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