http://upload.orthobullets.com/topic/7053/images/crossover toe.jpg
http://upload.orthobullets.com/topic/7053/images/plantar plate.jpg
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  • 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.
  • 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
  • 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
  • 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 surrounding structures
    • used in early stages of MTP synovitis to evaluate plantar plate but not necessarily useful in dislocation
  • 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 in 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.
  • 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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Questions (4)

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


Dorsal soft-tissue release with pin fixation




Silicone implant arthroplasty




MTP joint excisional arthroplasty




Metatarsal shaft osteotomy (Helal procedure)




Metatarsal neck osteotomy (Weil procedure)



Select Answer to see Preferred Response


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.


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(OBQ09.61) A 57-year-old man plays 45 holes of golf per week and has foot pain during the toe-off phase of gait. He notes the foot pain started 3 months ago after walking up a hill and falling forward on some wet grass. Your exam shows skin callosities dorsally at the 2nd PIP joint and plantarly at the 2nd MT head. Radiographs show a hyperextension deformity of the 2nd proximal phalanx in relation to the metatarsal. All of the following are true about this patient's condition EXCEPT: Review Topic


Symptomatic treatment initially includes extra depth shoes, metatarsal pads, and well-padded liners




The MTP drawer test will likely show laxity at the MTP joint in the dorsal-plantar plane




Repeated MTP dorsiflexion weakens the plantar aponeurosis, plantar plate, and capsular stabilizers




Plantar callosities result from dorsal displacement of the fatty cushion underneath the metatarsal head




Condition is a result of repetitive stresses causing microfractures with subsequent compromised blood supply to the metatarsal subchondral bone



Select Answer to see Preferred Response


This patient's 2nd MTP hyperextension deformity is a result of a plantar plate rupture. Answer 5 describes the disease process of Freibergs Infraction and AVN of the subchondral bone of the metatarsal.

The JAAOS article by Mizel describes lesser MTP joint conditions including MTP instability, subluxation, and dislocation. Patients with plantar plate ruptures have pain with toe-off as MTP dorsiflexion forces attenuate the plantar stabilizers and subsequently lead to the hyperextension of the proximal phalanx. A drawer test seen in Illustration A can demonstrate instability in the dorsal-plantar plane with plantar plate incompetence. The resulting MTP deformity leads to skin compromise at the PIP dorsally secondary to abutting the shoe box and the plantar metatarsal head due to dorsal migration of the plantar fatty cushion. Initial treatment includes off-loading the areas of increased pressure with metatarsal pads and relieving areas of high skin pressure with extra depth shoes. Surgical options include shortening osteotomy to decompress the area and allow the fatty cushion to resume its normal position.


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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: Review Topic


Higher patient satisfaction rates




Lower incidence of recurrent metatarsalgia




Fewer transfer lesions




Higher percentage of radiographic reduction and maintenance of the MTP joint reduction




Increased rate of malunion or pseudoarthrosis



Select Answer to see Preferred Response


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.

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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? Review Topic


Flexor tendon resection




Proximal phalangeal crescentic osteotomy




Metatarsophalangeal joint arthrodesis




Distraction osteogenesis of the metatarsal




Metatarsal shortening osteotomy



Select Answer to see Preferred Response


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 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 the 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.

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