Metatarsophalangeal Joint Pathology in Crossover Second Toe Deformity: A Cadaveric Study

Abstract

Background: Ligamentous and capsular insufficiency of the second metatarsophalangeal joint has been surgically treated for over two decades, mainly with indirect surgical repairs, which stabilize adjacent soft tissue and shorten or decompress the osseous structures. While ligamentous insufficiency has been described and recognized, degeneration of the plantar plate and tears of the capsule have rarely been documented. The purpose of this study was to document and describe the presence and pattern of plantar plate tears in specimens with crossover second toe deformities, and based on this, to develop an anatomical grading system to assist in the assessment and treatment of this condition. Methods: Sixteen below-knee cadaveric specimens with a clinical diagnosis of a second crossover toe deformity were examined, and dissected by removing the metatarsal head. The pathologic findings of plantar plate and capsular pathology, as well as ligamentous disruption, were observed and recorded. Demographics of the specimens were recorded, and simulated weightbearing radiographs were obtained prior to dissection so that pertinent angular measurements could be obtained. Results: Demographics demonstrated a high percentage of female specimens, and a typically older population that has been reported for this condition. Radiographic findings documented a high percentage of hallux valgus and hallux rigidus deformities. The MTP-2 and MTP-3 angles were divergent consistent with a crossover toe deformity. We consistently found transverse tears in the plantar plate region immediately proximal to the capsular insertion on the base of the proximal phalanx. With increasing deformity, wider distal transverse tears extending from lateral to medial were found. Midsubstance tears, collateral ligament tears, and complete disruption of the plantar plate were found in more severe deformities. Conclusion: In this largest series of cadaveric dissections of crossover second toe deformities, we describe the types and extent of plantar plate tears associated with increasing deformity of the second ray. We present, based on these findings, an anatomic grading system to describe the progressive anatomic changes in the plantar plate.

Keywords

Crossover Second Toe Plantar Plate Tear Instability Second Toe Hammertoe

Get full access to this article

View all access options for this article.

References

1. Barca

Acciaro

: A Surgical correction of crossover toe deformity of the second toe: a technique of tenodesis. Foot Ankle Int. 25:620–624, 2004.

2. Bhatia

Myerson

Curtis

: Anatomical restraints to dislocation of the second metatarsophalangeal joint and assessment of repair technique. J Bone Joint Surg. Am. 76:1371–1375, 1994.

3. Blitz

Ford

Christensen

: Second metatarsophalangeal joint arthrography: a cadaveric correlation study. J Foot Ankle Surg. 43:231–240, 2004. https://dx-doi-org.web.bisu.edu.cn/10.1053/j.jfas.2004.05.009

4. Blitz

Ford

Christensen

: Plantar plate repair of the second metatarsophalangeal joint: technique and tips. J Foot Ankle Surg. 43:266–270, 2004. https://dx-doi-org.web.bisu.edu.cn/10.1053/j.jfas.2004.05.011

5. Bouche

Heit

: Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. J Foot Ankle Surg. 47:125–137, 2008. https://dx-doi-org.web.bisu.edu.cn/10.1053/j.jfas.2007.12.008

6. Cooper

Coughlin

: Sequential dissection for exposure of the second metatarsophalangeal joint. Foot Ankle Int. 32:294–299, 2011. https://dx-doi-org.web.bisu.edu.cn/10.3113/FAI.2011.0294

7. Coughlin

Saltzman

Nunley

: Angular measurements in the evaluation of hallux valgus: A report of the ad hoc committee of the American Orthopedic Foot and Ankle Society on Angular Measurements. Foot Ankle Int. 23:68–74, 2002.

8. Coughlin

: When to suspect crossover second toe deformity. J. Musculoskeletal Med. 39–48, 1987.

9. Coughlin

: Crossover second toe deformity. Foot Ankle Int. 8:29–39, 1987.

10.

10. Coughlin

: Subluxation and dislocation of the second metatarsophalangeal joint. Orthop Clinics of North Am. 20:539–551, 1989.

11.

11. Coughlin

Shurnas

: Hallux Rigidus; demographics, etiology and radiographic assessment. Foot Ankle Int. 24:731–743, 2003.

12.

12. Coughlin

Jones

: Hallux Valgus; demographics, etiology and radiographic assessment. Foot Ankle Int. 28:759–777, 2007. https://dx-doi-org.web.bisu.edu.cn/10.3113/FAI.2007.0759

13.

13. Coughlin

: Second Metatarsophalangeal instability in the athlete. Foot Ankle Int. 14:309–319, 1993.

14.

14. Coughlin

: Lesser toe deformities. Surgery of the Foot and Ankle 8th Edition. Editors; Coughlin

Mann

Saltzman

: Mosby Elsevier

Philadelphia

1:363–464, 2007.

15.

15. Daly

Johnson

: Treatment of painful subluxation of the second and third metatarsophalangeal joints by partial proximal phalanx excision and subtotal webbing. Clin. Orthop Relat Res. 278:164, 1992.

16.

16. Deland

Lee

Sobel

DiCarlo

: Anatomy of the plantar plate and its attachments in the lesser metatarsophalangeal joint. Foot Ankle Int. 16:480–486, 1995.

17.

17. Deland

Sung

: The medial crossover toe: a cadaveric dissection. Foot Ankle Int. 21:375–378, 2000.

18.

18. Ford

Collins

Christensen

: Stabilization of the subluxed second metatarsophalangeal joint: flexor tendon transfer versus primary repair of the plantar plate. J Foot Ankle Surg. 37:217–222, 1998. https://dx-doi-org.web.bisu.edu.cn/10.1016/S1067-2516(98)80114-2

19.

19. Gazdag

Cracchiolo

: Surgical treatment of patients with painful instability of the second metatarsophalangeal joint. Foot Ankle Int. 19:137–143, 1998.

20.

20. Golano

Villadot

Alvarez

Coughlin

Grimes

: Static loading of foot structures for radiographic studies. Foot Ankle Int. 27:559–560, 2006.

21.

21. Grebbing

Coughlin

: Evaluation of Morton's theory of second metatarsal hypertrophy J Bone Joint Surgery. 86A:1375–1385, 2004.

22.

22. Gregg

Silberstein

Clark

Schneider

: Plantar plate repair and Weil Osteotomy for metatarsophalangeal joint instability. Foot and Ankle Surg. 13(3): 116–121, 2007. https://dx-doi-org.web.bisu.edu.cn/10.1016/j.fas.2007.01.001

23.

23. Haddad

Sabbagh

Resch

Myerson

: Results of flexor-to-extensor and extensor brevis tendon transfer for correction of the crossover second toe deformity. Foot Ankle Int. 20:781–788, 1999.

24.

24. Johnson

Price

: Crossover second toe deformity: etiology and treatment. J Foot Surg. 28:417–420, 1989.

25.

25. Johnston

Smith

Daniels

: The plantar plate of the lesser toes: an anatomical study in human cadavers. Foot Ankle Int. 15:276–282, 1994.

26.

26. Karpman

MacCollum

: Arthrography of the metatarsophalangeal joint. Foot Ankle Int. 9:125–129, 1988.

27.

27. Kaz

Coughlin

: Crossover second toe: demographics, etiology and radiographic assessment. Foot Ankle Int. 1223–1237, 2007. https://dx-doi-org.web.bisu.edu.cn/10.3113/FAI.2007.1223

28.

28. Mann

Mizel

: Monoarticular nontraumatic synovitis of the metatarsophalangeal joint: a new diagnosis? Foot Ankle Int. 6:18–21, 1985.

29.

29. Mendidino

Statler

Saltrick

Catanzariti

: Predislocation syndrome: a review and retrospective analysis of eight patients. J Foot ankle Surg. 40:214–224, 2001. https://dx-doi-org.web.bisu.edu.cn/10.1016/S1067-2516(01)80021-1

30.

30. Myerson

Jung

: The role of toe flexor-to-extensor transfer in correcting metatarsophalangeal joint instability of the second toe. Foot Ankle Int. 29:675–679, 2005.

31.

31. Powless

Elze

: Metatarsophalangeal joint capsular tears; an analysis by arthrography, a new classification system and surgical management. J Foot Ankle Surg. 40:374–389, 2001. https://dx-doi-org.web.bisu.edu.cn/10.1016/S1067-2516(01)80005-3

32.

32. Sarrafian

: Anatomy of the Foot and Ankle. JB Lippincott, Philadelphia. 207–211, 1993.

33.

33. Thompson

Hamilton

: Problems of the second metatarsophalangeal joint. Orthopedics. 10:83–89, 1987.

34.

34. Trnka

Liehbauer

Zetti

Myerson

Ritschler

: Comparison of the results of the Weil and Helal osteotomies for the treatment of metatarsalgia secondary to dislocation of the lesser metatarsophalangeal joints. Foot Ankle Int. 20:72–79, 1999.

35.

35. Thompson

Deland

: Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle Int. 14:385–388, 1993.

36.

36. Umans

Elsinger

: The plantar plate of the lesser metatarsophalangeal joints; potential for injury and role of MR imaging. Margn. Reson. Imaging Clin. N Am 9:659–669, 2001.

37.

37. Yao

Cracchiolo

Farahani

Seeger

: Magnetic resonance imaging of plantar plate rupture. Foot Ankle Int. 17:33–36, 1996.

38.

38. Yao

Cracchiolo

Farahani

: Plantar plate of the foot: findings on conventional arthrography and MR imaging. Am J. Roentgenol 163:641–644, 1994.

39.

39. Yu

Judge

Hudson

Seidelmann

: Predislocation syndrome. Progressive subluxation/dislocation of the lesser metatrsophalangeal joint. J. Am. Podiatr. Med Assoc. 92:182–199, 2002.