Three patients (3 feet: 1 right, 2 left) were operated between January 2020 and January 2021, 2 females and 1 male, with a mean BMI of 29.58 (min 25.22; max 34.58). The mean follow-up was 6.3 months (min 5; max 8).
Fifty-eight-year-old female patient with history of progressive and symptomatic deformity of the second toe. Symptoms were getting worse for the last one year. She had no history of symptoms or deformity in the first toe. She had tried conservative treatment for more than one year with taping, toe sleeves and footwear modification, that were all not enough anymore to control her symptoms. On preoperative physical exam the patient was found to have no hallux valgus deformity, but a moderate first ray instability with a neutral hindfoot alignment. Her LTD consisted of dynamic flexible dorsiflexion deformity of the 2nd MTPJ, and a rigid plantarflexion contracture of the PIPJ. She also had tenderness and thin callosities under the heads of the 2nd and 3rd metatarsals and over the PIPJ of the second toe. Patient underwent DMMO of the second and third metatarsals, PIPJ fusion of the 2nd toe, plantarflexion osteotomy of the medial cuneiform with a 6 mm allograft wedge and tenodesis of the flexor tendons to the plantar aspect of the proximal phalanx of the second toe using the TenoTac™ implant (Paragon 28®, Denver, CO, US).
Preoperative and postoperative weight bearing computed tomography (WBCT) images (3-months) and conventional radiographic (6-months) are presented in Figs. 4, 5, 6 and 7. Osteotomies and PIPJ fusion were completely healed after 3 months, with considerable clinical correction of the 2nd toe deformity and resolution of the central metatarsalgia and 2nd toe dorsal symptoms. Clinical correction was even better after 6 months (Fig. 8). Patient ROM of the 2nd MTPJ was almost completely restored, with a total passive dorsiflexion of 60°-70°. She developed no floating toe or dorsiflexion contracture and was extremely satisfied with the procedure. The total clinical follow-up time was 8 months. Patient demonstrated improved clinical outcomes in functional and pain domains, such as PROMIS Physical (29.6 to 44.9), EFAS scale (8 to 13), EFAS Sport Scale (1 to 16), FFI-R (37.5 to 27.2) and PCS (12 to 0).
Seventy-one-year-old male patient with a history of long-term hallux valgus deformity in the right foot. He underwent surgical treatment about 25 years ago, with a distal first metatarsal osteotomy for the HV deformity, with adequate correction for several years. With time, he developed a recurrence of the HV deformity, that got worse progressively, in association with a progressive deformity of the second toe. For about 8 years, he describes a cross-over deformity of the 1st and 2nd toes, with pain symptoms over the medial eminence of the 1st metatarsal head and dorsal aspect of the second toe, as well as some plantar forefoot pain. On physical exam, patient presented with the described cross-over deformity, severe HV 2nd LTD, a rigid ROM of the 1st MTPJ (total ROM of 35–40°), with some pain during ROM. He also had a diffuse callosity over the heads of the 2nd and 3rd metatarsal heads that was painful to palpation, as well as an asymptomatic bunionette deformity. Patient had exhausted conservative treatment options and decided to proceed with surgical treatment. He underwent 1st MTPJ fusion, DMMO of the 2nd, 3rd and 4th metatarsals, and PIPJ fusion with flexor tenodesis of the 2nd toe.
Preoperative and postoperative clinical (3 months), weight bearing conventional radiographic (6 weeks) and WBCT images (3 months) are presented in Figs. 9, 10 and 11. WBCT demonstrated completely healed fusions of the 1st MTPJ and PIPJ, as well as the DMMOs. At latest follow-up (6 months), the patient was doing extremely well with a stable 1st MTP joint fusion, well-aligned first toe, and significantly improved sagittal plane alignment of the second toe. He still has residual medial displacement of the lesser toes that was not addressed in the surgical procedure He also is now slightly symptomatic in the bunionette deformity that was asymptomatic preoperatively, which led the patient to decide not to have it corrected at the time of the surgery. The ROM of the second MTPJ is almost completely preserved, with a total of 70o of passive dorsiflexion. There is no residual floating of the 2nd toe. Improvement in clinical outcomes was noted on as PROMIS Physical (42.3 to 47.7), EFAS scale (0 to 3), FFI-R (60.29 to 50) and PCS (4 to 2).
Sixty-three-year-old female patient with a history of at least 10 years of progressive deformity of the first and second left toes. She had never had any surgical treatment. She was able to manage the deformities for a long time with footwear modifications and taping of the second toe, however, symptoms got significantly worse for the last several months. Symptoms are mostly located at the top of the 2nd toe, which has been rubbing on the shoe. On physical exam, the patient was tender on that location, had some mild pain over the medial aspect of the 1st MTPJ, painful callosities underneath the 2nd and 3rd metatarsal heads, a mild-moderate symptomatic bunionette deformity, and a severely unstable first ray. She had exhausted conservative treatment and was looking for surgical treatment options. Among other procedures, she was offered a 1st tarsometatarsal joint fusion to correct the hallux valgus deformity, but refused it, since she did not want any fusions other than a PIPJ fusion to correct her 2nd LTD deformity. She underwent double 1st metatarsal osteotomy to correct the HV, medial proximal opening wedge and distal biplanar chevron-type osteotomy, DMMO of the 2nd, 3rd and 4th metatarsals, PIPJ fusion and flexor tenodesis of the 2nd toe, as well as chevron-type osteotomy of the 5th metatarsal to correct the bunionette deformity.
Preoperative and postoperative clinical, conventional weight bearing radiographic and WBCT images are presented in Figs. 12, 13 and 14. At 6 weeks, incisions were completely healed, and patient resumed progressive weight bearing. At 3 months, WBCT demonstrated completely healed osteotomies and an adequately healing PIPJ. First, 2nd and 5th toes had considerably improved alignment, with mild stiffness of the 1st and 2nd MTPJ, and a minor residual 2nd floating toe. At the latest follow-up (5 months), the patient was doing better, with improved ROM of the 1st and 2nd MTPJ. The ROM of the second MTPJ is almost completely restored, with a total of 50o of passive dorsiflexion. There is mild residual floating of the 2nd toe, with no pain under the lesser metatarsal heads. Patient demonstrated improved clinical outcomes including PROMIS Physical (27.6 to 42.3), EFAS scale (1 to 4), FFI-R (77.94 to 64.7) and PCS (12 to 6).