The patient was brought to the operating room and placed supine on the operating room table where general anesthetic was administered by the Anesthesia Department. One gram of Kefzol was administered intravenously prior to beginning the procedure. The tourniquet was placed on the right calf. The foot was prepped and draped in the usual sterile fashion, exsanguinated with an Esmarch, and tourniquet inflated to 250 mmHg.

An incision was made on the medial aspect of the great toe, measuring about 4 cm centered over the metatarsophalangeal joint and carried down sharply through skin and subcutaneous tissues. A longitudinal capsular incision was made with subperiosteal dissection, exposing the medial eminence of the first metatarsal head. This was resected parallel to the medial border of the first ray. Distraction was applied across the joint, and a #15 blade was used to perform a lateral capsular release, and a medial capsular repair was performed in pants-over-vest fashion, reducing the hallux valgus deformity to neutral. The wound was then closed with 3-0 Vicryl in subcutaneous tissues and 4-0 nylon in the skin. An incision was then made on the medial aspect of the second toe, beginning at the level of the DIP joint, extending to the metatarsal neck and carried down sharply through skin and subcutaneous tissues. Dissection was carried out to the flexor tendon sheath which was incised. The flexor brevis was released from the insertion of the base of the middle phalanx, and the flexor digitorum longus was released from its insertion of the base of the distal phalanx and was transferred to the dorsal aspect of the proximal phalanx suturing it to the extensor tendon using a 4-0 Monocryl suture. This reduced the flexion contracture at the PIP joint and the hyperextension contracture at the metatarsophalangeal joint to neutral. Excess flexor tendon was excised with a #15 blade.

The wound was irrigated and closed with 4-0 nylon suture in the skin. The identical Girdlestone flexor to extensor transfer was performed on toe #3 and toe #4 reducing the hammertoe deformities to neutral without difficulty. The foot was then anesthestized with 0.5% plain Marcaine using an ankle-block technique, dressed with Adaptic, dry sterile dressings, and a Coban wrap. The tourniquet was deflated. Normal capillary refill returned to the toes. The patient was awakened and transferred to the recovery room in good condition having tolerated the procedure well.