An Eight-toed Foot: A Rare Pedal Polydactyly

Polydactyly is a fairly common congenital condition of the foot and is characterized literally by supernumerary toes (digit or metatarsal). The frequency of polydactyly varies widely among populations. It may be an isolated condition or part of a congenital syndrome. Eight-toed polydactyly is a distinctly rare congenital foot anomaly. In this report, an 18-month-old child with pre-axial 8-toed right foot had been treated with excision of the excess rays with muscular, tendentious, and ligamentous reconstructions. The patient had presented a good postoperative result. Through monthly follow-up visits for 1 year, the parents expressed excellent cosmesis, shoe fit, and walking function.     

Polydactyly of the foot

Polydactyly may be preaxial or tibial (hallux-side), postaxial or ulnar (side of the little toe) and central (middle toes). The duplication may appear at the distal and medial phalanges or at the whole digit. The metatarsal bone may be part wise or completely duplicated, the accessory toes may share only one metatarsal. Surgical intervention may be indicated in shoe problems, for esthetic reasons or, especially in duplication of the metatarsales, because of secondary deviation of the toes and therefore shoe problems or plantar callosities. Preoperative analysis including x-ray is of great importance to achieve good functional and cosmetic results.     

Polydactyly of the feet in children: suggestions for surgical management.

Polydactyly is the commonest congenital deformity of the foot, presenting as a range of defects from minor soft tissue duplications to major bony abnormalities. There is a relative paucity of information on the management of this condition in the literature compared to that concerning polydactyly of the hand. We present a consecutive series of 34 cases of polydactyly of the foot in 25 patients treated surgically at our unit and these are classified according to the protocol described by Blauth and Olason. We emphasise the importance of preoperative classification using radiographs and an individualised surgical approach giving consideration to aesthetic and functional outcome.In the literature a number of authors have expressed the view that in polydactyly of the fifth ray of the foot the most lateral digit should always be excised irrespective of whether this is the more fully formed digit. We believe this should not always be the case and we describe two cases of polysyndactyly where the more medial element of a fifth-ray polydactyly was excised to allow for better maintenance of the contour of the foot. This involved more complex surgery than excision of the lateral element but gave a superior cosmetic and functional result.     

Problems in polydactyly of the foot.

1. Polydactyly should be treated early. 2. Adequate bone and soft tissue should be removed. 3. One arm of the Y should be removed surgically in the incompletely duplicated Y metatarsal. 4. The incompletely duplicated Y metatarsal shaved to form a single shaft may at first be bowed, but will remodel to form normal or nearly normal bone. 5. The wide metatarsal head associated with a duplicated phalanx should be narrowed surgically to avoid the development of a painful bunion. 6. Short block-like metatarsals remain abnormal. 7. Polydactyly associated with a short first metatarsal and congenital hallux varus carriers a poorer treatment prognosis and may require continuing treatment. 8. Postoperative casting and taping should be utilized to prevent angular deformities and encourage normal forefoot contour.     

The Role of the Shortened Proximal Phalanx in the Setting of Brachymetatarsia

Brachymetatarsia is a condition in which a metatarsal bone does not grow out to full length. This is caused by premature physeal closure. The proximal phalanx associated with the shortened metatarsal helps achieve the natural parabola of the foot. A hypoplastic proximal phalanx is a common finding in patients with brachymetatarsia. The goal of this study was to determine the length of the proximal phalanx in the setting of brachymetatarsia, and how much the shortening is attributed to the clinically smaller toe. We performed a retrospective study to evaluate the length of the proximal phalanx in the shortened ray. After the metatarsal was brought out to the desired length of correction, the proximal phalanx was measured on radiographs. Ninety-seven feet with congenital brachymetatarsia were reviewed in a cohort of 66 patients who underwent surgical correction between January 2005 and February 2020 at a single institution. The group was comprised of 61 females and 5 males, with a mean age of 27.5 years. The average length of the proximal phalanx associated with the affected metatarsal was noted to be 18.9 ± 3.83 mm for males and 15.6 ± 4.02 mm for females. Our results indicate the shortened proximal phalanx is 5 mm shorter when compared to normal population and is a contributing factor to the shortened clinical appearance of the digit in brachymetatarsia. Treating surgeons should be aware of this to better educate patients on the influence of the digit on the overall shortening seen in cases of brachymetatarsia.     

Polydactyly

Polydactyly is a fairly common, genetically induced deformity of the hands and feet found more often in blacks than in whites. Careful clinical and radiographic evaluation should be made prior to treatment because the complexity of the deformity ranges from a simple soft tissue appendage to a completely developed accessory ray. Treatment usually consists of surgical excision of the least functional, least developed digit. Hallux varus, angular deformities, and a splayed forefoot are common postoperative complications.     

An Unusual Case of Postaxial Polydactyly of the Foot Treated by Metatarsal Transfer

Postaxial polydactyly is a relatively rare congenital deformity. We present a unique unusual fourth metatarsal type polydactyly in which the extra bone from the fourth metatarsal bone articulated with the most lateral ray proximal phalanx. We discuss the surgical management of this problem using a bone transfer from the extra metatarsal bone within the midfoot. This is the first reported case of fourth metatarsal-type polydactyly treated by bone transfer of the extra metatarsal bone and internal plate fixation to recover normal articulation. The normal orientation of the metatarsophalangeal joint, alignment, and cosmesis are important determinants when selecting the bone to be excised in cases of lateral ray foot polydactyly.     

Correction of Postaxial Metatarsal Polydactyly of the Foot by Percutaneous Ray Amputation and Osteotomy

Polydactyly of the foot is a congenital anomaly characterized by the appearance of all or part of 1 or more additional rays. The patient with this condition might complain of an abnormal cosmetic appearance or difficulty with footwear. A minimally invasive technique for correction of postaxial metatarsal polydactyly of the foot is presented in this techniques report.     

Surgical Reconstruction Technique of Two Patients With Tarsal Type Preaxial Polydactyly: Two True Prehalluces

Polydactyly of the foot occurs in 1.7 cases per 1000 live births, comprising 45% of congenital abnormalities of the foot. Most reported cases of polydactyly of the foot are postaxial, and 15% are preaxial; of those, tarsal type preaxial polydactyly (a true prehallux) occurs in only 3% of cases. Because of this rarity, there is minimal literature available to guide management or surgical reconstruction. Two newborns presented with similar tarsal type preaxial polydactylies in the context of multiple congenital anomalies at a single institution. Patient 1 presented at birth with an accessory digit arising medially from the right foot at the medial malleolus. Two weeks later, genetically unrelated, patient 2 presented at birth with an accessory digit arising medially from the right foot at the talus. Both patients underwent resection of the extra digit and reconstruction including transfer of the accessory anterior tibial tendon arising from the preaxial extra digit to the remaining first ray. Two years after surgery, both patients are walking well with preserved dorsiflexion strength. Given the rarity of true prehallux cases, reported surgical treatment and outcomes are lacking. This case demonstrates the management of 2 patients to better guide future patient care. Although nonsurgical treatment with shoewear modification is an option, surgical reconstruction facilitated wearing typical shoes while preserving ambulatory ability. Both patients in this series had an accessory anterior tibial tendon. Surgical transfer of the tendon prevented loss of dorsiflexion strength and foot drop postoperatively.     

Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.     

Analysis of results of treatment of hallux valgus by Dega osteotomy]

The evaluation included sixty eight feet (forty one patients) treated with Dega osteotomy for hallux valgus deformity. Patient's average age at the time of surgery was 47 years (ranging from 11 to 65). The average duration of follow-up was 4.5 years (ranging from 2 to 10). The clinical and X-ray examination found good results in 29% of cases, fair results in 59% and poor results in 12% of cases. Fair results were associated with persistent wide forefoot and shortening of first metatarsal bone. Poor results were associated with persistent valgus deformity of hallux, jatrogenic hallux varus (2 cases), shortening of first metatarsal bone amounting to more than 1.0 cm.     

The modified Mayo procedure combined with basal valgus osteotomy of the first metatarsal for severe hallux valgus

Summary The modified Mayo procedure corrects valgus deformity of the great toe secondary to osteoarthritis in the first metatarsophalangeal joint. Basal osteotomy of the first metatarsal to correct metatarsus primus varus and to maintain correction of the valgus deformity may be performed simultaneously. We retrospectively reviewed the results in 55 of 70 feet treated by this combined procedure. The average duration of follow-up was 4.2 years (range 0.5–6 years) and the average age at operation was 63 years (range 45–80 years). The results were either very good or good in 82%, moderate in 14%, and poor in 4%. Our technique of basal osteotomy of the first metatarsal is a simple and effective procedure to correct metatarsus primus varus and may restore the distal transverse arch. It should be considered as a possible method of treatment when the intermetatarsal angle is greater than 10°.     

Treatment of macrodactyly and foot gigantism]

Between 1996 and 2000 the authors followed-up 6 children with congenital hypertrophy of 7 feet. Surgical treatment was performed in 4 children (4 feet). The average age at the time of surgery was 9 years, and the average follow-up period was 3 years. 2 cases of macrodactyly of the I and II rays of the foot and 1 case of macrodactyly of the II ray of the foot were observed. Amputations of phalanges or toes in all 3 cases were performed with amputations of distal parts of adjacenet metatarsals in 2 cases. Soft tissue debulking was routinely done. Operative treatment of 1 case of the foot gigantism connected a resection of the IV and V metatarsals, a removal of the III metatarsal, an epiphysiodesis of II metatarsal and an amputation of all toes at the MIP joint level. A good cosmetic result was achieved in all children with macrodactyly and all of them were normal shoes. The treatment in the case of foot gigantism yielded good functional result and satisfactory cosmetic result. The patient required orthopaedic foot-wear. In the authors' opinion the resection of the lateral rays of the foot is superior the central ray resection.     

An unusual case of postaxial polydactyly of the feet

Polydactyly is a fairly common congenital anomaly characterized by additional fingers and/or toes, generally divided into three groups: medial ray (preaxial) and central and lateral ray (postaxial). We present a case of postaxial (fibular) polydactyly of the feet, assaying its clinical and radiological features and the method of surgical correction. Clinical outcomes after initial surgery were excellent in both feet. This surgical case shows that a careful individual preoperative planning is necessary to achieve good functional and cosmetic outcome. Level of Evidence: Level V, therapeutic study.     

Opening wedge osteotomy of the medial cuneiform before age 4 years in the treatment of forefoot adduction

Thirty-seven feet in 25 children (12 girls, 13 boys) treated surgically with medial cuneiform opening wedge osteotomy to correct forefoot adduction were assessed. Thirteen patients had unilateral deformity. Primary diagnoses were congenital clubfoot (33 feet), congenital forefoot adduction (3 feet), and skewfoot (1 foot). All children underwent operation before age 4 years. The age at operation ranged from 21 to 47 months (mean 35). In 18 feet, allografts were used. In 5 feet, autograft was used. In 14 feet, ceramic material was inserted as opening wedge. Follow-up ranged from 3 to 8 years (mean 4). In four feet, the ossification center of the medial cuneiform was invisible. The correction of the deformity was assessed clinically and radiographically. The first ray angle and talo-first metatarsal angle were evaluated on anteroposterior radiographs, the latter was evaluated on lateral radiographs, also. In 26 feet, normal position of the forefoot was achieved. In five feet, overgrowth of the medial cuneiform in comparison with the normal side was observed. Forefoot adduction persisted in six feet. The ossification center was often divided into two parts by bone graft, and subsequent independent growth of both parts was observed. This technique is safe and useful for correction of forefoot adduction in young children. It can be performed even in cartilaginous bone. The osteotomy causes overgrowth of the medial cuneiform and the medial ray.     

Acute traumatic hallux valgus

Post-traumatic hallux valgus is an uncommon condition with sporadic reports. The deformity usually develops in a gradual manner following direct injury to the first ray; including injury to the first metatarsophalangeal joint, the first metatarsal bone or the first metatarsal-cuneiform joint. A case of acute traumatic hallux valgus following metatarsal neck fractures of the lesser rays is reported. We believe that understanding the importance of the transverse ‘tie-bar’ system in the pathogenesis of post-traumatic hallux valgus deformity avoids unnecessary surgery to the great toe.     

The minimally invasive hallux valgus correction (S.E.R.I.)

Introduction Distal metatarsal osteotomies have been described for surgical treatment of hallux valgus with good results. The aim of this study is to review the results of 299 consecutive hallux valgus cases treated by minimally invasive distal metatarsal osteotomy, S.E.R.I. (Simple, Effective, Rapid, Inexpensive). Materials and methods 299 feet in 190 patients (109 bilateral), aged between 35 and 70 years (mean age: 53 years) affected by hallux valgus were studied. A 1 cm medial incision at the metatarsal neck, and a complete osteotomy, using an oscillating saw were performed. With the naked eye all characteristics of the deformity were corrected by displacement of the metatarsal head (HVA, IMA, DMAA, dorsal or plantar displacement). The osteotomy was stabilized by a 2 mm Kirschner wire. Immediate weight bearing was allowed with gauze bandage and Talus shoes for 4 weeks. All patients were checked at an average follow-up of 4 years. Results All osteotomies healed no avascular necrosis of the metatarsal head or pseudoarthrosis of the osteotomy was observed. Mean preoperative AOFAS score was 43 and 88 at follow-up. The mean preoperative HVA was 33, while at follow-up it was 16 (P < 0.05), mean preoperative IMA was 13, while at follow-up it was 7 (P < 0.05), mean preoperative DMAA was 20, while at follow-up it was 8 (P < 0.05). Conclusion S.E.R.I. osteotomy has been simple, effective, rapid and inexpensive in correcting hallux valgus deformity. Clinical and radiographic findings showed an adequate correction of the deformity.     

Hypermobility of the first ray

Hypermobility of the first ray is one of the causative components in common foot problems (such as hallux valgus) with a large intermetatarsal angle and metatarsus primus varus. Although not always associated with hallux valgus, hypermobility is a predisposing factor for this deformity, especially in conjunction with extrinsic factors, such as disruption of the plantar first metatarsal cuneiform ligament and tendon-muscle imbalance. Hypermobility is also frequently found in adolescents with hallux valgus, especially when associated with a large intermetatarsal angle. Motion at the first metatarsocuneiform joint occurs in the sagittal and transverse planes. Most studies agree that greater than 4 degrees and greater than 8 degrees, respectively, constitutes excessive motion. Clinically, hypermobility is evaluated by determining sagittal motion (the grasping test) and transverse motion (the clinical squeeze test) and by identifying signs such as the presence of a dorsal bunion, intractable plantar keratosis beneath the second metatarsal head, and arthritis of the first and second metatarsocuneiform joint. Radiographically, hypermobility is evaluated by measurements from the modified Coleman block test (for sagittal motion) and the radiographic squeeze test (for transverse motion) and by the identification of signs, such as cortical hypertrophy along the medial border of the second metatarsal shaft, a cuneiform split, the presence of os intermetatarseum, and the round shape and increased medial slope of the first metatarsocuneiform joint. Usually, treatment for hypermobility of the first ray is operative, but surgery is contraindicated for patients less than 20 years of age (especially when the epiphysis is not closed) and for patients with generalized ligamentous laxity, short first metatarsal, and arthritis of the hallux MTP joint. The authors' surgical treatment of choice is arthrodesis of the tarsometatarsal joint (as part of the hallux valgus correction), exostectomy, capsulorraphy, and distal soft tissue release to correct and stabilize the first metatarsal at the apex of the deformity. The authors have found it unnecessary to include the base of the second metatarsal. The main complications associated with the Lapidus procedure and its modifications are nonunion, malunion, and dorsal elevation of the first metatarsal. Although radiographic nonunion is the most frequent complication, only 25% of the patients with this condition have associated clinical findings; the results have been defined as good or excellent in two series. These results closely equal those in rheumatoid or sedentary patients managed with newer, modified, less traumatic techniques that stabilize the first metatarsocuneiform joint with screws rather than with arthrodesis.     

An actively mobile accessory digit arising from the dorsum of the foot: an unusual example of polydactyly

Polydactyly is one of the most common congenital deformities with an incidence of between 5 and 17 per 10,000 live births. Super-numerary digits of the foot present most commonly at the fibular border. A super-numerary digit arising from the dorsum of the foot has only been described on two occasions. In one case, the digit was thought to be a skin appendage. In the other, the digit shared morphological features with its neighbours but was relatively hypo-plastic and was incapable of active movement. The child was non-syndromic. We present a case of a mobile, active super-numerary digit arising from the dorsum of the foot, the first of its kind to be described in the literature. The child had the rare congenital disorder Kabuki syndrome.