Flail Toe with Bone Graft

Kieran T. Mahan

Although the outcomes of digital surgery are usually good, complications do occur. Excessive bone resection, bone resorption, and overlengthening of the extensors or flexors of the toe can cause a lack of stability. These unfavorable outcomes often occur after multiple surgeries have been performed on a toe. Excessive bone resection can cause lack of stability to the toe either directly by removal of the supporting skeleton or by “unloading” of the flexors and extensors through shortening of the digit. The flail toe is defined as one that lacks stability or structural integrity. It is not simply a cosmetic problem. The toe may drift laterally or catch on socks and stockings. It may become irritated in a shoe or fold back under itself. Since the toe no longer provides a buttressing effect, deformity of the adjacent digits is common as these toes converge under the flail toe. It is fair to say that patients find the flail toe to be one of the most annoying complications of digital surgery.

The possible surgical solutions to the problem are few. Implant arthroplasty, syndactylization, and amputation are three possible approaches. Implant arthroplasty requires good soft tissue coverage and good bone stock, neither of which may be present after multiple surgeries. Syndactylization relies on the stability of an adjacent toe and may be cosmetically unacceptable to a patient. Conversely, a patient may be so annoyed with the toe that amputation becomes an acceptable option. An additional alternative is the use of an autogenous bone graft to stabilize and lengthen the toe. This technique was first described by Mahan in 1992 (1,2).

EVALUATION

The flail toe is typically shortened and unstable. It is easily pushed in any direction, usually at the proximal interphalangeal joint where the bone resection or resorption has occurred. There may be deformity in one or more planes. The adjacent digits may impair reduction of the flail toe and need to be evaluated as well.

INDICATION FOR SURGERY

The technique of bone graft stabilization requires a much more prolonged course of immobilization than digital fusion or arthroplasty alone. It should be reserved for patients with significant shortening, instability with pain, and functional problems. It is a preferred functional alternative to implant arthroplasty, amputation, or syndactyly. Selected patients should have adequate perfusion to the toe and soft tissue coverage sufficient for healing. Both of these may be problematic if the toes have already had multiple surgeries. Bone stock in the toe should be adequate to support the graft-host junctions. The patient should be able to be non-weight-bearing in order to prevent disruption of the graft-host interface. Patients must understand the goals of the surgery: improved stability that may not be complete and possible restoration of some degree of length. Full restoration of the length pattern may not be possible due to length/breadth ratio requirements of the graft. Viability of the graft depends upon the width of the graft-host junctions, and the narrowness of the toe means that the length of the graft is limited.

TECHNIQUE

The surgical approach is through a linear incision with open Z-plasty lengthening of the extensor digitorum longus tendon to expose the proximal and middle phalanges. The bone proximally and distally must be remodeled sufficiently to provide a healthy host surface area for the graft. Although this shortens the toe even further, it is a critical step. Dead bone will not support a new graft. The interface should be squared off proximally and distally so that the graft can sit with full bone to bone apposition (Fig. 15.1).

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