Podcast Summary: "How I Treat This: Approaches and Solutions for the 2nd Toe"

The AOFAS Orthopod-Cast
Date: December 18, 2024
Host: Nick Strasser with AOFAS Podcast Committee
Guests: Joseph Park, Pamela Luke, Ben Jackson, Brett Smith, Matt Conti

Overview

This special end-of-year episode of the AOFAS Orthopod-Cast explores the latest techniques, challenges, and practical solutions for addressing 2nd toe deformities. The panel, composed of leading orthopaedic foot and ankle specialists, discusses evolving, minimally invasive approaches—particularly in-office procedures—that have improved outcomes for both patients and surgeons. The conversation centers on clinical pearls, pitfalls, coding nuances, and patient counseling, delivered in a frank and collegial roundtable style.

Key Discussion Points & Insights

1. Flexor Tenotomies as a First-Line Solution (01:26–05:16)

• Technique Shift:
  Ben Jackson explains his transition to routinely performing in-office flexor tenotomies for the second toe, often on Friday afternoons to allow for a weekend recovery.
  “I typically do ‘em on like a Friday afternoon and I numb up the bottom of their foot... I make incision just distal to the MTB joint and then on the medial side... try and get it up under both the tendons, turn the knife at 90 degrees...” (02:00, Ben Jackson)
• Success Rate:
  Claims about 80% of flexible hammertoes are resolved without escalation; over 200 procedures performed in-office with only two requiring revision.
• Patient Counseling:
  Clear communication is vital about post-tenotomy functional limitation—loss of toe flexion:
  “I literally show them with my hand what I’m talking about... Unless you’re climbing a tree to get a coconut, most people do not care how much they can flex their toes down.” (03:45, Ben Jackson)

2. Technique Variations—Needle vs. Blade (05:16–06:42)

• Use of 18-Gauge Needle:
  Nick Strasser and Brett Smith discuss favoring a percutaneous approach—using an 18-gauge needle for minimal incisions and effective tendon and capsule release.
  “One of the things I found helped me out... was I numb the toe, do the whole thing just bended, and then... just basically slices across... The 18 gauge works perfect, dirt cheap.” (05:46, Brett Smith)
• Coding Considerations:
  Pamela Luke notes coding distinctions—only procedures done with an 18-gauge needle count as “percutaneous”; all others, even with a tiny blade, are coded as open.

3. Office-Based Management Spectrum (07:42–09:05)

• Indications & Limitations:
  Jackson is selective, generally treating patients in their 30s and older, avoiding younger, athletic demographics. “I typically only do it in folks in their at least 30s or 40s... If you’re a sprinter, cutter, jumper, it may theoretically affect that.” (07:42, Ben Jackson)
• Addressing Rigid Hammer Toes:
  Osteoclasis (forced hyperextension at PIP joint) is added when tenotomy isn’t enough, with attention to audible release and postoperative function:
  “Often if you’ve released that PIP capsule, you will feel and hear an audible click, snap release...” (09:05, Ben Jackson)

4. Strategies for Severe or Multi-Planar Deformity (09:05–13:22)

• Akinette Procedure for Intractable Rigidity:
  Plantar-based closing wedge osteotomy described using a 2mm burr; greenstick fracture accomplished using a hemostat for leverage.
  “I make an incision... plantar-based closing wedge... green stick crack it down... I would say I’ve put in definitely less than five... implants in the last two years.” (10:46, Ben Jackson)
• Collateral Release & Bony Contouring:
  For varus (crossover) deformity, Ben releases dorsal and collateral MTP ligaments and, rarely, adds a lateral closing wedge or partial knuckle excision.

5. Recurrence and Post-Procedure Management (13:22–17:48)

• Handling Recurrence:
  Concerns about drift or recurrence after procedures like akinette are discussed. Close follow-up and, for minor recurrence, splinting/stretching are suggested over routine escalation.
• Dressing Protocol:
  Minimal dressing—dermabond instead of sutures, simple wraps, and early weightbearing post-three days.
  “For basically all of these, I only use Dermabond... tell them to stay off for 3 days ... on Monday, take your dressing off, start walking, start showering.” (14:10, Ben Jackson)
• Soft Tissue Suture Techniques:
  Suture-based correction, especially for the PIP joint, is described by Brett Smith as a viable alternative when implants/K-wires are undesirable:
  “Basically it’s a full thickness all the way down to almost periosteum and it’s a big mattress stitch... works really nice, especially... where I don’t want a K wire.” (15:49, Brett Smith)

6. Pearls, Pitfalls & Practice Evolutions (Throughout)

• Patient Selection & Education:
  Thoroughly explaining expected functional trade-offs is key to satisfaction; proper coding and billing also surfaced as relevant considerations.
• Less is More Philosophy:
  The group increasingly prioritizes minimally invasive, office-based procedures, reserving implants and K-wires for rare, severe cases.
• Regional/Cultural Variations:
  Lively banter about regional differences in patient activities (“Pilates problems” upper east side vs. South Carolina) highlights the importance of tailoring advice to each patient.

Notable Quotes & Memorable Moments

• “Unless you’re climbing a tree to get a coconut, most people do not care how much they can flex their toes down.”
  — Ben Jackson (03:45)
• “The 18 gauge works perfect, dirt cheap... Most people are way happier it seems.”
  — Brett Smith (05:46)
• “If it’s really bad, I do an akinette... I would say I’ve put in less than five implants into the PIP joint in the last two years... I used to put in 50–75 a year.”
  — Ben Jackson (11:23)
• “We all hate lesser toe deformities and... continue to need additional ways to treat them.”
  — Nick Strasser (18:37)
• [Joking about Pilates:] “Matt, I’m not sure you understand the geography of the United States, but he’s in South Carolina. Pilates hasn’t gotten there yet.”
  — Brett Smith (08:38)
• “For me, I will do collateral releases... The next step would be the kind of MCL release of the MTP joint.”
  — Ben Jackson (12:19)

Timestamps for Key Segments

• 01:26 — Ben Jackson introduces flexor tenotomy as primary in-office approach.
• 03:45 — Patient counseling on postoperative toe flexion loss.
• 05:16 — Needle-based percutaneous tenotomy and coding discussion.
• 07:42 — Discussion of patient selection and Pilates-related concerns.
• 09:05 — Osteoclasis technique for rigid toes.
• 10:46 — Akinette procedure for severely rigid or failed toes.
• 12:10 — Managing crossover/varus with soft tissue and bony techniques.
• 14:10 — Dressing and aftercare protocol.
• 15:49 — Mattress suture technique for PIP joint deformity.
• 18:37 — “Less is more” summation and outlook for the future.

Conclusion

A consensus emerges around using minimally invasive, office-based interventions as first-line treatment for most second toe issues, with clear communication to set expectations and meticulous technique selection based on rigidity, deformity, and patient activity needs. The conversation closes with optimism about further MIS (minimally invasive surgery) developments and an emphasis on adapting as new solutions emerge.

For more practice-changing discussions and educational resources, visit aofas.org.