03/16/2017    Jeff Kittay, DPM

The Crossover Second Toe Deformity

In 1980, I took over a palliative care practice
from an older retiring DPM in Boston and began
to introduce surgery into the services offered.
Patients were at first resistant but gradually
some were convinced that they did not have to
suffer any longer with their painful
deformities and permitted me to make repairs.

One problem that I remember vividly involved a
crossover 2nd toe with severe hallux valgus.
The bunion was asymptomatic and the patient's
chief complaint was the chronic painful
keratoma at the dorsum of the 2nd toe PIPJ.
The hallux was deviated so far laterally that I
knew that it would be difficult to bring the
2nd toe down, even with an aggressive PIPJ
arthroplasty, and this was discussed with the
patient.

Try as I might to convince her to let me repair
the bunion as well in order to create some
space for the 2nd toe, she was adamant that she
only wanted the 2nd toe fixed. As I had been in
practice approximately 18 months at that point,
I made the mistake many of us have, I let the
patient decide the treatment rather than the
other way around.

I performed my PIPJ arthroplasty aggressively,
released all soft tissue around the stump of
the proximal phalanx down to the level of the
MPJ, and cranked the toe plantarly with my
bandaging. All went well, no infection,
minimal pain and swelling post-op, sutures
removed two weeks post-op, and the toe was kept
in neutral/plantar-flexion via bandaging for
six weeks.

As you may have guessed, after 60+ years of
digital deformity, that toe simply wanted to be
where it had always been, and gradually
returned to a partial overlapping position.
Though the painful lesion was gone and the toe
asymptomatic, the patient was very unhappy with
the cosmetic result. That this possibility had
been thoroughly explained to her pre-
operatively was irrelevant at that point.
She left the practice permanently and never
referred a single patient to me.

My points are: 1. There is no one-size-fits-all
treatment for overlapping second toes, 2.
Regardless of patient wishes, sometimes the
more aggressive procedure(s) are appropriate. I
fixed the problem, got rid of the lesion, and
lost a patient who might have been a valuable
referral source if I had stuck to my guns. If
patients will not go along with your
recommendations for surgery, have them get a
second opinion to confirm yours, otherwise
please refer them out to an orthopod you don’t
like.

Jeff Kittay, DPM (retired)
San Rafael Norte, Costa Rica

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