Complications of Lesser Toe Surgery : Clinical Orthopaedics and Related Research®

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SECTION I SYMPOSIUM: Complications in Foot and Ankle Surgeries

Complications of Lesser Toe Surgery

Femino, John E. MD; Mueller, Kelly MD

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Clinical Orthopaedics and Related Research: October 2001 - Volume 391 - Issue - p 72-88
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Lesser toe deformities are among the most common of all foot and ankle disorders. The reported incidence of hammertoes and clawtoes range from 2% to 20%. 20,41,56 These disorders have been linked to footwear, 33,43 and have been shown to be uncommon among populations that do not wear shoes. 30,45 The type of footwear also seems to be important because the occurrence of deformities is more common in women than in men. 17 The forefoot shape of shoes worn by people in most western countries is not shaped anatomically. 17,19,43 The toe box often is more tapered than the natural outline of the forefoot. This especially is true for women’s footwear and may account for the increased incidence of lesser toe deformities between women and men of as much as 5:1. In addition, many people may not have their feet measured regularly, assuming that the size of their feet will not change once they reach skeletal maturity. It has been shown that 86% of women surveyed had shoes that were either too narrow, too short, or both. 33 Shoes that are too small cause toes to buckle and lead to attrition of the plantar plate and eventually contracture of the extensor mechanism and intrinsics. 16 As a result, the occurrence of most deformities also is reported to increase, in a linear fashion, with age. 7,77 This also may explain why some have observed that symptomatic deformity has been found to exist more often in the second toe, 15,59,86 the longest toe, or both. 15,42 Hammertoes rarely are seen in newborns. 42,43

Other causes of lesser toe deformities include neurologic disorders (Table 1), inflammatory diseases such as rheumatoid arthritis, biomechanical causes (Table 2), and muscle contracture after soft tissue trauma such as compartment syndrome. 16

Neurologic Causes of Lesser Toe Deformities
Conditions Associated With Metatarsalgia

Biomechanical Function

Gait consists of a stance phase and a swing phase. Stance phase accounts for 40% of the normal gait cycle. 1 As much as 75% of the stance phase is spent on the forefoot. The number of steps taken in a typical day may range from 10,000 to 15,000. The normal position of the toes during flat foot stance is 20° relative to the metatarsal shaft, and 70° to 90° during toe-off. Abnormalities of the hindfoot, first ray, or lesser toes can lead to altered weightbearing patterns and pain. 4,44,63 The action of toes in walking primarily is passive. As part of the windlass mechanism, they are important in more athletic activities such as running where they aid in balance and push-off. 63

Definitions of Toe Deformities

Hammertoe is defined as proximal interphalangeal joint plantar flexion. Metatarsophalangeal dorsiflexion may be present. The distal interphalangeal joint can be neutral or dorsiflexed. 16,67,86 Clawtoe is defined as proximal interphalangeal and distal interphalangeal plantar flexion with or without metatarsophalangeal dorsiflexion. This deformity usually is bilateral, involving all of the lesser toes. Clawtoes may be associated with the neurologic conditions (Table 1). Mallet toe is plantar flexion of the distal interphalangeal joint. Curly toe is plantar flexion of the distal interphalangeal and proximal interphalangeal joint with metatarsophalangeal joint in neutral. Crossover toe is a coronal plane deformity. It can be attributable to rupture of the first dorsal interosseous tendon or attenuation or tear of the capsule and the fibrocartilaginous plantar plate, therefore metatarsophalangeal instability or subluxation may be present.

Hammertoe and Clawtoe Correction

Flexible Deformities

The terms hammertoe and clawtoe often are used interchangeably in the literature, 16,67,86 mainly because the treatments for these deformities essentially are the same. Deformities can be flexible or fixed and require different approaches based on the disorder. Flexible hammertoes can be treated with proximal interphalangeal fusion 59; however, flexor digitorum longus to extensor tendon transfer is done more commonly for flexible deformities. 15,16,55,79 Fixed deformities require bone resection to accommodate contracted soft tissues as the deformity is corrected.

Taylor 79 reported a series of patients with clawtoes treated with flexor to extensor transfer. His operative technique included extensor tenotomy and division of the dorsal metatarsophalangeal capsule in addition to flexor transfer. Fifty patients were rated as having good results with satisfactory correction of deformity. Eleven fair results were reported, secondary to residual clawing. Seven patients had poor results with good correction but had persistent metatarsal pain. Overall, better results were achieved in younger patients and persistent dorsiflexion of the metatarsophalangeal joint contributed to failure.

Pyper 73 reported a series of 26 patients who underwent flexor to extensor transfer for dynamic clawtoes. Assessment included appearance of the toes, mobility of the toes, range and power of active plantar flexion at the metatarsophalangeal joint, and presence of callosities. Each patient also was asked to give a general assessment of the results of the operation. Sixty percent of subjects reported complete success or marked improvement, and 40% reported slight or no improvement. Reasons for unsatisfactory results included stiffness, residual pain and callosities beneath the metatarsal, and regeneration of the extensor tendon.

Kuwada and Dockery 55 described a modification of the flexor to extensor tendon transfer. They passed the flexor tendon through a drill hole in the neck of the proximal phalanx. Complications included stiffness at the interphalangeal joints, fracture at the drill hole site, and flexor digitorum longus tendonitis.

Barberi and Brevig 2 reviewed their results with flexor to extensor transfer for dynamic clawtoes. The procedures were done as described by Taylor in 11 feet, 79 and according to the Parrish modification 70 in 28 feet. Metatarsalgia was relieved in 70% of patients and callosities resolved in 68% of patients. Complications included two superficial wound infections. Decreased or absent passive range of motion in the interphalangeal joints was observed in 60% of patients. Unsatisfactory results were observed in three patients because of fixed contractures of the interphalangeal joints. Persistent dorsal subluxation of the second toe was observed in three patients.

Cyphers and Feiwell 20 reviewed their results with flexor to extensor transfer for clawtoes in patients with myelodysplasia. Flexion deformities of the metatarsophalangeal and interphalangeal joints were classified as mild (< 30°), moderate (30°–60°), and severe (> 60°). The technique included flexor digitorum longus transfer, dorsal capsulotomy of the metatarsophalangeal joint and volar capsulotomy of the interphalangeal joints. Postoperative results were classified as good if toes were in neutral, fair if there was improvement but some residual deformity, and poor if there was no improvement or recurrence of deformity. For the lesser toes there were 62% good, 33% fair, and 5% poor results. One patient with intact plantar sensation reported persistent metatarsal pain, and required surgery for this and recurrence of deformity in two of four toes. Residual extension of the metatarsophalangeal joint and gradual recurrence of deformity accounted for most of the fair and poor results in this series. There was no correlation between severity of preoperative deformity and poor postoperative results. A comparison of the results of surgical correction of dynamic clawing is summarized in Table 3.

Subjective and Objective Outcomes After Surgical Correction of Dynamic Clawing

Fixed Deformities

Proximal interphalangeal arthrodesis is the essential procedure for treatment of fixed proximal interphalangeal deformity. This may be done with other procedures such as flexor digitorum longus release and soft tissue release of the metatarsophalangeal joint. Proximal interphalangeal fusion techniques are based on the peg and dowel technique described by Higgs 42 or the flat cut technique described by Taylor. 79 A comparison of the results of proximal interphalangeal joint arthrodesis is summarized in Table 4.

Comparison of Proximal Interphalangeal Joint Fusion Techniques

Higgs 42 described a proximal interphalangeal fusion technique that involved shaping the distal end of the proximal phalanx into a spike, and then placing it into a corresponding hole created in the base of the middle phalanx. He resected part of the extensor tendon so that repair of the tendon under some tension helped to compress and stabilize the fusion site. Young 86 stressed the importance of preserving the dorsal cortex of the proximal phalanx to achieve a snug fit at the fusion site. He also included a dorsal release of the metatarsophalangeal joint when this was contracted. Taylor 79 described a flat cut osteotomy with minimal resection of the distal condyles of the proximal phalanx to preserve the length of the phalanx to achieve a snug fit. He used a Kirschner wire to hold the position. He also added metatarsophalangeal joint release of the long and short extensors to allow for the toe to be plantar flexed at the metatarsophalangeal joint. All three authors reported anecdotal success with these procedures. No data or reported complications were included.

Selig 76 reported a series of 20 cases in which he did flat cut resection arthrodesis with wire fixation. Fusion was obtained in all patients, and there were no infections or vascular insults. Kirschner wires were left in place for 6 weeks and there were four toes with some loosening and serous drainage at the time of removal. He stressed minimal bone resection and metatarsophalangeal dorsal release when needed.

Newman and Fitton 69 compared various surgical procedures that included flexor to extensor tendon transfer in 56 patients, proximal phalangectomy in 22 patients, excision arthrodesis of the proximal interphalangeal joint in 15 patients, excision arthrodesis with wire fixation in 15 patients, and peg and socket arthrodesis of the proximal interphalangeal joint in 15 patients. The procedures were done by multiple surgeons with different levels of experience. Patient interviews revealed the following: 32% who had excision only were satisfied; 40% of patients who had excision with wire fixation were satisfied, and 66% of patients who had peg and socket fusion were satisfied. Eighty-eight percent of patients interviewed stated they were improved by the procedure. The complications listed were short or flail toe in five patients of those who underwent proximal phalangectomy, and medial or lateral malalignment at the attempted proximal interphalangeal fusion site in six patients (10%). Malalignment was not more common with any one procedure. Fusion was achieved in 64% of patients. They did not think that evidence of fusion corresponded to relief of symptoms.

Alvine and Garvin 1 did proximal interphalangeal fusion with a peg and hole for painful clawtoes of the second, third, and fourth toes. Dorsal release of the metatarsophalangeal joint was done as needed. They reported a fusion rate of 97%. All patients were contacted with 87% reporting satisfaction with the procedure, pain relief, and resumption of wearing normal footwear. They reported no infections or skin sloughs. The length of followup and presence of postoperative deformity were not stated.

Lehman and Smith 59 reported a series of patients with flexible and fixed hammertoes who were treated with proximal interphalangeal joint arthrodesis using machined peg and hole cutters. Pain at the metatarsophalangeal joint was the presenting complaint in 32% of patients whereas 77% of patients complained of a dorsal callous at the proximal interphalangeal joint. Extensor tenotomy and dorsal capsulotomy were included. Axial pin fixation was used for 3 weeks. They reported a 95% radiographic fusion rate. Forty-eight percent of patients were satisfied without reservation, 37% were satisfied with reservation, and 15% were dissatisfied. The most common causes for reservation were incomplete pain relief (44% of patients), postoperative angulation (29% of patients), and restriction of wearing footwear postoperatively (24% of patients). Reasons for dissatisfaction were incomplete pain relief (31%), footwear restrictions postoperatively (31%), and residual toe angulation (23%). Fifteen percent of patients in both groups were bothered by the corrected toes being too straight. Flexion contracture of the distal interphalangeal joint was seen in 44% of patients. Seven feet had metatarsophalangeal joint stiffness resulting in three patients who were dissatisfied. Mediolateral angulation was observed in 11 feet; one patient was dissatisfied. Other complications included reoperation in five feet for treatment of the distal interphalangeal flexion contracture, amputation in one patient for persistent neuropathic pain, infection in two feet, prolonged swelling in two feet, and a bent pin in one patient caused by trauma. The authors suggested that a distal flexor tenotomy should be considered in those patients with preoperative distal interphalangeal joint flexion deformity.

Coughlin 15 evaluated patients who underwent proximal interphalangeal resection arthroplasty for fixed hammertoe deformity. Pain was the presenting complaint in 78% of patients, and 49% of patients complained of callous formation. Fusion was done with a flat cut condylectomy of the proximal phalanx, and wire fixation for 3 weeks was used to achieve fusion. Additional procedures included flexor tenotomy, extensor tenotomy, and metatarsophalangeal soft tissue release alone or with metatarsal condylectomy as deemed necessary. The results showed that 92% of those patients presenting with a complaint of pain achieved pain relief. Eighty four percent of patients were satisfied, 10% were satisfied with reservations, and 6% were dissatisfied. The rate of satisfaction was decreased when a concomitant hallux valgus correction was done. Patient rated alignment was excellent for 55%, good for 30%, fair for 8%, and poor in 6% of toes. One toe was amputated after a failed fifth toe hammertoe repair. Fusion was seen radiographically in 81% and fibrous union was seen in 19%. In patients whom bone fusion occurred in the toes, 88% were satisfied. Of those with fibrous union, 87% were satisfied. Mediolateral alignment based on anteroposterior radiographs obtained with the patient standing revealed that 79% had less than 10° angulation at the fusion site, 13% had less than 20° angulation, and 8% had more than 20° angulation. The alignment was judged as 21% either fair or poor. Hyperextension deformity at the proximal interphalangeal fusion site occurred in 13% of patients, none of whom had undergone concurrent flexor tenotomy. Among patients who were dissatisfied, the reasons for dissatisfaction were hyperextension, circulatory disturbance postoperatively, and a painful fibrous union. Among patients who were satisfied with reservations, the reasons were hyperextension deformity, numbness, mediolateral malalignment, and the development of a kissing corn in two toes. Malalignment accounted for 79% of those patients who were either dissatisfied or satisfied with reservations. Other complications included three wound infections postoperatively, two vascular impairments that required pin removal, and one extruded pin that led to recurrence of deformity and eventual amputation.

Proximal Phalangectomy

Cahill and Conner 6 reviewed their results with basilar resection of the proximal phalanx for hammertoe correction. Eighty percent of patients deemed the surgery successful, although for the subset of patients who had the hammertoe correction combined with a hallux valgus correction, this decreased to 65%. Objective results were based on clinical appearance, presence of plantar callosities, and pain. Objectively, the authors rated 50% success in the overall group and 24% in the hallux valgus group. The methods used in achieving these figures were not described and no data were presented, other than the categories of success and failure.

Conklin and Smith 10 reported that basal hemiphalangectomy worked reasonably well for relief of pain at the metatarsophalangeal joint but did not relieve symptoms of an associated proximal interphalangeal joint contracture. They found that a significant reason for dissatisfaction was related to residual proximal interphalangeal flexion deformity. They recommended adding a proximal interphalangeal joint fusion when flexion deformity of the proximal interphalangeal joint coexists with metatarsalgia.

Mallet Toe and Curly Toe Deformity

The major symptoms of mallet toe and curly toe deformities include callus and pain over the distal interphalangeal joint, pain at the tip of the toe, and nail deformity. 5,14 Three surgical approaches to the correction of this digital deformity have been proposed 14,38,74 including tenotomy, tendon transfer, and resection arthroplasty of the distal interphalangeal joint.

Hamer et al 38 conducted a prospective randomized trial to compare flexor tenotomy with flexor extensor transfer in patients with curly toe deformity. Toes were graded according to the degree of deformity: no deformity (Grade 0), mild rotation (Grade 1), overlapping (Grade 2) and fixed flexion (Grade 3). There was no significant difference in the preoperative grades between the two groups, and at 4 years, there was no significant difference between the postoperative grades. No child had symptoms at followup and all patients were satisfied. One child required fusion of the distal interphalangeal joint for fixed flexion deformity 1 year after the flexor tenotomy. The authors concluded that tenotomy of the flexor tendon is the important part of the operation and that transfer of the tendon to the extensor apparatus is not necessary.

Ross and Melaneus 74 reviewed a series of 62 patients (188 toes) after flexor tenotomy for hammertoe or curly toe. The appearance of the toe postoperatively was normal or nearly normal (slight interphalangeal flexion) in 95% of toes examined. Stiffness occurred in only one toe and was reportedly the result of the scar, which was tethering the toe. The authors did not distinguish any difference between the results of patients hammertoes versus curly toes. Long flexor function was seen in 15 toes. Eighty-four percent of the patients were satisfied with their results. Five patients had one or more toes assessed as poor (severe deformity), two had significant tethering, and three patients had no obvious cause for a poor result.

Coughlin 14 reported a series of 50 patients who underwent resection arthroplasty of the proximal interphalangeal joint for mallet toe deformity. With this technique, successful fusion at the proximal interphalangeal joint was achieved in 72% of patients and the remaining patients had a fibrous union. Pain relief was achieved in 97% of patients. Acceptable alignment was observed in 96% of toes with flexor tenotomy and 90% of toes without flexor tenotomy. Complications including nail matrix injury, devascularization, and recurrence were reported. Three patients had a hammertoe develop postoperatively. Residual deformity at the distal interphalangeal joint was more common when a flexor digitorum longus tenotomy was not done. The author reported a high incidence of nail deformity preoperatively and emphasized the importance of warning patients that although the toe may be realigned, the toenail deformity will not be corrected.


Metatarsalgia has been associated with many conditions affecting the foot (Table 2). The surgical treatment of primary metatarsalgia addresses the pain associated with dorsal subluxation or dislocation of the lesser metatarsophalangeal joints, which can be reducible or fixed. Subluxation of the proximal phalanx occurs as the plantar plate 24,47 becomes attenuated. Early instability of the metatarsophalangeal joint is flexible and usually affects the second metatarsophalangeal joint. 13,80,81 A dorsal translation or drawer sign 81 may be one of the earliest objective findings. Idiopathic synovitis has been reported to precede this condition 64,66,82 and may be associated with the mechanical factors listed in Table 2. The reducible second metatarsophalangeal joint subluxation is treated in a similar fashion as the dynamic hammertoe, with flexor tendon transfer and dorsal soft tissue release of the metatarsophalangeal joint as needed. 13,16,32 Pain has been attributed to the discomfort of the joint subluxation and callosities, which develop as the plantar fat pad is displaced. The plantar fat pad, which usually cushions the metatarsal head by moving with the proximal phalanx, is drawn distally as dorsiflexion of the proximal phalanyx becomes fixed. Callosities result as the metatarsal head presses on less padded skin. 13,16 Irreducible subluxation or dislocation requires either resection of bone at the metatarsophalangeal joint or an osteotomy to shorten the metatarsal.

Flexible Metatarsophalangeal Instability

Thompson and Deland 80 used the flexor to extensor transfer to treat painful second metatarsophalangeal instability. All patients had substantial pain relief despite the fact that radiographs showed joint reduction in only 54%. Stiffness seemed to be the cause of mild residual pain in five patients. All but one patient was satisfied with their result. They emphasized early removal of wire fixation to improve postoperative motion and decrease the chance for persistent discomfort.

Coughlin 13 reported on a group of athletic patients who were treated for symptomatic second metatarsophalangeal joint instability, defined by a positive drawer test. Seven toes in 15 patients underwent dorsomedial capsular release, lateral capsular reefing, extensor lengthening, and flexor transfer to stabilize the second metatarsophalangeal joint. Good to excellent results were observed in 71% of patients. The criteria were no pain, good alignment or mild deviation, and return to activity.

Gazzag and Cracchiolo 34 reported on 18 patients with a painful second metatarsophalangeal instability. Most patients had a hallux valgus deformity that also required correction. These patients underwent a flexor to extensor transfer. Sixty-one percent of patients had an excellent result. Thirty-nine percent of patients complained of mild, occasional pain with exertion. These patients had a fair result. The authors concluded that although some postoperative stiffness did occur, it provided stability. The alignment of the second toe was not always fully restored but did not contribute to residual pain. Correction of the concomitant hallux valgus and hammertoes was thought to be important in restoring stability and preventing recurrence of metatarsophalangeal instability.

Moderate Fixed Metatarsophalangeal Joint Subluxation

Moderate fixed metatarsophalangeal joint subluxation can be treated with a metatarsal osteotomy or soft tissue release of the metatarsophalangeal joint. Du Vries 28 described a partial metatarsal head resection that removed the distal portion of the metatarsal head while the remaining bone was rounded to articulate with the base of the proximal phalanx. 16,27,28 The preservation of the metatarsophalangeal joint has been the purpose behind the development of extraarticular metatarsal osteotomies for metatarsal shortening, and reduction of the metatarsophalangeal joint. A comparison of these osteotomies is listed in Table 5.

Metatarsal Osteotomies

Helal 39 described a distal oblique osteotomy of the metatarsal. No attempt was made to correct concomitant toe contractures. Some patients required subsequent treatment for these contractures, although the number was not reported. Complications were reported in 13% and included one infection, one symptomatic nonunion, and three patients who complained of increased stiffness at the metatarsophalangeal joint. Patient satisfaction was not reported.

Helal 40 later reported a review of a modified version of his earlier described osteotomy procedure. He included manipulation of clawtoe deformities and flexor tenotomy as needed. He stressed the benefit of not using fixation to obtain proper position of the osteotomized metatarsal heads with early weightbearing. Eighty-eight percent of those patients evaluated reported no pain, whereas 11% had pain. Four of these patients had painful nonunions. Seventeen patients had recurrence of their preoperative pain, and 15 had transfer pressure pain. Ninety-two percent of callosities were resolved. Forty-four percent of patients were unrestricted in wearing footwear. Forty-eight patients complained of residual edema, although all of these were less than 18 months after surgery. Other complications included hematoma (7%), wound dehiscence (12%), infection (4%), symptomatic nonunion (1.2%), and malunion (4%). The author reported overall good results in 77%, fair results in 14%, and poor results in 9% of patients.

Pedowitz 71 reported on 49 patients who underwent Helal type distal oblique metatarsal osteotomies. Ninety-seven percent of osteotomies achieved union by 6 weeks. Both patients with nonunions were reported to be asymptomatic. No cases of avascular necrosis were reported. Eighty-three percent of patients were rated as having a good outcome with no pain, no restriction of shoe wear, no limitation of activity, and no symptomatic callosities. Sixteen percent of patients were rated as having poor results. These patients had either had painful calluses or dorsally contracted metatarsophalangeal joints and limitation of shoe wear as a result. The author concluded that this was a good procedure for the treatment of metatarsalgia associated with intractable plantar keratoses as long as no contracture of the metatarsophalangeal joint was present.

Winson et al 85 reported a series of Helal type distal osteotomies for metatarsalgia in 94 patients (124 feet). They reported 47% good results for patients who were pain-free and without shoe wear restrictions postoperatively. Fair results were observed in 34% of patients who only could achieve relief of pain with shoe modifications, and poor results were observed in 19% of patients who had continued pain despite shoe modifications. There were 27 malunions and 16 nonunions. Three of 16 nonunions were symptomatic, and in 51 feet increased pressure remained on footprints analysis. The authors concluded that the factors associated with poor results were simultaneous surgery of the first and fifth rays, and patients older than 65 years.

Sammarco and Scioli 75 reported a metatarsal neck osteotomy with internal fixation in a series of 18 feet in 16 patients. Twelve of the 16 patients had undergone previous surgical procedures of the involved foot including six metatarsal osteotomy nonunions. Ninety-four percent had associated symptomatic foot conditions that required simultaneous surgery in 75% of patients. The operative technique involved resection of a dorsal closing wedge of the metatarsal neck, elevating the metatarsal head approximately 2 mm. A compression screw was used to fix the osteotomy. The overall postoperative complication rate was 38% including failure of fixation (two feet) trans-fer lesion, reflex sympathetic dystrophy, persistent metatarsalgia, and cross over toe deformity. Two patients accounted for six nonunions. One underwent advancement of the screw and eventually achieved union. The other patient presented with three nonunions on the left foot and two on the right foot. On the left foot, a second revision with bone grafting led to union, and on the right foot, a third revision surgery resulted in union. Of the 11 patients who had primary osteotomies, one required a second procedure to achieve union. This study showed the value of rigid internal fixation for metatarsal osteotomies but also highlighted the difficulty in treating patients with failed forefoot surgery.

Giannestras 35,36 reported a proximal shortening step cut osteotomy of the lesser metatarsals for treatment of metatarsalgia. Fixation was achieved using sutures placed through drill holes. He reported a consecutive series of 40 procedures with 82.5% excellent results. 35 In 10% of patients, transfer lesions occurred; therefore, good results were reported. The 7.5% failure rate was attributable to persistent pain. Inadequate shortening was given as a cause of failure.

Dreeban et al 26 reported results of transverse distal metatarsal osteotomies that were evaluated with pedobarographic analysis. No fixation was used. They reported no radiographic nonunions. There were three infections. Sixty-seven percent of patients were pain-free. Twenty-four percent of patients had residual pain and in four feet transfer lesions developed. The authors found that residual pain was associated with metatarsal head elevation less than 3.5 mm (decrease of < 7% of the pressure preoperatively, whereas elevation greater than 4.5 mm (> 50% drop in plantar pressure preoperatively led to transfer lesions.

Trnka et al 83 reported a series of 96 patients who underwent Helal osteotomies for treatment of metatarsalgia. Sixty-one percent of patients rated their result as excellent or good. Results were worse if a concomitant Keller arthroplasty was done. Complications included eight nonunions (one symptomatic), five superficial infections, and one avascular metatarsal head. The authors found that when only one osteotomy was done transfer lesions were more likely.

Trnka et al 84 reviewed a series of 30 patients treated for metatarsalgia with either the Helal osteotomy (n = 15) or the Weil osteotomy (n = 15). Patients treated with the Weil osteotomy had statistically significantly higher satisfaction, lower recurrence of pain (0% versus 27%), and fewer transfer lesions (0% versus 41%). Patients treated with the Weil osteotomy experienced no malunions or nonunions. The patients who had the Helal osteotomy had five malunions and three nonunions. Results showed that in the group of patients who had the Weil osteotomy, 12 were pain-free and three had persistent and severe pain all attributed to plantar penetration of the fixation screw. In the group of patients who had the Helal osteotomy, six were pain-free, six had occasional pain, two rated their pain as moderate after walking longer distances, and one had severe pain. Other complications for the patients who had Helal osteotomy were prolonged swelling in two feet, and superficial infection in two feet. In the Weil osteotomy group, three feet had delayed wound healing and three had plantar penetration of the screw. The authors concluded that the Weil osteotomy leads to more satisfactory outcomes than the Helal osteotomy.

Severe Fixed Metatarsophalangeal Joint Subluxation

In 1911, Hoffman 43 described a procedure for the treatment of multiple fixed clawtoes that consisted of complete resection of the metatarsal heads through a transverse plantar incision. He stressed the importance of removing enough bone to prevent recurrence. The measure of how much to resect was based on the ability of the proximal phalanyx to “drop into line with the resulting metatarsal stump without crowding against it 43 ”. Although no data were presented, he gave an anecdotal report that this uniformly resulted in painless functional feet.

Clayton 8 later described a modification of the Hoffman procedure, which included resection of the base of the proximal phalanx through a dorsal incision. He stressed the principle of the necessity to resect enough bone. He also showed the importance of beveling the metatarsal stumps so that there would be a smooth plantar surface. He reported 25 feet that had satisfactory cosmetic and functional results, again with uniform relief of pain.

Mann and Chou 62 reported on 15 patients who had nonrheumatoid intractable metatarsalgia. The patients underwent first metatarsophalangeal fusion and resection of the lesser metatarsal heads. The preoperative diagnosis included failed forefoot surgery in 15 of the 18 feet. Eighty-seven percent of patients were satisfied with the procedure. Fifty percent of patients were pain-free and seven had mild intermittent pain. The authors stated that based on function and pain, there were eight excellent results, seven good results, one fair result, and two poor results. Complications included three local wound infections, not associated with the lesser toe surgeries. There were no skin sloughs or hematomas. Three patients had persistent intractable plantar keratoses. One patient required a second procedure to relieve a painful prominence of the fifth metatarsal neck.

Silicone Implants

Silicone implants for disorders affecting the lesser toe metatarsophalangeal joints enjoyed early enthusiasm. 18 The long-term results have been less encouraging because of the foreign body reaction, associated osteolysis, and implant failure. 16,72 Silicone implants are not currently considered by orthopaedic foot and ankle surgeons to be a primary treatment for disorders of metatarsophalangeal joint. 16

Medial and Lateral Metatarsophalangeal Joint Instability

Mediolateral instability of the metatarsophalangeal joint is a part of the spectrum of metatarsophalangeal joint instability. Attenuation of the collateral ligament allows unopposed pull of the intrinsic muscles on the opposite side, creating deviation of the toe.

Coughlin 11 reported a series of patients who underwent metatarsophalangeal joint capsulotomy, extensor tenotomy, or lengthening and wire fixation of the repair. Eleven of the 15 (73%) underwent flexor tendon transfer, five (33%) underwent metatarsophalangeal arthroplasty and eight (55%) underwent repair for fixed hammertoe deformity (DuVries procedure). At final followup, patients were rated according to amount of pain, correction of deformity, and ability to get the corrected toe to touch the ground. Eight of 15 patients (53%) were rated as having excellent results, six (40%) had good results, and one patient had fair results because the toe remained elevated 2 mm. Three patients had a fixed hammertoe develop postoperatively. There were no reports of vascular compromise. The author emphasized the importance of early recognition to avoid more severe deformity necessitating more extensive operative intervention.

Haddad and colleagues 37 described a technique of transfer using the extensor digitorum brevis tendon. They reviewed 31 patients. Nineteen patients underwent an extensor digitorum brevis transfer and 16 underwent flexor to extensor transfer. Twenty-two patients had no pain and one experienced frequent pain. Three patients complained of a stiff metatarsophalangeal joint, each was treated with a flexor to extensor transfer. Stiffness was greater in the flexor to extensor group. One patient had recurrent crossover deformity develop and three feet had mild persistent deformity after extensor digitorum brevis transfer; these were all patients who had more advanced stages of deformity preoperatively (overlapping or complete dislocation at metatarsophalangeal joint). The authors concluded that the beneficial effect of decreased metatarsophalangeal joint stiffness provided by the extensor digitorum brevis transfer may decrease the stability at the joint. Because the flexor digitorum longus transfer seems to provide a more stable joint it may be more appropriate to use in those patients with advanced stages of disease.

Davis and colleagues 23 advocated proximal phalanx basilar osteotomy for treatment of recurrent angular deformity and failure to achieve reduction of the lesser toe after complete soft tissue release at the metatarsophalangeal joint. Anecdotally they reported good results.

Daly and Johnson 21 treated a group of patients with metatarsophalangeal subluxation and dislocation with basal phalangectomy and subtotal webbing. Seventy-five percent of patients had good or excellent results when assessed for pain relief, cosmesis, and shoe wear. Pain was most predictably improved. This procedure may be used as salvage when others have failed.


Bunionette deformities have been classified into three subgroups based on radiographic findings. 12,16 A Type 1 bunionette is characterized by an enlarged metatarsal head, a Type 2 deformity arises from bowing of the diaphysis laterally, and a widened fourth to fifth intermetatarsal angle defines a Type 3 deformity. Symptoms have been attributed to chronic irritation on the lateral side of the forefoot resulting in bursa formation, tender callus, varus toe deformity, and footwear restrictions. Du Vries 28 described several anatomic variations in the fifth metatarsal that may lead to symptomatic deformity. The preoperative measurement of the 4 to 5 intermetatarsal angle in symptomatic patients averages 9° to 10°. 12,31 Nestor et al 68 emphasized that patients with bunionette deformity have greater forefoot width, metatarsophalangeal angles and 4 to 5 intermetatarsal angles with the latter being most important. Numerous surgical procedures including lateral eminence resection, metatarsal head resection, ray resection and osteotomy have been described for correction of this deformity. 12,22,25,52,53,60,88 The underlying anatomic abnormality, magnitude, location of deformity, and patient characteristics influence operative decision-making.

For an isolated enlargement of the fifth metatarsal head lateral condyle a lateral condylectomy may be done. Although this procedure frequently has been recommended 22,50,53 a review of the literature reveals that followup is largely anecdotal. Reported complications include metatarsophalangeal instability postoperatively 48,78 and painful weightbearing when excessive bone is resected. 58 The significant recurrence rate has led some investigators to consider lateral condylectomy as a temporizing measure with few indications. 12,50

Kitaoka and Holiday 53 reported on 16 patients who underwent lateral condylar resection for a symptomatic bunionette. Seventy percent of patients were satisfied with their result. There were no transfer lesions in this series. There was no correlation between the amount of correction and level of patient satisfaction. In two feet the metatarsophalangeal joint subluxed postoperatively because the fifth toe displaced medially. A tight metatarsal capsular closure with excision of redundant metatarsophalangeal capsule was recommended for prevention of varus metatarsophalangeal subluxation.

McKeever 65 reported uniform success in a series of 38 patients. He removed the distal ½ to ⅔ of the fifth metatarsal. No patients required additional resection. Retraction of the toe averaged ¼ to ⅜ of an inch and was associated with easier shoe fit. Details of the assessment criteria were not provided.

Kitaoka and Holiday 52 reported a series of 11 feet in seven patients who underwent surgery for bunionette deformity. Eight patients had metatarsal head resection only and three had head resection and syndactylization of the fourth and fifth toes. Complications occurred in seven of eight feet. Deformity, defined as shortening and extension contracture of the fifth toe, occurred postoperatively in four feet. This resulted in a request for amputation by two patients. Fifth metatarsophalangeal joint stiffness occurred in two of eight feet. Two patients underwent revision resection secondary to a more proximal level for persistently tender callus. Postoperatively the mean intermetatarsal angle increased an average of 4°, the forefoot width and toe shortening averaged 4 mm and 10 mm, respectively. Two feet in this series previously had undergone lateral process resection. One improved to a fair result and the other still had a poor result.

Kitaoka et al 54 reported the results of 19 distal chevron osteotomies done in 13 patients with painful bunionettes. The mean 4 to 5 intermetatarsal angle was reduced 2° and forefoot width decreased 3 mm. Subjective results were good in 10 patients and fair in three, with no failures. They concluded that the distal chevron osteotomy is consistently successful in the correction of mild bunionette deformity with a low complication rate and high patient satisfaction. Transfer metatarsalgia occurred in only one foot. This is in contrast to another series where symptomatic transfer metatarsalgia was reported in 36% of patients. 49 The chevron osteotomy did not allow elevation of the distal fragment and is contraindicated in the presence of a plantar lateral or plantar keratosis.

Coughlin 12 reported a series of 20 patients (30 feet) who underwent longitudinal diaphyseal osteotomy, lateral condylectomy, and distal soft tissue repair. Radiographs obtained preoperatively were used to classify deformities into three groups as defined above: Type 1 (eight feet), Type 2 (seven feet), and Type 3 (15 feet). All osteotomies healed. Postoperative deformities included a hyperextension deformity of the metatarsophalangeal joint for which an extensor tenotomy and capsular release was required (one patient) and mild fifth hammertoe deformity for which treatment was not required (three patients). Reduction of the 4 to 5 intermetatarsal angle averaged 10° and no metatarsal shortening was observed. Excellent results, defined as a decrease in foot width, correction of deformity, and resolution of symptoms were obtained 80% of the time. Ninety-three percent of patients rated their results as excellent or good indicating they were satisfied, walked without difficulty, and had mild or no pain.

LeLievre 60 was one of the first to describe a proximal osteotomy at the level of the styloid. He emphasized the risk of disrupting the tarsometatarsal joint and the potential for the action of the peroneus brevis to modify the plane of the osteotomy. Basal osteotomy of the fifth metatarsal also has been advocated by Diebold. 25 He reported a series of 20 patients who underwent a chevron osteotomy at the level of the proximal metaphysis. The intermetatarsal angle was reduced from a mean of 12° to a mean of 1.3° postoperatively and the mean decrease in the width of the forefoot of 9 mm. Subjectively, 14 patients reported complete relief of symptoms, eight occasionally had slight pain, and two reported discomfort at the osteotomy site without footwear limitations. There were no infections or recurrences. A comparison of the procedures for correction of bunionette deformity is listed in Table 6.

Subjective and Objective Outcome After Surgical Correction of Bunionette Deformity

Crossover Fifth Toe

Rotational deformities of the fifth toe include overlapping and underlapping of the toe. The deformity usually is congenital, with bilateral presentation and an equal gender predilection; approximately 50% of people become symptomatic. There are three main components of the deformity including adduction contracture, dorsiflexion contracture at the metatarsophalangeal joint, and external rotation of the fifth toe. 57 The dorsal metatarsophalangeal capsule contracts and frequently the extensor tendon of the fifth toe is shortened. For progressive deformity and symptoms, surgical treatment includes soft tissue release of the extensor mechanism and the metatarsophalangeal joint contracture. Numerous surgical techniques have been proposed for correction of this deformity. The DuVries technique, consisting of extensor tenotomy, capsulotomy with medial collateral ligament release, is recommended for mild to moderate deformity. 27 DuVries 27 emphasized the importance of a complete soft tissue release at the time of surgical repair. Although this procedure achieves adequate realignment of the toe, soft tissue dissection may lead to complications including infection and scar formation. 3 For more severe conditions, Lapidus 57 recommended taking the extensor digitorum longus and rerouting this tendon under the metatarsophalangeal joint into abductor digiti quinti. The capsule of the fifth metatarsophalangeal joint is released dorsal and medially. He reported satisfactory results in several patients, although the assessment criteria were not reported. In two patients, a painful prominence under the fifth metatarsal head was more disabling than the original deformity.

Cocken 9 reported a series of patients treated for the overriding fifth toe. He described a dorsal racquet type incision, with a second handle added on the plantar foot. The extensor tendon to the fifth toe is released and the dorsal metatarsophalangeal capsule is divided. The criterion for a good result was full correction and patient satisfaction. A good result was obtained in 91% of patients. Four patients (6%) had a fair result; the toes were satisfactory to the patients but had an element of rotational deformity that was uncorrected. There were two failures in which deformity recurred rapidly within 1 year and the patients were treated with amputation. Wound infection was reported in two patients and delayed healing was reported in three patients. The investigators concluded that the Butler operation for correction of the overlapping fifth toe was simple and safe with predictably good results.

Leonard and Rising 61 recommended syndactylization of the fourth and fifth digits with phalangectomy in rigid conditions. Although adequate realignment may be achieved, the syndactylization procedure replaces one deformity with another and is largely a salvage procedure.

The Ruiz-Mora procedure has been advocated for treatment of congenital overlapping fifth toes and cock-up deformities of the fifth toe. 29,46 Through a plantar incision the entire proximal phalanx is removed and soft tissues are interposed. Janecki and Wilde 46 published the first long-term study using this procedure for the correction of hammertoe deformity of the fifth toe. They reviewed their experience with 22 patients. All patients reported complete pain relief at the initial 6-week followup. However, on additional followup, there were two significant complications. Ten patients had a corn develop over the fourth interphalangeal joint with an underlying hammertoe deformity and seven patients had painful bunionettes develop. Although shortening did not constitute a cosmetic problem for the patient, it likely contributed to the formation of hammertoe at the adjacent digit. The investigators recommend less bone resection, limited to only the head and neck of the proximal phalanx, to maintain patient satisfaction and limit complications.

Dyal et al 29 reported the results of 12 patients who underwent the Ruiz-Mora procedure. Postoperatively, nine of the 12 patients were satisfied; reasons for dissatisfaction include the toe being too short, poor position of the toe, and persistent cock-up deformity. Pain, function, and footwear all were improved based on preoperative and postoperative questionnaires. The average shortening of the fifth toe was 12.8 mm (range, 7–19 mm). Three patients had minor wound healing problems and one patient had a painful corn develop over the fourth interphalangeal joint. No patient had a bunionette deformity develop after surgery. Results were worse in those patients (n = 4) who had previous resection of the distal proximal phalanx. They concluded that the Ruiz-Mora procedure is a good salvage procedure for iatrogenic and congenital cock-up deformity and hard corns and that patients must be counseled carefully preoperatively about the appearance they should expect after surgery.


Lesser toe surgeries are among the most common procedures done in orthopaedic foot and ankle surgery. Satisfactory results from the studies reviewed here vary widely, and can be elusive. Some complications are seen more commonly within each of the groups of procedures, and therefore some general conclusions can be made regarding pitfalls. The results of soft tissue stabilization procedures for flexible deformities or instability of the metatarsophalangeal joint have the predictable result of increasing stiffness at the affected joint. Nonunions of the proximal interphalangeal arthrodesis site are not commonly symptomatic, but a nonunion of a metatarsal osteotomy is more likely to cause pain. Malalignment and the ensuing footwear limitations are a frequent cause of patient dissatisfaction. Recurrence of deformity is more likely when associated deformities are not addressed, such as a contracture of the metatarsophalangeal joint with correction of a hammertoe. The reported incidence of wire breakage and postoperative neuromas would seem to be low. However, Zingas et al 87 reported a series of 565 patients who underwent forefoot surgery with wire fixation. They reported 33 broken wires in 27 patients. All of the wires were .045 and had been placed across the metatarsophalangeal joint. The rate of wire breakage was higher in the patients with rheumatoid arthritis. Although retained fragments did not cause symptoms, it seems that this complication can be avoided by using larger wires when crossing the metatarsophalangeal joint is necessary.

Kenzora 51 showed the significance of postoperative neuromas leading to failed foot surgery. Of the 37 patients with 55 symptomatic neuromas, 27 elected surgical treatment for pain relief. Twenty-three patients were treated with proximal resection and burial of the stump into muscle. Four underwent neurolysis. Overall, 74% of patients obtained satisfactory results and 26% had unsatisfactory results. Kenzora showed that preventing sensory neuromas by using meticulous surgical technique is preferable.

As in all orthopaedic foot and ankle surgery, meticulous technique and careful planning are essential in increasing the chance of a good outcome in surgery of the lesser toes. Patient education regarding the likely chance of satisfactory results and possible limitations such as stiffness, nonunion, overcorrection, undercorrection, continued pain, and future shoewear limitations is an important part of the preoperative planning. It should be appreciated that the literature at this time is insufficient to fully understand the factors involved with these complications. Most of the literature to date either has been anecdotal or retrospective. It can be seen that the awareness of complications has continued to increase as more objective evaluations and outcome oriented questions have been asked. Hopefully in the future, prospective, controlled studies will be done which are large enough (multicenter) to help in the understanding of the factors that affect the outcomes in lesser toe surgery.


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Section Description

Osaretin B. Idusuyi, MD; and G. James Sammarco, MD, Guest Editors

© 2001 Lippincott Williams & Wilkins, Inc.