Forefoot Disorders : Lesser Toe deformities

• Forefoot deformities :• HAMMERTOES• MALLET TOES• CLAW TOES• CROSS-OVER TOES• MP SYNOVITIS• METATARSALGIAFor proper management of forefoot deformities, we need to understand the situationincluding normal anatomy and pathophysiology.Lateral view of the lesser toe demonstrates that both tendons of intrinsic musclespass plantar to the axis of motion of MP joint, thereby flexing it. They pass dorsalto the axis of motion of PIP and DIP joints, thereby extending them. The lumbricalsinsert into the extensor hood (not bone) and are strong extensors of the IP joints.there are few surgical options for hammer toe correction:– PIP arthrotomy– resect proximal phalanx head– interpose extensor hood flap into PIP joint or– fuse PIP joint or proximal phalanx shortening– spear with a K-wire in extensionMallet Toe correction:• Fixed deformity• Tip of toe hits ground - symptoms• Non-op tx: pad under toe• Surgical– Flexible: percutaneous FDL tendon release– Fixed: bony decompression DIP joint• FDL tenotomy• Fix with K-wireCross-over Toe Deformity:• Release capsule• reef lateral collateral• flexor tendon transfer• Lots of variation to re-create stability• Sometimes we need to do weil osteotomy at the same time of lesser toedeformity correction to limit such a dorsiflexion momentCock-up Fifth Toe:• Ruiz-Mora Procedure– plantar eliptical incision– remove base proximal phalanx– close transverse incision to pull toe down– problem: toe instability• Claw Toe Procedure• Extensor Tendon TransferFinally toe amputation is a good procedure in certain situation, its indications includebut not limited to:• Ulcer• Infection • Failure of previous 2nd toe reconstruction