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Forefoot and Toe Deformities

- See: Claw Toes

- Discussion:
    - in pts who have a rigid cock-up deformity of toe that is present at skeletal maturity, we perform arthrodeses of the proximal and DIP joints, removing wedges of articular cartilage and adjacent bone based dorsally to correct the deformity, shorten the toe, and allow for apposition of osseous surfaces for arthrodesis;
    - correction is held with threaded Kirschner wires;
    - metatarsophalangeal capsulotomy and extensor-tendon lengthening may be needed to ensure straightening of the toe;
    - in skeletally immature patients who have a severe deformity, flexor-to-extensor transfers are favored by some;
    - IP arthrodesis of the big toe can be combined with transfer of insertion of the extensor hallucis longus tendon from the proximal phalanx  into the distal end of the first metatarsal (the Jones procedure) to serve as a dorsiflexor;
    - as peripheral neuropathies affect the more distal muscles initially, mildest cases involve the forefoot alone (cock-up toes), while midfoot & hindfoot are progressively affected w/ increasing grades of neurological severity;
    - w/ even minimum weakness, invertor muscles (tibialis anterior & tibialis posterior) are stronger than evertors (peroneus longus), which favors the development of adduction & varus deformation;
    - claw toes deformities can be managed by combining Jones procedure (placing EHL into the first metatarsal head) with an arthrodesis of the IP joints;
    - deformities of the forefoot involve cock-up toes, plantar flexion of first metatarsal, & adduction-inversion malposition of metatarsals;
    - deformities of the midfoot involve malposition of navicular, cuboid, & cuneiform bones, leading to a high arch, w/ apex of equinus deformity at the mid-tarsal or tarsal-metatarsal joints