2nd toe drift

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Today,I was seen by a 68 year old diabetic.About 3 years ago,she underwent a bunionectomy R foot.Since then,she has been getting pain in the great toe.That is not my issue.As I evaluated her,I saw that her 2nd toe cannot purchase the ground and that it is drifting laterally.The surgeon seemed to correct the bunion nicelyas there is no hallux varus.I did not do the surgery,so it goes without saying that I do not know what it looked like prior to this.(I believethat she isplanning a suit against the surgeon.)I have a few questions:
1. Does anyone have a guess as to what can cause a lateral drift?I believe that with a correction of a bunion,one would get a medial drift of the 2nd toe.Correct me if I am wrong on this.
2.Samewith the dorsiflexion of the 2nd MPJ.I am GUESSING that an intinsic muscle was severed here,possibly the 1st dorsal interosseous.
3.Can this just be a case of the diabetic intrinsic minus type foot with contractures?
4.If I were dumb enough to do surgery(again,I am not planning to do it,this is just as an academic exercise),what can be done here?

 

John

The lateral drift is likely due to rupture or attenuation of the medial side of the 2nd MTP plantar plate. This is common in diabetic patients as the intrinsics fail and the plantar plate stretches out.

It is impossible to know if over-aggressive IM space dissection was the cause, or it was a spontaneous rupture.

To fix it would be a combination of delayed primary repair of the plantar plate +/- 2nd PIPJ arthrodesis, I would think.

Hope this helps,

LL

 

Is see this often after bunion surgery. The 2nd toe can go laterally or medially (crossover deformity) and is due to exessive shortening of the 1st metatarsal resulting in the 2nd toe and 2nd metatarsal becoming a fulcrom at push off and not from any mistep in surgical dissection, just a wrong choice of which procedure was used and/or which fixation was employed. I have also seen this happen when the distal fragment impacts back onto the proximal fragment with an Austin osteotomy associated with soft osteoporotic bone. If a first metatarsal is already short one must be very cautious as to which osteotomy to use and how it is fixated to prevent further shortening. The only solution now (other than lengthening the 1st metatarsal which is very difficult) is to shorten the 2nd metatarsal and arthodesis of the 2nd toe with a soft tissue rebalancing of the 2nd MTPJ. This is best done by a Weil osteotomy. I have not found it necessary to do a primary repair of a torn plantar plate since when one shortens the metatarsal the deforming forces are relieved enough to place the toe back on the weight bearing surface.

 

I agree with Rhines on this one. The Weil decompression osteotomy along with the PIPJ fusion seems to work the best with these patients. A flexor tendon transfer seem to be in order as well. Postoperatively, they do quite well.