Surgery: Attention was first drawn to the PIP joints, where on each of the toes 2, 3, 4, and 5, the same arthrodesing procedure was performed. Therefore, it will be only described once. This procedure was an elliptical incision made over transversely the PIP joint with the elliptical piece of skin removed. The soft tissue underneath was removed as well. This exposed the condyles of the proximal phalanx and the PIP joint itself. Using sharp dissection, the capsule was incised medially and laterally, which included the collateral ligaments. Dissection of the soft tissue surrounding the condyles was made back to the neck of the proximal phalanx. Using a bone cutter, the osteotomy of the neck was then performed without difficulty and the condyles were removed and sent to pathology. The proximal end of the medial phalanx was then exposed and Attention was then turned to the MTP joints where the same procedure was followed on joints 2, 3, 4, and 5. Here only 2 incisions were made, and therefore the dictation will proceed as follows. The second and third MTPs at the second interspace, a longitudinal incision was made from the webspace extending proximally to the midshaft of the metatarsals. This was taken down through subcutaneous tissue.

Attention was first turned to the second MTP area where dissection proceeded to isolate the extensor tendon longus and brevis of the second toe. A Z-lengthening was performed of the tendon, which would later be reanastomosed end-to-end. The dissection was continued down to the joint where the capsule overlying the second MTP was clearly tight and was incised transversely down to the collateral ligaments both on the medial and lateral side. This allowed full extension of the joint and maintain the stability of it. Having done this, the Z-lengthening previously noted was then reanastomosed end-to-end using a 2-0 Vicryl suture. In a similar manner, the procedure to the extensor tendon, longus and brevis of the third MTP, and the capsule of the third MTP was performed.

Attention was then turned to the fourth and fifth MTP and its extensor tendons and in a manner similar to that noted for the second and third. The procedure to the fourth and fifth was done in the equal manner. This allowed then full extension at the MTP joints and as a result, alignment with the PIP joints in the toes was straight and appropriate. In order to allow full healing, then the K-wire needed to be inserted. This was done in the following manner to each of the 4 toes. At the PIP joint, a 0.045 K-wire was inserted antegrade through the mid phalanx, distal phalanx, and then retrograde through the proximal phalanx and the MTP joint into the metatarsal itself. This was done under fluoroscopic viewing without difficulty. In a similar manner, a K-wire was inserted for the third, fourth, and fifth toes. Having done this, the wounds were irrigated out well and closed in layers in the usual fashion with 3-0 Monocryl used for the skin. With all 4 toes now straight in the MTP joints, no longer subluxed, the great toe was noted to be tight in its extensor tendon and pulling laterally overlapping to some degree of the second toe. As a result, it was felt that at least the extensor tendon needed to be lengthened in this area. Therefore, an incision was directly made over the extensor tendon of the hallices and the longus and brevis were isolated. The Z-lengthening was performed in the usual manner. With the Z-lengthening, it was noted that the MTP joint was not subluxed and could be fully extended even though there was slight PIP contraction. This, however, was felt to be acceptable and as a result, with end-to-end anastomosis of the Z-lengthening of the extensor tendon, adequate alignment was then produced of the forefoot.