Results of flexor-to-extensor and extensor brevis tendon transfer for correction of the crossover second toe deformity

Abstract

Between 1990 and 1995, 38 patients (42 feet) underwent repair for crossover toe deformity, 31 (35 feet) of whom returned for final examination at an average of 51.6 months (range, 24-81 months). Causes included trauma, iatrogenic, and unknown. Presenting complaints included dorsal pain with either metatarsalgia or joint pain, isolated metatarsophalangeal (MP) joint pain, metatarsalgia, painful plantar callus, metatarsalgia and joint pain, and painful dorsal callus. All patients were treated with one of two operative techniques, either the flexor-to-extensor tendon transfer or the extensor brevis tendon transfer. Choice of procedure depended on the stage of preoperative deformity. Twenty-four patients were completely satisfied with the surgical correction, 6 were satisfied with reservations, and 1 was dissatisfied. The average postoperative AOFAS score for all patients was 85 points (range, 54-100 points), which correlated strongly with patient satisfaction. Twenty-two patients stated that they had no postoperative pain, 8 reported some pain, and 1 had frequent pain at the corrected toe. In 30 feet, there was no recurrence; three patients had mild residual crossover toe deformity, and two patients had recurrent deformity, although all MP joints were stable. Follow-up radiographs demonstrated substantial reduction in MP joint angles in both the AP (from 7 degrees to -1 degree) and lateral (from 45 degrees to 25 degrees) projections. This article reviews the surgical technique of both procedures, proposes specific indications for each, and presents outcomes. Based on our findings, the extensor brevis tendon transfer is appropriate for stage 1, stage 2, and flexible stage 3 deformities. Flexor-to-extensor tendon transfer is appropriate for rigid stage 3 and stage 4 deformities and for all patients with a symptomatic neuroma of the second web space (where the extensor brevis transfer is not possible). Stiffness of the MP joint is a potential problem with the flexor-to-extensor tendon transfer.