Correcting The Lesser MPJ Transverse Plane With A Unique Metatarsal Osteotomy

Transverse plane deformity in the face of hammertoe correction is a common source of frustration. Authors have described various lesser metatarsal osteotomies to attempt correction of lesser metatarsophalangeal joint (MPJ) deformity and pain.^1,2 In addition to osseous correction, soft tissue reconstruction in the form of plantar plate repairs and tendon transfers is well-documented.^1,2

The current concept of any osseous correction is to offload the MPJ and realign the metatarsal parabola to a more normal position. This would inherently offload the soft tissue structures related to this deformity and therefore relieve the patient’s pain. Soft tissue reconstruction and plantar plate repairs have been an increasing source of conversation and research.^1-4 However, researchers have made few conclusions regarding the correction of both the transverse and sagittal plane deformity of the lesser toes.

Deland and Sung described a deficiency in the MPJ collateral ligaments as well as unbalanced muscular forces surrounding these lesser joints and how those factors will often lead to a deformity in all three planes.⁵ Most often, this angular contracture is present in the second MPJ due to the underlapping hallux with a concomitant moderate to severe hallux valgus deformity.

We understand the natural history of this deformity as an instability of the lesser MPJ and contracture of the medial soft tissue structures. This allows the digit to follow the pull of the flexor tendons just as one would see with a hallux valgus deformity. Over time, the medial collateral ligaments contract and the lateral collateral ligaments attenuate. The digit typically follows the tightened flexor tendons and contracts at the digital interphalangeal joints as well.

In addition, the thick fibrocartilaginous plantar plate may become attenuated and develop tears. Deland, Johnson and colleagues have described the anatomy of the plantar plate in detail and its associated pathology as it relates to chronic hammertoe and crossover toe deformities.^5-7 Direct plantar approaches and dorsal approaches have started a paradigm shift in the attempt to treat chronic hammertoes with or without a transverse plane element.

Non-operative treatments include toe spacers, metatarsal pads, orthotic offloading devices and taping. Due to the longstanding nature of these deformities, these options typically only provide temporary relief. For some patients, this is enough to provide comfort in a larger toe-boxed shoe and accommodate a patient’s needs. After exhausting conservative treatment options, one may offer operative interventions.

What Are The Available Surgical Options?

Surgical options for the lesser MPJ transverse plane include corrective metatarsal osteotomies, plantar plate repairs, flexor tendon transfers and digital arthrodesis. Misenbach first described the lesser metatarsal osteotomy in 1916.⁸ The author performed a transverse midshaft osteotomy without fixation to allow the capital fragment to translate dorsally. Researchers have described many other osteotomies but they have yielded only satisfactory results with various associated complications.^8-12

More recently, authors have described other distal metatarsal osteotomies that range from transverse and oblique to “V” osteotomies and various modifications of each.^13-18 The current gold standard metatarsal osteotomy is the Weil osteotomy.¹⁹ Typically, one performs an osteotomy from dorsal distal to plantar proximal, parallel to the weightbearing surface. Then the surgeon would translate the capital fragment proximal to the desired amount and fixate this with one or two screws. This osteotomy has been one of the most common forefoot procedures surgeons perform for digital deformities and metatarsalgia, but it is also fraught with complications.   

Results have varied with the main complication being a floating toe, defined as the incapacity of the toe to purchase the weightbearing surface appropriately during midstance. We believe this occurs because the attenuated plantar plate apparatus typically goes unaddressed and the moment arm of the metatarsal has shortened, which allows the plantar plate to be more attenuated. This allows the digit to succumb to the tightness of the long tendons. The incidence of a floating toe following a lesser metatarsal osteotomy ranges from 15 to 50 percent.^20-22 Again, this osteotomy is one of the more common corrective osteotomies surgeons perform when it comes to foot surgery but it typically does not address a true crossover toe deformity in the transverse and coronal planes.

A Guide To The Lesser Metatarsal Angular Osteotomy

The aim of this article is to describe a lesser metatarsal angular osteotomy that provides correction in multiple planes of deformity. Again, the crossover toe has contracted medially and the flexor and extensor tendons have shifted medially, which drives the digit medial and attenuates the lateral capsule and collateral ligaments. When performing a hallux valgus correction at the same time, perform the medial column procedure first and then proceed to digital and lesser MPJ correction. The angular osteotomy we describe shortens the metatarsal to offload and reduce the MPJ in the sagittal plane, translates the capital fragment in the direction of the flexor pull and dorsally translates to offload the plantar plate. We have utilized this osteotomy for dorsomedial contracture as well as laterally deviated lesser digits at the MPJ with success. We have also found it less necessary to perform a primary plantar plate repair or flexor tendon transfer.

Make a longitudinal incision over the affected proximal interphalangeal joint and extend the incision past the MPJ proximally in a curvilinear fashion. Then perform a standard proximal interphalangeal joint arthrodesis as per surgeon preference. We typically use intramedullary fixation to reduce pin site infection risk.   

Take the dissection down proximally to the MPJ and perform an extensor tendon lengthening at this level as well. Take care to dissect the medial and lateral collateral ligaments that one will use later for soft tissue augmentation. Perform a dorsal transverse capsulotomy and transect the collateral ligaments and capsule midsubstance. This allows appropriate working soft tissue to use for the collateral ligament repair.

At this point, perform the osteotomy in one of two ways. If there is medial deviation of the digit, make the osteotomy in an oblique fashion from dorsal proximal lateral to plantar distal medial. If there is lateral deviation of the digit, the osteotomy is the opposite direction. Of note, the osteotomy is approximately 45 degrees to the long axis of the metatarsal and just proximal to the neck. The intention is having a large enough capital fragment for fixation without having to violate the articular surface. This will allow the surgeon to translate the capital fragment medially, proximally and dorsally to the desired level.  

After performing the osteotomy, temporarily fixate the capital fragment with a small Kirschner wire and it will be apparent that the toe has shifted in the appropriate position. After confirming the correct position, fixate the capital fragment with one to two twist-off screws oriented perpendicular to the osteotomy from distal to proximal.

Confirm correction on intraoperative fluoroscopy. We have found that a medial or lateral shift of at least one-third to one-half the width of the metatarsal is required. One would close the attenuated collateral ligaments and capsule with a non-absorbable suture in the mid- to plantar aspect of the joint so as not to inadvertently cause a dorsal contracture. Proceed to repair the extensor digitorum longus at the appropriate tension per surgeon preference. Then perform a layered closure. Hold the corrected digit in a slightly plantarflexed position during bandaging.  

Postoperatively, the patient typically bears weight immediately in a controlled ankle motion (CAM) walker fracture boot for four to six weeks until radiographic healing occurs and then transitions to a supportive shoe.

Keys To Ensuring Optimal Outcomes

• The collateral ligament transection needs to be midsubstance for later repair.
• The capital fragment should follow the digital translation.
• Shift the fragment at least one-third the diameter of the metatarsal.
• Screw lengths are typically in the 14 to 16 mm range due to the obliquity of the osteotomy.
• Hold the digit in slight plantarflexion and in the overcorrected transverse plane while over sewing the collateral ligaments.

Dr. McAlister is in private practice at Sun City West Clinic in Sun City West, Ariz. He is a board-certified, fellowship-trained foot and ankle surgeon.

Dr. Holmes is in private practice at The CORE Institute in Phoenix.

References

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