Second MTP Joint Capsular Instability With Clawing Deformity: Metatarsal Osteotomy, Flexor Transfer with Biotenodesis, Hammer Toe Repair, and MTP Arthroplasty Without the Need for Plantar Incisions

Abstract

Capsular instability of the second metatarsophalangeal (MTP) joint (crossover second toe deformity) is a common source of forefoot pain and often but is not always associated with deformity. Various methods of surgical treatment have been described, each with its own success and limitations. A biomechanical approach to stabilization of the second metatarsophalangeal joint often includes a flexor tendon transfer, and the results of treatment with this method have been well documented. Persistent pain after stabilization in a patient without inflammatory arthritis may be indicative of concurrent interdigital neuroma, persistent joint-related symptoms, residual tenderness related to the plantar incisions, or a combination. When the deformity is obvious (fixed clawing or hammering, MTP subluxation, and tender plantar callous), a combination of procedures is considered to provide relief of symptoms and realignment of the joint and digit. The purpose of this paper is to describe a rational approach to treatment based on the deformity while minimizing potentially painful incisions and dissection. A combination of second metatarsal capital oblique osteotomy, MTP joint arthroplasty with extensor lengthening and ligamentous/capsular repair, open hammer-toe repair, and flexor tendon transfer with biotenodesis screw fixation in the proximal phalanx is described.