Abstract
Plantar plate deficiency is the major pathology causing metatarsophalangeal joint instability. As the joint subluxates dorsally, 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. Plantar plate repair or reconstruction is a logical surgical treatment option. This can be performed through a dorsal or plantar approach. The purpose of this technical note is to report a minimally invasive technique of crossover toe deformity correction by suturing the plantar plate to the extensor tendon. It is indicated for symptomatic crossover toe deformity that is not responsive to nonsurgical treatment. It is contraindicated if the metatarsophalangeal joint is degenerated, destructed, or dislocated, or there is interdigital neuroma at the sides of the deformed toe, or the deformity is caused by bony deformities of the metatarsal head or the proximal phalanx.
Crossover second toe is one of the common forefoot deformities. Plantar plate insufficiency is the most common cause. It may progress with time to toe coronal and sagittal plane malalignment and even frank metatarsophalangeal (MTP) joint dislocation.1, 2 Conservative treatment including the toe splint can rarely delay the progression. Surgical treatments of this deformity include soft tissue balancing procedures to stabilize the MTP joint (plantar plate repair, tendon release or transfer, and periarticular soft-tissue release) and/or bony procedures (metatarsal/phalangeal osteotomy, arthrodesis, and excisional arthroplasty), and even toe amputation.3 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.4, 5, 6 Postoperative toe stiffness is also common after the transfer.2, 5, 7 Plantar plate repair has the advantage of addressing the plantar plate insufficiency that is the primary pathology of instability of the MTP joint. It has been shown that plantar plate repair is as effective as tendon transfer in stabilization of the MTP joint with less postoperative stiffness and discomfort.5 Tears of the plantar plate can be treated by primary repair with or without the use of suture anchor or distal advancement of the plate to the base of the proximal phalanx through bone tunnels.8 It can be performed through the plantar2, 7 or dorsal3, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 approaches. The plantar approach can reach the plantar plate directly. However, blunt dissection at the plantar wound may disrupt the organized fat septae resulting in extensive plantar scarring.7 The dorsal approach has the advantage of avoidance of plantar dissection and scar formation. Concomitant procedures, for example, periarticular soft tissue release, extensor tendon lengthening, and Weil metatarsal osteotomy, can be performed together with repair of the plantar plate through the same dorsal incision.3, 8, 9, 10, 11, 12, 13 Nevertheless, the dorsal approach often relies on complex instrumentation and it can only provide a limited view of the involved structures.2, 3, 8, 9, 10, 11, 12, 13 Plantar plate tenodesis has been described to correct the claw toe deformity by stabilizing the attenuated plantar plate through suturing the plantar plate with the extensor tendon.14, 15, 16 This can be performed under arthroscopic assistance, which can provide adequate visualization even without metatarsal osteotomy. In this technical note, we report a modification of the plantar plate tenodesis to correct the crossover toe deformity. It is indicated for symptomatic crossover toe deformity that is not responsive to nonsurgical treatment.18 It is contraindicated if the MTP joint is degenerated, destructed, or dislocated, or there is interdigital neuroma at the sides of the deformed toe, or the deformity is caused by bony deformities of the metatarsal head or the proximal phalanx (Table 1).
Table 1.
Pearls and Pitfalls of Correction of Crossover Toe Deformity by Arthroscopically Assisted Plantar Plate Tenodesis
| Pearls | Pitfalls |
|---|---|
| 1. The release of the medial capsuloligamentous structure and dorsal capsule should be completed. | 1. It is not suitable if the metatarsophalangeal joint is degenerated, destructed, or dislocated. |
| 2. The needle should pierce the intact part of the plantar plate if possible. | 2. It is not suitable if there is interdigital neuroma at the sides of the deformed toe. |
| 3. The hemostat should be inserted along the lateral side of the metatarsal and no soft tissue should be trapped between the hemostat and the metatarsal. | 3. It is contraindicated if the deformity is caused by bony deformities of the metatarsal head or the proximal phalanx. |
| 4. The suture is retrieved from the plantar surface of the flexor tendon sheath so that the tendon sheath together with the plantar plate is incorporated in the tenodesis construct. |
Technique
Preoperative Assessment and Patient Positioning
The preoperative radiograph of the foot should confirm that there was no dislocation or degeneration of the involved MTP joint. There should not be any bone deformity at the metatarsal head or the base of the proximal phalanx accounting for the toe deformity. There should not be any clinical evidence of Morton's neuroma of the second toe web. The patient is in supine position with a thigh tourniquet to provide a bloodless operative field. A 1.9-mm 30° arthroscope (Henke Sass Wolf GmbH, Germany) is used for this procedure.
Arthroscopy of the Second Metatarsophalangeal Joint
Arthroscopy of the second metatarsophalangeal (MTP-2) joint is performed via the dorsomedial and dorsolateral portals. The dorsomedial and dorsolateral portals are located at the MTP-2 joint level, medial and lateral to the extensor tendons, respectively. Incisions of 3 mm are made at the portal sites. The subcutaneous tissue is bluntly dissected down to the joint capsule by a hemostat and the capsule is perforated by the tip of the hemostat. The portals can be switched as the viewing and working portals. No continuous traction of the joint is used. The MTP-2 joint is examined arthroscopically for the integrity of the plantar plate, the status of the articular cartilage, and the presence of synovitis. Arthroscopic synovectomy is performed with an arthroscopic shaver (Smith & Nephew, Andover, MA) if synovitis is present.
Release of the Dorsal Capsule and Medial Capsuloligamentous Complex
The dorsal capsule is stripped by the arthroscopic shaver via the dorsomedial and dorsolateral portals. With the dorsolateral portal as the viewing portal, the medial capsuloligamentous complex is cut down to the plantar plate by means of an arthroscopic cutter (Acufex, Smith & Nephew) or SuperCut scissors (Stille, Lombard, IL) via the dorsomedial portal (Fig 1).
Fig 1.
Correction of the crossover left second toe by arthroscopically assisted plantar plate tenodesis. Dorsolateral portal (DLP) is the viewing portal. (A) The medial collateral ligament is cut by an arthroscopic scissors via the dorsomedial portal (DMP). (B) Arthroscopic view shows that the medial capsule (MC) is cut open. (MT, metatarsal head.)
Passing Sutures Through the Lateral Part of the Plantar Plate and Retrieving to the Proximal Incision
The dorsomedial portal is the viewing portal. A No. 1 PDS (polydioxanone) suture (Ethicon, Johnson & Johnson, Cincinnati, OH) is passed through the lateral part of the plantar plate close to its phalangeal insertion by means of a straight-eyed needle (FavorMed, Ningbo, China) via the dorsolateral portal. The needle should pass through the intact lateral part of the plantar plate if possible. The needle and the suture pass through the plantar plate, the fibrous flexor tendon sheath, and the plantar skin. A 1-cm proximal incision is made at the dorsal side of the 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 (Fig 2). The other limb of the suture passes through the intact lateral part of the plantar plate proximal to the previous suture entry site by means of a straight-eyed needle via the dorsolateral portal (Fig 3). The suture limb 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. A suture loop is maintained at the dorsolateral portal to allow tensioning of the suture. This helps the hemostat to catch the suture at the plantar surface of the fibrous flexor tendon sheath (Fig 4). The procedure is repeated with another No. 1 PDS suture (Fig 5).
Fig 2.
Correction of the crossover left second toe by arthroscopically assisted plantar plate tenodesis. Dorsomedial portal (DMP) is the viewing portal. (A) A straight-eyed needle loaded with a No. 1 PDS (polydioxanone) suture is inserted via the dorsolateral portal (DLP). (B) The No. 1 PDS suture passes through the lateral part of the plantar plate (PLP) close to its phalangeal insertion. (MT, metatarsal head; PP, proximal phalanx.) (C) A hemostat is inserted along the lateral side of the metatarsal via the proximal incision (PI) to catch the suture limb at the plantar surface of the fibrous flexor tendon sheath. (D) The suture limb is retrieved to the proximal incision.
Fig 3.
Correction of the crossover left second toe by arthroscopically assisted plantar plate tenodesis. Dorsomedial portal (DMP) is the viewing portal. (A) The straight-eyed needle loaded with the other limb of the No. 1 polydioxanone suture is inserted via the dorsolateral portal (DLP). (B) Arthroscopic view shows that the needle (N) pierces the plantar plate (PLP) proximal to the previous suture entry point.
Fig 4.
Correction of the crossover left second toe by arthroscopically assisted plantar plate tenodesis. (A) Hemostat is inserted along the lateral side of the metatarsal via the proximal incision (PI) to catch the other limb of the polydioxanone (PDS) suture at the plantar surface of the fibrous flexor tendon sheath. A suture loop is maintained at the dorsolateral portal (DLP) to allow tensioning of the suture. This helps the hemostat to catch the suture. (B) The suture is retrieved to the proximal incision. (C) Arthroscopic view shows that the lateral part of the plantar plate (PLP) is grasped by the PDS suture. (PP, proximal phalanx.) (D) Medial deviation of the second toe can be corrected by tensioning of the suture.
Fig 5.
Correction of the crossover left second toe by arthroscopically assisted plantar plate tenodesis. Another No. 1 PDS (polydioxanone) suture is applied to grasp the lateral part of the plantar plate. Dorsomedial portal is the viewing portal. (A) The plantar plate is inserted via the dorsolateral portal and pierced by a straight-eyed needle medial to the previous suture entry points. (B) The other PDS suture passes through the plantar plate together with the needle. (C) Arthroscopic view shows that the plantar plate is grasped by 2 PDS sutures. (MT, metatarsal head; PLP, plantar plate; PP, proximal phalanx.)
Correction of the Deformity and Tying the Sutures to the Extensor Tendon
The crossover toe is slightly overcorrected in both sagittal and transverse planes. The sutures are tied to the extensor tendon to the second toe to complete the correction (Fig 6, Video 1, Table 2). Any concomitant hallux valgus deformity will be corrected under arthroscopic assistance.19, 20 Postoperatively, bulky dressing is applied to the operated foot for 2 weeks. The operated lesser toe is allowed free mobilization. The patient is advised for non-weight-bearing for 2 weeks and then weight-bearing walking as tolerated with wooden-based sandal for another 4 weeks before resuming normal shoe wear.
Fig 6.
Correction of the crossover left second toe by arthroscopically assisted plantar plate tenodesis. (A) The No. 1 polydioxanone sutures are sewed to the extensor digitorum longus (EDL) tendon to the second toe. (B) The sutures are tightened and tied on the extensor tendon to correct the crossover toe deformity. (C) Preoperative clinical photo of the illustrated case shows the crossover toe deformity of the second toe. (D) The crossover toe deformity is corrected after plantar plate tenodesis.
Table 2.
Summary of the Surgical Steps
| Surgical Step | Viewing Portal | Working Portal |
|---|---|---|
| 1. Arthroscopic examination and treatment of concomitant intra-articular lesion of the second metatarsophalangeal joint | Dorsomedial/dorsolateral portals | Dorsomedial/dorsolateral portals |
| 2. Release of the dorsal capsule | Dorsomedial/dorsolateral portals | Dorsomedial/dorsolateral portals |
| 3. Release of the medial capsuloligamentous complex | Dorsolateral portal | Dorsomedial portal |
| 4. Passing sutures through the lateral part of the plantar plate | Dorsomedial portal | Dorsolateral portal |
| 5. Retrieving sutures to the proximal incision | Proximal incision at the dorsal side of the diaphysis of the second metatarsal | |
| 6. Correction of the deformity and tying the sutures to the extensor tendon | Proximal incision at the dorsal side of the diaphysis of the second metatarsal |
Discussion
Plantar plate deficiency is the major pathology causing MTP joint instability.2, 21 As the joint stability 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 resulting in hyperextension of the MTP joint and flexion deformity of the interphalangeal 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.21 With time, the plantar plate is deformed and displaced dorsomedially and the flexor tendons are medially displaced in crossover toe deformity.22 With failure of the plate and medial displacement of the flexor tendons, procedures such as capsular releases, direct ligament repairs, or standard flexor to extensor tendon transfers cannot be expected to give reliable full correction of the medial deviation.22 Plantar plate tenodesis is a form of indirect repair of the plantar plate. The plantar plate and the fibrous flexor tendon sheath are anchored by the sutures and are pulled back to the normal position. The tension of the extensor digitorum longus is redirected plantarward to pull the plantar plate and the fibrous flexor tendon sheath proximally and laterally. The tension of the extensor digitorum longus distal to the suture is relieved. This, together with the release of the dorsal capsule and medial collateral ligament, can restore the soft tissue balance around the MTP-2 joint. The MTP-2 joint will be reduced and the interosseous tendons become plantar to the axis of rotation of the metatarsal head and the intrinsic minus toe will then be corrected.16
The role of arthroscopy in this technique is the assessment of the integrity of the phalangeal insertion of the plantar plate and guides the insertion of needle to avoid the tears of the plantar plate if present. Any concomitant intra-articular pathology can be treated arthroscopically. Retrieval of the stitches at the plantar surface of the fibrous flexor tendon sheath is possible because the plantar plate is in continuity with the tendon sheath.7, 16, 23 This technique can stabilize the plantar plate even in the case of massive or complicated tear or the quality of the tissue is poor as the fibrous tendon sheath is incorporated into the construct.22 Plantar plate tenodesis can also be performed together with the Weil osteotomy if metatarsal head overload is present.
Nery et al.11 described an improvement of American Orthopaedic Foot and Ankle Society score from an average of 52 points preoperatively to 92 points postoperatively after direct repair of the plantar plate combined with a Weil osteotomy and lateral soft tissue reefing. Lui et al.16 described that the American Orthopaedic Foot and Ankle Society score improved from an average of 45 points preoperatively to 87 points at the last follow-up after correction of claw toe deformity by plantar plate tenodesis.
The advantages of this technique include the following: precise insertion of the suture to the plantar plate under arthroscopic guidance, concomitant intra-articular pathology can be dealt with, 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 during needle insertion, and damage of the interdigital nerve during retrieval of the suture to the proximal incision and during the release of the medial collateral ligament. The deformity may recur if the sutures rupture or cut out from the extensor tendon or plantar plate before the plantar plate healed in reduced position by fibrosis (Table 3). This is technically demanding and should be reserved for the experienced foot and ankle arthroscopists.
Table 3.
Advantages and Risks of Correction of Crossover Toe Deformity by Arthroscopically Assisted Plantar Plate Tenodesis
| Advantages | Risks |
|---|---|
|
|
Footnotes
The author reports that he has no conflicts of interest in the authorship and publication of this article.
Supplementary Data
Correction of the crossover left second toe by arthroscopically assisted plantar plate tenodesis. Dorsolateral portal is the viewing portal. The medial collateral ligament and medial capsule is cut by scissors via the dorsomedial portals. The arthroscope is switched to the dorsomedial portal. The intact lateral part of the plantar plate is pierced by a straight-eyed needle loaded with a No. 1 PDS (polydioxanone) suture. The suture is retrieved at the plantar surface of the fibrous tendon sheath to the proximal incision along the lateral side of the metatarsal. The other limb of the suture is passed through the plantar plate again and retrieved to the proximal incision. The procedure is repeated with another No. 1 PDS suture. The sutures are sewed to the extensor tendon to the second toe to correct the toe deformity.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Correction of the crossover left second toe by arthroscopically assisted plantar plate tenodesis. Dorsolateral portal is the viewing portal. The medial collateral ligament and medial capsule is cut by scissors via the dorsomedial portals. The arthroscope is switched to the dorsomedial portal. The intact lateral part of the plantar plate is pierced by a straight-eyed needle loaded with a No. 1 PDS (polydioxanone) suture. The suture is retrieved at the plantar surface of the fibrous tendon sheath to the proximal incision along the lateral side of the metatarsal. The other limb of the suture is passed through the plantar plate again and retrieved to the proximal incision. The procedure is repeated with another No. 1 PDS suture. The sutures are sewed to the extensor tendon to the second toe to correct the toe deformity.