Early Diagnosis subluxation Coughlin,M. The Crossover toe Foot - - PowerPoint PPT Presentation

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Instability of the lesser MTP joints

(Crossover 2nd toe deformity)

• my 25 year journey-

Michael J Coughlin, M.D.

Conflicts of interest

• Arthrex- consultant
• Arthrex- royalties
• Elsevier-book royalties

Early Diagnosis

Coughlin,M. The Crossover toe Foot Ankle Int 1987

Progressive MTP joint subluxation

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Surgery

• 1987-2011-

Soft tissue balancing

• Extensor

tenotomy, lengthening

• Medial/dorsal

capsulotomy

Capsular reefing

Coughlin, M.J.: When to suspect crossover second toe

• deformity. J. Musculoskeletal Medicine 1987.

Flexor Tendon Transfer

1 2 3 4

MEDIOCRE RESULTS

Partial proximal phalangectomy Metatarsal condylectomy Akin-ette MTP joint arthrodesis Amputation Metatarsal osteotomy

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All of these treatments

• Never really treated the

problem!

• Indirect repairs
• Never saw the pathology
• (the plantar plate tear)

Grading and Staging (Barcelona-2011)

• 8 fellows-
• saved 12 specimens over 7 years-

PUBLISHED: Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study. Foot Ankle Int. 33:133-140, 2012

Grade 1

transverse tear < 50%

Removed met. head

Grade 2

Transverse distal > 50%

GRADE 2

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Grade 3

Transverse and longitudinal, extensive

GRADE 3 Phalanx

Grade 4

no repairable capsule

FDL

GRADE 4 FATPAD

PHALANX

We then devised a clinical staging system

• To help us

with our clinical examination

Stage 1

• Mild MTP joint

malalignment

• Plantar MTP joint pain
• Swelling MTP joint (plantar)
• Mild + drawer (subluxable,

<50%)

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Physical Examination Positive Drawer Physical Examination Positive Drawer

• Pathopneumonic

Stage 2

• Moderate malalignment
• Reduced swelling??
• No toe purchase
• ++ positive drawer

Stage 3

• Severe malaligment
• Plantar MTP joint

pain

• Little swelling
• Very positive drawer

–Can dislocate

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Stage 4

• Very severe deformity
• Dislocation
• Fixed hammertoe
• Little or no swelling
• ? Painless drawer

Began defining the extent of the plantar plate tear

We then developed a technique to expose and repair the plantar plate Weil osteotomy

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Incision

Direct dorsal interspace incision

Multiple joints? Neuroma present? Unsure of the diagnosis?

Deepening the incision

Versatile exposure Extensor brevis is available for transfer later

Proximal capsular release

Yes- we routinely release the proximal capsule Does it destroy the circulation to the metatarsal head? NO It does give 2-3 mm. more expansion of the joint

Base of proximal phalanx Met head Plantar Plate McGlamry Plantar blood supply Proximal synovial attachment

Courtesy of LS Weil, Jr.. DPM

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Proximal translation of the Weil

Distraction and visualization

Medial and lateral collateral ligament release

Releasing the plantar plate

So it is completely released!!

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Example

Exposing the tear

Free it up from the base of the proximal phalanx, and the flexor tendon

Plantar plate takedown

Passing the sutures

• Try the two different types
• f Micro-scorpion

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Scorpion suture #1 Scorpion suture #2 Suture number Suture pattern

• 8. Exposing the base of the

proximal phalanx

Towel clip on the phalanx, and twist downward

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Exposing the base of the proximal phalanx Fixing the Weil Tying the sutures

Plantar flex the PP 20 degrees Cartilage against cartilage Neutral deviation

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Prospective study

• Two year study
• 100 patients
• Improved stability
• Marked resolution of pain
• Coughlin, M.J.: Lesser toe deformities. Orthopaedics 10(1):63-75,

1987.

• Coughlin, M.J.: Crossover second toe deformity. Foot & Ankle 8:29-

39, 1987.

• Coughlin, M.J.: When to suspect crossover second toe deformity. J.

Musculoskeletal Medicine 39-48, 1987.

• Coughlin, M.J. Schenck, Jr., R.C., Shurnas, P.J.., Bloome,D.M.

Concurrent interdigital neuroma and MTP joint instability: long-term results of treatment. Foot and Ankle Int. 23:1018-1025, 2002.

• Coughlin, M.J.: Subluxation and dislocation of the second

metatarsophalangeal joint. Ortho. Clinics of North America 20(4):535-551, 1989.

• Coughlin, M.J.: Second metatarsophalangeal joint instability in the
• athlete. Foot & Ankle 14(6):309-319, 1993.
• Coughlin M. Lesser toe abnormalities. AAOS Instructional Course
• Lectures. 52:421-444, 2003
• Coughlin M, Grimes, J.S. Geometric Analysis of the Weil Osteotomy.

Foot Ankle Int. 27:985-992, 2006

• Kaz A, Coughlin M. Crossover second toe: demographics, etiology

and radiographic assessment. Foot Ankle Int. 1221-1237, 2007

• Nery C, Coughlin M. Arthroscopy and MRI evaluation of second MTP

joint capsular insufficiety. Submitted to FAI-May 2012

• Nery C, Coughlin M, Baumfeld D. Second MTP joint instability:

grading of the deformity and description of surgical repair of capsular

• insufficiency. FAI – April 2012
• Coughlin M, Schutt S, Hirose,C, Kennedy M, Grebing B, Smith B,

Cooper T, Golano P Viladot R, Alvarez F. Metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study. Foot Ankle Int. 33:133-140, 2012

• Nery C, Coughlin M, Baumfield D, Mann, T. Instabilidade das

articuladoes metatarsofalagicas e lesoes da plcas plantares: estudo clinico e morfologicl. Journal of the Brazilian Foot and Ankle Society 5:63-72, 2011

• Second MTP Joint Instability: Grading of the Deformity and

Description of Surgical Repair of Capsular Insufficiency., Coughlin M,Baumfield D,Nery . Physician and Sports Medicine, 39:132-141, 2011