12/14/2013    Barry Mullen, DPM

Floating Toe

The hallux doesn't appear to have drifted far
enough laterally to grossly interfere with the 2nd
toe. If this is clinically true, and no pain
exists about the 1st MTP, I advise leaving the 1st
ray alone. The last thing you need is to consider
additional surgery on a different ray that is
asymptomatic.

On the other hand, if the 1st MTP is symptomatic,
a distal 1st metatarsal osteotomy w/ PASA
correction if needed, and lateral release of the
fibular sesamoid and medial capsuloraphy should be
sufficient. If not, an Akin osteotomy of the
hallux can also be utilized. Successful
replacement of the 2nd digit in a more
plantarflexed position should halt further
abduction of the hallux, so less is more with
respect to 1st ray consideration.

As for the 2nd toe, plantar replacement is
critical and likely best accomplished with a
complete plantar plate repair. Though Weil
originally described this procedure w/ inclusion
of his 2nd metatarsal osteotomy, this technique
can also be performed following metatarsal head
resection. Any dorsal soft tissue contraction
should be released. If the hypertrophic dorsal
scar is also deemed a significant deforming force
of the 2nd toe extensus, this can be resolved with
either a V to Y, or Z skinplasty pending the
extent of dorsal skin contraction (z allows for
greater correction).

Another option, though I believe inferior to the
complete plantar plate repair, is a Girdlestone
procedure. Splitting the 2nd FDL and wrapping it
over the proximal phalangeal head and anchoring it
upon itself with the 2nd toe help in corrected
position has worked for floating toes. Like the
CPR, dorsal soft tissue and skin contracture
likely needs to be addressed. However, in this
particular case, it's inferior to the CPR because
it addresses contraction at the PIPJ, while the
current deformity is located more proximally at
the MTP, which CPR certainly addresses. Hope this
helps.

Barry Mullen, DPM, Hackettstown, NJ,
yazy630@aol.com

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