Chapter 26: Digital Deformities

and Surgery
Hammertoe Syndrome
Mallet Toe Syndrome
Claw Toe
Overlapping 5th Toe
Hallux Hammertoe
Hallux Interphalangeal Arthrodesis
Lesser Digital Arthrodesis
Overlapping 2nd Toe
Syndactlyization
Digital Implants
Floating Toe Syndrome
Blue Toe Syndrome
Polydactylism
 DIGITAL DEFORMITIES AND
SURGERY
Hammertoe Syndrome
There is a necessity for surgical procedures not only to relieve symptoms, but
also to preserve function. The toe functions to decelerate the foot, stabilize,
help in propulsion, and for kinesthetic sensation. To prevent a recurrence, it
is necessary to investigate and neutralize the deforming forces for full
correction of the deformity

1. Definitions:
a. Hallux hammertoe: This is a deformity whereby there is a dorsal
contracture of the 1st MTP joint and a plantar contracture of the hallux IPJ.
There is a dorsal contracture of the MTP joint capsule and plantar contracture
of the hallux IPJ capsule
b. Lesser hammertoe: Plantarflexion of the PIP joint with dorsiflexion of the
MTP joint.
c. Clawtoe: Dorsiflexion of the MTP joint and plantarflexion of the DIP and PIP
joints.
d. Mallet toe: Plantarflexion of the DIP joint
e. Clinodactyly: Curly toe (transverse plane deviation)
f. Digiti quinti varus: Overlapping 5th toe

2. Classification: Digital deformities are classed according to their

flexibility. This is determined by dorsiflexing the MTP joint and noting the
amount of reduction of the digit (Kelikian push up test) at the MTPJ
a. Flexible: Reducible on weight bearing and with the push up test
b. Semi-rigid: Slightly reducible by hand
c. Rigid: No change in the deformity when examiner attempts manual
correction

3. Anatomy: Electromyographic studies have shown that the long flexor fires
approximately at 15% of stance phase, the short flexor at 60%, the EDB at
40%, the EDL during swing and heel contact, and the intrinsics (interossei) at
50%.
a. Extensors:
i. The EDL goes to each lesser digit by a separate tendon
ii. The EDB goes to the middle three lesser toes
 EDL and EDB form a common tendon that passes over the proximal
phalanx to split into three slips. The middle slip goes to the middle
phalanx and the lateral two rejoin to insert over the distal phalanx
 The sling apparatus is part of the extensor hood. The sling mechanism
wraps around the base of the proximal phalanx and attaches to itself. It
can lift up on the proximal phalanx like a sling. There are no specific
attachments of the extensor apparatus into the proximal phalanx
 The EDL and EDB dorsiflex the MTP joint by the sling and cause weak
extension of the DIP and PIP joints, but in vivo cause passive flexion due to
the passive stretch on the fibers.
b. Flexors:
i. Goes to each digit to insert on the distal phalanx after passing deep and
superficial through the FDB under the proximal phalanx. It has the quadratus
plantae attached to its lateral border to help align its pull and the four
lumbricals attached distally and medially.
ii. The FDB is a 1st layer muscle that goes to each toe and inserts on the
middle phalanx.
 Flexor tendons do not insert on the proximal phalanx

 Action of the FDL and FDB gives active flexion of the IPJ's and secondary
passive extension of the MTP joint from the passive pull on the extensor
complex
 These are stance phase muscles that help in stabilization and propulsion
of the foot and digits
 Predominant action of the brevis vs. longus may determine whether the
PIPJ or DIPJ is contracted
c. Intrinsics:
i. There are 4 dorsal interossei. They abduct the digits around a central ray.
Their insertion is on the medial side of the 2nd and the lateral side of the
2nd, 3rd, and 4th proximal phalanx. There is also a point of attachment of
both plantar and dorsal interossei to the plantar plate under the MTP joint.
ii. Plantar interossei are 3 in number. They adduct the 3rd, 4th and 5th digits
toward the 2nd by attaching to the medial side of the phalanx and plantar
plate.
 The interossei run dorsal to the deep transverse metatarsal ligament, but
inferior to the axis of flexion of the MTP joint, and both function to
plantarflex the MP joint and extend the PIPJ and DIPJ
 When both interossei on each side of the MTP joint fire concurrently,
transverse plane abduction/adduction is stabilized
 These are stance phase muscles that help prevent buckling of the toes
due to the mechanism of the sling and production of passive stretch on
the longer extrinsic muscles
iii. Lumbricales are 4 muscles that originate from the medial side of each of
the 4 FDL tendons, run beneath the deep transverse intermetatarsal ligament
to insert into the base of the proximal phalanx and form the distal extent of
the extensor expansion.
 They plantarflex the MTP joint and dorsiflex the PIPJ's and DIPJ's
 Not recorded on EMG
 By limiting dorsiflexion of the MTP joint they help hold the digit in a more
rectus position
iv. Quadratus plantae is attached to the FDL laterally coming off the
calcaneus. Its proximal pull helps align the FDL pull to reduce the
adductovarus component to the lateral digits.

d. Arterial and venous supply:

i. The majority of the arterial supply is via the medial plantar artery
digital branches to each digit.
ii. Dorsally the digits are supplied by the dorsal digital proper branches
iii. The venous supply runs parallel to the arterial supply

e. Neurological supply: Divided into plantar and dorsal

i. Dorsal aspect:
 Saphenous nerve runs on the medial aspect of the foot to the 1st MTP joint
 The deep peroneal nerve supplies the adjacent sides of the lateral and
medial aspects of the 1 st and 2nd toes
 The medial dorsal cutaneous branch of the superficial peroneal nerve
supplies the medial aspect of the hallux and the contiguous sides of the
2nd and 3rd digits

 The intermediate dorsal cutaneous nerve from the superficial peroneal

nerve supplies the adjacent sides of the 3rd and 4th digits, and the 4th
and 5th digits
 The sural nerve supplies the lateral aspect of the dorsum of the foot and
 the lateral aspect of the 5th digit
ii. Plantar aspect:
 The medial plantar nerve of the posterior tibial nerve supplies the hallux,
2nd, 3rd, and medial aspect of the 4th digit
 The lateral plantar nerve supplies the lateral aspect of the 4th and 5th
digit

f. Summary:
i. Stance:
 FDL and FDB are deforming digital forces, but the FDB is the primary
deforming force
 Interossei and lumbricales have the potential for stabilizing the MTP joint
and neutralizing the deforming forces
 With intrinsic pathology, hammertoes form
 When the intrinsics function properly, stable digital function ensues
 Interossei are stance phase, lumbricales are not well documented (swing
phase hypothesized)
ii. Swing:
 EDL and EDB are active deforming forces that could create a hammer toe
in swing phase by creating MTP joint dorsiflexion and passive
plantarflexion of the IPJ's
 It is assumed in normal foot function, that lumbricales prevent
hammertoes from occurring

4. Etiology: The etiology of the hammertoe will depend to a degree on the

time in the gait cycle when the toe becomes initially deformed. There are 3
basic mechanisms.

NOTE* These all have a common mechanism: abnormal extention of the

proximal phalanx and secondary passive stretch of the flexors and
flexion of the PIPJ's and DIPJ's
a. Flexor stabilization: Is an increased pull of the long flexors as they gain
mechanical advantage over the intrinsics due to
i. Early flexor firing to help stabilize the hypermobile and flat foot
ii. Intrinsic pathology
 This is a stance phase condition seen from midstance on
 The foot is flexible and forefoot abducted
 The long flexors are firing early and longer to stabilize a pronated mobile
forefoot
 The intrinsics are not able to counter the deforming forces so hammertoe
deformities develop
 The flattened foot may come from forefoot varus, equinus, calcaneal
valgus, torsional problems, muscle imbalances, ligament laxity, and
neuromuscular problems
 Adducto-varus deformity of the 5th and sometimes the 4th toes

b. Extensor substitution: Is a swing phase condition due to weak anterior

muscles (due to ankle equinus, weak lumbricales, and spastic EDL)
i. Marked dorsiflexion of the MTP joint that may straighten on ground contact.
The extensor tendons and the metatarsal heads are prominent
ii. Progresses to a rigid deformity with time
iii. The extensors gain a mechanical advantage over the intrinsics
(lumbricales) when the anterior muscles are firing to dorsiflex the foot at the
ankle in swing to gain ground clearance and at heel contact to prevent foot
slap
iv. Patients may be diagnosed NWB by having them dorsiflex their foot.
Normally the digits will dorsiflex approximately 300 at the MTP joints. With
extensor substitution there will be more dorsiflexion of the proximal phalanx
v. Extensor substitution can occur in an equinus foot. There is an increased
declination of the front part of the foot
vi. Even though the digits are rectus on weight-bearing, during swing they
curl
vii. Results in an anterior pes cavus
viii. Whatever will allow the long extensors to fire early or gain a mechanical
advantage over the lumbricales will result in extensor substitution

c. Flexor substitution: Occurs where there is weakness of the triceps

surae.
i. The posterior deep muscles and the peronei attempt to produce heeloff in
place of the weakened triceps. This may be due to overlengthening of the
achilles or a congenital problem.
ii. A calcaneal gait is common
iii. Produces a hammertoe deformity without the adductovarus component
iv. A supinated high arch foot type is seen

5. Preoperative considerations:
a. If the Kelikian push-up test allows the digit to straighten, then the EDL and
MTP capsule is not so taut so that only a flexor tenotomy may be done
b. 90% of the hammertoe deformities are a result of FLEXOR STABILIZATION
compensation secondary to hypermobile flat feet.
Therefore following surgery orthoses must be used to neutralize the etiology
c. With EXTENSOR SUBSTITUTION an arthroplasty would only be temporary
due to lack of neutralization of the deforming forces, soft tissue releases
would only add a little time, and orthoses function during stance phase and
won't work here. Therefore an arthrodesis is the procedure of choice. A Hibbs
procedure would only be useful in a flexible deformity
d. With FLEXOR SUBSTITUTION strengthening of a weakened triceps by
tendon transfer and fusion of the digits would be in order

6. Surgical procedures:
a. Post procedure: Arthroplasty with proximal head resection
b. Lambrinudi procedure: Fusion of PIP and DIP joints
c. Young-Thompson procedure: Peg-in-hole fusion
d. Gotch procedure (or Gotch and Kreuz): Resection of the base of the
proximal phalanx and syndactylization of the digits
e. Girdlestone procedure: Transfer of the flexor tendons to the dorsum of the
proximal phalanx
f. Sgarlato procedure: Transfer of the FDL dorsally with capsular resection
through a 3 incision approach
g. Taylor procedure: PIPJ arthrodesis using a K-wire
h. Hibbs procedure: A tenosuspension transferring the EDL to the met heads
or base conjointly
i. Collins procedure: Repositioning of the medial and lateral extensor slips
dorsally on the digits
j. Suppan CAP procedure: Indicated for hammertoe correction in children.
Two transverse semielliptical incisions are made over the head of the
proximal phalanx, skin section and tendon and capsule removed, the
collaterals are left intact, metaphyseal osteotomy performed with cylinder of
bone removed. The capital fragment will fit snugly against the shaft of the
proximal phalanx and held snugly by the skin repair

7. Correction of the non-reducible hammertoe: Know the etiology and

neutralize it and follow a stepwise approach during surgery.
a. Arthroplasty to release PIPJ pressure and reduce the corn. Now do the
Kelikian push up test. (If the toe still does not straighten go to the next
procedure)
b. Extensor recession for release of the hood and sling fibers to slacken the
extensor apparatus to the proximal phalanx: If the toes still does not
straighten go to the next procedure

NOTE* When doing this do not cut the lumbricales to the base of the
proximal phalanx
c.
Hood release or EDL lengthening: If no straightening go on to the next
procedure
d. Capsulotomy of the MTP joint: If no straightening go on to the next
procedure
e. Plantar hood release
f. If a problem still exists fuse the PIPJ with a K-wire and extend through the
MTP joint held in a rectus position: Allows the digit to function as a rigid beam
and the deforming flexor to pull the entire toe into plantarflexion
 NOTE* Test the proximal phalanx for any dorsal resistance after each step. If
the proximal phalanx springs dorsally after it is placed in a corrected
position, go on to the next step

8. Correction of reducible hammertoe deformity:

a. Flexor tenotomy: When there is a flexion at the PIPJ which can be reduced,
the long flexor tendon may be the only pathological entity which needs
correction. If the skin is contracted, it is done through a plantar incision,
otherwise done through a medial or lateral approach.
b. Extensor tenotomy and capsulotomy: When the extensor tendons are
contracted along with the dorsal capsule of the MTP joint, this may be the
only pathological entity which needs correction. Care is made not to injure
the cartilage of the joint. The toe is splinted for 4-6 weeks.

NOTE* It is important to lengthen both the long and short extensors

c. Repositioning of the extensor slips: In digits in which the PIPJ is buckled but
completely reducible, the medial and lateral extensor slips may be
repositioned dorsally on the digits.

NOTE* By performing this procedure, one avoids resection of bone,

shortening of a digit, and flailness. The toe becomes straight, but very little
motion is present at the IPJ.

9. Complications:
a. Floppy digit with phalangeal base resection
b. Edema and sausage toe
c. Floating toe with metatarsalgia
d. Short toe
e. Regeneration of the phalangeal head
f. Infection
g. Decreased sensation
h. Blue toe secondary to venous congestion
i. White toe secondary to arterial spasm

NOTE* The difference between a floppy (flail) toe and a floating toe is that a
floating toe does not purchase the ground while a floppy toe may purchase
the ground however it is unstable.

Mallet Toe Syndrome

A sagittal plane deformity in which the distal phalanx is flexed on the middle
1. Surgery (adults):
a. Two semi-elliptical incisions encompassing the middle phalangeal head will
allow good access for resection of this deformity
b. Must be careful of the neurovascular structures with this procedure
c. Usually the deforming forces emanate from the contracture of the FDL or
abnormal morphology of the bony middle phalanx
2. Surgery (children):
a. Suppan CAP procedure: Performed similar to the hammertoe procedure,
except the metaphyseal osteotomy is done at the head of the intermediate
phalanx, and no subcutaneous sutures are used

1. Definition: Dorsiflexion of the proximal phalanx with plantarflexion of the

middle an distal phalanx

2. Surgery of severe claw toe with MPJ deformity:

a. Incision from DIPJ to metatarsal neck (curving across the metatarsal neck)
b. Z-plasty EDL and retract
c. Prepare bone for arthrodesis (now do Kelikian push up test)
d. Extensor hood release (Kelikian test)
e. Capsulotomy at MPJ
f. Fuse toe with K-wire across the MPJ
g. Repair EDL
h. If medial or lateral dislocation of the flexor plate present, you will need
capsulorrhaphy on one side of the MPJ

Adductovarus 5th Toe Deformity (overlapping 5th toe

This condition is usually hereditary and present most often bilaterally. Before
a procedure is done it is necessary to determine if any functional adaptation
has taken place in the 5th MTP joint. If this has occurred it is then necessary
to perform an osseus procedure (adults only). If there is any skin contracture,
a plastic release must be additionally performed
1. Etiology:
a. Proximal phalangeal base removed
b. Intrauterine position
c. Result of tailor's bunion procedure (tissue contracture)
d. Short EDL
e. Hammertoe toe repair sequelae

2. Diagnosis:
a. Adduction of the toe
b. Contracture of the MTP capsule
c. Medial contracted EDL
d. Varus rotation
e. Extention of MTP joint
f. Subluxed MTP joint

3. Surgical planning:
a. Skin incisions:
i. Z-plasty or V-Y

NOTE* The central arm of the Z-plasty is in line with the direction you want to
lengthen the skin

ii. Plantar elliptical

iii. Plantar V-Y
iv. Longitudinal incisions with dog ear resection
v. Syndactylization
b. Tendon/soft tissue:
i. Release and lengthening of the EDL
ii. Capsulotomy
iii. Plantar capsule release
iv. Transfer EDL to distal stump of abductor digiti quinti
v. Suspend EDL tendon around the metatarsal neck
v. FDL split and reattached dorsally
c. Bony procedures:
i. Resect 5th metatarsal head
ii. Proximal phalangeal head removal
iii. Removal of the base of the proximal phalanx
iv. Abductory wedge removal of phalanx
v. K -wire to hold position
4. Procedures:
a. Lapidus procedure: Extensor tenotomy with transfer of the distal stump
under the proximal phalanx to attach to abductor digiti quinti
b. Kelikian procedure: Syndactyly of the 4th and 5th after capsule release
and arthroplasty of the 5th toe
c. Ruiz Mora procedure: Resection of the proximal phalanx and semieliptical
plantar crease incisions to hold in corrected position
d. Lanzonis procedure: Extensor tenosuspension of the 5th metatarsal head
and fusion of the PIPJ and MTP capsulotomy
e. Goodman-Swisher procedure: A V-Y plasty, Z-tenotomy and capsulotomy
f. Butler procedure: Two concurrent racket shaped incisions completely
encircling the toe so to derotate and plantarflex
g. McFarland procedure: Proximal phalangeal head removed, Jones
suspension and syndactylization
h. Jahss procedure: Ruiz Mora incision with diaphesectomy of the proximal
phalanx

NOTE* In a child osseous procedures usually do not have to be performed. A

Zplasty or V-Y plasty may be utilized to release the skin contracture. An
extensor tenotomy at the level of the MTP joint and capsulotomy are
performed. A plantar skin wedge can be removed. Toes are splinted for 4
weeks

NOTE* In adults it is usually necessary to perform an osseous procedure at

the level of the MTP joint. If the base of the proximal phalanx is resected,
then syndactylism of the 4th and 5th digits should be performed. If a
partial metatarsal head resection is performed, then a Z-plasty or V-Y skin
plasty is performed. Some also advocate the removal of a transverse skin
ellipse plantarly to help hold the toe in position

Hallux Hammertoe Deformity

1. Etiology:
a. Muscle imbalance seen with a cavus foot type
b. Following surgical procedures of the 1 st MTP joint
i. Especially with removal of both sesamoids
ii. Detachment of the flexor brevis tendons at their insertion onto the base of
the hallux tendons
iii. Overzealous HAV surgery with medial subluxation of the tibial sesamoid
c. In the presence of IPJ sesamoids which bind down the long flexor tendon in
a shortened position
2. Flexible deformity: An IPJ fusion with EHL lengthening may be done,
approached through 2 semi-eliptical incisions,

NOTE* Fixation for fusion is either with 2 K-wires, AO fixation (4-0 cancellous,
3.5 cortical, 2.7 cortical), or 28 gauge monofilament wire loops
 NOTE* AO fixation of the IPJ cannot be used with a total joint replacement
unless 2.7 mm cortical screw modification is utilized, but can be difficult

NOTE* Monofilament wire fixation and crossed K-wires are the best choices
when planning to utilize a total joint replacement

NOTE* When doing an IPJ fusion, the propulsive phase of gait should be
eliminated for 6 weeks
3.
Rigid hammertoe deformity: Jones tendon transfer plus IPJ fusion

4. Rigid hammertoe deformity plus rigid plantarflexed 1st ray: IPJ

fusion plus dorsal wedge osteotomy of the 1st metatarsal

4. Postoperative complications:
a. Non-union
b. Hallux limitus or rigidus
c. Hallux extensus
d. Elevatus of the first metatarsal with IPK sub 2nd metatarsal

Hallux Interphalangeal Arthrodesis

1. Fixation techniques:
a. Stainless steel monofilament wire, 28 gauge
b. Two 0.045 Kirschner wires
c. 4.0 cancellous screw
d. 3.5 cortical screw (lag)
e. 2.7 cortical screw (lag)

2. Indications for fusion:

a. Semi or non-reducible IPJ contracture
b. Hyperkeratosis overlying the IPJ
c. Transverse or frontal plane deformity of the hallux
d. Clawtoe deformity
e. Abnormally long or short toe

Lesser Digital Arthrodesis

1. Biomechanics:
a. Flexor substitution
b. Extensor substitution

2. Signs and symptoms:

a. Semi-rigid or rigid deformity
b. Dorsal hyperkeratosis
c. Transverse plane deformity may be present
d. Clawtoe deformity may be present
e. Abnormally long or short toe may be present
f. Painful PIPJ motion may be present
g. Flail toe secondary to previous surgery
3. Fixation:
a. Stainless steel monofilament 28 gauge wire loops
b. 0.045 K-wire
c. Reese arthrodesis screw
d. Orthosorb®

NOTE* Fusion of the 2nd toe will not stop the formation of a hallux abductus
deformity

Overlapping 2nd Toe

1. Etiology:
a. Chronic biomechanical forces
b. Intra-articular steroid injections
c. Inflammation of the joint capsule (seen with RA)

2. Surgery:
a. Resection of phalangeal base
b. Flexor tendon transfer
c. Proximal IPJ arthrodesis
d. Partial met head resection
e. Relocation of the flexor plate
f. Freeing the base of the proximal phalanx from attachments and freeing
the metatarsal head from attachments and fixating with K-wire
g. Repositioning of a 2nd MTP capsular flap
h. Total implant arthroplasty

Syndactylization
1. Classification:
a. Type 1 (zygodactyly): Most common
i. 2nd and 3rd digits most frequently involved (followed by the 3rd and
4th digits)
ii. Asymptomatic and requires repair primarily for cosmetic reasons
b. Type 2 (synpolydactyly):
i. Associated with duplication of a part or entire digit (the duplicated
digit
usually intervenes between two essentially normal digits)
ii. 3rd and 4th digits primarily affected, followed by the 4th and 5th
toes
iii. Usually discomfort due to shoe irritation when the 5th toe is involved
c. Type 3: Fingers only
d. Type 4: Fingers only
e. Type 5
i. Syndactyly with concomitant metatarsal (or metacarpal) synostosis

2. Surgery: Plastic flap repairs (see following diagram)

Digital Implants
1. Signs:
a. Deformity involves the 2nd and or 3rd toe at the PIPJ
b. Semi-rigid or rigid hammertoe deformity
c. Painful PIPJ motion may be present
d. Hyperkeratosis may be present
e. Involved toe is of normal or shortened length when placed in its proper
position
f. Absence of significant MTP joint or DIP joint contracture of the involved
toe
g. Absence of significant frontal plane deformity of the involved toe
h. Normal skin condition, vascular status, and neurological status

2. Radiographic findings
a. Adequate bone stock to receive the stems of the implant
b. Adequate width of the proximal and intermediate phalanx to receive the
stems of the implant
c. Adequate length of the intermediate phalanx to receive the stem of the
implant
d. Absence of MTP and/or DIPJ contracture
e. DJD of the PIPJ may be present

3. Implant product selection:

a. Silastic H.P. 100, (Swanson Type) Weil Design, Dow Corning Wright:
A double stemmed flexible implant with cylindrical central body
b. Sutter Lesser Toe Proximal Interphalangeal Joint Prosthesis (Sgarlato
Design), Sutter Biomedical: A double stemmed very flexible implant with a
central hinge and rectangular stems with a polyester mesh internal fabric for
reinforcement
c. Sgarlato Hammertoe Implant Prosthesis, Sgarlato Labs: The newest device,
also a double stemmed with a trapezoidal solid central portion

4.
Implant procedure:
a. Two longitudinal semi-elliptical incisions (to prevent fat toe syndrome)
b. The dorsal tendinous structure is dissected free from the base of the distal
phalanx to the middle of the shaft of the proximal phalanx, and is retracted
medially or laterally
c. The PIPJ is entered by severing the capsular ligaments
d. The head of the proximal phalanx is excised at the surgical neck (a little
more bone is removed than with a traditional arthroplasty)
e. The proximal phalangeal stump is reamed first, and the middle phalangeal
stump is reamed
f. The implant is inserted, and there should be a 2-3 mm space between the
implant and each bone (very important)
g. The tendon and skin are then repaired

5. Advantages of digital implants:

a. Relief of pain
b. Maintenance of toe stability
c. Maintenance of toe length
d. Restoration of function
e. Allows for PIPJ motion and plantar gripping power of the toe
f. Minimal postop disability and early toe motion

6. Disadvantages (versus regular arthroplasty):

a. Cannot be performed in an abnormally big toe
b. Difficult to perform in the 4th and 5th toe due to small bone stock

NOTE* The Sgarlato (S.H.I.P.) and Sutter device have been used in the 5th
toe due to their size.. The Sutter which has the advantage of having a
small central portion whose thickness is less than its width, can be placed
either angled or vertical to prevent pressure from the shoes or adjacent
tissues. The S.H.I.P. can be placed normally

c. Need good bone stock and adequate width of bone

d. Need to have normal. sagittal plane position of the MTP joint
e. Needs specialized equipment
f. Cannot be used with frontal plane deformity
g. Need to remove implant if infection occurs
h. The Silastic Swanson design could permit lesion recurrence and digital
swelling due to the large diameter central portion
i. The Sgarlato implant is also available in a longer stemmed version which is
useful in revisional surgery as well as digits with longer phalanges

7. Contraindications:
a. Nonreducible contracture of MTP joint and/or DIPJ of the involved toe
b. Inadequate bone stock
c. Infection
d. Inadequate vascular status
e. Significant frontal plane deformity
f. Presence of an implant at the MTP joint of the involved toe
g. Inadequate skin coverage

Floating Toe Syndrome

1. Etiology:
a. Bradymetatarsia
b. Excessively elevated metatarsal
c. Dislocated flexor plate
d. Procedures which reduce the internal cubic content of the joint
e. Resection of the base of the proximal phalanx

2. Surgery:
a. Correct the underlying etiology
b. PIPJ fusion
c. Total joint replacement

Blue Toe Syndrome

1. Definition: Blue toe syndrome/purple toe syndrome results from
atheromatous embolization, which can eventually lead to gangrene if the
cause is not eliminated

2. Causes:
a. Atherosclerosis (most common)
i. Thrombosis formation,
b. Infection
i. Microthrombi formation
ii. Secondary syphilis
c. Atheroembolism
i. Cholesterol emboli from ulcerated plaques in the more proximal
vessels
ii. Mural wall thrombi
iii. Endocarditis
iv. Myxoma
v. Vascular surgery
vi. Angiography
vii. Meningitis
d. Anticoagulation
i. Coumadin
e. Thrombolytic activity
i. Tissue plasminogen activator
ii. Streptokinase
f. Drugs
i. Dopamine
ii. Beta blockers
iii. Steroids
iv. Epinephrine (in local anesthetics)
g. Hyperviscosity syndromes
i. Cryoglobulinemia
ii. Cold agglutinins
iii. Polycythemia vera
h. Hypercoagulable states
i. Malignancies
ii. Diabetes mellitus
i. Vasculitis
i. Polyarteritis nodosa group
ii. Hypersensitivity group
ii. Wegener's granulomatosis group
iv. Giant cell arteritis
j. Foot surgery

3. Signs and Symptoms:

a. Pain
b. Bluish mottling of the digit
c. Pedal pulses tend to be present
d. Can be either bilateral or unilateral

4. Origin of the Emboli:

a. Bilateral signs and symptoms in the toes suggests ulcerated plaques in the
aorta.
b. Unilateral signs suggests ulcerated plaques in the iliac, femoral, of
popliteal arteries.

5. Treatment:
a. Angiography to determine the location of the plaque
b. Photoplethysmography of the digits
c. Removal of the atheromatous plaque
d. Endarterectomy
d. Risk factor modification
e. Amputation as necessary
f. Medical therapy as needed (i.e. D/C anticoagulant or other suspected
causative agent, use of antibiotics or other drug)

Polydactylism
A hereditary malformation, transmitted as an autosomal dominant trait. It
may occur as a single deformity in the foot (nonsyndromatic) or may be
associated with accessory digits in the hand, and there may be other
congenital malformations as well (syndromatic). The digital deformities may
be pre-axial (hallux) or post-axial (5 toe) or central toes 2,3,4). The
duplication of the toe may be complete or involve the distal phalanx or the
distal and middle phalanx. The metatarsal may be partially or completely
duplicated. Duplicated digits may share a common metatarsal. Shoe fit is the
major problem.
1. Classification (Temtamy and McKusick): Adapted from the
classification of the hand (less applicable to the foot)
a. Pre-axial:
i. Type 1 to type 4
b. Post-axial:
i. Type A: A fully developed accessory digit that articulates with either the 5th
metatarsal or with a duplicated 5th metatarsal
ii. Type B: Characterized by an accessory digit devoid of osseous tissue which
represents a vestigal digit

NOTE* Venn-Watson further divided postaxial polydactyly into 5 specific

morphological patterns, based on the degree of metatarsal duplication
1. Surgical tenets:
a. The most rudimentary digit (least important) should be excised when
possible leaving 5 toes
b. Try to achieve a normal functioning foot as well as a cosmetically pleasing
one
c. Avoid scar on the medial or lateral side of the foot where shoe pressure will
irritate them

2. Surgical excision of lateral pre-axial toe:

a. If any other congenital deformities are present, they should be corrected

first

b. The above diagram shows an accessory pre-axial great toe that is in varus
secondary to a metatarsus adductus. The metatarsus adductus is treated first
via casting (which will help stretch the medial skin of the hallux prior to
surgery). In the above case it is best to remove the lateral toe so the scar line
is on the lateral aspect. Redundant soft tissue can be excised from the 1st
interspace, and the adductor hallucis stump from the amputated toe is
sutured to the base of the remaining proximal phalanx, and the
intermetatarsal ligaments are repaired. This helps straighten the toe and
close the intermetatarsal angle

3. Surgical excision of a medial postaxial toe:

a. The following diagram illustrates the lesser developed medial 5th toe.
Excision is made via two longitudinal eliptical incisions around the accessory
5th toe which meet at approximately midshaft of the 5th metatarsal