Abstract

Plantar plate deficiency is the major cause of instability of the metatarsophalangeal joint, and plantar plate tenodesis can provide dynamic stabilization of the plantar plate. In case of crossover toe deformity, incorporation of arthroscopic release of the medial capsuloligamentous complex and the lumbrical tendon can eliminate the medial deforming force. However, in case of severe deformity, the lateral capsuloligamentous complex is attenuated. The purpose of this Technical Note is to incorporate the technique of arthroscopic plication of the lateral capsuloligamentous complex into the technique of plantar plate tenodesis and arthroscopic release of the medial capsuloligamentous complex and the lumbrical tendon.

Crossover deformity of the second toe is a common forefoot deformity. Most commonly, it is caused by plantar plate insufficiency leading to instability of the metatarsophalangeal (MTP) joint.1Klein E.E. Weil Jr., L. Weil Sr., L.S. Coughlin M.J. Knight J. Clinical examination of plantar plate abnormality: A diagnostic perspective.,2The direct plantar plate repair technique. As the joint instability deteriorates and the joint subluxates dorsally, the axis of pull of the interossei shifts dorsal to the center of rotation of the MTP joint and becomes an ineffective flexor of the joint. The lumbrical is tethered at the medial side of the joint by the deep metatarsal ligament and becomes a deforming force for the development of crossover toe deformity.3Metatarsophalangeal joint instability of the lesser toes and plantar plate deficiency.,4Modified double plantar plate tenodesis. As the disease deteriorates, the MTP joint can be dislocated with attenuation or rupture of the lateral capsuloligamentous complex.Conservative treatment including the toe splint is usually ineffective to control the deformity and its symptoms, and surgical treatment is indicated for symptom control.5Correction of crossover toe deformity by arthroscopically assisted plantar plate tenodesis. Surgical treatments of this deformity include soft tissue balancing procedures to stabilize the MTPJ (plantar plate repair, tendon release or transfer, periarticular soft-tissue release) or bony procedures (metatarsal/phalangeal osteotomy, arthrodesis and excisional arthroplasty) and even toe amputation.6Sanhudo J.A. Ellera Gomes J.L. Pull-out technique for plantar plate repair of the metatarsophalangeal joint. The Girdlestone-Taylor flexor-to-extensor tendon transfer is an effective method to stabilize the sagittal alignment of the MTP joint, but it may not be able to restore a normal coronal alignment of the MTP joint in crossover toe deformity and postoperative toe stiffness is common.2The direct plantar plate repair technique.,7Chalayon O. Chertman C. Guss A.D. Saltzman C.L. Nickisch F. Bachus K.N. Role of plantar plate and surgical reconstruction techniques on static stability of lesser metatarsophalangeal joints: a biomechanical study., 8Ford L.A. Collins K.B. Christensen J.C. Stabilization of the subluxed second metatarsophalangeal joint: Flexor tendon transfer versus primary repair of the plantar plate., 9Gazdag A. Cracchiolo 3rd, A. Surgical treatment of patients with painful instability of the second metatarsophalangeal joint., 10Blitz N.M. Ford L.A. Christensen J.C. Plantar plate repair of the second metatarsophalangeal joint: Technique and tips. Because the primary pathology is the plantar plate deficiency, plantar plate repair is a logical surgical treatment choice.11Correction of crossover toe deformity by plantar plate tenodesis and arthroscopic release of lumbrical. Plantar plate repair is as effective as tendon transfer in stabilization of the MTP joint with less postoperative stiffness and discomfort.8Ford L.A. Collins K.B. Christensen J.C. Stabilization of the subluxed second metatarsophalangeal joint: Flexor tendon transfer versus primary repair of the plantar plate. Surgical options of plantar plate repair include primary repair with or without the use of suture anchor or repair by distal advancement of the plate to the base of the proximal phalanx through bone tunnels via the plantar or dorsal approaches.2The direct plantar plate repair technique.,3Metatarsophalangeal joint instability of the lesser toes and plantar plate deficiency.,6Sanhudo J.A. Ellera Gomes J.L. Pull-out technique for plantar plate repair of the metatarsophalangeal joint.,10Blitz N.M. Ford L.A. Christensen J.C. Plantar plate repair of the second metatarsophalangeal joint: Technique and tips.,12Doty J.F. Coughlin M.J. Weil Jr., L. Nery C. Etiology and management of lesser toe metatarsophalangeal joint instability., 13Nery C. Coughlin M.J. Baumfeld D. Raduan F.C. Mann T.S. Catena F. Prospective evaluation of protocol for surgical treatment of lesser MTP joint plantar plate tears., 14Nery C. Coughlin M.J. Baumfeld D. Mann T.S. Lesser metatarsophalangeal joint instability: Prospective evaluation and repair of plantar plate and capsular insufficiency., 15Weil Jr., L. Sung W. Weil Sr., L.S. Malinoski K. Anatomic plantar plate repair using the Weil metatarsal osteotomy approach., 16Yu G. Yu Y. Zhang P. Yang Y. Li B. Zhang M. Surgical repair of chronic tears of the second plantar plate., 17Arthroscopic-assisted correction of claw toe or overriding toe deformity: plantar plate tenodesis., 18Stabilization of first metatarsophalangeal instability with plantar plate tenodesis., 19Lui T.H. Chan L.K. Chan K.B. Modified plantar plate tenodesis for correction of claw toe deformity., 20Correction of crossover deformity of second toe by combined plantar plate tenodesis and extensor digitorum brevis transfer: a minimally invasive approach. However, open plantar plate repair requires extensive soft tissue dissection which may induce periarticular fibrosis. Plantar plate tenodesis, an arthroscopically assisted dynamic repair of the plantar plate, can stabilize the attenuated or ruptured plantar plate through suturing the plantar plate and fibrous flexor tendon sheath to the long extensor tendon of the second toe.4Modified double plantar plate tenodesis.,5Correction of crossover toe deformity by arthroscopically assisted plantar plate tenodesis.,17Arthroscopic-assisted correction of claw toe or overriding toe deformity: plantar plate tenodesis., 18Stabilization of first metatarsophalangeal instability with plantar plate tenodesis., 19Lui T.H. Chan L.K. Chan K.B. Modified plantar plate tenodesis for correction of claw toe deformity. This minimally invasive technique allows magnified arthroscopic visualization of the operative field without the need for extensive soft tissue dissection or metatarsal osteotomy. Recently, the technique of arthroscopic release of lumbrical tendon has been incorporated into the technique of plantar plate tenodesis.11Correction of crossover toe deformity by plantar plate tenodesis and arthroscopic release of lumbrical. This can eliminate the deforming force of the tethered lumbrical. In severe crossover toe deformity, in addition to the deforming force of the tethered lumbrical, the lateral capsuloligamentous complex of the MTP joint is attenuated. In this Technical Note, we report a modification of the plantar plate tenodesis and arthroscopic lumbrical release and incorporate arthroscopic plication of the attenuated lateral capsuloligamentous complex into the technique. It is indicated for symptomatic severe crossover toe deformity that is recalcitrant to conservative treatment.21Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: Preliminary observations. The procedure is still feasible in case of dislocated second MTP joint if the dislocation is reducible by the closed method. It is contraindicated if the MTP joint is degenerated or destructed, or there is Morton neuroma at the lateral side of the deformed toe, fixed dislocation of the second MTP joint, or the deformity is caused by bony deformities of the metatarsal or the proximal phalanx (Table 1).

Table 1Indications and Contraindications of Correction of Severe Crossover Toe Deformity By Plantar Plate Tenodesis, Arthroscopic Release of Lumbrical, and Plication of Lateral Capsuloligamentous Complex

MTP, metatarsophalangeal.

Technique Preoperative assessment and Patient Positioning

Preoperative standing radiograph of the foot is useful to document the severity of the deformity, the presence of any dislocation of the second MTP joint, degeneration or destruction of the involved MTP joint or the presence of any bone deformity of the metatarsal or proximal phalanx. There should not be any clinical evidence of Morton’s neuroma of the second toe web.

The patient is in the supine position with a thigh tourniquet to provide a bloodless operative field. A 1.9 mm 30° arthroscope (Henke Sass Wolf GmbH) is used for this procedure. Fluid inflow is driven by gravity, and no arthro-pump is used. Continuous toe traction is not needed.

 Portal Placement and Second Metatarsophalangeal ArthroscopyThe portals used are the standard dorsomedial and dorsolateral portals of second MTP arthroscopy, which are located at the MTP joint level and are at the medial and lateral side of the long extensor tendon respectively. Skin incisions of 3 to 4 mm are made at the portal sites. The subcutaneous tissue is bluntly dissected down to the joint capsule by a hemostat and the dorsal capsule is perforated by the tip of the hemostat. The MTP joint is examined arthroscopically for the integrity of the plantar plate, the status of the articular cartilage and the presence of synovitis (Fig 1). Arthroscopic synovectomy is performed with an arthroscopic shaver (Smith and Nephew) if synovitis is present.11Correction of crossover toe deformity by plantar plate tenodesis and arthroscopic release of lumbrical. The dorsal capsule is stripped from the metatarsal neck by a small periosteal elevator via the portals.

Fig 1Correction of severe crossover toe deformity of the right second toe by plantar plate tenodesis, arthroscopic release of lumbrical and plication of lateral capsuloligamentous complex. The patient is in the supine position. Second metatarsophalangeal arthroscopy is performed via the dorsomedial and dorsolateral portals. DMP, dorsomedial portal; DLP, dorsolateral portal.

 Release of Medial Capsuloligamentous ComplexThe dorsolateral portal is the viewing portal, and the dorsomedial portal is the working portal. The medial capsuloligamentous complex (medial capsule and medial proper collateral ligament) is released by means of a SuperCut scissors (Stille, Lombard, IL) (Fig 2).

Fig 2Correction of severe crossover toe deformity of the right second toe by plantar plate tenodesis, arthroscopic release of lumbrical and plication of lateral capsuloligamentous complex. The patient is in supine position. The dorsolateral portal is the viewing portal and the dorsomedial portal is the working portal. (A) Clinical photo shows that the scissors is inserted into the dorsomedial portal. (B) Arthroscopic view shows that the medial capsule together with the medial proper collateral ligament is released by the scissors. DMP, dorsomedial portal; DLP, dorsolateral portal; S, scissors; MCC, medial capsuloligamentous complex; MT, metatarsal head.

 Release of Lumbrical TendonThe dorsolateral portal is the viewing portal and the dorsomedial portal is the working portal. The lumbrical tendon can be seen after complete release of the medial capsuloligamentous complex. The lumbrical tendon can then be identified and released with the scissors (Fig 3).

Fig 3Correction of severe crossover toe deformity of the right second toe by plantar plate tenodesis, arthroscopic release of lumbrical and plication of lateral capsuloligamentous complex. The patient is in the supine position. The dorsolateral portal is the viewing portal, and the dorsomedial portal is the working portal. The lumbrical tendon can be seen after complete release of the medial capsuloligamentous complex. The lumbrical tendon can then be identified and released with the scissors. MCC, medial capsuloligamentous complex; L, lumbrical tendon.

 Anchoring Lateral Part of Plantar Plate and Plication of the Lateral Capsuloligamentous ComplexThe dorsomedial portal is the viewing portal and the dorsolateral portal is the working portal. The dorsolateral portal incision is retracted laterally. A straight-eyed needle (FavorMed, Ningbo, China) loaded with a no. 1 PDS suture (Ethicon, Johnson & Johnson, Cincinnati, OH) is passed through the dorsal corner of the lateral capsuloligamentous complex and is then entered into the second MTP joint. With further advancement of the needle in the lateral gutter of the MTP joint, the needle pierces the lateral edge of the plantar plate. The needle and the suture pass through the lateral edge of the plantar plate close to its phalangeal insertion, the fibrous flexor tendon sheath, and the plantar skin. It is important to make sure the sutures are staying in the lateral gutter and not across the joint proper to avoid subsequent scratching of the cartilage by the suture. A 1 cm proximal incision is made at the dorsal side of diaphysis of the second metatarsal. The suture is retrieved from the plantar surface of the flexor fibrous tendon sheath to the proximal incision by a curved hemostat along the lateral surface of the metatarsal. The suture is tensioned to facilitate catching of the suture by the hemostat. The other limb of the suture passes through the dorsal corner of the lateral capsuloligamentous complex, the lateral edge of the plantar plate, fibrous flexor tendon sheath, and the plantar skin by means of the straight-eyed needle via the dorsolateral portal. A suture loop is maintained at the dorsolateral portal to allow tensioning of the suture during retrieval of the suture limb back to the proximal incision. This helps the hemostat to catch the suture at the plantar surface of the fibrous flexor tendon sheath. The lateral gutter is obliterated, and the lateral capsuloligamentous complex is plicated by pulling the suture (Fig 4). The procedure is repeated with another no. 1 PDS suture. The crossover toe deformity can be corrected by pulling the sutures.

Fig 4Correction of severe crossover toe deformity of the right second toe by plantar plate tenodesis, arthroscopic release of lumbrical and plication of lateral capsuloligamentous complex. The patient is in the supine position. The dorsomedial portal is the viewing portal and the dorsolateral portal is the working portal. (A) The dorsolateral portal incision is retracted laterally. A straight-eyed needle loaded with a no. 1 PDS suture is passed through dorsal corner of the lateral capsuloligamentous complex and then entered into the second MTP joint. With further advancement of the needle in the lateral gutter of the MTP joint, the needle pierces the lateral edge of the plantar plate. The needle and the suture pass through the lateral edge of the plantar plate close to its phalangeal insertion, the fibrous flexor tendon sheath and the plantar skin. It is important to make sure the sutures are staying in the lateral gutter and not across the joint proper to avoid subsequent scratching of the cartilage by the suture. (B) A 1 cm proximal incision is made at the dorsal side of diaphysis of the second metatarsal. The suture is retrieved from the plantar surface of the flexor fibrous tendon sheath to the proximal incision by a curved hemostat along the lateral surface of the metatarsal. The suture is tensioned to facilitate catching of the suture by the hemostat. (C) The other limb of the suture passes through the dorsal corner of the lateral capsuloligamentous complex, the lateral edge of the plantar plate, fibrous flexor tendon sheath and the plantar skin by means of the straight eyed needle via the dorsolateral portal. (D) A suture loop is maintained at the dorsolateral portal in order to allow tensioning of the suture during retrieval of the suture limb back to the proximal incision. This helps the hemostat to catch the suture at the plantar surface of the fibrous flexor tendon sheath. (E) Arthroscopic view shows that the suture anchors the lateral capsuloligamentous complex and stays at the lateral gutter of the metatarsophalangeal joint. (F) Arthroscopic view shows that the suture limbs pass through the lateral edge of the plantar plate. (G) The lateral gutter is obliterated, and the lateral capsuloligamentous complex is plicated by pulling the suture. DMP, dorsomedial portal; DLP, dorsolateral portal; PI, proximal incision; LCC, lateral capsuloligamentous complex; MT, metatarsal head; PP, plantar plate.

 Correction of the Crossover Toe DeformityThe crossover toe is slightly overcorrected by 20° plantarflexion and 20° abduction of the MTP joint. The sutures are sewed under tension to the extensor digitorum longus (EDL) tendon to the second toe to complete the correction. If the EDL tendon distal to the sew point is still tight, distal EDL tenotomy can be performed at the portal incisions (Fig 5, Video 1, Table 2). Any concomitant hallux valgus deformity will be corrected under arthroscopic assistance.22Endoscopic distal soft tissue procedure in hallux valgus surgery.,23Lui T.H. Chan K.B. Chow H.T. Ma C.M. Chan P.K. Ngai W.K. Arthroscopy-assisted correction of hallux valgus deformity. After surgery, bulky dressing is applied to the operated foot for 2 weeks. The operated lesser toe is allowed free mobilization. The patient is advised for nonweightbearing for 2 weeks and then weightbearing walking as tolerated with wooden-based sandal for another 4 weeks before resuming normal shoe wear.5Correction of crossover toe deformity by arthroscopically assisted plantar plate tenodesis.

Fig 5Correction of severe crossover toe deformity of the right second toe by plantar plate tenodesis, arthroscopic release of lumbrical and plication of lateral capsuloligamentous complex. The patient is in the supine position. (A) Preoperative clinical photograph of the illustrated case shows the crossover second toe. (B) Preoperative radiograph of the illustrated case shows dislocation of the second metatarsophalangeal joint. (C) Clinical photo shows that correction of the crossover toe deformity is completed by sewing the sutures under tension to the extensor digitorum longus tendon to the second toe. (D) Fluoroscopic view after the procedure shows that the crossover toe deformity is corrected and the second metatarsophalangeal joint is reduced. The hallux valgus deformity is corrected by endoscopic distal soft tissue procedure. EDL, extensor digitorum longus tendon; DMTP2, dislocated second metatarsophalangeal joint; RMTP2, reduced second metatarsophalangeal joint.

Table 2Pearls and Pitfalls of Correction of Severe Crossover Toe Deformity by Plantar Plate Tenodesis, Arthroscopic Release of Lumbrical, and Plication of Lateral Capsuloligamentous Complex

DiscussionIn crossover toe deformity, the plantar plate is attenuated, deformed and displaced dorsomedially and the fibrous tendon sheath and the flexor tendons are medially displaced.24The medial crossover toe: A cadaveric dissection. Just stabilize the plantar plate in the sagittal plane may not be good enough. The medially displaced plantar plate, fibrous tendon sheath, and the flexor tendons should be reduced to restore normal flexor force vector. Plantar plate tenodesis provides corrective force to pull back the plantar plate and the flexor tendons to the normal position.4Modified double plantar plate tenodesis.,5Correction of crossover toe deformity by arthroscopically assisted plantar plate tenodesis. As the plantar plate sutures are tied to the EDL tendon, the pull of EDL is redirected plantarward to stabilize the plantar plate and the fibrous flexor tendon sheath. The tension of the EDL distal to the sutures is relieved. If there is residual tension at the EDL tendon distal to the sew point, as in case of severe crossover toe deformity, distal EDL tenotomy can be performed and all the pulling force of EDL will be transmitted plantarly to stabilize the plantar plate. This technique is still feasible even in case of massive or complicated tear or the quality of the tissue is poor as the fibrous tendon sheath is incorporated into the construct.5Correction of crossover toe deformity by arthroscopically assisted plantar plate tenodesis.,24The medial crossover toe: A cadaveric dissection. This, together with the release of the dorsal capsule, medial capsuloligamentous complex, and lumbrical, can restore the soft tissue balance around the MTP joint in most of the case and the MTP joint can be reduced and the interosseous tendons become plantar to the axis of rotation of metatarsal head and the intrinsic minus toe will be corrected.19Lui T.H. Chan L.K. Chan K.B. Modified plantar plate tenodesis for correction of claw toe deformity. In case of severe deformity, the lateral capsuloligamentous complex is attenuated, and we believe that lateral plication can further improve the correction. However, as the orientation of lateral plication sutures in our technique is not along the axis of the proper or accessory lateral collateral ligament, there may be increased risk of postoperative toe stiffness.The advantages of this technique include complete soft tissue balance around the MTP joint, precise placement of the suture to the plantar plate under arthroscopic guidance, minimal soft tissue dissection, avoidance of plantar wound, tendons of the toes can be preserved, and sophisticated instruments are not needed. The potential risks of this technique include injury to the articular cartilage, injury to the interdigital nerve, recurred or residual deformity, and postoperative toe stiffness (Table 3). This is technically demanding and should be reserved for the experienced foot and ankle arthroscopists.

Table 3Advantages and risks of correction of severe crossover toe deformity by plantar plate tenodesis, arthroscopic release of lumbrical and plication of lateral capsuloligamentous complex

Supplementary Data

Video 1

Correction of severe crossover toe deformity of the right second toe by plantar plate tenodesis, arthroscopic release of lumbrical and plication of lateral capsuloligamentous complex. The patient is in supine position. With the dorsolateral portal as the viewing portal and the dorsomedial portal as the working portal, the medial capsuloligamentous complex is released with an scissors. After of the medial capsuloligamentous complex, the lumbrical tendon can be seen and released. The arthroscope is then switched to the dorsomedial portal, A straight eyed needle loaded with a No. 1 PDS suture is passed through dorsal corner of the lateral capsuloligamentous complex, the lateral edge of the plantar plate, fibrous flexor tendon sheath and the plantar skin. The suture is retrieved from the superficial surface of the fibrous tendon sheath to the proximal incision. The same procedure is repeated with other limb of the suture. The lateral gutter is obliterated, the lateral capsuloligamentous complex is plicated and the crossover toe deformity is corrected by pulling the suture limbs.

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Metatarsophalangeal joint instability of the lesser toes and plantar plate deficiency.

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Correction of crossover toe deformity by arthroscopically assisted plantar plate tenodesis.

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Pull-out technique for plantar plate repair of the metatarsophalangeal joint.

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Role of plantar plate and surgical reconstruction techniques on static stability of lesser metatarsophalangeal joints: a biomechanical study.

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Stabilization of the subluxed second metatarsophalangeal joint: Flexor tendon transfer versus primary repair of the plantar plate.

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Surgical treatment of patients with painful instability of the second metatarsophalangeal joint.

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Plantar plate repair of the second metatarsophalangeal joint: Technique and tips.

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