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Girdlestone Taylor Procedure

- Discussion:
       - this procedure allows long toe flexors to behave like intrinsic muscles producing active plantar flexion at MP joints & extension at IP joint;
       - indicated for flexible hammer toes and claw toes;
       - inform pt that toe ischemia sometimes follows correction of this deformity;

- Physical Exam: flexibility is implied by:
       - absence of contractures of PIP or MTP joints;
       - deformity worsens w/ ambulation or dorsiflexion of ankle, but improves when when ankle is plantar-flexed while not bearing wt;
       - pressure under MTP heads should improve deformity;

- Surgical Considerations:
    - hammer toes:
         - in the hammer toe deformity, the intrinsic muscles of the foot are normal, and therefore inserting FDL tendon halves into the extensor mechanism may cause an intrinsic plus deformity;
         - consider sewing together the FDL tendon halves (over top of the extensor mechanism), inorder to create a flexion force on the proximal phalanx;
    - intrinsic minus toes:
         - place the toe in slight flexion and suture each half of the tendon to the extensor apparatus;
         - the FDL should be placed in slight tension as it is anchored down;
    - weak ankle dorsiflexors:
         - clawing during swing phase: may indicate weak ankle dorsiflexors and over-compensation of toe extensors;
         - consider the Forbes transfer: long extensor transfer to MT necks;
    - unstable 2nd MP joint:
         - rupture in the plantar plate of the 2nd metatarsal is often present;
         - hallux valgus and a long second metatarsal are risk factors, and high heel shoes are another risk factor;
         - vertical stress test demonstrates instability and reproduces pain as toe is translated anteriorly and posteriorly (dorsal subluxation usually produces pain);
         - girdlestone taylor procedure may be used to increase stability of the MP joint;
         - reference:
                 - Surgical treatment of patients with painful instability of the second metatarsophalangeal joint.

- Technique:
    - anesthesia: IV sedation w/ local block;
    - make a small longitudinal incision over platar surface of the affected metacarpal head / neck region;
           - FDL tendon is bluntly dissected out, elevated, and placed under tension w/ misquito clamp;
    - make a short transverse incision just distal to plantar DIP joint crease;
           - w/ FDL under tension from the misquito clamp, transect the tendon from its insertion thru the distal incision;
           - it is essential that the maximum length of FDL be obtained;
           - it is essential that the FDL not retract into the proximal wound;
    - FDL is pulled thru the proximal incision and is longitudinally split down its median raphe as far proximally as possible;
           - hold the edges of the split tendon w/ a clamp;
    - make a dorsal longitudinal incision over the proximal phalanx;
           - bluntly expose the extensor tendon;
           - on either side of the tendon, bluntly dissect down to bone, and then re-direct the misquito toward the plantar wound;
                  - the neurovascular bundle is therefore superficial to this dissection;
           - pass each arm of the FDL tendon into the tips of the protruding misquito clamp, inorder to pull each arm of the tendon into the dorsal
 wound on either side of the extensor tendon;
                  - toe should be in plantar flexion as the tendon is tightened down;
    - alternatively, make a small drill hole in the base of the proximal phalanx and the FDL tendon is passed superiorly thru the drill hole and the FDL is then sutured to the extensor tendon (w/ the MP joint held in flexion);
    - it is controversial as to whether the toe needs stabilization w/ K wires;
           - these are introduced across the PIP joint but not the MP joint and are removed 3 weeks postoperatively

Correction of clawtoes by the Girdlestone-Taylor flexor-extensor transfer procedure.

Transfer of the Flexor Digitorum Longus for the Correction of Lesser-Toe Deformities