Hammertoes pp 265-286 | Cite as

Lesser MTPJ Reconstruction

  • Emily A. CookEmail author
  • Jeremy J. Cook
  • Robin Cook


Digital deformities have been long associated metatarsophalangeal joint (MTPJ) pathology. Traditional rebalancing techniques, which include sequential joint releases and capsulorrhaphies, are commonly performed in conjunction with complex hammertoe and lesser metatarsal osteotomy procedures involving MTPJ contractures. Decades of clinical outcomes have clearly demonstrated that floating toes, digital instability, and malalignment are potential undesired outcomes.

In recent years, the known influence of the plantar plate on digital stability has become increasingly critical. A growing body of evidence suggests that the collateral ligaments also contribute to digital stability, particularly in regard to transverse plane deformities. A myopic surgical approach that solely focuses on the plantar plate without addressing the collateral ligaments will ultimately increase the risk of suboptimal outcomes.

This chapter specifically focuses on the technical details related to MTPJ repair in the context of a crossover toe deformity. This technique involves rebalancing both the accessory and proper medial and lateral collateral ligaments in addition to an insufficient or torn plantar plate. We highly recommend that this technique is combined with metatarsal osteotomies and hammertoe procedures where appropriate, but these additional techniques are covered in great detail in other chapters of this book.


Collateral ligaments Hammertoe syndrome Metatarsophalangeal joint Plantar plate Crossover toes 


  1. 1.
    Barbari SC, Brevig K. Correction of clawtoes by the Girdlestone-Taylor flexor-extensor transfer. Foot Ankle. 1984;5:67–73.CrossRefGoogle Scholar
  2. 2.
    Femino JE, Mueller K. Complications of lesser toe surgery. Clin Orthop Relat Res. 2001;391:72–88.CrossRefGoogle Scholar
  3. 3.
    Dhukaram V, Hossain S, Sampath J, Barrie JL. Correction of hammertoe with an extended release of the metatarsophalangeal joint. J Bone Joint Surg Br. 2002;84:986–90.CrossRefGoogle Scholar
  4. 4.
    Hofstaetter SG, Hoffstaetter JG. The Weil osteotomy: a 7 year follow up. J Bone Joint Surg Br. 2005;87:1507–11.CrossRefGoogle Scholar
  5. 5.
    Migues A, Slullitel G, Bilbae F. Floating toe deformity as a complication of the Weil osteotomy. Foot Ankle Int. 2004;25:609–13.CrossRefGoogle Scholar
  6. 6.
    Beech I, Rees S, Tagoe MJ. A retrospective review of the Weil osteotomy for lesser metatarsal deformities: an intermediate follow-up analysis. Foot Ankle Surg. 2005;44:358–64.CrossRefGoogle Scholar
  7. 7.
    Suero EM, Meyers KN, Bohne WH. Stability of the metatarsophalangeal joint of the lesser toes; a cadaveric study. J Orthop Res. 2012;30:1995–8.CrossRefGoogle Scholar
  8. 8.
    Deland JT, Lobel M, Arnockzky SP, Thompson FM. Collateral ligament reconstruction of the unstable metatarsophalangeal joint: an in vitro study. Foot Ankle Int. 1994;13:391–5.CrossRefGoogle Scholar
  9. 9.
    Bhatia D, Myerson MS, Curtis MJ, Cunningham BW. Anatomical restraints to dislocation of the second metatarsophalangeal joint. J Bone Joint Surg Am. 1994;76A:1371–5.CrossRefGoogle Scholar
  10. 10.
    Hannan MT, Menz HB Jordan JM, Cupples LA, Cheng C, Hsu Y. High heritability of hallux valgus and lesser toe deformities in adult men and women. Arthritis Care Res. 2013;65(9):1515–21.CrossRefGoogle Scholar
  11. 11.
    Yu GV, Judge MS, Hudson JR, Seidelmann FE. Predislocation syndrome. progressive subluxation/dislocation of the lesser metatarsophalangeal joint. J Am Podiatry Med Assoc. 2002;92(4):182–99.CrossRefGoogle Scholar
  12. 12.
    Coughlin MJ. Second metatarsophalangeal joint instability in the athlete. Foot Ankle. 1993;14:309–19.CrossRefGoogle Scholar
  13. 13.
    Menz HB, Zammit GV, Munteanu SE, Scott G. Plantarflexion strength of the toes: age and gender differences and evaluation of a clinical screening test. Foot Ankle Int. 2006;27(12):1103–8.CrossRefGoogle Scholar
  14. 14.
    Cook JJ, Johnson LJ, Cook EA. Anatomic reconstruction versus traditional rebalancing in lesser metatarsophalangeal joint reconstruction. J Foot Ankle Surg. 2018;57:509.CrossRefGoogle Scholar
  15. 15.
    Weil L Jr, Sung W, Weil LS Sr, Malinoski K. Anatomic plantar plate repair using the Weil metatarsal osteotomy approach. Foot Ankle Spec. 2011;4(3):145–50.CrossRefGoogle Scholar
  16. 16.
    Flint WW, Macias DM, Jastifer JR, Doty JF, Hirose CB, Coughlin MJ. Plantar plate repair for lesser MTP joint instability. Foot Ankle Int. 2017;38(3):234–42.CrossRefGoogle Scholar
  17. 17.
    Bouche RT, Heit EJ. 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. 2008;47:125–37.CrossRefGoogle Scholar
  18. 18.
    Roukis TS, Ringstrom JB. Lesser metatarsophalangeal release utilizing the #66 mini-blade. J Foot Ankle Surg. 1999;38(2):163–5.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Harvard Medical School, Division of Podiatry, Department of SurgeryMount Auburn HospitalCambridgeUSA

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