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Abstract In this technical report study, we describe the use of a flexor tenodesis procedure in the treatment of lesser toe deformities (LTD). Using a specific implant, both the flexor digitorum longus and brevis tendons are attached to the plantar aspect of the proximal phalanx, allowing dynamic correction of flexible deformities of metatarsophalangeal and interphalangeal joints. Good clinical results and absence of complications were observed in a series of 3 patients, with considerable correction of the LTD, and absence of substantial residual floating toe or metatarsophalangeal joint stiffness. Level of evidence V – Technical Report/Case Report/Expert Opinion.

Background: Lesser toe metatarsophalangeal (MTP) joint pathology presents a challenge for surgical treatment. At our institution, arthroplasty using a polyvinyl alcohol (PVA) hydrogel implant has been utilized in the second and third MTP joints for advanced arthritis, failed management of Freiberg’s infraction, and osteochondral defects. We present a case series describing the clinical outcomes of 13 patients following PVA implantation of the second or third MTP. Methods: We retrospectively identified 13 patients (14 joints) who underwent PVA hydrogel implantation of the second ( n = 12) or third ( n = 2) metatarsal between 2017 and 2019. The average age was 49 (range, 20-67) years, with 100% females. Patient-Reported Outcomes Measurement Information System (PROMIS) scores were collected preoperatively and at an average of 21.1 (range, 8.3-29.2) months postoperatively. Clinical outcomes were also evaluated. The average time to clinical follow-up was 24.7 (range, 7-35.8) months. Results: On average, patients demonstrated pre- to postoperative improvement in all PROMIS domains, with significant improvements in Pain Intensity ( P = .01) and Pain Interference ( P = .01). Five postoperative complications were observed: 1 case of persistent avascular necrosis, 1 revision with implant removal and bone grafting, 1 periprosthetic fracture, and 2 recurrences of pain requiring ultrasound-guided injection. Conclusion: This study represents the largest case series to date evaluating the use of PVA implant in the surgical correction of lesser toe MTP joint pathology. While the PVA implant presents a viable option in the setting of advanced arthritis, Freiberg’s infraction, and certain osteochondral defects, it is not without complications. The specific indications for use of the PVA implant should be carefully considered. Level of Evidence: Level IV, case series.

Background: Lesser toe metatarsal head degeneration and collapse can cause significant pain and disability. In the setting of global metatarsal head collapse, there are limited operative options. The purpose of our study was to evaluate clinical and radiographic outcomes after lesser toe metatarsophalangeal (MTP) joint interpositional arthroplasty with a tendon allograft and to describe the operative technique. Methods: We retrospectively reviewed a consecutive series of patients treated by 3 fellowship-trained foot and ankle surgeons at one institution. We created a phone survey to evaluate satisfaction, pain, and likelihood to repeat the surgery. Foot and Ankle Ability Measure (FAAM) scores were reviewed before and after surgery. Preoperative and postoperative radiographs were evaluated for preservation of metatarsal length. The procedure was performed through a dorsal midline approach. The metatarsal head was reamed to a concave shape. A tendon allograft was fashioned into a ball and secured to the metatarsal with an anchor. Fifteen feet in 14 patients underwent lesser MTP joint interposition arthroplasty, with the average age of 49 years (range, 24-69), and an average follow-up of 4.2 years. Results: Eighty percent (12/15) reported they would have the procedure again. Visual analog scale pain scores showed a decrease in pain from 7 to 1. FAAM sports subscale improved from 56% to 85%. Radiographically, the ratio of the affected metatarsal length to the adjacent metatarsal remained constant before and after surgery, suggesting preservation of the metatarsal cascade. Conclusion: Interpositional arthroplasty of the lesser MTP joints with a rolled tendon allograft provided a unique solution, as it allows the surgeon to fill a large void without harvesting an autograft. This study showed improved patient-reported outcomes, high patient satisfaction, and good radiographic outcomes. Lesser metatarsophalangeal joint allograft interposition arthroplasty was a viable solution as a salvage procedure in the setting of global metatarsal head collapse. Level of Evidence: Level IV, retrospective case series.

Resection arthroplasty for metatarsalgia is a selective procedure primarily indicated for patients with rheumatoid arthritis. These patients present with significant forefoot deformities, poor bone quality, and loss of soft tissue integrity. Resection of the metatarsal heads and correction of lesser toe deformities improve pain and decrease transfer metatarsalgia. Patients with concurrent hallux valgus may benefit from a lapidus procedure or hallux metatarsophalangeal fusion in an effort to improve outcomes and decrease incidence of recurrent hallux valgus. In rare cases, diabetics with neuropathy may require resection arthroplasty in the setting of forefoot deformities recalcitrant to other modalities.

Highlights • A case of boutonniere deformity of the second toe caused by sumo wrestling. • Forced passive flexion exerted on an actively extended PIP joint is the likely cause. • Surgical repair of the extensor mechanism and temporary pinning were effective., Introduction Traumatic boutonniere deformities of the fingers are well documented unlike those of the lesser toes. With few existing reports on boutonniere deformities of the lesser toes, the related pathology and treatment guidelines remain unclear. Presentation of case We present a case of traumatic boutonniere deformity of the second toe caused by sumo wrestling in a 23-year-old man. A flexion deformity of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint of the right second toe were observed, including a torn central slip and plantarly displaced lateral bands during surgery. Surgical repair of the extensor mechanism and temporary pinning led to good clinical results. Discussion Acute traumatic boutonniere deformity of the interphalangeal joint of the lesser toe is very rare. The mechanism of boutonniere deformity in this case is thought to be due to forced passive flexion exerted on an actively extended PIP joint, which is similar to that seen in fingers. Conclusion We describe the pathophysiology of a case of boutonniere deformity of the lesser toe and suggest the effectiveness of surgical treatment.

Distal phalanx fractures of the toes are common injuries. The majority of them are treated conservatively with good outcome. We present the case of a painful non-union fracture of the distal phalanx of the 4th toe in a 60-year-old female patient with symphalangism of the 4th and 5th toes. She underwent surgical fixation of the fracture with concomitant inter-phalangeal joint (IPJ) arthrodesis for better stability. A transverse dorsal incision was made just distal to the IPJ to allow preparation of both the fracture site and IPJ. Fibrous tissue at the fracture non-union site was removed and the opposing surfaces drilled with a 0.88mm K-wire. Cartilaginous tissue at the IPJ was removed and similarly drilled with the 0.88mm K-wire. Stabilisation was achieved with a percutaneous headless compression screw. Radiographic union was achieved and the patient had resolution of symptoms 16 weeks after the surgery. The patient continued to be symptom-free at one year follow-up. This is the first case report of a surgically treated symptomatic non-union of distal phalanx fracture of a lesser toe in the literature.

Background: Lesser toe plantar plate attenuation or disruption is being increasingly implicated in a variety of common clinical conditions. A multitude of surgical techniques and devices have been recently developed to facilitate surgical repair of the plantar plate. However, the microvascular anatomy, and therefore the healing potential in large part, has not been defined. We investigated the microvasculature of the plantar plate by employing a novel technique involving microvascular perfusion and nano–computed tomography (nano-CT) imaging. Methods: Twelve human adult cadaveric lower extremities were amputated distal to the knee. The anterior and posterior tibial arteries were perfused with a barium solution. The soft tissues of each foot were then counterstained with phosphomolybdic acid (PMA). The second through fourth toe metatarsophalangeal (MTP) joints of 12 feet were imaged with nano-CT at 14-micron resolution. Images were then reconstructed for analysis of the plantar plate microvasculature and calculation of the vascular density along the length of the plantar plate. Results: A microvascular network extends from the surrounding soft tissues at the attachments of the plantar plate on both the metatarsal and proximal phalanx. The midsubstance of the plantar plate appears to be relatively hypovascular. Analysis of the vascular density along the length of the plantar plate demonstrated a consistent trend with increased vascular density at approximately the proximal 29% and distal 22% of the plantar plate. Conclusion: There is a vascular network extending from the surrounding soft tissues into the proximal and distal attachments of the plantar plate. Clinical relevance: The hypovascular midportion of the plantar plate may play an important role in the underlying pathoanatomy and pathophysiology of this area. These findings may have significant clinical implications for the reparative potential of this region and the surgical procedures currently described to accomplish anatomic plantar plate repair.

Lesser toe plantar plate injuries at the metatarsophalangeal (MTP) joint are a common source of metatarsalgia. The second MTP joint is the most commonly affected digit. The fibrocartilaginous plantar plate is the most important static stabilizer of the MTP joint; high loading with weight bearing can lead to attritional plantar plate injuries. Chronic pain with weight bearing is the common presentation of lesser toe instability. Untreated plantar plate instability can lead to hammer toe and mallet toe deformities. Combined Weil osteotomy and plantar plate repair yields favorable pain relief and angular deformity correction for patients who fail conservative treatment.

Background: Recent surgical techniques have focused on anatomic repair of lesser toe metatarsophalangeal (MTP) plantar plate tears, yet it remains unknown whether the plantar plate has the biological capacity to heal these repairs. Therefore, a better understanding of the plantar plate vasculature in response to injury may provide further insight into the potential for healing after anatomic plantar plate repair. Recently, a study demonstrated that the microvasculature of the normal plantar plate is densest at the proximal and distal attachments. The purpose of this study was to compare the intact plantar plate microvasculature network to the microvasculature network of plantar plates in the presence of toe deformity using similar perfusion and nano–computed tomographic (CT) imaging methods. Methods: Seven fresh-frozen human cadaveric lower extremities with lesser toe deformities including hammertoe or crossover toe were perfused using a barium solution. The soft tissues of each foot were counterstained with phosphomolybdic acid (PMA). Then using nano-CT imaging, the second through fourth toe metatarsophalangeal joints of 7 feet were imaged. These images were then reconstructed, plantar plate tears were identified, and 11 toes remained. The plantar plate microvasculature for these 11 toes was analyzed, and calculation of vascular density along the plantar plate was performed. Using analysis of variance (ANOVA), this experimental group was compared to a control group of 35 toes from cadaveric feet without deformity and the vascular density compared between quartiles of plantar plate length proximal to distal. A power analysis was performed, determining that 11 experimental toes and 35 control toes would be adequate to provide 80% power with an alpha of 0.05. Results: Significantly greater vascular density (vascular volume/tissue volume) was found along the entire length of the plantar plate for the torn plantar plates compared to intact plantar plates (ANOVA, P < .001). For the first quartile of length (proximal to distal), the vascular density for the torn plantar plates was 0.365 (SD 0.058) compared to 0.281 (SD 0.036) for intact plantar plates; in the second quartile it was 0.300 (SD 0.044) vs 0.175 (SD 0.025); third quartile it was 0.326 (SD 0.051) vs 0.117 (SD 0.015); and fourth (most distal) quartile was 0.600 (SD 0.183) vs 0.319 (SD 0.082). Conclusion: Torn plantar plates showed increased vascular density throughout the length of the plantar plate with an increase in density most notable in the region at or just proximal to the attachment to the proximal phalanx. Our analysis revealed that torn plantar plates exhibit neovascularization around the site of a plantar plate tear that does not exist in normal plantar plates. Clinical Relevance: The clinical significance of the increased vascularity of torn plantar plates is unknown at this time. However, the increase in vasculature may suggest that the plantar plate is a structure that is attempting to heal.

Deformities of the lesser toes are one of the most commonly treated conditions by foot and ankle surgeons. Despite their frequency, a standardized classification has yet to take hold among providers. Generic nomenclature with the addition of multiple adjunctive descriptors continues to be the standard leading to international confusion. A literature review was conducted to analyze any literature and/or textbooks pertaining to lesser toe deformity classification systems. Seven sources met the inclusion criteria and were analyzed consisting of novel, modified, and previously published systems. A simplified and treatment driven lesser toe deformity classification utilized at the University of Louisville is introduced, which categorizes these deformities into one of two groups. Type 1 deformities are those isolated to the toe only and Type 2 deformities are toe deformities that include metatarsal phalangeal joint involvement. The intent of the University of Louisville Lesser Toe Deformity Classification (LTDC) is to improve communication and documentation, as well as assist surgical planning. LEVEL OF CLINICAL EVIDENCE: 5.

Category: Lesser Toes Introduction/Purpose: Recent surgical techniques have focused on anatomic repair of lesser toe metatarsophalangeal (MTP) plantar plate tears. MTP instability has been implicated in a number of common toe deformities as well as metatarsalgia. Recently, a study demonstrated that the microvasculature of the normal plantar plate is densest at the proximal and distal attachments. The purpose of this study was to compare the intact plantar plate microvasculature network to the microvasculature network of plantar plates in the presence of toe deformity using similar perfusion and nano-CT imaging methods. Methods: Eight fresh frozen human cadaveric lower extremities with lesser toe deformities including hammertoe or crossover toe were perfused using a barium solution. The soft tissues of each foot were counterstained with phosphomolybdic acid (PMA). Then using nano-CT imaging the second through fourth toe metatarsophalangeal joints of 8 feet were imaged. These images were then reconstructed, plantar plate tears were identified, and eleven toes remained. The plantar plate microvasculature for these eleven toes was analyzed and calculation of vascular density along the plantar plate was performed. Using ANOVA analysis this experimental group was compared to a control group of 35 toes from cadaveric feet without deformity and the vascular density compared between quartiles of plantar plate length proximal to distal. Results: Demonstrated in Figure 1, of the torn plantar plates the average percent vascular density (vascular volume/tissue volume) in the first quartile of length (proximal to distal) is 0.365 (SD 0.058) compared to 0.281 (SD 0.036) for intact plantar plates; in the second quartile it is 0.300 (SD 0.044) vs 0.175 (SD 0.025); third quartile it is 0.326 (SD 0.051) vs 0.117 (SD 0.015); and fourth (most distal) quartile is 0.600 (SD 0.183) vs 0.319 (SD 0.082) respectively. Using ANOVA testing all differences were found to be significant to pConclusion: Torn plantar plates demonstrate increased vascular density throughout the length of the plantar plate with an increase in density most notable in the region at or just proximal to the attachment to the proximal phalanx. The clinical significance of the increased vascularity of torn plantar plates is unknown at this time. However, the increase in vasculature may suggest that the plantar plate is a structure that is attempting to heal.

Delayed wound healing is one of the most common complications following forefoot surgery in patients with rheumatoid arthritis. We aimed to identify the risk factors for delayed wound healing following rheumatoid forefoot surgery.Consecutive patients who underwent primary rheumatoid forefoot surgery (86 feet; 53 patients) between April 2008 and February 2019 were retrospectively evaluated. Clinical data, including smoking history, duration of the disease, presence of diabetes mellitus, medication, white blood cell count, erythrocyte sedimentation rate (ESR), C-reactive protein, the surgical procedure performed, and the Japanese Society for Surgery of the Foot (JSSF) scores, were collected.Delayed wound healing was identified in 20 of 86 (23.3%) feet. In univariate analysis, participants showing delayed healing were older at the time of surgery (After rheumatoid forefoot surgery, surgeons should pay more attention to wound care in patients with lower preoperative JSSF Lesser toe score and high ESR.

Objective To examine differences in lower limb muscle strength between older people with varying degrees of hallux valgus deformity. Methods Muscle strength was measured at the knee, ankle and foot using hand-held dynamometry and a clinical test of toe strength (the paper grip test) in 157 older people (99 women and 58 men) aged 65 to 91 (mean 74.1, SD 5.9) years. Hallux valgus severity was documented as none, mild, moderate or severe using validated photographs. Differences in muscle strength according to hallux valgus severity were evaluated using analysis of variance, adjusting for age. Paper grip test performance was compared across the hallux valgus severity groups using the chi-square (χ2) statistic. Results Knee extension, ankle joint dorsiflexion, ankle joint plantar flexion, ankle joint inversion, ankle joint eversion and lesser toe plantarflexion strength were not significantly different across the four hallux valgus severity groups. However, there was a significant, dose-response reduction in hallux plantarflexion strength with increasing severity of hallux valgus. This persisted after adjustment for age (F3 = 5.5, p = 0.001) with a medium effect size (partial η2 = 0.10). The number of participants who could successfully complete the paper grip test of the hallux significantly reduced across the four hallux valgus categories (χ2 = 18.5, p Conclusions There is a specific and progressive reduction in hallux plantarflexion strength with increasing severity of hallux valgus in older people. This finding has potential implications for both the aetiology and treatment of this common and disabling condition.

The etiology of lesser toe pain in the athlete can be a difficult thing to diagnosis and treat. Athletes can have similar pathology to the normal patient population, but the added stress of repetitive use can cause exacerbation of these conditions. These diagnoses can include bony, soft-tissue, or nerve-related pathology. In most cases, conservative treatment improves the condition; however, surgical treatment may be an option.

A schwannoma is a solitary benign tumor composed of Schwann cells occurring anywhere in the peripheral nervous system. The diagnosis of a schwannoma is often difficult to make by clinical presentation and advanced imaging modalities. We present a case report of a 61-year-old Hispanic woman with a left-foot, third-digit, soft-tissue mass. The diagnosis of a schwannoma of the proper digital nerve was made postsurgically by means of histopathologic and immunohistochemistry parameters. This is a rare location for a schwannoma, and neurogenic tumor should be included in the differential diagnosis of soft-tissue mass, as there have been prior case reports.

Gewebeschonende, gelenkerhaltende Korrektur von Zehenfehlstellungen mit keilformiger oder linearer Osteotomie am jeweiligen Grund- und Mittelglied sowie Kapsulotomien und/oder Tenotomien zur weichteiligen Korrektur. Behandlung der Metatarsalgie durch eine extrakapsulare, distale metaphysare halbmondformige Osteotomie der betroffenen Metatarsalia in allen Ebenen. Symptomatische Deformitaten der Kleinzehen, schmerzhafte Exostosen, Transfermetatarsalgie, statische und propulsive Metatarsalgie, symptomatisches Malalignement des Vorfuses, Metatarsus adductus. Infektion oder Perfusionsstorungen der betroffenen Strahlen, Luxation der Kleinzehengrundgelenke, mangelhafte Compliance. Durchleuchtungskontrolle. Befundabhangige Osteotomie des Grund- und Mittelglieds (lateraler Zugang) sowie plantare Kapsulotomie des Zehenmittelgelenks; in seltenen Fallen dorsale Kondylektomie des Grundgliedkopfchens mit Tenotomie der Flexor-digitorum-brevis-Sehne sowie eine proximal des Zehengrundgelenks gelegene Tenotomie der Extensor-digitorum-longus-Sehne unter Verwendung einer Mikrofrase bzw. eines Mikroskalpells. Befundabhangige Mittelfusosteotomien (metaphysar proximal des Mittelfuskopfs) mit der Mikrofrase unter Durchleuchtungskontrolle von plantar medial nach dorsallateral. Die Osteotomie erfordert keine Osteosynthese. Redressionszugelverbande fur die Kleinzehen und selbsthaftende Kompressionsverbande zur Fixierung des Mittelfuses zur externen Stabilisierung der Osteotomien fur 6 Wochen; fruhzeitige Belastung moglich. Eine prospektive Fallstudie mit Vergleich von jeweils 30 Patienten mit minimal-invasiver distaler metaphysarer Metatarsaleosteotomie (DMMO; n = 73) und konventioneller Weil-Osteotomie (n = 45) ergab nach einer mittleren Nachuntersuchungszeit von 13 Monaten vergleichbare Ergebnisse. Die Operationsdauer war bei minimal-invasiver Technik deutlich kurzer als bei Weil-Osteotomie, allerdings mit hoherer Strahlenbelastung fur Operateur und Patient.

Lesser toe deformities are among the most common complaints presented to foot and ankle specialists. These deformities present in variable ways, which makes surgical decision making complex. For every type of deformity, there could be a combination of soft tissues and bony procedures, chosen according to the surgeon's preferences. This article first describes modern classification of lesser toe deformities, and then presents the different treatments and procedures available for those flexible deformities. In addition, this article proposes an algorithm based on clinical/radiological evaluation and step-by-step surgical decision making.

Ischemia after correction of lesser toe deformities is usually due to temporary vasospasm and can rarely cause gangrene. The published literature on dealing with the issue and been reviewed and used to suggest an algorithm for a logical step by step approach to a pale or white toe when encountered in the postoperative period.

Dorsal dislocation of metatarsophalangeal (MTP) joints of the lesser toe frequently occurs in patients with rheumatoid arthritis (RA), and may cause painful and uncomfortable plantar callosities and ulceration. The current study examined the reliability and clinical relevance of a novel radiographic parameter (the MTP overlap distance [MOD]) in evaluating the severity of MTP joint dislocation. The subjects of the current study were 147 RA patients (276 feet, 1104 toes). MOD, defined as the overlap distance of the metatarsal head and the proximal end of the phalanx, was measured on plain radiographs. The relationship between the MOD and clinical complaints (forefoot pain and/or callosity formation) was analyzed to create a severity grading system. As a result, toes with callosities had a significantly larger MOD. ROC analysis revealed that the MOD had a high AUC for predicting an asymptomatic foot (−0.70) and callosities (0.89). MOD grades were defined as follows: grade 1, 0 ≤ MOD &lt, 5 mm, grade 2, 5 ≤ MOD &lt, 10 mm, and grade 3, MOD ≥ 10 mm. The intra- and inter-observer reliability of the MOD grade had high reproducibility. Furthermore, the MOD and MOD grade improved significantly after joint-preserving surgeries for lesser toe deformities. Our results suggest that MOD and MOD grade might be useful tools for the evaluation of deformities of the lesser toe and the effect of surgical intervention for MTP joints in patients with RA.

With the current data concentrating on different operative treatment options for plantar plate tears, few data can be found on possible nonoperative treatment strategies for this entity and the specifics of such treatment. In the present case report, the successful nonoperative treatment of a patient with a rupture of the plantar plate in a lesser toe metatarsophalangeal joint is presented. The patient was followed up using repeat clinical examinations and high-resolution magnetic resonance imaging scans for 1 year after the imitation of therapy to provide information on the different stages of the healing process.

Background: Although standard fixation of proximal interphalangeal (PIP) arthrodesis by K-wire is relatively inexpensive and well established, it does have some drawbacks, making newer fixation devices interesting. The aim of this study was to clinically and radiologically assess the operative correction of the lesser toe deformation in the form of a PIP arthrodesis using a bioabsorbable 2.7-mm fixation screw. Methods: From January 2011 until October 2013, 34 patients underwent a PIP arthrodesis using the TRIM-IT (Arthrex) 2.7-mm fixation screw and were contacted for this retrospective cohort study. At an average of 3.3 years after the operation, 24 patients and 26 toes were evaluated clinically, radiologically, through pedobarography, and a patient-satisfaction survey. Results: Using the PLLA screw for fixation, 84.6% showed bony union of the arthrodesis, and 84.6% were satisfied. Mean AOFAS score was 82.7 points and thus regarded as good. The mean VAS score was 1.3/10. Overall, 73.1% of the toes showed good alignment, and 7.7% had a painless recurrence of deformity and were still satisfied with the intervention. In addition, 34.6% had floating toes, but only 4.2% without Weil osteotomy or encroachment. Further, 3.8% were advised to undergo a revision because of severe misalignment. Conclusion: The 2.7-mm bioabsorbable fixation screw yielded results that were comparable to other fixation devices for PIP fusion fixation regarding success rate, revisions, and patient acceptance. Level of Evidence: Level IV, retrospective case series.

Purpose To compare the 6-month outcome of Weil osteotomy with distal metatarsal mini-invasive osteotomy (DMMO) in 33 patients with lesser toe metatarsalgia. Methods Records of 33 patients who underwent Weil osteotomy (n=20, 41 toes) or DMMO (n=13, 22 toes) for lesser toe metatarsalgia by a single surgeon were reviewed. 25 of them had a concurrent procedure on the 1st toe. Outcome at 6 months was assessed using the visual analogue score (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) lesser toe metatarsophalangeal-interphalangeal (MTP-IP) score, and the RAND-36 score. Results The 2 groups were comparable in terms of age, gender, and preoperative MTP joint range of motion (ROM), VAS for pain, AOFAS lesser toe MTP-IP score, and RAND-36 scores. At 6 months, the Weil osteotomy group had a higher RAND-36 (mental) score (92 vs. 78, p=0.026), and the DMMO group had a higher percentage of toes with greater MTP joint ROM (p=0.043). All patients achieved bone union within 6 months. Two patients in the DMMO group had prolonged oedema until 3 months post-surgery. Conclusion DMMO is a safe and reliable alternative to Weil osteotomy for metatarsalgia and can preserve ROM of the MTP joints.

Deformities of the lesser toes are common and can be associated with significant morbidity. These deformities are often multiple, and numerous treatment strategies have been described in the literature. The goal of surgical treatment is to improve symptoms by restoring alignment and function, and avoiding recurrence. In order to achieve this, it is essential for the treating surgeon to understand the normal anatomy and pathology of the various deformities. There is a paucity of prospective studies and randomised-controlled trials assessing the efficacy of specific interventions. We describe the normal anatomy and biomechanics of the lesser toes, and the pathology of commonly adult deformities. The rationale behind various treatment strategies is discussed and the results of published literature presented. Algorithms for the management of lesser toe deformities based on current literature are proposed. Cite this article: Malhotra K, Davda K, Singh D. The pathology and management of lesser toe deformities. EFORT Open Rev 2016;1:409-419. DOI: 10.1302/2058-5241.1.160017.

Objectives: Joint-preserving rheumatoid forefoot surgery improves clinical outcomes, but postoperative range of motion (ROM) of the metatarsophalangeal (MTP) joint remains an issue. The objective of this study was to evaluate the effect of ROM exercise from the early period after lesser toe MTP joint-preserving surgery.Methods: A retrospective, observational study of 22 rheumatoid arthritis patients who underwent modified metatarsal shortening offset osteotomy was completed. Lesser toe scales were administered using the Japanese Society for Surgery of the Foot (JSSF) standard rating system, and the maximum distance of continuous walking was checked to evaluate clinical outcomes. Maximum passive ROM of the lesser toe MTP joints and the extension angle of the 2nd MTP joint at the terminal stance phase during gait were measured and evaluated.Results: Pain scores and ROM-related indices of the JSSF lesser toe scale improved significantly in the exercise group. The extension angle of the 2nd MTP joint at the terminal stance phase during gait was increased, and the maximum distance of continuous walking seemed longer.Conclusion: Passive/active ROM exercise from 2-weeks after surgery can improve a patient's activity and forefoot function through increasing ROM of the MTP joint at the terminal stance phase.

espanolCon este trabajo se pretende dar una actualizacion y opinion sobre los diferentes procedimientos en cirugia MIS para la correccion de la patologia digital mediante la descripcion e indicacion de las diferentes tecnicas, asi como la evolucion de las mismas. Las tecnicas originales en cirugia MIS para la correccion de la patologia digital fueron las osteotomias completas; a continuacion se adaptaron de la cirugia a campo abierto la artroplastia y la artrodesis por MIS, para mas tarde desarrollar las osteotomias incompletas, en las que una parte de la cortical osea se deja intacta. En sus inicios era indispensable la cirugia sobre tejidos blandos, tenotomias y capsulectomias como parte de la cirugia digital. Hoy en dia en las actuaciones digitales, segun el grado de deformidad y edad del paciente, se intenta evitar la cirugia sobre tejido blando y corregir la deformidad mediante la actuacion en tejido oseo para evitar la deficiencia de movilidad postoperatoria que se produce al realizar tenotomias. EnglishThis study aims to update the various minimally invasive procedures when surgically restoring the normal alignment of the lesser toes and also provides the opinion of the author. This is done through the description and indication of the different MIS techniques and their evolution over time. The first lesser toe MIS procedures were initially performed in a complete osteotomy treatment. Over the years, this alternative was expanded into arthroplasties and arthrodesis surgeries, both commonly used as open methods and finally the minimally invasive correction was practised on partial osteotomies where a portion of the cortical is retained. In the past, lesser toe surgery procedures always involved soft tissue damage, tenotomies and capsular release. Nowadays, based on the type of the deformity and patient age, soft tissue work is avoided and the corrective surgery is preferably done through bone structure treatment strategies instead. This option is carried out to minimise the longer recovery time and mobility impairment associated with tenotomies.

Metatarsophalangeal joint dislocations of lesser toes are often seen in the setting of severe claw toes. Traumatic irreducible dislocations have been reported in rare cases following both low-energy and high-energy injuries to the forefoot. In this case report, I present a previously unreported association of a metatarsal shaft fracture with metatarsophalangeal joint dislocation of a lesser toe.

Background This prospective randomised controlled trial was performed to determine whether the incidence of local infection is reduced in patients who are administered prophylactic antibiotics for lesser toe fusion surgery. Methods 100 adult patients undergoing toe fusion surgery that required K-wires to be left in situ for 4–6 weeks were randomly allocated into those who received prophylactic antibiotics (Group 1, n =48) and those who did not (Group 2, n =52). Patients were followed up regularly and during each visit K-wire insertion sites were assessed for signs of pin tract infection. Results The mean age of Group 1 was 58.0 (SD 17.5) and Group 2 was 62.7 years (SD 14.7). The overall infection rate was 4%. Three patients (6.2%) in Group 1 and one patient (1.9%) in Group 2 developed signs of infection, which required treatment by oral antibiotics. All infections were low grade. There were no features suggestive of osteomyelitis in any of the patients. Conclusion The overall infection rate in lesser toe fusion surgery is low and that using prophylactic antibiotics does not reduce the incidence. Inappropriate use of antibiotics, however, may contribute to the development of antibiotic resistance and adds to healthcare costs.

Background: Lesser toe proximal interphalangeal (PIP) joint arthrodesis is one of the most common foot and ankle elective procedures often using K-wires for fixation. K-wire associated complications led to development of intramedullary fixation devices. We hypothesized that X Fuse (Stryker) and Smart Toe (Stryker) would provide stronger and stiffer fixation than K-wire fixation. Methods: 12 cadaveric second toe pairs were used. In one group, K-wires stabilized 6 PIP joints, and 6 contralateral PIP joints were fixed with X Fuse. A second group used K-wires to stabilize 6 PIP joints, and 6 contralateral PIP joints were fixed with Smart Toe. Specimens were loaded cyclically with extension bending using 2-N step increases (10 cycles per step). Load to failure and initial stiffness were assessed. Statistical analysis used paired t tests. Results: K-wire average failure force, 91.0 N (SD 28.3), was significantly greater than X Fuse, 63.3 N (SD 12.9) ( P < .01). K-wire average failure force, 102.3 N (SD 17.7), was also significantly greater than Smart Toe, 53.3 N (SD 18.7) ( P < .01). K-wire initial stiffness 21.3 N/mm (SD 5.7) was greater than Smart Toe 14.4 N/mm (SD 9.3) ( P = .02). K-wire failure resulted from bending of K-wire or breaching cortical bone. X Fuse typically failed by implant pullout. Smart Toe failure resulted from breaching cortical bone. Conclusion: K-wires may provide stiffer and stronger constructs in extension bending than the X Fuse or Smart Toe system. This cadaver study assessed stability of the fusion site at time zero after surgery. Clinical Relevance: Our findings provide new data supporting biomechanical stability of K-wires for lesser toe PIP arthrodesis, at least in this clinically relevant mode of cyclic loading.

Background: Lesser toe metatarsal-phalangeal (MTP) joint instability can be a major source of pain and dysfunction. Instability occurs when there is incompetence of the plantar plate and/or collateral ligaments. Newer operative treatments focus on performing anatomic repairs of the plantar plate. The goal of this study was to compare the biomechanical properties of 3 suture configurations that may be used for plantar plate repairs. Methods: Biomechanical analysis of 27 lesser toe plantar plates from fresh frozen human cadavers was completed. The plantar plate was detached from the proximal phalanx, and suture was placed in the distal plantar plate in a horizontal mattress, luggage-tag, or Mason-Allen suture configuration. Cyclic loading followed by load-to-failure testing was performed. Results: There was a significant difference in peak load-to-failure force between constructs (mattress: 115.53 ± 15.95 N; luggage-tag 102.42 ± 19.33 N; Mason-Allen: 89.96 ± 15.78 N; P = .015). Post hoc analysis demonstrated that the mattress configuration had significantly higher load-to-failure force compared with the Mason-Allen configuration ( P = .004). There were no significant differences between the mattress and the luggage-tag configurations or the luggage-tag and the Mason-Allen configurations. There were no differences in construct stiffness, axial displacement at the time of failure, or number of cycles required to produce 2 mm of displacement. Conclusion: The mattress configuration demonstrated better peak load-to-failure force compared with the Mason-Allen configuration but was not statistically different from the luggage-tag configuration. Although not significant, the mattress configuration trended toward higher load-to-failure force compared with the luggage-tag. Clinical Relevance: The horizontal mattress stitch may be the biomechanically superior configuration in plantar plate repairs.

The anatomy of the lesser toes is highly complicated and not yet well understood. The high propensity of the metatarsophalangeal joint to develop hyperextension deformity should be recognized. Surgeons should provide each patient with a realistic expectation for lesser toe reconstructive procedures. A successful surgical result requires a well-planned procedure, accurate execution using proper techniques, and meticulous postoperative care. When complications occur, surgeons should identify culprits so that proper treatment strategies can be successfully executed. This article discusses a wide array of tactics to manage common complications in lesser toe surgery.