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Congenital curly fifth toe correction

    Overview

    Learn the Congenital curly fifth toe correction surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Congenital curly fifth toe correction surgical procedure.
    Two main types of chronic fifth toe deformity are seen , under-lapping and overlapping. These are most commonly multi-planar deformities associated also with adduction and rotation.
    The corrective procedure is adapted to the level and flexibility of the deformity. Both dorsal and plantar approaches may be required.

    Indications

    INDICATIONS.
    Overlapping congenital curly 5th toe deformity
    SYMPTOMS AND EXAMINATION.
    The deformity will have been present since childhood with varying levels of symptoms.
    Patients have local discomfort in shoe-wear , the location of which is largely predictable by the level and nature of the deformities. On occasion the deformity is purely one of hyper-extension at the Metatarso-phalangeal (MTP) joint and flexion at the Inter-phalangeal joints. The degree of correctability should be assessed. The majority of even very stiff and fixed deformities at the MTP level can be corrected by soft tissue releases. Rarely excision of the base of the proximal phalanx may be required to allow correction at the MTP joint. The IP joint flexion may not require correction if mild and flexible .Flexor tenotomy or joint fusion may also be required.
    More often there are elements of adduction and lateral rotation at the MTP joint also present which produce local impingement of the digit upon the 4th toe and also in shoewear. On occasion symptoms will also be present from the plantar aspect of the metatarsal head. The joints are addressed sequentially during surgery from the MTP distally and the rotational profile of the toe corrects usually with the saggital plane deformities.
    This deformity should be differentiated from a purely under-lapping (and also curly) 5th toe (often associated with a similar 4th toe deformity) which is treated either with a flexor tenotomy or flexor to extensor transfer (see clinical images at end of technique).
    The classical deformity is effects the 5th toe in isolation but is not uncommonly bilateral .The presence of a number of other toes effected should alert one to the possibility of an associated neurological aetiology.
    INVESTIGATION.
    It is good practice to document the deformity and its extent with plain X-Ray. On occasion additional insight may be gained if there is contributory bony deformity associated , such as a Delta Phalanx , contributing to angular toe malalignment.
    If an underlying neurological condition is queried then nerve conduction studies may be appropriate.
    NON-SURGICAL ALTERNATIVES.
    In the paediatric population the deformity may resolve as the child develops
    Corrective strapping and splintage should also be considered.
    SURGICAL ALTERNATIVES.
    Tendon transfer, for example the Lapidus operation ( transferring EDL tendon to the short flexor )
    Syndactyly of 4th & 5th toes and excision of base of proximal phalanx
    Amputation (reserved usually for significant recurrence)

    Setup

    Ga or Regional anaesthesia
    Popliteal nerve block for post-operative pain relief
    Thigh or ankle tourniquet

    Operation

    A classical curly 5th toe deformity.
    It is usually an isolated deformity on the foot though may be bilateral.
    Here (& unusually) the deformity is limited to hyper-extension at the MTP joint and flexion at the PIP joint.

    The approach is through a V shaped incision, whose apex lies at the level of the MTP joint. The skin incision is best done with the MTP joint in a reduced position. Once the skin is incised fine scissors should be used to raise full-thickness skin flaps with attached fat and then define the extensor tendons.

    The apex of the skin flap is sutured temporarily to the skin of the distal phalanx to improve access.Blunt dissection proceeds through the fat to produce a full thickness skin flap.The extensor mechanism must then be identified
    The long extensor is Z lengthened .The Z should be made as long as possible given the amount of lengthening required will usually be great.

    Once the long extensor has been divided the joint can be approached. This may contain dense and contracted arthrofibrosis which must be excised.
    This is not always the case (especially in more mobile deformities) and the joint may be clear of such adhesions.

    The soft tissues will need to be released sub-periosteally from both sides of the joint by sharp dissection to fully correct the hyper-extension at the MTP joint.This release may need to be fairly circumferential(as indicated by the direction of the blue line) and if so the bone will need to be adhered to carefully. The vascular supply to the toe is from its two digital arteries , which sit plantar medial and lateral from the mid-line and are at risk with the plantar extension of the dissection.

    With the joint adequately released the MTP is fully corrected now. The position of the PIP joint should be noted. If this is too flexed then a correction at this level will also be required. If the deformity is fixed (which is not usual) then a corrective fusion of the joint should be performed.
    If the deformity is correctible then release of the long flexor tendon will suffice. This is done on the plantar aspect of the proximal phalanx, just distal to the plantar crease. A small transverse incision is used for the skin , tenotomy scissors to define centrally the flexor sheath and the Flexor digitorum longus lies centrally here and should be transected with a small blade under direct vision .

    The extensor mechanism is now repaired in an elongated fashion with 2.0 Vicryl sutures.
    With the joints in corrected positions the apex of the skin flap can be positioned appropriately. The original V shape thus becomes a Y(this is known as a V to Y plasty).

    The first skin suture is placed at the apex of the V as above. A non-absorbable 3.0 Prolene suture is used to close. Futher interrupted sutures are then used.

    There is logic to the pattern of post operative strapping using steri strips. The longitudinally orientated dorsal strapping holds the plantar released PIP joint into a corrected position in relative extension(though not especially effectually here). The dorsal to plantar strapping holds the previously hyper-extended MTP into a reduced position . Once sutures are removed the patient should be encouraged to perform a daily change of the corrective taping which should continue up to 12 weeks post operatively.

    An underlapping fifth toe deformity.

    It is more evident from this plantar projection the nature of this under-lapping curly 5th toe deformity.

    Correction has required fusion through 5th to 3rd PIP joints as well as soft tissue measures.

    A good correction of the deformities has been achieved.

    Post Operative

    The patient can weight-bear as soon as nerve blocks worn off
    They need a stiff soled shoe for 5 weeks post surgery
    The initial 2 weeks (at least) should be with a post-operative type Velcro-fastening shoe whilst the heavier bandaging is in place.
    Beyond this a fit-flop or equally stiff soled shoe is acceptable
    Dressing changes/ wound cleaning at 1 & 2 weeks , during which a wool & crepe bandage is also applied in the outpatients
    After this the patient should change dressings alternate days , keeping wounds covered to avoid them rubbing on shoe-wear.
    The foot may be showered from 3 weeks post operatively
    The Fifth toe should be strapped in the corrected position using a daily change of Micro-pore tape until 12 weeks post operatively.

    Recommended Reading

    Butler’s procedure for correction of overriding 5th toe
    Foot & Ankle surgery 2007 .13(2):67-68
    S Gollamudi, TJ Turnball
    An average 6 year follow up of 12 patients of average age 15 years in whom 6 had excellent results , 3 good and 2 poor. Some degree of residual/recurrent deformity noted in all
    Fifth toe deformities: underlapping and overlapping toe
    Foot Ankle spec.2013.6(2):145-9
    Talusan PG, Milewski MD, Reach JS.
    Butlers operation for an overlapping 5th toe
    J Bone Joint Surg .50 B(1):78-81
    J Cockin
    Not exactly the operation described in our technique. The incision is a racquet shaped one with both dorsal and plantar “handles” to the raquets. The principles of the releases is the same.
    70 operations followed up for a period of 1-10 years in a cohort of patients aged 5 months to 45 years (though the majority were sub 15 years old). Over 90% were graded as “good” (the highest grade) which equated to being satisfactory to patient and clinician with full correction of deformity also.
    2 early recurrences in teenage girls treated by digital amputation.

    Reference

    • orthoracle.com

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