MTP Dislocations

Author: Jason McKean

Topic updated on 05/24/13 7:11pm

Introduction
A condition characterized by multiplanar instability of MTP joint often seen with "crossover toe" dorsomedial subluxation Pathoanatomic stages plantar plate disrupted can be caused by traumatic rupture chronic inflammation (more common) lateral collateral ligament fails leads to medial deviation of the second toe plantar plate, with its flexor tendon attachments, displace medially medial displacement of the proximal phalanx relative to the metatarsal medial structures become contracted lumbrical and interosseous tendons, medial collateral ligament (MCL), and medial capsule become tight and contracted creating adduction force plantar plate subsequently fails hyperextension forces on the proximal phalanx result in dorsal instability Associated conditions MTP synovitis, deformity often accelerated by cortisone injection done for either misdiagnosed Morton's neuroma or into the MPJ for synovitis.
Anatomy
Plantar plate anatomy broad, thick ligamentous structure that spans the plantar aspect of the MTP joint origin on the metatarsal head via a thin synovial attachment, just proximal to the metatarsal articular surface insertion plantar base of the proximal phalanx function resists tensile loads in the sagittal plane (particularly in dorsiflexion of the joint) cushion the joint and support weightbearing forces
Presentation
Symptoms pain walking on “marble in the ball of their foot” early instability (prior to deformity) may be confused with Morton's neuroma, deformity often follows cortisone injection for presumed neuroma Physical exam callus under the metatarsal head dorsomedial deviation of the toe in relation to the metatarsal hammertoe (flexion at the PIPJ, extension at the MPJ) dorsal instability found on "drawer test " grip toe (proximal phalanx) with one hand and the metatarsal head with the other and move toe dorsally
Imaging
Radiographs recommended views weightbearing AP, oblique, and lateral findings AP shows dislocation of the proximal phalanx (medial more often than lateral) weightbearing lateral shows hyperextension and dorsal dislocation of the proximal phalanx MRI indications rule out other pathology elucidate pathology of surroundling structures used in early stages of MTP synovitis to evaluate plantar plate but not necessarily useful in dislocation
Treatment
Nonoperative taping, shoe modification, metatarsal pads, Budin splint, and NSAIDS indications first line of treatment will not correct deformity Operative distal oblique shortening MT osteotomy (Weil procedure) indications significant pain and loss of function fixed deformity plantar plate repair performed with metatarsal osteotomy sutures passed through distal plantar plate and then through drill holes is proximal phalanx flexor to extensor tendon transfer FDL split and brought over top of proximal phalanx to stabilize joint EDB transfer under intermetatarsal ligament
Surgical Techniques
Distal oblique shortening MT osteotomy (Weil procedure) soft tissue balancing dorsal and medial capsular release with lateral capsular reefing can be used in combination with Weil osteotomy EDB tendon transfer after rerouting tendon through transverse intermetatarsal ligament results in a dynamic stabilizer of incompetent lateral structures flexor digitorum longus (FDL)–to–extensor digitorum longus (EDL) tendon transfer (Girdlestone-Taylor procedure) resection arthroplasty of the metatarsal head (DuVries) plantar plate repair as above osteotomy intra-articular osteotomy that achieves longitudinal decompression through shortening and allows joint reduction. metatarsal (MT) is exposed and the direction of shortening in the original Weil procedure runs mostly parallel to the plantar aspect of the foot. fixation osteotomy is fixed by means of a screw running perpendicular to the osteotomy line.
Complications
Floating toe deformity inability to flex MTP joint causing 2nd digit dorsiflexion deformity (ie. floating toe) most common complication Toe vascular compromise if correcting a chronic dislocation, the soft tissue (including vasculature) can contract stretching of the vasculature can compromise flow procedure may need to be reversed to save digit

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(OBQ11.24) Floating-toe deformity is the most common complication of which of the following surgical procedures used to treat central metatarsalgia? Topic

Review Topic

1. Dorsal soft-tissue release with pin fixation
2. Silicone implant arthroplasty
3. MTP joint excisional arthroplasty
4. Metatarsal shaft osteotomy (Helal procedure)
5. Metatarsal neck osteotomy (Weil procedure)

PREFERRED RESPONSE ▶

DISCUSSION: The Weil osteotomy is a joint preserving metatarsal head osteotomy which is commonly used for the treatment of the subluxed or dislocated joint lesser MTP joint associated with central metatarsalgia. The most common complication associated with the Weil osteotomy is the development of a floating-toe deformity post-operatively. A floating toe is a deformity characterized by the sagittal plane elevation of the affected toe in relation to the other adjacent toes. When standing the toe does not touch the floor. It is commonly caused by surgery or injury to the affected toe or a shortened metatarsal bone.

Migues et al followed 70 Weil osteotomy patients for 18 months post-operatively. They found a high occurence of floating-toe deformity in the patients who underwent a concomitant PIP joint arthrodesis. Although it was not associated with functional impairment, they recommended that concurrent PIP arthrodesis be avoided to reduce the occurrence of floating toes.

Highlander et al performed a literature review and reported on the details of 1,131 Weil osteotomies. The most commonly reported complication of the Weil osteotomy was floating toe, reported in 233 cases, with an overall occurrence of 36%.

Ilustration A shows the Weil osteotomy technique, and Illustration B is an example of a floating toe.

Illustrations: A

REFERENCES:

1. Migues A, Slullitel G, Bilbao F, Carrasco M, Solari G. Floating-toe deformity as a complication of the Weil osteotomy. Foot Ankle Int. 2004 Sep;25(9):609-13. PMID:15563380 (Link to Abstract)

2. Highlander P, VonHerbulis E, Gonzalez A, Britt J, Buchman J. Complications of the Weil osteotomy. Foot Ankle Spec. 2011 Jun;4(3):165-70. Epub 2011 Apr 13. PMID:21490179 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Ben Taylor MD, John Badylak MD,

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(OBQ09.191) A 40-year-old man has metatarsalgia secondary to a chronically dislocated 2nd metatarsalphalangeal(MTP) joint. Nonoperative modalities including shoe modifications have failed to improved his symptoms. When comparing osteotomy B (Weil osteotomy) to osteotomy A (Helal osteotomy) as shown in Figure A, all of the following are true EXCEPT: Topic

Review Topic

FIGURES: A

1. Higher patient satisfaction rates
2. Lower incidence of recurrent metatarsalgia
3. Fewer transfer lesions
4. Higher percentage of radiographic reduction and maintenance of the MTP joint reduction
5. Increased rate of malunion or pseudoarthrosis

PREFERRED RESPONSE ▶

DISCUSSION: The goal of surgery for metatarsalgia and a dislocated MTP joint is to improve pressure distribution within the forefoot following failure of nonsurgical measures including shoe modifications. The Weil procedure is an intra-articular osteotomy that achieves longitudinal decompression through shortening and allows joint reduction. In a Weil osteotomy the metatarsal (MT) is exposed and the direction of shortening in the original Weil procedure runs mostly parallel to the plantar aspect of the foot. The Weil osteotomy is fixed by means of a screw running perpendicular to the osteotomy line. The Helal osteotomy has no form of fixation and is made more proximally. The article by Trnka et al compared 30 patients receiving the 2 types of procedures and found that satisfaction rates, AOFAS scores, malunion rates, pseudoarthrosis rates, and MTP reduction rates were all better with the Weil osteotomy. The article by Coughlin is a review article on lesser toe deformities.

REFERENCES:

1. Trnka HJ, Mühlbauer M, Zettl R, Myerson MS, Ritschl P. Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int. 1999 Feb;20(2):72-9. PMID:10063974 (Link to Abstract)

2. Coughlin MJ. Lesser toe abnormalities. Instr Course Lect. 2003;52:421-44. PMID:12690869 (Link to Abstract)

Question Authors:

Michael Hughes MD,

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(OBQ04.107) A 70-year-old man complains of inability to wear normal shoes on his left foot due to a second and third toe deformities. Radiographs are shown in Figures A and B. He decides to undergo surgical treatment. After intra-operative extensor tendon lengthening and capsular release, the joints continue to subluxate. What is the next step to correct the deformities? Topic

Review Topic

FIGURES: A

1. Flexor tendon resection
2. Proximal phalangeal crescentic osteotomy
3. Metatarsophalangeal joint arthrodesis
4. Distraction osteogenesis of the metatarsal
5. Metatarsal shortening osteotomy

PREFERRED RESPONSE ▶

DISCUSSION: Metatarsophalangeal joint capsular release, tightening of collateral ligaments, tendon lengthening, and flexor tendon transfers can provide correction of mild to moderate deformities of the 2nd (and other) MP joints. For more severe deformities with subluxation or dislocation, soft-tissue release alone is often insufficient. Shortening osteotomies have been recognized as effective by decompressing the joint and effectively lengthening the adjacent soft-tissue structures. One technique is a capital osteotomy of the metatarsal bone (such as the Helal or Weil osteotomy) which provides controlled shortening and relatively easy fixation.

Trinka reported on 25 capital oblique osteotomies on 15 patients. 21 of the 25 MTP joint dislocations were successfully relocated with an average shortening of 4.4mm. 12 of the 15 patients were satisfied with the result. Complications included limited plantar flexion and the recurrence of the deformity. An often tested concept is the "floating toe" that can result from these osteotomies because of their effect on the intrinsic muscles.

The reference by Coughlin is an Instructional Course Lecture review article on lesser toe abnormalities and reviews the wide variety of lesser toe pathology, including diagnosis and treatment.

Incorrect answers:
1: Flexor tendon resection would not address the dorsal subluxation of the MP joint and could lead to a floppy toe.
2: Phalangeal base osteotomy would not lead to any change in joint balance as that is distal to problem area.
3: Joint arthrodesis would not be the next step in balancing the unstable joint. MPJ arthrodesis of the lesser toes is poorly tolerated and would not be a primary choice of treatment.
4: Distraction osteogenesis would lengthen the metatarsal, potentially leading to further instability/imbalance.

REFERENCES:

1. Coughlin MJ: Lesser toe abnormalities. Instr. Course lect. 2003: 52: 421-444 PMID:12690869 (Link to Abstract)

2. Trinka HJ. Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999; 20: 72-79 PMID:10063974 (Link to Abstract)

Question Authors:

Ben Taylor MD, John Badylak MD, Daniel Farber MD,

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ABOS II: MTP Dislocations

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Trnka HJ, Mühlbauer M, Zettl R, Myerson MS, Ritschl P. Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int. 1999 Feb;20(2):72-9. PMID:10063974 (Link to Abstract)
Trinka HJ. Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int 1999; 20: 72-79 PMID:10063974 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Coughlin MJ. Lesser toe abnormalities. Instr Course Lect. 2003;52:421-44. PMID:12690869 (Link to Abstract)
Coughlin MJ: Lesser toe abnormalities. Instr. Course lect. 2003: 52: 421-444 PMID:12690869 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Migues A, Slullitel G, Bilbao F, Carrasco M, Solari G. Floating-toe deformity as a complication of the Weil osteotomy. Foot Ankle Int. 2004 Sep;25(9):609-13. PMID:15563380 (Link to Abstract)
Highlander P, VonHerbulis E, Gonzalez A, Britt J, Buchman J. Complications of the Weil osteotomy. Foot Ankle Spec. 2011 Jun;4(3):165-70. Epub 2011 Apr 13. PMID:21490179 (Link to Abstract)

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MTP Dislocations

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