Early Diagnosis. Instability of the lesser MTP joints (Crossover 2 nd toe deformity) -my 25 year journey- Progressive MTP joint subluxation

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1 Instability of the lesser MTP joints (Crossover 2 nd toe deformity) -my 25 year journey- Conflicts of interest Arthrex- consultant Arthrex- royalties Elsevier-book royalties Michael J Coughlin, M.D. Early Diagnosis Progressive MTP joint subluxation Coughlin,M. The Crossover toe Foot Ankle Int

2 Surgery Soft tissue balancing Capsular reefing Extensor tenotomy, lengthening Medial/dorsal capsulotomy Coughlin, M.J.: When to suspect crossover second toe deformity. J. Musculoskeletal Medicine Flexor Tendon Transfer MEDIOCRE RESULTS 1 2 Partial proximal phalangectomy Metatarsal condylectomy Akin-ette MTP joint arthrodesis Amputation Metatarsal osteotomy 3 4 2

3 All of these treatments Never really treated the problem! Indirect repairs Never saw the pathology (the plantar plate tear) Grading and Staging (Barcelona-2011) -8 fellows- -saved 12 specimens over 7 years- PUBLISHED: Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study. Foot Ankle Int. 33: , 2012 Grade 1 transverse tear < 50% Grade 2 Transverse distal > 50% GRADE 2 Removed met. head 3

4 Grade 3 Transverse and longitudinal, extensive Grade 4 no repairable capsule PHALANX FDL Phalanx FATPAD GRADE 4 GRADE 3 We then devised a clinical staging system To help us with our clinical examination Stage 1 Mild MTP joint malalignment Plantar MTP joint pain Swelling MTP joint (plantar) Mild + drawer (subluxable, <50%) 4

5 Physical Examination Positive Drawer Physical Examination Positive Drawer Pathopneumonic Stage 2 Moderate malalignment Reduced swelling?? No toe purchase ++ positive drawer Stage 3 Severe malaligment Plantar MTP joint pain Little swelling Very positive drawer Can dislocate 5

6 Stage 4 Began defining the extent of the plantar plate tear Very severe deformity Dislocation Fixed hammertoe Little or no swelling? Painless drawer We then developed a technique to expose and repair the plantar plate Weil osteotomy 6

7 Incision Deepening the incision Direct dorsal interspace incision Multiple joints? Neuroma present? Unsure of the diagnosis? Versatile exposure Extensor brevis is available for transfer later Proximal capsular release McGlamry Base of proximal phalanx Met head Plantar Plate Plantar blood supply Proximal synovial attachment Yes- we routinely release the proximal capsule Does it destroy the circulation to the metatarsal head? NO It does give 2-3 mm. more expansion of the joint Courtesy of LS Weil, Jr.. DPM 7

8 Proximal translation of the Weil Distraction and visualization Medial and lateral collateral ligament release Releasing the plantar plate So it is completely released!! 8

9 Example Exposing the tear Free it up from the base of the proximal phalanx, and the flexor tendon Plantar plate takedown Passing the sutures Try the two different types of Micro-scorpion 9

10 Scorpion suture #1 Scorpion suture #2 Suture number Suture pattern 8. Exposing the base of the proximal phalanx Towel clip on the phalanx, and twist downward 10

11 Exposing the base of the proximal phalanx Fixing the Weil Tying the sutures Plantar flex the PP 20 degrees Cartilage against cartilage Neutral deviation 11

12 Prospective study Two year study 100 patients Improved stability Marked resolution of pain Coughlin, M.J.: Lesser toe deformities. Orthopaedics 10(1):63-75, Coughlin, M.J.: Crossover second toe deformity. Foot & Ankle 8:29-39, Coughlin, M.J.: When to suspect crossover second toe deformity. J. Musculoskeletal Medicine 39-48, Coughlin, M.J. Schenck, Jr., R.C., Shurnas, P.J.., Bloome,D.M. Concurrent interdigital neuroma and MTP joint instability: long-term results of treatment. Foot and Ankle Int. 23: , Coughlin, M.J.: Subluxation and dislocation of the second metatarsophalangeal joint. Ortho. Clinics of North America 20(4): , Coughlin, M.J.: Second metatarsophalangeal joint instability in the athlete. Foot & Ankle 14(6): , Coughlin M. Lesser toe abnormalities. AAOS Instructional Course Lectures. 52: , 2003 Coughlin M, Grimes, J.S. Geometric Analysis of the Weil Osteotomy. Foot Ankle Int. 27: , 2006 Kaz A, Coughlin M. Crossover second toe: demographics, etiology and radiographic assessment. Foot Ankle Int , 2007 Nery C, Coughlin M. Arthroscopy and MRI evaluation of second MTP joint capsular insufficiety. Submitted to FAI-May 2012 Nery C, Coughlin M, Baumfeld D. Second MTP joint instability: grading of the deformity and description of surgical repair of capsular insufficiency. FAI April 2012 Coughlin M, Schutt S, Hirose,C, Kennedy M, Grebing B, Smith B, Cooper T, Golano P Viladot R, Alvarez F. Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study. Foot Ankle Int. 33: , 2012 Nery C, Coughlin M, Baumfield D, Mann, T. Instabilidade das articuladoes metatarsofalagicas e lesoes da plcas plantares: estudo clinico e morfologicl. Journal of the Brazilian Foot and Ankle Society 5:63-72, 2011 Second MTP Joint Instability: Grading of the Deformity and Description of Surgical Repair of Capsular Insufficiency., Coughlin M,Baumfield D,Nery. Physician and Sports Medicine, 39: ,