[Subligamentous transfer of the extensor digitorum brevis tendon for medial malalignment of the lesser toes].

OBJECTIVE

Realignment of medially deviated lesser toes II-IV via subligamentous transfer of the extensor digitorum brevis tendon to treat painful toe disorders.

INDICATIONS

Flexible medial malalignment of the lesser toes II-IV attributed to transverse instability of the metatarsophalangeal joint.

CONTRAINDICATIONS

Contract lesser toe deformities. Medial malalignment due to an osseous pathology or instability of the proximal interphalangeal joint. Neuropathy. Infection.

SURGICAL TECHNIQUE

Regional anesthesia. Patient in supine position. Dorsal S-shaped skin incision at the metatarsophalangeal joint. Medial split of the extensor hood. Dorsomedial capsular release. Distal tenotomy of the extensor digitorum brevis tendon. Transfer of the tendon slip beneath the intermetatarsal ligament to the lateral aspect of the proximal phalanx. After manual realignment of the toe periosteal or intraosseous fixation of the tendon.

POSTOPERATIVE MANAGEMENT

Bulky dressing with well-aligned toes. Anti-inflammatory drugs. Walking (full weight bearing) with a forefoot relief orthosis for 4 weeks. Toe splint and/or bandage for 12 weeks. Active exercises (toe flexion, standing on tiptoes, aquajogging) can be started after 4 weeks. Comfortable shoeware after 4 weeks.

RESULTS

23 of 32 patients with flexible medial malalignment of the lesser toes II and/or III were followed up after a mean of 19 months. Medial malalignment could be reduced markedly (preoperatively 28 degrees, postoperatively 6 degrees). Four patients treated with the tendon transfer alone developed a recurrent deformity with dorsal subluxation at the metatarsophalangeal joint level. These patients revealed a concomitant hallux valgus deformity of >30 degrees. Six patients with an additional metatarsal shortening presented with floating toes. Although all patients were able to stand on tiptoes, the active range of toe motion was decreased. Radiologically, joint congruency was improved. 18 patients revealed a congruent joint, and five patients presented with a medial subluxation of the proximal phalanx.