Flexor tenodesis for the correction of sagittal and axial plane lesser toe deformities at the metatarsophalangeal joint: A technical tip.

INTRODUCTION: Sagittal- and axial-plane lesser-toe deformities may be associated with plantar-plate attenuation, scarring, or rupture - limiting the feasibility of direct repair. Conventional options include osseous decompression, plantar-plate repair and flexor-to-extensor transfer. This technical tip describes a suture-based flexor digitorum longus (FDL) tenodesis to the proximal phalanx as an alternative for selected deformities. TECHNIQUE: Two operative approaches are presented. For deformity centred at the metatarsophalangeal (MTP) joint with preserved interphalangeal joints, the FDL is accessed through a dorsal approach following a Weil osteotomy and sutured to the proximal phalanx via a tunnel drilled through the base of the phalanx. Tendon position and suture tension are adjusted to provide dorsiflexion restraint and axial correction. Where concomitant proximal interphalangeal (PIP) joint fusion is required in a primarily sagittal plane deformity, the FDL may be accessed through the PIP joint, and sutures passed along either side of the proximal phalanx and tensioned after fusion. RESULTS: We have used this technique to provide dynamic stabilisation of the MTPJ. Asymmetric tendon positioning or tensioning can also generate an axial corrective moment. Established procedures remain appropriate, but this technique may have a role in selected patients. CONCLUSION: FDL tenodesis offers a suture-based option for multiplanar lesser-toe deformities as an alternative to plantar-plate repair. Its role may be considered within an individualised reconstructive strategy, with further clinical studies warranted to clarify its long-term comparative performance.