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

Summary

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

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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.

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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.

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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)

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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.

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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.

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

Transcript

[A]

Welcome to AOFAS Ortho Podcast, where leaders in foot and ankle orthopedic surgery discuss the issues that affect you and your practice. Please note that the views expressed on this podcast do not necessarily represent the views of the AOFAS or its members.

[B]

Welcome to the AOFAS Ortho Podcast. My name is Nick Strasser and today we are recording a special edition of our podcast. We're here with our podcast committee and it's the end of the year. We have Joseph park, we have Pamela Luke, we have Ben Jackson, we have Brett Smith, and we have Matt Conti as well. Recording live in 2024. I guess it's not live but. And tonight we're talking about the second toe and before we started recording we were all visiting a little bit about new techniques and new procedures that we've learned in the past year and Ben started talking about the second toe and it sounds like he has it all figured out and so the rest of us were very excited to hear what he has to share and figured the rest of the AOFAs would be as well. So welcome everyone tonight and Ben, you're on the hot seat.

[C]

Oh man, the hot seat. It's feeling pretty hot here. I believe I'm getting everybody's second toes and even better, I'm sure we get everybody's second toes and patients that are unhappy with their second toe. I'll be the referral center for the unhappy second toe patient, which I'm sure we all have a lot of those. I believe my nurse practitioner complains more about patients complaining about their dissatisfaction with their second toe and she has more disdain for that than any other patient. Because of that I've been trying some new things. So I'd maybe say that there are three things that I have been doing in the past really couple of years that I think have really overall improved my practice. And I would say for most folks I'm able to get it in a pretty good position with these things. So the first thing I've been doing a lot more of are flexor tenotomies. So I'll even do those as an in office procedure. When I do it as an in office procedure I basically bring em in. I typically do em on like a Friday afternoon and I numb up the bottom of their foot, light it with epi, marking it with epi, numb up the bottom of their foot. The way I do my flex tratonomy is make incision just because I'm right handed. So if it's a right foot I make incision Just distal to the MTB joint and then on the medial side. So basically put the knife in on what I think is more medial than both the tendons. I turn the knife, I try and get it up under both the tendons, turn the knife at 90 degrees and then I basically extend the toe and vis a vis the tendon sort of into the knife. And I'll perform an FDL and FDB tenot and then I'll continue that dissection deep and form a plantar based pip joint capsulotomy. And I would say for probably all the flexible hammer toes, if you will just do that, takes care of probably 80% of them and I don't need to do anything more. So I just do that fdl, FDB tenotomy and then I'll do a pip capsulotomy. If they still have an.

[B]

Are you doing those on it just flexible or are you doing them on rigid and flexible?

[C]

I I will do them on both. And the, the talk I give to folks that have the rigid ones is I will, I'll just, you know, passively examine it in and on the ridgewoods. I'll say I can get it this straight. We. And I think this is what I tell patients. Sometimes good enough is good enough and I think this will likely be good enough. And I would say I've probably done over 200 toe tenotomies in the office and I probably had to revise probably about two of them. So it's pretty rare that I have to revise them. And the important things I tell them about them is number one, I demonstrate with my fingers that they will not be able to flex their toe. I'm like, right now you can curl your toe down like this and I flex my, my index finger down all the. And then I show them after I'm done with this procedure, only be able to to flex it down this much, which is a very little bit just with their intrinsics. However, I tell people, unless you're climbing a tree to get a coconut, most people do not care how much they can flex their toes down. And then they have a good laugh about it and they understand. Yep, I don't care how much I flex my toes down, I just don't want them to rub in my shoes. But it's very important to disclose that to patients because at a few patients early on, I don't think I did a good enough job telling them that. And particularly there were some younger people in their 30s or 40s and a couple of them were pretty upset. They Couldn't curl their to toes down. So I, I tell them and I literally show them with my hand what I'm talking about as far as that and the one.

[D]

Can I. Can I ask you a quick question? Go ahead. One of the things I'm always nervous about and you have done so many. So just out of curiosity, these patients who have let's say long metatarsals and may need ws for example, if you totally cut their FL both flexors, do you ever worry that they're going to get it like a cock up deformity or floating toe at the MTP joint.

[C]

If they just have truly a flexible hammer toe and that is it. No extension for me through the mtp. I have not seen that happen. And I would say I've probably done two wild osteotomies in the past two years maybe and they've only been for like dislocated MTP joints. So those are the only ones that I've had to do those on. Wow.

[B]

Okay, Ben. Alongside the things I've learned in the last year at a resident that we were doing some tenotomies and one of our podiatry residents showed showed me how to do it with an 18 gauge needle, which I thought was interesting because then it even kept that skin incision even smaller which was nice for in the clinic. I know that you probably don't have a pretty small incision. It doesn't sound like you put any stitches in there, but use the needle as the tenotomy to do the release and release the capsule as well. It was really.

[E]

So that's how I do it, Nick. I use I actually I like in office flexor tenotomies. I do them quite a bit. The 18 gauge works perfect dirt cheap. You don't even have to really get more than just your stir a little packet open. One of the things that I found helped me out a lot doing these in the office was I numb the toe, do the whole thing just bended and then I basically have the patient curl their toes down as hard as possible as I put the 18 gauge needle in and just basically slices across. You can get to the capsule almost immediately once you've got tendons out of the way and then you just basically release the whole thing. And yeah, I agree with Ben 100% on this that I've gone less is more with lesser toes. I used to do all kinds of crazy stuff and now I do as little as possible. And most people are way happier it seems. And I'll echo what Ben said with the wiles, they've dropped precipitously. On my practice with working on first ray alignment and soft tissue releases around the lessers.

[F]

To that same point, I had. I'd gone to a coding course that was discussed with aophis and akfas, and they were actually saying that even if we do these really small percutaneous incisions with the 15 blade, you should still bill it as an open procedure unless you're doing it with the 18 gauge, which is a true percutaneous. So I think that's one of the changes in my practice. I always thought if I made a small enough incision, I'm actually doing it per because I'm not seeing the tendon. But other people would code differently. And for multiple tendons, it's about the same work rvu, but it's one additional RVU if you do it open versus percutaneous for a single tendon.

[G]

But, Ben, what do you tell? Because the most common question I get in my practice is, so how am I going to do Pilates? Now, that might be because I live on the Upper east side, but that's like, number one thing. It's, I need to curl my toes. I've actually never done Pilates, so I don't know. But apparently you need to curl your toes to do it. That's a little bit of a problem. But I don't know if you have people coming back complaining of that.

[C]

I don't have people who've come back and complained about that. So I think it's because I tell them they're not going to be able to do it and they have some sense of it. I would say that I typically only do it in folks that are in their at least 30s or 40s. I'm not doing it in people that are in their teens or twenties. I don't know why. I'm just not. Because I think that it may affect. If you're a sprinter cutter jumper doing that kind, it may theoretically affect that. I haven't had patients complain to me about that. The only people who really complain are people that I felt like it was actually a me problem. I did not explain well enough to them what to expect post surgically. And the codes I use 28011 and 28272. So 28272 is for the IP capsulotomy, and the 28011 is for the multiple toe tendons. I believe our coders are having me code it. I think that's the perk code. But maybe I'LL have a discussion with them about that based on what Pam had to say there.

[E]

So, Matt, I'm not sure if you understand the geography of the United States, but he's in South Carolina. Pilates hasn't gotten there yet. It's right.

[C]

Yeah.

[E]

Now they don't have Pilates.

[G]

Yeah.

[E]

I think the Upper east side has.

[G]

The highest number of my Ben. And I'll just say that my 80 year olds would be very offended by what you just said because. Because they're still just gonna say Pilates class has been.

[D]

So I was gonna say in New York at 1820, they don't do Pilates.

[C]

It's.

[D]

This is like the 60.

[E]

Yeah, it's like this.

[G]

Yeah, yeah.

[E]

They're playing pickleball as well.

[C]

So then moving on. So if they are rigid, I will. So the first thing I'll tell them if they're rigid is I may not be able to get it all the way straight in the office. I will typically try and numb them up a little bit more and I will do an osteoclasis, which is basically do a really firm pressure hyperextension through the pip joint. And often if you've released that pipe capsule, you will feel and hear an audible click, snap release of that tendon. And for the vast majority of them I can make it pretty straight. I've only had to revise really a couple of folks that weren't happy with how straight it was. But virtually all the time I can get it where at least it's not rubbing in the shoe. And I tell them usually good enough is good enough here and if it's not, we can always take you to the operating room. But most people, it's not bothering them them enough that they want to have that happen. So I'll do fdl, ftv, Tsunami and then potentially an osteocalasis. If they have an extension deformity through the MTB joint, I will plan I numb up the top of their foot as well. And, and I would do sometimes just an MTP capsulotomy. Sometimes I'll release their extensor tendon as well if I believe I'm going to do that. Usually I can identify that kind of preoperatively just based on my exam. I'll tell them you're going to have a pretty floppy toe. Generally the only time that bothers folks is when they're like putting on socks. And sometimes it bothers them like when they're putting on socks because it'll catch in their socks. I just, I tell them about that. And I would say I can probably manage 95% of people's second toes as an in office procedure. So I haven't had to take many folks to the the OR for that. And then if it's really rigid and really bad, which I had two of today, I did, I think four bunions today. And for three of them we did some lesser toe work. Two of them had really rigid second toes. Even when I tried to do the osteoclasis, it would not. On one of them it would not crack at all. I do an achonet and so what I do with that is I make an incision on the medial side of the toe in the mid lateral line. I'll then take a 2 millimeter bur and do a plantar based closing wedge. So I probably burr through about 80% of the bone from the planter side. I try not to complete it. And then I'll green stick crack it down. That can sometimes be a challenge because there's not enough toe to hold on to to crack it. So sometimes I will take the, the ring from like a hemostat and I'll put that on the toe and use that to try and give me some leverage to crack it down. Or just really hyperplanar flex the toe and that'll usually green sit crack it. And I would say with that I have, I don't remember. I would say I've put in definitely less than five and maybe less than three implants into the pip joint in the last two years. And I would say I probably used to put in 50 to 75 a year somewhere in that range. So with those procedures, based on the severity of the toe, I feel like I've been able to solve 99 of the second toe problems without very much floating toe at all. Which is. People complain about that all the time.

[D]

What about coronal plane malignant like varus? Usually it goes into varus like crossover if it's pointing towards the first toe.

[C]

So for me I do, I will do collateral releases of the MTP joint. And so I'll release the dorsal MTP and then the mcl, I'll release that both distally and proximally. Again all percutaneous. If it's, if it's really bad, which is rare, I will do a kind of lateral closing wedge, a connect. But it's not very often I need to do that. The other thing I've done, in some people, they have a really big knuckle like at their pip joint. So it's really just a matter of the knuckle is huge. I will make an incision and use the bur and simply shave the knuckle down. So do like a partial excision of like the proximal or middle phalanx or both if it's at that pip joint. And that seems to help people as well. Often once you get the hallux well aligned, you can get the second toe pretty well aligned as well. And often I found the flexor tendons are deforming force even a little bit into varus. So once you like release the flexor tendons and generally the virus is not quite as bad. But the next step would be the kind of MCL release of the MTP joint.

[G]

So for the akonets like one of the problems that I've done a couple of those and I just, I don't know how bad one like one did really well and then one had just recurred like it looked great for six weeks, three months and then now she's five or six months out and it's just, it's just drifting back. And is there like a limit of how much varus deformity? Because I think at some point or my worry is that and she had a pretty bad varus deformity. It wasn't dislocated. But do you need something to stabilize the lateral part of the joint? And if you just do the aching head it looks good but then the joint can still continue to go into varus.

[C]

I haven't had that yet. I'm sure that I will at some point if other folks had that challenge.

[F]

Maybe do you splint the toe or dress how do you dress it after you do your office procedures or so.

[C]

The in office procedures? I so for basically all of these procedures I've described, I only use dermabond. I've gotten away so even by bunions. I'm an mis bunion guy at this point. It is a no stitch surgery. It is dermabond for all of them. For the in office procedures it's Dermabond. I wait for dermabond to dry. I put a few four by fours on it and I put some like web roll around it with around the foot for a few wraps. One wrap around their ankle and then down around the foot a single piece of tape and put them in a post op shoe. I tell them to stay off it for three days. That's what I do. On Friday afternoon I say stay off the foot. Friday, Saturday, Sunday, on Monday take your dressing off Start walking on it and start showering. And many of them, probably over half them are back into a regular shoe when they come back and see me at the two week visit.

[B]

Ben, I've heard others talk about using like suture to try to help correct some of the hammer toe. So almost doing putting a stitch in through the skin to try to correct the deformity. Have you had any experience or anybody on the call had any experience with that that might be more in Europe or South America?

[C]

I, I've done that before and I think maybe Brett has too and I, I'll comment and then get you read the opportunity but I actually, because I get so pissed at the second toe for a few years I haven't tried ellipsing out skin just distal to the MTB joint. Like I would take, like would pinch the skin with an accent. I'd take a scissor and I'd cut the skin and then I'd suture it down to try and just take away some of the skin so it would sit down for that extension of for me through the MTP joint. And I was pretty disappointed with that as well. So I did not have as much success as I hoped I'd have with that.

[E]

Yeah. So for me I've used that suture technique, Nick, quite a number of times on the pip joint area. Basically it's a full thickness all the way down to almost periosteum and it's a big mattress stitch and I found it works really nice, especially in situations where I don't want to have a K wire in place. And yeah, it surprisingly does work quite well in the right patient scenario and situation. And I've done that both as a backup to like an osteoclesis has been mentioned or even a true de Vries resection and just use suture as opposed to an implant or KY or anything else.

[C]

So Brett, you're talking extension through the pip?

[E]

Yes, correct.

[C]

Nick, were you talking about flexion through the MTP or which one?

[B]

No, I was talking about what Brett was referring to where you. I'm sorry use it in the, at the pip joint to help with the flexion deformity.

[E]

Yeah, it works really nicely. It's super simple, very easy. I usually like just a simple Prolene, something like that and leave it does it.

[B]

Is there problems with skin necrosis in that situation if you're pulling through the skin in that situation.

[E]

So you have to really make sure that you space the suture out really far. So I'm going back all the way Almost the base of the proximal and almost the the distal portion of the middle. So I'm really using as much skin as I can and I don't overly tighten. And as I say it's like a mattress type suture. So I'm trying to get as much soft tissue contained so I'm spreading out all of that force as much as I can. And then I'll usually do some simple either soft tissue splinting with dressings, I'll use some Curlex or four by fours and I'll just crisscross applesauce them and then wrap them up, try to support them that way. And I'll leave them at first dressing for at least a few days. Maybe even in that situation I'll usually leave them in at least a week or more just so the soft tissues even get more support from the dressing, post op shoe, all that good stuff as well. And I leave those sutures in for depending on which way I'm going, whether I'm doing DeVries type bony procedure or soft tissue, those probably stay in about four weeks at least.

[C]

And Pam, to answer your question, I don't do any really fancy dressing on them right away in particular because I only stayed up for three days. What I will do if people are starting to get a little bit of extension just because they don't have their flexors like when they come see me at two weeks they really haven't been walking properly. They haven't been able to curl their toes down. Also because it hurts some too, I will do two things. I'll encourage them to basically stretch their toe with plantar flexion and show them how to do that. Also put them in like a Boudin splint, the one that goes on the bottom and the little elastic strap. So I'll put them in a. Depending on how many toes we did and how many are a little bit are trying to extend back to the mtp a two or three toe or one toe boudin splint. And with that and the stretching that tends to take care of a little bit of extension by that you've created by releasing the flexors.

[B]

Well this has been a fun discussion and I think two things are apparent is we all hate lesser toe deformities and I think that's probably unanimous and we're probably all in agreement that we continue to need additional way to treat them. So I really appreciate your insights Ben and, and everyone who contributed and I'm looking forward to seeing more options come out there. I think with MIS surgery, we're going to see more options available. And I think less is more is certainly very interesting, especially if you can do a lot manage in an office type of setting. So thanks everybody for jumping on the call and talking through things.

[A]

Thank you for listening to the AOFAS Ortho Podcast, a Convey Med production. To learn more about joining our dynamic community of highly skilled orthopedic specialists, visit aofas.org.