neonate, observation may be reasonable at first. Discouraging belly
sleeping may be beneficial as well. The prone sleeping position perpetuates any abnormal foot position because the foot cannot rest in a
rectus state. Fears of sudden infant death syndrome from aspiration of vomitus while the infant is supine are unfounded, based on
published data (48 ).
Manipulation
“Stretching” the infant's foot deformity is a misnomer. As stated earlier, the ligaments are stronger than the cartilaginous bone analog.
Manipulation of the foot by family members has been advocated by some authors (49 ). Other investigators have little confidence in the
parents' ability to proceed correctly (3 ). It appears that the neonate with mild to moderate deformity can be treated by manual
manipulation from the family while they wait for the elimination of the maternal hormones from the infant, with little risk to the patient.
Neutral positioning of the normal structures (usually
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the rearfoot) must be explained and demonstrated, to reduce the risk further that family members will induce new deformity. Frequent
reexamination is necessary and more thorough treatment is indicated if progress is not satisfactory.
FIG. 15. Cast correction of metatarsus adductus. A: Hand position is important during casting. The rearfoot is held in neutral or slight
varus, the tarsus is stabilized at the cuboid level, and the forefoot is abducted. B: Deformity in child before casting. With the knees
in neutral, the feet are medially rotated and in adductovarus. C: After serial casting, both knees are again placed in neutral and the
feet are rectus. The correction will be maintained with splints.
Casting
Casting is the favored method of treatment for infants from birth to 9 months (50 ) (Fig. 15 ). Some clinicians even consider casting until
the patient is up to 4 years of age (21 ). The use of various materials for holding the deformed foot firmly in an improved position has been
practiced since antiquity. No other noninvasive technique offers such a precise, “around the clock” influence on growing bone (51 ).
Extrafast-setting plaster and fiberglass tape have been most popular. I prefer plaster because it is more precisely moldable and easily
removed by the family, although other interesting casting methods exist (22 ,51 ,52 ). The method described by Ganley optimizes these
two important characteristics of plaster casting (53 ). Extended manipulation of the patient's foot before the casting is impractical because
of the infant's limited patience. It is also unproductive because only the constant, gentle pressure provided by the cast results in bone
remodeling. Again, attempting to “stretch” the infant's deformity is unrealistic. Instead, the foot is gently positioned in the direction of
desired correction and rapidly grows in that direction like a young plant. A minimal layer of cotton cast padding is applied under controlled
compression. Too much padding reduces the cast's ability to influence the bone. Skin adherent may be needed on particularly elusive feet
(i.e., small feet or extremely active patients).
Other options exist for infants 6 to 12 months old. Thompson and Simons did not recommend using reversed shoes because these devices
may induce eversion of the heel and may cause skin irritation (21 ). Besides casting, splints and surgical procedures are available for
patients in this age group.
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FIG. 16. Rear view of a Ganley splint configured to position the legs in some lateral rotation and the forefeet in abduction. Note the
ability of the splint to hold the heels in slight inversion to resist inadvertent pronation while correcting the deformity.
Splinting
Various splints have been designed for the treatment of metatarsus adductus. Most authors recommend the use of splints after cast
correction for the retention of the corrected position, although some advocate use of their splint as monotherapy. As previously described,
most deformities that include metatarsus adductus may preclude the use of non-adjustable, prefabricated splints (26 ). Fortunately, many
splints are readily adjusted (54 ). One user-friendly, easily adjustable, and inexpensive splint is the Ganley splint (55 ) (Fig. 16 ). This
device permits positioning of the forefoot and rearfoot in their ideal state in all three planes, independent of one another. The splint may
also be adjusted, in conjunction with appropriate shoes, to accommodate growth of the patient's foot. The Ganley splint is reusable.
Although splinting is usually reserved for follow-up care after casting or surgery, splinting has some merit as isolated therapy (56 ). The
ability to remove the device for skin care and range-of-motion exercises is desirable, as is the freedom of movement of unrelated
structures that some splints offer. Rapidly improving deformities may even be treated during sleep only, to allow unrestricted movement
at other times. It certainly seems reasonable to attempt splinting before considering surgical correction for some deformities, especially in
a toddler (1 to 2 years old), for whom effective surgical procedures are scarce.
A newer splinting technique has become possible thanks to improvements in synthetic cast materials. A posterior splint may be fabricated
using these materials and then snugly molded to the toddler's foot in a corrected position (Fig. 17 ). The patient's caregivers can then apply
the splint by using an elastic bandage, and the foot will be precisely held in position. The cost of the materials is minimal, often an
important consideration in today's managed-care environment.
Shoe Therapy
Shoe therapy was popular in toddlers in the past. Often, however, the walking toddler is old to begin such therapy. Other treatment, such
as casting or splinting, may be more effective, although it may also be more cumbersome. This and possibly other factors may make shoe
therapy more appealing. However, investigators have shown that shoes are not able to control the rearfoot (57 ). Therefore, attempts to
achieve correction with shoes more likely force rearfoot pronation to occur and induce iatrogenic compensated metatarsus adductus
deformity (58 ).
Surgical Therapy
Failure of conservative treatment in children older than 2 years of age may be an indication for surgery (56 ). Surgical treatment at an
early age has been primarily targeted at soft tissue release, whereas osseous procedures have been advocated in older children,
adolescents, and adults (59 ). Many different surgical procedures have been proposed for metatarsus adductus deformity. The choice of
surgical procedures depends on several factors including age, severity of deformity, and the presence of associated deformities. The
surgical alternatives can be broadly divided into soft tissue and osseous procedures. A combination of soft tissue and osseous techniques
may be required in some cases.
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FIG. 17. Splint for correction of metatarsus adductus deformity. A: After rolling about four layers of 4-inch cast padding and 3- or 4-
inch fiberglass, measured from the infant's toe tips to the proximal thigh, the assistant wraps the device snugly against the posterior
leg. B: While the parents entertain the patient, the assistant gently controls the patient's thigh. The operator positions the patient's
heel in a neutral to slightly inverted position and gently pushes the fiberglass over the cuboid medially. The other hand clamps the
metatarsal heads in the transverse plane while the first metatarsal head is pushed laterally. C: The hardened splint is dispensed with
instructions for the patient's parents to apply before bed, by using an elastic bandage to hold the splint just tightly enough to stay in
position. Evaluation of the digital venous filling time must be taught to the family and executed by them before bed.

Isolated soft tissue procedures have limited usefulness in the skeletally mature patient. This finding makes the window of opportunity in
which these procedures would be helpful small. Soft tissue procedures are most effective from birth to about 6 years of age. However, soft
tissue procedures may be used in some older patients or as adjuncts to osseous procedures at almost any age. Soft tissue procedures
generally fall into one of two categories: abductor hallucis release and tarsometatarsal release.
Abductor Hallucis Release

Thompson and Simons mentioned that dynamic hallux varus may persist after conservative correction of metatarsus adductus but
spontaneously resolves after 12 years of age (21 ). However, severe contraction of the abductor hallucis is present in some cases of
metatarsus adductus and presents as a hallux adductus or hallux varus deformity (Fig. 18 ). This condition often delays diagnosis because it
is readily apparent only on weight bearing (Fig. 19 ). Abduction of the hallux can aid in identifying the abnormally inserted or tight
abductor
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hallucis tendon as well (Fig. 20 ). Surgical treatment by sectioning, lengthening, or removal of the abductor hallucis tendon or muscle has
been advocated (33 ,60 , 61 , 62 , 63 , 64 ). Thomson described resection of the abductor hallucis muscle and reported good results (60 )
(Fig. 21 ). Lichtblau was the first to describe a tenotomy of the abductor hallucis tendon for persistent bowstringing at the joint level (61 )
(Fig. 22 ). More recently, Fagan reported effective results when abductor hallucis tendon release was combined with limited midfoot
arthrotomy in more mild deformity and younger patients (42 ). Procedures to release or resect the abductor hallucis muscle-tendon
complex are indicated at any age for isolated hallux adductus or metatarsus primus adductus, but not for the overall structural correction
of a metatarsus adductus deformity.
FIG. 18. Clinical appearance of a child with mild metatarsus adductus and severe hallux adductus.
FIG. 19. Weight bearing accentuates the hallux adductus deformity. The patient has severe hallux adductus with splaying between
the hallux and second toe with only mild metatarsus adductus.
FIG. 20. Abductory force applied to the great toe with rearfoot held stable can be a good clinical aid in diagnosing a tight abductor
hallucis muscle-tendon complex.
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FIG. 21. A: Incisional approach for the Thomson procedure or partial resection of the abductor hallucis tendon-muscle complex. B:
Exposure of the insertional area of the abductor hallucis. C: Resection of the insertional portion of the abductor hallucis tendon-
muscle complex. D: Medial first metatarsophalangeal joint capsulotomy is also performed. E: Immediate postoperative appearance.
F: Healed incision 2 months postoperatively. G: Preoperative radiograph demonstrating metatarsus adductus deformity with hallux
adductus. H: Postoperative radiograph after Thomson procedure. Note the improved position of the hallux. The metatarsus adductus
deformity remains, because it was not surgically addressed in this case.
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FIG. 21. Continued.
FIG. 22. A: A small, 1- to 2-cm, medially placed incision allows excellent exposure to perform the tenotomy of the abductor hallucis.
B: Sectioning of the tendon of the abductor hallucis tendon as described by Lichtblau.
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FIG. 23. Heyman, Herndon, Strong procedure. A: Dorsal transverse incision for tarsometatarsal mobilization. B: Alternative dorsal
approach using two longitudinal incisions. Exposure of the first and second metatarsocuneiform joint by a medial incision is shown. C:
A hemostat may be inserted between first and second metatarsals and spread to help delineate the intermetatarsal and first
metatarsocuneiform joints before transection of appropriate ligaments. D: Division of the remaining capsular, intermetatarsal, and
tarsometatarsal ligaments. Plantar lateral ligaments supporting the tarsometatarsal joints are not transected to avoid inadvertent
dislocation of the metatarsal bases.
Tarsometatarsal Release
Heyman, Herndon, and Strong described the procedure named for them, also known as tarsometatarsal soft tissue release (65 ). These
surgeons made a dorsal transverse incision over the bases of the metatarsals and performed capsulotomies and ligament releases of all the
tarsometatarsal joints (i.e., Lisfranc's joints) (Fig. 23 ). They also described syndesmotomy of the naviculocuneiform joint and release of
the anterior tibial tendon. The metatarsals and foot were then manipulated into a rectus position, and a plaster cast was applied for 3
months. Heyman and his associates described this as “anterior capsulotomies” or “tarsometatarsal mobilization” (65 ). Their research
yielded excellent results in 25 of 29 feet. Kendrick et al. similarly reported good to excellent results in their study (66 ). They modified the
original procedure by keeping the plantar lateral ligaments and joint capsules intact. This maneuver helps to prevent dorsal subluxation or
dislocation of the metatarsal bases and subsequent arthritic changes. However, a more recent study by Stark and others described a high
risk of late deformity of Lisfranc's joint, a dorsal arthritic ridge, and stiff feet (67 ). These authors reported a 41% failure rate and
cautioned that, besides a painful dorsal prominence, one may not be correcting the actual disorder causing the metatarsus adductus.
Cummings and Lovell also reported that the procedure was followed by stiffness and pain (68 ). Ghali and associates added release of the
naviculocunieform joint to the complete arthrotomy of Lisfranc's joint (17 ).
Currently, the Heyman, Herndon, and Strong procedure is performed less frequently, but it still has some indication in the 2- to 6-year age
range (Fig. 24 ). When it is performed, three dorsal longitudinal incisions are used (as opposed to the transverse incision, which caused
undue neurovascular risk), the plantar lateral ligaments and joint capsules are preserved to prevent dorsal subluxation or luxation, and a
cast is applied for at least 3 months to allow remodeling of the metatarsals in their corrected position. Alternatively, smooth Kirschner
wires may be inserted to aid in maintaining the corrected position and to resist tarsometatarsal subluxation.
Transfer of the tibialis anterior tendon has also been performed for the correction of metatarsus adductus. Although certainly the tibialis
anterior tendon or muscle causes or accentuates the metatarsus adductus deformity in some patients, transplantation of the tendon should
be performed cautiously (69 ).
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FIG. 24. A: The three dorsal linear incision approach for performance of the Heyman, Herndon, Strong tarsometatarsal capsulotomies
and mobilization. B,C: Accurate identification of the tarsometatarsal joint spaces is critical to avoid accidental laceration of cartilage
and osseous structures. D: Plantar lateral joint ligaments are preserved to resist dorsal subluxation or luxation of the joints. E: After
the entire tarsometatarsal joint complex has been mobilized, the metatarsus adductus deformity can be manually reduced. F:
Preoperative radiograph. G: Intraoperative radiograph. With abductory stress, the metatarsals can be brought to a rectus position.
This position must be maintained until the metatarsal bases have ossified and adapted in a corrected, rectus alignment. This typically
takes 3 months. H: Smooth Kirschner wires may be used medially and laterally to stabilize the area and to help maintain correction,
if desired.
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FIG. 24. Continued.

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Osseous Procedures
Metatarsal Osteotomies
From 6 to 8 years of age, osseous adaptation and squaring of the metatarsal bases have started and are present to varying degrees.
Consequently, soft tissue tarsometatarsal releases no longer provide adequate correction. Historically, many different procedures have
been espoused for the osseous correction of the metatarsus adductus deformity. Although many of these procedures are not performed
frequently today, a review of them reveals the evolution of the currently popular procedures.
In 1921, Bankart reported that, in six feet, he totally excised the cuboid bone to counterbalance an anatomic defect characterized by
congenital absence of the medial cuneiform bone (15 ). Although Bankart believed that the ideal treatment of the metatarsus adductus
deformity was to lengthen the medial column with a bone graft, he did not do this because of the problems associated with bone grafting
at that time.
In 1933, Peabody and Muro recommended excision of the bases of the three central metatarsals, osteotomy of the fifth metatarsal,
mobilization and reduction of luxation of the first metatarsocuneiform joint, and correction of any abnormal insertion of the tibialis
anterior tendon (70 ). A Hoke triple arthrodesis was recommended for realignment of the rearfoot complex when necessary (Fig. 25 ).
In 1949, McCormick and Blount performed an arthrodesis of the first metatarsocuneiform joint along with an osteotomy at the bases of the
central three metatarsals (5 ). In neglected cases, these surgeons performed a wedge resection of the cuboid. No clinical follow-up studies
of their procedure have been published.
In 1966, Steytler and Van der Walt described a procedure that is still often performed (71 ). They used oblique V-shaped osteotomies at the
bases of each metatarsal with the apex of the “V” angled toward the rearfoot. They reported good results on eight feet in patients
between the ages of 3 and 10 years old. These surgeons believed that their operation was easier than a tarsometatarsal mobilization and
had the advantage of being extraarticular. The Steytler and Van der Walt procedure is still popular today and has been modified to
incorporate combinations of wire and screw fixation (Fig. 26 ).
FIG. 25. A: Diagrammatic representation of the Peabody and Muro procedure. B: McCormick and Blount procedure. C: Procedure of
Steytler and Van der Walt. D: Berman and Gartland procedure.
Like the Steytler and Van der Walt procedure, the procedure described by Berman and Gartland (72 ), in 1970, has achieved wide
acceptance (73 ). This is a variation of the panmetatarsal base wedge osteotomies described by Steytler and Van Der Walt and involves
dome-shaped or crescentic base osteotomies of all the metatarsals. Berman and Gartland recommended that the procedure be reserved for
patients older than 6 years. The original description involved the creation of the osteotomies with an air drill that had high velocity and
low torque. The forefoot was then manipulated into correction and was maintained by means of pin fixation through the first and fifth
metatarsals and casting for 6 weeks. These authors also recommended rearfoot surgery to correct combined deformities. Berman and
Gartland reported that in the 18 feet operated on for metatarsus adductus, 17 had excellent results at 5-year follow-up. Additionally,
these surgeons reported their results in 44 more patients who had their procedure performed for residual forefoot adduction associated
with clubfoot. These patients had 84% good or excellent results and 16% fair or poor results. Reported complications included 4 superficial
skin sloughs in patients who had transverse incisions, 6 asymptomatic nonunions, and 3 case of shortening of the first metatarsal
attributable to damage of the physis during the osteotomy.
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FIG. 26. Modified Steyler and Van der Walt procedure. A: Preoperative radiograph of patient with metatarsus adductus. B: Wedge
osteotomy of lesser metatarsal. The apex is proximal medial and the base is distal lateral. C: Correction achieved with combination
of Kirschner wire and screw fixation. D: Postoperative radiograph demonstrating fixation of the lesser metatarsal osteotomies with
Kirschner wires and the first metatarsal osteotomy with a screw.
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FIG. 27. A-C: Diagrammatic representation of the Lepird procedure for correction of metatarsus adductus. Oblique wedge
osteotomies of the first and fifth metatarsals are performed in conjunction with through-and-through rotational osteotomies of the
second, third, and fourth metatarsals. If desired, a rotational osteotomy may be performed on the first and fifth metatarsals as well.
Even more recently, recognizing concerns about undercorrection and overcorrection by improperly sized osteotomy wedges and difficulty
with osteosynthesis, Lepird, in 1981, described transverse plane osteotomies of the second through fourth metatarsal bases (74 ). The
direction of the osteotomies is from dorsal distal to plantar proximal in relation to the long axis of the metatarsals and are made parallel
to the weight-bearing surface of the foot (Fig. 27 ). This orientation permits the precise alignment of these metatarsals and use of
osteosynthesis after techniques recommended by the AO and the Association for the Study of Internal Fixation. The first and fifth
metatarsals are corrected with oblique base wedge osteotomies and are also fixed with compression screws.
Technique. Through three dorsal linear incisions, minimal traumatic anatomic dissection is followed (Fig. 28A ). The medial incision is
placed over the proximal aspect of the first metatarsal base, and the central incision is completed between the same area of the second
and third metatarsals, as is the lateral incision between the fourth and fifth metatarsals. After predrilling screw holes in the proximal
aspect of the central metatarsals, the osteotomies are fashioned (Fig. 28B-D ). The osteotomies must be as parallel as possible to the
weight-bearing plane of the foot. Precise transverse plane orientation is also necessary, to avoid sagittal plane displacement on correction
of the metatarsal deformity. These are essentially through-and-though osteotomies, although it is recommended that the lateral cortices
of each metatarsal be preserved until after the screws are inserted. Appropriately selected screws are placed, but they are not tightened
(Fig. 28E ). The lateral cortices are then cut (Fig. 28F ), and the central metatarsals are placed into their desired abducted positions (Fig.
28G,H ). The oblique base wedge osteotomies of the first and fifth metatarsals need to be concomitantly performed and may be
temporarily fixated with Kirschner wires or bone clamps. Once the central metatarsals are fixed, the first and fifth metatarsals may be
fixed as desired (Fig. 28I,J ). Non-weight-bearing casting is then applied for an appropriate period of time, typically 6 to 12 weeks (Fig.
28K ).
Tarsal Osteotomies
Alternatively, many surgeons prefer the procedure reported by Fowler et al. in 1959 (75 ), and modified by others (76 , 77 , 78 ), which
involves addressing the deformity in the tarsus, as opposed to the metatarsal bases. These procedures were initially designed to correct
residual forefoot adduction after incomplete correction of talipes equinovarus, alone or in combination with other procedures (77 ).
Greater correction in the less malleable foot may also be achieved by performing a lateral closing wedge osteotomy of the cuboid, as
advocated by Grumbine (Baja Project, CA, 1964), and as described elsewhere (78 ,79 ). In addition to the decreased dissection needed
with this procedure compared with the osseous procedures previously mentioned, the risk of iatrogenic frontal or sagittal plane deformity
associated with malunion of the metatarsal base osteotomies may be lessened. Hoffman and others reported 72% correction of forefoot
adduction deformity with the Fowler procedure (80 ).
Abnormality of the medial cunieform has been histologically demonstrated in some cases of metatarsus adductus (16 ,47 ). Although it is
unproven, many investigators support Ganley and Ganley's contention that the apex of many “metatarsus adductus” deformities is actually
within the medial first metatarsocuneiform joint and medial cuneiform (1 ). Hubbard and associates also showed this with magnetic
resonance imaging studies in unossified medial cunieforms (38 ). Ganley and Ganley termed this deformity an abnormal Lisfranc articular
set angle (1 ) (Fig. 29 ). Because the metatarsals ossify before the cuneiforms, it is logical that they will be more easily deformed. Ganley
and Ganley advocated cuboid and medial cunieform osteotomies, but they recommended that these procedures generally be reserved for
patients older than 7 years of age (1 ). Ganley and Ganley recommended the following sequence of procedures (Fig. 30 ):
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FIG. 28. Lepird procedure for the correction of metatarsus adductus. A: Surgical approach through three dorsal, longitudinal
incisions. B: Predrilling of central metatarsal for screw insertion. C,D: Through-and-through osteotomies of central three metatarsals
are performed with bone cuts made parallel to the weight-bearing surface of the foot. E: Screw is inserted. F: Lateral portion of the
osteotomy is completed. G,H: Central metatarsals are rotated into a corrected alignment and the screws are tightened. I: Oblique
osteotomy of the fifth metatarsal with screw fixation. J: Oblique osteotomy of the first metatarsal with screw fixation. The
osteotomy is performed distal to the physis in a growing child. K: Postoperative radiograph demonstrating the final fixation and
correction of the deformity.
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FIG. 28. Continued.

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FIG. 29. Ganley and Ganley believed that the primary deformity was within the medial cuneiform and first metatarsocuneiform joint
(1). They termed the medial deviation of the articular surface of the medial cuneiform an abnormal Lisfranc articular set angle. A:
Radiographs of abnormal (left) and normal (right) feet. Abnormal foot has severe metatarsus adductus deformity. B: When tracings of
the medial cuneiform and first metatarsal are made of each foot, the deformities of the medial cuneiform and first
metatarsocuneiform joint become readily apparent.
Step 1: Opening wedge medial cuneiform osteotomy.
Step 2: Soft tissue release as individually needed, which may include the plantar fascia, the abductor hallucis, the tibialis anterior tendon,
or the secondary insertion of the tibialis posterior tendon.
Step 3: Closing wedge osteotomy of the cuboid.
Technique. If the need for a cuboid shortening osteotomy is anticipated, I perform this procedure first, with the exception of fixation,
which may not even be needed (Fig. 31 ). This technique permits maximum lengthening and angular correction of the medial cuneiform as
well as additional bone removal from the cuboid if needed later. The cuboid is approached by a dorsal lateral curvilinear incision from the
calcaneus to the fourth metatarsal shaft. The lateral dorsal cutaneous nerve may be encountered during minimal traumatic anatomic
dissection and should be retracted. A laterally based wedge or truncated wedge is removed from the cuboid. The size of the wedge should
be conservative, to avoid difficulty with approximation of the cut surfaces later. The removed bone may be used for the medial opening
wedge of the first cuneiform and supplemented with autogenous bone, if needed, for additional volume or strength.
FIG. 30. A: If medial angulation of the distal aspect of the medial cuneiform is the principal deformity (deviated Lisfranc articular set
angle), open wedge cuneiform osteotomy may be performed. If made at the midpoint of the cuneiform, the osteotomy may be
deepened through the second cuneiform without harm to the base of the second metatarsal. B: If the deformity is fixed and the foot
is rigid, it may not be possible to gain adequate correction by cuneiform osteotomy alone. Additional correction may be gained by
removing a wedge of bone from the cuboid. The apex is directed toward the medial cuneiform cut.
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FIG. 31. A: Preoperative appearance of patient with severe, fixed metatarsus adductus. B: Closing wedge osteotomy of the cuboid.
C: Opening wedge osteotomy of the medial cuneiform with insertion of bone graft. D: Postoperative appearance of the foot after
combined cuneiform and cuboid osteotomies. E: Preoperative (left) and postoperative (right) radiographs of the foot. Note the
deviated Lisfranc articular set angle on the preoperative radiograph. This angle is improved on the 6-week postoperative radiograph.
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The medial column is then approached by a dorsal medial curvilinear incision. If the saphenous nerve or vein is encountered, it may be reflected dorsally. The plantar aspect of the anterior
tibial tendon must be mobilized and reflected or partially detached. This tendon may also be lengthened if needed. The center of the medial cuneiform is then cut transversely and completely.
The middle cuneiform may also be opened if necessary. A baby lamina spreader is then used to open the osteotomy. The cuboid is then reinspected, and more bone is removed if necessary. The
widest possible bone graft is then inserted medially. Combining allogenous and autogenous bone provides both strength and osteogenic potential.
Each osteotomy may then be internally stabilized if indicated. A staple is suggested laterally and a threaded Kirschner wire medially, to provide compression without bulk and to prevent graft
extrusion, respectively. The threads of the Kirschner wire also help to prevent collapse of the graft. Ganley and Ganley espoused several theoretic advantages to cuneiform osteotomy over
metatarsal osteotomy: (a) the procedure avoids the first metatarsal physis completely; (b) the broad contact area and greater blood supply are also advantages for bone healing; (c) any
persistent tendency toward metatarsus adductus compresses the medial osteotomy and enhances stability; and (d) multiplanar correction of deformity may also be easier, if needed, because of
the tall profile of the cuneiform (1 ) (Fig. 32 ). Ganley and Ganley also pointed out the potential disadvantages of their approach to surgical correction of metatarsus adductus (1 ). These
disadvantages include the presence of the anterior tibial tendon in the operative field and the inherent risks of bone grafting. Other surgeons have modified the procedure to include lateral
cunieform opening osteotomy, with excellent results (81 ).
FIG. 32. Considerable dorsoplantar dimension of medial cuneiform bone lends itself to correction of sagittal plane deformities. In this case, a biplane wedge is used to correct cavovarus
deformity. To correct the plantarflexed medial column, the wedge is wider plantarly. To correct the adduction, the wedge is wider medially.
SUMMARY
Metatarsus adductus is an excellent example of a deformity that may be completely corrected. For this goal to be achieved, timely intervention is necessary. With some exceptions, this goal
can and should be accomplished through early conservative treatment that is both safe and painless. Optimally, metatarsus adductus should be diagnosed in the nursery and should be treated
early with manipulation or casting.
Unfortunately, it is fashionable to delay treatment either through ignorance or intent, so the older patient with uncorrected metatarsus adductus is introduced as a surgical challenge. Failure
to correct the condition results in extensive forefoot and rearfoot deformities that may require a lifetime of treatment and serial surgical approaches. Early intervention can do much to
minimize these future problems.
ACKNOWLEDGMENT
This chapter is dedicated to the memory of James V. Ganley, D.P.M., author, mentor, and friend. Dr. Ganley said that the study of medicine was not unlike warfare; colleagues work side by
side against a hated foe in challenging and even dangerous conditions. Dr. Ganley fought the good fight.
REFERENCES
1. Ganley JV, Ganley TJ. Metarsus adductus deformity. In: McGlamry ED, Banks AS, Downey MS, eds. Comprehensive textbook of foot surgery, 2nd ed. Baltimore: Williams & Wilkins,
1992:829-852.
2. Turco VJ. Clubfoot. New York: Churchill Livingstone, 1981:180.
3. Kite JH. The clubfoot. New York: Grune & Stratton, 1964.
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20. Sgarlato TE. A discussion of metatarsus adducutus. Arch Podiatr Med Foot Surg 1973;1:35.
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26. Bestard EA, Lal SR, Schoene HR. A modified furlong procedure for the correction of metatarsus adductus. Contemp Orthop 1984;8:19.
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midcuboid osteotomy. J Foot Surg 1987;26:412-418.
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Chapter 17
Congenital Deformities
Carl R. Wagreich
The purpose of this chapter is to present certain congenital deformities of the foot. Areas of discussion include epidemiology, genetic
factors, pertinent classification systems, and various modes of conservative and surgical treatment. The conditions addressed include
polydactyly, syndactyly, macrodactyly, cleft foot deformity, congenital overlapping toes exemplified by digiti quinti varus, underlapping or
varus rotated lesser toes, hallux abductus interphalangeus, and congenital hemihypertrophy.
POLYDACTYLY
Polydactyly, defined as the presence of one or more extra or supernumerary digits or metatarsals of the feet or metacarpals of the or
hands, is often described as one of the most common congenital deformities in these anatomic areas (1 , 2 , 3 ). Polydactyly has been
reported throughout history. Within the Bible, in the Book of Samuel, 21:22, a giant with polydactyly is mentioned: “There was a man of
great stature, that had on every hand six fingers, on every foot six toes.” In an ancient Arabian tribe, the Hyabites, polydactyly was so
common that a child born with a normal compliment of digits was thought to be a product of adultery and was put to death (4 ).
Etiology
The origin of polydactyly appears to be genetic. Thirty-nine percent of patients' charts that Venn-Watson reviewed noted a positive family
history of polydactyly (3 ). However, he believed that the actual incidence of genetic association would have been higher had the history
not been omitted in many of the charts. Several patients described distant relatives with similar conditions, and this finding led Venn-
Watson to conclude that there was an incomplete penetrance. In other patients, he believed that polydactyly was possibly the result of a
mutant gene. Phelps and Grogan found a positive family history of polydactyly in 30% of their patients (4 ). Watanabe et al. noted a
familial incidence in only 8% of their patients (5 ). Their explanation of the disparate pattern when compared with studies in the United
States was that polydactyly in the Asian population was possibly derived from other sources.
Temtamy and McKusick proposed that one form of polydactyly (postaxial type A) was inherited as a dominant trait with marked penetrance,
whereas other forms were noted to be of more complex genetic types. Various other hand deformities were also discussed, most
transmitted through autosomal dominant inheritance (6 ). When found in conjunction with other malformation syndromes, these conditions
are thought to be the result of autosomal recessive inheritance (7 ,8 ).
No specific sex predilection has been reported (3 , 4 , 5 ,9 ,10 ). Bilateral involvement is seen in 25% to 50% of patients (3 , 4 , 5 ,10 ), and
the incidence of polydactyly appears to be higher in black and Asian populations (9 ,11 ). In a large study involving 120,127 live births,
Frazier listed an incidence of 3.6 in 1,000 live births in the black population and 0.3 in 1,000 live births in the white population (11 ).
Woolf and Myrianthopolous reported the incidence of polydactyly to be 1.3 in 1,000 live births in the white population and 13.9 in 1,000
live births in the black population (12 ).
Classification
Various systems for classification of polydactyly have emerged over the years (3 , 4 , 5 ,13 ,14 ). Temtamy and McKusick differentiated
medial ray (preaxial) polydactyly from lateral ray (postaxial) polydactyly and mixed forms (13 ). This basic nomenclature has been
accepted, although several modifications and expansions to their classification system have been offered.
Postaxial Polydactyly
Postaxial polydactyly, the most common presentation of this condition, accounts for 79% to 86% of reported cases
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in larger studies (4 ,5 ). Postaxial polydactyly was further differentiated by Tetamy and McKusick into types A and B. Type A represents a
fully developed accessory digit that articulates with either the fifth metatarsal or metacarpal or with a duplicated fifth metatarsal or
metacarpal. In type B, the accessory digit is devoid of osseous components and frequently manifests as only a skin tag (13 ). However, this
basic classification system failed to distinguish the wide range of intermediate forms of postaxial polydactyly. Venn-Watson further divided
postaxial polydactyly into five specific morphologic patterns, based on the degree of metatarsal duplication (3 ). From the least
differentiated to the most differentiated, they are as follows: soft tissue duplication, wide metatarsal head, T-metatarsal, Y-metatarsal,
and complete duplication (Fig. 1 ). Phelps and Grogan noted that the most common form of postaxial polydactyly found in their patients
was duplication of the proximal phalanx with either a block or a wide metatarsal head (4 ).
FIG. 1. Postaxial polydactyly, modified from the Venn-Watson classification. A: Wide metatarsal head. B: T-shaped metatarsal. C: Y-
shaped metatarsal. D: Partial polydactyly. E: Complete duplication.
Watanabe et al. compiled the most extensive study of polydactyly of the foot that included 265 individual cases (5 ). These investigators
provided an even more elaborate classification system, with postaxial polydactyly divided into fifth and sixth ray duplication, each with
subtypes. Fifth ray duplication accounted for 76% of all postaxial polydactyly. Fifth ray polydactyly was accompanied by a 3% incidence of
associated anomalies, and a 35% incidence of associated anomalies was seen in patients with sixth ray duplication.
Preaxial Polydactyly
Preaxial polydactyly of the foot is seen in 8% to 15% of patients (4 ,5 ). Temtamy and McKusick described four subtypes: type 1, duplication
of the first digit; type 2, polydactyly of a triphalangeal first digit; type 3, polydactyly of the second digit; and type 4, polysyndactyly (13 ).
Venn-Watson
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described variants consisting of a short block metatarsal or a wide metatarsal head (3 ). Phelps and Grogan noted that the most common
configuration was duplication at the proximal phalangeal level with a block first metatarsal (4 ) (Fig. 2 ).
FIG. 2. Preaxial polydactyly, modified from the Venn-Watson classification. A: Short block first metatarsal. B: Wide metatarsal head.
Watanabe et al. proposed four groups: tarsal, metatarsal (with three subtypes), proximal phalangeal (with five subtypes), and distal
phalangeal (with six subtypes) (5 ). Metatarsal and proximal phalangeal types were most commonly noted, each accounting for 36% of
preaxial polydactyly. These authors postulated that the tarsal type of medial ray duplication represented the true prehallux. It was seen in
only one patient, with the duplicated digit articulating with the navicular. Associated anomalies including deformity syndromes were found
in 59% of the patients with preaxial polydactyly, frequently involving the hand.
Central Ray Polydactyly

Duplication involving the central rays has been reported in approximately 6% of patients presenting with polydactyly (4 ,5 ). Phelps and
Grogan noted that this most often consisted of a hypoplastic metatarsal (4 ). Watanabe et al. divided this condition into four types:
metatarsal, proximal phalangeal, middle phalangeal (divided into two subtypes), and distal phalangeal (5 ). All patients except one had
duplication of the second toe. The most common level of duplication was the distal phalangeal type. Associated anomalies were found in
20% of patients with central ray polydactyly.
Associated Syndromes
Polydactyly may be associated with other syndromes. Therefore, when a child is born with polydactyly, it may not be an isolated deformity.
Opinions vary regarding whether preaxial polydactyly or postaxial polydactyly is accompanied by a higher incidence of associated
congenital anomalies. According to Castle, preaxial polydactyly is usually an isolated deformity and is rarely associated with another
syndrome. The most common associated syndrome seen with polydactyly of the foot is polydactyly of the hand (4 ,10 ). Syndactylism of the
toes was the second most common associated syndrome, found in 22% of patients with polydactyly of the foot (4 ). Postaxial polydactyly
has been more commonly associated with genetic syndromes (7 ). Conversely, Watanabe et al., in their study, found a 59% incidence of
associated congenital anomalies in preaxial polydactyly as opposed to a 38% incidence in postaxial polydactyly (5 ).
One set of genetic syndromes that include polydactyly comprises the short rib polydactyly syndromes. These disorders are a group of lethal
syndromes in which the child usually does not survive through infancy (15 ). In 1992, the International Working Group on Constitutional
Diseases of Bone recognized six types of short rib polydactyly syndromes. They include type I (Saldino-Noonan), type II (Majewski), type III
(Verma-Naumoff), type IV (Breemer-Langer), plus asphyxiating thoracic dysplasia, and Ellis-van Creveld dysplasia (16 ). Skeletal dysplasias
include extremely short ribs, ovoid vertebral bodies, an irregularly shaped pelvis, horizontal acetabula, short long bones, and premature
ossification of distal femoral epiphyses. The skeletal abnormalities accompany many visceral anomalies including cystic kidneys, liver, and
pancreas, cleft lip and palate, esophageal and anal atresia, and congenital heart defects (7 ,15 , 16 , 17 , 18 , 19 ). Apert syndrome is
similar to the short rib polydactyly syndromes in skeletal and visceral abnormalities. However, polydactyly
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is not as commonly seen in Apert syndrome. In addition, craniofacial abnormalities with varying degrees of mental retardation have been
noted (20 ,21 ).
Polydactyly has been associated with atrioventricular septal defect (22 ,23 ), fibular dimelia, absent tibiae (24 , 25 , 26 , 27 ), syndactyly
(28 , 29 , 30 , 31 ), talipes equinovarus (28 ), hydrolethalus syndrome (32 ,33 ), hydrometrocolpos (34 ), drug-related fetal hydantoin
syndrome (35 ), Proteus syndrome (36 ), and a host of newly reported syndromes. Because many deformity syndromes are poorly defined,
any variability in the components that are reported may at times result in the description of a new syndrome (29 ,30 ,37 ,38 ).
Treatment
Conservative treatment is not routinely practiced in the symptomatic child with polydactyly. In many instances, duplication of the part
makes shoe fitting and subsequent function difficult. Parents are often concerned about future potential functional impairment as well as
cosmetic appearance (3 ). Because the deformity has both physical and emotional sequelae, treatment of polydactyly is usually surgical
(1 ,39 ). Conservative measures that may be used include padding, strapping, orthodigital devices, wider shoes, extra-depth shoes, and
orthotic devices (9 ,40 ). Generally speaking, these measures provide only temporary relief.
Treatment of postaxial polydactyly, type B (rudimentary digit only) may be initiated shortly after birth once the neonate's condition is
stable. The treatment includes tying off the rudimentary digit with a ligature suture in the nursery (41 ). No reports of exsanguination have
been reported. However, this procedure is generally not performed if osseous components are present in the digit. If skeletal components
are present, it is generally preferable to wait until the child is a few months old before a surgical procedure is performed, to ensure
complete excision of all accessory osseous structures (42 ).
Opinions on the timing of surgical intervention vary. Chiang and Huang reported an age range at the time of surgery between 4 months and
13 years and 4 months, with a mean age of 3 years and 3 months (1 ). Phelps and Grogan reported an average age of 3.8 years but noted
that an age of approximately 1 year was preferred (4 ). Watanabe et al. reported a range from 3 months to 5 years with an average of 22
months in preaxial polydactyly, 36 months in central ray polydactyly, and 26 months in postaxial polydactyly (5 ). According to Tachdjian,
the optimum age for surgical treatment is between 9 months and 1 year (43 ). Other investigators have advocated surgical treatment
before the child's initiation of weight bearing, to allow better shoe fitting (3 ). DeValentine noted that surgery for polydactyly should
generally be delayed until the child is at least 1 year of age. Anesthesia is better tolerated at that point, and osseous development is more
advanced, a feature that, in turn, allows for better surgical planning and facilitates the operation because of the larger size of the foot. In
some cases, phalangeal and metatarsal ossification may not be adequate to determine which toe should be removed until the patient is 2
to 3 years of age. Surgical treatment is generally preferred before the child starts school, to avoid problems with shoe wear (42 ).
Surgical Considerations
The preoperative evaluation of the patient with polydactyly should, most importantly, take into account the central metabolic and genetic
status. As previously discussed, the factor of other disease states may need to be investigated. Standard radiographs are often useful in
assessing the level and severity of the pathologic anatomy. However, they may not be sufficient to render a complete picture of soft tissue
anomalies that may be encountered at the time of surgery. Investigators have suggested that computed tomography scans and magnetic
resonance imaging studies may be helpful in preoperative planning (2 ,40 ). However, besides being costly, these tests may require
significant levels of patient sedation to obtain a valid study.
Each case of polydactyly should be considered individually. The goals of surgery in polydactyly are to remove anomalous tissue and to
restore function (39 ,44 , 45 , 46 ). Skin incisions over bony prominences are preferably avoided to prevent the formation of scar tissue
over pressure areas. Furthermore, the incision should be planned to create equal length and shape to the wound, to promote good plastic
skin closure. Resecting bone at the junction of the anomaly reduces the risk of cortical splitting.
In most patients with preaxial polydactyly, the most medial duplicated metatarsal and digit are excised, whereas in most cases of postaxial
polydactyly, the most lateral duplicated metatarsal and digit are excised (4 ,9 ,47 ). The exception to this rule is when the most lateral or
medial duplicated digit is preferred cosmetically or would provide better function. Then, alternatively, the innermost duplicated digit is
excised (3 ,4 ,42 ). This excision, unfortunately, tends to leave a space between the remaining digits and a wider foot. Under
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these circumstances, after removal of the inner metatarsal and digit, osteotomy of the most medial metatarsal in a preaxial deformity and
of the most lateral metatarsal in a postaxial deformity may be undertaken to narrow the foot (39 ,45 ) (Figs. 3 , 4 , 5 and 6 ).
FIG. 3. Clinical appearance of a patient with preaxial polydactyly.
FIG. 4. A: Radiograph of a patient with preaxial polydactyly with complete duplication of the hallux and a block metatarsal. B:
Postoperative radiograph after removal of the medial duplicated digit with Kirschner wire stabilization. C: Radiograph 6 weeks after
surgery.
Excision of a digit is often performed through a rackettype incision. If the metatarsal head is widened, then it may be narrowed to a more
normal width. Resection through the physis has not been shown to result in premature closure of the growth plate (3 ,4 ). Any duplication
of the metatarsal is removed flush with the remaining bone. If complete duplication of a metatarsal is present, then a ray resection may
be preferred. With excision of a central ray duplication, the intermetatarsal ligaments may be reconstructed to counteract splaying of the
forefoot. However, residual forefoot splaying has been noted to persist in most patients despite this technique (4 ). Fixation devices such
as pins, staples, and casts may provide added stability to the remaining segments. Joint
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incongruity is frequently noted to persist after resection. If they are properly stabilized postoperatively, these articular surfaces remodel,
especially in the young child. In addition, any residual bowing of the metatarsal after resection of the lateral portion of the duplicated Y-
shaped metatarsal remodels (3 ).
FIG. 5. Repair of postaxial polydactyly with duplication of the fifth digit and a wide metatarsal head. Preoperative appearance of the
foot from the dorsal view (A) and the plantar view (B). On the dorsal view, the fifth toe is not visible because of the extreme plantar
adducto varus rotation. C: Preoperative radiograph. D: Two converging semielliptic incisions are used around the most lateral digit.
The extensor and flexor tendons are severed proximally. The wide metatarsal head before (E) and after (F) remodeling. G: The
deformity at the proximal interphalangeal joint is reduced and is maintained in position with a Kirschner wire. H: Appearance of the
foot 7 weeks postoperatively.
FIG. 5. Continued.
The main complication associated with the repair of postaxial polydactyly is residual soft tissue or osseous bulk that impairs shoe fitting.
Venn-Watson attributed this problem to an inadvertent shaving of a Y-shaped metatarsal head or when a duplicated metatarsal was left
once the digit itself was removed while the child was in the nursery (3 ).
The most common complication associated with the repair of preaxial polydactyly in the report by Venn-Watson was
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a residual hallux varus. Because of this complication, Venn-Watson recommended that the surgeon lengthen the abductor hallucis tendon
and plicate the adductor tendon into the joint capsule. Casting was advocated to maintain position (3 ). Phelps and Grogan noted similar
problems with hallux varus, which developed in 14 of 16 patients. The duplicated digit was removed and capsular tissues were
reapproximated without addressing tendon structures (4 ). Pinning the joint for several weeks would probably be a more suitable method
of splinting than casting while the soft tissues are healing (42 ). Other problems associated with this type of surgery have been increased
tissue bulk and a short first metatarsal, the latter of which typically creates later problems with foot function (3 ,4 ,42 ).
FIG. 6. A: Central ray polydactyly with duplication of the second metatarsal and digit. B: Postoperative radiographs after removal of
the duplicated medial second metatarsal and digit.
SYNDACTYLY
Syndactyly is defined as a congenital or acquired deformity in which webbing persists between adjacent digits from birth or secondary to
injury (48 ,49 ). Drinkwater provided one of the earliest reports of syndactyly with synphalangism in 1917 and traced the deformity to the
time of King Henry VI of England. The first member of the family who was known to have the condition was killed in 1453. His tomb was
opened in 1874, and his finger bones were shown to have the same bony ankylosis as those of his descendants (50 ).
Etiology
Syndactyly of the toes is one of the most frequently encountered congenital anomalies (51 ). It often involves the second and third toes in
the foot (8 ,52 ). Investigators generally agree that syndactyly is caused by a rapid arrest of embryologic development from the sixth to
eighth week of intrauterine life. Because the webbing between the second and third toes is the last to disappear, this area is the most
sensitive to intrauterine insult (42 ,44 ,48 ,53 ). Genetic factors have most often been implicated as the source for this condition (13 ).
Traumatic causes are usually secondary to burns. Syndactyly is ten times more common in whites than in blacks and presents in roughly
equal numbers in bilateral and unilateral forms. Males and females are similarly affected, although Davis and German noted a greater male
predominance of 68% (52 ). The incidence is about 1 in 2,500 to 3,000 live births (8 ,52 ).
Classification
Two classification systems for syndactyly are recognized. Davis and German divided the condition into four classes (52 ), as follows:
Incomplete: Webbing does not extend to the most distal aspect of the involved digits.
Complete: Webbing extends to the ends of the involved digits.

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Simple: A soft tissue connection alone exists.
Complicated: The phalanges are abnormal in size, shape, number, or arrangement.
DeValentine noted that the complicated forms may share neurovascular, tendinous, or osseous structures. Furthermore, he noted that a
fifth class, complicated-complex, was used by some investigators. This class consists of three or more digits with interposed incomplete
structures (42 ).
Temtamy and McKusick described a classification based on associated syndromes and deformities (13 ). Two classes were described:
syndactyly and syndromatic syndactyly. Isolated syndactyly is divided into five phenotypic types that are all inherited as autosomal
dominant disorders. They are as follows:
Type 1. Zygodactyly Webbing is usually present between the third and fourth fingers. In the foot, it usually involves the second and third
toes. Syndactyly may be partial or complete. These investigators also noted that frequently one could see some degree of webbing
between the second and third toes, but this was not necessarily related to type 1.
Type 2. Synpolydactyly Syndactyly of the third and fourth fingers is present, with polydactyly of components of the fourth finger in the
web. In the foot, one would see polydactyly of the fifth toe included in the web between the fourth and fifth digits.
Type 3. Ring finger-small finger syndactyly This type manifests with complete syndactyly between the fourth and fifth fingers, typically
bilaterally. The feet are not affected.
Type 4. Hass type This type involves complete syndactyly of all fingers. Occasionally, patients have a sixth metatarsal and phalanx. No foot
involvement occurs.
Type 5. Syndactyly with metacarpal and metatarsal fusion There is syndactyly of the third and fourth fingers and the second and third toes.
Associated findings are fusion of the fourth and fifth metacarpals and metatarsals and occasionally the third and fourth metatarsals.
Syndromatic syndactyly is divided into two groups: the first comprises syndromes in which syndactyly is predominant, and in the second
group, syndactyly is secondary to other medical problems. The list of associated syndromes and deformities is voluminous. A partial list
includes split hand-split foot (Czeizel-Losonci syndrome) (54 ), talipes equinovarus (28 ), tibial hypoplasia or aplasia, polydactyly (30 ),
occipitocervical encephalocele, vertebral fusion (29 ), cleft palate, Apert syndrome (55 ), renal and anogenital malformations (56 ), mental
retardation (57 ), dysplasia epiphysealis hemimelica (58 ), cardiac conduction deficits (59 ), amniotic band syndrome (60 ), and Fraser
syndrome (crypto-phthalmos, hidden eye syndrome) (61 ).
Treatment
The definitive treatment of syndactyly is surgery. Virtually all reports in the literature represent syndactyly as a purely cosmetic problem,
yet the emotional sequelae of the deformity are recognized (31 ,44 ). Some authors believe that because the problem is purely cosmetic, it
should not be repaired surgically (43 ,62 ). However, some reports have noted syndactyly involving the hallux and second digit that
resulted in the use of altered gait patterns to avoid pain (49 ).
Surgery is generally performed in the pediatric patient after 1 year of age because the results in younger children are generally poor. At
this earlier age, the commissures tend to close and advance. Children older than 5 years of age are subject to ridicule in school. Therefore,
investigators have recommended that surgical correction be performed when patients are between the ages of 2 and 4 years (8 ).
DeValentine recommended waiting until adolescence so the child could participate in the decision and better assist in the postoperative
care. However, he also indicated that more complex cases could require earlier intervention, generally between the ages of 1 and 5 years.
Preference was expressed for the upper limit of this range, so a more complete radiographic assessment and better intraoperative
visualization of anatomic structures could be available (42 ).
As in the patient with polydactyly, one should consider the general metabolic and genetic status of the patient and the potential for other
disease states. Standard radiographs are typically made preoperatively to evaluate for the presence of synphalangism.
The goals of surgery for syndactyly are to provide adequate soft tissue coverage to adjacent toes, to prevent contractures secondary to the
surgical procedure, and to create a commissure or space at the base of the digits (49 ). Various considerations are important in planning a
procedure that will achieve these goals. Vascular compromise may occur, and to avoid excessive tension on the desyndactylized digits, skin
grafting may be necessary. Curved or zig-zag incisions may result in less digital contracture. After suture removal, continuous-pressure
taping may be applied to the web space for up to 2 months to reduce “web creep” (51 ).
Three types of surgical procedures are used in desyndactylization. They include flaps, grafts, and tissue expansion. Flaps may take on a
number of configurations for desyndactylization. Itoh and Arai described proximal zig-zag lines on the dorsum that are made parallel to the
metatarsophalangeal joint axis (63 ) (Fig. 7 ). Flaps C and D are made of dorsal skin because they will be under greater tension. A
subcutaneous pentagonal pedicle flap of plantar skin is advanced to cover the base of the interdigital space. Coleman et al. discussed this
technique in the foot (48 ). After the tracing of the dorsal flaps with a skin marker, 27-gauge needles were placed through the toes from
dorsal to plantar to provide proper positioning for the apices of the plantar flaps. DeValentine similarly discussed this type of approach and
noted that a
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small area on each digit would require grafting in some instances (42 ).
FIG. 7. Itoh method of desyndactylization. A,B: Proposed dorsal and plantar skin incisions with proximal advancement flap on the
plantar side. C,D: After coverage of the interdigital spaces. E: Advancement of plantar flap to cover the central defect.
Other authors have presented cases using the technique initially proposed by Didot in 1849 for desyndactyly of the fingers (49 ,64 ). Today,
this procedure is rarely performed in the hand because of restrictive scar formation. However, the toes do not require the same degree of
flexibility, and the procedure is much simpler than some of the alternative methods and provides excellent functional and cosmetic results
in the foot (Fig. 8 ).
Grafting is also commonly practiced. Full-thickness grafts are recommended over split-thickness (defatted) grafts because the split-
thickness grafts are more likely to contract and to deform the digits (8 ,65 ). Other investigators recommend full-thickness grafts in
children, but they consider split-thickness grafts in adults and adolescents because full-thickness grafts require a greater blood supply for
viability (42 ). Postoperative defects should be avoided because they also add to contracture formation (31 ). Donor sites may include the
medial submalleolar region (65 ), the lateral submalleolar region (66 ), the dorsum of the foot (67 ), the groin (8 ), and the abdominal
region (68 ). Tissue expanders have been used to reduce the need for skin grafts (68 ). This procedure allows local tissue to cover the soft
tissue defects that are created. Furthermore, the tissue appears to be free from the pigmentation problems sometimes associated with
skin grafts, and scarring and contracture are minimal. The disadvantages of this approach include the necessity for two operations,
possible rupture or leakage of the expander, repeated injections, and a greater amount of time to complete the treatment.
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FIG. 8. Surgical correction of bilateral incomplete simple syndactyly of the second and third toes. A: Preoperative appearance. B:
Dorsal skin flap design with the base on the third toe. C: Dissection proceeds carefully to preserve the interface between the dermis
and superficial fascia, to avoid the neurovascular structures. D: Dissection and retraction of the plantar skin flap with the base on the
second toe. E: Web space incision. F: Blunt dissection is used with care in the web space to preserve the neurovascular structures. G:
Positioning of the plantar skin flap on the second toe. Note the triangular defect at the base of the web space. H: Positioning of the
dorsal skin flap on the third toe. I: Immediate postoperative result with the defect of the web space covered by a proximally based
rotational skin flap from the dorsum of the foot. J: Immediate postoperative result, plantar view. (Courtesy of A.L. Jimenez.)
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FIG. 8. Continued.
MACRODACTYLY
Macrodactyly is a rare congenital deformity of the hands or feet characterized by an increase in the size of the elements or structures of
the affected part including the bones, nerves, subcutaneous fat, nails, and skin. The tendons and blood vessels seem to be unaffected
(69 ,42 ) (Fig. 9 ). The hypertrophy primarily involves the plantar and distal tissues. In 1967, Barsky reviewed the literature for the previous
140 years and found 56 cases he considered to represent genuine cases of macrodactyly. He believed that some cases previously reported
were not accurately diagnosed. He later included 8 more cases, to bring the total number of patients reported with the condition to 64
(69 ). De Greef and Pretorius reported that 300 cases had been described in the literature since 1824 and classified the deformity as very
rare (70 ). DeValentine reviewed the medical literature from 1865 to 1988 and found 62 cases of macrodactyly involving 67 feet (42 ).
Macrodactyly usually appears alone, as opposed to in conjunction with other congenital deformities. It affects the hands more commonly
than the feet (70 ,71 ), and it typically involves the entire digit. Although it is thought to affect the metacarpals, metatarsals, or areas
proximal to the metacarpal or metatarsophalangeal joints rarely, in one study of macrodactyly of the foot, the metatarsals were involved
in approximately 50% of the patients (72 ). The first, second, and third toes are most commonly involved, with the highest incidence
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in the second digit (72 ). The digit may deviate as a result of more rapid growth on one side (71 ,73 ). More commonly, the digit
hyperextends because the plantar and distal tissues appear to create most of the additional mass.
FIG. 9. A: Clinical appearance of macrodactyly in a young child. B: Radiographic appearance.
Male and female patients and right and left hands are equally affected (70 ), although later authors found an overwhelming majority of
cases in the foot in male patients and no sex predilection for the condition in the hand (72 ). However, Kalen et al. noted that when their
cases were combined with those previously described in the literature, there was a slight male predominance (1.7:1 in hands, 1.2:1 in feet)
(72 ). Only one case has been described that involved both hands and both feet of the same patient (74 ).
Etiology and Pathology

The origin of macrodactyly is unknown. Heredity does not appear to play a role (42 ,69 ,75 ). Various theories include vasomotor
disturbances, endocrine aberrations, abnormal nerve supply (76 ), in utero mechanical abnormalities including twisting of the umbilical
cord around a segment, defective fetal position, lymphatic defects, local abnormalities of growth limiting factor (69 ), and autonomic
nervous system disturbance (70 ) or a localized form of neurofibromatosis (77 ).
Several consistent findings have been described with macrodactyly. The most striking feature is the amount of fat in the affected digits.
The bones demonstrate abundant fat in the marrow, and marked periosteal thickening and fibrosis are present. Tendon size is normal, but
with thick fibrous tissue peripherally. Fat even infiltrates the dermis and skeletal muscle and is separated by thick, fibrous septa. The
larger digital blood vessels are absent and are replaced by several vessels of smaller diameter, thereby reducing the overall circulatory
capacity relative to normal tissue. Nerve enlargement is reported in virtually every case increasing from proximal to distal. The nerves are
enlarged secondary to endoneural and perineural thickening and fibrous tissue infiltration. The substantial neural changes have been
profound enough to cause some authors to suggest that macrodactyly may be a localized form of neurofibromatosis (21 ,42 ,69 ,78 ,79 ).
However, although enlargement of the nerve structures was a consistent finding in macrodactyly of the hand, Kalen et al. found that only
minimal neural involvement was mentioned in 3 of 25 patients with macrodactyly of the foot (72 ).
Classification
Two varieties of macrodactyly are accepted: isolated nonprogressive or static macrodactyly, also known as macrodactyly simplex congenita,
and progressive macrodactyly or macrodystrophia lipomatosis progressiva (80 ). The static form presents with a growth rate of the involved
digit that is proportionate to the growth rate of the patient. The increased rate of growth is typically most profound in the first few years
of life and tends to cease at maturity (42 ). Progressive macrodactyly is less common and presents with a disproportionately faster growth
rate of the involved part until puberty (21 ,69 ,71 ,80 ). The progressive form is more likely to be associated with involvement of multiple
digits with hypertrophy
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trophy extending proximally involving the metatarsal and soft tissues (81 ). Both forms are present at birth, and a firm diagnosis regarding
which variant is present may be evident by 6 months of age (80 ).
TABLE 1. Diagnoses associated with segmental and crossed hypertrophy and hemihypertrophy
Primary lymphatic disorders
Vascular malformations
Hemangioma
Arteriovenous malformation
Congenital venous malformation
Klippel-Trenaunay-Weber syndrome
Macrodactyly
Beckwith-Wiedemann syndrome
Neoplasia
Testicular tumor
Wilms' tumor
Adrenocortical tumor
Proteus syndrome
Bannayan-Zonana syndrome
Bone dysplasias
The differential diagnosis of macrodactyly includes a variety of syndromes and conditions summarized in Table 1 . D'Costa et al.
demonstrated how magnetic resonance imaging scans can be useful in differentiating macrodactyly from other causes of hypertrophy (82 ).
Treatment
Treatment varies based on the type and extent of the deformity as well on as the age of the patient. Asymmetric growth within a single
digit can cause a hyperextended toe because most of the enlargement is noted distally. The mass of the enlarged digit may also create
transverse plane deviations in the adjacent toes. Shoe fitting is obviously a problem in some patients.
Surgery is the primary treatment for macrodactyly. The goal of surgery is to obtain a pain-free plantigrade foot with a shoe size that is
similar to that of the contralateral normal foot. Each case must be considered individually because presentations are diverse. Standard
radiographs are the mainstay in preparation of surgical treatment. Magnetic resonance imaging and computed tomography scans have also
been used to help in surgical planning (82 ,83 ).
Perhaps the simplest means of addressing the condition is by amputation of all or part of the digit (72 ,84 ). Ray resection may be
preferred to amputation of the digit in patients with metatarsal involvement (72 ). However, DeValentine argued against amputation of
digits in children or adults with the progressive form of macrodactyly (42 ). Partial or complete amputation may be helpful in adults with
the static form of macrodactyly. Partial resection should concentrate on the distal aspect of the toe because this is the site of most of the
hypertrophy.
Techniques to salvage the digit may be divided into soft tissue procedures to reduce the bulk of the toe and osseous procedures such as
epiphysiodesis. However, resection of osseous components to shorten the toe are typically combined with soft tissue procedures. In the
nonprogressive milder deformity, excision of soft tissue is the mainstay of treatment (81 ). The voluminous amounts of adipose tissue make
the dissection difficult and increase the risks of postoperative infection. Because of the amount of tissue that must be excised, as well as
the types of procedures that must be employed, the risk of vascular embarrassment is higher. If large amounts of tissue are to be removed,
then the procedure may best be staged at 3-month intervals. One side of the digit should be debulked, and 3 months later, the opposite
side should be addressed, to reduce the risk of vascular compromise.
Barsky described a plantar wormlike shortening of the involved digit, which was later modified by Tsuge, who described a dorsal wormlike
shortening that preserves the nail (69 ,85 ) (Fig. 10 ). In progressive macrodactyly, Tsuge described his procedure as follows: Incisions are
made bilaterally along the midline of the toe to form a flap with the dorsal skin. The nail and one-third of the dorsal side of the distal
phalanx are elevated with the flap. The nail and bone are moved proximally and are placed into a recipient site on the dorsal third of the
intermediate phalanx. The surplus portion of the fingertip and the distal part of the nail are excised to a suitable length, and the dorsal
and plantar skin is sutured. The skin bulge created by the proximal transposition of the dorsal skin flap is excised, along with an additional
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debulking surgical procedure 5 to 6 weeks after the first procedure.
FIG. 10. Surgical reduction of digital macrodactyly. A: Deformity with enlargement of the tissues. B: A portion of the middle and
distal phalanges is excised with proximal retraction of a dorsal flap, including the nail, to a shortened position. C: Excision of the
distal aspect of the toe and partial excision of the nail. D: Excision of redundant dorsal skin and plastic skin closure. (Modified from
Tsuge K. Treatment of macrodactyly. Plast Reconstr Surg 1967;39:590, with permission.)
McCarroll reported that growth ceased postoperatively when the severely enlarged digital nerves were excised. Instead of removing the
entire digital nerve, Tsuge removed only the multiple smaller branches, yet this investigator reported good results and cessation of growth
(85 ). Subsequently, Tsuge recommended excision of the epiphyseal plate at the base of the intermediate or distal phalanx and also
reported performing resection of the metacarpal head. However, despite this evolution in technique, he concluded that no decisive
treatment existed for macrodactyly (86 ).
Epiphysiodesis has been advocated in children less than 10 years of age at the time of surgery. However, the bone may continue to enlarge
in girth and possibly a small amount in length. Topoleski et al. found good results with epiphysiodesis of the proximal phalanx with soft
tissue debulking. Their study confirmed that although longitudinal growth was arrested, appositional growth of the phalanx continued. The
physis of the proximal phalanx is ablated using small curettes and electrocautery. A smooth Kirschner wire (K-wire) is placed through the
digit and across the metatarsophalangeal joint. Debulking is performed through a separate transverse incision at the base of the plantar
aspect of the toes. A below-knee cast is employed, and the K-wire is removed in 6 weeks (87 ).
DeValentine specified that only the distal and middle phalangeal growth plates should be destroyed if the toe has not yet reached adult
length. In older children, destruction of the corresponding metatarsal physis is also recommended (42 ).
The most common postoperative complication is poor or delayed wound healing. Other complications are prolonged edema and sensory
disturbances (81 ). Another frequent complication encountered in patients with progressive macrodactyly is the continued proliferation of
fatty tissue at the amputation site postoperatively, necessitating additional surgery (69 ,81 ). Again, these cases represent great challenges
to any skilled surgeon, and no easy answers exist to the question of either the origin or the surgical management of this deformity.
CLEFT FOOT
Cleft foot is a form of ectrodactyly characterized by the congenital absence of two or three central rays or digits (43 ). Ectrodactyly is a
term used to denote a missing digit or part of a digit. Other terms for this deformity are lobster claw and split hand or split foot deformity
(88 ) (Fig. 11 ). As early as 1770, Hartsinck reported the trait of ectrodactyly in an African population he called the Touvingas (89 ).
Cruveilhier first coined the term lobster claw deformity in 1829. His patients had the characteristic absence of the second, third, and
fourth rays with medial deviation of the fifth toe and hallux abductus (90 ).
Cleft foot is a rare congenital deformity with an estimated incidence of 1 in 180,000 births. The deformity is considered to be inherited by
an autosomal dominant trait with variable penetrance. It is believed that something occurs during the first 8 to 12 weeks of gestation to
disturb the normal development of the apical portion of the limbs. However, the specific influences are unknown (42 ). Other investigators
believe that isolated ectrodactyly may be related to external exposure of certain gene loci to outside agents. Mice have been bred
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with dactylaplasia, which closely resembles the human cleft limb. There has also been a report of a child exposed in utero to a retinoic acid derivative during the period of crucial limb
development who was born with absent digits and syndactyly (88 ).
FIG. 11. A: Clinical appearance of a patient with bilateral cleft foot. B: Radiographic appearance. (Courtesy of J.E. Williams.)
The typical description of the condition includes a central cone-shaped cleft that is tapered proximally and wide distally. In most instances, the first and fifth rays form the medial and lateral
borders of the cleft. As the child ages and begins to bear weight, the foot widens, and the result frequently is a hallux abducto valgus deformity with a fifth toe that deviates medially. The
hindfoot is usually normal (43 ). Although cleft foot is usually noted bilaterally, the clinical presentation may vary, and unilateral cases have been reported (89 ,91 ,92 ). Bilateral cleft foot
deformity occurs occasionally as an isolated condition. However, a more common presentation includes cleft hand, cleft lip, and cleft palate (90 ,93 ).
Classification
Barsky was the first to describe a classification system for cleft hand consisting of typical and atypical forms. The typical form was most often seen bilaterally and in conjunction with bilateral
cleft foot deformity. The condition was frequently familial. The atypical form of cleft hand was less common and most often occurred as an isolated condition without familial tendency. Barsky
believed that cleft foot would not be found associated with the atypical form of cleft hand because the latter was presumably an isolated deformity. However, several cases of isolated cleft
foot have been described without apparent involvement of the hand (94 ).
Blauth and Borisch developed another classification for cleft foot deformity based on radiographic findings (95 ). Six forms were described, depending on the number of segments that were
affected.
Type 1: This is a mild form in which the only aberration is aplasia affecting the second, third, or fourth toe. Commissures between the digits may be deepened. All the metatarsal segments are
normal.
Type 2: Patients possess all five metatarsals, but there may be partial hypoplasia or synostoses with adjacent metatarsals or proximal phalanges. One digit is always absent, and the second or
third ray is always affected.
Type 3: Only four metatarsals are present, with the second or third absent and the other hypoplastic. Typically, two toes are missing. Multiple synostoses may be noted between the remaining
digits or metatarsals. The shape of the foot is changed, at times warranting surgical correction.
Type 4: This type is characterized by the absence of two metatarsals, either the second and third or the third and fourth. The second, third, and fourth digits are typically missing. In addition
to multiple synostoses between the metatarsals or phalanges, the tarsal bones may also be affected. Some patients have aplasia of the intermediate cuneiform. The clinical appearance of the
foot is significantly altered in this type, as well as in the remaining types of cleft foot.
Type 5: This is the typical lobster foot. The second, third, and fourth rays are absent. Significant aberrations may also be noted in the tarsus.
Type 6: Also termed monodactylous cleft foot, this foot possesses only the fifth metatarsal and the digit. Hypoplasia is noted in the tarsal bones.
Associated Syndromes
David described 13 presentations of cleft foot and cleft hand deformities (96 ). This represents a comprehensive list of associated deformities and syndromes:
 Bilateral cleft foot, with or without hand deformity

 Cleft foot and triphalangeal thumb
 Cleft hand and foot in addition to other skeletal defects
 Cleft hand and foot with absent permanent teeth
 Cleft hand and foot with perceptive deafness
 Cleft foot with mandibulofacial dystosis
 Cleft hand, variable foot defect, cleft lip or palate, and ectodermal defects
 Cleft hand and foot, with nasolacrimal duct obstruction
 Clefts of the hand or feet with anonychia
 Cleft hand and foot with eye defects
 Cleft hands with tibial aplasia
 Cleft hand with absence of pectoralis major
 Cleft hand as part of the “de Lange” syndrome
Wood et al. found that 9 of 20 patients with cleft hand also had cleft foot deformity (93 ).
Treatment
Generally, many patients with cleft hand or foot have little functional impairment, with shoe accommodation and cosmesis being primary concerns (42 ). Conservative treatment usually
consists of custom molded shoes to accommodate the splaying of the forefoot (90 ,97 ). However, surgery may be indicated in certain circumstances such as patients with painful deformities
with associated hallux valgus and intractable plantar tylomas (90 ). Another indication for surgery is to attempt to alleviate the deep emotional disturbance caused by the bizarre appearance of
the deformity.
No surgical procedures will cause the cleft foot to have a normal appearance. The family must understand this fact. Furthermore, multiple-staged procedures may be required because of
limitations of tourniquet time, blood loss, and tissue trauma. The goals of surgery are to attempt to restore function, to provide a stable, weight-bearing foot, and to alleviate the patient's
physical pain and emotional trauma while enhancing the cosmetic appearance to the best of the
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surgeon's ability (42 ,92 ). Surgery is best undertaken when the patient is young. Tachdjian recommended surgical treatment for patients
between 1 and 2 years of age (43 ). Other surgeons recommended that their procedures be performed when patients are about 6 to 8
months old, so as to not interfere with the onset of walking and because the bones and soft tissues are more readily molded into an
improved position (93 ,98 ). Surgical treatment at an early age tends to provide a better result because increased splay and deformity may
be seen in the first few years of life if the condition is untreated (42 ).
FIG. 12. A-D: Giorgini method of repairing a cleft foot.
Single-stage procedures have been described by Tachdjian and Barsky, but generally they do not provide the same degree of improvement
seen with other approaches (43 ,94 ). Staged procedures appear to be most accepted and effective (42 ,89 ,98 ). The first step is used to
reduce the width of the forefoot by skin plasties, osteotomies, and ostectomies. The patient is allowed to heal, and a second procedure is
performed consisting of digital desyndactylization, toenail modifications, bunionectomies, arthroplasties, and exostectomies (92 ).
An approach that exemplifies this philosophy was described

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by Giorgini et al. in a patient with four metatarsals. In the first procedure, a V-shaped wedge of skin and soft tissue with the apex proximal
and the base distal was excised. A bone wedge was removed from the second and third metatarsal bases, and an arthrodesis was
performed. The wound was closed to eliminate the cleft. A subsequent second operation was performed to narrow the cleft further by
reosteotomy on the second and third metatarsals. A soft tissue procedure was also performed in the second stage to desyndactylize the
hallux and second digit (89 ) (Fig. 12 ). A similar procedure has also been employed by Wood et al. (93 ). Three tissue flaps were raised on
the inner border of each side of the cleft for bridging of the deficit. Metatarsal osteotomies were used as required to achieve a more
functional and cosmetically appealing result. Seven patients underwent repair of cleft foot deformities with good results. All could wear
normal shoes, but shoe inserts were occasionally needed.
Sumiya and Onizuka described a procedure that was directed toward improving the cosmetic appearance and attempting to reconstruct a
“normal-appearing foot” with toes. First, a double-pedicled flap from the cleft area is raised and is turned down to make a wide third toe.
Next, the second and fourth metatarsals are approximated and are fixed by a strip of fascia lata. Either a free skin graft or a local flap
covers the dorsal skin defect. After several weeks, the third and old lateral toes are each divided to make two new toes, by means of a
free skin graft (98 ) (Fig. 13 ).
FIG. 13. Sumiya and Onizuka method of repairing a cleft foot. A and B: A double-pedicle flap is raised from the dorsal skin and is
advanced to create a new “toe.” C: A graft is used to close the dorsal defect. D and E: The new toe and the lateral toe are incised as
in a desyndactyly procedure. Skin grafts are used to cover any defects. F: The skin graft from the first surgical procedure may create
retraction of the new digits. G: Therefore, this is excised and is covered with a rotational flap. H: Final appearance.
After the procedure, the newly formed toes do not grow to the same degree as the other digits. This may be addressed at a later date by
lengthening of the flap. When surgery is postponed beyond 1 year of age, the foot widens, and the first and fifth toes make a “pincer”
deformity that may be prevented by the creation of the additional digits. The newly formed toes are non-weight bearing and need not
touch the floor. They may also be insensate. These authors reported good results in three of eight children undergoing surgery. Two of the
patients required subsequent repeat local transpositional skin flaps to address contracture associated with skin grafts.
An entirely different approach was taken by Weissman and Plaschkes (99 ). They used a transverse incision at the cleft, elevated full-
thickness flaps, and rotated the deformed digits into the cleft, eliminating the toes (Fig. 14 ). This procedure creates a foot that appears
to have undergone a transmetatarsal amputation. DeValentine noted that this approach could work suitably for an adult, but it could be
potentially problematic in younger patients in whom additional digital growth could be anticipated (42 ).
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FIG. 13. Continued.
FIG. 14. A,B: Weissman and Plaschkes procedure for cleft foot.
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CONGENITAL OVERLAPPING LESSER TOE

Congenital overlapping lesser toe is a general term used to describe a common congenital occurrence in which one toe lies on the dorsal
aspect of the adjacent toe. This deformity is most commonly seen in the fifth toe, although it may involve other digits as well. The second
toe overlapping the hallux is the next most common deformity of this type (44 ). For the purpose of this chapter, we use the example of
the overlapping fifth toe to represent this deformity (Fig. 15 ).
Etiology
General agreement exists that the overlappping toe deformities are congenital. Several authors have proposed various causes. Lantzounis
believed that the overlapping fifth toe was secondary to a prolonged malposition of the fifth toe during intrauterine life (100 ). Other
investigators have suggested that the deformity may be secondary to the failure of proper development of the articular surfaces of the
fifth metatarsophalangeal joint. Dobbs suggested that a displacement of the insertion of the flexor digitorum longus may develop as the
forefoot abducts on the rearfoot in patients with excess pronation. However, this would not likely be the source of most cases of
overlapping fifth toe (Fig. 16 ).
The three primary components to the overlapping fifth toe are transverse plane adduction, sagittal plane dorsiflexion, and varus rotation
in the frontal plane. Each of these deviations occurs at the metatarsophalangeal joint, although in some instances there may be
contracture within the toe itself. Because of the position of the toe, contracture develops at the medial collateral ligament, the medial
aspect of the metatarsophalangeal joint, the extensor digitorum longus, and the skin at the dorsomedial aspect of the fourth interdigital
web space. Over time, osseous adaptation of the proximal phalanx or fifth metatarsal head may also develop. Because of its position, the
overlapping fifth toe often appears smaller and flattened; it loses its cylindric appearance and takes on a paddle-like shape (101 ,102 ).
FIG. 15. Appearance of an overlapping fifth toe deformity in an adult. Note the flattened or paddle-like appearance of the toe.
FIG. 16. Congenital overlapping fifth toe deformity in a newborn infant. The presence of the condition at this age strongly supports
the theory that intrauterine or developmental factors influence the creation of the deformity.
The congenital overlapping fifth toe is generally asymptomatic in infancy and early childhood, but it does create problems for some
adolescents and adults. Approximately 50% of patients remain asymptomatic. In those who do develop symptoms, most complain of dorsal
digital irritation, sometimes with an associated heloma. Less frequently, patients may have an interdigital heloma in the fourth web space
or a callus along the margin of the nail.
Careful evaluation of the digit allows the clinician to determine the flexibility and status of the fifth metatarsophalangeal joint. The
tautness of the extensor tendon and the dorsal skin may be assessed by plantarflexing the toe. Palpation of the fifth metatarsophalangeal
joint itself generally provides some idea whether subluxation or overt dislocation is present. Radiographs may be helpful in determining the
degree of joint adaptation.
Treatment
Most authors believe that conservative treatment is fruitless in patients with congenital overlapping fifth toe. In extremely
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mild cases, or in the very young, stretching or strapping of the toe in abduction and plantarflexion may be attempted. Jordan and Caselli
advocated a simple adhesive splint that they indicated would improve alignment in 4 to 6 weeks, depending on the age of the patient and
the severity of the deformity (103 ). Complete correction was achieved by maintaining the proper alignment for 2 to 8 weeks. Patients less
than 5 to 6 months of age have generally not undergone tape splinting because of the small size of the digit (103 ,104 ). However, the
earlier the deformity is addressed, the shorter and more effective the treatment will be (Fig. 17 ). Tape strapping can be modified to
address the fifth digit by strapping it to the fourth digit or by abducting, everting, and plantarflexing it alone to the lateral side of the foot.
Many variations on the specifics of strapping exist, including the materials and methods used. In older patients, conservative measures
usually consist of padding, digital shields, extra-depth shoes, or sandals.
Many surgical procedures have been devised for correction of the overlapping fifth toe. The oldest operation is amputation. However, after
amputation, calluses may develop around the remaining fifth metatarsal head (105 ). Other problems such as irritation to the fourth toe
may also be a problem once the lateral buffer of the fifth digit is absent.
FIG. 17. A: Taping for the overlapping digit. B: Generally, half-inch tape is used around the distal aspect of the deformed toe, and
the digit is derotated. C: The tape is then used to encircle the adjacent digits to maintain the alignment.
In the 1940s, owing to the stigma associated with amputation, and because some surgeons believed that patients with an overlapping fifth
toe were unfit for civil service (106 ), other methods were developed. Most surgical methods for correction on congenital digiti quinti varus
involve soft tissue procedures. Lantzounis sectioned the extensor digitorum longus tendon within the fifth toe (100 ). The periosteum of
the fifth metatarsal, the joint capsule, and the periosteum of the proximal phalanx were then incised longitudinally. A flap was raised by
elevating the periosteum and capsule dorsally, medially, and laterally. A drill hole was created in the distal fifth metatarsal, and the
proximal end of the severed tendon was passed through this hole and sutured back onto
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itself. A horizontal mattress suture was then placed into the periosteal-capsular flap and was tied with the toe in the corrected position.
Simply stated, the procedure consisted of a modified Jones suspension, a dorsal capsulotomy, and a plantar capsulorrhaphy. In patients
undergoing 25 procedures, Lantzounis reported excellent results in 70%, good results in 17%, and poor results in 13%.
Lapidus approached the deformity through a hockey-stick incision that started at the distal interphalangeal joint of the toe, extended
proximally to the fourth web space, and then curved laterally over the dorsum of the fifth metatarsophalangeal joint, to continue
dorsolaterally to the lateral aspect of the fifth metatarsal head (106 ). A separate incision was made further proximally over the extensor
digitorum longus slip to the fifth toe. The tendon was transected and was pulled distally through the incision over the metatarsophalangeal
joint. A capsulotomy was performed at the fifth metatarsophalangeal joint. The free tendon graft was then routed through a subcutaneous
channel from the medial aspect of the distal interphalangeal joint under the phalanges to the plantar lateral aspect of the fifth
metatarsophalangeal joint. It was then sutured into the capsule and conjoined tendons laterally. Lapidus noted satisfactory results in a few
cases but did not expound on these results.
Goodwin and Swisher recognized that the dorsal skin contracture could also be a limiting factor in achieving good correction (105 ). These
authors advocated a Y-shaped incision with the stem of the Y directed proximally. The extensor tendon was lengthened in a Z-plasty
fashion and a dorsal or dorsomedial capsulotomy performed at the metatarsophalangeal joint. The digit was then held in the corrected
position, and the dorsal skin was closed from proximal to distal. During closure, the proximal arm of the Y actually shifted distally, in
essence creating a V-Y skin plasty. The correction was maintained for up to 6 weeks with a plaster of Paris cast or adhesive strapping. The
authors noted complete success in about 20 cases.
In a similar manner, Stamm and Wilson described a dorsal V-Y skin plasty as part of the correction for overlapping fifth toe (107 ,108 ). The
V-shaped skin incision was placed over the fourth interspace with the base oriented from distal to lateral and the apex from proximal to
medial. Once the skin flap was elevated, a tenotomy was performed on the extensor tendon, and a capsulotomy was done on the
metatarsophalangeal joint. The toe was held in the corrected position, and the incision was closed in a Y shape. Plaster of Paris casting
was advocated for several weeks. Wilson noted good results in seven cases (108 ). No other specifics were noted by Stamm (107 ). However,
in later years, Paton reported on the long-term results of this approach (109 ). Early assessments revealed good results, but a longer-term
evaluation found good or acceptable results in only 40% of patients.
Cockin reported on an operation that he credited to Butler that consisted of a double-racket incision with a circumferential incision around
the base of the fifth toe with a dorsal and plantar handle (110 ). The plantar handle was made slightly longer and was inclined laterally to
allow improved position of the toe at closure. The skin flaps created were then raised, with careful preservation of the neurovascular
bundles. An extensor tenotomy and dorsal capsulotomy of the fifth metatarsophalangeal joint were then performed. The toe was relocated
in the corrected position, and the wounds were closed. Cockin reported on 70 cases in patients ranging in age from 5 months to 45 years at
the time of surgery (110 ). Of these results, 91% were deemed good, with 4 cases rated fair and 2 rated poor. A 78% rate of excellent
results was also described by Black et al. after 36 procedures (111 ).
Syndactylization of the fourth and fifth toes has been advocated by several authors (43 ,112 , 113 , 114 , 115 ). In infants and young
children, this procedure has been used to achieve correction, but as the patient ages, the deformity becomes more fixed, so syndactyly is
often accompanied by partial or complete phalangectomy. Good results have been reported (43 ,112 ,113 ,115 ), although Giannestras
believed that other approaches were superior (104 ).
Ruiz-Mora described a procedure consisting of a complete proximal phalangectomy performed through a plantar longitudinal skin ellipse
(116 ). Closure of the plantar ellipse was believed to enhance correction and to prevent recurrence of the condition. Although Janecki and
Wilde reported that their patients sustained complete relief of symptoms, in 10 of 31 procedures, a hammer toe deformity developed in
the adjacent fourth toe (117 ). This was attributed to the significant shortening that occurred in the fifth digit after surgery. Seven
additional patients had a painful prominence or tailor's bunion deformity. The recommendations of these investigators were for a more
conservative bone resection. Thompson modified the original Ruiz-Mora procedure by including a dorsal Z-plasty which he believed was
helpful in maintaining correction, but no specifics were discussed. Dyal et al. found that most of their 12 patients who underwent the Ruiz-
Mora procedure were happy with the results (118 ). However, an unacceptable cosmetic result was the primary complaint in all those
patients who were dissatisfied (Fig. 18 ). The average amount of shortening experienced was 12.8 mm. A single patient developed a lesion
of the fourth toe, and no patients presented with tailor's bunions.
Kaplan reported success using his modifications (119 ). Through a dorsal longitudinal incision, the head of the proximal phalanx was
removed, and the extensor tendon was sectioned at this level. A dorsal, medial, and lateral capsulotomy was performed at the fifth
metatarsophalangeal joint. The extensor tendon was then reinserted into the base of the proximal phalanx. Plantarly, two semielliptic
incisions were made at the base of the fifth toe, and the resulting wedge was excised.
Although numerous procedures have been proposed for the correction of the congenital overlapping fifth toe deformity, none has met with
universal or even overwhelming
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acceptance. The reasons are most likely the recalcitrant nature of the deformity and the difficulty in reproducing the early success of
many authors who used a variety of approaches. Furthermore, those procedures that do limit the likelihood of recurrence such as the Ruiz-
Mora procedure tend to create new problems or deformities. Most of the procedures described previously may work well in patients with
mild deformity and even in some with more severe conditions. Unfortunately, most of the procedures discussed fail to address one of the
components of the deformity.
FIG. 18. A patient seen 2 years after the Ruiz-Mora procedure. Note the significant shortening that may lead to lesser digital
irritation, as in this patient.
Therefore, to create a more reliable means of restoring alignment and maintaining correction, all aspects of the deformity must be
addressed. Downey and Rubin described their “consolidated surgical approach” as a means of achieving this goal (101 ,102 ) (Fig. 19 ). A
dorsal or dorsomedial Z-plasty is performed in line with the skin contracture to alleviate this component of the deformity. In patients with
severe contracture, these investigators noted that a double Z-plasty may be required. The central line of the incision may then be
extended onto the dorsal aspect of the fifth toe.
FIG. 19. Downey's consolidated approach to the repair of a congenital overlapping fifth toe. A: Preoperative appearance of the
deformity. B: Dorsal double Z-plasty skin incision. C: With plantarflexion of the toe and metatarsophalangeal joint, the flaps
advance, to alleviate the dorsal skin contracture. D: The extensor tendon is sectioned at the level of the proximal interphalangeal
joint, an extensor hood recession is performed, and the tendon is retracted. E: The fifth metatarsophalangeal joint is exposed after a
dorsal and dorsomedial capsulotomy. F: A McGlamry elevator is passed beneath the fifth metatarsal head to release the plantar plate
of the fifth metatarsophalangeal joint. G: The head of the proximal phalanx is resected to alleviate deformity at the digital level. H:
A segment of skin is excised plantarly to remove redundant tissue. Care is used to preserve the neurovascular structures in the
subcutaneous tissue. I: Closure is accomplished with nonabsorbable sutures. All the sutures are placed into position before tying to
allow easier visualization. J: A bone trephine is used to create a medial to lateral hole in the fifth metatarsal neck. K: The previously
harvested extensor tendon is then routed through the hole in the fifth metatarsal. L: The extensor tendon is sutured on itself. M: A
0.062-inch Kirschner wire is inserted to aid in maintaining alignment of the digit. N: Immediate postoperative appearance after
closure of all wounds.
Contracture of the extensor digitorum longus is addressed in an open Z-plasty lengthening if the deformity is mild or flexible. Once
correction is attained, the tendon is then sutured in the lengthened position. When the deformity is moderate to severe, or fixed, then the
tendon is transected at the level of the proximal interphalangeal joint and is subsequently transferred to the head of the fifth metatarsal
neck. In either instance, a complete release of the extensor hood is performed as well.
Next, the capsule at the fifth metatarsal phalangeal joint is incised dorsally, medially, and at times laterally as well. A McGlamry elevator
or similar instrument is then used to release the flexor plate. The capsule is not closed dorsally or medially. After this complete soft tissue
release, the osseous structures may be assessed for any significant adaptive changes. When deformity exists at the proximal
interphalangeal joint, then the head of the phalanx is resected. This is most commonly required in adults or in more rigid conditions. In
rare circumstances of severe conditions, or in cases of recurrent deformity, a partial or complete fifth metatarsal head resection is
performed. Alternatively, an implant arthroplasty may be considered.
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FIG. 19. Continued.

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FIG. 19. Continued.

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The plantar aspects of the toe and metatarsophalangeal joint are addressed next. The fifth metatarsophalangeal joint capsular redundancy
is addressed by a plantar capsulorrhaphy. In milder cases, sufficient release of the tissues may be accomplished without this step. Finally,
a plantar skin wedge is removed. This wedge is usually ovoid or elliptic and aids in maintaining correction. Careful dissection is necessary
to preserve the deeper subcutaneous tissues, which should not be violated. The skin ellipse may be angled slightly more laterally at its
proximal end to aid in maintaining the desired correction further.
When each component of the deformity is addressed, closure is accomplished. A K-wire may be placed across the metatarsophalangeal
joint to maintain position. This may be employed for 4 to 6 weeks. Otherwise, the bandage is vital in maintaining the corrected position.
Alternatively, a V-Y skin plasty may be used, as opposed to the dorsal Z-plasty, as a means of releasing this component of deformity.
Postoperative Considerations
After surgery, a surgical shoe may be used and padded from the heel to the digital sulcus to alleviate dorsiflexory stress to the digit. Some
surgeons may prefer a non-weight-bearing cast. Once the bandages are discontinued, then some form of additional splinting may be helpful
in maintaining alignment. Compression over the area may also help to reduce the congestion that develops in the flaps of the skin plasty
and to speed the resolution of this localized edema.
CONGENITAL UNDERLAPPING TOES

Congenital underlapping toes comprise a relatively common deformity in which one or more toes may be deviated plantarward, medially,
and rotated in a varus direction. The terminal pulp of the toe eventually begins to impinge on and curl under the adjacent toe (43 ). In
many instances, only the distal interphalangeal joint is involved, but in others, deformity may exist in both proximal and distal
interphalangeal levels. Trethowan described the underlapping toe as a congenital form of hammer toe (120 ). Sweetnam coined the term
congenital curly toe (121 ). He noted that the deformity does not spontaneously correct and usually becomes worse with growth.
Etiology
The exact cause of the condition is uncertain. Some authors have suggested that the condition is due to hypoplasia of the intrinsic muscles
of the affected toe (43 ,121 ). Gamble and Yale proposed that underlapping toes were caused by ligamentous restrictions present at birth
that usually responded to conservative splinting of an infant's toe with tape (122 ). Yale noted that generalized hypermobility of the foot
may predispose one to the condition (123 ). Downey and Rubin noted that a patient with weakness or hypoplasia of the quadratus plantae
muscle would have a long flexor tendon with a more medially directed vector of force that could lead to deformity in one or more toes
(101 ). Furthermore, in the hypermobile foot with forefoot abductus, one may see excess activity of the long flexor in an attempt to help
in stabilizing the foot. This situation tends to create a greater and more profound medial force from the long flexor tendons. The
deformity may also be acquired by an abnormal foot type with secondary influences from shoes (44 ).
In children, the underlapping toe is often flexible and asymptomatic. Symptoms may be seen if the toe underlaps the medially adjacent
digit to the extent that the digit does not bear weight, a condition that leads to potentially greater degrees of shoe irritation. This may
also create pain or heloma between the toes or a lesion dorsally or at the lateral nail area of the underlapping toe.
Treatment
Treatment of congenital underlapping toe varies with the degree of deformity, the biomechanics of the foot, the age of the patient, and
the symptoms. If the deformity is mild and does not impinge on the adjacent toe, then no treatment is necessary. Conservative treatment
consists of various types of orthodigital devices in older persons. For many authors, conservative measures have proven to be of benefit in
some patients (124 , 125 , 126 , 127 ). In infants, strapping and taping measures have been most commonly used as conservative treatment.
Tachdjian calls this type of treatment useless and of no permanent benefit (43 ). However, I have seen lasting benefit when this type of
treatment is initiated within the first weeks of life and is applied incessantly by the patient's parents. Contrarily, Turner noted good
success with strapping while active treatment was provided, but a significant loss of correction developed once strapping was discontinued
(128 ). Trethowan also described repetitive manipulation of the deformity with passive stretching (120 ).
Surgical Treatment
Surgical correction is performed if the deformity is creating pain with or without heloma formation or bursitis or if conservative therapy
has failed to render the patient asymptomatic. In children, Kelikian recommended surgical syndactyly with its normal neighbor (129 ). In
adults, a partial phalangectomy was also performed. When the condition was flexible, Downey and Rubin performed tenotomies of the long
and short flexor tendons in children with derotational skin plasties (101 ). In fixed deformities, an arthroplasty of the affected joint area
was performed. Transfer of the long flexor tendon into the dorsal lateral side of the extensor hood with and without K-wire fixation has
also been advocated by several authors (43 ,130 ,131 ) (Fig. 20 ).
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FIG. 20. Surgical correction of congenital underlapping (varus) toes third and fourth toes. A: Preoperative right foot. B: Postoperative
right foot. C: Preoperative left foot. D: Postoperative left foot. E: Preoperative radiograph of left foot. F: Preoperative radiograph of
right foot. G: Postoperative film at 2 weeks after surgical correction. H: Postoperative films of both feet, at 2½ years. I:
Postoperative long-lasting clinical correction of curly toe deformity at 2½ years.
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FIG. 20. Continued.

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FIG. 20. Continued.
Arthroplasty techniques have proven effective in alleviating pain and in improving the overall alignment of underlapping toes. Generally,
the joint that is resected corresponds to the maximal level of deformity. This may be combined with excisional skin plasties to help to
maintain correction. K-wire stabilization for several weeks is another good means of enhancing results. The wire allows the initial healing
phase to proceed in a organized manner in the corrected position. Subsequent splinting for a period after surgery may be helpful regardless
of the techniques involved.
HALLUX ABDUCTUS INTERPHALANGEUS

Abductus deformity of the distal phalanx of the hallux is a common congenital deformity. The term hallux valgus interphalangeus was first
coined by Daw and was used to denote a fibular deviation of the distal phalanx of the great toe (132 ). Sorto et al. modified the term for
the sake of accuracy to hallux abductus interphalangeus (133 ). Radiographically, the angular relationship of the longitudinal bisections of
the distal and proximal phalanges of the great toe are used to denote the condition. A normal value is considered to be less than 10
degrees (Fig. 21 ).
Etiology
The specific origin of an excessive hallux abductus interphalangeus is unknown. Barnett believed that hallux abductus interphalangeus was
congenital and even present at birth (134 ). He compared unshod New Guinea natives with British citizens and noted no statistical
difference in the degree of hallux abductus interphalangeus between the two groups. Gillett believed that most patients acquired
deformity early in life, most likely as a consequence of shoes (135 ). Other investigators suggested that the condition results
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from asymmetric overgrowth of the medial portion of the physis of the distal phalanx of the hallux (43 ).
FIG. 21. Factors associated with hallux abductus interphalangeus. A: Obliquity. This represents an oblique orientation of the articular
surface of the head of the proximal phalanx. To measure obliquity, one draws a tangent to the articular surface of the proximal
phalangeal head (AB). A perpendicular line (CD) is then extended from the longitudinal bisection of the proximal phalanx. The
obliquity is then the measurement of the angle between lines A and C. B: Asymmetry. Asymmetry is defined as the angular
relationship between the articular surface of the base and the longitudinal axis of the distal phalanx. A tangent (AB) is drawn at the
articular surface of the base of the distal phalanx. The longitudinal bisection is defined, and a perpendicular line is created (CD). The
angle measured between lines A and C represents the amount of asymmetry. C: Joint deviation. Joint deviation is the angular
relationship between the articular surfaces on each side of the interphalangeal joint. Tangents are drawn on each side of the joint,
and the resultant angle is measured. (From Sorto LA, Balding MG, Weil LS, et al. Hallux abductus interphalangeus: etiology, x-ray
evaluation and treatment. J Am Podiatry Assoc 1976;66:384-396, with permission.)
Sorto et al. indicated that hallux abductus interphalangeus is a normal finding at birth (133 ). They also concluded that the interphalangeal
abductus increases with growth, mainly because of lateral hypoplasia of the distal phalangeal epiphysis caused by shoe pressure. They also
believed that an inverse relationship existed between hallux abductus and hallux abductus interphalangeus. Therefore, with a more
unstable metatarsophalangeal joint, one would anticipate less abductus at the interphalangeal level, yet with a stable
metatarsophalangeal joint, the hallux itself would tend to demonstrate more abductory change (Fig. 21 ).
The clinical presentation of an excessive hallux abductus interphalangeus varies greatly. Younger patients tend to have fewer symptoms,
but irritation at the dorsomedial aspect of the interphalangeal joint may be seen in many age groups.
Treatment
The specific treatment for hallux abductus interphalangeus varies, based on the degree of symptoms, deformity, and age of the patient.
Tachdjian recommended medial epiphyseal arrest along with medial exostectomy in the younger
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patient. Interphalangeal joint fusion was advocated in the skeletally mature patient in conjunction with exostectomy (43 ). However, most
other authors have recommended Akin osteotomy for treatment of symptomatic hallux abductus interphalangeus (62 ,104 ,129 ).
Downey and Rubin recommended that treatment be based on the level of deformity (101 ). In patients with a lateral deviation in the distal
aspect of the proximal phalanx, an Akin osteotomy was performed. A medial closing wedge osteotomy of the distal phalanx proved suitable
in patients with asymmetry in the distal segment. However, this procedure proved difficult because of the short length of the distal
phalanx, and even more trying in a young patient with an open growth plate. In patients with severe deformities, particularly with an
increase in the angle of joint deviation, arthrodesis of the interphalangeal joint was advocated.
CONGENITAL HEMIHYPERTROPHY
Congenital hemihypertrophy is defined as a unilateral overgrowth of the body, which may include the structures of the head, trunk, and
limbs, with no discernible cause (136 ). Most commonly, this condition involves the upper and lower extremities or part of an extremity.
Asymmetry of the human body has fascinated artists, sculptors, and physicians for thousands of years. Evidence of the condition is found in
Egyptian and Greek art, as well as in the works of medieval and modern painters (136 ). The first clinical case of hemihypertrophy was
reported by Wagner in 1839 (136 , 137 , 138 ). Ringrose et al. in 1965 reported fewer than 200 cases of congenital hemihypertrophy (139 ).
Other names for this condition include true hypertrophy, hyperplasia, hemigigantism, congenital hemicorporal dysharmony, partial
macrosomia, and megalosomia.
The patient with a classic case of congential hemihypertrophy presents with an enlargement of one side of the body, including the skeleton,
the pupil of the eye, the ear, half the tongue, thorax, and abdomen, the arm, and the leg (138 ) (Fig. 22 ). More commonly, the condition
involves the upper and lower extremities or part of an extremity (137 ). The asymmetry is almost always evident at birth. The enlarged
side generally grows at a rate proportional to the normal side (139 ).
Mental deficiency is said to occur in 20% of patients with congenital hemihypertrophy. Wilms' tumor affects about 3% of these patients, and
other urinary tract diseases such as medullary sponge kidney and renal medullary cysts are more common as well. Investigators have
suggested that these patients also have a higher freqency of other tumors in the liver and adrenal cortex (136 ). Other clinical findings that
may be noted include telangectasias, hemangioma, varicosities, lymphedema, congenital heart disease, arteriovenous fistula, nevi, café-
au-lait spots, brain abnormalities, and skeletal deformities such as polydactyly and macrodactyly (6 ,139 , 140 , 141 , 142 ). No
predilection for a particular side of the body affected appears to exist, and female patients with the condition predominate at a ratio of
3:2.
The origin of this condition is not fully understood. Gesell considered that these patients had “imbalance in the normal process of twinning
exerted in the early stages of cleavage” (143 ). Schwartzman et al. believed that abnormal functions of the pituitary and adrenal glands
were possible sources (144 ). Tachdjian proposed that vascular and lymphatic abnormalities and lesions in the hypothalamus were possible
(145 ). Essentially, an increased blood supply to one side of the body seems to be the mediating factor. The condition has been noted in
patients with arteriovenous fistulas and neurofibromatosis, as well as secondary to malignant disease. Heredity does not appear to be a
factor.
Classification
Congenital hemihypertrophy may be confused with other disease states. Because the prognosis varies depending on the condition,
differentiation is important. Klippel-Trenaunay-Weber syndrome also presents with vascular malformations such as multiple cutaneous
hemangiomas, macrodactyly, and large hands and feet. It is also necessary to differentiate congenital hemihypertrophy from
hemihypotrophy. The latter represents a failure of growth of one side as opposed to the excessive growth of the former condition.
Hemihypotrophy is considered a more benign condition and is associated with less morbidity. Classification of congenital hemihypertrophy
as described by Ward and Lerner is provided in Table 2 (146 ).
Treatment
The treatment of congenital hemihypertrophy varies with the degree of deformity, the age of the patient, and the interference with
normal function. Most authors agree that femoral and tibial epiphysiodesis is indicated if significant limb length discrepancy exists. Shoe
modifications may be required to accommodate the foot (138 ,145 ). However, this conservative approach may not be practical in certain
cases, and surgical measures may be of benefit. In rare instances in which localized muscular hypertrophy seems to be the only
manifestation, then excision of hypertrophic muscle may reduce the bulk of the foot to allow greater ease of fitting shoes (147 ). Bouchard
described one case in a patient whose foot was reduced with a combination of osseous and soft tissue procedures (44 ). This included
partial excision of the muscle bellies of the abductor hallucis and abductor digiti quinti with skin plasties. Osseous procedures included
closing wedge fusions of the first and fifth metatarsals to reduce forefoot splay (44 ) (Fig. 22 ).
FIG. 22. A: Clinical appearance of a 13-year-old girl with hemihypertrophy of the left foot. B: Radiographs demonstrate increased
size of the osseous structures and splaying of the first and fifth metatarsals on the left foot. C: Radiographic appearance after
surgery. D: Clinical appearance 18 months postoperatively with a good cosmetic and functional result.
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FIG. 22. Continued.

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TABLE 2. Possible causes of acquired and congenital forms of hemihypertrophy

Congenital
Total hypertrophy (involving all systems)
Segmental
Crossed
Hemihypertrophy
Limited hypertrophy (in which one or more but not all systems are involved)
Muscular
Vascular
Skeletal
Neurologic
Acquired
Total hypertrophy
Gigantism-hyperpituitarism
Neurofibromatosis
Limited hypertrophy
Milroy's disease
Elephantiasis
Lipomatosis
Neurofibromatosis
Vascular anomalies
Multiple arteriovenous aneurysms
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66. Weinstock RE, Bass SJ, Farmer MA. Desyndactylization: a new modification. J Am Podiatr Assoc 1984;74:458-461.
67. Mondolfi PE. Syndactyly of the toes. Plast Reconstr Surg 1983;71: 212-218.
68. Ishikura N, Heshiki T, Kimura T, et al. Repair of complete syndactyly by tissue expansion and composite grafts. Br J Plast Surg 1995;48: 396-400.
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75. Kumar K, Kumar D, Gadegone WM, et al. Macrodactyly of the hand and foot. Int Orthop 1985;9:259-264.
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77. Edgerton M, Tuerk D. Macrodactyly: its nature and treatment. In: Littler J, ed. Symposium of reconstructive hand surgery. St. Louis: CV Mosby, 1974:103.
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79. Dennyson WG, Bear JN, Bhoola KD. Macrodactyly in the foot. J Bone Joint Surg Br 1977;59:355-359.
80. Pearn J, Bloch CE, Nelson MM. Macrodactyly simplex congenita: a case series and considerations of differential diagnosis and aetiology. S Afr Med J 1986;70:755-758.
81. Perdiue RL, Mason WH, Bernard TN. Macrodactyly: a rare malformation. Review of the literature and case report. J Am Podiatr Assoc 1979;69:657-664.
82. D'Costa H, Hunter JD, O'Sullivan G, et al. Magnetic resonance imaging in macromelia and macrodactyly. Br J Radiol 1996;69:502-507.
83. McDonald JF, Pruzansky JD, Meltzer RM. Evaluation of recurrent macrodactyly with three-dimensional imaging. J Am Podiatr Med Assoc 1991;81:84-87.
84. Boberg JS, Yu GV, Xenos D. Macrodactyly: a case report. J Am Podiatr Med Assoc 1985;75:41-45.
85. Tsuge K. Treatment of macrodactyly. Plast Reconstr Surg 1967;39: 590-599.
86. Tsuge K. Treatment of macrodactyly. J Hand Surg [Am] 1985;10: 968-969.
87. Topoleski TA, Ganel A, Grogan DP. Effect of proximal phalangeal epiphysiodesis in the treatment of macrodactyly. Foot Ankle Int 1997; 18:500-503.
88. Buss PW. Cleft hand/foot: clinical and developmental aspects. J Med Genet 1994;31:726-730.
89. Giorgini RJ, Capa CJ, Potter GK. Two-stage surgical correction of cleft foot: a seven year follow-up of one case. J Am Podiatr Med Assoc 1985;75:481-487.
90. Mason WH. Congenital cleft foot deformity (split foot or lobster claw). J Am Podiatr Med Assoc 1991;81:575-579.
91. Koldas T, Sirin F, Hayirlioglu T. Unilateral cleft foot deformity. Arch Orthop Trauma Surg 1996;115:295-296.
92. Coleman WB, Aronovitz DC. Surgical management of cleft foot deformity. J Foot Surg 1988;27:497-502.
93. Wood V, Peppers T, Shook J. Cleft-foot closure: a simplified technique and review of the literature. J Pediatr Orthop 1997;17:501-504.
94. Barsky A. Cleft hand: classification, incidence, and treatment. Review of the literature and report of nineteen cases. J Bone Joint Surg Am 1964;46:1707.
95. Blauth W, Borisch N. Cleft feet. Clin Orthop 1990;258:41-48.

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Chapter 18
Trauma to the Nail and Associated Structures
Scot D. Malay
Injuries involving the pedal nail bed and associated structures are common. Acute toenail injuries are most frequently caused by dropping
a heavy object on the toe or by stubbing the toe. Other, less common mechanisms of acute injury include puncture wounds, as well as
lacerations caused by lawn mower blades (1 ), axes, and other tools or machinery. Chronic nail trauma is usually caused by repetitive
mechanical pressure associated with digital deformities and shoe gear. Delayed nail bed repair may result in less than satisfactory
reconstruction, most notably nail bed scar formation and resultant onycholysis. Therefore, it is important that timely identification of the
extent of the injury (2 ) and appropriate acute care of nail bed injuries be provided in the office, emergency department, or operating
room.
NAIL ANATOMY, PHYSIOLOGY, AND FUNCTION

The perionychium consists of the paronychium (proximal nail fold, medial and lateral nail grooves), the nail matrix, and the nail bed (Fig.
1 ) (3 ). The proximal end of the nail plate rests in the proximal nail groove, with the proximal nail fold situated dorsally. The stratum
corneum of the proximal nail fold forms the cuticle, which adheres to the dorsal surface of the nail plate. The nail plate consists of
specialized keratin formed from germinative matrix cells located deep to the proximal nail fold and extending distally to the level
corresponding to the distal margin of the lunula. The lunula is the visibly whitish-appearing semilunar area of matrix extending distal to
the proximal nail fold and cuticle. The nail bed consists of epithelial cells that do not add to the ventral (plantar) surface of the nail plate
but form a relatively smooth, longitudinally furrowed plateau on which the nail plate glides as it grows distally (4 ,5 ). It takes at least 5 to
6 months, and frequently as long as 9 months, to grow an entirely new toenail in a healthy adult. In general, toenails grow faster in
children as compared with adults, and fingernails grow faster than do toenails. Moreover, toenails tend to grow faster in warmer
environments and well-perfused digits.
The subcutaneous region deep to the nail bed is highly vascularized, and the nail bed and matrix are situated almost immediately adjacent
to the periosteum of the distal phalanx. In essence, the nail bed anchors the nail plate to the distal phalanx, and at least 5 mm of healthy
nail bed distal to the lunula is generally necessary for satisfactory nail plate adherence and stability (6 ). This is an important guideline for
reconstruction of digital tip injuries that involve loss of the distal portion of the nail bed.
The plantar toe pulp consists primarily of subcutaneous tissue providing a firm, yet elastic pad for contact with the weight-bearing surface.
Afferent nerves terminating in the toe conduct touch-pressure and temperature sensations, allowing proprioception and nocioception,
whereas digital vascular structures (subungual glomus) permit effective peripheral temperature regulation. The resilient nail plate protects
these underlying structures from injury and combines with the distal phalanx to provide a stable support against ground reactive force as
the toe pulp contacts the substrate.
Nail matrix and bed damage can result in poor nail plate adherence and malalignment. Onycholysis, onychocryptosis, and a predisposition
to onychomycosis, or bacterial infection, may develop following injury. Hypertrophic, dystrophic, and deformed nails with ridges, split-nail
(canaliformis) changes, discoloration including streaking and loss of normal nail plate sheen, and pterygium formation (permanent
adherence of the proximal nail fold ventral epithelium to the dorsal surface of the nail plate) may occur after perionychial injuries. It has
been reported that distal growth of the nail plate is arrested or delayed for up to 21 days following local trauma or significant systemic
stress to the individual (7 ). This results in the appearance of relative thickening of the nail plate proximal and distal to the visibly thinner
transverse line of diminished nail plate production. Proximally, the newly formed nail plate is actually thicker than the normally formed,
distal segment of the plate. The proximal thickening results from an approximately 50-day period of increased matrix activity without
distal elongation of the
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plate. Toward the end (last 30 days) of the period of increased matrix activity, distal progression of the nail plate occurs. Following the
period of increased nail plate production, there is an approximately 30-day period of decreased activity before normal matrix activity
resumes. Therefore, approximately 100 days of abnormal nail plate production can be expected following trauma. The nail plate will
typically reveal a transverse groove, or Beau's line, after such an injury (Fig. 2 ).
FIG. 1. Nail anatomy and associated structures. NB, nail bed; NP, nail plate; PNF, proximal nail fold.
The nail plate and perionychium are subject to a variety of injuries ranging from minor contusions to trauma causing severe tissue loss and
the need for either acute or delayed surgical reconstruction. The hierarchy of nail bed injuries, ranging from least extensive to most
extensive, includes primary (idiopathic) onycholysis, subungual hematoma, simple nail bed lacerations, complex (crushing or stellate) nail
bed lacerations, nail bed lacerations with distal phalangeal fracture, and a variety of nail bed and toe tip tissue loss (avulsion, amputation,
and degloving) injuries. Patients with such injuries may seek medical attention at the hospital emergency room or the local podiatrist's
office. Accurate initial diagnosis of the extent of injury and proper initial treatment will greatly enhance the chance that posttraumatic
sequelae will be minimized (8 ). A useful guideline to remember for the acute care of the traumatized nail is to preserve the unity of the
toe tip: nail plate, nail bed and matrix, proximal and medial and lateral nail folds, distal phalanx, and the toe pulp.
FIG. 2. Dystrophic nail plate with Beau's line approximately 4½ months following stubbing injury. Note the new, wellformed nail
growth proximally and residual distal-medial subungual hematoma.
MECHANICAL ONYCHOLYSIS
Mechanical onycholysis, or minor separation of the nail plate from the underlying bed due to repetitive friction and pressure, is not, in any
way, considered an emergency situation. However, a distinction between chronic mechanical nail injury and pathogenic onychomycosis
should be made so that appropriate therapy can be rendered (9 ). Separation of the nail plate from the underlying nail bed effects a
change in the nail plate's refractive index to light, and the area of separation appears as a small white blotch in the nail plate.
Mechanically induced separation of the distal margin or edges of the nail plate from the nail bed often occurs in conjunction with hammer
toes and other digital contractures, or digital pressure caused by tight-fitting shoes, and frequently affects the hallux or longest toe. The
area of nail plate separation may become secondarily infected with dermatophytes, yeast, or bacteria. Associated subungual hematoma
may also occur, especially in athletes (turf toe). Treatment is aimed at alleviating the cause of the repetitive mechanical trauma and
providing appropriate antimicrobial therapy, if necessary.
SUBUNGUAL HEMATOMA
A potential space exists between the nail plate and the underlying nail bed and matrix (Fig. 3 ). Onycholysis results in the creation of a
space between the plate and bed, which may or may not fill with blood. Acute injuries that create visible onycholysis greater than 1 mm2
usually result in subungual hematoma. When a patient is seen with a swollen toe and reports throbbing pain shortly after sustaining a
digital injury, nail bed damage and subungual hematoma should be suspected. Subungual pressure secondary to hemorrhage can damage
cells of the matrix and nail bed, especially if it is not relieved within 6 to 12 hours after the initial trauma. Hemorrhagic nail plate
discoloration, which appears reddish blue initially and brownish black after 5 to 7 days, confirms
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the diagnosis of a disrupted nail bed. Unless subungual hematoma is suspected, it may be overlooked in the presence of a thick, discolored,
or mycotic nail plate, because the hematoma can be hidden by the overlying dystrophic nail plate. Moreover, radiographs of the digit
should be considered during the initial evaluation of a subungual hematoma because approximately 19% to 25% of these lesions are
associated with an underlying phalangeal fracture (2 ,10 ).
FIG. 3. Subungual hematoma. NB, nail bed; NP, nail plate.
FIG. 4. Crush injury, with 100% subungual hematoma. Note the dissecting hematoma separating the proximal nail fold epidermis from
the underlying dermis.
Treatment of subungual hematoma involves draining the blood to reduce subungual pressure. If the hematoma involves an area less than
25% of the visible nail plate, drainage can be obtained through the nail plate with the use of a hand cautery unit, an 18-gauge needle, a No.
11 blade scalpel, a heated paper clip, or the podiatry drill with an appropriate small ball bur (3 ,10 ). The status of the patient's tetanus
prophylaxis should be ascertained and the nail plate cleansed before penetrating it. Consideration should also be given to the use of
appropriate antibiotic prophylaxis or therapy, when indicated. Once the plate is penetrated, blood is expressed and subungual pressure
alleviated. A water-soluble antiseptic solution or antibiotic cream and a dry sterile dressing with appropriate splinting are then applied,
and the patient is reevaluated in 1 to 2 weeks. If the subungual hematoma involves more than 25% of the visible nail plate or the nail plate
has been avulsed in such a way as to disrupt the proximal, medial, or lateral nail folds, then a significant nail bed laceration should be
suspected and direct visualization and surgical repair of the nail bed is recommended (Fig. 4 ) (3 ,11 ).
NAIL BED LACERATIONS
Simple Nail Bed Laceration

When a significant nail bed laceration is suspected, the nail plate is avulsed following digital block and a surgical scrub and draping.
Tetanus prophylaxis and appropriate antibiotics are initiated. If indicated, a Penrose or another type of digital tourniquet may be used for
hemostasis at the base of the toe. If the toe is too edematous for further fluid injection, a more proximal regional block (Mayo block) is
employed and the digital tourniquet is not used.
Once the nail plate has been removed, dilute povidoneiodine irrigation is used to flush away hematoma and debris, and the nail bed is
inspected (Fig. 5 ). Because of the friable nature of the tissue, nail bed débridement is kept to a minimum. The margins of the laceration
are then meticulously reapproximated with the use of a 5-0 or 6-0 absorbable suture on an atraumatic needle in a simple interrupted
fashion. Suturing can be difficult because the nail bed is very friable and intimately adherent to the periosteum of the underlying phalanx.
Although superglue (octylcyanoacrylate) has been used successfully in the repair of other friable tissues (12 , 13 , 14 ), the author has
encountered robust scar hypertrophy and resultant onycholysis in the single case in which this technique was used for a transverse nail bed
laceration without fracture. Lacerations of the proximal and lateral nail folds are repaired with 4-0 or 5-0 suture. Nonabsorbable suture on
a reverse cutting needle has worked well. Care must be taken to avoid driving the needle through the germinative nail matrix. Primary
repair of the nail bed can be attempted up to 7 days following laceration, after which time wound contraction and granulation are
typically too advanced for accurate nail bed reapproximation (3 ).
After the nail bed has been repaired, attention should be directed toward preserving or repairing the proximal nail groove and overlying
proximal nail fold. Initially it is important to maintain the cul-de-sac nature of the proximal nail groove inasmuch as epidermal
epithelization and dermal contraction occur in the proximal nail fold and underlying nail bed. This process will prevent posttraumatic
adherence of the proximal nail fold to the nail bed and subsequently will allow the new nail plate to grow out from the matrix
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with minimal scar tissue impedance (4 ,5 ,15 ,16 ). It is also desirable to splint or mold the repaired nail bed so that it will provide a
smooth surface for the newly formed nail as it grows distalward.
FIG. 5. Simple nail bed laceration (same patient as in Fig. 4, after nail plate removal and lavage).
Very little controversy remains as to what method best preserves the proximal nail groove and the contour of the nail bed. The older
method, described by Schiller (17 ), of cleansing and trimming the patient's avulsed nail plate and placing it over the nail bed and into the
proximal groove. A small hole may be made in the nail plate to facilitate drainage when this method is employed, and the nail plate is
anchored with two simple interrupted 4-0 nonabsorbable sutures through the nail bed and lateral nail folds, one on each side of the nail
plate. Alternatively, a 0.02-inch thickness of silicone polymer cut to fit over the nail bed and into the proximal groove may be used. The
silicone sheet is anchored in the same way that the nail plate would have been anchored. The material that has been used most commonly
to cover the nail bed and to support the nail fold has been nonadherent gauze (Adaptic, Xeroform). This material is convenient and sterile,
and it has been shown that no significant difference exists between results obtained using the patient's own nail plate, a silicone template,
or nonadherent gauze during the acute care of the injured nail bed (18 ). Even when the trimmed and cleansed nail plate or the silicone
template is used, a nonadherent gauze is applied on top of the nail plate or silicone. This is followed by the application of a single
salinemoistened dressing sponge and a dry sterile dressing. A digital splint may be indicated, especially if phalangeal fracture is present,
and the patient may abstain from weight bearing on the affected side. The first redressing is performed 3 to 5 days after the initial repair.
Nonabsorbable sutures used to repair lateral or proximal nail fold injuries are removed after 10 to 14 days, and those used to anchor nail
plate or silicone to the nail bed are removed after 3 weeks. The old nail plate or silicone template is usually pushed off the nail bed by the
initial growth of the new nail plate, at about 3 or 4 months after injury.
Crushing (Stellate) Nail Bed Laceration

Crushing nail bed lacerations are managed in the same way as simple nail bed lacerations; however, the degree of tissue disruption is
greater (Fig. 6 ). Accurate reapproximation of wound margins may be difficult, and posttraumatic sequelae caused by nail bed scarification
are common. Stellate lacerations of the nail bed frequently propagate through the nail folds, thereby producing large segments of unstable
tissue, and concomitant underlying phalangeal fractures are almost always present.
Nail Bed Defects with Phalangeal Fractures

Distal phalangeal fractures, both simple and comminuted, frequently result from crushing or stubbing injuries to the toe (Fig. 7 ). When
the nail bed or surrounding nail folds are disrupted and the cutaneous barrier is violated, these injuries represent open fractures and
require appropriate local wound care, tetanus prophylaxis, and antibiotic therapy. Small fragments of bone that are exposed to the
external environment should be débrided. If the wound is obviously infected or heavily contaminated, further surgical débridement and
delayed closure should be considered. Otherwise, fragments that are in good alignment with minimal displacement can usually be reduced
and stabilized by reapproximating the nail bed and splinting with replaced nail plate, a silicone nail bed template, or a surgical bandage.
Satisfactory spontaneous reduction of transverse or short oblique distal phalangeal fractures usually occurs with repair of the nail bed
because of the intimate proximity of the nail bed to the periosteum of the distal phalanx. If the nail bed injury is associated with an
irreducible distal interphalangeal dislocation, consideration should be given to plantar plate interposition, especially in the presence of a
hallux interphalangeal sesamoid (19 ). Large fragments that remain grossly unstable can be reduced with a single axial Kirschner wire (K-
wire) or, if necessary, other reduction and fixation techniques may be applicable (20 ).
FIG. 6. Complex (stellate) nail bed laceration. The laceration may occur in any irregular configuration.
In young people, the status of the distal phalangeal physis should be assessed, and a contralateral radiograph may be indicated for
comparison. The proximal center of ossification appears in the distal phalanx between 3 and 6 years of age, and the two centers are
usually fused by 18 years of age. Severe stubbing or plantarflexory injuries can effect nail bed laceration and phalangeal fracture that
propagates along the dorsal surface of the nail plate into the proximal nail fold and through the physeal plate of the distal phalanx (Fig. 8 )
(21 ). This injury occurs when the nail plate is avulsed from the ventral surface of the proximal nail fold. The basilar epiphysis displaces
dorsally relative to the nail bed because the epiphysis remains anchored to the interphalangeal collateral ligaments and the extensor
tendon (22 ). In such injuries, at least the proximal portion of the nail plate should be removed to allow for adequate inspection and
cleansing, and the nail bed lacerations may require primary repair. After a thorough cleansing and débridement, the phalanx can often be
realigned simply by splinting the toe in mild hyperextension and applying a surgical bandage. Splinting and a surgical shoe are used for 3 to
4 weeks. Antibiotic therapy should be administered (open fracture) and the wound should be closely monitored for signs of infection. If
drainage or other signs of infection develop, further débridement should be performed and it is advisable to avulse the residual nail plate
fully if this has not already been done during the initial repair.
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FIG. 7. A: Crushed hallux with subungual hemorrhage, displaced nail plate, and extensive proximal nail fold and pulp injury. B: The
radiograph reveals a comminuted distal phalangeal fracture. C: Removal of the nail plate reveals a complex nail bed laceration. D:
Displaced bony fragments are excised. E: The nail bed and paronychium are reapproximated and a rubber band drain employed. F:
Nonadherent gauze is placed under the proximal nail fold and over the nail bed. G,H: Follow-up at 14 days revealed intact sensation
and an even nail bed and toe pulp contour.
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FIG. 8. Distal phalangeal physeal fracture with proximal nail fold laceration after stubbing injury in a 14-year-old boy. Appearance in
the emergency room revealed the nail plate to be firmly attached to the nail bed.
NAIL BED AVULSION, PHALANGEAL DEGLOVING, AND PARTIAL DIGITAL AMPUTATION

The likelihood of achieving a satisfactory functional and cosmetic result following acute care decreases substantially with nail bed avulsion
injuries, phalangeal degloving, and partial digital amputations. Treatment of these injuries varies with the level and direction of tissue loss.
Rosenthal (6 ) classifies nail bed tissue loss injuries according to level and direction. There are three levels of injury (Fig. 9 ):
Zone I: Distal to bony phalanx
Zone II: Distal to lunula
Zone III: Proximal to distal end of lunula
The directions (planes) of tissue loss (Fig. 10 ) are:
Dorsal (oblique)
Transverse
Plantar (oblique)
FIG. 9. Level of tissue loss: zone I, distal to bony phalanx; zone II, distal to lunula; zone III, proximal to distal end of lunula.
Axial (tibial or fibular oblique)
Central (gouging)
Distal digital injuries with nail bed defects within zone I, without exposed bone, can usually be allowed to granulate closed by secondary
intention (Fig. 11 ). The injury is cleansed, mildly débrided, dressed with an antiseptic-soaked sponge (povidone-iodine or another agent)
and sterile dressing, and the patient is allowed to ambulate to tolerance in a
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surgical shoe. Redressing is performed within 1 to 2 weeks, or sooner if indicated.
FIG. 10. Direction (plane) of tissue loss. A: Dorsal (oblique). B: Transverse. C: Plantar (oblique). D: Axial (tibial or fibular oblique). E:
Central (gouging).
FIG. 11. Zone I nail bed defect secondary to crush injury.
If the zone I tissue loss is more than 1 cm2, skin grafting on an acute or delayed basis should be considered. Newmeyer and Kilgore (23 )
advocated using a split-thickness skin graft (STSG) on an acute care basis, and they developed a simple and effective method easily
performed in the office or emergency room. This technique can also be useful in the repair of chronic superficial nail bed lesions (Fig. 12 ).
Newmeyer and Kilgore recommended the use of the STSG on fingertips. Donor sites for a STSG include the dorsum of the foot, calf, thigh,
buttocks, or volar surface of the arm. The use of such grafts, however, for weight-bearing or contact-area toe-tip injuries has been
criticized for poor graft durability. Moreover, excessive contraction of a STSG may require secondary surgical reconstruction (3 ,6 ). Strong
consideration should be given to the application of a full-thickness skin graft (FTSG) for digital-tip injuries that display tissue loss of more
than 1 cm2 on weight bearing and contact areas, especially in the repair of hallucal defects. The sinus tarsi and pre-Achilles (retromalleolar)
pinch grafts serve well in this regard, and require primary closure of the donor site. Clayburgh et al. (24 ) recommended reverse dermal
grafts, procured from the calf, thigh, buttocks, or volar surface of the forearm, for filling large nail bed avulsion defects and believed that
the newly formed nail plate would adhere better to a dermal graft than it would to a nail bed covered with skin epithelium. The use of a
skin graft requires intact periosteum (acute phase), or granulation tissue (delayed phase), on which the graft is placed. Avulsed or
amputated portions of adjacent digits too severely injured to be salvaged may also be used as autogenous graft sources. Except for
emergency coverage of a large defect with a STSG as described by Newmeyer, skin grafting is best performed on a delayed basis in the
operating room.
FIG. 12. Split-thickness skin graft coverage of a superficial nail bed defect. A: Chronic granulating, nonepithelializing nail beds in an
elderly man. B: Punch biopsy (4 mm) of the nail bed, performed bilaterally, with resultant diagnosis of chronic granulation tissue. C:
Makeshift dermatome consisting of sterilized straight-edge razor blade and a hemostat. D: Procuring the STSG from the right leg
donor site, harvesting enough graft to cover both hallux defects. E,F: Left and right, hallux nail bed recipient sites following graft
application. G: Fully healed recipient site several months following graft application.
Zone II injuries are complicated by exposed bone and substantial nail bed loss. In the toes, local (adjacent) pedicle flaps are used for both
acute and delayed repair of such injuries (25 ). The direction, or plane, of the amputation dictates the type of flap to be used. The Atasoy-
type plantar (Fig. 13 ) (26 ) or Kutler-type biaxial (Fig. 14 ) (27 ) neurovascular V-Y advancement flaps are best suited for toe
reconstruction. These flap procedures can be readily performed in the emergency room or office. A certain amount of bone reduction may
be necessary to allow the flap or flaps to cover the defect, and it is preferable to sacrifice digital length in order to enhance closure (28 ).
Nail bed augmentation is best performed by means of the Atasoy-type plantar advancement flap after dorsal-oblique tissue loss. Central
gouging zone II defects typically require significant distal phalangeal reduction in order to create adequate plantar soft tissue flaps for
wound coverage and proximal nail bed preservation (Fig. 15 ).
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FIG. 12. Continued.

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FIG. 13. Atasoy-type plantar V-Y advancement flap.
The use of distant pedicle flaps is not typically feasible in partial amputations of the toes unless the contralateral foot or leg is being
considered as the donor site. In fingertip injuries, cross-finger and thenar distant pedicle flaps are commonly used. Because of the short
length of the toes, distant pedicle grafts using the ipsilateral foot or toes are not practical.
FIG. 14. Kutler-type biaxial V-Y advancement flap.
Nail bed augmentation can also be performed using free grafts of salvaged, autogenous nail bed fragments procured from the plantar
surface of the avulsed nail plate. The autogenous nail bed fragments are placed in a jigsaw fashion over exposed periosteum of the distal
phalanx at the time of the initial repair of a fresh injury. Reattachment of a distally amputated (distal to the distal interphalangeal joint)
toe as a free composite toe-tip graft is not recommended because results are predictably unfavorable, and the potential risks outweigh the
potential benefits in most cases. If too much of the nail bed has been lost (proximal zone II injury) and subsequent nail plate instability is
anticipated (less than 5 mm of remaining, intact nail bed), then consideration should be given to ablation of the inadequate residual nail
bed and reconstruction of the digital tip.
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FIG. 15. Zone II central gouging defect secondary to an ax injury through shoe gear. A: Initial appearance almost 12 hours after
injury. B: Radiograph showing comminuted distal phalangeal open fracture. C: Initial surgical débridement in the operating room
after procurement of soft tissue and bone specimens for bacteriologic and pathologic evaluation. D: Immediate postoperative
radiograph. E: Appearance after several days of local care and systemic antibiotics. Note preservation of plantar soft tissue flaps and
the degree of osseous reduction. F-H: Definitive surgical repair of redundant tissues and delayed primary closure, after identification
of negative bacteriology results and good wound appearance. (Courtesy of Thomas D. Cain, D.P.M.)
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FIG. 15. Continued.

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FIG. 16. A: Gunshot wound causing a zone I lesion in the right hallux and a zone III lesion of second toe. B: Anteroposterior
radiograph reveals comminution of the distal phalanx of the second toe, and foreign body shrapnel in both wounded digits. C:
Intraoperative surgical débridement reveals extensive second-toe nail bed and pulp, and phalangeal damage. D: Definitive ablation of
any residual germinative nail matrix must be completed before closure. E: Reapproximation of the laterally based pedicle flap
reveals excessive, robust plantar subcutaneous pulp that will require debulking (excision of bulbous fat protrusion). F: Immediate
postoperative appearance reveals primarily closed second toe, and the hallux will heal by secondary intention (a split-thickness skin
graft could have been used, as well). (From Scurran BL, ed. Foot and ankle trauma, 2nd ed. New York: Churchill Livingstone,
1996:123, with permission.)
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FIG. 16. Continued.
Zone III injuries in the toes are generally not considered amenable to nail bed reconstruction (Fig. 16 ). This type of defect is usually
associated with proximal nail fold and germinative matrix damage that is usually irreparable, and terminal ablation of the perionychium at
an appropriate level is recommended. Primary amputation is usually performed in the operating room, and preservation of the distal
interphalangeal joint and digital tendon function should be attempted.
REFERENCES
1. Bornstein B, Profera B. Lawn mower injury: the surgical management of a hallux amputation. J Am Podiatry Assoc 1980;70:478-480.
2. Tucker DJ, Jules KT, Raymond F. Nailbed injuries with hallucal phalangeal fractures—evaluation and treatment. J Am Podiatr Med
Assoc 1996;86:170-173.
3. Zook EG. The perionychium: anatomy, physiology, and care of injuries. Clin Plast Surg 1981;8:21-31.
4. Zaias N. Embryology of the nail. Arch Dermatol 1963;87:37-53.
5. Zaias N, Alvarez J. The formation of the primate nail plate. An autoradiographic study in squirrel monkey. J Invest Dermatol
1968;51: 120-136.
6. Rosenthal EA. Treatment of fingertip and nail bed injuries. Orthop Clin North Am 1983;14:675-697.
7. Baden HP. Regeneration of the nail. Arch Dermatol 1965;91:619-620.
8. Clark RE, Madani S, Bettencourt MS. Nail surgery. Dermatol Clin 1998;16:145-164.
9. Baran R, Badillet G. Primary onycholysis of the big toenails: a review of 113 cases. Br J Dermatol 1982;106:529-534.
10. Farrington GH. Subungual hematoma: an evaluation of treatment. Br Med J 1964;21:742-744.
11. Martin C, Gonzalez del Pino J. Controversies in the treatment of fingertip amputations. Conservative versus surgical
reconstruction. Clin Orthop 1998;353:63-73.
12. Noordzij JP, Foresman PA, Rodeheaver GT, et al. Tissue adhesive wound repair revisited. J Emerg Med 1994;12:645-648.
13. Singer AJ, Hollander JE, Valentine SM, et al. Prospective, randomized, controlled trial of tissue adhesive (20-octylcyanoacrylate)
vs standard wound closure techniques for laceration repair. Acad Emerg Med 1998; 5:94-100.
14. Quinn J, Wells G, Sutcliff T, et al. A randomized trial comparing Octylcyanoacrylate tissue adhesive and sutures in the
management of lacerations. JAMA 1997;277:1527-1531.
15. Kligman AM. Why do nails grow out instead of up? Arch Dermatol 1961;84:313-315.
16. Baran R. Nail growth direction revisited. J Am Acad Dermatol 1981; 4:78-83.
17. Schiller C: Nail replacement in fingertip injuries. Plast Reconstr Surg 1957;19:521-530.
18. Zook EG, Guy RJ, Russell RC. A study of nail bed injuries: causes, treatment, and prognosis. J Hand Surg [Am] 1984;9:247-252.
19. Aboushar MK, Poblete JV. Irreducible dorsal dislocation of the distal interphalangeal joint: case report and literature review. J
Trauma 1997; 42:743-745.
20. Baratz ME, Divelbiss B. Fixation of phalangeal fractures. Hand Clin 1997;13:541-555.
21. Banks AS, Cain TD, Ruch JA. Physeal fractures of the distal phalanx of the hallux. J Am Podiatr Med Assoc 1988;78:310-313.
22. Hashisume H, Nishida K, Mizumoto D, et al. Dorsally displaced epiphyseal fracture of the phalangeal base. J Hand Surg [Br]
1996;21: 136-138.
23. Newmeyer WL, Kilgore ES. Fingertip injuries: a simple, effective method of treatment. J Trauma 1974;14:58-64.
24. Clayburgh RH, Wood MB, Cooney WP. Nail bed repair and reconstruction by reverse dermal grafts. J Hand Surg [Am] 1983;8:594-
599.
25. Goitz RJ, Westkaemper JG, Tomaino MM, et al. Soft tissue defects of the digits. Coverage considerations. Hand Clin 1997;13:189-
205.
26. Atasoy E, Iokimidis E, Kasdan ML, et al. Reconstruction of the amputated fingertip with a triangular volar flap. J Bone Joint Surg
Am 1970; 52:921-926.
27. Kutler W. A new method for fingertip amputation. JAMA 1947;133: 29-30.
28. Zachary SV, Peimer CA. Salvaging the “unsalvageable” digit. Hand Clin 1997;13:239-249.
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Chapter 19
Dislocations
Thomas F. Smith
Robert G. Aguilar
Sonya Kurichh
Dislocations represent injuries to the structures that bind joints together. The soft tissue structures around joints provide
strength for stability yet permit freedom for motion. There are a large number of joints within the foot and ankle, each of
which may be susceptible to some form of soft tissue injury. The osseous disruption witnessed in fractures may be obvious on
radiographs, but the ligamentous damage that occurs with dislocations can be extrapolated only from clinical and x-ray
evaluation. The injury may vary from a simple sprain to occult joint subluxation to frank joint dislocation. The findings may be
representative of a significant degree of ligamentous compromise, depending on the joint involved.
Careful diagnosis and appropriate early reduction, stabilization, and later rehabilitation of dislocations of the foot aid in
reducing the recovery time and the ultimate functional impairment from these injuries. In some instances, pedal dislocations
can be missed or misdiagnosed. Generally, patients with unreduced dislocations or unidentified redislocations are more prone to
posttraumatic arthrosis and pain. With an awareness of dislocations that may develop within the foot, one may more readily
identify the acute problem or better understand the processes that may lead to chronic symptoms.
GENERAL CONSIDERATIONS
The history may be an important component in appreciating dislocations within the foot. Understanding pedal dislocations may
be facilitated by an understanding of the how, where, and when of the traumatic incident. It is important to evaluate the
neurovascular status of the foot to ensure tissue viability. Pedal dislocations may involve tremendous forces, and the resultant
damage may affect not only neurovascular structures but also the tendons in the involved area. Loss of tendon function may be
due to entrapment of the tendon within the affected joint, potentially preventing closed reduction of the dislocation. Careful
palpation of the involved joint area may help in detecting subtle injuries. Breaks in the continuity of the skin should be
evaluated because an open dislocation requires special attention and may drastically alter the postreduction treatment program.
Standard radiographs of the foot are usually adequate for the initial assessment of a pedal joint injury. Three views may be
necessary to depict subtle dislocations. Significant pedal injuries may warrant the use of ankle radiographs to rule out other
associated trauma. In some patients, the presence of associated injuries may be the only clue of a dislocation within the foot or
ankle. The malalignments associated with dislocations may be very subtle. Main and Jowett (1 ) reported a delay in diagnosis in
30 of 73 cases of midtarsal dislocation related to inadequate radiographs. Fractures may accompany dislocations, thus requiring
that all pedal and ankle osseous structures be carefully evaluated. The normal joint alignments of all pedal joints in all planes
should be appreciated on evaluation.
Once these factors have been evaluated, then the mechanism of the injury may be more evident. Establishing the mechanism of
the injury is important for two reasons. The reduction maneuvers of most pedal dislocations are primarily an exaggeration of the
original injury pattern, followed by a reversal of this process. Furthermore, associated trauma around the joint may be
evaluated more logically if the mechanism of injury can be determined. Some injury patterns are predictable and the
components less likely to be unappreciated if a pattern of injury is established.
Postreduction radiographs should be carefully evaluated for fractures or dislocations obscured by osseous overlap and
malalignment present in the prereduction films. Depending on the type of injury, there may be certain sequelae that are
predictable complications. Although the postreduction radiographs of a dislocated joint may appear normal, the extraarticular
damage can have a devastating prognosis, even in a properly managed patient.
SUBTALAR JOINT DISLOCATION

According to Shands (2 ), the first case involving subtalar joint dislocation was reported in the literature in 1811 by
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Judey and Dufaurest. The incidence of this injury is estimated to be approximately 1% of all dislocations (3 ,4 ). The
nomenclature for subtalar dislocations has varied, and descriptions have appeared in the medical literature under many
headings including luxatio pedis sub talo, subastragalar dislocation, and peritalar dislocation (5 ). Classic subtalar dislocation
actually involves disruption of not only the subtalar joint but the talonavicular joint as well (6 ). Talocalcaneonavicular joint
dislocation is probably a more descriptive nomenclature. At present, the term most commonly employed is subtalar dislocation.
Subtalar dislocations are categorized by the position of the foot in relation to the talus. In medial subtalar dislocation, the foot
lies medial to the talus. In a lateral subtalar dislocation, the foot is lateral to the talus (Fig. 1 ). In an anterior subtalar
dislocation, the foot is anterior to the talus, and in posterior subtalar dislocation, the foot is posterior.
FIG. 1. Comparison of anteroposterior ankle radiographs of subtalar dislocations. A: Medial subtalar dislocation. B: Lateral
subtalar dislocation. The extent of the ankle and tarsal soft tissue compromise can be extrapolated to appreciate potential
complications.
A subtalar dislocation is nearly identical in clinical presentation to a Hawkins type II fracture of the neck of the talus. Both
injuries include complete disruption of the subtalar joint in either a medial or lateral injury pattern. However, in a Hawkins
type II injury, radiographic evaluation demonstrates a displaced talar neck fracture and an intact talonavicular joint, as opposed
to the disruption of the talonavicular joint associated with a classic subtalar dislocation (Fig. 2C,D ). Interestingly, swivel
dislocations of the midtarsal joint are also nearly identical in clinical presentation to Hawkins I talar neck fractures. Both
present with little clinical evidence of malalignment. Either injury can be easily missed both clinically or radiographically (Fig.
2A,B ). The swivel dislocation of the midtarsal joint presents with a total disruption or, more commonly, a partial subluxation of
the talonavicular joint. The Hawkins I talar neck fracture generally has minimal displacement of the fracture and, like a swivel
dislocation of the midtarsal joint, minimal subtalar involvement.
Anatomic Considerations
Ligaments and soft tissues that normally support the subtalar and ankle joints can be disrupted in subtalar dislocations. The
subtalar joint is reinforced by a joint capsule. Thickenings within the capsule known as the medial and lateral talocalcaneal
ligaments help bind the subtalar joint medially and laterally. The sinus tarsi contains the interosseous talocalcaneal ligament. It
is composed of thickenings of the anterior aspect of the subtalar joint and the posterior aspect of the talocalcaneonavicular
joint capsules. The ligamentum cervicis lies at the lateral aspect of the sinus tarsi, attached to the neck of the talus and below
to the calcaneus (7 ). These ligaments are all disrupted with subtalar joint dislocations.
The talocalcaneonavicular joint complex is supported by a joint capsule known as the talonavicular ligament. The
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ligament surrounds the joint and blends into the deltoid ligament as the two main supporting structures of the talonavicular
joint. In the first phase of a subtalar dislocation, the talar head punctures the talonavicular joint capsule. The bifurcate
ligament and the spring ligament are not disrupted in this injury because these ligaments course directly from the calcaneus to
the cuboid or navicular and do not include the talus. The relationship of the calcaneus, cuboid, and navicular, and the
associated soft tissue structures remains intact in subtalar joint dislocations.
FIG. 2. Lateral view of the foot for comparison. Swivel dislocation of the midtarsal joint (A) and Hawkins I talar neck
fracture (B). Subtalar dislocation (C) and Hawkins II talar neck fracture (D). A versus B and C versus D may have a nearly
identical clinical presentation; the diagnosis is based on radiographic findings.
An important clinical consideration is the involvement of the ankle ligaments in this injury because the deep portions of the
deltoid ligament and the calcaneofibular ligament are torn with both medial and lateral subtalar dislocations (8 ). This is
understandable because both ligaments cross the subtalar joint and bind the calcaneus to the ankle through the talus. The
deltoid ligament inserts along the sustentaculum tali of the calcaneus from the tibia. The calcaneofibular ligament attaches to
the midportion of the lateral surface of the calcaneus from the fibula (7 ). Instability, stiffness, and pain of the ankle are
potential sequelae of a subtalar dislocation.
Classification
Medial Subtalar Dislocations

The most common type of subtalar dislocation is the medial subtalar dislocation (2 ,3 ,9 , 10 , 11 , 12 , 13 ), and it may be the
predominant injury pattern in as much as 84% of patients (12 ). The higher incidence of medial subtalar dislocations may be due
to the greater degree of instability in the subtalar joint to inversion forces (14 ). The clinical appearance of the injury has
prompted some authors to describe the medial subtalar dislocation as “basketball foot” or “acquired clubfoot” (15 , 16 , 17 ).
Larsen (16 ) described the mechanism of injury for medial subtalar joint dislocations as a forceful inversion of the foot. The
sustentaculum tali acts as a fulcrum for the posterior body of the talus to produce the dislocation. The talonavicular joint is
dislocated first as the talar head punctures the lateral talonavicular joint capsule. A rotary subluxation of the subtalar joint
itself then occurs as the calcaneus proceeds medially with the navicular under the talus. Leitner (18 ) believed further that
medial subtalar dislocation represented
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the primary stage of a total dislocation of the tarsus and ankle. The ankle is weakened by this injury and further inversion force
could produce gross ankle dislocation (Fig. 1A ).
FIG. 3. Associated fractures with subtalar dislocations. These fractures can occur individually or be important markers to aid
diagnosis of more subtle subtalar injury. A: Medial subtalar dislocation. B: Lateral subtalar dislocation.
A number of subtalar dislocations can present as open injuries, 37% in one report (12 ). Open subtalar dislocation is a severe
injury in which only fair functional and poor anatomic results can be expected (19 ). The primary factor that influences the
outcome of open subtalar dislocations is infection, not the time elapsed before treatment, direction of the dislocation, or
associated fractures (20 ). Subtalar joint dislocations have a high incidence of associated fractures, approaching nearly 30% (13 ).
In one study, 68% of patients were found to possess associated osteocartilaginous joint injuries (12 ). The inversion force that
produces the dislocation can produce predictable bone and soft tissue injuries at remote sites in the foot and ankle. The
associated injuries and their incidence were summarized by Christensen et al. (10 ). With the force of inversion, avulsion of
bone or rupture of soft tissue elements may develop elsewhere in the lateral column of the foot and ankle. In the medial column,
one will more likely note compression injuries of the respective bones and soft tissues. Fractures of the lateral navicular,
dorsomedial head of the talus, and posterior process of the talus are the most common associated osseous injuries (Fig. 3 ).
Associated soft tissue injuries include injury to the tibial nerve, laceration of the posterior tibial artery, and rupture of the
posterior tibial tendon (21 ). The dorsalis pedis artery and deep peroneal nerve can become entrapped between the talus and
navicular (22 ).
In patients with medial subtalar dislocation, the head of the talus is palpable on the dorsum of the foot (Fig. 4 ). The head of
the talus is disarticulated from the navicular and lies between the extensor hallucis longus and the extensor digitorum longus
tendons, and rests on the dorsal surface of the navicular or cuboid. The overlying skin may be tight and blanched, and soft
tissue necrosis is possible if reduction is delayed. The calcaneus, along with the rest of the foot, is displaced medially with
respect to the leg. The medial border of the foot appears shortened, whereas the lateral border appears lengthened. The digits
may appear dorsiflexed. The lateral process of the talus is easily palpable laterally. The sustentaculum tali and navicular are
palpable medially, whereas the tibial malleolus is not visible.
Radiographic examination of medial subtalar dislocations is facilitated by both ankle and foot studies (Fig. 5 ). Ankle injuries
may require surgical reduction and, therefore, may alter the postreduction treatment program. The anterior ankle radiograph
demonstrates the medially displaced foot through the subtalar joint, with the talus intact in the ankle mortise. Lateral
radiographs of the foot and ankle demonstrate overlap of the talus with the tarsal bones and no clear subtalar joint. Depending
on the angle of the x-ray tube, the head of the talus may be visible dorsal to the midtarsal bones. The foot appears more as it
would in an oblique radiograph. The calcaneocuboid joint remains congruous. The dorsoplantar radiograph exhibits a medially
displaced navicular with a nonarticular talonavicular joint. Kite's angle is negative.
Lateral Subtalar Dislocations

Lateral subtalar dislocation results from forced eversion of the tarsus. The anterior calcaneal process acts as a fulcrum
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for the anterolateral corner of the talus (8 ). The joint disruptions of this injury follow a sequential pattern. First, the head of
the talus is forced through the talonavicular joint capsule medially. In the next step, the subtalar joint is disrupted as the
calcaneus is forced laterally. Lateral subtalar dislocations may require a greater force to develop. As in medial subtalar
dislocation, disruption of the ankle ligaments and other soft tissues occurs in lateral subtalar dislocation, yet with an opposite
effect (Fig. 1B ). Lateral subtalar dislocations have a greater incidence of associated fractures than do medial subtalar
dislocations (9 ,13 ). The fractures tend to consist of avulsion injuries along the medial column of the foot and ankle, and
compression injuries along the lateral column.
FIG. 4. Clinical presentation of a medial subtalar dislocation. Prereduction (A) and postreduction anteroposterior view of
foot (B). Prereduction (C) and postreduction lateral view of foot (D).
In a lateral subtalar dislocation, the foot is displaced lateral to the leg (Fig. 6 ). The lateral border of the foot appears
shortened, whereas the medial border appears lengthened. The digits appear plantarflexed because of the stretch placed on the
structures of the tarsal canal. The talar head is palpable medially, and the fibular malleolus is obscured laterally.
Radiographic evaluation of lateral subtalar dislocations is facilitated by studies of both the ankle and the foot. Associated
eversion-type ankle injuries are possible. Foot fractures remote from the dislocation may be noted. As in medial subtalar
dislocations, lateral foot radiographs demonstrate overlap of the tarsal bones without a demonstrable subtalar joint. The
navicular is laterally displaced from the talus in the anteroposterior foot radiograph (Fig. 7 ). Anterior ankle radiographs reveal
an intact ankle mortise and talus, with the foot laterally displaced. The calcaneocuboid joint remains congruous.
Posterior Subtalar Dislocations

Posterior dislocations of the subtalar joint have been reported, but are extremely rare, accounting for less than 1% of subtalar
joint dislocations (15 ,23 ). These injuries usually result from falls from a height on an outstretched foot in a plantarflexed
position, resulting in hyperplantarflexion injury (16 ). Clinically, the longitudinal axis of the foot appears normal. The forefoot
appears shortened, with the heel protruding posteriorly. Radiographs demonstrate a foot that is posteriorly displaced, with the
talus remaining in the ankle mortise (Fig. 8 ). Reduction is carried out by reversal of the mechanism of injury. Heel traction is
first applied to disengage the dislocation for reduction, and the foot is then dorsiflexed on the talus (24 ).
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FIG. 5. Radiographic presentation of a medial subtalar dislocation. Prereduction (A) and postreduction anteroposterior view
of foot (B). Prereduction (C) and postreduction (D) lateral view of foot.
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FIG. 6. Clinical presentation of a lateral subtalar dislocation. Dorsal (A) and plantar view of foot (B).
Anterior Subtalar Dislocations

Anterior dislocations are also rare injuries (15 ). Anterior dislocation results from a fall from a height with axial loading onto a
dorsiflexed foot. Clinically, the foot appears lengthened longitudinally with a flattened heel (16 ). Reduction is accomplished by
distracting the foot distally with heel traction. The foot is then forcefully directed backward under the talus (24 ). A rare case
of anterior subtalar joint dislocation associated with a large talar fragment that prevented closed reduction has been reported
(25 ).
FIG. 7. Radiographic presentation of a lateral subtalar dislocation. Lateral view of foot (A) and anteroposterior view of ankle
(B).
Treatment
Generally, closed reduction is a procedure that requires general or spinal anesthesia, or intravenous sedation. Intravenous
muscle relaxants may be needed to relax muscle
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spasms and splinting about the tarsal joints and ankle. Reduction of the dislocation should proceed as quickly as possible to
relieve pressure on vital structures and relax skin tension over the bony prominences created by the injury. The reduction
maneuvers are based on the mechanism of injury and the sequence of events involved in the dislocation.
FIG. 8. Posterior subtalar dislocation. Lateral view of foot.
For medial subtalar dislocations, distal traction is initially applied to the heel and countertraction is applied to a flexed knee.
This helps relax the gastrocnemius muscle and facilitates reduction. First, relocation of the talocalcaneal component of the
subtalar joint dislocation is accomplished. An inversion force is applied to the foot, followed by an eversion force and a return
to the neutral subtalar joint position while distal traction force is maintained. Second, the talonavicular component of the
subtalar dislocation is reduced by downward pressure on the head of the talus while the foot is plantarflexed. The foot is then
dorsiflexed and pronated to relocate the head of the talus with the navicular.
Certain obstacles may prevent a successful closed reduction of the medial subtalar joint dislocation. These obstacles include
impaction of the navicular with the talar head, talar head buttonholing through the extensor retinaculum, peroneal tendons that
may become entrapped around the talar head, and talar head buttonholing through the extensor digitorum brevis muscle belly
(3 ). Closed reduction maneuvers are possible to help overcome these obstacles (3 ,22 ). Open reduction may be indicated in
resistant cases to release the talar head from entrapment in local soft tissue or osseous structures. The incision is placed
laterally over the head of the talus and oriented proximal to distal. Any structures that bind the head of the talus may then be
released, permitting reduction.
The maneuvers for reduction of lateral subtalar dislocations follow the same principles as those for medial dislocations. Distal
traction is applied to the calcaneus around a flexed knee. Relocation of the talocalcaneal joint is accomplished first because
this phase of the injury occurred last. The foot is forcefully everted, followed by inversion of the foot about the talus to a
neutral position. The talonavicular joint is reduced by pressure on the head of the talus, with the foot held in a pronated
position. The tibialis posterior tendon (3 ,26 ,27 ), long flexor tendon (6 ), or impaction fracture of the navicular and talus (8 )
may prevent closed reduction. Open reduction is carried out through an incision lateral to the head of the talus oriented
proximal to distal. Structures that may be binding the head of the talus may be released, and compromise of medial skin is thus
avoided.
After reduction, a compression dressing is applied. These dressings are maintained and vascular status is monitored until
swelling is controlled, generally for the first 3 to 5 days following the injury. Internal fixation or percutaneous wire fixation is
generally not indicated for subtalar dislocation alone, although fixation may be required for fractures associated with the injury.
There has been one report of an unstable reduction of the subtalar joint that required fixation owing to an associated fracture
of the sustentaculum tali (28 ). Postreduction radiographs are employed to assess the adequacy of reduction. A reevaluation is
then performed because fractures may be more evident at this point than with the overlap of osseous structures in the
prereduction radiographs.
As devastating as these injuries may seem, the long-term disabilities and complications have not been reported as severe (5 ,8 ,
9 , 10 , 11 ,16 ,28 ,29 ). Skin necrosis is the most immediate complication that may be encountered. Christensen et al. (10 )
reported skin necrosis in 3 of 30 patients, one requiring skin grafting. Trauma blisters may also be noted (30 ). The long-term
complications resulting from this injury include postural deformations, ankle instability, avascular necrosis of the talus, arthritis,
and pain (10 ). Stiffness of the subtalar joint has been consistently noted, although a limited range of motion is not necessarily
related to disability and pain (8 ,9 ,11 ). Radiographic changes in the posterior facet of the subtalar joint appear most
frequently, although Monson and Ryan (11 ) noted that when tarsal pain did develop after injury that the most common site was
at the talonavicular joint. Significant subtalar joint pain was not appreciated in their patients. Avascular necrosis of the talus is
not considered a common complication of subtalar dislocation as an isolated injury (10 ,11 ,29 ).
In 1944, Plewes and McKelvey (31 ) first reported the absence of this complication. Two cases have been reported with
associated fractures of the posterior process of the talus (9 ,10 ). Damage to the posterior talus may serve to compromise
further circulation already affected by damage to the vessels of the sinus tarsi and appears to increase the risk of avascular
necrosis. If a fracture of the posterior process fracture is present, then careful monitoring of the talus is indicated. Subtalar
dislocations associated with ankle dislocations have a poor prognosis, with avascular necrosis of the talus being a strong
possibility.
An interesting finding has been that subjective long-term pain is greater when associated injuries have required prolonged
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immobilization (8 ,10 ,12 ). Current trends in treatment are to promote early ambulation with the protection of a below-the-
knee cast. Guarded weight-bearing cast support has been used as initial treatment in these cases. Physical therapy modalities,
including whirlpool and range-of-motion exercises, may be continued for 3 to 4 months. Early results after an average of 2 years
have been encouraging. This bears out McKeever's findings in 1963 that early guarded ambulation helps prevent subtalar
stiffness and pain (32 ).
MIDTARSAL (CHOPART'S) JOINT DISLOCATION

Trauma to the midtarsal, or Chopart's, joint is a relatively common injury and is frequently overlooked. Main and Jowett (1 )
reported a delay in diagnosis in 30 of 73 cases owing to inadequate radiographs. They recommend anteroposterior, lateral, and
oblique views of the foot for a more accurate diagnosis and postreduction assessment. A feature that is common to both
midtarsal and classic subtalar dislocation is a subtle disruption of the talocalcaneal relationship. Radiographic evidence of
subluxation and malalignment of the subtalar joint may be a helpful clue to identify minimally incongruous midtarsal
dislocations. Both subtalar dislocations and midtarsal dislocations can involve a talonavicular dislocation.
Main and Jowett (1 ) proposed a classification system based on the mechanism of injury. They defined midtarsal joint injuries
according to the direction of the force producing the dislocation. The forces that produce these injuries make up the basis for
the classification system and include medial, longitudinal, compression, lateral, plantar, and crushing force injuries. They also
proposed a classification of swivel injury or tarsal rotation injury. This dislocation may occur within either medial or lateral
force injury classifications. In the classification proposed by Main and Jowett, there were no components described of pure
dorsal midtarsal injury. Others have agreed (33 ,34 ), and the premise is that a force directed dorsally through the foot will
produce injury primarily at the tarsometatarsal joint.
FIG. 9. Medial force midtarsal joint fracture sprain. A: Dorsal talonavicular joint flake fractures. B: Calcaneocuboid joint
avulsion fracture.
Medial Force Midtarsal Injury

Medial force midtarsal joint injury occurs secondary to a force directed at the lateral aspect of the foot in a medial direction.
An inversion-type midfoot injury similar to an inversion ankle sprain is typical of this pattern. Medial force midtarsal joint
dislocation can result in three grades of joint trauma. The first type, fracture sprain, is the mildest form of midtarsal injury.
Radiographically, with a fracture sprain, one may visualize only flake fractures of the talus or navicular dorsally and avulsion
fractures of the calcaneus or cuboid laterally (Fig. 9 ). The second type or stage of medial force midtarsal injury is fracture
subluxation. Fracture subluxations are evidenced by a medially displaced forefoot through the midtarsal joint, with a normal
talocalcaneal relationship. This injury represents a greater degree of compromise to the midtarsal joint soft tissues (Fig. 10 ).
The third type of medial force midtarsal joint dislocation is the swivel dislocation. Swivel dislocations may be considered similar
to the first step of a subtalar dislocation. The mechanism appears to be a rotation of the midtarsal joint about an axis that
corresponds to the interosseous talocalcaneal joint. The talonavicular
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joint subluxates with the head of the talus lateral or dorsal to the navicular. The calcaneocuboid joint remains intact (Fig. 11 ).
The subtalar joint is subtly deviated but not totally disrupted. The mild radiographic incongruity of the subtalar joint can be a
useful radiographic clue that a swivel dislocation exists.
FIG. 10. Medial force midtarsal joint fracture subluxation. Prereduction (A) and postreduction anteroposterior view of foot
(B). Prereduction (C) and postreduction lateral view of foot (D).
Medial force midtarsal injuries are reduced by distal forefoot traction and reversal of the mechanism of injury. A wide variety of
treatment programs have been attempted from strapping to casting, both with and without weight bearing. The most
satisfactory treatment for medial fracture sprain and fracture subluxation has been a compression dressing and non-weight
bearing for 1 to 2 weeks, followed by use of a weight-bearing cast for 4 to 6 weeks. Persistent midtarsal pain has accompanied
immediate weight bearing with or without a cast. Early identification and treatment is essential.
Swivel dislocation of the midtarsal joint represents a severe tarsal malalignment mandating immediate reduction. Delay in
reduction of these injuries due to misdiagnosis most often results in arthritic destruction of the tarsal joints. Triple
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arthrodesis appears to afford the only surgical solution to aid in the persistent pain if the diagnosis is missed and reduction is
not effected (35 ) (Fig. 12 ).
FIG. 11. Medial force midtarsal joint swivel dislocation. Note the talonavicular joint incongruity with subtalar joint
congruity.
Longitudinal Force Midtarsal Injury

Longitudinal force midtarsal joint injury is due to a force directed from distal to proximal through the foot. This injury can be
likened to kicking or striking the forefoot distally against a fixed or firm object. These longitudinal forces can result in fractures
and dislocations of either the proximal or distal joints of the navicular. The fracture and dislocation pattern depends on the site
of maximal compression between the talus and cuneiforms. Dorsal or plantar subluxation of the navicular fracture fragments is
possible. This is a serious injury to the articular portions of the navicular, both proximally and distally (Fig. 13 ).
Lateral Force Midtarsal Injury

Lateral force injuries result from stress directed to the medial foot in a lateral direction. Fracture sprains are mild clinical
injuries with tenderness about the midfoot region and few radiographic findings other than edema. The primary factor that
distinguishes a lateral force midtarsal injury from a medial force midtarsal injury is a history of an eversion-type force through
the foot. Lateral force fracture sprains can be identified radiographically by avulsion fractures of the navicular tuberosity, flake
fractures over the dorsal talonavicular joint region, and impaction fractures of the calcaneus and cuboid. Fracture subluxations
result from greater force and may result in a talonavicular lateral subluxation combined with compression injury of the cuboid.
Hermel and Gershon-Cohen's (36 ) nutcracker cuboid fracture and the cuboid extrusion injury of Drummond and Hastings (37 )
fall into this category. Swivel injuries result in a medially displaced talus from the navicular and an intact calcaneocuboid joint.
Lateral force midtarsal injuries are potentially the most serious in terms of joint pain and long-term instability (38 ). This is
believed to be caused by disruption of the rigid lateral column needed for normal ambulation. Calcaneocuboid fusion is
recommended for persistent symptoms. For most patients with persistent pain and instability following medial or lateral
midtarsal injury, triple arthrodesis is recommended as opposed to talonavicular arthrodesis alone. This recommendation is based
on the fact that all three major tarsal joints are typically involved in most tarsal joint dislocations. Recurrent midtarsal joint
subluxations have been reported (39 ).
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FIG. 12. Swivel dislocation midtarsal joint. The diagnosis was missed for 3 months. A: Preoperative foot series showing
talonavicular incongruity. B: Postoperative foot series following triple arthrodesis.
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FIG. 13. Longitudinal force midtarsal joint fracture-dislocation. Note the fractures of the navicular and the adductus
attitude of the foot.
Lateral force midtarsal joint injuries are managed in a similar manner to medial force midtarsal joint injuries. The degree of
non-weight bearing and immobilization is based on the severity of the injury. The distinction of the various grades of lateral
force midtarsal joint injury is pertinent also for accurate prognosis.
Plantar Force Midtarsal Injury

These injuries result from forces directed on the dorsum of the foot in a plantar direction. Mild forms of this injury can result in
little clinical evidence of malalignment, with pain only in the midfoot region. The talocalcaneal relationship generally remains
intact. Milder injuries are demonstrated radiographically with dorsal talonavicular avulsion flake fractures and an intact
midtarsal joint relationship. More severe forms of plantar force midtarsal injury can result in a plantarly dislocated navicular
and cuboid relative to the talus and calcaneus, with gross evidence of deformity. Impaction fractures of the inferior aspect of
the calcaneocuboid joint or the talonavicular joint can occur. Avulsion fracture of the bifurcate ligament origin from the
calcaneus can occur with varying degrees of size and complexity (Fig. 14 ).
FIG. 14. Plantar force midtarsal joint dislocation. A: Talonavicular joint congruity with plantarflexory disruption of the
calcaneocuboid joint. B: Avulsion fracture of the anterior process of the calcaneus. C: Avulsion fracture of the dorsal
talonavicular joint.
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FIG. 14. Continued.
Crush Midtarsal Injury

Crush injuries of the midtarsal joint vary in the nature and pattern of injury, and are usually associated with open wounds.
Contusion to soft tissues may result in serious vascular compromise and loss of skin and soft tissues (Fig. 15 ). Review of this
injury pattern is more appropriate as a fracture than a dislocation.
TARSOMETATARSAL (LISFRANC'S) JOINT DISLOCATION

Lisfranc's, or the tarsometatarsal, joint forms a bony arc from medial to lateral across the midfoot region. The anatomy of the
articulating surfaces appears as a stone arch with wide dorsal and narrow plantar contours. This osseous configuration, along
with the strong ligaments and recessed second metatarsal base, provides the stability for this joint complex (Fig. 16 ).
Dislocations of these joints are rare, representing less than 1% of dislocations reported (40 , 41 , 42 , 43 , 44 , 45 , 46 ). The
severity of the presentation may range from obvious clinical and radiographic malalignment and deformity to a near-normal
clinical and radiographic presentation (47 ,48 ). Even with accurate diagnosis and appropriate reduction, the chance for
morbidity after this injury is great whether the reduction is open or closed. The diagnosis has reportedly been missed in up to
20% of cases (49 ,50 ). The potential for disability following a tarsometatarsal dislocation is worse when the diagnosis or
treatment is delayed, the reduction is inadequate, or the dislocation recurs (51 ).
FIG. 15. Midtarsal joint crush injury. A: Contusion and open lacerations around the midtarsal joint. B: Contusion and edema
around the midtarsal joint without an open wound.
The diagnosis of tarsometatarsal dislocation requires little insight when obvious clinical and radiographic malalignment is
present. This is contrasted with a diagnosis of tarsometatarsal dislocation that requires a high index of clinical suspicion when
few, if any, clinical or radiographic findings exist. Often, the patient recalls an audible snap or pop after experiencing a forced
plantarflexion of the forefoot on the
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rearfoot. The patient may relate stepping off a curb, slipping on the stairs, or stepping in a hole. The plantarflexed foot sustains
a longitudinal force against a fixed surface. This was classically considered an equestrian injury, occurring as the foot was
caught in a stirrup by a falling rider (52 ). Many injuries have also been sustained as the patient stepped into a hole while
walking. At present, industrial injuries and motor vehicle accidents appear to be the source of disruption in the majority of
cases (43 ,45 ,48 ).
FIG. 16. Anatomic relationships of Lisfranc's joint. A: Dorsal perspective of Lisfranc's joint, right foot. Note the recessed
position of the second metatarsal and the greater width of the metatarsal bases. B: Plantar perspective of Lisfranc's joint,
right foot, including the strong plantar ligaments. Note the absence of ligaments to the first metatarsal from the second
metatarsal as well as the narrower width of the metatarsal bases.
Clinically, edema is noted about the midfoot region. The foot may appear shortened, with the forefoot at times appearing
abducted or adducted on the rearfoot when compared with the unaffected contralateral extremity. Dorsiflexion or
plantarflexion displacement of the forefoot on the rearfoot is possible as well. Pain is noted about the tarsometatarsal joint and
the midfoot area. Palpation may reveal the dorsal or plantar deviation of the second metatarsal base from an even contour with
the cuneiforms dorsally (Fig. 17 ). Excessive range of motion and instability at Lisfranc's joint may be palpable.
FIG. 17. Clinical presentations of Lisfranc's joint dislocation. A: Obvious severe injury. B: Subtle injury with edema, no
malalignment. C: Posttraumatic hypermobility with abductory stress.
Identification of pedal pulses is important. If the dorsalis pedis and the posterior tibial artery cannot be palpated, noninvasive
Doppler ultrasound evaluation may need to be considered. Damage to the perforating vessels, arterial spasm,
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or significant hematoma may compromise the blood supply to the forefoot. Amputations may be necessary, depending on the
degree of necrosis produced (53 ). These injuries may constitute medical emergencies. Control of edema and monitoring of the
peripheral vascular status is important.
In patients with overt dislocation, the injury may be readily apparent in most radiographic views. However, in more subtle cases,
radiographs in three planes are important to evaluate more fully the joint and the associated articular relationships. Comparison
contralateral foot images of the uninvolved extremity may not only aid diagnosis, but assist in postreduction assessment. The
lateral foot radiograph may demonstrate an uneven osseous dorsal contour of Lisfranc's joint. Normally, there is an even
curvature of metatarsals and cuneiforms dorsally. With Lisfranc's joint dislocation, the second metatarsal base can be deviated
dorsally from the cuneiforms in stair-step fashion. The first metatarsal may likewise show dorsal deviation on the lateral foot
radiograph.
FIG. 18. Highlighted radiographic presentation of normal tarsometatarsal joint radiographic articular relationships in the
uninjured foot. A: Anteroposterior view. B: Lateral view. C: Oblique view.
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The relationship of the plantar border of the medial cuneiform to the plantar border of the fifth metatarsal on lateral weight-
bearing foot radiographs has been described as a valuable diagnostic tool (54 ,55 ). This is a form of a stress radiograph because
the foot is placed in a typical weight-bearing position, or manual stress is applied if the patient is non-weight bearing.
Significant tarsometatarsal joint injury is considered to be present if the plantar border of the fifth metatarsal lies dorsal to the
plantar border of the medial cuneiform. Restoration of the plantar border of the fifth metatarsal to a normal position correlates
well with a favorable prognosis (54 ).
Radiographically, the most consistent osseous relationship of the tarsometatarsal joint complex is the medial margin of the base
of the second metatarsal and the medial margin of the second cuneiform (48 ). An increase in the space between the first and
second metatarsals is not considered significant unless a step defect exists between the second metatarsal and the second
cuneiform. The first metatarsal usually aligns laterally with the first cuneiform. Other alignments of the metatarsals to the
midfoot are not as consistent. Comparison radiographs may be helpful to confirm alignment in the remaining metatarsals.
Norfray et al. (47 ) did note a consistent alignment of the lateral margin of the third metatarsocuneiform joint 72% of the time.
The fourth metatarsocuboid joint is aligned medially in the oblique and anteroposterior projections. A notch in the base of the
fifth metatarsal is aligned with the lateral cuboid in 80% of the cases studied. Because of the range of motion in the fourth and
fifth metatarsocuboid joints, offsets of up to 3 mm are considered normal. Offsets in the first, second, and third metatarsals do
not occur in a normal foot (48 ) (Fig. 18 ).
FIG. 19. Subtle Lisfranc's joint dislocation. A: Unremarkable immediate postinjury radiograph. B: Abductory stress
radiograph demonstrating disruption of Lisfranc's joint. C: Postreduction radiograph with fixation.
Stress pronation and supination radiographs have been recommended in cases in which dislocation is clinically suspected (49 )
and may demonstrate pathologic laxity of the joint in an otherwise normal-appearing radiograph. This procedure may have to be
performed with the patient under anesthesia (Fig. 19 ). Fractures at the Lisfranc's joint level are present in most cases, even if
they are too small to be detected on the radiograph (56 ,57 ).
The radiographs should be examined for injuries known to occur in association with Lisfranc's dislocation. Fractures of the
metatarsal shafts and metatarsophalangeal joint dislocations have been observed. Compression fractures of the navicular or
cuboid are possible, depending on the direction of the dislocation (43 ,45 ,48 ,58 ,59 ). Cuneometatarsal disruption or
intercuneiform injury may likewise be present (60 ). A more unstable postreduction situation is typically present after reduction
of tarsometatarsal dislocations associated with other midfoot fractures or dislocations (61 ).
Anatomic Considerations
The principles essential to understanding Lisfranc's joint dislocation are centered on the structural anatomy of the joint complex
(Fig. 16 ). The mechanism of the injury, subsequent
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injury patterns, and reduction maneuvers are dependent on the osseous relationships and the ligaments that not only bind the
metatarsals together but also bind the metatarsals to the midtarsus. The metatarsals are bound to one another by the
transverse dorsal and plantar ligaments (62 ,63 ). There is no ligament joining the first metatarsal to the lesser metatarsals
proximally at the base. This accounts for injury patterns in which the four lesser metatarsals generally dislocate as a unit (63 ).
The first metatarsal may or may not dislocate with the lesser rays because the first metatarsal pattern of dislocation is
independent of the lesser metatarsals (53 ,64 ). The intermetatarsal ligaments are not necessarily disrupted in the dislocation.
The integrity of the intact intermetatarsal ligaments of the lesser metatarsals helps facilitate reduction.
FIG. 20. Lisfranc's ligament avulsion fracture of the second metatarsal. Radiographic (A) and tomographic (B)
representations.
Computed tomography (CT) has been advocated in the evaluation of tarsometatarsal joint dislocations. CT scans allow for better
visualization of osseous midfoot structures that are normally obscured by overlap on plain radiographs. The increased sensitivity
of CT scans versus plain radiographs results in the ability to detect tarsometatarsal joint dislocations as small as 1 mm (65 ,66 )
(Fig. 20 ).
The ligaments that tether the metatarsals to the midfoot are disrupted during this injury. The ligaments are stronger plantarly
than dorsally. The dorsal medial ligament from the medial cuneiform to the first metatarsal is the largest ligament at this level.
During open repairs of this injury, it is often possible to repair this ligament primarily (67 ). Probably the most significant
ligament of the tarsometatarsal joint is the interosseous ligament between the medial cuneiform to the second metatarsal base.
This structure is commonly designated the Lisfranc ligament and is responsible for the production of an avulsion fracture of the
medial aspect of the second metatarsal (Fig. 20 ). The remaining ligaments are either disrupted or avulsed from their
attachments, at times creating multiple small flake fractures.
Classification
The exact mechanism of tarsometatarsal joint dislocations continues to be studied and researched. Vuori and Aro (68 ) found no
apparent relationship between the mechanism of injury and the type of tarsometatarsal joint dislocation. The recessed
articulation of the second metatarsal provides the stability to this joint. The remaining metatarsals are not as interlocked as the
second. The second metatarsal must be disrupted first, whether by fracture or dislocation, to permit total disruption of the
tarsometatarsal joint to proceed. With the release of the second metatarsal, the remaining metatarsals may be easily dislocated.
Two mechanisms of tarsometatarsal joint injury have been postulated, namely the direct injury mechanism and the indirect
injury mechanism.
Direct Injury
Aiken and Poulson (44 ) evaluated tarsometatarsal joint dislocations based on the force that was applied to the joint to create
the dislocation. A direct injury was described as occurring when the foot is struck by an object. For example, a weight dropped
from above causes a plantar Lisfranc's dislocation if the second metatarsal is fractured. Plantar dislocation of the second
metatarsal is unlikely and rare. Variable dislocations and fractures may occur at the base of the
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lesser metatarsals. Direct dorsal dislocation of the tarsometatarsal joint has been shown to be impossible (56 ,61 ,63 ). A
dorsally directed force to the midfoot generally results in injury elsewhere within the foot or ankle.
Indirect Injury
The indirect mechanism of tarsometatarsal joint dislocation is the least understood and the most variable. It is generally
believed that a torsional type of force is applied to the midfoot that first unlocks the second metatarsal. Wiley (61 ) performed
cadaver studies and proposed that there were two main forces associated with the indirect mechanism: forefoot abduction and
forced forefoot plantarflexion. The foot is usually injured while in a plantarflexed or equinus position. A traumatic abductory
force applied to the forefoot produces an excessive amount of shear stress at the second metatarsal base. This results in either
a transverse fracture of the second metatarsal base or an avulsion fracture of the medial aspect of the second metatarsal base.
The avulsion fragment is usually attached to the Lisfranc ligament. If the abduction force continues, the lesser metatarsals may
shift laterally as the lateral tarsometatarsal ligaments fail and rupture.
Occasionally, a severe abductory force results in a compression fracture of the distal cuboid. Plantar dislocation of the
metatarsal bases has been reported (49 ,69 ). The most common force is pronatory that produces a dorsolateral deviation of the
lateral metatarsals. The metatarsals may deviate medially, laterally, dorsally, or plantarly depending on the direction of the
indirect deforming injury force.
Other classification systems have been proposed for tarsometatarsal joint dislocations. These classification systems have been
based on a number of factors, including the mechanism of injury (56 ,61 ,63 ,70 ,71 ), the way the force was applied (44 ), and
the resultant injury pattern (33 ,45 ,72 ). Each system has merit in attempting to identify particular aspects of the injury.
However, Hardcastle et al. (45 ) pointed out that no system aided in the selection of treatment and prognosis. In particular,
they studied the pattern of metatarsal displacement because this type was found to influence the degree of fixation required
and the ultimate prognosis. The classification system of Hardcastle et al. (45 ) is simple and is based on the radiographic
presentation of the joint following the injury. This classification system does not necessarily accurately represent the full extent
of the injury evidenced on standard radiographs. Stress radiography of Lisfranc's joint may be used to define the complete
extent of the injury (Fig. 21 ). However, if there is evidence of injury on standard radiographs, then the clinical examination
may be adequate to identify what, if any, additional segments are involved, thus avoiding the need for stress radiographs.
Type A or Total Incongruity

In type A tarsometatarsal dislocation, total incongruity of the entire tarsometatarsal joint occurs. The displacement may occur
in the sagittal plane as a dorsoplantar displacement or in the transverse plane as a lateral displacement. All five metatarsals
displace as a unit (Fig. 22A,B ).
Type B or Partial Incongruity

Partial incongruity of the tarsometatarsal joint complex occurs in either the sagittal plane, transverse plane, or both. Partial
injuries not including all five metatarsals can occur and are of two types. The first type is a medial displacement of the first
metatarsal, either in isolation or combined with displacement of one or more of the second, third, or fourth metatarsals. The
second type is a lateral displacement involving one or more of the four lesser metatarsals, whereas the first metatarsal is
unaffected. The number of metatarsals truly involved in either medial or lateral partial incongruity types may not be
appreciated unless stress radiography is performed (Fig. 22C,D ).
Type C or Divergent
There may be partial or total incongruity of the tarsometatarsal joint in this type of injury pattern. The first metatarsal is
displaced medially, and any combination of the lateral four metatarsals is displaced laterally in either the sagittal plane or the
transverse plane, or both (Fig. 22E,F ).
Treatment
Most articles concerning the treatment of tarsometatarsal joint dislocations tend to combine all injuries under the heading of
Lisfranc's joint dislocation and describe the management regardless of the injury pattern. Some authors have noted differences
in the injury pattern and the subsequent treatment (45 ). Accurate anatomic reduction, whether open or closed, has
consistently provided better functional results (43 ,44 ,56 ,57 ,73 ), although anatomic reduction is not a guarantee of a
satisfactory result. Cases of resistant, nonsymptomatic subluxation have been reported (44 ). Brunett and Wiley (50 ) found no
correlation between radiographic findings and patient symptoms or between the type of dislocation and treatment on
subsequent function.
Percutaneous wire fixation has proven helpful in maintaining alignment after reduction to prevent recurrence in unstable joints
(43 ,45 ). Internal temporary screw stabilization has also been found to work suitably (74 , 75 , 76 ). Casting of unstable joints
without fixation has not proven to be effective (43 ,45 ,49 ). Conservative casting of the injury without reduction or fixation is
ineffective as well (45 ,49 ). Primary arthrodesis is rarely used (57 ) but may be indicated when significant loss of articular
surfaces is noted. Secondary arthrodesis is always a possibility (74 ).
The management of tarsometatarsal joint dislocations may vary depending on a variety of factors, including the type of injury,
the degree of stability and displacement, and the status of the soft tissues. Closed reduction may be attempted
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first (44 ,45 ,73 ,77 , 78 , 79 ), particularly if closed percutaneous pinning is being considered. Anesthesia, either general or
regional, combined with muscle paralyzing agents may be required. Distal forefoot traction is applied, with countertraction
being applied on the heel. The forefoot may be suspended from the operating room table by digital finger traps or tape applied
distal to the injury. Countertraction weights may be suspended from the leg once adequate relaxation has been achieved.
Manipulation may then be attempted to engage the second metatarsal base between the cuneiforms. A pronating type of force
is required if the metatarsals are dorsally dislocated. The lesser metatarsals will follow the reduction maneuver consistent with
the vassal phenomenon and the intact intermetatarsal ligaments. The first metatarsal is reduced individually in divergent type C
injuries. Once relocation is verified radiographically, wire stabilization may be employed.
FIG. 21. Classification system of Hardcastle and associates (45) for Lisfranc's joint injuries. (From DiNapoli DR, Cain TD.
Lisfranc's fracture-dislocation: update 1988. In: McGlamry ED, ed. Reconstructive surgery of the foot and leg, update '88.
Tucker, GA: The Podiatry Institute, 1988:200, with permission.)
Open reduction may also be employed to permit visual

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assurance of adequate anatomic reduction, and it is preferred by some surgeons as a primary approach to Lisfranc's dislocation.
Percutaneous pinning may then be employed to stabilize the joints.
Soft tissue and bony fragments may become interposed and prevent closed reduction. The tibialis anterior tendon has been
noted to become lodged in the medial-intermediate cuneiform articulation, preventing reduction (63 ,78 , 79 , 80 , 81 ). The
avulsed fracture fragment of the Lisfranc ligament from the second metatarsal may also block reduction (52 ,77 ). In cases in
which closed reduction is difficult, careful inspection of the first intermetatarsal space through open reduction
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may be necessary. Closed reduction can be impossible until interposed soft tissues are released or interposed bony fragments
are removed.
FIG. 22. Radiographic presentations of Lisfranc's joint dislocation. A,B: Type A Lisfranc's joint dislocation, definitive
diagnosis established with abductory stress radiograph. C,D: Type B Lisfranc's joint dislocation with intact fourth and fifth
metatarsocuboid area. Note associated intercuneiform subluxation. E,F: Type C Lisfranc's joint dislocation.
FIG. 22. Continued.

If closed reduction methods fail, are deemed inadequate, or instability persists, then open reduction is necessary. Open
reduction is also indicated to inspect pedal blood vessels when vascular compromise is evident (45 ,53 ). Incisions are placed
longitudinally to help prevent further vascular compromise. Two or three incisions are generally used. One incision is placed
medially for the first metatarsal base. A dorsal incision is made over the second and third metatarsal bases. If there is
incongruity at the fourth and fifth metatarsal cuboid articulation, then a third incision may be employed as well. The first
metatarsal is relocated and fixated first. In most instances, the insertion of a transverse wire between the cuneiforms aids in
the relocation of the first metatarsocuneiform joint because there may be concomitant instability at the intercuneiform level.
All interposed soft tissues and bony fragments should be excised. The lesser metatarsals may then be relocated anatomically
under direct visualization. After radiographic confirmation of alignment following reduction and fixation, soft tissue repair is
completed. Primary repair of the dorsomedial ligament of the first metatarsocuneiform joint and other compromised soft tissues
may be possible. Delayed closure may be considered if severe edema or extensive trauma to the soft tissues is present.
Compression dressings are applied until the edema and the vascular status have stabilized. The time interval may vary
depending on the extent of the injury and associated injuries. Generally 5 to 14 days is required. Below-knee casting is
maintained for 6 to 12 weeks. Pins may be removed at 6 to 8 weeks. Weight-bearing ambulation has been initiated as early as 2
weeks (45 ). Careful monitoring for redislocation is very important. Once the cast is removed and the joint is assessed as stable,
supportive footwear is instituted.
Redislocation and circulatory compromise are the most important short-term complications. Arthritis and Sudeck's atrophy are
possible long-term complications. Sudeck's atrophy has been noted in patients in whom the diagnosis has been missed and
inappropriate treatment administered, and in cases in which unsatisfactory alignment was achieved after reduction (49 ). There
may also be an association between tarsometatarsal joint dislocation and the development of a mobile flatfoot (82 ). Arthrosis is
an almost inevitable long-term sequela of this injury (43 ,62 ). Radiographic evidence of posttraumatic arthritic changes do not
always correlate with clinical findings. Accuracy of reduction plays a key role in the potential for developing symptomatic
arthritis.
Resection of painful bony prominences about the tarsometatarsal joint in patients with a history of Lisfranc's dislocation
generally has not proven satisfactory in relieving symptoms. Arthrodesis of Lisfranc's joint can provide a more stable and less
symptomatic foot. Arthrodesis as a primary procedure has been advocated after this injury (57 ,71 ), although this procedure is
not recommended unless there is severe comminution of the joints.
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FIRST METATARSOPHALANGEAL JOINT DISLOCATION

Dislocations of the first metatarsophalangeal joint are rare (78 ,79 ). Jahss reported seeing only two cases among 25,000 foot
patients in 18 years (83 ). This injury continues to receive attention in the literature owing to an association with athletic
endeavors (84 ). With the advent of artificial playing surfaces, hyperextension injuries to the great toe are more commonplace
(85 ). Dislocation of the first metatarsophalangeal joint represents an interesting anatomic and pathomechanical study. The first
metatarsophalangeal joint is a complex structure in both design and function. A multitude of soft tissues, including ligaments,
tendons, and joint capsule, not only bind the osseous components but permit motion for ambulatory function.
The injury occurs primarily as a result of motor vehicle accidents (83 ,86 , 87 , 88 , 89 ). Falls from heights account for a
secondary number of cases (90 , 91 , 92 ). Pathologic dislocations have been reported in association with spina bifida, leprosy,
and insulin-dependent diabetes mellitus (93 , 94 , 95 ) (Fig. 23 ). First metatarsophalangeal joint dislocations may occur
concomitantly with Lisfranc's dislocations or Lisfranc's fracture-dislocations (51 ,96 ,97 ). Less commonly reported are first
metatarsophalangeal joint dislocations in association with second metatarsophalangeal joint dislocation or first cuneometatarsal
joint injury (98 ,99 ). First metatarsophalangeal joint dislocations are being seen with increasing frequency in sports injuries.
Hyperextension is believed to be the primary force that creates the injury. The clinical presentation supports this mechanism.
Typically, the hallux is dorsally dislocated at the metatarsophalangeal joint, although a rare case of lateral dislocation of the
first metatarsophalangeal joint has been reported (100 ). The prominent first metatarsal head is usually noted plantarly. Pain is
elicited on attempted range of motion and palpation of the joint. The extensor apparatus is in a contracted state. The flexor
apparatus is tightened because of the dorsal direction of the dislocation, and a flexion attitude of the interphalangeal joint of
the hallux may be present. In some instances, the clinical appearance of the dislocation may be more subtle due to swelling that
follows the injury. A delay in diagnosis and reduction of the dislocation can result in a greater chance for continued pain and
disability (51 ).
FIG. 23. Pathologic dislocation of the first metatarsophalangeal joint in patient with spina bifida (A) and as part of a Charcot
process in a patient with diabetes mellitus (B).
Classification
The pathologic anatomy is the basis for the classification of the injury and also affects the ease of reduction. The soft tissue
damage must be extrapolated from the radiographs. Jahss (83 ) noted two basic radiographic patterns, type I and type II, based
on the sesamoid position following the injury. Reports of other dislocation patterns about the first metatarsophalangeal joint
have been presented. The osseous relationships of the first metatarsal, proximal phalanx, and sesamoids are important to
understanding the classification of the first metatarsophalangeal joint dislocation. The sesamoid position has correlated well
with the ease of reduction (101 ). In both types of dislocation, the base of the proximal phalanx will rest dorsally on the first
metatarsal. The sesamoid position is variable and is the basis for defining the subtypes of the classification.
Type I First Metatarsophalangeal Joint Dislocation

In type I dislocations, the intersesamoidal ligament remains intact (83 ) and the sesamoids are not fractured. The
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normal apposition between the sesamoids is maintained but the normal relationship between the sesamoids and the proximal
phalanx may be altered (Fig. 24 ). Their position relative to the first metatarsal and proximal phalanx is variable. The sesamoids
generally remain apposed to the proximal phalangeal base and come to lie dorsal to the metatarsal head. This is a classic type I
dislocation. One case has been described in which the sesamoids remained plantar to the first metatarsal and the
intersesamoidal ligament appeared to remain intact (86 ). However, in most other type I injuries, the sesamoids are noted
dorsal to the first metatarsal (89 ).
FIG. 24. A,B: Type I dislocation of the first metatarsophalangeal joint with sesamoids remaining in a plantar position. Note
the associated fracture of the second metatarsal.
Immediate closed reduction is generally unsuccessful in either subtype, and open reduction is necessary (86 ,89 ,90 ). This factor
may be attributed to the locked position of the metatarsal beneath the proximal phalanx and joint capsule. The first metatarsal
is reigned in medially by the abductor hallucis tendon and laterally by the adductor hallucis tendon and the flexor hallucis
longus. The collateral ligaments remain intact and reinforce the position of the deformity (83 ).
If dorsal dislocation occurs and the sesamoids remain plantarly, the short flexor tendon is disrupted between the sesamoids and
the proximal phalanx (102 ). The sesamoids remain in a constant position relative to the proximal phalanx in normal flexion and
extension. Nabarro and Powell (102 ) noted complete avulsion of tissues from the plantar base of the proximal phalanx with
intact collateral ligaments. The open repair was maintained with a percutaneous suture from the sesamoids plantarly tied
dorsally over the joint. Results at follow-up in these cases showed no difference in hallux position or function based on type I
dorsal or plantar sesamoid position. Even though the anatomic disruption is different whether a dorsal or a plantar sesamoid
position exists following dislocation, the prognosis is similar (103 ).
Type II First Metatarsophalangeal Joint Dislocation

Type II injuries demonstrate a disruption in the intersesamoidal apparatus. The sesamoids no longer remain apposed to one
another (83 ). This disruption may occur in two ways. In type II-A dislocations, neither sesamoid is fractured. The sesamoids
come to lie widely separated medially and laterally about the first metatarsal head (Fig. 25 ). Type II-B dislocations demonstrate
a transverse fracture of one of the sesamoids. This fracture is an avulsion type caused by further hyperextension force (Fig. 26 ).
Crushing may also fracture the sesamoid, as in falls from a height (92 ). The proximal fragment remains apposed to the opposite
sesamoid through an intact intersesamoidal ligament, and the distal fragment remains apposed to the base of the proximal
phalanx. Brown (90 ) reported a case in which this fracture healed uneventfully, although generally, the distal fragment must be
excised (88 ,91 ) because it may act as a loose body and produce pain. The avulsion injury associated with first
metatarsophalangeal joint dislocations generally involves the fibular sesamoid and is transverse in orientation.
An addition to the classification system to include type II-C has been proposed (104 ). Type II-C represents a combination of type
II-A and type II-B injury patterns. This type of first metatarsophalangeal joint dislocation represents a complete disruption of the
intersesamoidal ligament combined
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with fracture of either of the sesamoids. Another variant of the type II injury with disruption of a previously bipartite sesamoid
has been reported (97 ). In this variant, there is complete disruption of the sesamoid-plantar-plate complex and proximal
migration of the fibular sesamoid and proximal fragment of the tibial sesamoid. Open reduction of the tibial sesamoid disruption
is performed after successful closed reduction of the joint dislocation.
FIG. 25. Type II-A dislocation of the first metatarsophalangeal joint. Prereduction (A,B) and postreduction radiographs (C).
Note the associated dorsal dislocation of the second metatarsophalangeal joint.
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FIG. 26. Type II-B dislocation of the first metatarsophalangeal joint. Clinical (A) and radiographic prereduction presentation
(B). Clinical (C) and radiographic postreduction presentation (D).
Treatment
Type I dislocations are generally irreducible and require open reduction (83 ,101 ,105 ). The joint may be approached through a
dorsal, plantar, or medial incision. The medial approach allows access to the sesamoids if fracture reduction is needed and is
minimally disruptive to the flexor plate, if those structures remain intact after the injury. Open reduction through a dorsal
longitudinal incision has been described (89 ). Adequate exposure of all soft tissue structures was noted. The dorsal approach
allows easy access to release any dorsal contracture. Limited plantar exposure to the flexor plate or sesamoids may be achieved.
A plantar approach has also been described (92 ,106 ). The plantar approach provides the best visualization of the flexor plate
and sesamoids.
The dorsal linear incision (89 ) is recommended in most cases of dislocation of the first metatarsophalangeal joint that require
open reduction. Splinting or below-knee casting is recommended postoperatively for 3 to 4 weeks to permit adequate healing of
soft tissues. Ambulation as tolerated in a stiff-soled shoe may then be encouraged. Common complaints following open
reduction include a painful plantar scar as well as sensitive plantar wounds (97 ). Joint ankylosis and sesamoid sensitivity are
possible as well. These problems are exaggerated if a delay in diagnosis occurs (51 ). Gangrene of the hallux has been reported
following open reduction of a combined interphalangeal joint and first metatarsophalangeal joint dislocation (107 ).
Type II injuries are generally reduced by closed manipulation (86 ,88 ,90 ,91 ). Distal traction is effected across the joint with a
plantarflexory force. The soft tissue buttressing effect appears to be loose enough to permit reduction in patients
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with disruption of the intersesamoidal apparatus. Splinting and supportive dressings are used for 3 to 4 weeks in a surgical shoe.
Range-of-motion exercises are initiated as tolerated. Ambulation is then encouraged as tolerated by the patient. First
metatarsophalangeal joint dislocations have not usually resulted in long-term disability, although significant hallux limitus may
develop depending on the degree of scarring that develops around the joint during the healing process. Recurrent dislocations
have been reported (108 ).
When dislocations are left unreduced, joint arthroplasty is generally required to permit reduction. Giannikas et al. (86 )
reported a case in which extensive internal injuries and unsuccessful closed reduction resulted in delay of open reduction for 3
weeks. A Keller type of arthroplasty was required to effect correction. The chronic pathologic dislocation reported by Schlefman
et al. (93 ) likewise required Keller-type arthroplasty. The sesamoids were excised because of a chronic ulcer, and an
interphalangeal joint arthrodesis was employed to assist with hallux stabilization.
Occult dislocation may develop, and stress radiographs have proven helpful in identifying the full extent of the injury (109 ).
Disruption of the first metatarsophalangeal joint may occur in any plane (84 ,109 ,110 ) and may be suspected in the presence of
persistent joint pain, especially in the active athletic person.
Clanton et al. (84 ) discussed the association of athletic injuries and the first metatarsophalangeal joint. They describe injuries
from mild sprains to severe tearing of the capsule ligamentous complex including avulsion fractures of the sesamoids. They
recommend stiffening of the forefoot in athletic shoes or the use of orthotic devices within shoes to prevent these injuries in
patients who participate in sports on athletic fields with artificial turf. The flexible nature of shoes that evolved with the
transition of athletic endeavors from grass to artificial turf is possibly implicated in the increased incidence of these injuries.
LESSER METATARSOPHALANGEAL JOINT DISLOCATION

Lesser metatarsophalangeal joint dislocations are rare injuries (111 ,112 ) that may be quite subtle. The injury may involve
multiple metatarsophalangeal joints (112 ) or occur as an isolated dislocation (111 ). Lesser metatarsophalangeal joint
dislocations may be associated with other more obvious foot trauma, such as Lisfranc's dislocation (113 ), and therefore, can be
overlooked. In this instance, reduction of the lesser metatarsophalangeal joint dislocation may not be possible until Lisfranc's
joint is reduced. Pathologic dislocations of the lesser metatarsophalangeal joints may be found associated with inflammatory
types of arthritis or chronic local inflammatory states. There is the possibility of a patient with a chronic dislocation presenting
after an unrelated traumatic incident and being misdiagnosed as an acute dislocation. The past history and comparison with the
contralateral foot clinically and possibly with radiographs may aid in the differential diagnosis.
Diagnosis
Hyperextension appears to be the primary mechanism for this injury (86 ,111 ,112 ,114 ). As the proximal phalanx dorsiflexes,
the metatarsal head is forced plantarly through the fibrocartilaginous flexor plate. The metatarsal becomes prominent and
palpable plantarly. The digit is dorsally displaced on the metatarsal. Pain is elicited on palpation of the joint and attempted
range of motion. The flexor tendon may become medially or laterally displaced. The metatarsal head can become locked in
plantarflexion by the fibrocartilaginous flexor plate, the deep transverse intermetatarsal ligament, and the remaining joint
capsule. Soft tissue entrapment of the metatarsal head may necessitate open reduction.
Medial and lateral dislocations of the lesser metatarsophalangeal joints are possible when an object is forced between the toes.
These injuries are unstable because of rupture of the collateral ligaments on one side of the joint (113 ). Percutaneous pinning
has been recommended (115 ). Experience with this type of injury shows subtle recurrence of the malaligned digit to be more
the exception than the rule because transverse plane instability of the lesser digit may be extremely difficult to control. Plantar
dislocation of the lesser metatarsophalangeal joints has been reported as an isolated case presentation (116 ).
The anteroposterior radiograph of the foot demonstrates either overlap of the metatarsal and phalanx or widening of the joint
margins in a typical hyperextension injury. Lateral deviation of the proximal phalanx at the metatarsophalangeal joint can be
noted as well (Fig. 27 ). The lateral foot radiograph will reveal a dorsally displaced and isolated proximal phalanx that is not
superimposed with the other lesser digits of the foot. The oblique foot radiograph may be helpful in subtle injury presentations.
Radiographic variance may exist depending on the mechanism of injury. Associated injuries include fracture of either the
metatarsals or the phalanges as well as Lisfranc's dislocation. The metatarsophalangeal joints of patients with metatarsal
fractures, phalangeal fractures, or Lisfranc's dislocations should be carefully evaluated. Radiographs of the uninjured foot for
comparison of both the prereduction and postreduction state of the injured foot can be very helpful.
Management
Closed reduction has proven to be a satisfactory means of treating the acute lesser metatarsophalangeal joint dislocation (114 ).
Following closed reduction, splinting is used for 2 to 3 weeks (115 ). Casting is only considered if a greater degree of protection
is needed. Generally 3 or 4 weeks of immobilization in a non-weight-bearing attitude is all that is required. Ambulation may be
continued in a surgical shoe with increases in activity as tolerated. There should be careful monitoring for recurrence of the
dislocation.
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FIG. 27. Type II dorsal dislocation of the interphalangeal joint of the hallux. A,B: Clinical appearance. C,D: Prereduction
radiographs. E,F: Radiographs following closed reduction.
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Occasionally, these injuries are not reducible by closed manipulation. On open reduction of a dislocated joint, Roa and Manuel
(112 ) noted that the metatarsal head was entrapped within the fibrocartilaginous flexor plate plantarly, the dorsal capsule and
deep transverse intermetatarsal ligament dorsally, the flexor tendon medially, and the lumbricale tendon laterally. Reduction
could only be accomplished after release of the fibrocartilaginous flexor plate, deep transverse intermetatarsal ligament, and
dorsal capsule. There has also been another report of the fibrocartilaginous flexor plate acting as an obstacle to closed
reduction (111 ). There has been one description of a plantar dislocation of the lesser metatarsophalangeal joint. The extensor
digitorum longus and brevis tendon were trapped beneath the plantar aspect of the involved metatarsal, and open reduction
was necessary to reduce the dislocation (116 ).

The long-term problems of unreduced lesser metatarsophalangeal joint dislocation include claw toe or hammer toe deformity.
Painful plantar keratomas and metatarsalgia are also possible. The unreduced dislocation may be analogous to amputation of a
digit. Transverse plane angular deformity of the adjacent digits caused by the loss of the buttressing effect of the involved toe
can occur. Degenerative changes in the involved metatarsophalangeal joint can necessitate resection procedures to aid in
management of chronic pain. Good results have been reported in one case of unreduced dislocation treated with phalangeal
base resection and partial syndactyly (117 ). Generally speaking, favorable long-term results have been achieved with closed or
open reduction of lesser metatarsophalangeal joint dislocations. Digital deformity or discomfort has not been noted. Patients
with rheumatoid arthritis or significant osteoarthritis may have chronic dislocations of the lesser metatarsophalangeal joints.
Chronic dislocations generally are not reducible by closed manipulation. Reduction may only be possible by arthroplasty
techniques with resection of a portion of the joint to permit reduction of the digit to a more normal anatomic alignment.
INTERPHALANGEAL JOINT DISLOCATION

Dislocations of the interphalangeal joints of the toes are rare injuries. The hallux interphalangeal joint is the most common site
for this type of dislocation, with the second digit being the next most commonly involved toe (64 ,111 ,118 ). Interphalangeal
dislocations may be associated with other pedal injuries, and careful radiographic evaluation of the periarticular structures may
reveal fracture or osseous avulsions. Open interphalangeal dislocation injuries can occur (94 ,119 ).
Dorsal dislocation of the interphalangeal joint in hyperextension is the most common injury pattern. Medial fracture-dislocation
of the interphalangeal joint of the hallux has also been reported (120 ). Subtle injury may be missed owing to edema or the
minimal degree of clinical deformity.
Diagnosis
The interphalangeal joints of the digits are ginglymus or hinge joints in which the trochlear surface of the phalangeal head
articulates with the inversely shaped proximal phalangeal base. The joint is surrounded by a capsule. Medial and lateral
collateral ligaments reinforce the joint for dorsiflexory and plantarflexory hingelike motion. The plantar capsule of the hallux
interphalangeal joint is thickened to form a firm fibrous plate known as the plantar plate. It has also been termed the plantar
ligament. A hallux interphalangeal sesamoid bone has been found in 56.3% of 958 radiographs of ambulatory patients (121 ). The
incidence of interphalangeal sesamoids increased to 93% when a one-quarter sensitivity-intensifying radiographic film was used.
The sesamoid bone was found in 95.5% of 144 feet of 73 adult cadavers by macroscopic observation. Most adults then can be
said to have an interphalangeal sesamoid bone of the great toe that is not always demonstrated radiographically. The
interphalangeal sesamoid and flexor plate usually plays a critical role in irreducible dislocations of the interphalangeal joints of
the hallux.
Classification
Interphalangeal joint dislocations are generally relocated by closed reduction (112 ,122 ). Irreducible dislocations are possible,
especially of the interphalangeal joint of the hallux (118 ,123 , 124 , 125 , 126 ). Entrapment of the volar plate and
interphalangeal sesamoid within the interphalangeal joint is blamed for preventing reduction (127 , 128 , 129 , 130 ). Miki et al.
(118 ) discusses two types of injury patterns that correlate well with clinical findings of irreducible hallux interphalangeal
dislocations. Type I interphalangeal joint dislocation is a subtle injury with interposition of the volar plate without gross
malalignment of the interphalangeal joint. Widening of the joint space is noted radiographically. Subtle elongation of the digit
may be noted clinically without gross malalignment. Type II interphalangeal joint dislocation demonstrates gross hyperextension
injury of the distal phalangeal segment on the more proximal phalanx with dimpling of the overlying dorsal skin of the toe. The
interphalangeal sesamoid and volar plate are subluxated dorsally onto the proximal phalanx. Type II dislocations appear
radiographically with malalignment and dorsal positioning of the more distal phalanx (Fig. 27 ).
Management
Closed reduction of interphalangeal joint hyperextension injury is performed by first applying an extension force, followed by
traction and a plantarflexory relocation force to the dislocated joint. Most interphalangeal joint dislocations
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are easily reduced in this fashion. The toe is then evaluated for any evidence of instability that might compromise the reduction.
Radiographic evaluation is necessary to ensure both adequacy of realignment as well as a normal joint space distance. Medial
dislocation of the hallux interphalangeal joint has been reported as easily reducible by closed manipulation (120 ).
Irreducible dislocations of the hallux may be of either the type I or type II variety. Type II dislocations may relocate clinically in
terms of hyperextension, and yet a type I distraction type of dislocation persists. The resultant type I dislocation is an
unsatisfactory reduction because soft tissue interposition and instability of the interphalangeal joint still remains. Reduction is
effectively accomplished when a normal joint space is observed on the postreduction radiograph.
Irreducible dislocations can be addressed with open reduction and possible use of percutaneous pin fixation of the dislocated
interphalangeal joint. Repair of the disrupted soft tissues may be carried out as well (119 ). Generally, a transverse dorsal
approach to the interphalangeal joint is used (123 ). Successful use of a medial approach to the joint has been described
(124 ,131 ). A lateral approach has been employed as well (126 ). A plantar approach has been described which afforded good
access for repair of the flexor plate with preservation of the sesamoid bone and soft tissues (128 ). The goal of the open
reduction is to relocate the flexor plate and sesamoid apparatus of the interphalangeal joint to a normal plantar attitude.
Excision of the sesamoid or any small fracture fragments may be necessary to permit adequate reduction.
FIG. 28. Proximal interphalangeal joint dorsal dislocation of the second digit. Prereduction (A) and postreduction clinical
presentations (B). C: Prereduction radiograph.
Stability for the maintenance of the reduction, whether open or closed, should be evaluated critically. If satisfactory stability is
present, a splint and surgical shoe is adequate. If instability of the interphalangeal joint persists, careful scrutiny of the
radiographs for possible soft tissue interposition is suggested. If adequate reduction of the interphalangeal joint is noted,
percutaneous pinning of the joint may be necessary to maintain alignment through the early phases of
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joint healing. Splinting and casting are then used for 3 to 4 weeks. Rarely is below-knee casting necessary unless protection of a
pin or a severely unstable postreduction joint exists. Pin removal is followed by splinting and a return to normal activities as
tolerated. Delay in diagnosis and reduction resulted in poorer results than more immediate relocation of the dislocation (119 ).
FIG. 29. Long-term unstable proximal interphalangeal joint of the fifth digit, following dislocation. Preoperative (A) and
postoperative views (B) following proximal phalangeal arthroplasty of fifth digit with syndactyly of fourth and fifth digits.
Interphalangeal joint dislocation of the lesser digits is generally due to a hyperextension mechanism with a dorsal dislocation of
one phalanx on another. The dorsal overlap of the displaced distal phalanx on the more proximal phalanx is evident both
clinically and radiographically (Fig. 28 ). Interphalangeal joint dislocations of the lesser digits are typically reduced by closed
means (132 ,133 ). However, open reduction has been required in limited cases (122 ). Interposition of the small flexor plate
within the interphalangeal joint may prevent reduction. The long flexor tendon can likewise become interposed in the joint and
prevent closed reduction (134 ). Open reduction is effected through a dorsal transverse incision. The flexor plate and tendon are
repositioned inferior to the interphalangeal joint. Buddy taping or splinting techniques are generally used for 3 to 4 weeks to
maintain alignment until satisfactory healing and stability of the joint are present. Instability or pain is a possible complication
after reduction of dislocations of the interphalangeal joints of the lesser digits (94 ). Digital surgical procedures such as joint
resection, arthrodesis, and syndactyly are effective techniques for managing chronic problems associated with a history of
digital interphalangeal joint dislocation (Fig. 29 ).
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Chapter 20
Digital and Sesamoid Fractures
Michael S. Downey
Stephanie Comer Merritt
Carolyn J. Sharrock-Maher
Marc R. Bernbach
Digital and sesamoid fractures are common injuries affecting all age groups, even those patients who are sedentary. In most circumstances,
the fractures are amenable to conservative treatment and generally do not pose a problem. However, many patients who have sustained a
digital fracture do not seek care for their injury in an expedient manner and thus render what would otherwise be a simple yet
inconvenient problem more difficult to treat and prolong the recovery period. A certain mindset seems to exist among many lay people
that there is really no specific treatment for digital fractures, and this attitude likely contributes to the delay between injury and seeking
treatment.
However, significant fractures may affect the digit and may require more prompt attention, particularly if dislocation or displacement
occurs or if the fracture is open. In most injuries of this nature, deformity is obvious, and patients tend to seek treatment quickly.
DIGITAL FRACTURES
As with any injury, the pathologic forces that cause digital fractures may be directed in any one or a combination of the cardinal body
planes. Although most injuries involve a combination of these forces, a predominant plane of force can often be identified. Certain
fracture patterns are more frequently observed and can be related to these injury mechanisms. Understanding the predominant plane of
injury facilitates reduction, realignment, and treatment of digital fractures.
Sagittal Plane
Injury occurring in the sagittal plane and resulting from direct trauma, hyperextension, or hyperflexion of the involved digit is the cause of
most digital fractures. Sagittal plane crushing is the most frequent mechanism of injury associated with a fractured hallux. Crush injuries
are most often caused by a heavy object, which may be dropped or may fall, or by industrial or motor vehicle accidents. A subungual
hematoma is often a component of the injury. Protocols for care of the nail injury can be found in Chapter 18 . The digital fractures seen
in direct traumatic injuries are frequently comminuted and most commonly involve the phalanges of the hallux and the middle and distal
phalanges of the lesser digits (1 , 2 , 3 ).
Transverse Plane
Abduction-adduction forces are also common and generally result in transverse or short oblique fractures of the proximal phalanges. The
most notorious example of this injury has been termed the bedroom fracture because it often results from striking the fifth digit against a
bedpost while the patient is walking in the dark (Fig. 1 ). At times, the injury may consist of a dislocation of the interphalangeal joint or
the lesser metatarsophalangeal joint. Even though the proximal phalanx of the fifth digit is the most commonly involved, other digits may
be injured through abduction or adduction forces. A transverse fracture free from the articular surfaces may be treated with closed
reduction, whereas comminuted or open fractures may require surgical intervention.
Frontal Plane
Rotational or inversion-eversion injuries occurring predominantly in the frontal plane are less frequent and generally are secondary
components of transverse or sagittal plane fractures. When spiral fractures of the phalanges occur, closed reduction is more difficult, as is
maintaining the reduction once it has been achieved, because the more unstable nature of the fracture pattern.
The signs and symptoms of digital fractures consist of pain, ecchymosis, and edema that develop within a few hours
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after injury. The patient experiences acute pain, has difficulties with weight bearing, and finds wearing shoes that compress the area
uncomfortable. In some instances, an obvious clinical deformity is seen in the digit as a result of displacement of the fracture. Other
patients may relate that they relocated the deformed toe themselves after the injury.
FIG. 1. A short oblique fracture of the fifth digit that is potentially stable and may be treated with splinting.
Treatment
Closed Injuries
The initial evaluation is directed toward assessing the neurovascular status of the toe or toes and evaluating the degree of tissue
compromise and clinical deformity. Two to three radiographic views are adequate to demonstrate the injury in most cases.
The treatment methods of closed digital fractures range from simple protection of the toe to surgical reduction or excision of all or some
of the fracture fragments. Treatment of closed digital fractures may be divided into criteria based on several factors, including the
following: (a) alignment of the fracture fragments; (b) if malaligned, the possibility that the fragments can be adequately realigned with
closed reduction; and (c) the possibility that alignment can be maintained once the fragments are reduced. Reduction of the fracture is
performed in an attempt to prevent shortening, angulation, and rotational malalignment.
Protection alone consists of maintaining stability to the injured region with immobilization. Comfort and stability may be enhanced by
splinting the injured digits to the uninjured neighboring toes with tape, felt, silicone molds, urethane molds, prefabricated digital splints,
or other similar materials. This method of splintage is termed buddy splinting (Fig. 2 ). A splint or rigid material can be formed around the
hallux and secured along the medial aspect of the foot for phalangeal fractures of the hallux (Fig. 3 ). After splintage, the injured foot can
be additionally protected with a surgical shoe or in a non-weight-bearing position if necessary. Most phalangeal fractures are immobilized
in the position of function, and the duration of immobilization is determined by clinical and radiographic evidence of healing. In most cases,
consolidation of the osseous fragments develops in 4 to 8 weeks. During this period, the clinician must correlate the clinical findings with
radiographic evidence because fracture lines will remain radiographically visible for several months.
FIG. 2. Splinting of a fractured third digit to the neighboring second digit with felt and tape.
The alignment of the fracture fragments is the key in determining whether reduction is necessary. It is important to understand the
principles of closed and open reduction as well as the anatomy and the mechanism of injury if malalignment exists. Bone injury is less
significant than the soft tissue disruptions that occur on the convex side of the fracture site. Generally, the soft tissues on the concave side
of the injury remain intact. These soft tissue structures guide the fracture fragments into a more normal position and tend to prevent
overcorrection during closed reduction by acting as a hinge on the concave surface. Manipulative reduction is achieved, exaggerating the
plane of deformity, followed by distraction and then reduction. After completion of the reduction, radiographs
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are made to assess alignment (Fig. 4 ). The configuration of the fracture may be described as stable, potentially stable, and unstable.
Stable, reduced fractures are able to withstand telescoping forces with protection and immobilization and are generally transverse in
orientation to the longitudinal axis of the bone or a short oblique phalangeal fracture. Both fracture types are usually treated with closed
reduction and immobilization and typically respond well and heal without adverse sequelae unless the injury has an intraarticular
component. In this circumstance, the patient may later develop stiffness or painful arthrosis even if healing progresses uneventfully.
FIG. 3. Immobilization of a hallux fracture with a splint of cast material. A,B: Splint made by sandwiching a layer of cast material
(e.g., 2- or 3-inch synthetic cast material) between layers of cast padding. C,D: Splint applied along the medial aspect of the first ray
and hallux.
Unstable fractures possess minimal intrinsic ability to withstand shortening and consist of long oblique, spiral, or some comminuted
fractures. Creating adequate stability may require additional support from external fixation or open reduction with fixation. Kirschner
wires can be inserted percutaneously to maintain a fracture that has been realigned with closed reduction. Serial postreduction
radiographs or fluoroscopy may be used to ascertain proper placement and reduction. Direct open reduction with the wires may prove
necessary in some instances.
Fractures that are unstable, nonreducible, intraarticular, or associated with coexisting neurovascular compromise need immediate
attention and may require open reduction with fixation for proper alignment and stability. Surgical intervention with open reduction is
performed with standard sterile technique and insertion of appropriate hardware as deemed necessary (Fig. 5 ). Achieving proper fixation
is required, especially with intraarticular fractures that have a significant potential to develop posttraumatic arthritis, as seen in fractures
of the hallux interphalangeal joint (4 ) (Fig. 6 ).
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FIG. 4. Demonstration of a closed reduction of a potentially stable fracture of the proximal phalanx of the fifth digit. A,B:
Prereduction clinical and radiographic appearance. C: Attempted closed reduction stabilizing the proximal segment and reducing the
distal segment. The intact soft tissue hinge is on the lateral (concave) side of the injury. D,E: Postreduction clinical and radiographic
appearance. F: Immobilization of the fifth digit by splinting to the neighboring third and fourth digits.
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FIG. 5. A,B: Two examples of open reduction and internal fixation of hallux fractures with screws.
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FIG. 6. A,B: Intraoperative clinical appearance of an intraarticular fracture of hallux with fracture extension into the interphalangeal
joint. C: Intraoperative clinical appearance after reduction and fixation. D: Postoperative radiograph demonstrating reduction of
fracture with internal fixation.
In the lesser digits, the concern for complete reduction of the intraarticular components of the fracture is not as great. Stiffness or
arthrosis is generally not as disabling as in the hallux interphalangeal joint, the lesser toes are not subjected to the same degree of weight-
bearing stress, and surgical options for repair of these digits are generally easily accomplished. Infrequently, comminuted fractures of the
lesser digits may require excision of the fragments because of the numerous minute fractures. Excision may be carried out immediately in
patients with traumatic open fractures or later with closed fractures if fragments become symptomatic after conservative treatment has
failed. If painful arthrosis or malunion of the bone persists, resectional arthroplasty of the involved joint may be necessary (5 ).
Even with proper immobilization and fixation, posttraumatic sequelae may occur with digital fractures. Included in the potential long-term
problems are delayed union or nonunion of the fractured segments, malunion, chronic pain, and posttraumatic intraarticular arthrosis. In
these instances, surgical intervention, possibly including arthroplasty or arthrodesis, may be necessary to obtain pain relief for the patient
(4 , 5 , 6 , 7 ).
Open Injuries
Open injuries frequently represent a surgical emergency. One should initially evaluate the neurovascular status of the injured part as well
as the extent of any soft tissue loss (Fig. 7 ). Specimens for Gram's stain and culture should be taken from the wound. Multiple radiographs
aid in assessing the bone disruption. Thorough irrigation is then necessary to reduce the risk of infection. The wounds may then be
evaluated relative to repair of the injuries and soft tissues.
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FIG. 7. Traumatic open injury to the fifth digit. Clinical (A) and radiographic (B) appearance. Clinical (C) and radiographic (D)
appearance after irrigation, débridement, and Kirschner wire stabilization.
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SESAMOID FRACTURES
Anatomy
The sesamoid bones of the hallux are located at the plantar aspect of the first metatarsophalangeal joint and are embedded within a
fibrous tendoligamentous network. No periosteum surrounds the sesamoid, but rather an aponeurosis surrounds the plantar cortex (8 ,9 ). A
cartilaginous dorsal surface articulates with the first metatarsal head (10 ). This is believed to increase the mechanical leverage of the
great toe by acting as a fulcrum for the flexor tendons.
Initially, the sesamoids become identifiable as undifferentiated connective tissue within the tendon of the flexor hallucis brevis by the
eighth week of embryonic life, and chondrification arises during the twelfth week of gestation. Ossification usually occurs between 8 and
10 years of age. The multiple foci of ossification may or may not coalesce leading to bipartite, tripartite, or quadripartite sesamoid bones.
The incidence of bipartite sesamoids varies widely. Kewenter reported a 35.5% incidence in 1,588 feet, and Inge and Ferguson stated a
10.7% incidence in 1,025 feet, with 75% of cases being unilateral (11 ). Both studies described numerous variations in partite sesamoids (Fig.
8 ).
The medial (tibial) and lateral (fibular) hallux sesamoids are enclosed within the medial and lateral tendon slips of the flexor hallucis
brevis muscle, with the abductor and conjoined adductor hallucis tendons inserting into the medial and lateral sesamoid complex,
respectively. The sesamoids are held in place in their grooves beneath the first metatarsal head by the plantar plate, which consists of the
intersesamoidal ligament, medial and lateral collateral ligaments, and medial and lateral metatarsal sesamoidal and phalangeal sesamoidal
ligaments. The plantar fascia blends into the plantar surface of both sesamoids (9 ). The lateral sesamoid is also attached on its plantar
surface by the intermetatarsal ligament (Figs. 9 and 10 ).
FIG. 8. Bipartite tibial sesamoid.
FIG. 9. Hallux sesamoid complex anatomy: coronal view. FHB, flexor hallucis brevis; FHL, flexor hallucis longus; I, lateral; m, medial.
(Redrawn from Karasick D, Schweitzer M. Disorders of the hallux sesamoid complex: MR features. Skeletal Radiol 1998;27:411-418,
with permission.)
The arterial supply of the hallux sesamoids is variable, with the number of vessels ranging between one (55%) and three (10%) (8 ) (Fig. 11 ).
When three arteries are present, they are derived from the superficial and deep branches of the medial plantar artery, the lateral plantar
artery, and the perforating branch of the dorsalis pedis artery. Most of the blood supply comes from arteries proximal and plantar to the
sesamoids through the flexor hallucis brevis insertion
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and capsular attachments, respectively, and less from distal arterial anastomoses (8 ,12 ).
FIG. 10. Hallux sesamoid complex anatomy: transverse view: 1, tibial and fibular sesamoid; 2, flexor hallucis brevis tendon medial
and lateral slips; 3, flexor hallucis longus tendon; 4, abductor hallucis tendon; 5, adductor hallucis tendon; 6, intersesamoidal
ligament. (Redrawn from Jahss MH. The sesamoids of the hallux. Clin Orthop 1981;157:88-97, with permission.)
FIG. 11. Illustration of plantar arteries of the hallucal sesamoids. A-C: Types of plantar arteries of the hallux. Encircled: enlarged
sketches of the plantar aspect of the first metatarsophalangeal joint with the sesamoid arteries entering the nonarticular surfaces of
the sesamoids. Arrowheads, medial sesamoid arteries; stars, lateral sesamoid arteries; A, plantar arch; L, lateral plantar artery; M,
medial plantar artery; ml, first plantar metatarsal artery; p, perforating branch of dorsalis pedis artery; pl, proper plantar artery; s,
superficial branch of the medial plantar artery; d, deep branch of the medial plantar artery. (Redrawn from Pretterklieber ML,
Wanivenhaus A. The arterial supply of the sesamoid bones of the hallux: the course and source of the nutrient arteries as an
anatomical basis for surgical approaches to the great toe. Foot Ankle Int 1992;13:27-31, with permission.)
Etiology
Traumatic injury to the sesamoid bone may result from falls, forced dorsiflexion, or repetitive stress. These injuries have become more
common with the rise in sports such as aerobics, jogging, long-distance running, and speed or power walking. Athletes competing in
acceleration-deceleration sports such as football, soccer, tennis, or jumping activities may also present with sesamoidal injuries. Sesamoid
fractures are usually transverse or comminuted, and one or both of the sesamoids may be involved. They are frequently created from
direct force in the sagittal plane, with the tibial sesamoid injured more often because of the increased weight bearing at the medial
aspect of the joint. Sagittal plane injuries tend to crush the sesamoid between the first metatarsal head and the supporting surface.
Many other sesamoid injuries are insidious in onset, and the patient is unable to recall any single, acute traumatic event. Because the
sesamoids of the first metatarsophalangeal joint receive the weight-bearing forces carried by the first metatarsal head, they have a
supportive role comparable to that of the lesser metatarsal heads (11 , 12 , 13 ). Certain biomechanical derangements and foot types (e.g.,
the cavus foot or the foot with metatarsus primus equinus) are predisposed to chronic repetitive sesamoid trauma and possible fracture
(14 , 15 , 16 ).
In addition, forceful dorsiflexion or hyperflexion of the great toe may result in sesamoid dislocation, avulsion, or diastasis of a multipartite
sesamoid component. Hyperextension injuries are much more common. Sesamoid dislocations occur as a result of plantar capsular rupture,
which may be associated with motor vehicle or motorcycle accidents, ballet dancing, or playing sports activities on artificial turf (9 ).
Hyperextension injuries of the hallux may cause first metatarsophalangeal joint dislocation by disrupting the plantar
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aspect of the first metatarsophalangeal joint capsule, with or without rupture of the intersesamoidal ligament, or fracture of one or both
sesamoids (17 ). Usually, only one of the sesamoids fractures, most commonly the tibial sesamoid.
Typically, the patient with a sesamoid fracture or disease has acute or chronic pain beneath the first metatarsophalangeal joint that
increases with hallux motion and weight-bearing activity. In an acute process, the patient usually has an episode of inciting trauma.
Swelling is present to a variable degree, and ecchymosis may be absent. The patient guards against weight bearing and dorsiflexion of the
joint.
Correlating the patients' activity with the onset of pain aids in diagnosis and treatment. Chronic injuries may be the result of repeated
trauma from activities such as jogging or from overly short rigid shoe inserts that rest over the proximal border of the sesamoid bone.
On physical examination, one notes localized tenderness in the area of the injured sesamoid with palpation, as well as with range of
motion of the metatarsophalangeal joint. Because of the fibrous tendoligamentous attachments to the sesamoids, motion in any direction
stresses the fracture site and leads to pain. This pain may shift with movement as the sesamoids are distracted (18 ).
Diagnosis and Treatment

The fractured sesamoid is typically seen in most standard radiographic views. The lateral view may prove least helpful because of the
superimposition of the adjacent structures. Simple fractures usually have a transverse cleft with variable degrees of displacement and
fragment sizes (19 ) (Fig. 12 ). It is often difficult to differentiate an acute fracture from a bipartite or multipartite sesamoid that has
undergone an injury to the synchondrosis. Fractures usually have serrated, irregular edges, whereas partitioned sesamoids have smoother,
rounder edges. Both types of injury are painful to palpation and with range of motion, and both have positive bone scintigraphy studies.
Fortunately, treatment is the same for both. Contralateral films can be obtained to aid in the diagnosis of a bipartite sesamoid versus an
acute fracture; however, the incidence of partitioned sesamoids is speculative, with reports ranging from 7.8% to 33.3% and bilateral
involvement occurring in 13.5% to 90% of cases (20 , 21 , 22 ). Thus, contralateral films are helpful but not diagnostic (11 ,23 ). The tibial
sesamoid is more commonly fractured because of its increased load in closed kinetic chain gait. Rarely, both sesamoids of the same
metatarsal may be fractured (24 ).
FIG. 12. Fractured fibular sesamoid.
If no changes are seen radiographically, technetium-99 bone scans, computed tomography, or magnetic resonance imaging may be
considered. Magnetic resonance studies are useful in that they may differentiate an acute fracture from other forms of sesamoid disease,
as well as provide information regarding the status of the surrounding soft tissues. An acute fracture is hypointense on T1-weighted images
and shows increased intensity on T2-weighted and STIR images consistent with marrow edema (19 ,25 ). Bone scans have been helpful in
distinguishing sesamoid fractures from an uninjured multipartite sesamoid bone in the symptomatic patient (Fig. 13 ). The bone scan shows
increased isotope uptake secondary to osteoblastic new bone formation and reveals disturbance at the acute fracture site before changes
are seen radiographically (26 ). However, the reliability of bone scans in discerning fractures from sesamoiditis has been found to be low
(10 ). An additional disadvantage of the bone scan is poor image quality, which limits the ability to determine the actual structure of the
lesion. Moreover, acute fractures, stress fractures, sesamoiditis, and synchondral injuries to the partitioned sesamoid may all produce
positive bone scans.
Conservative treatment modalities vary from one practitioner to another, but the general goal is to reduce stress to the sesamoid bone.
This can be accomplished by padding,
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splints, or taping to immobilize the first metatarsophalangeal joint, reduced activity, or non-weight bearing. During normal function,
tension from the fibrous tendoligamentous attachments is applied to the sesamoids during joint motion in the sagittal and transverse
planes. Relief of these forces may be achieved by limitation of dorsiflexion, adduction, or abduction of the first metatarsophalangeal joint
by using orthotic devices or splinting. The limitation of dorsiflexion is most important, and the first metatarsophalangeal joint may even be
splinted in plantarflexion to neutralize this tension. Oral antiinflammatory medications may be used in conjunction with off-loading. The
use of injectable steroids remains a controversial issue in patients with fresh fracture or dislocation.
FIG. 13. A: Suspected fracture of the tibial sesamoid of the left foot. B: Sesamoid axial view demonstrating suspected tibial sesamoid
fracture. C: Third phase of a technetium-99 bone scan of the foot. The increased activity in the area of the tibial sesamoid of the left
foot strongly suggests a fracture.
In more chronic injuries or in fractures that are seen several months after an acute traumatic event, a technetium-99 bone scan or
magnetic resonance imaging study may be helpful in determining the vascularity of the injured osseous fragments and their potential to
heal with conservative management. The sesamoids are susceptible to the development of delayed or nonunion (27 ), and some surgeons
have advocated aggressive immobilization and electric bone stimulation before initiating surgical intervention (19 ). However, it is largely
presumed that sesamoid fractures do not heal by true osseous union, but they form a fibrous bridge or nonunion that, in many instances, is
asymptomatic.
Surgical intervention may be contemplated after conservative therapy fails. The continued symptoms on the weight-bearing area may be
from complications of nonunion, malunion, or intraarticular arthritis. Blake found that more than 30% of all sesamoid fractures eventually
required surgery consisting of excising the symptomatic sesamoid (28 ).
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FIG. 14. Nonunion after fracture of the tibial sesamoid of the left foot. Surgical approach to the removal of the sesamoid. A and B:
Dorsoplantar and oblique views of injured tibial sesamoid (arrows). C: Plantar medial incision at the level of the first metatarsal-
sesamoid articulation. D: Incision deepened to the level of the joint capsule. Care is taken to avoid the proper digital branches of the
medial dorsocutaneous nerve and medial plantar nerve. E: Capsular incision at the dorsomedial aspect of the tibial sesamoid. The
plantar aspect of the first metatarsal head (identified by end of Metzenbaum scissors) and the dorsal portion of the sesamoid (just
above forceps) are clearly visible. F: The tibial sesamoid is carefully freed from intrinsic attachments. G: Fractured tibial sesamoid
removed in toto. H: On removal, fracture fragments and nonunion of the tibial sesamoid are easily separated and visualized.
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FIG. 14. Continued.
Surgical treatment of an injured sesamoid has almost exclusively been focused on partial or total excision of the bone. Anecdotal concerns
have been raised regarding the development of subsequent deformities at the first metatarsophalangeal joint after removal of a sesamoid.
In particular, these deformities have ranged from hallux malleus, loss of hallux purchase, or hallux valgus with removal of the tibial
sesamoid or hallux varus with removal of the fibular segment. These types of problems may be avoided in the majority of cases if the
surrounding soft tissues are preserved as the bone is dissected free.
Another area of discussion relative to the surgical management of these problems has been whether to remove the entire sesamoid or only
the smallest fragment. Marcinko and Elleby suggested removal of only the distal fragment of a fractured tibial sesamoid, with retention of
the proximal fragment. Although their results have been promising, as they have noted, additional long-term evaluation of this technique is
needed (7 ). Clearly, if the sesamoid has undergone a crush injury and multiple segments are present, then removal of all the fragments
would be warranted. However, if the sesamoid is in only two pieces, the surgeon must decide whether a total or partial sesamoidectomy is
in order. If the larger of the two pieces is in good position without any evidence of cartilaginous destruction, an argument can be made to
leave this fragment intact and to remove only the smaller of the two pieces (19 ). If both pieces have undergone cartilage damage, leaving
one would still likely result in first metatarsophalangeal joint irritation, and this piece would eventually require excision as well.
Because of the bone's small size and location and the general success with excisional procedures, open reduction with internal fixation of
acute fractures has not been commonly employed, although one report has noted successful outcomes with autogenous bone grafting for
treatment of sesamoid nonunions (29 ). On initial review, this technique would appear to be extensive for a condition in which partial or
total excision of the bone has provided good results.
The surgical exposure to the tibial sesamoid is best achieved through a plantar medial approach (Fig. 14 ) overlying the first
metatarsophalangeal joint. Dissection is carried through the deep tissue, with care taken to retract neurovascular structures including the
proper digital branches of the medial plantar and medial dorsocutaneous nerves to the capsular level. The capsule is incised along the
dorsomedial margin of the sesamoid, and the sesamoid is shelled from its tendoligamentous attachments. Care should be taken with the
tendons of the abductor hallucis and the medial head of the flexor hallucis brevis. After excision of the sesamoid, layer closure of the
capsule, the superficial fascia, and the skin is performed.
A fractured fibular sesamoid that has not responded to conservative therapy may also require surgical removal to relieve symptoms. This
operation may be performed with a dorsal incision overlying the first webspace. Alternatively, a more standard dorsomedial incision like
that of a hallux valgus repair may be employed. Access to the first interspace is similar to that for the repair of a bunion. A plantar incision
may be used, but there may be some risk of a painful weight-bearing scar or irritation of the local interdigital nerve. Dorsal approach
dissection is carried down through the deep soft tissue structures to the level of the joint capsule. When the sesamoid has been identified,
it may be clamped or skewered with a Kirschner wire for manipulation to release the soft tissue attachments and then excised. The
sesamoid is sequentially released from its soft tissue attachments: first, the lateral capsule is incised and the sesamoid is freed from its
tendinous attachments at this level; next, the proximal and distal attachments are released; then, the intersesamoidal ligament is
transected, to allow the sesamoid to be completely excised. Care should be taken during dissection of the soft tissue to avoid transection
of the flexor hallucis longus tendon.
Postoperatively, the patient may be allowed to ambulate

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with a dressing and surgical shoe. If concern exists about the potential for later joint deviation, then some form of removable splint may be employed for a period after the dressings are no
longer required. Patients are allowed to return to the use of standard shoes as tolerated. In some patients, a period of immobilization in a non-weight-bearing or weight-bearing cast for the
first 3 weeks may be helpful.
Removal of both sesamoids may result in a hallux malleus deformity or a cocked-up great toe. Therefore, additional procedures may be necessary such as an interphalangeal joint fusion with or
without a Jones tenosuspension of the extensor hallucis longus tendon. These supplementary techniques reduce the muscular imbalance created by weakening the flexor apparatus. However,
removal of both sesamoids eliminates the normal protection afforded the flexor hallucis longus tendon during weight bearing. As a consequence, this tendon may be subject to pain and
inflammation postoperatively. Surgical options for severe arthritic conditions of the sesamoids may include a Keller arthroplasty or first metatarsophalangeal arthrodesis (30 ).
REFERENCES
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3. Farrington GH. Subungual hematoma: an evaluation of treatment. BMJ 1964;21:742-744.
4. Jahss MH. Stubbing injuries to the hallux. Foot Ankle 1980;1:327-332.
5. Elleby DH, Marcinko DE. Digital fractures and dislocations: diagnosis and treatment. Clin Podiatr 1985;2:233-245.
6. Heim U, Pfeiffer KM. Internal fixation of small fractures: technique recommended by the AO-ASIF group, 3rd ed. New York: Springer-Verlag, 1988:371.
7. Marcinko DE, Elleby DH. Digital fractures and dislocations. In: Scurran BL, ed. Foot and ankle trauma. New York: Churchill Livingstone, 1989:309-322.
8. Pretterklieber ML, Wanivenhaus A. The arterial supply of the sesamoid bones of the hallux: the course and source of the nutrient arteries as an anatomical basis for surgical
approaches to the great toe. Foot Ankle Int 1992;13:27-31.
9. Karasick D, Schweitzer M. Disorders of the hallux sesamoid complex: MR features. Skeletal Radiol 1998;27:411-418.
10. Dietzen C. Great toe sesamoid injuries in the athlete. Orthop Rev 1990; 19:966-972.
11. Jahss MH. The sesamoids of the hallux. Clin Orthop 1981;157:88-97.
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13. David RD, Delagoutte JP, Renard MM. Anatomical study of the sesamoid bones of the first metatarsal. J Am Podiatr Med Assoc 1989;79:536-544.
14. Speed K. Injuries of the great toe sesamoids. Ann Surg 1914;60:478-480.
15. Goldman F. Ipsilateral dual sesamoid injury: a case report. J Am Podiatr Med Assoc 1984;74:187-191.
16. Frankel JP, Harrington J. Symptomatic bipartite sesamoids. J Foot Surg 1990;29:318-323.
17. Jahss MH. Traumatic dislocations of the first metatarsophalangeal joint. Foot Ankle 1980;1:15-21.
18. Bizarro AH. On the traumatology of the sesamoid structures. Ann Surg 1921;74:783-791.
19. Oloff L, Schulhofer D. Sesamoid complex disorders. Clin Podiatr Med Surg 1996;13:497-513.
20. Inge G, Ferguson A. Surgery of the sesamoid bones of the great toe. Arch Surg 1933;27:466.
21. Prieskorn D, Graves S, Smith R. Morphometric analysis of the plantar plate apparatus of the first metatarsophalangeal joint. Foot Ankle 1993;14:204-207.
22. Scranton P, Rutkowski R. Anatomic variations in the first ray. II. Disorders of the sesamoids. Clin Orthop 1980;151:256-264.
23. Kenrick D, McKinney S. Sesamoids and accessory bone of the foot. Clin Podiatr Med Surg 1990;70:717-723.
24. Abraham M, Sage R, Lorenz M. Tibial and fibular sesamoid fractures on the same metatarsal: a review of two cases. J Foot Surg 1989;28:308-311.
25. Burton E, Amaker B. Stress fracture of the great toe sesamoid in a ballerina: MRI appearance. Pediatr Radiol 1994;24:37-38.
26. Weiss J. Fracture of the medial sesamoid bone of the great toe: controversies in therapy. Orthopedics 1991;14:1003-1007.
27. McBryde A, Anderson R. Sesamoid foot problems in the athlete. Clin Sports Med 1988;7:51-59.
28. Blake RL. Athletic injuries: orthoses versus surgery. In: Jay RM, ed. Current therapy in podiatric surgery. Philadelphia: BC Decker, 1989:296-301.
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30. Stroh KI, Altman MI, Yee DYS. First metatarsophalangeal joint arthrodesis: treatment for sesamoid fractures. J Am Podiatr Med Assoc 1990;80:595-599.
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Clin Orthop 1980;149:229-231.
Christensen SE, Cetti R, Niebuhr-Jorgensen U. Fracture of the fibular sesamoid of the hallux. Br J Sports Med 1983;17:177-179.
Cobey JC. Treatment of undisplaced toe fractures with a metatarsal bar made from tongue blades. Clin Orthop 1974;103:56.
Connolly JF. Fractures of the toes. In: DePalma's the management of fractures and dislocations: an atlas, vol 2, 3rd ed. Philadelphia: WB Saunders, 1981:2073-2077.
Dennis KJ, McKinney S. Sesamoids and accessory bones of the foot. Clin Podiatr Med Surg 1990;7:717-723.
Dix R. Fractured sesamoid, a case report. J Am Podiatry Assoc 1963;53:663.
Dobas DC, Slavitt JA. Impact fractures of the lesser digits: a clinical description with a case history. J Am Podiatry Assoc 1977;67:571-573.
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Giannestras NJ, Sammarco GJ. Fractures and dislocations in the foot. In: Rockwood CA Jr, Green DP, eds. Fractures, vol 2. Philadelphia: JB Lippincott, 1975:1400-1495.
Gilchrist AK. Surgical care of the traumatized foot. J Am Podiatry Assoc 1975;65:816-824.
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Heppenstall RB. Fracture treatment and healing. Philadelphia: WB Saunders, 1980:878-880.
Hobart MH. Fracture of sesamoid bones of the foot: with report of a case. J Bone Joint Surg 1929;11:298-302.
Hulkko A, Orava S, Pellinen P, Puranen J. Stress fractures of the sesamoid bones of the first metatarsophalangeal joint in athletes. Arch Orthop Trauma Surg 1985;104:113-117.
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Chapter 21
Callus Distraction Principles and Indications
Dennis E. Martin
The technique of callus distraction has been employed since the early 1900s, but it has only been recently that the methodology
has evolved and surgeons have taken advantage of this alternative surgical approach to bone grafting (1 ). There are a number
of potential indications for callus distraction, and these include the correction of a number of congenital, hereditary, traumatic,
and septic sources of foot and extremity deformity. In this chapter the principles, science, and indications for callus distraction
are discussed.
HISTORY
The origins of callus distraction can be traced back to the early 1900s. Although Codivilla (1 ) is most commonly cited as the first
surgeon to address a shortened limb by distraction and traction concepts, the contributions of several other pioneers from this
era cannot be overlooked (2 ,3 ). Codvilla performed an oblique osteotomy of the femur that was then lengthened by placing a
sudden and intense pull on a steel rod inserted through the calcaneus. The correction was then maintained by a plaster cast that
incorporated the steel bars until healing occurred. If greater lengths were needed, the process was repeated at later intervals.
Steinmann (2 ) modified this technique by placing his newly developed Steinmann pin through the distal tibia as opposed to the
calcaneus. Correction was secured by applying traction with weights to the extremity. Freiberg (2 ) placed a steel rod through
the posterior process of the os calcis and connected it to a traction screw via a heavy picture wire. A spring-loaded scale was
used and served as a dynamometer. Forces as high as 45 kg were often needed to achieve the desired length. Any subsequent
lengthening that was needed was performed without anesthesia. All of these procedures were quite traumatic and poorly
tolerated by the patients.
In 1913, Magnunson (3 ) attempted to improve this technique by making it simpler and less risky for patients. He executed a Z-
osteotomy of the femur and separated the two fragments by traction and countertraction with weights. Once the desired length
was obtained, a plug was placed between the bone ends and the weights were removed. The bony fragments were fixed with
absorbable ivory screws. Despite what appeared to be an excellent attempt at improving patient morbidity, all patients were
greatly traumatized, and one patient died. The frustration and disappointment resulting from these complications resulted in
surgeons abandoning the techniques of callus distraction for a short period of time.
Interest in bone lengthening via traction increased again in the late 1920s and early 1930s. In 1927, Abbott (4 ) described a
procedure that, with some modification, became a popular operation in the United States. He was the first to use the tibia as
his target tissue for lengthening. Following osteotomy of the fibula and insertion of Steinmann pins in the proximal and distal
ends of the tibia, the tibial osteotomy was performed and the distraction apparatus applied. He cautioned against correcting
over 5.08 cm of deformity. Abbott also performed a lengthening to the Achilles tendon as part of his correction. Carrell (5 ) was
concerned about forward angulation of the fragments secondary to the bowstring action of the tightened leg muscles. He
attempted to offset these forces by placing a third pin in front of the fragments. Unfortunately, this led to significant skin
damage in adjacent areas and proved to be unsuccessful. Brockway and Fowler (6 ) used an off-center pin on the proximal end
of the osteotomy to try to address the potential angulation problem. Two pins were inserted on each side of the osteotomy and
the more distal of the two proximal pins was placed slightly more anterior. Some surgeons preferred Kirschner wires (K-wires) to
Steinmann pins (7 ,8 ).
Haboush and Finkelstein (8 ) were the first to emphasize the importance of maintaining the periosteum at the level of the
osteotomy. The sleeve of periosteum that was preserved resulted in a quicker deposition of callus and more rapid healing.
Bosworth (9 ) also advocated the Abbott technique and suggested a delay of 10 days between execution of the
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osteotomy and the initiation of lengthening. He was also one of the earliest surgeons to report positive results with few
complications.
In 1934, Putti (10 ) described a femoral osteotomy that was gradually lengthened over an 18- to 21-day period. He designed an
apparatus that allowed for traction and countertraction forces to be applied during the lengthening period. With this technique,
he typically achieved between 6.35 and 10.16 cm of length.
Despite these efforts to improve the success of the procedure and to reduce patient morbidity, complications persisted and leg
lengthening through traction techniques became unpopular again in the late 1930s. Compere (11 ) stated that all surgeons
performing leg lengthening procedures had encountered some degree of complication. He divided complications into three
broad categories: (a) overstretching, (b) interference of blood supply to the fragments, and (c) insufficient fixation of the
fragments.
Following World War II, there was a renewed interest in leg-lengthening procedures. The emphasis during this era was placed on
trying to develop better means of fixation. Attempts were made to not only improve the strength of fixation but to make the
devices less traumatic. Allan (12 ) created an apparatus that allowed the K-wires used for fixation to be placed in stirrups and
clamped in a carrier. One of the pairs of wires was fixed while the other was capable of moving in a direction away from the
stationary counterparts. Allan also advocated leaving the periosteum intact while performing an oblique osteotomy. He
recognized the importance of preserving as much soft tissue as possible around the lengthening site. Once the desired length
was obtained, he secured the position with screws. Allan's modification was also short lived owing to a variety of complications
that arose.
Other authors tried to improve on the type of fixation used to stabilize the osseous fragments. McCarroll (13 ) used a slotted
plate with traction, whereas Bost and Larsen (14 ) proposed use of an intramedullary rod to hold the alignment as traction was
applied.
In an effort to improve success rates and reduce patient morbidity, alternative techniques were investigated. Several surgeons
(15 ,16 ) attempted epiphyseal growth plate stapling with modest results. However, there was still a need for a more effective,
yet less complicated procedure owing to the limited amount of correction that could be obtained through epiphyseal stapling.
This led Anderson (17 ), in 1952, to return to bone lengthening through traction. He performed the correction in two stages. The
first stage consisted of a fibular osteotomy and a slotting technique of the distal fibula under an osteoperiosteal flap of the
adjacent tibia. Once it was confirmed that there was no continuity to the fibula (approximately 6 weeks later), the tibial
lengthening was started. Several surgeons modified this technique further in an effort to accomplish the correction in one stage.
Coleman and Noonan (18 ), Gross (19 ), and Mitchell (20 ) all provided immediate fixation of the fibula to the tibia, along with
executing the tibial osteotomy and assembling the distraction frame.
Agerholm (21 ) modified the osteotomy design by making it zigzag in effort to increase stability to the osseous fragments.
Kawamura (22 ) made an important addition to Anderson's technique by performing the osteotomy through the cortex only in an
attempt to preserve the nutrient vessels and endosteal tissue. These developments during Anderson's era mark the beginning of
positive progress that continued over the next 30 years.
Modern day advancements in the science of callus distraction for bone lengthening actually began with the work of Wagner (23 )
in the early 1970s. Although his suggestions of sectioning the periosteum at the level of the osteotomy and his choice of a mid-
diaphyseal location are points of controversy, Wagner made many positive contributions. He recognized the importance of slow
gradual lengthening versus sudden extreme corrections. His device allowed for 1.5 mm of lengthening per complete revolution,
which was executed with one full turn daily. Wagner also noted the importance of maintaining function to the limb and
advocated partial weight bearing with the frame in place to allow joint motion to be preserved. This was a definite
improvement over the Anderson device, the latter of which required the patient to be confined to bed. Furthermore, Wagner's
device was smaller and lighter, with a simpler method of elongation. He employed a unilateral frame with 6-mm Schanz pins.
This device is very similar to the modern day external fixators (Fig. 1 ).
FIG. 1. Large external frame for axial lengthening.

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The final era in the development of callus distraction is that dominated by the concepts of Ilizarov. Ilizarov (24 ) began working
on and publishing his ideas on bone transport as early as the 1950s in Russia. However, owing to the political climate of that
time and difficulties in translation, it was not until many years later that individuals in other countries noted his work. He felt
strongly about preserving the contents of the intramedullary canal during osteotomy to improve osteogenesis and decrease
consolidation time. However, the actual significance of this aspect of the technique remains a controversial issue. He also
expanded the understanding regarding the timing of initiating the lengthening and the rate of subsequent distraction. A delay of
5 to 7 days following osteotomy was recommended to allow for better consolidation (25 ). He also showed that a lengthening of
1.5 mm per day, as proposed by Wagner, is dangerous and can lead to ischemic changes. Ilizarov believed that slower, more
frequent lengthening would allow for better osteogenesis and elongation of soft tissues.
These ideas are very important and have shaped our understanding of today's science of callus distraction. Ilizarov was also a
proponent of early mobilization and weight bearing, and actually prescribed participation in calisthenics for his patients while
they were still in their frames.
Although these contributions changed the course of bone lengthening as a science, it was actually Ilizarov's fixator that led to
his notoriety. He popularized the concept of a ring fixator with multiple transfixation pins to stabilize the osseous fragments. By
fixing each of the segments at more than one level, he was able to increase bending stiffness, but because of the flexibility
afforded by the smaller size wires (1 to 2 mm), axial loading resulted in some motion. This axial movement has been thought to
be very beneficial for osteogenesis in the lengthening gap. Hence, here lies the wisdom in early weight bearing following
execution of the osteotomy. This continues to be one of the most popular methods used to distract and lengthen bone. This
device is discussed and demonstrated in detail in Chapter 4 .
PHYSIOLOGY AND HISTOLOGY
Fracture Repair
The histologic events that take place in callus distraction are quite similar to those seen in normal fracture repair. The natural
sequence of repair is interrupted at the “soft callus” stage, and a distraction sequence is started. Therefore, a basic knowledge
of the histophysiologic features behind fracture repair is helpful in understanding the overall process.
The intrinsic process of bone healing has been broadly referred to as callus formation. Generally speaking, there are two types
of callus formation: (a) periosteal or extrinsic callus and (b) endosteal callus. External or periosteal callus is the type that is
most familiar to clinicians. It represents the expanding cuff of healing bone that is often seen on a radiograph in a fracture that
is undergoing repair (Fig. 2 ). Its formation is related to the periosteal activity and the mechanical stability or instability of the
fracture. Although it is less appreciated on radiographs, endosteal callus formation also plays an important role in bone healing.
This type of fracture repair is most commonly seen in metaphyseal or short bones.
FIG. 2. Fracture repair demonstrating aggressive callus production.
The basic process of repair begins with hemorrhage at the fracture site created by tearing of osseous and periosteal vessels.
Hematoma then forms and fills the gap between the fracture fragments. As the hematoma begins to organize, it is invaded by a
variety of cells with different functions. Macrophages dominate the early phase of healing as they enter to remove the necrotic
blood and tissue debris. Within several days, fibroblasts from the surrounding periosteal and mesenchymal tissues invade the
organized clot and begin to lay deposits of collagen and fibrocartilage. This allows for stiffening of the clot and aids in
decreasing motion between the bone ends. As a result of several factors, including low oxygen tension at the clot site,
fibrocartilage is the basic ground substance produced at this early callus production stage. Resorption of necrotic bone occurs as
the haversian system begins the process of removal of nonviable osseous tissue.
Vascularization of the maturing hematoma or procallus begins to occur simultaneously. This vascular infiltrate comes from three
separate areas. Capillaries infiltrate from the external periosteal vessels and internally from the endosteal
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tissue. The haversian system of the surrounding cortical bone also supplies vascular elements. This latter source of vascularity
accompanies the haversian structure and consists of a leading edge of osteoclastic cells with a trailing deposition of osteoblasts.
As the oxygen tension of this procallus increases, the product of the osteoprogenitor cells becomes that of osteoid. The calcium
hydroxyapatite that comprises the deposited osteoid allows more rigidity and stiffening between the fragments. It is at this
stage that the repair becomes radiographically visible. The mechanical stability of the fracture will determine how much callus
is formed. The callus will then mature and create clinical union between the fragments. This callus will eventually be replaced
with the normal architecture of the primary osseous structure.
In the science of callus distraction, controlled mechanical instability is induced at the stage of soft callus production just before
or simultaneous with mineralization. Fracture stability is then reestablished when the desired correction is obtained.
Callus Distraction
When distraction of an osteotomy is initiated, a gap is created and filled with hematoma and fibrous exudate. Within days, the
gap is invaded by immature connective tissue. Vascular channels then appear, and at approximately 3 weeks, callus begins to
form as fine cancellous bone is laid down in columns (Fig. 3 ). The callus is initially represented by longitudinally oriented
collagen fibers, around which bone spicules eventually form. Some of these fibers span the entire distance between bone ends
(Fig. 4 ). At either end of the gap, fibrocartilage is seen between the bone end and the ossified or sclerotic edge of the
distraction zone. The central growth zone appears in the center of the gap and is primarily composed of fibroblasts and
chondrocytes (Fig. 5 ).
Regenerating bone continuously matures during and after lengthening. The radiolucent growth zone becomes ablated
approximately 4 weeks after distraction has been stopped (Fig. 6 ). Cortex formation, called corticalization, takes place around
4 to 6 months after surgery and continues to remodel over a period of a year or more. Radiographically, the difference between
regenerate bone and fracture callus is the organized longitudinal striations seen in callus distraction. Fracture callus is typically
more bulbous in shape and lacks longitudinal striations.
FIG. 3. Note the organized appearance of the callus production on a stained slide.
FIG. 4. Radiograph 6 weeks postoperatively, demonstrating the axial callus formation spanning the distance of the
osteotomy site.
There are also differences seen histologically between regenerate and normal bone, at least in the early stages of repair. Walsh
et al. (26 ) determined that the tensile properties of the lengthened bone improved and increased with time following the
cessation of distraction. However, they remained significantly weaker (50%) than the controls, even at 12 weeks. Hamdy et al.
(27 ) added that even when 80% to 90% of the cortices regained their continuity, the strength of the lengthened bone was only
50% to 60% that of normal controls. Hence, the importance of initiating a slow gradual return to normal activity. Sferra et al.
(28 ) found that on torsional testing of the lengthened tibia, five out of six bones fractured within the diaphysis but outside the
regenerate area. These findings suggested that the strength of the lengthened segment exceeded that of the original diaphysis,
which was exposed to stress shielding by the external fixator.
Periosteum
In the early years of bone lengthening, the exact role of the periosteum during the reparative process was unclear. It is now
well accepted that preservation of the periosteum is critical to timely and efficient callus production. Most authors agree with
this concept, and convincing evidence has been derived in the laboratory (29 ). In this study, the role of the periosteum and
endosteum were evaluated. A group of 27 rabbits was divided into one of three groups: (a) The periosteum was sutured
following osteotomy and the bone ends were repositioned; (b) the periosteum was removed from the segments around the
osteotomy and no attempt at repairing it was made; (c) the endosteum was scraped out from the bone ends on each side of the
osteotomy, and the periosteum was sutured. The most successful group consisted of those who had the endosteum maintained
and the periosteum repaired. When the periosteum was removed, callus formation was greatly disturbed and there was failure
of bone healing. In contrast, scraping of the endosteum had little effect on the healing process. Clinically, this would allow the
surgeon to execute the osteotomy, recognizing that violating the endosteum would not result in a delayed healing so long as the
periosteum is repaired.
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FIG. 5. Histologic changes seen in callus distraction.
FIG. 6. A,B: Radiolucent callus eventually is replaced with mineralized bone, ablating the distraction zone.
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Soft Tissue Lengthening

The vast majority of attention surrounding the science of callus distraction is dedicated to the cellular and physiologic changes
occurring in the bone and the distraction zone. Although this knowledge is important to understanding the science of the
procedure, the effects of the peripheral soft tissues cannot be overlooked. In order for this technique to be successful, the
muscles, ligaments, and neurovascular structures must be able to accommodate the amount and rate of lengthening. There is
considerable research being performed on these particular structures. Several studies have already shown that muscle and nerve
will respond to a slow gradual distraction process (30 ,31 ). The smaller and more frequent distracting sequence, suggested
earlier for bone, also appears to be optimal for soft tissues. However, excessive amounts of sudden lengthening (2 mm) can lead
to permanent damage to the muscles and other soft tissues (30 ). This may result in muscle weakness and imbalance, as well as
neurovascular damage and prolonged edematous changes. Although more work needs to be done in this particular area, a good
rule of thumb is to use the same distraction parameters for soft tissues that are suggested for bone.
Understanding the physiology behind callus distraction can be summarized by reviewing Ilizarov's law of tension-stress (32 ). The
law states that living tissue, when it is subject to slow steady distraction, can become metabolically activated in both the
biosynthetic and proliferative pathways. This theory has been tested and confirmed more recently by several other surgeons (33 ,
34 , 35 , 36 , 37 , 38 ).
PARAMETERS OF DISTRACTION
Once the concepts of callus distraction were understood at the histologic level, the next stage was to choose a set of distraction
parameters that would provide for the quickest and most efficient means of bone consolidation. Important parameters to
consider included osteotomy versus corticotomy, level of osteotomy, latency period, amount and rate of distraction, and the
ossification period.
Osteotomy versus Corticotomy

There is still some debate over whether there is any benefit to performing a corticotomy as opposed to a complete osteotomy. A
corticotomy refers to a technique in which sequential drill holes are placed circumferentially around the bone and are
eventually connected by an osteotome or scalpel. The potential benefits include preservation of the endosteum with perhaps a
more timely consolidation period. However, the benefit of preserving the endosteum has been found to be of little clinical
significance (29 ). In addition, performing a corticotomy alone is at times technically difficult owing to the juxtaposition of
other anatomic structures that may prevent full access to the bone. Obviously, preservation of the endosteum might be optimal
if it is anatomically feasible and if this can be accomplished with minimal disruption to the surrounding soft tissues.
Level of Osteotomy
One of the most important decisions relative to callus distraction is the determination of the proper level in which to perform
the osteotomy. Potential sites may include the proximal metaphysis, diaphysis, distal metaphysis, and the growth plate, if it is
still present. Considerations when making this decision include the level of deformity, the amount of length and angulation
needed for correction, the size and the extent of the vasculature in the area, the amount of soft tissue coverage in the vicinity,
and the technical ease with which the osteotomy can be performed, and the available access for accurate insertion of the
fixation pins.
Diaphyseal Osteotomies
Much of the early literature identifies the diaphysis as the location of choice for placement of the osteotomy (4 , 5 , 6 ,9 ).
Although metaphyseal lengthening is becoming increasingly popular, diaphyseal osteotomy is still recommended and performed
by many surgeons (39 , 40 , 41 ). This area typically allows for easier access, and surgery is often less demanding. The osteotomy
site is usually well defined, and accurate pin placement is easier. Diaphyseal locations also offer easier manipulation of the
periosteum. A periosteal sleeve can be created and resutured following osteotomy. This is more difficult to accomplish in
metaphyseal bone.
However, there are differing opinions regarding diaphyseal osteotomies. The bone is this area is relatively less active
metabolically when compared with the rich cancellous bone found in the metaphysis. This cancellous network combined with
the increased soft tissues around the metaphysis should allow for faster, more homogeneous osteogenesis. Additionally, the
mechanical strength of a structure varies with the
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square of its diameter when subjected to bending loads. This means that at any given stage of lengthening, if the diameter of
the metaphysis is twice that of the diaphysis, then the strength is greater by a factor of four (41 ). Therefore, a wider segment
of bone will tend to be more stable throughout the lengthening process, and should lead to a stronger end result (Fig. 7 ).
FIG. 7. A: Ten-week postdiaphyseal lengthening. B: Nine-week postmetaphyseal lengthening with an obvious improvement
in callus consolidation.
Metaphyseal Osteotomies
Despite the fact that callus distraction has worked well when the osteotomy is performed in the diaphysis, most surgeons prefer
to perform the osteotomy in the proximal metaphysis (36 , 37 , 38 ,41 , 42 , 43 , 44 , 45 ). As suggested previously, performing
the osteotomy in the metaphyseal area of bone may have certain advantages, one of which is a greater surface area for
distraction. The increase in stability and strength afforded by the larger diameter of bone at the level of distraction helps
balance some of the osteopenic changes that result from disuse during the lengthening period. This becomes important when
weight bearing is initiated or when the concept of dynamization is desired. Dynamization is a concept based on the assumption
that longitudinal compression stimulates bone formation in long bones. In practical terms, this means that the surgeon allows
some degree of well-controlled weight bearing to be applied to the bone before final consolidation. This can be provided by
deliberately loosening of the frame, or it can be a characteristic of the frame itself, such as in the Ilizarov device.
Other potential advantages of performing the surgery in the metaphysis of the bone include an increased vascularity and
osteogenic potential specific to this area, and a greater amount of soft tissue coverage, which not only increases the available
circulation but also enhances the stability of the proximal segment via ligamentous and muscular attachments. However, it is
more difficult to manipulate the bone and periosteum at the metaphysis, and occasionally, placement of the fixation pins can
be more difficult.
Epiphysis
Callus distraction can also be performed in the area of the growth plate and the epiphysis. De Pablos et al. (46 ) demonstrated
that the survival of the growth plate was directly depended on the rate of distraction. Based on his animal experiments, two
distinct forms of physeal distraction were noted: (a) epiphysiolysis and (b) chondrodiastasis. The term epiphysiolysis was first
coined by Zazjyalov and Plaskin (47 ), and the process was later studied by others (48 ). Histologically, it was shown that with a
fast rate of distraction, the physeal plate would fracture at the hypertrophic zone with the fracture gap filling with hematoma
produced from the periosteal sleeve and metaphyseal bone. This led to membranous osteogenesis, resulting in bridges forming
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between the physeal plate and the metaphyseal bone. Eventually, the entire growth plate was replaced by trabecular bone.
Chondrodiastasis is a slower type of distraction that produces more controlled and symmetric results (49 ). Although the exact
histologic changes that take place in this modification are not entirely agreed on, most authorities concur that the osteogenesis
is created through endochondral mechanisms (46 ,50 , 51 , 52 , 53 , 54 ). In essence, this represents an accelerated reaction of
the growth plate. The viability of the physeal plate is maintained with this technique.
Chondrodiastasis has been used to treat patients with hypochondroplasia and achondroplasia. The physical, emotional, and
social problems these individuals face make them good candidates for lengthening of the extremity. The debate lies in the
selection of the appropriate site for osteotomy or lengthening, or both. Because Ring's (55 ) report over 30 years ago, several
other surgeons have compared the benefits of lengthening through the growth plate versus other methods, including callus
distraction (36 ,38 ,49 ,56 ). The general consensus appears to be that lengthening through the physeal plates of the femur
offers an excellent alternative for those individuals nearing the end of their growth. However, the potential complication of
premature closure of the growth plate increases the risks when used earlier in childhood. These same studies have also shown
that distraction of the tibial plate has a much higher incidence of complications and is no longer recommended. Despite its
potential use in treating a congenital brachymetatarsia, chondrodiastasis has yet to be reported in the bones of the foot.
Latency Period
The latency period refers to that interval of time between the execution of the osteotomy and the initiation of distraction.
There has been rather constant debate over the best time to begin the actual distraction process (35 ,36 ,57 ,58 ).
Recommendations have ranged from immediately to 3 to 4 weeks after osteotomy. Immediate distraction at the time of
osteotomy can result in increased fibrin deposition and decreased bone formation. With these thoughts in mind, some latency is
best employed to allow for an increased vascularity and potential for bone formation. However, not all bones behave alike. In
the clinical portion of this chapter, the parameters that are used for the short and long bones of the foot are contrasted.
Factors that need to be considered when determining the optimal latency period include age and health of the patient, smoking
history, the type of bone being lengthened, area of osteotomy, amount of peripheral soft tissue disruption, and the
intraoperative stability of the osteotomy and fixation. Younger patients possess an increased periosteal activity, and therefore,
improved osteogenesis and faster consolidation rates. The overall health of the patient also plays a role in the efficiency of bone
formation. Patients afflicted with any type of vascular disease (arterial, venous, lymphatic) are at greater risk of experiencing
longer consolidation periods and increased complication rates, such as prolonged and excessive edema. The metabolic and
nutritional status of the patient also play an important role in callus distraction surgery. Lumpkin et al. (59 ) demonstrated that
the added nutritional support dramatically increased the amount of mineralized bone formed during distraction. Although this
study was performed in rat models, a clinical correlation in humans may be extrapolated.
The effects of cigarette smoking on the bone remodeling process have also been studied (60 ). Histologic findings in rabbits
undergoing callus distraction of the tibia revealed that the granulation tissue resorption, bone formation, and remodeling were
delayed in the smoke inhalation group. Therefore, intermittent smoke inhalation delays, but does not prevent, bone formation.
Hence, this may be an important consideration when determining the optimal latency period in patients who smoke.
The site of the osteotomy (e.g., metaphyseal versus diaphyseal) may also influence the latency period. The intraoperative
stability achieved following osteotomy and pin placement is another concern. If significant disruption and manipulation of the
bone fragments occurred during the procedure, or if the osteotomy gap cannot be fully compressed upon placement of the
fixation frame, then a greater latency period should be considered. There are no defined parameters available for when this
scenario occurs. However, a 1-week extension beyond what was originally planned for the procedure has worked well in the
author's hands.
In summary, the optimal latency period appears to be anywhere from 4 to 5 days to 2 weeks postoperatively, depending on the
previously discussed considerations. This time interval can be compared with that of normal fracture repair, in which bone
formation begins at 4 to 12 days after injury following completion of the inflammatory phase. DeBastiani suggests delaying
distraction until callus formation becomes evident radiographically (33 ). However, when working in metaphyseal bone and in
cases in which excellent compression of the fragments occurred intraoperatively, mineralized callus formation can be hard to
appreciate radiographically (Fig. 8 ). In these cases, prolonging the latency period may result in premature consolidation at the
osteotomy site.
Rate and Frequency of Distraction

The rate of distraction has also been a topic of controversy. The debate centers around the most efficient means of achieving
the maximum amount of correction in the shortest period of time. Some surgeons (61 ,62 ) have suggested that the desired
length be obtained with one large event per day. However, more commonly, smaller and more frequent intervals are
recommended (36 , 37 , 38 ,43 , 44 , 45 ,49 ,57 ,63 ,64 ). This slower rate has been shown to favor a more gradual relaxation of
the surrounding soft tissues, more stable neovascularization, and more efficient osteogenesis.
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FIG. 8. Immediate postoperative appearance following osteotomy and application of an external frame. At this stage, the
osteotomy is difficult to visualize, demonstrating excellent compression of fragments. Fracture callus at the surgical site is
difficult to appreciate before initiating distraction.
Ilizarov (63 ) compared six different distraction rates and frequencies using an autodistractor. The best results occurred in the
group with lengthening proceeding at a rate of 0.0170 mm/24 minutes (60 times per day) for a total of 1 mm of length a day.
When the distraction was slowed to 0.0085 mm/24 minutes, for a total of 0.5 mm of length a day, premature consolidation
occurred. At present, autodistractors are not readily available to most surgeons. However, until these devices are available, the
next best rate and frequency of distraction was found to be 0.25 mm every 6 hours (1 mm total length per day). This sequence is
easily executed with the external fixators available. Some of the poorest results in this study occurred in the group in which
lengthening progressed at 1 mm/day in one stage.
The slower, more gradual lengthening process suggested by Ilizarov continues to be the most popular approach. Modifications
should be made as the clinical scenario demands. For example, the smaller long bones of the foot may benefit from a slightly
slower rate and frequency of distraction to achieve the optimum consolidation time. As mentioned earlier, the medical and
physical condition of the patient may also necessitate that the surgeon modify the parameters. Although tremendous strides
have been made in the science of callus distraction, these parameters are not absolute and the recommendations can only be
used as guidelines.
Ossification Period
Once the desired length is obtained, distraction is ceased. The external fixator should be left in place until osseous
consolidation is advanced and confirmed radiographically. This interval is referred to as the ossification period. If the
lengthening has been performed in the tibial or femoral segment and there are plans to induce dynamization, an additional 0.5
mm of length is recommended during the distraction period to offset some of the compressive effects of weight bearing (35 ).
Remember, dynamization is based on the theory that longitudinal compression stimulates bone formation. Obviously, this will
only be of assistance when the compression forces are in line with the plane of lengthening. In the foot, most surgeries involving
callus distraction are performed in a plane that is perpendicular to the weight-bearing forces so that one can rarely take
advantage of dynamization.
Several factors affect the duration of the ossification period. These factors include the age and general health of the patient,
the type of procedure, level of osteotomy, latency period, rate and frequency of distraction, amount of correction, and smoking
history. A general rule of thumb used to estimate the duration of the ossification period is to compare it in a 1:1 ratio with the
time required to perform the actual distraction. For example, if it took 3 weeks to obtain the desired length, then the patient
should be prepared for at least an additional 3 weeks of non-weight bearing.
Until consolidation has reached a suitable level, the patient is usually maintained with non-weight bearing. However, the
strength of the newer external frames and the traditional Ilizarov frame normally resists weight-bearing forces if maintenance
of function is a top priority and concern. This is often the case when large femoral and tibial lengthenings are performed and
loss of knee extension and possible posterior subluxation of the tibia are potential complications (41 ). This early controlled
weight bearing is advocated by Wagner, Ilizarov, and DeBastiani (33 ,61 ,63 ). Physical therapy may also play a role in
maintaining function during the entire postoperative period. As mentioned earlier, Ilizarov (41 ) went as far as to advocate full
weight bearing and prescribed participation in a calisthenics program.
Owing to the potential destructive effects of weight bearing with this type of procedure in the foot, non-weight bearing is
employed until suitable consolidation occurs. When weight bearing is initiated, the fixator is generally left in place. A gradual
disassembly of the frame allows the bone to adapt and strengthen slowly to the forces of weight bearing.
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Periodic x-ray studies should be taken to ensure maintenance of the alignment.
Lengthening Devices (External Frames)

Generally speaking, there are two types of external fixators used for callus distraction surgery: (a) ring fixators and (b)
unilateral frames. Both types have telescoping units that allow for gradual distraction. Although a complete discussion on
external fixators is not presented here, several important elements are reviewed.
Ring Fixators
Although the first ring fixator was reported by Hempel in 1929 (41 ), it is Ilizarov who has contributed the most extensive body
of work regarding ring frames (65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 ). These devices are complex and at first can be somewhat
time consuming to construct. However, like most surgical techniques, once the learning curve has been overcome, performance
becomes quite efficient. The benefits of being able to fix multiple segments of bone, correct multiple planes and levels of
deformity, and resist the compressive forces of weight bearing may outweigh any frustration experienced by the patient or the
physician resulting from the cumbersome nature of the frame.
The exoskeleton of a ring fixator consists of longitudinal rods and circular ring elements. They are generally connected over
universal joints that allow for gradual and multiplanar adjustments. Bone fragments are fixed and suspended by transfixation
wires placed under tension. At least two wires are used at each level of fixation. When placing the wires across the extremity,
care must be taken to minimize accidental injury to the soft tissues and neurovascular structures (Figs. 9 and 10 ).
FIG. 9. An example of a ring external fixator. Note the circular ring elements with longitudinal rods, which allow for
multiplane correction.
FIG. 10. Clinical appearance of the ring external fixator following final construction.
Unilateral Frames
The other popular style of lengthening device is the unilateral frame. DeBastiani (49 ) was the first to popularize this type of
frame, and his device is still being used today (Fig. 11 ). These fixators are usually less bulky and easier to construct and apply.
However, although this device is more simply applied, some of the versatility is lost compared with ring fixators. For instance,
once the device is in place, angulatory adjustments cannot be made. Although the ring fixators have shown a greater degree of
regularity in collagen formation, the clinical significance is questionable (44 ). The unilateral configuration is also susceptible to
slight uneven distraction and possible secondary angular deformity.
Mini-external Fixators
There are also a variety of mini-external fixators that may be used in callus distraction surgery (Fig. 12 ). These devices
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are used in most lengthenings performed in the foot. There are several key elements to consider when choosing a mini-external
fixator. Owing to the size of the bones within the foot, the pin size must be strong enough to accomplish the distraction yet
small enough to prevent stress risers and other osseous complications. Most of the mini-external fixators are uniplanar
lengtheners, with correction occurring perpendicular to the level of osteotomy and pin placement. Another critical factor when
deciding on a particular fixator is the ease with which the patient may use the device. The rightangled wrench that is typically
employed to turn the elements of the frame that provide distraction is easy to use.
FIG. 11. Standard unilateral frame designed for axial lengthening. The telescoping elements provide for gradual
lengthening of the bone.
FIG. 12. A,B: Additional commercially available miniframes.
TABLE 1. Potential complications of bone lengthening in the foot

Loss of joint motion
Subluxation/dislocation
Delayed union or nonunion
Malalignment
Chronic edema
Premature consolidation
Neurovascular compromise
Pin site irritation/infection
Pin loosening
Neuropraxia
Hyperpigmentation and/or hypertrophy of incision
COMPLICATIONS
Although significant improvements and advances have been made over the century, a number of complications can still occur.
Clinical studies show complication rates ranging from 5.6% to 200% (74 ,75 ). These numbers can be very misleading, because
many complications are minor and of little to no clinical significance. Table 1 lists the most common problems noted with callus
distraction.
As with any bone-lengthening technique, the potential for a delayed union or nonunion exists. This can occur from a variety of
reasons, including a too-rapid or aggressive
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lengthening routine (Fig. 13 ). When this factor is noted, lengthening should be stopped immediately and strict immobilization
applied until callus production resumes. Some surgeons have recommended compressing the osteotomy site using the same
parameters that were applied during the distraction period (37 ). Several authors have looked at the potential benefit of using
electrical stimulation to augment bone healing in callus distraction surgery (76 ,77 ). Huang (30 ) concluded that electrical
stimulation applied during the lengthening phase can significantly reduce treatment time and improve healing.
FIG. 13. This patient demonstrates a delayed union of the metatarsal 4 months postoperatively.
Soft tissue contractures and loss of joint motion are also important considerations and must be noted early for successful
correction. Although this is more commonly seen in the larger tibial and femoral lengthenings, it can be seen in the smaller
bones of the foot when large amounts of correction are required (Fig. 14 ). Clinically, distracting less than 10% of the initial
length of the bone rarely results in problems. When soft tissue contractures do occur, the correct etiology must be identified
and addressed. In cases in which transfixation pins are used, the contractures may result from accidental piercing of the
surrounding musculature. This usually responds to postfixation rehabilitation and therapy with no permanent consequences.
Knee extension and flexion deformities have been observed with aggressive femoral lengthenings. Knee extension is more
common, better tolerated, and less likely to result in subluxation (35 ). Knee flexion deformities occur less frequently but are
more often associated with posterior subluxations. Contractures of up to 30 degree are permissible and can usually be alleviated
with an aggressive therapy program (74 ,75 ,78 ).
Ankle plantarflexion contractures have also been noted with tibial elongations. This deformity is usually well tolerated up to 30
degrees and can be minimized by a variety of casting or splinting techniques (18 ,74 ,75 ).
The best prevention against muscle contracture is early ambulation and stretching therapy if it can be instituted safely. If
therapy is unable to restore adequate motion, then tendon lengthening may be necessary.
Angulation deformities and malunions can occur with lengthenings performed at any level. Malunion can result from a variety of
causes, including inaccurate osteotomy design, poor pin placement, and loosening of fixation or other factors that may be
beyond the surgeon's control (Fig. 15 ). If they are severe, these deformities may require a second procedure to restore a more
appropriate alignment.
Premature consolidation may occur and result in an ineffective correction or possibly angular deformity. This problem can
happen secondary to an above-average rate of healing, inappropriate choice of lengthening parameters for the respective bone,
or patient noncompliance. When it is noted, the lengthening sequence should be altered to include a greater rate and frequency
of distraction. If this maneuver is unsuccessful and correction is still needed, then a second osteotomy may be required.
FIG. 14. Metatarsalphalangeal joint subluxation and interphalangeal dislocation following an aggressive lengthening
sequence in this patient.
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FIG. 15. A: Severe sagittal plane malalignment of the second metatarsal following callus distraction. B: Metatarsal
lengthening with an accompanying unintended transverse plane movement.
Neurovascular compromise is another concern with callotasis. The most common clinical manifestations include neuropraxia and
chronic edema. In many instances, the neuropraxia is stretch related and is only temporary. However, if the nerve injury has
resulted from accidental puncture, the damage may be long lasting. The lymphatic channels can also be damaged from
excessive stretching and occasionally produce a resistant edematous process.
Although full-blown sepsis is uncommon, pin tract infection or irritation can be seen frequently with callus distraction surgery.
Topical antibiotics applied at the skin-pin interface in conjunction with a short course of oral antibiotics normally control the
process with little difficulty. If severe infection is present, intravenous antibiotics may be used or the pin may need to be
removed and the wound managed more aggressively.
CLINICAL INDICATIONS
The use of callus distraction techniques in the lower extremity is constantly growing. The various indications that are discussed
are by no means all inclusive but do detail a number of different types of procedures in which this form of surgery has worked
successfully. It is anticipated that further indications will evolve over time. Owing to the increased versatility of the frame and
its subsequent expanded indication list, the Ilizarov technique deserves separate mention and is discussed in Chapter 4 .
Callus Distraction—Standard Technique
Brachymetatarsia
Congenitally Shortened Metatarsals

Congenital shortness of the metatarsal bone represents one of the best and most useful indications for callus distraction in the
foot. This technique is especially effective considering the soft tissue contractures that coexist with the deformity. In the past,
correction of this condition was attempted through interpositional bone grafting or other methods. In cases in which fairly
significant correction is required, neurovascular compromise is a great concern when a one-stage lengthening procedure is
performed owing to the abrupt stretch that is placed on the vessels. Furthermore, the soft tissues will limit the total amount of
lengthening that may be achieved in a single stage procedure so that residual shortening may persist. The use of callus
distraction has all but eliminated these problems.
Callus distraction has been described by a number of authors for the repair of brachymetatarsia (40 ,45 ,64 ,78 , 79 , 80 , 81 ,
82 , 83 , 84 ). The common denominator in each setting has been the successful lengthening of the metatarsal with minimal
complications. However, the methods and parameters employed in
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the actual distraction process have varied, most notably, the level of the osteotomy, time of initiation of distraction, and the
rate and frequency of distraction. Distraction has been initiated as early as 1 week following surgery (64 ) or delayed as long as
3 weeks (40 ). Distraction rates have varied between 0.25 mm every 12 hours (40 ) to 0.25 mm every 6 hours (64 ). The
guidelines discussed subsequently are believed to provide predictable results with an efficient ossification process.
Iatrogenically Shortened Metatarsals

Metatarsal bones may also become shortened owing to surgical complications as a result of metatarsal osteotomies or resection
of the metatarsal head. Shortening may also be seen in patients following fracture. In either event, pain may be experienced in
the other metatarsal rays as a consequence. In the past, a short metatarsal may have been addressed with a lengthening
osteotomy, a bone graft of one form or another, or by a pan metatarsal head resection. Callus distraction is a good means of
achieving improved metatarsal alignment in these circumstances as well. If the metatarsal head has been previously resected,
then a number of options may be available once the appropriate length of the ray is achieved. At times, the pseudarthrosis at
the metatarsophalangeal joint may be asymptomatic and stable. In this circumstance, no further measures may be required. In
cases in which symptoms or significant deformity persists, options such as joint arthroplasty, with or without an implant, or joint
fusion may be entertained.
FIG. 16. A: Preoperative iatrogenic brachymetatarsia following resection of the third metatarsal head. B: Following callus
distraction to restore a more normal weight-bearing length.
In patients with loss of the metatarsal head, calculation of the optimal length may be difficult owing to the loss of the
metatarsal condyles. Therefore, one may choose to lengthen the bone more than the actual plane of the normal metatarsal
parabola. Another option would be to plantarflex the bone as it is lengthened to help offset the loss of the metatarsal head. The
soft tissues in this type of case are not congenitally shortened, but significant resistance to distraction may be encountered in
some patients owing to localized scarring. Although the deformity is generally distal in the metatarsal segment, the correction is
usually performed at the metaphyseal base (Fig. 16 ).
Surgical Approach
The procedure is initiated via a dorsal-linear incision over the metatarsal base and cuboid or cuneiforms. There is no need to
lengthen the extensor digitorum brevis or longus tendons. With most brachymetatarsia deformities, the joint is not contracted
and does not require surgical reduction. An accurate incision through the deep fascia allows for easy retraction of the tendons
to one side. The periosteum may be incised and an envelope created around the bone. Alternatively, the periosteum may be left
intact and the osteotomy performed through this layer. The decision may vary depending on the location of the osteotomy. If
the osteotomy is
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placed in the diaphysis or just proximal, then an envelope can be created that can be resutured following pin placement. If the
osteotomy is placed in the most proximal portion of the metaphyseal base where the periosteum is tightly adhered, then this
layer may be left intact as the bone is sectioned. This approach may create less trauma to the periosteum and enhance bone
healing and consolidation time.
The procedure is facilitated by inserting the pins before performing the osteotomy. The process starts by determining the most
distal aspect of the ray for pin placement. This distal pin is then inserted and the frame applied in the desired position and
alignment over the ray. Then, using the frame itself as a guide, each of the remaining pins are inserted with attempts made to
maintain each pin parallel. In some instances, the most proximal and distal pins may be inserted percutaneously, or at least
without incising the periosteum. If the pins are inserted after osteotomy, the bone fragments are mobile and unstable, making
accurate insertion difficult.
The osteotomy can be executed with osteotome or saw, depending on the surgeon's preference. Once the osteotomy has been
completed, anatomic wound closure should be performed before placement of the external frame. This will make wound closure
much easier and less awkward than if the frame is positioned before closure.
Postoperative Care
Postoperatively, the patient is maintained non-weight bearing, with no manipulation of the frame for 1 to 2 weeks depending on
the initiation of distraction. If the osteotomy was placed in the metaphyseal base, then distraction may begin at 7 to 10 days
following surgery. If the location of osteotomy was in the diaphysis, then a full 2 weeks delay may be preferable before
lengthening is initiated. There is no universal agreement on the rate of distraction for lesser metatarsals. However, the
following recommendations may be of benefit. It is assumed that most mini-external frames allow approximately 1 mm of length
per full revolution of turning. Performing one eighth of a turn every 4 to 5 hours will result in just over a 0.5 mm of distraction a
day. This sequence leads to a quick and efficient remodeling process. However, distraction intervals of one quarter of a turn are
usually easier for the patient to perform and appreciate, and has been used successfully as well. The interval may vary between
two to four times per day. If distraction becomes difficult to perform, then premature consolidation may be occurring and the
parameters will need to be adjusted. Radiographically visible callus may not be present for a period of 2 weeks. If this fact is
not appreciated, the large radiolucent space that is created during this time can be disconcerting and cause the surgeon great
concern. However, the lengthening process should be continued until the desired length is obtained.
Once the desired length is obtained, distraction is ceased and immobilization of the foot continues until mineralization is
complete. Once radiographic evidence of healing is seen along the entire distraction gap, careful weight bearing may be
initiated. The author's choice is to begin this process with the frame in place to lend a little more support against the potentially
destructive effects of weight bearing (Fig. 17 ).
Evans' Calcaneal Osteotomy—Distraction Technique

The techniques of callus distraction have also been applied as an alternative to the traditional Evans osteotomy with allogenic
bone graft. Using distraction osteogenesis for this procedure may offer some advantages. Potentially, a greater degree of
correction can be achieved with the gradual lengthening process as opposed to the abrupt change in length with the graft
material. Lengthening may also be adjusted to provide a fairly specific degree of correction. One may also note a faster
consolidation time as opposed to graft material.
The author has employed this approach in both children and adults. General observation has shown no significant differences as
long as the correct parameters are used. The guidelines for the rate of lengthening are identical to those mentioned before.
However, because the calcaneus is more of a cancellous bone structure and, therefore, is quicker to consolidate the osteotomy,
the latency period before initiating distraction is reduced to 5 to 7 days after osteotomy (Fig. 18 ).
FIG. 17. A: Ten days after initiation of distraction for a congenital brachymetatarsia. B: Note the radiographic callus on
each end of the distraction zone 4 weeks later. C: Eight weeks after distraction. Note the slight overlengthening to
accommodate a coexisting brachydactyly. D: Eighteen weeks after distraction was initiated, demonstrating complete
consolidation. E: Preoperative appearance of the foot. F: Clinical appearance 18 months postoperatively. G: Radiographic
appearance 18 months following surgery.
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FIG. 17. Continued.

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FIG. 18. A: Anteroposterior radiograph of a patient with symptomatic collapsed pes valgus deformity demonstrating
subluxation at the subtalar and midtarsal joints. B: The lateral view demonstrates severe collapse of the medial arch and
forefoot supinatus. C: Five days following an Evans osteotomy and before distraction. D: 4½ weeks postoperatively (3½
weeks distraction). E: Lateral radiograph at 4½ weeks reveals complete restoration of the medial arch following surgical
reconstruction. F: 7½ weeks after surgery (6½ weeks after distraction) showing an efficient consolidation process already
occurring at the distraction zone. G: Complete consolidation noted at 11 weeks. H: Seven-month weight-bearing
radiograph with excellent maintenance of correction.
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FIG. 18. Continued.
Medial Column Osteotomies

The traditional surgical repair for metatarsus adductus deformity consists of multiple metatarsal osteotomies. These procedures
are often challenging. An alternative surgical approach is to perform a closing wedge osteotomy at the cuboid and an opening
wedge osteotomy at the medial cuneiform. Historically, the bone graft that has been employed in the medial opening wedge
procedure was removed from the closing wedge osteotomy laterally, or allogenic bone. However, the medial cuneiform
lengthening procedure can also be addressed with callus distraction techniques. The medial incision is placed along the
dorsomedial aspect of the metatarsal-cuneiform-navicular joints. The pins were placed proximal and distal to the proposed
osteotomy site before its execution. The medial osteotomy is performed through the medial and intermediate cuneiforms. This
may an allow for a more complete or specific reduction of the deformity as opposed to cutting the medial cuneiform alone. The
osteotomy may be angled so as to afford abduction and slight medial column plantarflexion as it lengthened (Fig. 19 ).
Opening plantarflexory osteotomies to reduce sagittal plane anomalies associated with pes valgus deformity may also be
addressed with callus distraction as opposed to bone grafting. The osteotomy may be angled to allow for medial column
lengthening and plantarflexion simultaneous with the distraction process. The parameters for distraction in these types of
procedures are the same as those employed in patients with brachymetatarsia deformity.
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FIG. 19. A: Clinical appearance of a patient with uncompensated metatarsus adductus. B: Preoperative radiograph with an
abnormal talar-first metatarsal angle. C: Postoperative radiograph before D: Four weeks after surgery (3 weeks after
distraction). E: Six weeks after surgery, with minimal callus noted in the distraction zone. F: One year after surgery,
demonstrating excellent correction with absence of any degenerative joint changes at the cuneiform level.
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FIG. 19. Continued.
CONCLUSION
Callus distraction has been used in attempts to correct deformities in the lower extremity since the early part of the 20th
century. However, it has only been in the more modern era that this approach has evolved into a viable alternative to bone
grafting. As the parameters of distraction have become more accurately identified for the various bones of the foot and lower
extremity, the clinical indications have been expanded. Although some complications still exist with these techniques, they
have been significantly reduced as the technology of external fixators has improved. The greatest advantages of callus
distraction over traditional bone lengthening include an unlimited amount of corrective ability and the avoidance of the
potential complications associated with the bone graft itself.
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Subject Index
A sequential release of plantar lateral contracture in,
Abductor digiti minimi, 103, 104, 104f 232
Abductor hallucis muscle tenotomy of lateral head of flexor hallucis brevis
hallux varus and, 397 tendon in, 234, 235f
release in metatarsus adductus deformity, 460, 461, 461f, incision in, 230
462f, 463f in juvenile hallux abducto valgus deformity, 350
Abductor tendon release, 338, 339 medial capsulotomy in, 236, 236f
Abnormal Lisfranc articular set angle, 469, 470, 471, 472, medial eminence resection in, 237
473, 474, 472f, 473f muscle-tendon balancing and soft tissue procedures in,
Absorbable screw in Akin procedure, 382, 383f 237, 238, 238f
Achondroplasia, 582 perioperative anesthesia in, 230
Acquired digital fibrokeratoma, 8, 8f principles of, 229, 230
Acumed Great Toe System, 184, 185, 185f subcutaneous dissection in, 230, 231, 231f
Adductor tendon Ancillary procedures in arthrodesis of first
release of, 232 metatarsophalangeal joint, 337, 338, 339, 340, 338f, 339f
transfer in hallux valgus surgery, 237 Anesthesia
Adolescent bunion, 345, 346, 347, 348, 349, 350, 351, 352, in anatomic dissection of first metatarsophalangeal joint,
353, 354, 355, 356, 357 230
associated deformities, 348, 349 injection in Morton's neuroma, 37, 38
clinical features of, 346, 347 in nail surgery, 14, 15, 16, 15f, 16f
conservative management of, 349 Ankle ligaments, subtalar dislocation and, 527
distal osteotomies for, 350, 351 Ankylosis with double-stem hinged implant, 205f, 205, 206
epiphysiodesis for, 352, 353, 353f, 354f, 355f, 356f Anonychia, 3
metatarsocuneiform joint arthrodesis and cuneiform Anterior subtalar dislocation, 531
osteotomy for, 351, 352 Antiinflammatory medications, 72
phalangeal osteotomies for, 356 Apert syndrome, 479, 480
proximal osteotomies for, 351, 351f, 352f ARM method of physical examination, 453f, 453, 454
radiographic evaluation of, 347f, 347, 348 Arthritis
soft tissue procedures for, 350 after tarsometatarsal joint dislocation, 546
Akin osteotomy, 375, 376, 377, 378, 379, 380, 381, 382, 383 contraindication to fusion of metatarsophalangeal joint,
complications of, 383, 384f 323
dissection in, 375, 376, 377, 376f hallux limitus and hallux rigidus and, 418, 419, 419f
distal, 377, 378, 378f Arthrodesis
fixation in, 380, 381, 382, 381f, 382f, 383f first metatarsocuneiform, 280, 281, 282, 283, 284, 285, 286,
in hallux abductus interphalangeus, 506 287, 288
in juvenile hallux abducto valgus deformity, 356 bone grafting in, 282, 283
modifications of, 378, 379, 380, 380f complications of, 287, 288, 288f
postoperative management in, 383 fixation in, 283, 284, 285, 284f, 285f, 286f
proximal, 377, 377f indications for, 280, 281, 282
Alcohol solution for Morton's neuroma, 38 modifications of, 283
Alignment abnormalities after implant, 200 postoperative management of, 285
Ambulation results of, 285, 286, 287, 287f
after first metatarsophalangeal joint dislocation, 551 first metatarsophalangeal joint, 317, 318, 319, 320, 321, 322,
after joint implantation, 194 323, 324, 325, 326, 327, 328, 329, 330, 331, 332, 333, 334,
after subtalar dislocation, 533 335, 336, 337, 338, 339, 340, 341, 342, 343, 318t, 319t
Amputation ancillary procedures in, 337, 338, 339, 340, 338f, 339f
for correction of overlapping fifth toe, 496 clinical evaluation of, 319
in fifth digit deformities, 118, 119 complications of, 340f, 340, 341, 342, 341f
in Lisfranc's joint dislocation, 540 contraindications for, 323, 324
for macrodactyly, 489 external fixation in, 337, 337f
in zone III injury of toe, 523 for hallux limitus, 444
Anastomosis in syndactyly, 79, 80f indications for, 320f, 320, 321, 322, 323, 321t, 322f
Anatomic dissection of first metatarsophalangeal joint, 229, joint resection in, 325, 326, 327, 326f, 328f
230, 231, 232, 233, 234, 235, 236, 237, 238, 239, 240 pin or wire fixation in, 330f, 330, 331, 332, 331f
capsular considerations in, 237, 237f plate fixation in, 333, 334, 335, 333f, 334f, 335f, 336f
first interspace dissection in, 232, 233, 234, 235, 236 position of fusion in, 327, 328, 329, 329f
lateral collateral ligament of first postoperative care in, 340
metatarsophalangeal joint and, 236 screw fixation in, 332f, 332, 333, 333f
release of adductor tendon in, 232, 233f skin incision and exposure in, 324, 325
release of fibular sesamoidal ligament in, 233, 234, in hallux varus deformity with concomitant hallux malleus,
233f, 234f, 235f 401f, 402
removal of fibular sesamoid in, 234, 235
P.598
interphalangeal joint long plantar arm modification of, 245
of hallux, 384, 385, 386, 385f, 386f proximal chevron osteotomy versus, 275
with Kirschner wire fixation, 82, 83, 83f results of, 244
proximal, 95 Scarf procedure verses, 299, 305
using internal pins, 85, 86, 86f Youngswick modification of, 245, 246, 247, 247f
Lapidus, 436, 437 Autodistractor, 583
in lateral force midtarsal injuries, 535 Avascular necrosis
of Lisfranc's joint, 546 after distal metaphyseal osteotomy, 258, 259
peg-in-hole, 83, 84, 85, 84f subtalar dislocation and, 532
in swivel dislocation midtarsal joint, 535, 536f Avulsion
Arthropathies, lesser metatarsal pain in, 122 of nail, 1, 2, 3, 3f
Arthroplasty, 171, 172, 173, 174, 175, 176, 177, 178, 179, of nail bed, 516, 517, 518, 519, 520, 521, 522, 523,
180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 516f, 517f, 518f, 519f, 520f, 521f, 522f, 523f
191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 201, Avulsion fracture
202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, of bifurcate ligament, 537, 538f
213, 214, 215 calcaneocuboid joint, 533, 533f
adjacent bone abnormalities after, 200, 201, 202, 201f Lisfranc's ligament and, 542
after first metatarsophalangeal joint dislocation, 551 Axis guide
alignment abnormalities after, 200 in base wedge osteotomy, 270
biomaterial failure in, 198, 199, 200, 199f in distal metaphyseal osteotomy, 241, 242, 243, 241f,
biomaterials for, 172, 173, 174, 175, 173t 242f, 243f
biomechanical joint failure in, 202 in Scarf osteotomy, 300, 301f
bone resection in, 192, 193f
canal preparation for, 192 B
capsular repair in, 193, 194
capsulotomy in, 191, 192 Bacterial infection
closure and postoperative course in, 194 after phenol matrixectomy, 25
design and function of implant, 175, 176, 177, 178, in joint implant, 202
179, 180, 181, 177f, 178f, 179f, 180f, 181f of toenail, 7, 7f, 7t, 8f
evolution of, 171, 172 Balance padding
in fifth digit deformities, 109, 110, 110f, 111f for Morton's neuroma, 37
complications of, 114, 115 for transverse plane digital deformity, 157, 158f
with hemiphalangectomy, 110, 111, 112, 111f, Basal cell carcinoma of toenail, 9
112f, 113f Base wedge osteotomy, 265, 266
host response to, 188, 189, 190, 191 Basilar osteotomy, 124, 124f
metals and, 188, 189f Beau's line, 512, 512f
polyethylene and, 188 Bedroom fracture, 559
polymers and, 188 Benign bone cyst, 9
polymethylmethacrylate and, 189 Benign tumor of nail, 8f, 8t, 8, 9, 9f
silicone rubber and, 189, 190, 191, 190f, 198, 199, Berman-Gartland procedure, 467, 467f
199f Bicorrectional bunionectomy, 247
implant grommets and, 192, 193 Bio-Action Great Toe Implant, 182, 183f
indications for, 191, 191f Biocompatibility of internal implant, 188
insertion of implant, 193 Biomaterials for implant, 172, 173, 174, 175, 173t
Keller, 363, 364, 365, 366, 367, 368, 369, 370, 371, failure of, 198, 199, 200, 199f
372 Biomechanics
complications of, 372 of central rays, 96f, 96, 97, 98, 97f, 121f, 121, 122,
contraindications for, 371, 372 122f
dissection in, 366, 367f of hallux abducto valgus, 220
flexor tendon and capsular reattachment in, 366, of intermediate digit and metatarsophalangeal joint
367, 368, 369, 370, 371, 368f, 369f, 370f deformities, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60
indications for, 363, 364, 365f extensor digitorum brevis and longus function and,
modifications of, 371, 371f, 372f 51f, 52f, 53f, 51, 52, 53, 54
osseous resection in, 366 flexor digitorum brevis and longus function and,
results in, 364, 365, 366 54f, 55f, 56f
of proximal interphalangeal joint, 80, 81, 82, 81f lumbricales function and, 57, 58, 59, 60, 59f
radiology in, 194f, 195f, 196f, 197f, 194, 195, 196, plantar interossei function and, 54, 55, 56, 57, 56f,
197, 198 57f, 58f
results of, 210, 211 quadratus plantae muscle function and, 60, 60f
revision of, 204, 205, 206, 207, 208, 209, 210 joint failure in implant arthroplasty and, 202
failed interpositional implant and, 204, 205, 206, of Morton's neuroma, 36, 37, 37t
204f, 205f, 206f of toenail abnormalities, 9, 10, 10f
failed total joint system and, 206, 207, 208, 209, Biomet Total Toe system, 181, 182f
210, 208f, 209f, 210f Biopsy of toenail, 11, 12, 12f
soft tissue abnormalities after, 202, 203f Bipartite sesamoids, 566, 566f
surgical approach in, 191 Blauth and Borisch classification for cleft foot deformity,
for tailor's bunion, 143, 144, 144f, 145f 491
total joint replacement and, 181, 182, 183, 184, 185, Blood supply
186, 187, 188 of hallux, 1, 2f
Acumed Great Toe System in, 184, 185, 185f of sesamoids, 566, 567, 567f
Bio-Action Great Toe Implant in, 182, 183f Bone cement
Biomet Total Toe system in, 181, 182f host response to, 189
Kinetik Great Toe Implant in, 185, 186f for joint implants, 173t, 174
Osteomed Reflexion First Metatarsophalangeal Bone cyst
Joint Implant System in, 185, 186, 187f benign, 9
for transverse plane digital deformity, 168 hemisilicone implant and, 198, 200, 201, 201f
of underlapping toes, 504 Bone grafting
Aseptic necrosis, hemijoint replacement and, 200, 201f in arthrodesis of first metatarsophalangeal joint, 282,
Asymptomatic malalignment, 403 283, 327
Atasoy-type plantar V-Y advancement flap, 517, 518, 519, callus distraction versus, 575
519f in delayed union and nonunion, 407, 408, 409, 410,
Atrophic nonunion, 406 408f, 409f
Austin procedure, 237, 237f, 243f, 243, 244, 245, 246, in digital repair, 89, 90, 91, 90f
247, 248, 249, 250, 251 epiphysiodesis by, 352
bicorrectional and tricorrectional osteotomies in, 247, in lesser metatarsal surgery, 130
248 in offset-V osteotomy, 295, 296f
fixation in, 248f, 249f, 250f, 248, 249, 250, 251 in opening base wedge osteotomy, 275
for hallux limitus, 432f, 432, 433, 433f in opening wedge cuneiform osteotomy, 290
for juvenile hallux abducto valgus deformity, 351 to resist troughing, 305f, 306
long dorsal arm modification of, 244, 245, 244f, 245f,
246f, 247f
P.599
Bone healing, 577f, 577, 578 history of, 575, 576, 577, 576f
abnormalities after joint implant, 200, 201, 202, 201f latency period in, 582, 583f
after first metatarsophalangeal joint arthrodesis, 341 lengthening devices in, 584f, 584, 585, 585f
complications of, 403, 404, 405, 406, 407, 408, 409, medial column osteotomies in, 592, 593f, 594f
410, 411, 412 for nonunion of first metatarsal, 410, 410f
delayed unions and nonunions in, 405, 406, 407, ossification period in, 583
408, 409, 410, 411, 412, 408f, 409f, 410f, 411f osteotomy versus corticotomy in, 580, 581, 582, 581f
malunion in, 403f, 403, 404, 405, 404f physiology and histology of, 577f, 578f, 579f, 577, 578,
Bone loss, arthrodesis and, 323 579, 580
Bone regeneration postoperative management in, 583, 584
after digital arthroplasty, 100 rate and frequency of, 582, 583
after hemiimplant arthroplasty, 196, 196f, 200 Canal preparation
Bone resection for implant, 192
for hemiphalangectomy, 112, 113f for peg-in-hole digital arthrodesis, 84
in joint implant, 192, 193f Cancellous bone screw
Bone scan in sesamoid fracture, 568, 569f in closing base wedge osteotomy, 271, 272f
Bony ankylosis, 421 in first metatarsocuneiform joint arthrodesis, 283
Bowen's disease of nail bed, 9, 9f for fixation in first metatarsophalangeal joint
Brachymetapody, 69f, 69, 70 arthrodesis, 332f, 332, 333, 333f
Brachymetatarsia, 69f, 69, 70, 587, 588f, 589, 589f in hallux interphalangeal joint arthrodesis, 385, 386,
Bratkowski's sign, 32 386f
Brittleness of nails, 3 nonunion after first metatarsophalangeal joint fusion
Bruising with, 341f
in digital fracture, 559, 560 Candidal onychomycosis, 7, 7t
in sesamoid fracture, 568 Cannulated screw
Buddy splinting, 560, 560f in Akin procedure, 382, 383f
Bunion. See Hallux abducto valgus deformity. in crescentic osteotomy, 273, 274f
Bunionectomy Capsular reflection in anatomic dissection of first
Austin, 243f, 243, 244, 245, 246, 247, 248, 249, 250, metatarsophalangeal joint, 236, 236f
251 Capsular repair in implant, 193, 194
bicorrectional and tricorrectional osteotomies in, Capsulorrhaphy
247, 248 in hallux varus deformity, 402
fixation of, 248f, 249f, 250f, 248, 249, 250, 251 in transverse plane digital deformity, 157, 158
for juvenile hallux abducto valgus deformity, 351 Capsulotomy
long dorsal arm modification of, 244, 245, 244f, in correction of overlapping fifth toe, 497
245f, 246f, 247f extensor tenotomy and, 74
long plantar arm modification of, 245 flexor tenotomy and, 74, 75, 75f
results of, 244 in hallux varus deformity, 400, 401f
Youngswick modification of, 245, 246, 247, 247f in joint implant, 191, 192
Hohmann, 255, 256, 256f in metatarsophalangeal joint deformity, 94
Keller, 363, 364, 365, 366, 367, 368, 369, 370, 371, in transverse plane digital deformity, 157
372 Carbolic acid, 38
complications of, 372 Carbon dioxide laser partial matrixectomy, 19, 20
contraindications for, 371, 372 Carbon dioxide laser treatment in Morton's neuroma, 42,
dissection in, 366, 367f 43
flexor tendon and capsular reattachment in, 366, Carbon for joint implants, 173t, 174
367, 368, 369, 370, 371, 368f, 369f, 370f Cartilage grafting for hallux limitus, 445
indications for, 363, 364, 365f Casting
modifications of, 371, 371f, 372f in bone grafting in digital surgery, 91
osseous resection in, 366 in metatarsus adductus, 458, 458f
results in, 364, 365, 366 Cavoadducto varus, 449, 450f, 452
McBride, 360, 361, 362, 363, 361f, 362f Cavometatarsus adductus, 449
Mitchell, 253, 254, 255, 253f, 254f, 255f Cavus foot deformity
Reverdin, 251, 252, 253, 251f, 252f, 253f hallux interphalangeal joint arthrodesis in, 384
Silver, 268f, 359, 360, 360f loading pressures in forefoot and, 121, 212f
Wilson, 256, 257, 257f Cefazolin, 211
Bunionette, 137, 138, 139, 140, 141, 142, 143, 144, 145, Central ray polydactyly, 479
146, 147, 148, 149, 150, 138f Central rays
arthroplasty in, 143, 144, 144f, 145f biomechanics of, 96f, 96, 97, 98, 97f
clinical evaluation in, 139 lesser metatarsal symptoms and, 120, 121, 122, 123,
conservative treatment and, 142 124, 125, 126, 127, 128, 129, 130, 131, 132, 133,
distal metatarsal osteotomies in, 144, 145, 146, 147, 134, 135, 136
148, 149, 145f, 146f, 147f, 148f, 149f anatomy in, 120, 120f, 121f
etiology of, 137, 138, 139 bone grafting for, 130
exostectomy in, 142, 143, 143f clinical examination in, 122, 123, 123f
intermetatarsal angle of fourth and fifth metatarsals conservative treatment in, 123, 124
and, 140, 140f dorsiflexory osteotomies for, 126, 127, 127f, 128f
lateral deviation angle and, 140, 141, 142, 140f, 141f, elevated or short metatarsals and, 128, 129, 130,
142f 130f, 131f, 132f
proximal base osteotomies in, 149, 150, 150f etiology of, 121f, 121, 122, 122f
radiographic evaluation in, 139, 140 historical review of surgery in, 124f, 124, 125, 125f
signs and symptoms in, 137 long or plantarly displaced metatarsals and, 126
plantar condylectomy for, 130, 131, 132, 133, 134,
C 133f, 134f
shortening osteotomies for, 127, 128, 128f, 129f
Calcaneal-second metatarsal angle, 455, 455f surgical approach in, 125, 126
Calcaneocuboid joint avulsion fracture, 533, 533f surgical considerations in, 125, 126t
Calcaneus deformity, 419 Ceramics for joint implants, 173t, 173, 174
Callus distraction, 575, 576, 577, 578, 579, 580, 581, 582, Cerclage wire in closing base wedge osteotomy, 271
583, 584, 585, 586, 587, 588, 589, 590, 591, 592, 593, Cheilectomy, 426, 427, 428, 427f, 428f
594, 595 Chemical nail avulsion, 13, 14, 14f
for brachymetatarsia, 587, 588, 589, 588f, 589f, 590f Chevron osteotomy, 273, 274, 275, 275f
complications of, 585t, 585, 586, 587, 586f, 587f in hallux abducto valgus deformity, 238f
Evans' calcaneal osteotomy-distraction technique in, for shortening of hallux, 379, 380f
589, 591f, 592f
P.600
Chondrodiastasis, 581, 582 hemihypertrophy in, 506f, 507f, 506, 507, 508, 508t
Chopart's joint dislocation, 533, 534, 535, 536, 537, 538 macrodactyly in, 487, 488, 489, 490, 488f, 489f, 489t
crush injury in, 538, 538f malalignment of big toenail in, 10, 11, 11f
lateral force, 535, 536, 537 metatarsus adductus in, 451
longitudinal force, 535, 537f overlapping lesser toe in, 495, 496, 497, 498, 499, 500,
medial force, 533, 534, 535, 533f, 534f, 535f, 536f 501
plantar force, 537f, 538f conservative management of, 495, 496, 496f
Chronic pain etiology and clinical presentation of, 495, 495f
from foreign body-centered infection, 207, 208f postoperative care in, 501
with hemimetallic implant, 206, 206f surgical considerations of, 497, 498, 499, 500, 501,
in total joint replacement, 207, 208, 209, 210, 209f, 498f, 499f, 500f
210f polydactyly in, 477, 478, 479, 480, 481, 482, 483
Chymotrypsin ointment after phenolization treatment for associated syndromes in, 479, 480
ingrown toenail, 24 classification of, 477, 478, 479, 478f, 479f
Claw toe, 61f, 67, 68 etiology of, 477
of fifth digit, 104 surgical considerations in, 480, 481, 482, 483, 480f,
unreduced lesser metatarsophalangeal joint 481f, 482f, 483f
dislocation and, 553 shortened metatarsals in, 587, 588
Cleft foot, 490f, 490, 491, 492, 493, 494, 495, 492f, 493f, syndactyly in, 483, 484, 485, 486, 487, 485f, 486f,
494f 487f
Closed digital fracture, 560, 561, 562, 563, 564, 560f, underlapping toes in, 501, 502, 503, 504, 502f, 503f,
561f, 562f, 563f, 564f 504f
Closed reduction Congenital lymphedema, secondary nail changes in, 10
of digital fracture, 561, 562f Conservative management
of first metatarsophalangeal joint dislocation, 550, of congenital underlapping toe, 501
551 of delayed union and nonunion, 407
of interphalangeal joint dislocation, 553, 554 of fifth toe keratoses, 113
of lesser metatarsophalangeal joint dislocation, 551, of hallux abducto valgus deformities, 226
552, 553 of hallux limitus and rigidus, 425, 426, 426f
of subtalar dislocation, 531, 532 of ingrown toenail, 13, 14, 14f
of tarsometatarsal joint dislocation, 543, 544 of juvenile hallux abducto valgus deformity, 349
Closing base wedge osteotomy, 269f, 270f, 271f, 272f, of lesser metatarsal pain, 123, 124
269, 270, 271, 272, 273 of malunion of first metatarsal, 404
arthrodesis of first metatarsophalangeal joint and, 339 of metatarsus adductus, 457, 458, 459, 458f, 459f
for excessive abduction of hallux, 377 of Morton's neuroma, 37, 38
for juvenile hallux abducto valgus deformity, 351, of overlapping lesser toe, 495, 496, 496f
351f, 352f of sesamoid fracture, 568, 569
in recurrent hallux abducto valgus deformity, 396 of tailor's bunion, 142
Closing cuneiform osteotomy, 289, 290f of transverse plane digital deformity, 157, 158f
Clubbing of nails, 3 Contracture
Cobalt chromium after callus distraction, 586
in Acumed Great Toe system, 184 of fifth toe, 105
in Bio-Action implant, 182, 183f of flexor hallucis brevis muscle, 418
for joint implants, 173, 173t of plantar lateral structures of metatarsophalangeal
in Kinetik Great Toe Implant, 185 joint, 232
Coleman block test, 281 Cortical bone screw
Collapsing pes valgus deformity, 348 in Akin procedure, 382, 383f
Compensated metatarsus adductus foot, 449, 451f in first metatarsocuneiform joint arthrodesis, 283
Complete metatarsal head resection, 165 in first metatarsophalangeal joint arthrodesis, 332f,
Complex metatarsus adductus, 452 332, 333, 333f
Complex skewfoot, 452 in hallux interphalangeal joint arthrodesis, 386, 386f
Compound deformities, 449, 450, 451, 452, 453, 454, 455, Corticalization, 578
456, 457, 458, 459, 460, 461, 462, 463, 464, 465, 466, Corticosteroids
467, 468, 469, 470, 471, 472, 473, 474, 475, 476 for Morton's neuroma, 37, 38
clinical evaluation of, 452, 453, 454, 453f, 454f for psoriatic dystrophic nails, 14
conservative management of, 457, 458, 459, 458f, for transverse plane digital deformity, 157
459f Corticotomy
diagnostic imaging in, 454, 455, 456, 457, 455f, 456f, in arthrodesis of first metatarsophalangeal joint, 327
457f in callus distraction, 580
incidence and etiology of, 449, 450, 451, 451f, 452f Cotton procedure, 352
metatarsal osteotomies for, 467, 468, 469, 467f, 468f, Crawford L-shaped osteotomy, 146, 147, 147f
469f, 470f, 471f Crescentic osteotomy, 273, 273f, 274f
nomenclature in, 449, 450f, 451f Crush midtarsal injury, 538, 538f
soft tissue procedures for, 460, 461, 462, 463, 464, Crushing nail bed laceration, 514, 514f
461f, 462f, 463f, 464f, 465f, 466f Cryogenic denervation in Morton's neuroma, 43
tarsal osteotomies for, 469, 470, 471, 472, 473, 474, Culture of toenail specimen, 11
472f, 473f, 474f Cuneiform osteotomy, 351, 352
Compression dressing, 534 Curly toes, 66, 67
Compression screw, 283 Cylindric Akin procedure, 379, 379f
Computed tomography Cystine in nails, 1
in metatarsus adductus, 459 Czeizel-Losonci syndrome, 484
in tarsometatarsal joint dislocation, 542, 542f
Condylectomy D
in fifth digit deformities, 112, 113, 114, 113f, 114f
in medial pinch callus, 389 Dactylaplasia, 491
plantar, 125, 125f Darier's disease, 10, 10t
Congenital deformities, 477, 478, 479, 480, 481, 482, 483, DASA. See Distal articular set angle.
484, 485, 486, 487, 488, 489, 490, 491, 492, 493, 494, Davis-German classification of syndactyly, 483, 484
495, 496, 497, 498, 499, 500, 501, 502, 503, 504, 505, Davis law, 325
506, 507, 508, 509, 510 Deafness, onycho osteodystrophy, mental retardation
cleft foot in, 490f, 490, 491, 492, 493, 494, 495, 492f, syndrome, 10t
493f, 494f Debulking procedure, 490
congenital hemihypertrophy in, 506f, 507f, 506, 507, Deep transverse intermetatarsal ligament, 120, 120f
508, 508t Degloving, phalangeal, 516, 517, 518, 519, 520, 521, 522,
digiti quinti varus deformity in, 108 523, 516f, 517f, 518f, 519f, 520f, 521f, 522f, 523f
hallux abductus interphalangeus in, 504, 505, 506, Delayed union
505f after callus distraction, 585, 586, 586f
hallux valgus in, 345 after digital surgery, 100
hallux varus in, 321
P.601
after first metatarsophalangeal joint arthrodesis, 341 intraoperative stepwise approach to, 91, 92, 93, 94,
after hallux abducto valgus surgery, 405, 406, 407, 408, 95, 96, 92f, 93f, 94f, 95f
409, 410, 411, 412 lesser metatarsal surgery in, 96f, 96, 97, 98, 97f
clinical and radiographic evaluation of, 406, 407 long metatarsals and, 69
definition, incidence, and causes of, 405, 406 lumbricales function and, 57, 58, 59, 60, 59f
treatment considerations in, 407, 408, 409, 410, mallet toe and, 66
411, 412, 408f, 409f, 410f, 411f metatarsal cavus and, 68, 69
after metatarsal osteotomies, 168 metatarsophalangeal joint adductus or abductus
after proximal osteotomies, 277 and, 70f, 70, 71, 71f
of sesamoid fracture, 569 metatarsophalangeal joint dislocation and, 73, 98,
Delayed wound healing in macrodactyly, 490 99, 100, 99f
Demyelination in Morton's neuroma, 36 metatarsophalangeal joint limitation and, 71f, 71,
Deranged metatarsophalangeal joints, 70, 71, 72, 70f, 71f, 72
72f peg-in-hole arthrodesis in, 83, 84, 85, 84f
Dermatopathology, lesser metatarsal pain in, 122 plantar interossei function and, 54, 55, 56, 57, 56f,
Dermatophyte test, 11 57f, 58f
Derotation of hallux, 380 predislocation syndrome of lesser
Desyndactylization, 484, 485, 486, 487, 485f, 486f, 487f metatarsophalangeal joint and, 72, 72f
Detritic synovitis quadratus plantae muscle function and, 60, 60f
in joint implant, 203f resection of base of proximal phalanx in, 86, 87, 88,
with silicone hemiimplant, 204f, 204, 205 89, 88f, 89f
Developmental dysplasia of hip, metatarsus adductus and, syndactyly procedure in, 79, 80f
453 tenotomy in, 73, 74
Diabetes mellitus, first metatarsophalangeal joint transverse plane deformity and, 98
dislocation and, 547, 547f in fifth digit deformities, 103, 104, 105, 106, 107, 108,
Diagnostic tests for Morton's neuroma, 32, 33, 34, 35, 36, 109, 110, 111, 112, 113, 114, 115, 116, 117, 118,
33f, 34t, 35f, 36f 119
Diaphyseal osteotomy, 124, 124f amputation in, 118, 119
in callus distraction, 580, 581, 581f anatomy in, 103f, 103, 104, 104f
Digital arteries, 1, 2f arthroplasty in, 109, 110, 110f, 111f
Digital deviation angle, 153f arthroplasty with hemiphalangectomy in, 110, 111,
Digital fracture, 559, 560, 561, 562, 563, 564 112, 111f, 112f, 113f
clinical presentation of, 559, 560 clinical appearance and, 107, 108
closed, 560, 561, 562, 563, 564, 560f, 561f, 562f, 563f, complications of arthroplasty in, 114, 115
564f condylectomy in, 112, 113, 114, 113f, 114f
frontal plane, 559 distal phalangectomy in, 115f, 115, 116
open, 564, 565f flexibility and, 104, 105
sagittal plane, 559 lesion pattern and types and, 105, 106, 107, 107f,
transverse plane, 559, 560f, 562f 108f
Digital surgery, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, metatarsophalangeal joint release in, 108, 109,
62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 109f
76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, planes of deformity in, 104, 105f, 106f
90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102, skin plasty in, 116f, 116, 117, 118, 117f
103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, syndactyly in, 118, 118f
114, 115, 116, 117, 118, 119, 120, 121, 122, 123, 124, of hallux, 375, 376, 377, 378, 379, 380, 381, 382, 383,
125, 126, 127, 128, 129, 130, 131, 132, 133, 134, 135, 384, 385, 386, 387, 388, 389, 390
136, 137, 138, 139, 140, 141, 142, 143, 144, 145, 146, Akin osteotomy in, 375, 376, 377, 378, 379, 380,
147, 148, 149, 150, 151, 152, 153, 154, 155, 156, 157, 381, 382, 383See also Akin osteotomy.
158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, exostectomy in, 389
169 interphalangeal joint arthrodesis in, 384, 385, 386,
complications in hallux abducto valgus deformity, 391, 385f, 386f
392, 393, 394, 395, 396, 397, 398, 399, 400, 401, interphalangeal sesamoid management in, 386, 387,
402, 403, 404, 405, 406, 407, 408, 409, 410, 411, 388, 389, 387f, 388f
412, 413 in lesser metatarsal symptoms, 120, 121, 122, 123,
delayed unions and nonunions in, 405, 406, 407, 124, 125, 126, 127, 128, 129, 130, 131, 132, 133,
408, 409, 410, 411, 412, 408f, 409f, 410f, 411f 134, 135, 136
hallux varus in, 396, 397, 398, 399, 400, 401, 402, anatomy in, 120, 120f, 121f
397f, 399f, 401f, 402f bone grafting for, 130
malunion of first metatarsal in, 403f, 403, 404, 405, clinical examination in, 122, 123, 123f
404f conservative treatment in, 123, 124
recurrence of deformity in, 391, 392, 393, 394, 395, dorsiflexory osteotomies for, 126, 127, 127f, 128f
396, 392f, 393f, 394f, 396f elevated or short metatarsals and, 128, 129, 130,
in deformities of intermediate digits and 130f, 131f, 132f
metatarsophalangeal joint, 51, 52, 53, 54, 55, 56, etiology of, 121f, 121, 122, 122f
57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, historical review of surgery in, 124f, 124, 125, 125f
70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, long or plantarly displaced metatarsals and, 126
83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, plantar condylectomy for, 130, 131, 132, 133, 134,
96, 97, 98, 99, 100, 101, 102 133f, 134f
arthroplasty of proximal interphalangeal joint in, shortening osteotomies for, 127, 128, 128f, 129f
80, 81, 82, 81f surgical approach in, 125, 126
bone grafting in, 89, 90, 91, 90f surgical considerations in, 125, 126t
brachymetatarsia and, 69f, 69, 70 of nail, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25
claw toe and, 67, 68 local anesthesia in, 14, 15, 16, 15f, 16f
complications of, 100f, 100, 101 partial and total nail avulsion in, 17, 17f
curly toes and, 66, 67 partial matrixectomy in, 17f, 18f, 19f, 17, 18, 19,
digital arthrodesis using internal pins in, 85, 86, 20
86f postoperative care in, 24, 25
digitus abductus and, 68 skin closure and suture techniques in, 22, 23, 24,
digitus adductus and, 68 23f, 24f
extensor digitorum brevis and longus function and, soft tissue correction in, 16f, 16, 17
51f, 52f, 53f, 51, 52, 53, 54 total matrixectomy in, 20, 21, 22, 20f, 21f, 22f,
extensor substitution and, 62, 63, 64, 65, 66, 63f, 23f
64f, 65f, 66f in plantar keratoma, 150
extensor tendon lengthening in, 75, 76 in tailor's bunion, 137, 138, 139, 140, 141, 142, 143,
extensor tenotomy and capsulotomy in, 74 144, 145, 146, 147, 148, 149, 150, 138f
flexor digitorum brevis and longus function and, arthroplasty in, 143, 144, 144f, 145f
54f, 55f, 56f clinical evaluation in, 139
flexor dislocation and, 70 conservative treatment and, 142
flexor stabilization and, 61f, 61, 62 distal metatarsal osteotomies in, 144, 145, 146,
flexor substitution and, 62, 62f 147, 148, 149, 145f, 146f, 147f, 148f, 149f
flexor tendon transfer in, 75, 76, 77, 78, 79, 76f, etiology of, 137, 138, 139
77f, 78f, 79f exostectomy in, 142, 143, 143f
flexor tenotomy and capsulotomy in, 74, 75, 75f intermetatarsal angle of fourth and fifth
hammer toe and, 67 metatarsals and, 140, 140f
heloma molle and, 68 lateral deviation angle and, 140, 141, 142, 140f,
interphalangeal arthrodesis with Kirschner wire 141f, 142f
fixation in, 82, 83, 83f proximal base osteotomies in, 149, 150, 150f
P.602
radiographic evaluation in, 139, 140 malunion in, 403f, 403, 404, 405, 404f
signs and symptoms in, 137 comparative studies of, 257, 258
in transverse plane digital deformities, 98, 152f, 152, displacement of, 259f, 260f, 261f, 261
153, 154, 155, 156, 157, 158, 159, 160, 161, 162, dorsal angulation after, 404
163, 164, 165, 166, 167, 168, 169 for hallux limitus and rigidus, 428, 429, 430, 431, 432,
complications of, 168 433
conservative management of, 157, 158f Austin procedure and, 432f, 432, 433, 433f
etiology of, 152, 153, 154, 153f, 154f modified Green-Watermann procedure and, 429,
evaluation of, 155, 156f, 157f 430, 430f, 431f, 432f
joint-destructive procedures in, 165, 166, 167, 168 Watermann procedure and, 428, 429, 429f
joint-preservation procedures in, 164f, 164, 165, Hohmann bunionectomy as, 255, 256, 256f
166f, 167f for juvenile hallux abducto valgus deformity, 350, 351
postoperative care in, 168 Mitchell bunionectomy as, 253, 254, 255, 253f, 254f,
soft tissue procedures in, 157, 158, 159, 160, 161, 255f
162, 163, 164, 158f, 159f, 160f, 161f, 162f, postoperative management of, 258
163f, 164f recurrence rate after, 393
Digital syndactyly, 79, 80f in recurrent hallux abducto valgus deformity, 396
Digitus abductus, 68 Reverdin bunionectomy as, 251, 252, 253, 251f, 252f,
Digitus adductus, 68 253f
Discoloration of nails, 3 sagittal and transverse plane deviations after, 259,
Dislocation, 525, 526, 527, 528, 529, 530, 531, 532, 533, 260
534, 535, 536, 537, 538, 539, 540, 541, 542, 543, 544, for tailor's bunion, 144, 145, 146, 147, 148, 149, 145f,
545, 546, 547, 548, 549, 550, 551, 552, 553, 554, 555 146f, 147f, 148f, 149f
Chopart's joint, 533, 534, 535, 536, 537, 538 Wilson bunionectomy as, 256, 257, 257f
crush injury in, 538, 538f Distal oblique osteotomy, 126, 127f
lateral force, 535, 536, 537 Distal phalangectomy in fifth digit deformity, 115f, 115,
longitudinal force, 535, 537f 116
medial force, 533, 534, 535, 533f, 534f, 535f, 536f Distal subungual onychomycosis, 6, 7t
plantar force, 537f, 538f Distal V-osteotomy, 126, 127f
first metatarsophalangeal joint, 547f, 547, 548, 549, Divergent tarsometatarsal joint dislocation, 543, 546f
550, 551 DOOR syndrome, 10t
treatment of, 550, 551 Dorsal approach
type I, 547, 548, 548f for excision of interphalangeal sesamoid, 388
type II, 548, 549, 549f, 550f for Morton's neuroma resection, 38, 39, 39f
general considerations in, 525 Dorsal dislocation of metatarsophalangeal joint, 98, 99,
interphalangeal joint, 553, 554, 555 100, 99f
lesser metatarsophalangeal joint, 551, 552, 553, 552f Dorsal interossei, 54, 55, 56, 57, 56f, 57f, 58f
Lisfranc's joint, 538, 539, 540, 541, 542, 543, 544, 545, Dorsal talonavicular joint flake fractures, 533, 533f
546, 539f, 540f, 541f Dorsiflexory osteotomy, 126, 127, 127f, 128f
anatomic considerations in, 541, 542, 542f Dorsiflexory wedge osteotomy
direct injury in, 542, 543 of metatarsal base, 124, 124f
indirect injury in, 543, 544f of metatarsal neck, 125, 125f
treatment of, 543, 544, 545, 546 Double Kirschner wire technique, 331, 331f
type A or total incongruity, 543, 545f Double osteotomy, 433, 434
type B or partial incongruity, 543, 545f Double-stem hinged silicone implant, 178, 179, 180, 180f
type C of divergent, 543, 546f Downey approach to congenital overlapping fifth toe,
metatarsophalangeal joint, 73, 98, 99, 100, 99f 498f, 499f, 500f, 498, 499, 500, 501
predislocation syndrome of lesser metatarsophalangeal Drainage of subungual hematoma, 513
joint and, 72, 72f Dressing
sesamoid, 567 after reduction, 532
subtalar joint, 525, 526, 527, 528, 529, 530, 531, 532, compression, 534
533, 526f, 527f Dynamization, 581, 583
anatomic considerations in, 526, 527 Dyskeratosis congenita, 10t
anterior, 531 Dystrophic fissured nail, 3, 4f
lateral, 528, 529, 531f
medial, 527, 528, 528f, 529f, 530f E
posterior, 529, 530, 531, 532f
treatment of, 531, 532, 533 Ecchymosis
of Z-osteotomy, 307 in digital fracture, 559, 560
Displacement of distal metaphyseal osteotomy, 259f, 260f, in sesamoid fracture, 568
261f, 261 Ectopic bone formation after hemiimplant arthroplasty,
Distal Akin osteotomy, 377, 378, 378f 196, 196f, 200
Distal articular set angle Ectrodactyly, 490
Akin procedure for, 377 Edema
hallux abducto valgus and, 219, 221, 222, 222f callus distraction surgery and, 587
hallux osteotomy and, 375 in digital fracture, 559, 560
Distal head osteotomy, 165, 166f in Lisfranc's joint dislocation, 539, 539f
Distal metaphyseal osteotomy, 124, 125, 125f, 241, 242, in Morton's neuroma, 36
243, 244, 245, 246, 247, 248, 249, 250, 251, 252, 253, in transverse plane digital deformity, 155
254, 255, 256, 257, 258, 259, 260, 261, 262, 263 Ehlers-Danlos syndrome, 452f
Akin, 377, 378, 378f Electrical stimulation for nonunion or delayed union, 410,
apical axis guide in, 241, 242, 243, 241f, 242f, 243f 411
Austin bunionectomy as, 243f, 243, 244, 245, 246, 247, Elevated metatarsals, 128, 129, 130, 130f, 131f, 132f
248, 249, 250, 251 Elevatus, 403
bicorrectional and tricorrectional osteotomies in, Ellis-van Creveld dysplasia, 479
247, 248 Enchondroma, nail involvement in, 6, 7t
fixation of, 248f, 249f, 250f, 248, 249, 250, 251 Endoneurium, peripheral neurectomy and, 40
long dorsal arm modification of, 244, 245, 244f, Endoscopic decompression of Morton's neuroma, 41, 42
245f, 246f, 247f Endosteal callus, 577, 580
long plantar arm modification of, 245 Entrapment neuropathy, 29, 30
results of, 244 Epinephrine, 16
Youngswick modification of, 245, 246, 247, 247f Epineural neurolysis, 41
avascular necrosis after, 258, 259 Epineurectomy, 41
bone healing complications of, 403, 404, 405, 406, 407, Epineurium, peripheral neurectomy and, 40
408, 409, 410, 411, 412 Epineurotomy, 41
delayed unions and nonunions in, 405, 406, 407,
408, 409, 410, 411, 412, 408f, 409f, 410f, 411f
P.603
Epiphysiodesis metatarsophalangeal joint release in, 108, 109,
for juvenile hallux abducto valgus, 352, 353, 353f, 109f
354f, 355f, 356f planes of deformity in, 104, 105f, 106f
for macrodactyly, 489, 490 skin plasty for, 116f, 116, 117, 118, 117f
Epiphysiolysis, callus distraction and, 581, 582 syndactyly for, 118, 118f
Epiphysis, callus distraction and, 581, 582 fracture of, 559, 560f, 562f
Eponychium, 1, 2f hammer toe deformity of, 96
Equinus, 68, 69 plantar keratoma of, 151
Escherichia coli nail infection, 7 tailor's bunion of, 137, 138, 139, 140, 141, 142, 143,
Evans' calcaneal osteotomy, distraction technique, 589, 144, 145, 146, 147, 148, 149, 150, 138f
591f, 592f arthroplasty in, 143, 144, 144f, 145f
Excision clinical evaluation in, 139
in macrodactyly, 489, 489f conservative treatment and, 142
in preaxial polydactyly, 480, 481 distal metatarsal osteotomies in, 144, 145, 146,
Exostectomy, 359 147, 148, 149, 145f, 146f, 147f, 148f, 149f
of hallux, 389 etiology of, 137, 138, 139
for tailor's bunion deformity, 142, 143, 143f exostectomy in, 142, 143, 143f
Exostosis of fifth toe, 107, 108f intermetatarsal angle of fourth and fifth
Extension contracture of fifth toe, 107, 108 metatarsals and, 140, 140f
Extensor digitorum brevis lateral deviation angle and, 140, 141, 142, 140f,
biomechanics of, 51f, 52f, 53f, 51, 52, 53, 54 141f, 142f
Hibbs suspension and, 96 proximal base osteotomies in, 149, 150, 150f
resection of proximal phalangeal base and, 87 radiographic evaluation in, 139, 140
transfer in transverse plane deformity, 160, 161f, 162f, signs and symptoms in, 137
163f traumatic open injury to, 565f
Extensor digitorum longus, 52, 53, 54, 62, 63 Fifth metatarsal declination angle, 142, 142f
biomechanics of, 51f, 52f, 53f, 51, 52, 53, 54 Fifth metatarsal deformities, 137, 138, 139, 140, 141, 142,
Hibbs suspension and, 96 143, 144, 145, 146, 147, 148, 149, 150, 151
transfer to metatarsal neck, 95 plantar keratoma in, 151
Extensor digitorum longus tendon tailor's bunion in, 137, 138, 139, 140, 141, 142, 143,
interphalangeal arthrodesis with Kirschner wire 144, 145, 146, 147, 148, 149, 150, 138f
fixation and, 82 arthroplasty in, 143, 144, 144f, 145f
proximal interphalangeal joint arthroplasty and, 80, clinical evaluation in, 139
81, 82, 81f conservative treatment and, 142
resection of proximal phalangeal base and, 87, 88f distal metatarsal osteotomies in, 144, 145, 146,
Extensor hallucis longus tendon 147, 148, 149, 145f, 146f, 147f, 148f, 149f
arthrodesis of first metatarsophalangeal joint and, 324 etiology of, 137, 138, 139
Z-plasty lengthening of, 371f, 372f, 372f exostectomy in, 142, 143, 143f
Extensor hood recession, 91 intermetatarsal angle of fourth and fifth
Extensor substitution, 62, 63f, 64f, 65f, 66f, 66 metatarsals and, 140, 140f
Extensor tendon lengthening, 75, 76, 91, 92, 93, 94 lateral deviation angle and, 140, 141, 142, 140f,
Extensor tenotomy, 73, 74 141f, 142f
for metatarsophalangeal joint deformity, 74, 91, 92, proximal base osteotomies in, 149, 150, 150f
93, 94 radiographic evaluation in, 139, 140
in resection of proximal phalangeal base, 87 signs and symptoms in, 137
for transverse plane digital deformity, 157, 158 First interspace dissection, 232, 233, 234, 235, 236
External fixation in arthrodesis of first lateral collateral ligament of first
metatarsophalangeal joint, 337, 337f metatarsophalangeal joint and, 236
External frames in callus distraction, 584f, 584, 585, 585f release of adductor tendon in, 232, 233f
External neurolysis, 41 release of fibular sesamoidal ligament in, 233, 234,
Extrinsic elevatus, 433 233f, 234f, 235f
Extrinsic joint implant failure, 198 removal of fibular sesamoid in, 234, 235
Extrinsic metatarsus primus elevatus, 425, 425f sequential release of plantar lateral contracture in,
232
F tenotomy of lateral head of flexor hallucis brevis
tendon in, 234, 235f
Failed implant arthroplasty, 204, 205, 206, 207, 208, 209, First metatarsal base osteotomy, 265, 266, 267, 268, 269,
210 270, 271, 272, 273, 274, 275, 276, 277, 278, 279
interpositional implant and, 204, 205, 206, 204f, 205f, anatomic considerations in, 268, 269, 269f
206f chevron osteotomy in, 273, 274, 275, 275f
total joint system and, 206, 207, 208, 209, 210, 208f, closing base wedge osteotomy in, 269f, 270f, 271f,
209f, 210f 272f, 269, 270, 271, 272, 273
Fatty degeneration of nerve fiber, 35, 36f crescentic osteotomy in, 273, 273f, 274f
Femoral torsion, metatarsus adductus and, 453 indications for, 265, 266, 267, 268, 266f, 267f, 268f
Fibrosis in Morton's neuroma, 35, 35f opening base wedge osteotomy in, 275, 275f
Fibular sesamoid removal, 234, 235 postoperative management of, 276f, 277, 277f
Fibular sesamoidal ligament release, 233, 234, 233f, 234f, First metatarsal bone healing complications, 403, 404,
235f 405, 406, 407, 408, 409, 410, 411, 412
Fibular sesamoidectomy, 360, 361, 362f delayed unions and nonunions in, 405, 406, 407, 408,
Fifth digit 409, 410, 411, 412, 408f, 409f, 410f, 411f
congenital overlapping of, 495, 496, 497, 498, 499, malunion in, 403f, 403, 404, 405, 404f
500, 501 First metatarsal shaft osteotomy, 293, 294, 295, 296, 297,
conservative management of, 495, 496, 496f 298, 299, 300, 301, 302, 303, 304, 305, 306, 307, 308,
etiology and clinical presentation of, 495, 495f 309, 310, 311, 312, 313, 314, 315
postoperative care in, 501 Mau and Ludloff osteotomies and, 308, 309, 310, 311,
surgical considerations of, 497, 498, 499, 500, 501, 312, 313, 308f, 309f, 310f, 311f, 312f, 313f, 314f
498f, 499f, 500f offset-V osteotomy and, 293, 294, 295, 296, 297, 294f,
deformities of, 103, 104, 105, 106, 107, 108, 109, 110, 295f, 296f, 297f
111, 112, 113, 114, 115, 116, 117, 118, 119 Scarf Z-osteotomy and, 299, 300, 301, 302, 303, 304,
amputation in, 118, 119 305, 306, 307, 300f, 301f, 302f, 303f, 304f, 305f,
anatomy in, 103f, 103, 104, 104f 306f
arthroplasty for, 109, 110, 110f, 111f First metatarsocuneiform arthrodesis, 280, 281, 282, 283,
arthroplasty with hemiphalangectomy for, 110, 111, 284, 285, 286, 287, 288
112, 111f, 112f, 113f bone grafting in, 282, 283
clinical appearance of, 107, 108 complications of, 287, 288, 288f
complications of arthroplasty for, 114, 115 fixation in, 283, 284, 285, 284f, 285f, 286f
condylectomy for, 112, 113, 114, 113f, 114f indications for, 280, 281, 282
distal phalangectomy for, 115f, 115, 116 modifications of, 283
flexibility and, 104, 105 postoperative management of, 285
lesion pattern and types in, 105, 106, 107, 107f, results of, 285, 286, 287, 287f
108f First metatarsophalangeal joint
P.604
anatomic dissection in hallux valgus surgery, 229, 230, Osteomed Reflexion First Metatarsophalangeal
231, 232, 233, 234, 235, 236, 237, 238, 239, 240 Joint Implant System in, 185, 186, 187f
capsular considerations in, 237, 237f Fixation
first interspace dissection in, 232, 233, 234, 235, after postaxial polydactyly repair, 481, 482, 482f
236, 233f, 234f, 235f in Akin osteotomy, 380, 381, 382, 381f, 382f, 383f
incision in, 230 in arthrodesis of first metatarsophalangeal joint, 329,
medial capsulotomy in, 236, 236f 330, 331, 332, 333, 334, 335, 336, 337
medial eminence resection in, 237 external, 337, 337f
muscle-tendon balancing and soft tissue pin or wire, 330f, 330, 331, 332, 331f
procedures in, 237, 238, 238f plate, 333, 334, 335, 333f, 334f, 335f, 336f
perioperative anesthesia in, 230 screw, 332f, 332, 333, 333f
principles of, 229, 230 in Austin bunionectomy, 248f, 249f, 250f, 248, 249,
subcutaneous dissection in, 230, 231, 231f 250, 251
arthrodesis of, 317, 318, 319, 320, 321, 322, 323, 324, in closing base wedge osteotomy, 271
325, 326, 327, 328, 329, 330, 331, 332, 333, 334, by encapsulization, 189
335, 336, 337, 338, 339, 340, 341, 342, 343, 318t, in first metatarsocuneiform arthrodesis, 283, 284, 285,
319t, 444 284f, 285f, 286f
ancillary procedures in, 337, 338, 339, 340, 338f, in Green-Watermann procedure, 430, 432f
339f in hallux interphalangeal joint arthrodesis, 385f, 385,
clinical evaluation of, 319 386, 386f
complications of, 340f, 340, 341, 342, 341f in Mau and Ludloff osteotomies, 313
contraindications for, 323, 324 in opening base wedge osteotomy, 275
external fixation in, 337, 337f in proximal plantarflexory osteotomies, 434, 435
indications for, 320f, 320, 321, 322, 323, 321t, in Regnauld procedure, 439
322f in Scarf osteotomy, 300, 302f
joint resection in, 325, 326, 327, 326f, 328f in subtalar dislocation, 532
pin or wire fixation in, 330f, 330, 331, 332, 331f in unstable fracture, 561, 562, 563, 564, 563f, 564f
plate fixation in, 333, 334, 335, 333f, 334f, 335f, in Vanore-Corey procedure, 439
336f in Watermann osteotomy, 428, 429
position of fusion in, 327, 328, 329, 329f Flail deformity of hallux, 364, 365, 366
postoperative care in, 340 Flail toe, 89, 90, 91, 90f, 100, 321
screw fixation in, 332f, 332, 333, 333f Flap
skin incision and exposure in, 324, 325 in cleft foot repair, 493, 493f, 494f
dislocation of, 547f, 547, 548, 549, 550, 551 for correction of overlapping fifth toe, 496, 497
treatment of, 550, 551 for desyndactylization, 484, 485, 486, 487, 485f, 486f,
type I, 547, 548, 548f 487f
type II, 548, 549, 549f, 550f in hallux interphalangeal joint sesamoidectomy, 388,
fractures of, 419 389
hallux abducto valgus and, 222, 223f for nail bed augmentation, 517, 518, 519, 519f
hallux limitus and, 416 in resection arthroplasty, 366, 367f, 368, 368f
McBride procedure and, 360, 361, 362, 363, 361f, 362f Flexibility test, 454
plantar fascia and, 420 Flexible extension contracture of fifth toe, 105
Silver bunionectomy and, 359, 360, 360f Flexor digiti quinti brevis, 54, 55, 56, 57, 56f, 57f, 58f,
First metatarsophalangeal joint cheilectomy, 426, 427, 103
428, 427f Flexor digitorum brevis
First metatarsophalangeal joint implant arthroplasty, 171, biomechanics of, 54f, 55f, 56f
172, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, resecting head of proximal phalanx and, 91
183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, Flexor digitorum longus
194, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204, biomechanics of, 54f, 55f, 56f
205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215 resecting head of proximal phalanx and, 91
adjacent bone abnormalities after, 200, 201, 202, 201f resection of proximal phalangeal base and, 87, 88f
alignment abnormalities after, 200 Flexor dislocation, 70
biomaterial failure in, 198, 199, 200, 199f Flexor hallucis brevis muscle
biomaterials for, 172, 173, 174, 175, 173t hallux limitus or hallux rigidus and, 420
biomechanical joint failure in, 202 tenotomy of, 234, 235f
bone resection in, 192, 193f Flexor stabilization, 61f, 61, 62, 417
canal preparation for, 192 Flexor substitution, 62, 62f
capsular repair in, 193, 194 Flexor tendon
capsulotomy in, 191, 192 Keller joint resection arthroplasty and, 366, 367, 368,
closure and postoperative course in, 194 369, 370, 371, 368f, 369f, 370f
design and function implant in, 175, 176, 177, 178, lesser metatarsophalangeal joint dislocations and, 551
179, 180, 181, 177f, 178f, 179f, 180f, 181f Flexor tendon transfer
evolution of, 171, 172 for metatarsophalangeal joint deformity, 75, 76, 77,
host response to, 188, 189, 190, 191 78, 79, 76f, 77f, 78f, 79f
metals and, 188, 189f to proximal phalanx, 95
polyethylene and, 188 for transverse plane digital deformity, 160
polymers and, 188 Flexor tenotomy, 73, 74, 75, 75f
polymethylmethacrylate and, 189 Floating toe syndrome, 100f, 100, 101
silicone rubber and, 189, 190, 191, 190f, 198, 199, Fluocinolone acetonide, 14
199f Foot dislocation, 525, 526, 527, 528, 529, 530, 531, 532,
implant grommets and, 192, 193 533, 534, 535, 536, 537, 538, 539, 540, 541, 542, 543,
implant insertion in, 193 544, 545, 546, 547, 548, 549, 550, 551, 552, 553, 554,
indications for, 191, 191f 555
radiology in, 194f, 195f, 196f, 197f, 194, 195, 196, Chopart's joint, 533, 534, 535, 536, 537, 538
197, 198 crush injury in, 538, 538f
results of, 210, 211 lateral force, 535, 536, 537
revision of, 204, 205, 206, 207, 208, 209, 210 longitudinal force, 535, 537f
failed interpositional implant and, 204, 205, 206, medial force, 533, 534, 535, 533f, 534f, 535f, 536f
204f, 205f, 206f plantar force, 537f, 538f
failed total joint system and, 206, 207, 208, 209, first metatarsophalangeal joint, 547f, 547, 548, 549,
210, 208f, 209f, 210f 550, 551
soft tissue abnormalities after, 202, 203f treatment of, 550, 551
surgical approach in, 191 type I, 547, 548, 548f
total joint replacement and, 181, 182, 183, 184, 185, type II, 548, 549, 549f, 550f
186, 187, 188 general considerations in, 525
Acumed Great Toe System in, 184, 185, 185f interphalangeal joint, 553, 554, 555
Bio-Action Great Toe Implant in, 182, 183f lesser metatarsophalangeal joint, 551, 552, 553, 552f
Biomet Total Toe system in, 181, 182f Lisfranc's joint, 538, 539, 540, 541, 542, 543, 544, 545,
Kinetik Great Toe Implant in, 185, 186f 546, 539f, 540f, 541f
anatomic considerations in, 541, 542, 542f
P.605
direct injury in, 542, 543 H-block of Frost, 15, 16f
indirect injury in, 543, 544f Hallux, 375, 376, 377, 378, 379, 380, 381, 382, 383, 384, 385, 386,
treatment of, 543, 544, 545, 546 387, 388, 389, 390
type A or total incongruity, 543, 545f Akin osteotomy of, 375, 376, 377, 378, 379, 380, 381, 382, 383
type B or partial incongruity, 543, 545f complications of, 383, 384f
type C of divergent, 543, 546f dissection in, 375, 376, 377, 376f
subtalar joint, 525, 526, 527, 528, 529, 530, 531, 532, 533, distal, 377, 378, 378f
526f, 527f fixation in, 380, 381, 382, 381f, 382f, 383f
anatomic considerations in, 526, 527 modifications of, 378, 379, 380, 380f
anterior, 531 postoperative management in, 383
lateral, 528, 529, 531f proximal, 377, 377f
medial, 527, 528, 528f, 529f, 530f dorsal dislocation of interphalangeal joint, 552f, 553
posterior, 529, 530, 531, 532f exostectomy of, 389
treatment of, 531, 532, 533 first metatarsal base osteotomies of, 265, 266, 267, 268, 269,
Forefoot block test, 422 270, 271, 272, 273, 274, 275, 276, 277, 278, 279
Forefoot cavus, 69 anatomic considerations in, 268, 269, 269f
Forefoot supinatus deformity, 422 chevron osteotomy in, 273, 274, 275, 275f
Foreign body granuloma in joint implant, 203f closing base wedge osteotomy in, 269f, 270f, 271f, 272f,
Fowler procedure, 352 269, 270, 271, 272, 273
Fracture crescentic osteotomy in, 273, 273f, 274f
after first metatarsophalangeal joint arthrodesis, 341 indications for, 265, 266, 267, 268, 266f, 267f, 268f
after Scarf osteotomy, 306, 306f opening base wedge osteotomy in, 275, 275f
bone healing in, 577f, 577, 578 postoperative management of, 276f, 277, 277f
digital, 559, 560, 561, 562, 563, 564 first metatarsophalangeal joint implant arthroplasty and, 171,
clinical presentation of, 559, 560 172, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, 183,
closed, 560, 561, 562, 563, 564, 560f, 561f, 562f, 563f, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195,
564f 196, 197, 198, 199, 200, 201, 202, 203, 204, 205, 206, 207,
frontal plane, 559 208, 209, 210, 211, 212, 213, 214, 215
open, 564, 565f Acumed Great Toe System in, 184, 185, 185f
sagittal plane, 559 adjacent bone abnormalities after, 200, 201, 202, 201f
transverse plane, 559, 560f, 562f alignment abnormalities after, 200
hallux, 418, 419f Bio-Action Great Toe Implant in, 182, 183f
sesamoid, 566, 567, 568, 569, 570, 571, 572 biomaterial failure in, 198, 199, 200, 199f
anatomy in, 566f, 566, 567, 567f biomaterials for, 172, 173, 174, 175, 173t
clinical presentation of, 568 biomechanical joint failure in, 202
diagnosis and treatment of, 568f, 569f, 570f, 571f, 568, Biomet Total Toe system in, 181, 182f
569, 570, 571, 572 bone resection in, 192, 193f
etiology of, 567, 568 canal preparation for, 192
with subtalar dislocations, 528, 528f capsular repair in, 193, 194
Fracture callus, 578 capsulotomy in, 191, 192
Fracture sprain closure and postoperative course in, 194
lateral force, 535 design and function implant in, 175, 176, 177, 178, 179,
medial force, 533 180, 181, 177f, 178f, 179f, 180f, 181f
Fracture subluxation evolution of, 171, 172
lateral force, 535 failed interpositional implant and, 204, 205, 206, 204f,
medial force, 533 205f, 206f
Fraser syndrome, 484 failed total joint system and, 206, 207, 208, 209, 210, 208f,
Freiberg's infraction, 122 209f, 210f
Frontal plane digital fracture, 559 host response to, 188, 189, 190, 191, 189f, 190f
Frontal plane varus rotation of fifth toe, 104, 105f implant grommets and, 192, 193
Frost partial matrixectomy procedure, 17, 18, 18f implant insertion in, 193
Functional hallux limitus, 416, 417, 417 indications for, 191, 191f
Futura metallic hemiimplant, 178, 179f Kinetik Great Toe Implant in, 185, 186f
Osteomed Reflexion First Metatarsophalangeal Joint
G Implant System in, 185, 186, 187f
radiology in, 194f, 195f, 196f, 197f, 194, 195, 196, 197,
Gait in hallux limitus and hallux rigidus, 415, 416, 417 198
Ganley-Ganley procedure, 469, 470, 471, 472, 473, 474, 472f, 473f results of, 210, 211
Ganley splint, 459, 459f soft tissue abnormalities after, 202, 203f
Genetic factors surgical approach in, 191
in hallux abducto valgus deformity, 217 flail deformity of, 364, 365, 366
in juvenile hallux abducto valgus deformity, 345 fracture of, 560, 561f, 563f
in nail pathology, 10t, 10, 11, 11f hypermobility of, 280, 281
in polydactyly, 477 innervation of, 1, 2f
in syndactyly, 483 interphalangeal joint arthrodesis of, 384, 385, 386, 385f, 386f
Giannestras step-down osteotomy, 127, 129f interphalangeal sesamoid management of, 386, 387, 388, 389,
Giant cell formation in joint implant, 203f 387f, 388f
Giorgini method of repairing cleft foot, 492f, 493 large intermetatarsal angles of, 265, 266
Gout, 418, 419 rigid, 266, 266f
Graft Hallux abducto valgus deformity, 217, 218, 219, 220, 221, 222, 223,
bone 224, 225, 226, 227, 228, 229, 230, 231, 232, 233, 234, 235, 236,
in arthrodesis of first metatarsophalangeal joint, 282, 283, 237, 238, 239, 240, 241, 242, 243, 244, 245, 246, 247, 248, 249,
327 250, 251, 252, 253, 254, 255, 256, 257, 258, 259, 260, 261, 262,
callus distraction versus, 575 263, 264, 265, 266, 267, 268, 269, 270, 271, 272, 273, 274, 275,
in delayed union and nonunion, 407, 408, 409, 410, 408f, 276, 277, 278, 279, 280, 281, 282, 283, 284, 285, 286, 287, 288,
409f 289, 290, 291, 292, 293, 294, 295, 296, 297, 298, 299, 300, 301,
in digital repair, 89, 90, 91, 90f 302, 303, 304, 305, 306, 307, 308, 309, 310, 311, 312, 313, 314,
epiphysiodesis by, 352 315, 316, 317, 318, 319, 320, 321, 322, 323, 324, 325, 326, 327,
in lesser metatarsal surgery, 130 328, 329, 330, 331, 332, 333, 334, 335, 336, 337, 338, 339, 340,
in offset-V osteotomy, 295, 296f 341, 342, 343, 344, 345, 346, 347, 348, 349, 350, 351, 352, 353,
in opening base wedge osteotomy, 275 354, 355, 356, 357, 358, 359, 360, 361, 362, 363, 364, 365, 366,
in opening wedge cuneiform osteotomy, 290 367, 368, 369, 370, 371, 372, 373
to resist troughing, 305f, 306 Akin osteotomy for, 375, 376, 377, 378, 379, 380, 381, 382,
skin 383
in cleft foot repair, 493, 493f, 494f complications of, 383, 384f
for desyndactylization, 484, 485, 486, 487, 485f, 486f, dissection in, 375, 376, 377, 376f
487f distal, 377, 378, 378f
in zone 1 nail bed defect secondary to crush injury 517, fixation in, 380, 381, 382, 381f, 382f, 383f
517f, 518f modifications of, 378, 379, 380, 380f
Green-Watermann modification, 429, 430, 431f, 432f postoperative management in, 383
proximal, 377, 377f
H
P.606
anatomic dissection of first metatarsophalangeal joint offset-V osteotomy and, 293, 294, 295, 296, 297,
for, 229, 230, 231, 232, 233, 234, 235, 236, 237, 294f, 295f, 296f, 297f
238, 239, 240 Scarf Z-osteotomy and, 299, 300, 301, 302, 303,
capsular considerations in, 237, 237f 304, 305, 306, 307, 300f, 301f, 302f, 303f, 304f,
first interspace dissection in, 232, 233, 234, 235, 305f, 306f
236, 233f, 234f, 235f first metatarsocuneiform arthrodesis for, 280, 281,
incision in, 230 282, 283, 284, 285, 286, 287, 288
medial capsulotomy in, 236, 236f bone grafting in, 282, 283
medial eminence resection in, 237 complications of, 287, 288, 288f
muscle-tendon balancing and soft tissue fixation in, 283, 284, 285, 284f, 285f, 286f
procedures in, 237, 238, 238f indications for, 280, 281, 282
perioperative anesthesia in, 230 modifications of, 283
principles of, 229, 230 postoperative management of, 285
subcutaneous dissection in, 230, 231, 231f results of, 285, 286, 287, 287f
arthrodesis of first metatarsophalangeal joint for, 317, hemijoint replacement and, 200
318, 319, 320, 321, 322, 323, 324, 325, 326, 327, juvenile, 345, 346, 347, 348, 349, 350, 351, 352, 353,
328, 329, 330, 331, 332, 333, 334, 335, 336, 337, 354, 355, 356, 357
338, 339, 340, 341, 342, 343, 318t, 319t associated deformities, 348, 349
ancillary procedures in, 337, 338, 339, 340, 338f, clinical features of, 346, 347
339f conservative management of, 349
clinical evaluation of, 319 distal osteotomies for, 350, 351
complications of, 340f, 340, 341, 342, 341f epiphysiodesis for, 352, 353, 353f, 354f, 355f, 356f
contraindications for, 323, 324 metatarsocuneiform joint arthrodesis and
external fixation in, 337, 337f cuneiform osteotomy for, 351, 352
indications for, 320f, 320, 321, 322, 323, 321t, phalangeal osteotomies for, 356
322f proximal osteotomies for, 351, 351f, 352f
joint resection in, 325, 326, 327, 326f, 328f radiographic evaluation of, 347f, 347, 348
pin or wire fixation in, 330f, 330, 331, 332, 331f soft tissue procedures for, 350
plate fixation in, 333, 334, 335, 333f, 334f, 335f, Keller joint resection arthroplasty for, 363, 364, 365,
336f 366, 367, 368, 369, 370, 371, 372
position of fusion in, 327, 328, 329, 329f complications of, 372
postoperative care in, 340 contraindications for, 371, 372
screw fixation in, 332f, 332, 333, 333f dissection in, 366, 367f
skin incision and exposure in, 324, 325 flexor tendon and capsular reattachment in, 366,
complications of surgery, 391, 392, 393, 394, 395, 396, 367, 368, 369, 370, 371, 368f, 369f, 370f
397, 398, 399, 400, 401, 402, 403, 404, 405, 406, indications for, 363, 364, 365f
407, 408, 409, 410, 411, 412, 413 modifications of, 371, 371f, 372f
delayed unions and nonunions in, 405, 406, 407, osseous resection in, 366
408, 409, 410, 411, 412, 408f, 409f, 410f, 411f results in, 364, 365, 366
hallux varus in, 396, 397, 398, 399, 400, 401, 402, McBride bunionectomy for, 360, 361, 362, 363, 361f,
397f, 399f, 401f, 402f 362f
malunion of first metatarsal in, 403f, 403, 404, 405, postsurgical hallux limitus in, 418
404f Silver bunionectomy for, 359, 360, 360f
recurrence of deformity in, 391, 392, 393, 394, 395, transverse plane digital deformity and, 152, 153, 154,
396, 392f, 393f, 394f, 396f 153f
distal metaphyseal osteotomies for, 241, 242, 243, 244, Hallux abductus, 219
245, 246, 247, 248, 249, 250, 251, 252, 253, 254, Hallux abductus angle, 221, 222, 222f
255, 256, 257, 258, 259, 260, 261, 262, 263 Hallux abductus interphalangeus, 504, 505, 506, 505f
apical axis guide in, 241, 242, 243, 241f, 242f, 243f Hallux abductus interphalangeus angle, 224, 225f
Austin bunionectomy as, 243f, 243, 244, 245, 246, Hallux equinus, 422, 424f
247, 248, 249, 250, 251See also Austin Hallux extensus, 260
bunionectomy. Hallux flexus, 321
avascular necrosis after, 258, 259 Hallux limitus and hallux rigidus, 415, 416, 417, 418, 419,
comparative studies of, 257, 258 420, 421, 422, 423, 424, 425, 426, 427, 428, 429, 430,
displacement of, 259f, 260f, 261f, 261 431, 432, 433, 434, 435, 436, 437, 438, 439, 440, 441,
Hohmann bunionectomy as, 255, 256, 256f 442, 443, 444, 445, 446, 447
Mitchell bunionectomy as, 253, 254, 255, 253f, arthrodesis of first metatarsocuneiform joint for, 288
254f, 255f arthrodesis of first metatarsophalangeal joint for, 317,
postoperative management of, 258 318, 319, 320, 321, 322, 323, 324, 325, 326, 327,
Reverdin bunionectomy as, 251, 252, 253, 251f, 328, 329, 330, 331, 332, 333, 334, 335, 336, 337,
252f, 253f 338, 339, 340, 341, 342, 343, 318t, 319t, 444
sagittal and transverse plane deviations after, 259, ancillary procedures in, 337, 338, 339, 340, 338f,
260 339f
Wilson bunionectomy as, 256, 257, 257f clinical evaluation of, 319
early procedures for, 359 complications of, 340f, 340, 341, 342, 341f
evaluation of, 217, 218, 219, 220, 221, 222, 223, 224, contraindications for, 323, 324
225, 226, 227 external fixation in, 337, 337f
biomechanical examination in, 220 indications for, 320f, 320, 321, 322, 323, 321t,
clinical examination in, 219, 220 322f
evolution of deformity and, 217, 218 joint resection in, 325, 326, 327, 326f, 328f
history in, 218, 219 pin or wire fixation in, 330f, 330, 331, 332, 331f
radiographic examination in, 220, 221, 222, 223, plate fixation in, 333, 334, 335, 333f, 334f, 335f,
224, 225, 226, 221f, 222f, 223f, 224f, 225f 336f
treatment considerations in, 226 position of fusion in, 327, 328, 329, 329f
first metatarsal base osteotomies for, 265, 266, 267, postoperative care in, 340
268, 269, 270, 271, 272, 273, 274, 275, 276, 277, screw fixation in, 332f, 332, 333, 333f
278, 279 skin incision and exposure in, 324, 325
anatomic considerations in, 268, 269, 269f cheilectomy and initial soft tissue releases for, 426,
chevron osteotomy in, 273, 274, 275, 275f 427, 428, 427f, 428f
closing base wedge osteotomy in, 269f, 270f, 271f, clinical features of, 415, 416, 417, 416f, 417f
272f, 269, 270, 271, 272, 273 conservative management of, 425, 426, 426f
crescentic osteotomy in, 273, 273f, 274f distal osteotomies for, 428, 429, 430, 431, 432, 433
indications for, 265, 266, 267, 268, 266f, 267f, Austin procedure and, 432f, 432, 433, 433f
268f modified Green-Watermann procedure and, 429,
opening base wedge osteotomy in, 275, 275f 430, 430f, 431f, 432f
postoperative management of, 276f, 277, 277f Watermann procedure and, 428, 429, 429f
first metatarsal shaft osteotomies for, 293, 294, 295, etiology of, 417, 418, 419, 420, 418f, 419f
296, 297, 298, 299, 300, 301, 302, 303, 304, 305, implant arthroplasty for, 442, 443, 443f, 444f
306, 307, 308, 309, 310, 311, 312, 313, 314, 315 interphalangeal sesamoid and, 387
Mau and Ludloff osteotomies and, 308, 309, 310, joint salvage and preservation in, 426
311, 312, 313, 308f, 309f, 310f, 311f, 312f, Keller arthroplasty for, 440, 441
313f, 314f Kessel-Bonney osteotomy for, 437, 438, 438f
P.607
Lambrinudi osteotomy for, 434, 435 of fifth metatarsal head, 150
Mayo-Stone and Valenti arthroplasty for, 441, 442 of fifth toe, 107, 108f
oblique head osteotomies for, 433, 434f pressure-induced, 416f
oblique sagittal base and sagittal Z osteotomy for, 435, Hypermobility in hallux abducto valgus deformity, 217,
436, 437, 436f, 437f, 438f 218
postoperative management in, 444, 445 Hypertrophic nonunion, 406
proximal osteotomies for, 433, 434, 435f Hypertrophy of toenail, 3
Regnauld, Vanore, and sagittal Z procedures for, 438, Hypochondroplasia, 582
439, 440, 439f Hyponychium, 1, 2f
role of plantar structures in, 420, 421, 422, 423, 424,
425, 420f, 421f, 422f, 423f, 424f, 425f I
soft tissue release for, 440, 440f, 441f
surgical complications in, 445 Ilizarov's law of tension-stress, 580
Hallux malleus, 321, 397 IM angle. See Intermetatarsal angle.
Hallux osteotomy, 437, 438, 439, 440 Immune response, 188
Hallux rigidus. See Hallux limitus and hallux rigidus. Implant, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180,
Hallux varus 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191,
after hallux abducto valgus surgery, 259, 260, 396, 397, 192, 193, 194, 195, 196, 197, 198, 199, 200, 201, 202,
398, 399, 400, 401, 402 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213,
clinical and radiographic evaluation of, 399f, 399, 214, 215, 401, 402
400 adjacent bone abnormalities after, 200, 201, 202, 201f
definition, incidence, and etiology of, 396, 397, alignment abnormalities after, 200
398, 399, 397f arthrodesis after, 323
treatment considerations for, 400, 401, 402, 401f, biomaterial failure in, 198, 199, 200, 199f
402f biomaterials for, 172, 173, 174, 175, 173t
after postaxial polydactyly repair, 483 biomechanical joint failure in, 202
with concomitant hallux malleus, 397, 397f bone resection in, 192, 193f
fibular sesamoidectomy and, 363 canal preparation for, 192
Hammer toe capsular repair in, 193, 194
after Morton's neuroma resection, 44 capsulotomy in, 191, 192
central rays and, 121, 122, 122f closure and postoperative course in, 194
of fifth digit, 104, 109, 109f696 design and function of, 175, 176, 177, 178, 179, 180,
hallux limitus and hallux rigidus and, 417 181, 177f, 178f, 179f, 180f, 181f
pathomechanics of, 60, 61, 62, 63, 64, 65, 66 evolution of arthroplasty and, 171, 172
extensor substitution in, 62, 63, 64, 65, 66, 63f, for hallux rigidus, 442, 443, 443f, 444f
64f, 65f, 66f host response to, 188, 189, 190, 191
flexor stabilization in, 61f, 61, 62 metals and, 188, 189f
flexor substitution in, 62, 62f polyethylene and, 188
unreduced lesser metatarsophalangeal joint polymers and, 188
dislocation and, 553 polymethylmethacrylate and, 189
Hardcastle classification of Lisfranc's joint injuries, 543, silicone rubber and, 189, 190, 191, 190f, 198, 199,
544f 199f
Hass type syndactyly, 484 implant grommets and, 192, 193
Hawkins talar neck fractures, 526, 527f indications for, 191, 191f
Heloma molle, 68 insertion of, 193
of fifth toe, 137 radiology in, 194f, 195f, 196f, 197f, 194, 195, 196,
in underlapping toe, 501 197, 198
Hematoma results of, 210, 211
after Morton's neuroma resection, 44 revision of, 204, 205, 206, 207, 208, 209, 210
fracture repair and, 577, 578 failed interpositional implant and, 204, 205, 206,
in Lisfranc's joint dislocation, 540 204f, 205f, 206f
subungual, 512f, 512, 513, 513f failed total joint system and, 206, 207, 208, 209,
Hemihypertrophy, congenital, 506f, 507f, 506, 507, 508, 210, 208f, 209f, 210f
508t soft tissue abnormalities after, 202, 203f
Hemiimplant for hallux limitus, 443, 443f surgical approach in, 191
Hemiphalangectomy with arthroplasty in fifth digit total joint replacement and, 181, 182, 183, 184, 185,
deformity, 110, 111, 112, 111f, 112f, 113f 186, 187, 188
Hemostasis, anatomic dissection process and, 230 Acumed Great Toe System in, 184, 185, 185f
Herbert bone screw, 249, 250, 250f Bio-Action Great Toe Implant in, 182, 183f
in first metatarsophalangeal joint arthrodesis, 332, Biomet Total Toe system in, 181, 182f
333 Kinetik Great Toe Implant in, 185, 186f
in Mitchell bunionectomy, 255, 255f Osteomed Reflexion First Metatarsophalangeal
nonunion after first metatarsophalangeal joint fusion Joint Implant System in, 185, 186, 187f
with, 341f Implant grommets, 192, 193
in Vanore-Corey procedure, 439 Incision
Heyman-Herndon-Strong procedure, 464f, 465f, 466f in Akin procedure, 375
Hibbs suspension, 96 in anatomic dissection of first metatarsophalangeal
Hinged wedge osteotomy, 148 joint, 230, 231f
Histopathology of Morton's neuroma, 33f, 34t, 34, 35, 36, in arthrodesis of first metatarsophalangeal joint, 282,
35f, 36f 324, 325
History in arthroplasty of fifth toe, 110, 110f
in foot dislocation, 252 in arthroplasty of proximal interphalangeal joint, 80,
in hallux abducto valgus deformity, 218, 219 81, 82, 81f
in transverse plane digital deformity, 155 in arthroplasty with hemiphalangectomy, 112, 112f
Hohmann procedure, 144, 145f, 146, 255, 256, 256f in bone grafting, 91
Hood apparatus, 52 in brachymetatarsia surgery, 588
Horizontal nail biopsy, 12, 12f in capsulotomy, 74
Host response to implant, 188, 189, 190, 191 in cheilectomy, 428
metals and, 188, 189f for correction of overlapping fifth toe, 497
polyethylene and, 188 in derotational skin wedge plasty, 116, 117, 117f
polymers and, 188 in distal metaphyseal osteotomy, 149
polymethylmethacrylate and, 189 in distal phalangectomy of fifth toe, 115, 115f
silicone rubber and, 189, 190, 191, 190f, 198, 199, in excision of digit, 481
199f in excision of interphalangeal sesamoid, 388, 388f
Hyperextension in extensor tendon lengthening, 75
in dorsal dislocation of interphalangeal joint, 553 in fifth toe condylectomy, 113, 114, 114f
in first metatarsophalangeal joint dislocation, 547 in flexor tendon transfer, 76, 77, 77f, 78f
in lesser metatarsophalangeal joint dislocations, 551
Hyperkeratosis
P.608
in hallux exostectomy, 389 heloma molle in, 68
in hallux interphalangeal joint arthrodesis, 384, 385, 385f lesser metatarsal surgery in, 96f, 96, 97, 98, 97f
in hallux valgus surgery, 230, 231f long metatarsals in, 69
in hallux varus deformity, 400, 401f mallet toe in, 66
in hammer toe repair, 92f, 93f metatarsal cavus in, 68, 69
in Heyman-Herndon-Strong procedure, 464, 465f metatarsophalangeal joint adductus or abductus in, 70f, 70, 71,
in interphalangeal arthrodesis with Kirschner wire fixation, 82 71f
in Lepird procedure, 469, 470f metatarsophalangeal joint dislocation in, 73, 98, 99, 100, 99f
in lesser metatarsal surgery, 125, 126 metatarsophalangeal joint limitation and, 71f, 71, 72
in long flexor tenotomy, 74, 75f osseous procedures for, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88,
in Mau osteotomy, 309, 309f 89, 90, 91
in medial capsulotomy, 236, 236f arthroplasty of proximal interphalangeal joint in, 80, 81,
in offset-V osteotomy, 293 82, 81f
in open reduction of Lisfranc's joint dislocation, 546 bone grafting in, 89, 90, 91, 90f
in opening wedge cuneiform osteotomy, 290 digital arthrodesis using internal pins in, 85, 86, 86f
in partial resection of abductor hallucis tendon-muscle historical review of, 79, 80
complex, 462f interphalangeal arthrodesis with Kirschner wire fixation in,
in peg-in-hole arthrodesis, 83, 84, 84f 82, 83, 83f
in plantar condylectomy, 133, 133f peg-in-hole arthrodesis in, 83, 84, 85, 84f
principles of anatomic dissection and, 229, 230 resection of base of proximal phalanx in, 86, 87, 88, 89,
in proximal base osteotomy, 150 88f, 89f
in proximal osteotomies, 268, 269, 269f pathomechanics of, 60, 61, 62, 63, 64, 65, 66
in recurrent hallux abducto valgus deformity, 395 extensor substitution and, 62, 63, 64, 65, 66, 63f, 64f, 65f,
in resection arthroplasty, 366, 367f 66f
in resection of proximal phalangeal base, 87 flexor stabilization and, 61f, 61, 62
in Scarf osteotomy, 299, 300 flexor substitution and, 62, 62f
in soft tissue release for hallux limitus, 440f, 441f predislocation syndrome of lesser metatarsophalangeal joint in,
in Swanson double-stem implant arthroplasty, 191 72, 72f
in syndactyly, 79, 80f, 118 soft tissue surgery for, 73, 74, 75, 76, 77, 78, 79
in tibial sesamoid fracture, 570f, 571 extensor tendon lengthening in, 75, 76
Infection extensor tenotomy and capsulotomy in, 74
dystrophic fissured toenail secondary to, 3, 4f flexor tendon transfer in, 75, 76, 77, 78, 79, 76f, 77f, 78f,
in joint implant, 202 79f
of toenail, 6, 7, 6f, 7f, 8f, 7t flexor tenotomy and capsulotomy in, 74, 75, 75f
Inflammation tenotomy in, 73, 74
in joint implant, 202, 203f stepwise surgical approach to, 91, 92, 93, 94, 95, 96, 92f, 93f,
lesser metatarsal pain in, 122 94f, 95f
transverse plane digital deformity and, 154 syndactyly procedure in, 79, 80f
Ingrown toenail, 4 transverse plane deformity in, 98
biomechanical imbalance in, 9, 10, 10f Intermetatarsal angle
conservative care of, 13 arthrodesis of first metatarsocuneiform joint and, 280
conservative management of, 13, 14, 14f Austin bunionectomy and, 243, 244
prevention of, 12, 13 crescentic first metatarsal osteotomy and, 273
surgical management of, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, first metatarsal base osteotomy and, 265, 266
25 of fourth and fifth metatarsals, 140, 140f
local anesthesia in, 14, 15, 16, 15f, 16f hallux abducto valgus and, 223, 224, 224f
partial and total nail avulsion in, 17, 17f hallux limitus and, 433
partial matrixectomy in, 17f, 18f, 19f, 17, 18, 19, 20 hallux varus deformity and, 398, 399
postoperative care in, 24, 25 Hohmann osteotomy and, 255, 256
skin closure and suture techniques in, 22, 23, 24, 23f, 24f Keller joint resection arthroplasty and, 363, 364
soft tissue correction in, 16f, 16, 17 Ludloff and Mau procedures and, 308
total matrixectomy in, 20, 21, 22, 20f, 21f, 22f, 23f offset-V osteotomy and, 293, 294, 295, 294f
Injection therapy for Morton's neuroma, 37, 38 recurrent hallux abducto valgus and, 392f, 392, 393
Instability in great toe hemiimplant, 200 Reverdin bunionectomy and, 251
Interdigital pressure keratoses, 107, 108f Scarf procedure and, 300, 301f, 303
Interfascicular neurolysis, 41 Intermetatarsal bursa, Morton's neuroma and, 36, 37
Interfragmentary screw in first metatarsophalangeal joint Intermetatarsal neuroma, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39,
arthrodesis, 335, 335f 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50
Intermediate digit deformities, 51, 52, 53, 54, 55, 56, 57, 58, 59, conservative management of, 37, 38
60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, definition, anatomy, and incidence of, 29, 30, 31, 30f, 31t
77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, differential diagnosis of, 32, 32t
94, 95, 96, 97, 98, 99, 100, 101, 102 etiology and biomechanics of, 36, 37, 37t
biomechanics of, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60 future considerations in, 47
extensor digitorum brevis and longus function and, 51f, 52f, histopathology of, 33f, 34t, 34, 35, 36, 35f, 36f
53f, 51, 52, 53, 54 magnetic resonance imaging for, 32, 33, 33f
flexor digitorum brevis and longus function and, 54f, 55f, pain in, 31, 32
56f palpation of, 32
lumbricales function and, 57, 58, 59, 60, 59f radiography of, 32
plantar interossei function and, 54, 55, 56, 57, 56f, 57f, sensory nerve conduction tests for, 32
58f signs and symptoms of, 31, 31t
quadratus plantae muscle function and, 60, 60f surgical management of, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47
brachymetatarsia in, 69f, 69, 70 carbon dioxide laser treatment in, 42, 43
claw toe in, 67, 68 complications of, 43, 44, 45, 46, 47, 45t, 46f, 46t
complications of surgery for, 100f, 100, 101 cryogenic denervation in, 43
curly toes in, 66, 67 endoscopic decompression in, 41, 42
digitus abductus in, 68 general considerations in, 38
digitus adductus in, 68 neurolysis in, 40, 41, 41f, 42f
etiology of, 51 radiosurgical destruction in, 42, 43f
flexor dislocation and, 70 resection in, 38, 39, 40, 39f
hammer toe in, 67 ultrasonography of, 33, 33f
P.609
Internal neurolysis, 41 contraindications for, 371, 372
Internal pin digital arthrodesis, 85, 86, 86f dissection in, 366, 367f
Interossei muscles flexor tendon and capsular reattachment in, 366, 367,
biomechanics of, 54, 55, 56, 57, 56f, 57f, 58f 368, 369, 370, 371, 368f, 369f, 370f
flexor stabilization and, 61 indications for, 363, 364, 365f
flexor substitution and, 62 modifications of, 371, 371f, 372f
Interphalangeal arthrodesis osseous resection in, 366
of hallux, 384, 385, 386, 385f, 386f results in, 364, 365, 366
with Kirschner wire fixation, 82, 83, 83f Juvenile hallux abducto valgus deformity, 345, 346, 347,
using internal pins, 85, 86, 86f 348, 349, 350, 351, 352, 353, 354, 355, 356, 357
Interphalangeal joint associated deformities, 348, 349
dislocation of, 553, 554, 555, 554f clinical features of, 346, 347
hallux limitus and hallux rigidus and, 416 conservative management of, 349
Interphalangeal sesamoids, 386, 387, 388, 389, 387f, 388f, distal osteotomies for, 350, 351
553 epiphysiodesis for, 352, 353, 353f, 354f, 355f, 356f
Interpositional joint implant, 176, 177, 178, 179, 180, 181, first metatarsocuneiform arthrodesis for, 281
177f, 178f, 179f, 180f, 181f metatarsocuneiform joint arthrodesis and cuneiform
Interspacectomy, 44 osteotomy for, 351, 352
Intrinsic elevatus, 433 metatarsus adductus with, 267
Intrinsic joint implant failure, 198 phalangeal osteotomies for, 356
Intrinsic metatarsus primus elevatus, 424f, 425 proximal osteotomies for, 268, 351, 351f, 352f
Inverted Z-osteotomy, 303, 303f radiographic evaluation of, 347f, 347, 348
Isoxsuprine, 44 soft tissue procedures for, 350
Itoh method of desyndactylization, 484, 485, 485f
K
J
K-wire. See Kirschner wire.
Jaddassohn-Lewandowsky syndrome, 10, 10t Kalish procedure, 244, 245, 245f
Joint-destructive procedures Kelikian push-up test, 100
for hallux limitus and hallux rigidus, 440, 441, 442 Keller joint resection arthroplasty, 363, 364, 365, 366,
for transverse plane digital deformity, 165, 166, 167, 367, 368, 369, 370, 371, 372
168 after first metatarsophalangeal joint dislocation, 551
Joint implant arthroplasty, 171, 172, 173, 174, 175, 176, complications of, 372
177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187, contraindications for, 371, 372
188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, dissection in, 366, 367f
199, 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, flexor tendon and capsular reattachment in, 366, 367,
210, 211, 212, 213, 214, 215 368, 369, 370, 371, 368f, 369f, 370f
adjacent bone abnormalities after, 200, 201, 202, 201f for hallux limitus and hallux rigidus, 440, 441
alignment abnormalities after, 200 indications for, 363, 364, 365f
biomaterial failure in, 198, 199, 200, 199f modifications of, 371, 371f, 372f
biomaterials for, 172, 173, 174, 175, 173t osseous resection in, 366
biomechanical joint failure in, 202 results in, 364, 365, 366
bone resection in, 192, 193f Keratoma, plantar, 150
canal preparation for, 192 Keratosis
capsular repair in, 193, 194 after hallux abducto valgus repair, 260
capsulotomy in, 191, 192 of fifth digit, 115
closure and postoperative course in, 194 Kessel-Bonney osteotomy, 437, 438, 438f
design and function implant in, 175, 176, 177, 178, Kinetik Great Toe Implant, 185, 186f
179, 180, 181, 177f, 178f, 179f, 180f, 181f Kinetikos total joint implant, 443f
evolution of, 171, 172 Kirschner wire
host response to, 188, 189, 190, 191 in Akin procedure, 380, 381, 381f
metals and, 188, 189f as apical axis guide, 241, 242f
polyethylene and, 188 in Austin bunionectomy, 245, 248f, 248, 249, 249f
polymers and, 188 in bone grafting in digital surgery, 91
polymethylmethacrylate and, 189 in closing base wedge osteotomy, 270, 271
silicone rubber and, 189, 190, 191, 190f, 198, 199, in dislocated metatarsophalangeal joint, 99
199f in distal V-osteotomy, 126
implant grommets and, 192, 193 for fifth digit open fracture, 565f
implant insertion in, 193 in first metatarsocuneiform joint arthrodesis, 283
indications for, 191, 191f in first metatarsophalangeal joint arthrodesis, 330f,
radiology in, 194f, 195f, 196f, 197f, 194, 195, 196, 330, 331, 332, 331f
197, 198 in Ganley-Ganley procedure, 474
results of, 210, 211 in Green-Watermann procedure, 430
revision of, 204, 205, 206, 207, 208, 209, 210 in hallux interphalangeal joint arthrodesis, 385, 385f
failed interpositional implant and, 204, 205, 206, in interphalangeal arthrodesis, 82, 83, 83f
204f, 205f, 206f in Mau procedure, 309, 310f
failed total joint system and, 206, 207, 208, 209, in Mitchell osteotomy, 254f, 255
210, 208f, 209f, 210f in modified Steytler-Van der Walt procedure, 468f
soft tissue abnormalities after, 202, 203f for nonunion of first metatarsal osteotomy, 408f
surgical approach in, 191 in offset-V osteotomy, 293, 295, 296f
total joint replacement and, 181, 182, 183, 184, 185, in peg-in-hole arthrodesis, 83, 84, 85, 84f
186, 187, 188 in plantar condylectomy, 133, 133f
Acumed Great Toe System in, 184, 185, 185f in postaxial polydactyly repair, 482f
Bio-Action Great Toe Implant in, 182, 183f in resection arthroplasty, 368, 369, 369f
Biomet Total Toe system in, 181, 182f to resist troughing, 306
Kinetik Great Toe Implant in, 185, 186f in Scarf osteotomy, 300
Osteomed Reflexion First Metatarsophalangeal Klippel-Trenaunay-Weber syndrome, 506
Joint Implant System in, 185, 186, 187f Koenig Biomet two-component implant, 442
Joint-preservation procedures Koilonychia, 3
in hallux limitus, 426 Kutler-type biaxial V-Y advancement flap, 517, 518, 519,
in recurrent hallux abducto valgus deformity, 395 519f
in transverse plane digital deformity, 164f, 164, 165,
166f, 167f L
Joint resection, 363, 364, 365, 366, 367, 368, 369, 370,
371, 372 Laceration of nail bed
in arthrodesis of first metatarsophalangeal joint, 282, crushing, 514, 514f
283f, 325, 326, 327, 326f, 328f simple, 513f, 513, 514
complications of, 372
P.610
Lag screw in hallux interphalangeal joint arthrodesis, 386, 386f congenital underlapping of toe, 501, 502, 503, 504, 502f, 503f, 504f
Lambrinudi osteotomy, 434, 435 fifth digit, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114,
Lapidus arthrodesis, 436, 437 115, 116, 117, 118, 119
LaPorta implant, 180, 180f amputation in, 118, 119
Lateral deviation angle of fifth metatarsal, 140, 141, 142, 140f, 141f, anatomy in, 103f, 103, 104, 104f
142f arthroplasty for, 109, 110, 110f, 111f
Lateral force midtarsal injury, 535, 536, 537 arthroplasty with hemiphalangectomy for, 110, 111, 112, 111f,
Lateral gap sign, 200 112f, 113f
Lateral nail biopsy, 12, 12f clinical appearance of, 107, 108
Lateral subtalar dislocation, 528, 529, 531f complications of arthroplasty for, 114, 115
Lawrence hinge, 180f, 180, 181 condylectomy for, 112, 113, 114, 113f, 114f
Length pattern aberrations in hallux limitus or hallux rigidus, 417 distal phalangectomy for, 115f, 115, 116
Lengthening devices in callus distraction, 584f, 584, 585, 585f flexibility and, 104, 105
Lengthening osteotomy in lesser metatarsal surgery, 130, 132f lesion pattern and types in, 105, 106, 107, 107f, 108f
Lepird procedure, 469f, 470f, 471f metatarsophalangeal joint release in, 108, 109, 109f
Lesser metatarsal overload, 121 planes of deformity in, 104, 105f, 106f
Lesser metatarsal surgery, 120, 121, 122, 123, 124, 125, 126, 127, 128, skin plasty for, 116f, 116, 117, 118, 117f
129, 130, 131, 132, 133, 134, 135, 136 syndactyly for, 118, 118f
anatomy in, 120, 120f, 121f intermediate digits and metatarsophalangeal joint, 51, 52, 53, 54, 55,
approach in, 125, 126 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73,
bone grafting in, 130 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91,
clinical examination in, 122, 123, 123f 92, 93, 94, 95, 96, 97, 98, 99, 100, 101, 102
conservative treatment and, 123, 124 arthroplasty of proximal interphalangeal joint in, 80, 81, 82, 81f
considerations in, 125, 126t bone grafting in, 89, 90, 91, 90f
dorsiflexory osteotomies in, 126, 127, 127f, 128f brachymetatarsia and, 69f, 69, 70
for elevated or short metatarsals, 128, 129, 130, 130f, 131f, 132f claw toe and, 67, 68
etiology of lesser metatarsal symptoms and, 121f, 121, 122, 122f complications of digital surgery and, 100f, 100, 101
historical review of, 124f, 124, 125, 125f curly toes and, 66, 67
for intermediate and metatarsophalangeal joint deformities, 96f, 96, digital arthrodesis using internal pins in, 85, 86, 86f
97, 98, 97f digitus abductus and, 68
for long or plantarly displaced metatarsals, 126 digitus adductus and, 68
plantar condylectomy in, 130, 131, 132, 133, 134, 133f, 134f etiology of, 51
shortening osteotomies in, 127, 128, 128f, 129f extensor digitorum brevis and longus function and, 51f, 52f, 53f,
Lesser metatarsalgia, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 51, 52, 53, 54
130, 131, 132, 133, 134, 135, 136 extensor substitution and, 62, 63, 64, 65, 66, 63f, 64f, 65f, 66f
after Keller procedure, 372 extensor tendon lengthening for, 75, 76
anatomy in, 120, 120f, 121f extensor tenotomy and capsulotomy for, 74
bone grafting for, 130 flexor digitorum brevis and longus function and, 54f, 55f, 56f
clinical examination in, 122, 123, 123f flexor dislocation and, 70
conservative treatment in, 123, 124 flexor stabilization and, 61f, 61, 62
dorsiflexory osteotomies for, 126, 127, 127f, 128f flexor substitution and, 62, 62f
elevated or short metatarsals and, 128, 129, 130, 130f, 131f, 132f flexor tendon transfer for, 75, 76, 77, 78, 79, 76f, 77f, 78f, 79f
etiology of, 121f, 121, 122, 122f flexor tenotomy and capsulotomy for, 74, 75, 75f
historical review of surgery in, 124f, 124, 125, 125f hammer toe and, 67
long or plantarly displaced metatarsals and, 126 heloma molle and, 68
plantar condylectomy for, 130, 131, 132, 133, 134, 133f, 134f interphalangeal arthrodesis with Kirschner wire fixation for, 82, 83,
shortening osteotomies for, 127, 128, 128f, 129f 83f
surgical approach in, 125, 126 lesser metatarsal surgery in, 96f, 96, 97, 98, 97f
surgical considerations in, 125, 126t long metatarsals and, 69
Lesser metatarsophalangeal joint lumbricales function and, 57, 58, 59, 60, 59f
derangement of, 70, 71, 72, 70f, 71f, 72f mallet toe and, 66
dislocation of, 551, 552, 553, 552f metatarsal cavus and, 68, 69
Lesser ray deformities, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, metatarsophalangeal joint adductus or abductus and, 70f, 70, 71,
64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 71f
83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 100, metatarsophalangeal joint dislocation and, 73, 98, 99, 100, 99f
101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, metatarsophalangeal joint limitation and, 71f, 71, 72
115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127, 128, peg-in-hole arthrodesis in, 83, 84, 85, 84f
129, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 141, 142, plantar interossei function and, 54, 55, 56, 57, 56f, 57f, 58f
143, 144, 145, 146, 147, 148, 149, 150, 151, 152, 153, 154, 155, 156, predislocation syndrome of lesser metatarsophalangeal joint and,
157, 158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 169 72, 72f
central rays, 120, 121, 122, 123, 124, 125, 126, 127, 128, 129, 130, quadratus plantae muscle function and, 60, 60f
131, 132, 133, 134, 135, 136 resection of base of proximal phalanx in, 86, 87, 88, 89, 88f, 89f
anatomy in, 120, 120f, 121f stepwise approach to digital surgery in, 91, 92, 93, 94, 95, 96, 92f,
bone grafting for, 130 93f, 94f, 95f
clinical examination in, 122, 123, 123f syndactyly procedure for, 79, 80f
conservative treatment in, 123, 124 tenotomy for, 73, 74
dorsiflexory osteotomies for, 126, 127, 127f, 128f transverse plane deformity and, 98
elevated or short metatarsals and, 128, 129, 130, 130f, 131f, 132f plantar keratoma, 151
etiology of, 121f, 121, 122, 122f tailor's bunion, 137, 138, 139, 140, 141, 142, 143, 144, 145, 146, 147,
historical review of surgery in, 124f, 124, 125, 125f 148, 149, 150, 138f
long or plantarly displaced metatarsals and, 126 arthroplasty in, 143, 144, 144f, 145f
plantar condylectomy for, 130, 131, 132, 133, 134, 133f, 134f clinical evaluation in, 139
shortening osteotomies for, 127, 128, 128f, 129f conservative treatment and, 142
surgical approach in, 125, 126 distal metatarsal osteotomies in, 144, 145, 146, 147, 148, 149,
surgical considerations in, 125, 126t 145f, 146f, 147f, 148f, 149f
congenital overlapping of toe, 495, 496, 497, 498, 499, 500, 501 etiology of, 137, 138, 139
conservative management of, 495, 496, 496f exostectomy in, 142, 143, 143f
etiology and clinical presentation of, 495, 495f intermetatarsal angle of fourth and fifth metatarsals and,
postoperative care in, 501 140, 140f
surgical considerations in, 497, 498, 499, 500, 501, 498f, 499f,
500f
P.611
lateral deviation angle and, 140, 141, 142, 140f, 141f, Medial closing wedge osteotomy, 506
142f Medial cuneiform
proximal base osteotomies in, 149, 150, 150f absence in metatarsus varus, 450, 451
radiographic evaluation in, 139, 140 lengthening procedure of, 592, 593f, 594f
signs and symptoms in, 137 metatarsus adductus deformity and, 470, 471, 472, 473,
transverse plane, 98, 152f, 152, 153, 154, 155, 156, 157, 474, 472f, 473f
158, 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, Medial displacement metatarsal osteotomy, 146
169 Medial eminence resection, 237
conservative management of, 157, 158f in anatomic dissection of first metatarsophalangeal joint,
etiology of, 152, 153, 154, 153f, 154f 237
evaluation of, 155, 156f, 157f arthrodesis of first metatarsophalangeal joint and, 325
joint-destructive procedures for, 165, 166, 167, 168 Medial force midtarsal injury, 533, 534, 535, 533f, 534f, 535f,
joint-preservation procedures in, 164f, 164, 165, 166f, 536f
167f Medial pinch callus, 389
postoperative care in, 168 Medial subtalar dislocation, 527, 528, 528f, 529f, 530f
soft tissue procedures for, 157, 158, 159, 160, 161, 162, Mendelssohn modification suture technique, 22, 23, 23f
163, 164, 158f, 159f, 160f, 161f, 162f, 163f, 164f Metabolic disorders, metatarsalgia in, 122
Lichtblau tenotomy of abductor hallucis, 461, 463f Metals
Ligamentous laxity, hallux abducto valgus deformity and, 321 host response to, 188, 189f
Lisfranc's joint dislocation, 538, 539, 540, 541, 542, 543, 544, for joint implants, 172, 173, 173t
545, 546, 539f, 540f, 541f Metaphyseal osteotomy
anatomic considerations in, 541, 542, 542f in callus distraction, 581
direct injury in, 542, 543 distal, 241, 242, 243, 244, 245, 246, 247, 248, 249, 250,
indirect injury in, 543, 544f 251, 252, 253, 254, 255, 256, 257, 258, 259, 260, 261,
lesser metatarsophalangeal joint dislocations and, 551 262, 263
treatment of, 543, 544, 545, 546 apical axis guide in, 241, 242, 243, 241f, 242f, 243f
type A or total incongruity, 543, 545f Austin bunionectomy as, 243f, 243, 244, 245, 246, 247,
type B or partial incongruity, 543, 545f 248, 249, 250, 251See also Austin bunionectomy.
type C of divergent, 543, 546f avascular necrosis after, 258, 259
Lister's corn on fifth toe, 112, 113, 114, 113f, 114f comparative studies of, 257, 258
Loading phenomenon, tenotomy and, 74 displacement of, 259f, 260f, 261f, 261
Lobster claw deformity, 490 Hohmann bunionectomy as, 255, 256, 256f
Local anesthesia Mitchell bunionectomy as, 253, 254, 255, 253f, 254f,
in Morton's neuroma, 37, 38 255f
in nail surgery, 14, 15, 16, 15f, 16f postoperative management of, 258
Logroscino approach, 252, 253, 253f Reverdin bunionectomy as, 251, 252, 253, 251f, 252f,
Long dorsal arm modification of Austin osteotomy, 244, 245, 253f
244f, 245f, 246f, 247f sagittal and transverse plane deviations after, 259, 260
Long flexor tenotomy, 74, 75, 75f Wilson bunionectomy as, 256, 257, 257f
Long metatarsal, 69, 126 Metatarsal artery, Morton's neuroma and, 29, 30f
in hallux abducto valgus, 224, 225, 225f Metatarsal cavus, 68, 69
hallux limitus and, 418 Metatarsal cuneiform procedures, 280, 281, 282, 283, 284,
Long plantar arm modification of Austin osteotomy, 245 285, 286, 287, 288, 289, 290, 291
Longitudinal biopsy of nail, 11, 12f cuneiform osteotomies in, 289f, 289, 290, 291, 290f
Longitudinal force midtarsal injury, 535, 537f first metatarsocuneiform arthrodesis in, 280, 281, 282, 283,
Ludloff osteotomy, 308, 309, 310, 311, 312, 313, 308f, 309f, 284, 285, 286, 287, 288
310f, 311f, 312f, 313f, 314f bone grafting in, 282, 283
Lumbricales complications of, 287, 288, 288f
biomechanics of, 57, 58, 59, 60, 59f fixation in, 283, 284, 285, 284f, 285f, 286f
extensor substitution and, 62 indications for, 280, 281, 282
Lunula, 511 modifications of, 283
Lymphedema praecox, 10 postoperative management of, 285
results of, 285, 286, 287, 287f
M Metatarsal disorders, 68, 69, 70, 69f
Metatarsal head
Macrodactyly, 487, 488, 489, 490, 488f, 489f, 489t arthrodesis of first metatarsophalangeal joint and, 325
Macrodystrophia lipomatosis progressiva, 488, 489 exposure in hallux valgus surgery, 236, 236f
Macrotrauma in hallux rigidus, 421f, 421, 422, 422f hallux abducto valgus and, 224, 225f
Magnetic resonance imaging resection arthroplasty techniques for, 441, 442
in metatarsus adductus, 459 resection in callus distraction, 588, 588f
in Morton's neuroma, 32, 33, 33f Metatarsal osteotomy
in sesamoid fracture, 568, 569f in cleft foot repair, 493
in transverse plane digital deformity, 155, 157f for metatarsus adductus, 467, 468, 469, 467f, 468f, 469f,
Malignant melanoma of toenail, 9 470f, 471f
Malignant tumor of toenail, 8f, 8t, 8, 9, 9f Metatarsal pads for Morton's neuroma, 37
Mallet toe, 61f, 66, 104 Metatarsal protrusion distance, hallux abducto valgus and,
Malunion 225
after hallux abducto valgus surgery, 403f, 403, 404, 405, Metatarsalgia
404f after Wilson osteotomy, 257
in callus distraction, 586, 587f in claw toes, 68
of first metatarsal, 403f, 403, 404, 405, 404f in hallux limitus, 416
in first metatarsal osteotomy, 418 in hammer toes, 67
in metatarsal osteotomies, 168 in lesser metatarsals, 120, 121, 122, 123, 124, 125, 126,
Manipulation in metatarsus adductus, 457, 458 127, 128, 129, 130, 131, 132, 133, 134, 135, 136
Matatarsus primus elevatus, 403, 404 after Keller procedure, 372
Matrixectomy anatomy in, 120, 120f, 121f
partial, 17f, 18f, 19f, 17, 18, 19, 20 bone grafting for, 130
total, 20, 21, 22, 20f, 21f, 22f, 23f clinical examination in, 122, 123, 123f
Mau osteotomy, 299, 308, 309, 310, 311, 312, 313, 308f, 309f, conservative treatment in, 123, 124
310f, 311f, 312f, 313f, 314f dorsiflexory osteotomies for, 126, 127, 127f, 128f
Mayo-Stone procedure, 441, 442 elevated or short metatarsals and, 128, 129, 130, 130f,
McBride procedure, 360, 361, 362, 363, 361f, 362f 131f, 132f
development of hallux varus deformity after, 398 etiology of, 121f, 121, 122, 122f
McCormick-Blount procedure, 467, 467f historical review of surgery in, 124f, 124, 125, 125f
Mechanical onycholysis, 512 long or plantarly displaced metatarsals and,
Medial capsulorrhaphy, 238 126
Medial capsulotomy, 236, 236f
P.612
plantar condylectomy for, 130, 131, 132, 133, 134, 133f, 134f extensor substitution and, 62, 63, 64, 65, 66, 63f, 64f, 65f, 66f
shortening osteotomies for, 127, 128, 128f, 129f flexor stabilization and, 61f, 61, 62
surgical approach in, 125, 126 flexor substitution and, 62, 62f
surgical considerations in, 125, 126t predislocation syndrome of lesser metatarsophalangeal joint in, 72,
in Morton's neuroma, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 72f
42, 43, 44, 45, 46, 47, 48, 49, 50 soft tissue surgery for, 73, 74, 75, 76, 77, 78, 79
carbon dioxide laser treatment in, 42, 43 extensor tendon lengthening in, 75, 76
conservative management of, 37, 38 extensor tenotomy and capsulotomy in, 74
cryogenic denervation in, 43 flexor tendon transfer in, 75, 76, 77, 78, 79, 76f, 77f, 78f, 79f
definition, anatomy, and incidence of, 29, 30, 31, 30f, 31t flexor tenotomy and capsulotomy in, 74, 75, 75f
differential diagnosis of, 32, 32t tenotomy in, 73, 74
endoscopic decompression of, 41, 42 stepwise surgical approach to, 91, 92, 93, 94, 95, 96, 92f, 93f, 94f,
etiology and biomechanics of, 36, 37, 37t 95f
future considerations in, 47 syndactyly procedure in, 79, 80f
histopathology of, 33f, 34t, 34, 35, 36, 35f, 36f transverse plane, 98, 152f, 152, 153, 154, 155, 156, 157, 158, 159, 160,
magnetic resonance imaging for, 32, 33, 33f 161, 162, 163, 164, 165, 166, 167, 168, 169
neurolysis in, 40, 41, 41f, 42f conservative management of, 157, 158f
pain in, 31, 32 etiology of, 152, 153, 154, 153f, 154f
palpation of, 32 evaluation of, 155, 156f, 157f
radiography of, 32 joint-destructive procedures for, 165, 166, 167, 168
radiosurgical destruction of, 42, 43f joint-preservation procedures in, 164f, 164, 165, 166f, 167f
resection of, 38, 39, 40, 39f postoperative care in, 168
sensory nerve conduction tests for, 32 soft tissue procedures for, 157, 158, 159, 160, 161, 162, 163, 164,
signs and symptoms of, 31, 31t 158f, 159f, 160f, 161f, 162f, 163f, 164f
surgical complications in, 43, 44, 45, 46, 47, 45t, 46f, 46t Metatarsophalangeal joint dislocation, 73
ultrasonography of, 33, 33f Metatarsophalangeal joint limitation, 71f, 71, 72
unreduced lesser metatarsophalangeal joint dislocation and, 553 Metatarsophalangeal joint release in fifth digit deformity, 108, 109, 109f
Metatarsocuneiform joint arthrodesis Metatarsus adducto varus, 452
for adolescent bunion, 351, 352 Metatarsus adductus, 345, 346, 347, 348, 349, 350, 351, 352, 353, 354,
first metatarsophalangeal joint and, 339 355, 356, 357, 449, 450, 451, 452, 453, 454, 455, 456, 457, 458, 459,
Metatarsophalangeal joint 460, 461, 462, 463, 464, 465, 466, 467, 468, 469, 470, 471, 472, 473,
osseous impingement of, 421 474, 475, 476
plantar plate of, 120, 120f associated deformities, 348, 349
positional deviation in hallux valgus deformity, 222, 223f callus distraction for, 592, 593f, 594f
Metatarsophalangeal joint abductus, 70f, 70, 71, 71f clinical evaluation of, 452, 453, 454, 453f, 454f
Metatarsophalangeal joint adductus, 70f, 70, 71, 71f clinical features of, 346, 347
Metatarsophalangeal joint capsulotomy, 74 conservative management of, 349, 457, 458, 459, 458f, 459f
Metatarsophalangeal joint deformities, 51, 52, 53, 54, 55, 56, 57, 58, 59, diagnostic imaging in, 454, 455, 456, 457, 455f, 456f, 457f
60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, distal osteotomies for, 350, 351
79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, epiphysiodesis for, 352, 353, 353f, 354f, 355f, 356f
98, 99, 100, 101, 102 failure to recognize, 394f, 394, 395
biomechanics of, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60 first cuneiform closing wedge abductory osteotomy, 290
extensor digitorum brevis and longus function and, 51f, 52f, 53f, first metatarsal base osteotomies for, 265, 266, 267, 268, 269, 270,
51, 52, 53, 54 271, 272, 273, 274, 275, 276, 277, 278, 279
flexor digitorum brevis and longus function and, 54f, 55f, 56f anatomic considerations in, 268, 269, 269f
lumbricales function and, 57, 58, 59, 60, 59f chevron osteotomy in, 273, 274, 275, 275f
plantar interossei function and, 54, 55, 56, 57, 56f, 57f, 58f closing base wedge osteotomy in, 269f, 270f, 271f, 272f, 269, 270,
quadratus plantae muscle function and, 60, 60f 271, 272, 273
brachymetatarsia in, 69f, 69, 70 crescentic osteotomy in, 273, 273f, 274f
claw toe in, 67, 68 indications for, 265, 266, 267, 268, 266f, 267f, 268f
complications of surgery for, 100f, 100, 101 opening base wedge osteotomy in, 275, 275f
curly toes in, 66, 67 postoperative management of, 276f, 277, 277f
digitus abductus in, 68 first metatarsophalangeal joint arthrodesis in, 321
digitus adductus in, 68 incidence and etiology of, 449, 450, 451, 451f, 452f
etiology of, 51 juvenile hallux abducto valgus and, 347
flexor dislocation and, 70 metatarsal osteotomies for, 467, 468, 469, 467f, 468f, 469f, 470f,
hammer toe in, 67 471f
heloma molle in, 68 metatarsocuneiform joint arthrodesis and cuneiform osteotomy for,
lesser metatarsal surgery in, 96f, 96, 97, 98, 97f 351, 352
long metatarsals in, 69 nomenclature in, 449, 450f, 451f
mallet toe in, 66 phalangeal osteotomies for, 356
metatarsal cavus in, 68, 69 proximal osteotomies for, 351, 351f, 352f
metatarsophalangeal joint adductus or abductus in, 70f, 70, 71, 71f radiographic evaluation of, 347f, 347, 348
metatarsophalangeal joint dislocation in, 73, 98, 99, 100, 99f soft tissue procedures for, 350, 460, 461, 462, 463, 464
metatarsophalangeal joint limitation and, 71f, 71, 72 tarsal osteotomies for, 469, 470, 471, 472, 473, 474, 472f, 473f, 474f
osseous procedures for, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, Metatarsus adductus angle, 455, 456f, 457f
91 hallux abducto valgus and, 224, 224f
arthroplasty of proximal interphalangeal joint in, 80, 81, 82, 81f Metatarsus primus elevatus
bone grafting in, 89, 90, 91, 90f hallux limitus and, 422
digital arthrodesis using internal pins in, 85, 86, 86f radiographic evaluation of, 424f, 424, 425, 425f
historical review of, 79, 80 Metatarsus primus varus, 345, 346, 347, 348, 349, 350, 351, 352, 353, 354,
interphalangeal arthrodesis with Kirschner wire fixation in, 82, 83, 355, 356, 357
83f associated deformities, 348, 349
peg-in-hole arthrodesis in, 83, 84, 85, 84f clinical features of, 346, 347
resection of base of proximal phalanx in, 86, 87, 88, 89, 88f, 89f conservative management of, 349
pathomechanics of, 60, 61, 62, 63, 64, 65, 66 distal osteotomies for, 350, 351
P.613
epiphysiodesis for, 352, 353, 353f, 354f, 355f, 356f postoperative care in, 24, 25
metatarsocuneiform joint arthrodesis and cuneiform osteotomy for, skin closure and suture techniques in, 22, 23, 24, 23f, 24f
351, 352 soft tissue correction in, 16f, 16, 17
metatarsus adductus in, 449 total matrixectomy in, 20, 21, 22, 20f, 21f, 22f, 23f
phalangeal osteotomies for, 356 trauma to, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, 521, 522,
proximal osteotomies for, 351, 351f, 352f 523
radiographic evaluation of, 347f, 347, 348 crushing nail bed laceration in, 514, 514f
soft tissue procedures for, 350 mechanical onycholysis and, 512
Microfragmentation of silicone implant, 190, 191, 198, 199, 199f nail bed avulsion, phalangeal degloving, and partial digital
Microtrauma in hallux rigidus, 421f, 421, 422, 422f amputation in, 516, 517, 518, 519, 520, 521, 522, 523, 516f,
Middle phalangectomy of fifth toe, 116, 116f 517f, 518f, 519f, 520f, 521f, 522f, 523f
Midtarsal joint dislocation, 533, 534, 535, 536, 537, 538 nail bed defects with phalangeal fracture in, 514, 515, 515f, 516f
crush injury in, 538, 538f simple nail bed laceration in, 513f, 513, 514
lateral force, 535, 536, 537 subungual hematoma in, 512f, 512, 513, 513f
longitudinal force, 535, 537f Nail bed, 1, 2f, 511, 512f
medial force, 533, 534, 535, 533f, 534f, 535f, 536f avulsion of, 516, 517, 518, 519, 520, 521, 522, 523, 516f, 517f, 518f,
plantar force, 537f, 538f 519f, 520f, 521f, 522f, 523f
Mini-external fixator, 584, 585, 585f defects with phalangeal fracture, 514, 515, 515f, 516f
Mitchell bunionectomy, 253, 254, 255, 253f, 254f, 255f laceration of
Modification of DuVries skin plasty, 16f, 16, 17 crushing, 514, 514f
Modified Green-Watermann osteotomy, 429, 430, 431f, 432f simple, 513f, 513, 514
Modified McBride procedure, 361 subungual hematoma and, 512f, 512, 513, 513f
Modified Steytler-Van der Walt procedure, 467, 468f Nail matrix, 1, 2f, 511
Morton's neuroma, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, subungual hematoma and, 512f, 512, 513, 513f
43, 44, 45, 46, 47, 48, 49, 50 Nail-patella syndrome, 10t
complications of, 43, 44, 45, 46, 47, 45t, 46f, 46t Nail plate, 1, 2f, 511, 512f
conservative management of, 37, 38 mechanical onycholysis and, 512
definition, anatomy, and incidence of, 29, 30, 31, 30f, 31t subungual hematoma and, 512f, 512, 513, 513f
differential diagnosis of, 32, 32t Nerve block
etiology and biomechanics of, 36, 37, 37t for Morton's neuroma, 38
future considerations in, 47 in toenail surgery, 15, 15f
general considerations in, 38 Nerve injury in arthrodesis of first metatarsocuneiform joint, 288
histopathology of, 33f, 34t, 34, 35, 36, 35f, 36f Nerve supply to hallux, 1, 2f
magnetic resonance imaging for, 32, 33, 33f Neuritic symptoms in transverse plane digital deformity, 155
pain in, 31, 32 Neurogenic hallux valgus, 345
palpation of, 32 Neurolysis in Morton's neuroma, 40, 41, 41f, 42f
radiography of, 32 Neuroma, Morton's, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42,
sensory nerve conduction tests for, 32 43, 44, 45, 46, 47, 48, 49, 50
signs and symptoms of, 31, 31t carbon dioxide laser treatment in, 42, 43
surgical management of, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47 conservative management of, 37, 38
carbon dioxide laser treatment in, 42, 43 cryogenic denervation in, 43
complications of, 43, 44, 45, 46, 47, 45t, 46f, 46t definition, anatomy, and incidence of, 29, 30, 31, 30f, 31t
cryogenic denervation in, 43 differential diagnosis of, 32, 32t
endoscopic decompression in, 41, 42 endoscopic decompression of, 41, 42
general considerations in, 38 etiology and biomechanics of, 36, 37, 37t
neurolysis in, 40, 41, 41f, 42f future considerations in, 47
radiosurgical destruction in, 42, 43f histopathology of, 33f, 34t, 34, 35, 36, 35f, 36f
resection in, 38, 39, 40, 39f magnetic resonance imaging for, 32, 33, 33f
ultrasonography of, 33, 33f neurolysis in, 40, 41, 41f, 42f
Mulder's sign, 32 pain in, 31, 32
Multiple short metatarsals, 69f, 69, 70 palpation of, 32
Muscle-tendon balancing radiography of, 32
in anatomic dissection of first metatarsophalangeal joint, 237, 238, radiosurgical destruction of, 42, 43f
238f resection of, 38, 39, 40, 39f
in hallux varus, 400 sensory nerve conduction tests for, 32
in juvenile hallux abducto valgus deformity, 350 signs and symptoms of, 31, 31t
with resection of proximal phalanx, 95f, 95, 96 surgical complications in, 43, 44, 45, 46, 47, 45t, 46f, 46t
ultrasonography of, 33, 33f
N Neuropraxia, callus distraction surgery and, 587
Nifedipine, 44
Nail, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, Nitrofurazone, 13
22, 23, 24, 25, 26, 27 Nonsteroidal antiinflammatory drugs, 157
anatomy of, 1, 2, 3, 2f, 3f, 512f, 551 Nonunion
biopsy of, 11, 12, 12f after Akin osteotomy, 383, 384f
chemical nail avulsion, 13, 14, 14f after first metatarsophalangeal joint arthrodesis, 341, 341f
pathology of, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 after hallux abducto valgus surgery, 405, 406, 407, 408, 409, 410, 411,
anatomy and, 3, 4, 5, 4f, 5f 412, 408f, 409f, 410f, 411f
benign and malignant tumors in, 8f, 8t, 8, 9, 9f in callus distraction, 585, 586
biomechanical abnormalities and, 9, 10, 10f in digital surgery, 100
fifth nail thickening and dystrophy in, 108 in first metatarsocuneiform fusion, 287, 288f, 289f
hereditary and genetic factors in, 10t, 10, 11, 11f in metatarsal osteotomies, 168
infections in, 6, 7, 6f, 7f, 8f, 7t in proximal osteotomies, 277, 277f
prevention of, 12, 13 in sesamoid fracture, 569, 570f, 571f
systemic diseases and, 5, 5f
trauma and, 5f, 5, 6, 6f, 7t O
surgical management of, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25
local anesthesia in, 14, 15, 16, 15f, 16f Oblique base wedge osteotomy, 269f, 269, 270, 272
partial and total nail avulsion in, 17, 17f for tailor's bunion deformity, 147, 148, 148f, 149f
partial matrix ectomy in, 17f, 18f, 19f, 17, 18, 19, 20
P.614
Oblique head osteotomy long plantar arm modification of, 245
for hallux limitus, 433, 434f proximal chevron osteotomy versus, 275
Oblique proximal Akin osteotomy, 378f, 378, 379 results of, 244
Oblique sagittal base osteotomy, 435, 436, 437, 436f, 437f, 438f Scarf procedure verses, 299, 305
Offset-V osteotomy, 293, 294, 295, 296, 297, 294f, 295f, 296f, 297f Youngswick modification of, 245, 246, 247, 247f
Onychauxis, 3, 4 basilar, 124, 124f
Onychoclavus, 4 in brachymetatarsia surgery, 588, 589
Onychocryptosis, 4, 9, 10, 10f in callus distraction, 580, 581, 581f
Onycholysis, 4, 512 Crawford L-shaped, 146, 147, 147f
Onychomycosis, 6, 7, 7t, 14, 14f cuneiform, 351, 352
Onychoosteodysplasia, 10t distal metaphyseal, 241, 242, 243, 244, 245, 246, 247, 248, 249, 250,
Open digital fracture, 564, 565f 251, 252, 253, 254, 255, 256, 257, 258, 259, 260, 261, 262, 263
Open reduction apical axis guide in, 241, 242, 243, 241f, 242f, 243f
of first metatarsophalangeal joint dislocation, 550 Austin bunionectomy as, 243f, 243, 244, 245, 246, 247, 248, 249,
of hallux fracture, 561, 563f, 564f 250, 251See also Austin bunionectomy.
of interphalangeal joint dislocation, 554 avascular necrosis after, 258, 259
of Lisfranc's fracture-dislocation, 544, 545, 546, 545f, 546f comparative studies of, 257, 258
of subtalar dislocation, 532 displacement of, 259f, 260f, 261f, 261
Open subtalar dislocation, 528 Hohmann bunionectomy as, 255, 256, 256f
Opening base wedge osteotomy, 275, 276f, 277f Mitchell bunionectomy as, 253, 254, 255, 253f, 254f, 255f
Opening wedge cuneiform osteotomy, 289f, 289, 290, 291, 290f postoperative management of, 258
Opening wedge osteotomy, 128, 129, 130, 130f, 131f Reverdin bunionectomy as, 251, 252, 253, 251f, 252f, 253f
for excessive abduction of hallux, 377 sagittal and transverse plane deviations after, 259, 260
for juvenile hallux abducto valgus deformity, 351 Wilson bunionectomy as, 256, 257, 257f
in malunion of first metatarsal, 405 dorsiflexory, 126, 127, 127f, 128f
in Watermann osteotomy, 429 double, 433, 434
Organisms in onychomycosis, 6, 7, 7t Evans,' 589, 591f, 592f
Orthotic therapy first metatarsal base, 265, 266, 267, 268, 269, 270, 271, 272, 273, 274,
in hallux limitus, 425, 426, 426f 275, 276, 277, 278, 279
in juvenile hallux abducto valgus, 349 anatomic considerations in, 268, 269, 269f
Osseous impingement of metatarsophalangeal joint, 421 chevron osteotomy in, 273, 274, 275, 275f
Osseous procedures closing base wedge osteotomy in, 269f, 270f, 271f, 272f, 269, 270,
for intermediate digit and metatarsophalangeal joint deformities, 79, 271, 272, 273
80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91 crescentic osteotomy in, 273, 273f, 274f
arthroplasty of proximal interphalangeal joint in, 80, 81, 82, 81f indications for, 265, 266, 267, 268, 266f, 267f, 268f
bone grafting in, 89, 90, 91, 90f opening base wedge osteotomy in, 275, 275f
digital arthrodesis using internal pins in, 85, 86, 86f postoperative management of, 276f, 277, 277f
historical review of, 79, 80 Giannestras step-down, 127, 129f
interphalangeal arthrodesis with Kirschner wire fixation in, 82, 83, Lambrinudi, 434, 435
83f Ludloff, 308, 309, 310, 311, 312, 313, 308f, 309f, 310f, 311f, 312f,
peg-in-hole arthrodesis in, 83, 84, 85, 84f 313f, 314f
resection of base of proximal phalanx in, 86, 87, 88, 89, 88f, 89f in malunion of first metatarsal, 404
for metatarsus adductus Mau and Ludloff, 308, 309, 310, 311, 312, 313, 308f, 309f, 310f, 311f,
metatarsal osteotomies in, 467, 468, 469, 467f, 468f, 469f, 470f, 312f, 313f, 314f
471f modified Green-Watermann, 429, 430, 431f, 432f
tarsal osteotomies in, 469, 470, 471, 472, 473, 474, 472f, 473f, offset-V, 293, 294, 295, 296, 297, 294f, 295f, 296f, 297f
474f plantarflexory, 405, 434, 435
for transverse plane digital deformities, 164, 165, 166, 167, 168 in recurrent hallux abducto valgus deformity, 396
complications of, 168 sagittal base, 435, 436, 437, 436f, 437f, 438f
joint-destructive procedures in, 165, 166, 167, 168 Scarf, 299, 300, 301, 302, 303, 304, 305, 306, 307
joint-preservation procedures in, 164f, 164, 165, 166f, 167f complications of, 305f, 305, 306, 307, 306f
postoperative care in, 168 fixation in, 300, 302f
Ossification period in callus distraction, 583 historical review of, 299, 300f
Osteoarthritis, 423 indications and contraindications for, 299
Osteochondritis dissecans, 419, 421, 421f modifications of, 302, 303, 303f
Osteochondroma, 6, 6f, 7t postoperative care in, 300, 302f
Osteoclasis, 124 results of, 303, 304, 305, 304f
Osteomed Reflexion First Metatarsophalangeal Joint Implant System, 185, surgical technique in, 299, 300, 300f, 301f
186, 187f Watermann, 428, 429, 429f
Osteotomy Overlapping lesser toe, 495, 496, 497, 498, 499, 500, 501
Akin, 375, 376, 377, 378, 379, 380, 381, 382, 383 conservative management of, 495, 496, 496f
complications of, 383, 384f etiology and clinical presentation of, 495, 495f
dissection in, 375, 376, 377, 376f postoperative care in, 501
distal, 377, 378, 378f surgical considerations of, 497, 498, 499, 500, 501, 498f, 499f, 500f
fixation in, 380, 381, 382, 381f, 382f, 383f
in hallux abductus interphalangeus, 506 P
for juvenile hallux abducto valgus deformity, 356
modifications of, 378, 379, 380, 380f Pachyonychia congenita, 10, 10t
postoperative management in, 383 Packaging defect, 450
proximal, 377, 377f Padding
Austin, 237, 237f, 243f, 243, 244, 245, 246, 247, 248, 249, 250, 251 for Morton's neuroma, 37
bicorrectional and tricorrectional osteotomies in, 247, 248 for predislocation syndrome of lesser metatarsophalangeal joint, 72,
fixation in, 248f, 249f, 250f, 248, 249, 250, 251 72f
for hallux limitus, 432f, 432, 433, 433f for transverse plane digital deformity, 157, 158f
for juvenile hallux abducto valgus deformity, 351 Pain
long dorsal arm modification of, 244, 245, 244f, 245f, 246f, 247f after hallux abducto valgus repair, 260
P.615
in digital fracture, 559, 560 Phalangeal base
in fifth toe pressure keratoses, 107 arthrodesis of first metatarsophalangeal joint and, 325
in hallux abducto valgus deformity, 219 resection in transverse plane digital deformity, 165
in hallux limitus and hallux rigidus, 415, 416 Phalangeal degloving, 516, 517, 518, 519, 520, 521, 522, 523, 516f, 517f,
in juvenile hallux abducto valgus, 346 518f, 519f, 520f, 521f, 522f, 523f
in lateral force midtarsal injuries, 535 Phalangeal fracture, 559, 560, 561, 562, 563, 564
in Lisfranc's joint dislocation, 539, 539f clinical presentation of, 559, 560
in Morton's neuroma, 31, 32 closed, 560, 561, 562, 563, 564, 560f, 561f, 562f, 563f, 564f
after resection, 44, 45, 45t frontal plane, 559
in predislocation syndrome of lesser metatarsophalangeal joint, 72 nail bed defects with, 514, 515, 515f, 516f
in recurrent hallux abducto valgus deformity, 395 open, 564, 565f
in sesamoid fracture, 568 sagittal plane, 559
in subtalar dislocation, 532 subungual hematoma and, 513
in transverse plane digital deformity, 155 transverse plane, 559, 560f, 562f
in underlapping toe, 501 Phalangeal osteotomy
Palpation of Morton's neuroma, 32 in implant arthroplasty, 192
Paralytic deformities, hallux limitus or hallux rigidus and, 419 for juvenile hallux abducto valgus deformity, 356
Paronychia, 7, 7f, 7t, 8f, 511, 512f Phalangectomy in fifth digit deformities, 115f, 115, 116
Partial digital amputation, 516, 517, 518, 519, 520, 521, 522, 523, 516f, Phenol-alcohol chemical partial matrixectomy, 18, 19f
517f, 518f, 519f, 520f, 521f, 522f, 523f Phenol therapy in Morton's neuroma, 38
Partial incongruity of tarsometatarsal joint, 543, 545f Phentolamine, 44
Partial matrixectomy, 17f, 18f, 19f, 17, 18, 19, 20 Physical examination
Partial nail avulsion, 17, 17f in hallux abducto valgus deformity, 219, 220
PASA. See Proximal articular set angle. in metatarsus adductus, 453f, 453, 454
Passive range-of-motion evaluation, 155, 156f Pin fixation
Pathomechanics of hammer toe, 60, 61, 62, 63, 64, 65, 66 in first metatarsocuneiform joint arthrodesis, 283
extensor substitution in, 62, 63, 64, 65, 66, 63f, 64f, 65f, 66f in first metatarsophalangeal joint arthrodesis, 330f, 330, 331, 332
flexor stabilization in, 61f, 61, 62 in Green-Watermann osteotomy, 430, 432f
flexor substitution in, 62, 62f in interphalangeal joint dislocation, 554, 555
Patient selection for joint implant, 211 Pincer nail formation, 5, 5f
Peabody-Muro procedure, 467, 467f Pitting of toenail, 4
Pedal joint dislocation, 525, 526, 527, 528, 529, 530, 531, 532, 533, 534, Planes of deformity, fifth toe and, 104, 105f, 106f
535, 536, 537, 538, 539, 540, 541, 542, 543, 544, 545, 546, 547, 548, Plantar approach in Morton's neuroma, 39f, 39, 40
549, 550, 551, 552, 553, 554, 555 Plantar capsular release, 94, 95
Chopart's joint, 533, 534, 535, 536, 537, 538 Plantar condylectomy, 125, 125f
crush injury in, 538, 538f in lesser metatarsal surgery, 130, 131, 132, 133, 134, 133f, 134f
lateral force, 535, 536, 537 Plantar fascia, hallux limitus or hallux rigidus and, 420
longitudinal force, 535, 537f Plantar force midtarsal injury, 537f, 538f
medial force, 533, 534, 535, 533f, 534f, 535f, 536f Plantar hyperkeratoses, 122
plantar force, 537f, 538f Plantar interossei, 54, 55, 56, 57, 56f, 57f, 58f
first metatarsophalangeal joint, 547f, 547, 548, 549, 550, 551 Plantar keratoma, 150, 553
treatment of, 550, 551 Plantar lateral contracture release, 232
type I, 547, 548, 548f Plantar nerves, 30f
type II, 548, 549, 549f, 550f Plantar plate, sesamoids and, 566
general considerations in, 525 Plantar plate release
interphalangeal joint, 553, 554, 555 in hallux abducto valgus, 219, 220, 220f
lesser metatarsophalangeal joint, 551, 552, 553, 552f for interphalangeal sesamoids, 158
Lisfranc's joint, 538, 539, 540, 541, 542, 543, 544, 545, 546, 539f, Plantar skin plasty, 117f, 117, 118
540f, 541f Plantar toe pulp, 511
anatomic considerations in, 541, 542, 542f Plantar transverse incision, 389
direct injury in, 542, 543 Plantar-V infiltration block of Hara, 15, 15f
indirect injury in, 543, 544f Plantarflexory osteotomy, 405, 434, 435
treatment of, 543, 544, 545, 546 Plantarly displaced metatarsals, 126
type A or total incongruity, 543, 545f Plate fixation in first metatarsocuneiform joint arthrodesis, 284f, 285,
type B or partial incongruity, 543, 545f 285f
type C of divergent, 543, 546f Podiatry Institute Flush Pin Cutter, 430
subtalar joint, 525, 526, 527, 528, 529, 530, 531, 532, 533, 526f, 527f Polydactyly, 477, 478, 479, 480, 481, 482, 483
anatomic considerations in, 526, 527 associated syndromes in, 479, 480
anterior, 531 classification of, 477, 478, 479, 478f, 479f
lateral, 528, 529, 531f etiology of, 477
medial, 527, 528, 528f, 529f, 530f surgical considerations in, 480, 481, 482, 483, 480f, 481f, 482f, 483f
posterior, 529, 530, 531, 532f Polyethylene
treatment of, 531, 532, 533 host response to, 188
Peg-in-hole arthrodesis, 83, 84, 85, 84f for joint implants, 173t, 174
Perineural fibroma, 36 in Osteomed total joint system, 186, 187f
Perineurium, peripheral neurectomy and, 40 Polymers
Perionychium, 511, 512f host response to, 188
Periosteal callus, 577 for joint implants, 173t, 174, 175
Periosteum Polymethylmethacrylate
Akin osteotomy and, 376, 377 host response to, 189
callus production and, 578, 579, 580 for joint implants, 173t, 174
Peripheral nerve, 40, 41, 41f Porcine xenograft on nail bed, 25
Periungual fibroma, 8 Postaxial polydactyly, 477, 478, 478f
Pes cavus foot Posterior subtalar dislocation, 529, 530, 531, 532f
additional loading in, 121, 121f Postoperative management
increased declination of forefoot in, 63, 64, 64f in Akin osteotomy, 383
Pes valgus deformity in arthrodesis of first metatarsophalangeal joint, 340
Evans' osteotomy-distraction surgery for, 591f, 592f in arthroplasty of proximal interphalangeal joint, 82
hallux abducto valgus deformities and, 218 in callus distraction, 583, 584
hallux limitus and hallux rigidus and, 417 in correction of overlapping fifth toe, 501
juvenile hallux valgus and, 348
P.616
in dislocated metatarsophalangeal joint, 99 metatarsal cuneiform procedures in, 280, 281, 282, 283, 284, 285, 286,
in distal metaphyseal osteotomy, 149, 258 287, 288, 289, 290, 291
in distraction for congenital brachymetatarsia, 589f, 590f cuneiform osteotomies in, 289f, 289, 290, 291, 290f
in first metatarsal base osteotomies, 276f, 277, 277f first metatarsocuneiform arthrodesis in, 280, 281, 282, 283, 284,
in first metatarsocuneiform fusion, 285 285, 286, 287, 288, 281f, 283f, 284f, 285f, 286f, 287f, 288f,
in flexor tendon transfer, 78 289f
in hallux interphalangeal joint arthrodesis, 386, 386f Proximal subungual onychomycosis, 6, 7, 7t
in hallux limitus and rigidus, 444, 445 Pseudoepiphysis, 420
in hammer toe repair, 95 Pseudomonas nail infection, 7
in interphalangeal arthrodesis with Kirschner wire fixation, 82, 83 Psoriasis, nail pitting in, 4
in long flexor tenotomy, 74 Psoriatic arthritis, hallux limitus or hallux rigidus and, 418, 419
in Mau and Ludloff osteotomies, 313 Pterygium, 4, 4f
in nail surgery, 24, 25 Punch biopsy of nail, 11, 12f
in offset-V osteotomy, 297 Push-up test in hammer toe repair, 92f, 93f
in peg-in-hole digital arthrodesis, 85 Pyocyanin, 7, 8t
in proximal base osteotomy, 150 Pyogenic granuloma, 8, 9
recurrence of hallux abducto valgus and, 393, 394 Pyrolytic carbon, 174
in resection of proximal phalangeal base, 87
in Scarf Z-osteotomy, 300, 302f Q
in sesamoid fracture, 571, 572
in syndactyly, 79, 118 Quadratus plantae muscle
in tenotomy, 73, 74 biomechanics of, 60, 60f
in transverse plane digital deformity, 168 flexor stabilization and, 61
Postreduction radiograph, 252 Quenu total matrixectomy procedure, 20, 21, 21f, 22f, 23f
Preaxial polydactyly, 478, 479, 479f
R
Predislocation syndrome, 72, 72f, 154, 155, 157f, 158, 159f
Prednisone, 72 Radiography
Pregnancy, nail changes during, 3 in delayed union or nonunion, 406, 407
Pressure-induced hyperkeratosis, 416f in hallux abducto valgus deformity, 220, 221, 222, 223, 224, 225, 226
Pressure keratosis of fifth toe, 105, 106, 107, 107f, 108f first intermetatarsal angle in, 223, 224, 224f
Primary dermatosis, lesser metatarsal pain in, 122 general factors in, 220, 221f
Prognostic classification of metatarsus adductus, 454, 454f hallux abductus angle and, 221, 222, 222f
Progressive macrodactyly, 488, 489 hallux abductus interphalangeal angle in, 224, 225f
Proximal Akin osteotomy, 377, 377f juvenile, 347f, 347, 348
Proximal articular set angle long metatarsal in, 224, 225, 226, 225f
Austin osteotomy and, 247, 248 metatarsophalangeal joint position in, 222, 223f
hallux abducto valgus deformity and, 221, 222, 222f metatarsus adductus angle in, 224, 224f
hallux osteotomy and, 375 recurrent, 395
Mau and Ludloff procedures and, 311, 312, 313, 313f sesamoid position in, 222, 223, 223f
offset-V osteotomy and, 293, 295, 295f shape of metatarsal head in, 224, 225f
Reverdin-type osteotomy and, 251f, 251, 252, 253 in hallux limitus and hallux rigidus, 422, 423, 424, 425, 423f, 424f
Roux modification of Mitchell bunionectomy and, 255 in hallux varus and hallux malleus deformity, 399f, 399, 400
Proximal base osteotomies, 149, 150, 150f in joint implant, 194f, 195f, 196f, 197f, 194, 195, 196, 197, 198
Proximal interphalangeal joint in lateral subtalar dislocation, 529, 531f
arthrodesis of, 95 in lesser metatarsal complaints, 122, 123, 123f
arthroplasty of, 80, 81, 82, 81f, 109, 109f in Lisfranc's joint dislocation, 540f, 540, 541, 541f
Proximal nail fold, 511, 512f in malunion of first metatarsal, 403f, 403, 404, 404f
Proximal nail groove, 511, 512f in medial subtalar dislocation, 528, 530f
Proximal osteotomy in metatarsus adductus, 454, 455, 456, 457, 455f, 456f, 457f
for hallux limitus, 433, 434, 435f in Morton's neuroma, 32
for juvenile hallux abducto valgus deformity, 351, 351f, 352f in pedal joint injury, 252
oblique, 126, 127, 128f in posterior subtalar dislocation, 532
postoperative metatarsus primus elevatus, 405 of rigid first ray, 266, 266f
for transverse plane digital deformity, 165, 167f in sesamoid fracture, 568, 568f, 569f
Proximal phalanx in tailor's bunion, 139, 140
flexor tendon transfer to, 95 in transverse plane digital deformity, 155, 156f
resection of, 110, 366 Radiosurgical destruction of Morton's neuroma, 42, 43f
base, 86, 87, 88, 89, 88f, 89f, 165 Range of motion
head, 91, 92f, 93f, 94f in hallux abducto valgus deformity, 219, 220, 220f
with muscle tendon balancing, 95f, 95, 96 in recurrent hallux abducto valgus deformity, 395
Proximal procedures of first ray, 265, 266, 267, 268, 269, 270, 271, 272, in transverse plane digital deformity, 155
273, 274, 275, 276, 277, 278, 279, 280, 281, 282, 283, 284, 285, 286, Recurrent hallux abducto valgus, 391, 392, 393, 394, 395, 396, 392f, 393f,
287, 288, 289, 290, 291, 292 394f, 396f
first metatarsal base osteotomies in, 265, 266, 267, 268, 269, 270, 271, Recurrent neuroma, 45, 46, 47, 46f, 46t
272, 273, 274, 275, 276, 277, 278, 279 Reduction
anatomic considerations in, 268, 269, 269f closed
chevron osteotomy in, 273, 274, 275, 275f of digital fracture, 561, 562f
closing base wedge osteotomy in, 269f, 270f, 271f, 272f, 269, 270, of first metatarsophalangeal joint dislocation, 550, 551
271, 272, 273 of interphalangeal joint dislocation, 553, 554
crescentic osteotomy in, 273, 273f, 274f of lesser metatarsophalangeal joint dislocation, 551, 552, 553
indications for, 265, 266, 267, 268, 266f, 267f, 268f of subtalar dislocation, 531, 532
opening base wedge osteotomy in, 275, 275f of tarsometatarsal joint dislocation, 543, 544
postoperative management of, 276f, 277, 277f
P.617
of medial force midtarsal injuries, 534, 535 fixation in, 300, 302f
open historical review of, 299, 300f
of first metatarsophalangeal joint dislocation, 550 indications and contraindications for, 299
of hallux fracture, 561, 563f, 564f Mau procedure versus, 299
of interphalangeal joint dislocation, 554 modifications of, 302, 303, 303f
of Lisfranc's fracture-dislocation, 544, 545, 546, 545f, 546f postoperative care in, 300, 302f
of subtalar dislocation, 532 results of, 303, 304, 305, 304f
Reese osteotomy guide, 241, 241f surgical technique in, 299, 300, 300f, 301f
Regnauld procedure, 438, 439f Sclerosis after hemiimplant arthroplasty, 196, 197f
Renaut's body formation, 35 Screw fixation
Reoperation in Akin procedure, 382, 383f
for intermetatarsal neuroma, 46t, 46, 47 in arthrodesis of first metatarsophalangeal joint, 332f, 332, 333, 333f,
in revision of joint implant, 204, 205, 206, 207, 208, 209, 210 335, 335f
failed interpositional implant and, 204, 205, 206, 204f, 205f, 206f in Austin bunionectomy, 245, 246f, 247f, 249, 250, 250f
failed total joint system and, 206, 207, 208, 209, 210, 208f, 209f, in closing base wedge osteotomy, 271, 272f
210f in crescentic osteotomy, 273, 274f
Resection in first metatarsocuneiform joint arthrodesis, 283
abductor hallucis muscle, 461, 462f in hallux fracture, 563f
fifth metatarsal head, 143, 144, 144f, 145f in hallux interphalangeal joint arthrodesis, 385, 386, 386f
for macrodactyly, 489 Herbert bone screw and, 249, 250, 250f
of metatarsal head, 588, 588f in Hohmann bunionectomy, 255
of Morton's neuroma, 38, 39, 40, 39f in Lepird procedure, 469, 470f, 471f
of proximal phalanx, 366 in Mau and Ludloff osteotomies, 313
base, 86, 87, 88, 89, 88f, 89f in Mitchell bunionectomy, 255, 255f
of fifth toe, 110 in modified Steytler-Van der Walt procedure, 468f
head, 91, 92f, 93f, 94f nonunion after first metatarsophalangeal joint fusion with, 341f
with muscle tendon balancing, 95f, 95, 96 for nonunion of first metatarsal osteotomy, 408f, 409f
Resection arthroplasty, 363, 364, 365, 366, 367, 368, 369, 370, 371, 372 in offset-V osteotomy, 295, 296f
complications of, 372 in proximal plantarflexory osteotomies, 434, 435
contraindications for, 371, 372 in Scarf osteotomy, 300, 302f
dissection in, 366, 367f in Vanore-Corey procedure, 439
flexor tendon and capsular reattachment in, 366, 367, 368, 369, 370, Sensory nerve conduction tests for Morton's neuroma, 32
371, 368f, 369f, 370f Sepsis, callus distraction surgery and, 587
indications for, 363, 364, 365f Serpentine foot, 452
modifications of, 371, 371f, 372f Sesamoid fracture, 566, 567, 568, 569, 570, 571, 572
osseous resection in, 366 anatomy in, 566f, 566, 567, 567f
results in, 364, 365, 366 clinical presentation of, 568
Reverdin bunionectomy, 251, 252, 253, 251f, 252f, 253f, 351 diagnosis and treatment of, 568f, 569f, 570f, 571f, 568, 569, 570, 571,
Reverdin-Green-Laird procedure, 251, 252, 252f 572
Reverdin-Green osteotomy, 401, 401f etiology of, 567, 568
Revision Sesamoidectomy, 571
of joint implant, 204, 205, 206, 207, 208, 209, 210 Sesamoiditis, 287
failed interpositional implant and, 204, 205, 206, 204f, 205f, 206f Sesamoids
failed total joint system and, 206, 207, 208, 209, 210, 208f, 209f, arthrodesis of first metatarsophalangeal joint and, 324, 325
210f dislocation of first metatarsophalangeal joint and, 547, 548, 549, 548f
in recurrent hallux abducto valgus deformity, 395, 396, 396f hallux abducto valgus and, 222, 223, 223f
Rheumatoid arthritis hallux limitus and rigidus and, 420f, 420, 421, 423, 423f
arthrodesis of first metatarsophalangeal joint and, 323 soft tissue release and, 440
hallux limitus or hallux rigidus and, 418, 419 transverse plane digital deformity and, 154
Rigid metatarsus primus adductus, 324 Sgarlate hinge, 180f, 181
Ring finger-small ringer syndactyly, 484 Shave biopsy, 11, 12f
Ring fixator, 584, 584f Shedding of nail, 4
Rocker-bottom sole, 425, 426, 426f Shede's procedure, 359
Roux modification of Mitchell osteotomy, 254f, 255 Shoes
Ruiz-Mora procedure, 497, 498, 498f after Akin osteotomy, 383
after first metatarsophalangeal joint arthrodesis, 340
S complication of digital surgery and, 100
first metatarsophalangeal joint dislocation and, 551
Sagittal base osteotomy, 435, 436, 437, 436f, 437f, 438f hallux abducto valgus and, 217
Sagittal plane alignment, hallux abducto valgus and, 225f, 225, 226 hallux limitus or hallux rigidus and, 415, 416, 417f, 425
Sagittal plane deformity hammer toe deformity and, 67
after distal metaphyseal osteotomy, 259, 260 intermetatarsal neuroma and, 36
proximal osteotomies for, 267 metatarsus adductus and, 459
Sagittal plane digital fracture, 559 tailors' bunion deformity and, 137
Sagittal plane Logroscino technique, 429 transverse plane digital deformity and, 152
Sagittal Z-osteotomy Short metatarsal, 69f, 69, 70
for hallux limitus, 433, 434, 435, 436, 437, 435f, 436f, 437f, 438f en bloc grafting for, 130
in malunion of first metatarsal, 405 hallux limitus and, 418
for shortening of hallux, 379, 380f lengthening osteotomy for, 130, 132f
Salicylic acid in lanolin, 13 opening wedge osteotomy for, 128, 129, 130, 130f, 131f
Salvage technique for fusion of first metatarsophalangeal joint, 337f Short rib polydactyly syndromes, 479
Scar formation Shortening osteotomy, 127, 128, 128f, 129f
around incision site, 100 in modified Green-Watermann procedure, 430
in neuroma excision, 40 for transverse plane digital deformity, 165, 167f
Scarf Z-osteotomy, 299, 300, 301, 302, 303, 304, 305, 306, 307 Silicone rubber
Austin procedure versus, 299, 305 detritic synovitis and, 204f, 204, 205
complications of, 305f, 305, 306, 307, 306f
P.618
host response to, 189, 190, 191, 190f Stance examination in transverse plane digital deformity, 155
for joint implants, 173t, 174, 175 Staphylococcal nail infection, 7
plastic deformation and fracture of, 198, 199f Staple fixation
Silver bunionectomy, 268f, 359, 360, 360f in Akin procedure, 382
Simple metatarsus adductus, 452 for epiphysiodesis, 352, 353, 353f, 354f, 355f, 356f
Simple nail bed laceration, 513f, 513, 514 Static macrodactyly, 488
Skewfoot, 449, 452 Steinmann pin
Skin closure in first metatarsocuneiform joint arthrodesis, 283
in arthroplasty with hemiphalangectomy, 112, 112f in first metatarsophalangeal joint arthrodesis, 330f, 330, 331, 332
in fifth toe condylectomy, 114 Stellate nail bed laceration, 514, 514f
in joint implant, 194 Steroids
in nail surgery, 22, 23, 24, 23f, 24f for Morton's neuroma, 38
in offset-V osteotomy, 295 for psoriatic dystrophic nails, 14
in syndactyly of fourth and fifth toes, 118 for transverse plane digital deformity, 157
Skin flap Steytler-Van der Walt procedure, 467, 467f
in cleft foot repair, 493, 493f, 494f Strapping of congenital underlapping toe, 501
for correction of overlapping fifth toe, 496, 497 Streptococcal nail infection, 7
for desyndactylization, 484, 485, 486, 487, 485f, 486f, 487f Stress fracture after first metatarsophalangeal joint arthrodesis, 341
in hallux interphalangeal joint sesamoidectomy, 388, 389 Striation in nail, 5
for nail bed augmentation, 517, 518, 519, 519f Stump neuroma, 45, 46, 47, 46f, 46t
in resection arthroplasty, 366, 367f, 368, 368f Subtalar joint dislocation, 525, 526, 527, 528, 529, 530, 531, 532, 533,
Skin graft 526f, 527f
in cleft foot repair, 493, 493f, 494f anatomic considerations in, 526, 527
for desyndactylization, 484, 485, 486, 487, 485f, 486f, 487f anterior, 531
in zone 1 nail bed defect secondary to crush injury, 517, 517f, 518f lateral, 528, 529, 531f
Skin necrosis, subtalar dislocation and, 532 medial, 527, 528, 528f, 529f, 530f
Skin plasty in fifth digit deformities, 116f, 116, 117, 118, 117f posterior, 529, 530, 531, 532f
Smith variation of Frost procedure, 23, 24f treatment of, 531, 532, 533
Sodium hydroxide chemical partial matrixectomy, 18, 19 Subungual exostosis, 5, 6, 5f, 6f, 7t, 21f
Soft corn, 68 Subungual hematoma, 3, 4f, 512f, 512, 513, 513f
of fifth toe, 137 Sudeck's atrophy, 546
syndactyly procedure for, 79 Sulfur content in nail, 1
Soft tissue Sullivan's sign, 32
abnormalities after joint implant, 202, 203f Sumiya-Onizuka method of repairing cleft foot, 493f, 494f
contracture after callus distraction, 586 Superficial white onychomycosis, 7, 7t
injury with subtalar dislocation, 528 Sutilains ointment, 24
phalangeal fracture and, 560 Sutter great toe metatarsophalangeal implant, 180, 180f
Soft tissue lengthening, 580 Suture techniques
Soft tissue procedures in nail surgery, 22, 23, 24, 23f, 24f
in anatomic dissection of first metatarsophalangeal joint, 237, 238, in resection arthroplasty, 368, 368f
238f Swanson flexible hinge toe with grommets, 180, 181f
for fifth digit deformities, 116, 117, 118, 116f, 117f, 118f Swanson great toe hemiimplant, 176, 177, 178, 177f
for intermediate digit and metatarsophalangeal joint deformities, 73, Swanson titanium hemiimplant, 177f, 177, 178
74, 75, 76, 77, 78, 79 Swelling
extensor tendon lengthening in, 75, 76 callus distraction surgery and, 587
extensor tenotomy and capsulotomy in, 74 in digital fracture, 559, 560
flexor tendon transfer in, 75, 76, 77, 78, 79, 76f, 77f, 78f, 79f in Lisfranc's joint dislocation, 539, 539f
flexor tenotomy and capsulotomy in, 74, 75, 75f in Morton's neuroma, 36
tenotomy in, 73, 74 in transverse plane digital deformity, 155
for juvenile hallux abducto valgus deformity, 350 Swivel dislocation
for metatarsus adductus, 460, 461, 462, 463, 464, 461f, 462f, 463f, lateral force, 535
464f, 465f, 466f medial force, 533, 534, 535f, 536f
in nail surgery, 16f, 16, 17 Syndactylization of fourth and fifth toes, 497
release in hallux limitus, 426, 427, 428, 427f, 428f, 440, 440f, 441f Syndactyly, 483, 484, 485, 486, 487, 485f, 486f, 487f
for transverse plane digital deformity, 157, 158, 159, 160, 161, 162, Syndactyly procedure
163, 164, 158f, 159f, 160f, 161f, 162f, 163f, 164f for fifth digit deformities, 118, 118f
Splay foot, 137, 138f for intermediate digit deformities, 79, 80f
Splinter hemorrhages of toenail, 3, 4f with metacarpal and metatarsal fusion, 484
Splinting Syndromatic syndactyly, 484
after fifth toe arthroplasty, 110 Synovial joint, 175
for correction of overlapping fifth toe, 496 Synovitis
in digital fracture, 560, 560f, 561f, 562f in hammer toes, 67
in interphalangeal arthrodesis with Kirschner wire fixation, 82, 83f transverse plane digital deformity and, 154
in metatarsus adductus, 459, 459f, 460f Synpolydactyly, 484
in phalangeal physeal fracture with proximal nail fold laceration, 516 Systemic disease
for predislocation syndrome of lesser metatarsophalangeal joint, 72, metatarsalgia in, 122
72f nail involvement in, 5, 5f
in sesamoid fracture, 569
in syndactyly of fourth and fifth toes, 118 T
Split-thickness skin graft, 517, 517f, 518f
Splitting of nail, 5 Tailor's bunion deformity, 137, 138, 139, 140, 141, 142, 143, 144, 145,
Squamous cell carcinoma of toenail, 9, 9f 146, 147, 148, 149, 150, 138f
Stainless steel arthroplasty in, 143, 144, 144f, 145f
host response to, 188, 189f clinical evaluation in, 139
for joint implant, 172, 173, 173t conservative treatment and, 142
Staking of first metatarsal head, 398
P.619
distal metatarsal osteotomies in, 144, 145, 146, 147, 148, 149, 145f, Total nail avulsion, 17, 17f
146f, 147f, 148f, 149f Townley first metatarsophalangeal joint metallic hemiimplant, 177, 178,
etiology of, 137, 138, 139 178f, 179f
exostectomy in, 142, 143, 143f Traction in Lisfranc's fracture-dislocation, 544
intermetatarsal angle of fourth and fifth metatarsals and, 140, 140f Transpositional metatarsal osteotomy, 164f, 164, 165
lateral deviation angle and, 140, 141, 142, 140f, 141f, 142f Transverse closing base wedge osteotomy, 269, 269f
proximal base osteotomies in, 149, 150, 150f Transverse plane deformity, 98, 152f, 152, 153, 154, 155, 156, 157, 158,
radiographic evaluation in, 139, 140 159, 160, 161, 162, 163, 164, 165, 166, 167, 168, 169
signs and symptoms in, 137 after distal metaphyseal osteotomy, 259, 260
Talipes equinovarus, 450, 452 conservative management of, 157, 158f
Talocalcaneal angle, 455, 455f etiology of, 152, 153, 154, 153f, 154f
Talocalcaneonavicular joint dislocation, 256 evaluation of, 155, 156f, 157f
Talonavicular ligament, 526, 527 of fifth digit, 104, 106f
Taping of lesser digits, 64, 65, 66, 66f
of congenital underlapping toe, 501 lesser metatarsal pain in, 122
for overlapping fifth toe, 496, 496f osseous procedures for, 164, 165, 166, 167, 168
Tarsal osteotomy in metatarsus adductus, 469, 470, 471, 472, 473, 474, complications of, 168
472f, 473f, 474f joint-destructive procedures for, 165, 166, 167, 168
Tarsometatarsal joint dislocation, 538, 539, 540, 541, 542, 543, 544, 545, joint-preservation procedures in, 164f, 164, 165, 166f, 167f
546, 539f, 540f, 541f postoperative care in, 168
anatomic considerations in, 541, 542, 542f soft tissue procedures for, 157, 158, 159, 160, 161, 162, 163, 164,
direct injury in, 542, 543 158f, 159f, 160f, 161f, 162f, 163f, 164f
indirect injury in, 543, 544f Transverse plane digital fracture, 559, 560f, 562f
treatment of, 543, 544, 545, 546 Transverse wedge osteotomy
type A or total incongruity, 543, 545f in distal Akin procedure, 378
type B or partial incongruity, 543, 545f in tailor's bunion deformity, 147, 147f
type C of divergent, 543, 546f Trauma
Tarsometatarsal release, 464f, 465f, 466f bunion formation and, 218
Tendon balancing technique, 87, 88, 89 Chopart's joint dislocation, 533, 534, 535, 536, 537, 538
Tendon lengthening crush injury in, 538, 538f
for metatarsophalangeal joint deformity, 75, 76, 91, 92, 93, 94 lateral force, 535, 536, 537
for transverse plane digital deformity, 160, 161, 162, 163, 164, 161f longitudinal force, 535, 537f
Tendon transfer medial force, 533, 534, 535, 533f, 534f, 535f, 536f
in hallux abducto valgus deformity, 238, 239 plantar force, 537f, 538f
in McBride bunionectomy, 360, 361, 362, 363 digital fracture, 559, 560, 561, 562, 563, 564
in metatarsophalangeal joint deformity, 75, 76, 77, 78, 79, 76f, 77f, clinical presentation of, 559, 560
78f, 79f closed, 560, 561, 562, 563, 564, 560f, 561f, 562f, 563f, 564f
in metatarsus adductus, 464 frontal plane, 559
phalangeal base resection with, 87, 88f open, 564, 565f
to proximal phalanx, 95 sagittal plane, 559
in transverse plane deformity, 158, 159, 160, 161, 162, 163, 164, 160f, transverse plane, 559, 560f, 562f
161f, 162f, 163f, 164f first metatarsophalangeal joint dislocation, 547f, 547, 548, 549, 550,
Tenotomy 551
of abductor hallucis, 461, 463f treatment of, 550, 551
in anatomic dissection of first metatarsophalangeal joint, 234, 235f type I, 547, 548, 548f
for correction of overlapping fifth toe, 497 type II, 548, 549, 549f, 550f
extensor, 73, 74 hallux limitus and hallux rigidus and, 418, 419, 419f
for metatarsophalangeal joint deformity, 74, 91, 92, 93, 94 interphalangeal joint dislocation, 553, 554, 555, 554f
in resection of proximal phalangeal base, 87 lesser metatarsophalangeal joint dislocation, 551, 552, 553, 552f
for transverse plane digital deformity, 157, 158 Lisfranc's joint dislocation, 538, 539, 540, 541, 542, 543, 544, 545, 546,
flexor, 74, 75, 75f 539f, 540f, 541f
Terbinafine hydrochloride, 13 anatomic considerations in, 541, 542, 542f
Terminal Syme operation for total nail removal, 20, 20f direct injury in, 542, 543
Thinning of nail plate, 5 indirect injury in, 543, 544f
Thomson procedure, 461, 462f, 463f treatment of, 543, 544, 545, 546
Tibial sesamoidectomy, 338 type A or total incongruity, 543, 545f
Tibial torsion, 453 type B or partial incongruity, 543, 545f
Tibialis anterior tendon type C of divergent, 543, 546f
Lisfranc's dislocation and, 545 metatarsophalangeal joint dislocation, 73
transfer of, 464 nail, 5f, 5, 6, 6f, 7t, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520,
Tissue expansion for desyndactylization, 484, 485, 486, 487, 485f, 486f, 521, 522, 523
487f anatomy, physiology, and function of nail and, 511, 512f
Titanium crushing nail bed laceration in, 514, 514f
in Biomet Total Toe system, 181 mechanical onycholysis and, 512
host response to, 188 nail bed avulsion, phalangeal degloving, and partial digital
for joint implants, 173, 173t amputation in, 516, 517, 518, 519, 520, 521, 522, 523, 516f,
in Kinetik Great Toe Implant, 185 517f, 518f, 519f, 520f, 521f, 522f, 523f
microfragmentation of, 199 nail bed defects with phalangeal fracture in, 514, 515, 515f, 516f
in Osteomed total joint system, 186, 187f simple nail bed laceration in, 513f, 513, 514
Toe pulp, 511 subungual hematoma in, 512f, 512, 513, 513f
Toe surgery. See Digital surgery. sesamoid fracture, 566, 567, 568, 569, 570, 571, 572
Total incongruity of tarsometatarsal joint, 543, 545f anatomy in, 566f, 566, 567, 567f
Total joint replacement, 181, 182, 183, 184, 185, 186, 187, 188 clinical presentation of, 568
Acumed Great Toe System in, 184, 185, 185f diagnosis and treatment of, 568f, 569f, 570f, 571f, 568, 569, 570,
Bio-Action Great Toe Implant in, 182, 183f 571, 572
Biomet Total Toe system in, 181, 182f etiology of, 567, 568
Kinetik Great Toe Implant in, 185, 186f subtalar joint dislocation, 525, 526, 527, 528, 529, 530, 531, 532, 533,
Osteomed Reflexion First Metatarsophalangeal Joint Implant System in, 526f, 527f
185, 186, 187f anatomic considerations in, 526, 527
Total matrixectomy, 20, 21, 22, 20f, 21f, 22f, 23f
P.620
anterior, 531 after distal osteotomies for hallux abducto valgus repair, 258
lateral, 528, 529, 531f after first metatarsophalangeal joint arthrodesis, 340
medial, 527, 528, 528f, 529f, 530f bone healing and, 410, 411
posterior, 529, 530, 531, 532f callus distraction and, 583, 584
treatment of, 531, 532, 533 in hallux adductus deformity, 460, 461f
transverse plane digital deformity and, 152 Reverdin bunionectomy and, 252
Triamcinolone acetonide, 14 Weight-bearing cast
Triangular block of Ross, 15, 16f after subtalar dislocation, 533
Trichophyton mentagrophytes, 7 for medial fracture sprain and fracture subluxation, 534
Trichophyton rubrum, 6, 7, 7t Weight-bearing radiography in Morton's neuroma, 32
Tricorrectional bunionectomy, 247, 248 Weissman-Plaschkes procedure for cleft foot, 493, 494, 495, 494f
Troughing in shaft type osteotomy, 305f, 305, 306, 306f Wilson bunionectomy, 256, 257, 257f
True McBride procedure, 361 Wilson medial displacement osteotomy, 144, 145f
True metatarsus primus elevatus, 323 Winograd partial matrixectomy procedure, 17f, 17, 18, 18f
Tumor of toenail, 8f, 8t, 8, 9, 9f Wire fixation
Tungsten, 173 in Akin procedure, 380, 381, 382, 381f, 382f
Turf toe, 512 in arthrodesis of first metatarsophalangeal joint, 330f, 330, 331, 332,
Two-point local anesthesia block of Mercado, 15, 15f 331f
Tyloma, 416f in Austin bunionectomy, 245, 248f, 248, 249, 249f
Type A tarsometatarsal dislocation, 543, 545f in bone grafting, 91
Type B tarsometatarsal dislocation, 543, 545f in closing base wedge osteotomy, 270, 271
Type C tarsometatarsal joint dislocation, 543, 546f in dislocated metatarsophalangeal joint, 99
Type I first metatarsophalangeal joint dislocation, 547, 548, 548f in distal V-osteotomy, 126
Type II first metatarsophalangeal joint dislocation, 548, 549, 549f, 550f in fifth digit open fracture, 565f
in first metatarsocuneiform joint arthrodesis, 283
U in first metatarsophalangeal joint arthrodesis, 330f, 330, 331, 332,
331f
Ultrahigh-molecular-weight polyethylene in Ganley-Ganley procedure, 474
in Acumed Great Toe system, 184 in Green-Watermann procedure, 430
in Bio-Action implant, 182, 183f in hallux interphalangeal joint arthrodesis, 385, 385f
in Biomet Total Toe system, 181 in interphalangeal arthrodesis, 82, 83, 83f
deformation of, 198 in Mau procedure, 309, 310f
host response to, 188 in Mitchell osteotomy, 254f, 255
for joint implants, 173t, 174 in modified Steytler-Van der Walt procedure, 468f
in Kinetik Great Toe Implant, 185 for nonunion of first metatarsal osteotomy, 408f
Ultrasonography in Morton's neuroma, 33, 33f in offset-V osteotomy, 293, 295, 296f
Uncompensated varus deformity, 418 in peg-in-hole arthrodesis, 83, 84, 85, 84f
Underlapping toe, 66, 67, 501, 502, 503, 504, 502f, 503f, 504f in plantar condylectomy, 133, 133f
Unilateral frame, 584, 585f in postaxial polydactyly repair, 482f
Unilateral infiltration block of Steinberg, 15, 15f in resection arthroplasty, 368, 369, 370, 371, 369f
Urea compound ointment, 13, 14 to resist troughing, 306
in Scarf osteotomy, 300
V
in tarsometatarsal joint dislocation, 543
V-osteotomy of lesser metatarsal, 125, 125f Wound healing in macrodactyly, 490
Valenti arthroplasty, 441, 442
Y
Vanore-Corey procedure, 438, 439, 440, 439f
Varus toes, 66, 67 Yellow nail syndrome, 10
Vascular disease Youngswick-Austin modification, 245, 246, 247, 247f, 432f, 432, 433, 433f
after Morton's neuroma resection, 44
painful toes in, 5, 5f Z
Vascularization, fracture repair and, 577, 578
Vasoconstrictors, 16 Z-foot, 452
Venn-Weston classification of polydactyly, 478, 478f, 479f Z-osteotomy, 299, 300, 301, 302, 303, 304, 305, 306, 307
Verruca, 8, 8f complications of, 305f, 305, 306, 307, 306f
Vitallium, 173 fixation in, 300, 302f
historical review of, 299, 300f
W indications and contraindications for, 299
modifications of, 302, 303, 303f
Wallerian degeneration, 35, 36f postoperative care in, 300, 302f
Water flux across nail, 1 results of, 303, 304, 305, 304f
Watermann osteotomy, 428, 429, 429f surgical technique in, 299, 300, 300f, 301f
Wedge osteotomy Z-plasty
in Akin procedure, 377, 377f, 378 in bone grafting in digital surgery, 91
in arthrodesis of first metatarsophalangeal joint, 282, 283f in correction of overlapping fifth toe, 498, 498f, 499f
in Ganley-Ganley procedure, 472, 472f, 473f in extensor tendon lengthening, 75, 76
in Lepird procedure, 469, 469f in extensor tenotomy, 91, 92, 93, 94
soft tissue, 16f, 16, 17 in peg-in-hole digital arthrodesis, 84
in tailor's bunion, 147f, 147, 148, 148f Zadik procedure, 20, 21, 21f, 22f, 23f
in transverse plane digital deformity, 165, 166f Zygodactyly, 484
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Lippincott Williams & Wilkins

530 Walnut Street, Philadelphia, PA 19106 USA

Alan S. Banks D.P.M., F.A.C.F.A.S.

Director of Residency Training

Michael S. Downey D.P.M., F.A.C.F.A.S.

Dennis E. Martin D.P.M., F.A.C.F.A.S.

Stephen J. Miller D.P.M., F.A.C.F.A.S.

Clinical Adjunct Faculty

Patrick S. Agnew D.P.M. Albert E. Burns D.P.M.

Podiatry Residency Director Professor

Alan R. Catanzariti D.P.M.

Stephen J. Miller D.P.M., F.A.C.F.A.S. Molly Schnirring-Judge D.P.M.

John A. Ruch D.P.M., F.A.C.F.A.S. Claire A. Sun D.P.M.

John V. Vanore D.P.M.

Harold W. Vogler D.P.M., F.A.C.F.A.S.

Carl R. Wagreich D.P.M.

Senior Clinical Instructor

Chapter 2 Morton&apos;s Neuroma

Chapter 3 Lesser Ray Deformities

Chapter 5 Introduction and Evaluation of Hallux Abducto Valgus

Chapter 7 Distal Metaphyseal Osteotomies in Hallux Abducto Valgus Surgery

Chapter 8 Proximal Procedures of the First Ray

Chapter 9 Osteotomies of the First Metatarsal Shaft in Hallux Abducto Valgus

Chapter 10 Arthrodesis of the First Metatarsophalangeal Joint

Chapter 11 Juvenile Hallux Abducto Valgus Deformity

Chapter 12 Traditional Procedures for the Repair of Hallux Abducto Valgus

Chapter 13 Surgical Procedures of the Hallux

Chapter 14 Complications of Hallux Abducto Valgus Surgery

Chapter 15 Hallux Limitus and Hallux Rigidus

Chapter 16 Metatarsus Adductus and Allied Disorders

Chapter 17 Congenital Deformities

Chapter 18 Trauma to the Nail and Associated Structures

Chapter 20 Digital and Sesamoid Fractures

Chapter 21 Callus Distraction Principles and Indications

FIG. 4. Nerve supply to the hallux.

FIG. 6. Dystrophic fissured toenail secondary to infection.

FIG. 7. Subungual hematoma of the hallux caused by trauma.

FIG. 8. Subungual hematomas typically seen in runners.

FIG. 9. Pterygium of the hallux toenail in lichen planus.

FIG. 15. Subungual hallux osteochondroma in a 13-year-old boy.

TABLE 1. Differential characteristics of exostosis, osteochondroma, and enchondroma

Exostosis 20- Female/male Occasionally Moderate Trabeculated osseous

TABLE 2. Organisms in onychomycosis

FIG. 16. Stage I (mild) paronychia.

FIG. 17. Stage II (moderate) paronychia.

FIG. 18. Stage III (severe) paronychia.

TABLE 3. Benign and malignant tumors involving the nails

Benign and Malignant Tumors

FIG. 21. Subungual and periungual verrucae of the hallux.

FIG. 23. Bowen's disease of the hallux nail plate.

TABLE 4. Genetic disorders with nail changes

Hereditary and Genetic Factors

DIAGNOSIS AND METHODS

Lateral and Horizontal Biopsy

Chemical Nail Avulsion

Anhydrous lanolin 20%

White petrolatum 25%

Silica gel type H 10%

Chapter 2 Morton's Neuroma