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The Podiatry Institute - Seminars, Surgery Courses, Board Date 12/29/2011 12:52:04 PM

Sep 03, 2020





    Kieran T. Maham, DPM

    Reprinted.from the Journal of the American Podiatric Medical Association Volunte 82, Number 5, May1992, pp, 264-268. Witb permission.


    The author presents a case report with a 1-yearfollow-up period demonstrating successful bonegraft stabilization of an iatrogenic flai1 second toe.The author discusses the techniques for calcanealautogenous bone grafting for reconstruction ofthe iatrogenic shofiened toe combined with ancil-lary proceclures to improve the digital length partern. After 18 months, this staged approach to sta-bilization of the digit and realignment of thedigital length pattern appears to be successful.


    Digital surgery is one of the most common surg-eries performed on the human foot. The compli-cation rate is relatively 1ow, and the surgery isgenerally predictable. Complications that canoccr'tr with digital surgery include infection, recur-rence of deformrty, dehiscence, prolongedswelling, circulatory embarrassment to the digit,and nerve entrapment or injury. An additionalcomplication that can occur is an unstable digit.Two examples of an unstable cligit are the floatingtoe and the flail toe.

    The floating toe syndrome was described byMcGlamry in 7982 as "...failure of the flexormechanism to function effectively".' The syn-drome is most commonly related to elevation ofthe metatarsal ray. Elevation of the ray preventsloading of the flexor mechanism, including the

    plantar fascia. The result is a toe that rides dorsal-ly, failing to purchase the ground during standingor walking. The floating toe may be structurallyintact, but the deformity is positional.

    Friend' described the floating toe syndromefrom base resection of the proximal phalanx. Hedescribed a case report with V-Y skin plasty, soft-tissue release, ancl partial metatarsal head resec-tion. Following excessive resection of the base ofthe proximal phalanx, the toe may be bothfloating and flail.

    A flail toe can be defined as one that lacksstability and structural integrity. Voluntary musclepower may be absent. Although the complicationis infrequent in digital surgery, it is nonethelessquite significant. The flail toe presents functionaland cosmetic considerations, as well as irritationwithin a shoe.

    The flail toe has received very little attentionin the literature. Lawton3 described excessivebone resection during digital afihroplasty proce-dures as a possible cause for flail toes. Thepatient with a flail toe will complain of the toecatching on stockings or shoes. The toe may foldback on or under itself. The cause of the flail toeis generally either excessive bone resection orresection or over-lengthening of the extensorsand flexors to the toe. Because the flail toe is usu-ally a short toe, it also will unload the flexors andextensors to the adfacent digits, which may causeadditional digital problems.



    A 43-year-old Caucasian female was referrecl tothe Foot & Ankle Institute with a chief complaintof a flail right second toe. She was concernedbecause the toe was riding up in shoes and caus-ing significant irritation. She was unable to wearmany types of shoes and was concerned aboutthe cosmetic appearance of the digit. Her historyfor this problem had begun 4 years previouslywith arthroplasty procedures on multiple digits ofboth feet. Her chief complaint at that time hadbeen milc1 hammertoe deformities. (Figure 1) Thedigital length pattern at that time dernonstratedlong toes with the second toe being slightlylonger than the hallux.

    Figure 1. Dorsoplantar radiograph of the rightfoot prior to any sulgical procedures.

    The initial sllrgery was unsllccessful andadditional surgical procedures were performed onmultiple digits 1 year later. Following this secondsurgery, there was a significant length discrepancybetx..een the second toe and the tip of the hallux.The seconcl toe extended out only to the inter-phalangeal joint of the hallux. The third toe atthat point n'as longer than the second toe, anclthe fourth toe became increasingly curled in aflexion deformity. One year later, an additionalarthroplasty procedure was performecl on the sec-ond toe, compounding the shortening. At the timeof her presentation to the Foot & Ankle Institute,

    Figure 2. The patient's right foot at the time of initial presentation.Note the trans\rerse crease in the second toe and the lack of toepulchase.

    Figure 3. Dorsoplantar radiograph of right footat the tjme of initial presentation. Note thesevere shortening of the second toe comparedto the length pattern in Figure 1.

    the second toe was riding dorsally in the sagittalplane and was unstable. (Figures 2, 3)

    The patient's medical history was significantfor an asymptomatic mitral valve prolapse. Hersr-rrgical history included a tonsillectomy, hysterec-tomy, dental surgeries, and four foot surgeries.These had all been tolerated well. At the time ofpresentation she was not taking any medicationsand denied any allergies. Musculoskeletal exami-nation revealed the digital length pattern to beseverely disturbed, rvith the hallux being much


  • longer than the remaining lesser digits. The sec-ond toe was significantly shorter than the first andthird toes. The second toe was unstable and dis-placed dorsally in the sagittal plane at the level ofthe proximal interphalangeal joint. There was novoluntary muscle control to the second toe. A hal-lux abductus interphalangeous deformity was alsonoted to be present. The remaining toes had nor-mal active flexion and extension. A11 musclegroups u,ere +5/5. Neurologic evaluation revealeda severe decrease in sensation to the second toe,with a more minor decrease in light touch to thefourth toe. The remainder of the neurologic examwas normal.

    The dermatologic exam demonstrated asmall heloma durum on the lateral side of thefourth toe. The second toe demonstrated linearand transverse scars with atrophic dorsal skin.The vascular examination demonstrated strongdorsalis pedis and posterior tibial pulses. The cap-i1lary refill was immediate to the hallux and 4 to 5seconds for the second toe.

    The right foot repair was performed in astaged sequence in order to decrease the risk ofcirculatory embarrassment to the second toe. Thesecond toe skin was thin and scarred as a resultof the four prior surgeries. The decision to stagewas made to avoid performing surgery on thesecond toe and on both sides of the second toe atthe same time. The initial stage was a bone graftlengthening from the calcaneus to the second toeand an arthroplasty of the fourth toe with a dero-tation skin wedge. The second toe wasapproached through the previons linear incision.The subcutaneous tissue was particularly thin.The scarred extensor tendon was lengthened bymeans of an open Z-plasty to expose the proxi-mal phalanx and the middle phalanx. The longflexor tendon to the second toe had been disrupt-ed during prior surgeries. The plantar scar tissuewas incised in order to allow for lengthening ofthe digit. The distal end of the proximal phalanxwas remodeled until at1 area of healthy bleedingbone was obserwed. The base of the middle pha-lanx was also remodeled until raw, bleeding bonewas observed. This served to remove scleroticbone and present two heaithy bone surfaces. Italso served to increase the shortening of the toe.

    A corticocancellous graft was procured fromthe posterior superior aspect of the ipsilateral ca1-caneus. (Figure 4) The approach for procuring the

    graft as it is being removed from the calcaneus.

    Figure J. Dorsoplantar radiograph of right foot immediately postop-erative. Note Kirschner wire fixatioo and the xmount of bone resected fiom the second toe base of the proximal phalanx,

    calcaneal bone graft was through a lateral incisionwith careful attention being paid to insure protec-tion of the sural nelve. The graft was pre-dri11edwith a .035 K-wire. The graft was trimmed to alength of 18 mm and a width of 5 mm. A .045K-wire was then retrograded out through the endof the toe and drillecl from distal to proximalthrough the distal and middle phalanges, andthrough the bone graft, and through the remain-ing base of the proximal phalanx into the secondmetatarsai. (Figure 5)

    Following completion of the second toe cor-rection, an oblique skin wedge was removedfrom the fourth toe to provide correction for theadducto varus deformity, as well as to provideexposure to the middle phalanx which wasremodeled. The procedures were performedunder thigh tourniquet hemostasis. At the conclu-sion of the procedure, immediate capillary refill


    ^{fFigure 4. Bone


  • occurred to all the digits except the second,which refilled within 5 min. A below the kneecast was applied, and the patient u,,as allowed towalk non-weight bearing with crutches. At Bweeks postoperatively, the pin was removedwhen consolidation was noted at the proximal

    Figure 6. Oblique radiograph of right foot at 8weeks postoperatively.

    and distal graft host junctions. (Figure 6) fhepatient was allowed partial weight bearing in acast for 2 weeks. The cast was removed at 10weeks, and the patient was given a surgical shoeand allowed partial weight bearing for 1additional week in an elastic wrap and thenallowed full weight bearing for 2 weeks. By 3months, there were good consolidation and stabil-ity along the graft, and by 5 months, excellentremodeling had occurred.

    Seven months after the initial surgery, thesecond stage was performed. A modified McBridebunionectomy and shortening Akin osteotomy ofthe right hal1ux were performed, as well as anarthroplasty of the third toe. The procedures wereperformed under ankle tourniquet. A truncatedwedge was removed from the proximal phalanxof the hallux in order to correct the hallux abduc-tus interphalangeous and shorten the halluxenough to create a more normal digital lengthpattern. Fixation was achieved with a percuta-neous .045 Kirschner wire and a 2.7-mm cortical

    screw. Attention was directed to the third toe,which was remodeled at the proximal interpha-langeal joint and stabilized with a .045 K-wire.The patient was given a surgical shoe andinstructed to remain non-weight bearing oncrutches. At 4 weeks postoperatively, the pinswere removed and the patient was returned topartial weight bearing for 1 week, followed byfull weight bearing in a surgical shoe.

    At 10 months postoperatively, following thefirst stage of the surgery, and 3 months postopera-tively, following the second surgery, the patientwas pleased with both the cosmetic and function-al results. (Figures 7, B) The patient was able towear all types of footgear and she was pleasedwith the digital length pattern. Approximately 1year following the first surgery, similar procedureswere performed on the left foot. Because the sec-ond toe on the left foot did not have the samedegree of soft tissue atrophy, a1l the procedureswere performed at one time. The patient is now18 months postoperative foilowing her originaisurgery on her right foot and is walking comfort-ably. AII of her osteotomy and bone graft sites arewell healed.


    The treatment of a fl.all toe can be difficult. Inorder to create stability in an unstable toe, the pri-mary alternatives are implant arthroplasty, syndac-tiTization to an adjacent toe,4 and bone graft stabi-lization. Amputation of the digit is an option thatsome of these patients would be more thanhnppy to consider because of the pain, disabilityand nuisance associated with this deformity. Inthis particular case, implant arthroplasty was dis-carded as a surgical option because of the poorquality of the soft tissues, and as the questionablevitality of the bone stock. Syndactilizalion was analternative that the patient refused to consider.The syndactllization would have provided someincreased stability to the toe, but would not haveachieved complete stability, nor would it haverestored the digital length pattern.

    A bone graft repair for this type of deformitymust be considered to be an extraordinary mea-sure. The graft-host interface is sma1l in this area,particularly for such a long bone graft as wasrequired in this case. Debridement of necroticbone is mandatory to provide a good bed for the


  • Figure 7A.. Radiograph of right foot at 10months postopel':1tilel,v. Dorsoplantar \.ie\\rdenonstrating digital length pettern rc-alignmentand consolidation of second toe bone graft,

    Figure 8. Photograph of right foot at 10 monthspostoperativelY.

    bone graft. The use of autogenous bone isimportant in order to improve the chancessuccessful take. A variety of sources can befor an autogenous bone graft. The hip, fibulatibia have all lreen suggested.5 The calcaneusexcellent source for smal1 bone grafts such as

    Figure 78. Oblique view of right foot at 10lnonths postoperatiYe.

    The quality of the bone is good. It provides astrong cofiical surface with outstancling cancellousbone. The cortical surface is not circumferential,btrt it cloes span approximzrtely 30o/o to 40% of thecircumference. The cortical surface is placed onthe dorsal side of the toe in orcler to maintainstability.

    Complications from calcaneal bone grafts areinfrequent and certainly are less than the docu-mented complication rates frorn the procurelnentof iliac crest bone grafts.o Because the calcaneusis vascular, a hematoma may develop after pro-curement of an autogenolls calcaneal bone graft.The risk of this can be minimized by three tech-niques: application of bone wax to the raw can-cellous bone, use of a closed suction drain, orpacking of the defect with freeze-dried allogeneiccorticocancellous chips. Each of these techniquesseems to be effective, as hematomzr has not beena problem in the author's series of calcaneal bonegrafts.

    The reconstruction was staged in order todecrease the chances of circulatory embarrass-ment. Four prior surgeries had resulted in a thinlayer of superficial fascia in the second toe.Lengthening procedures can also place a digit atrisk for ischemia. The sr,rbsequent surgeries on thethird and first toes might have placed the secondtoe at risk by decreasing cutaneous blood supply


    is anthis.


  • from lateral to the second toe and by riskinginjury to the metatarsal artery medial to the sec-ond toe.


    Bone grafting is one treatment for stabilization ofa flail toe. As a treatment choice, it must beweighed carefully against the possible disadvan-tages of circulatory embarrassment caused byoverlengthening of the toe, and the possibility offailure of the bone graft. A patient who has

    multiple surgeries on the digit shouldthat additional surgery may cause loss


    already hadbe advisedof the toe.





    McGlamry ED: Floatingl toe syndrome. J Am Pod Assoc 72:567-568, 1982.Friend G: Correction of iatrogenic floatingi toe follow:ing resec-tion of the base of the proximal phalanx. Clin Podiatr MedSttrg 3:57 -64, 7986.Lar.ton JH: "Forefoot Surgely" in Marcus SA, Block BH. Cctm-plications in Foot SulEery. 2nd edition, pp 156-120, williamsantl Wilkins. Beltimorc 1984.Bernbach E: A surg;ical procedure to syndactilize. J Am Pctd MedAssoc 16:147 157, 7L)i6.Mahan KT: "Bone Grafting". In McGlamry ED (ec1), Comprebensiue Textbook of Foot Surgery1 Vol II, pp 616 667. \(illiams andWilkins, Baltimore, 1!87.Younger EM, Chapman M$(i: Morbidity at bone graft donorsttes. J Oilhop Trauma, 3:792-195, 7989.


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