Two cases of complete polymetatarsia without polydactyly.

We report two patients exhibiting complete polymetatarsia between the fourth and fifth metatarsals of the right foot, without supernumerary digit. To our knowledge, only a few cases of polymetatarsia without supernumerary digit have been reported, and all of those cases have involved incomplete duplication. Although there were no externally visible deformities in the present cases, plain radiographs revealed an extra bone between the fourth and fifth metatarsals. Case 1 presented with pain between the fourth and fifth metatarsals, and this pain ceased after resection of the extra metatarsal. Although case 2 was asymptomatic, the extra metatarsal of the left foot was resected during surgery for postaxial polydactyly of the right foot. Although differential diagnosis with os intermetatarseum was problematic, we concluded that the extra bones in the present cases were duplicated metatarsals, rather than accessory bones, based on three clinical findings: configuration of the extra metatarsal (articular cartilage and growth plate), in case 1; location of extra metatarsal (the most common site of polydactyly of the foot), in both cases; and polydactyly of the opposite foot, in case 2.     

Rare Presentation of Foot Postaxial Polydactyly

Polydactyly is a prevalent birth anomaly observed in the foot, and a number of classification systems have been suggested for this condition. Postaxial (fifth or little toe) polydactyly is the most common type. We encountered an exceedingly rare presentation of foot postaxial polydactyly that, to our inspection, had neither been previously classified nor described in published studies. In the present report, we have described an otherwise healthy 2-year-old female who had presented to our clinic with an isolated, extra little toe on her left foot. Foot radiographs revealed the presence of all 5 metatarsals; however, the fifth metatarsal was blocked and did not give rise to the fifth toe. Instead, the fifth (medial normal) and sixth (lateral extra) toes had originated from a single, separate accessory bud from the fourth metatarsal, and the main fourth metatarsal had given rise to the normal fourth toe. The lateral sixth toe was excised, and a periosteal sleeve of the excised extra toe was used for reconstruction of the lateral collateral ligament. We propose that this heretofore unmentioned presentation of postaxial polydactyly be added to the existing systems of classification of pedal polydactyly. A review of the published data pertaining to pedal polydactyly has also been presented.     

Examination of Postoperative Outcomes Using Morphological and X-Ray Classifications and Selection of the Toe to Be Excised in Postaxial Polydactyly of the Foot

The treatment of postaxial polydactyly requires excision of the medial fifth or lateral sixth toe, and separation of the adjacent fourth/fifth toes if the adjacent toes exhibit skin syndactyly. Morphological changes in the retained toes and reoperation are common problems after such surgery. This study examined the effects of preoperative classifications and selecting the medial fifth or lateral sixth toe for excision on the postoperative outcomes of surgery for postaxial polydactyly. From April 2006 to March 2019, surgery for postaxial polydactyly was performed on 55 feet in 49 patients. The patients’ mean age at surgery was 28.8 months. Postoperative esthetic and bone alignment scores, the reoperation rate, and postoperative dysfunction were examined. The postoperative esthetic and bone alignment evaluations were performed by examining postoperative photograph and X-ray images using original scoring systems. The surgical procedure was chosen by the surgeon-in-charge during a preoperative conference after considering the toe growth and bone alignment. In the postoperative esthetic evaluation, excising the lateral sixth toe produced significantly better outcomes than excising the medial fifth toe. The morphological classification also indicated that excising the lateral sixth toe produced better outcomes, as it resulted in the bifurcated toes being clearly independent. Interestingly, the postoperative X-ray-based bone alignment score was not correlated with the esthetic score. The reoperation rate tended to be high after medial fifth toe excision. There were no postoperative functional complications. Lateral sixth toe excision for postaxial polydactyly of the foot produces good postoperative esthetic outcomes.     

Polydactyly of the foot. Literature review and case presentations

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. Polydactyly is generally classified into three major groups: medial ray (preaxial), central ray and lateral ray (postaxial). The duplication may appear at the distal and middle phalanges or at the whole digit and metatarsal. The complexity of the deformity ranges from a simple soft-tissue problem to a completely developed accessory ray. Careful clinical and radiographic evaluation should be made prior to treatment to achieve good functional and cosmetic results. Most cases are treated during childhood before walking age. Adult cases are more rare, and surgical management of the deformity is still debated. Nevertheless, surgery can be performed at any age as in our series with good results.     

Polydactyly and polysyndactyly of the fifth toe

Classification and treatment of polydactyly and polysyndactyly of the fifth toe are described based on a study of 37 patients with 46 affected feet. Polydactyly was seen in 26.1% of duplicated toes, polysyndactyly in 28.3%, and polysyndactyly fused with the fourth toe in 45.7%. Thirty-three patients with 42 toes were surgically treated. The medial toe was removed in patients with the duplicated fifth toe fused with the neighboring fourth toe; if necessary, a free full-thickness skin graft was performed on the fourth toe and not on the fifth toe. Either the lateral or the medial fifth toe was excised for better contour of the forefoot in patients with polysyndactyly without fusion with the fourth toe. The lateral digital ray, including the metatarsal, was excised in patients with polydactyly of the metatarsal type. The average age of patients at operation was 12.3 months (range, five days to five years). Reorganization of the foot was facilitated when the child was treated early or before it could walk.     

Bizarre accessory metatarsal located between the left fourth and fifth metatarsals: A case report

We report a case of bizarre accessory metatarsal located between the left fourth and fifth metatarsals without a supernumerary digit in a 6-year-old girl. The accessory metatarsal was resected to alleviate foot pain on walking. This metatarsal dysplasia might have arisen from sequential failures of digital formation at an early stage of development.     

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.     

Surgical Procedures Based on the Arthrographic Findings of the Fifth MTP Joint With Proximal Phalanx Duplication in Postaxial Polydactyly of the Foot

Radiographic findings in several atypical cases of postaxial polydactyly of the foot do not provide sufficient information to assess the cartilaginous structures or duplicated digit connections at the MTP joint. The purpose of this study was to demonstrate the surgical procedures using arthrography for the cartilaginous structures of the MTP joint in postaxial polydactyly of the foot. We performed arthrography in 7 feet of 7 patients with postaxial polydactyly of the foot in which duplication of the proximal phalanx was observed at the fifth MTP joint on the basis of radiographic evaluation. The average age at surgery was 13.5 months and average duration of postsurgical follow-up was 36 months. Individual surgical procedures were confirmed or modified during the operation by reference to the arthrographic findings. Radiographic and arthrographic findings were assessed in relation to the findings from direct observation of the cartilaginous structures at surgery. Postoperative malalignment, functional disturbance and pain in the reconstructed toe were evaluated. The arthrographic findings provided different forms of cartilaginous structures that could be categorized in 4 types, and reflected the cartilaginous connection visualized at surgery that could not be detected on radiographs in each case. No cases revealed any deformities, functional disturbance, or pain in the reconstructed toe after surgery. The parents’ evaluation in each case was “very satisfied” or “satisfied.” The arthrographic findings provided additional information regarding variations in the cartilaginous structures of the fifth MTP joint and for determining individual surgical procedure for postaxial polydactyly of the foot.     

An unusual case of preaxial polydactyly of the hands and feet: a case report

An unusual case of polydactyly of the hands and feet is described. The ulnar 4 digits of both hands and the outer 4 digits of both feet appeared normal, and the extra digits were on the radial side of the hands and on the medial side of the feet. The pattern of polydactyly did not fit any of the well-known deformities associated with radial digital duplication such as thumb polydactyly, mirror hand, or duplicated (multiple) hands. The harmonious deformities of the hands and feet suggest a genetic alteration to the development of all 4 limb buds, but the case did not fit any of the known syndromes that have high-level preaxial digital duplication of the hands and feet.     

The "necktie lasso": a new technique for the simultaneous treatment of Wartenberg's sign and claw deformities in the hand due to ulnar nerve palsy

The "necktie lasso" is a new technique that allows the simultaneous active treatment, of both Wartenberg's sign and claw deformity of the fifth and the fourth digits in the hand with ulnar nerve palsy. The flexor sublimis of the fourth digit is taken by a palmar approach. It is then divided into two strips up to the proximal part of the palm; The radial strip is used as a classical "direct lasso" to treat the claw deformity of the fourth digit; The ulnar strip is wound around the base of the fifth digit by a palmar and dorsal approaches at the level of the proximal phalanx, like a necktie, being medial to its radial pedicle, dorsal and superficial to its extensor apparatus, then lateral to its ulnar pedicle; It is then recovered in the palm and sutured to itself. From September 1998 to April 2003, this technique has been used in eight patients aged between 21 and 35 years old and suffering from post traumatic low ulnar nerve palsy. It was always very effective in dealing with Wartenberg's sign: the active adduction of the fifth digit appearing at the start of flexion. The claw deformity of the fourth and fifth digits was equally actively corrected. No complications are reported in this series. With a mean follow-up of 3 years there was no recurrence of any of the deformities.     

An unusual presentation of postaxial polydactyly of the foot

A 6‐month‐old Caucasian baby is described with a postaxial polydactyly of the letf foot. Radiographic examination revealed the accessory digit was composed of soft tissue, some with a tiny osseous element, originated from around the metatarsophalangeal joint, defined by floating type (FT). The parents had consistent difficulty putting shoes. We encountered an exceedingly rare presentation of FT, to our inspection, had neither been previously related in published studies. To the best of our knowledge, this represents the unusual case of congenital deformity lesion on the left foot to be reported in the medical literature.     

Proximal dome-shaped osteotomy for symptomatic bunionette

The results of a dome-shaped osteotomy of the proximal third of the fifth metatarsal in patients with symptomatic bunionette deformity were reviewed. The series was comprised of eight patients (10 feet; mean age of patients, 21 years). The average followup was 30 months. All patients were free from pain at the fifth metatarsophalangeal joint and were satisfied with the results of this procedure. The mean angle between the longitudinal axes of the fifth metatarsal and the proximal phalanx was 18.9 degrees before surgery and 2.6 degrees after surgery. The mean angle between the longitudinal axes of the fourth and fifth metatarsals was 12.2 degrees before surgery and 4.8 degrees after surgery. The overall results were good in all 10 feet. Three feet had delayed union at the osteotomy site, but union was obtained in all feet. The osteotomy site of the fifth metatarsal in feet with delayed union was more proximal than that of the other feet. Therefore, proximal osteotomy of the fifth metatarsal should be done not at the base, but at the proximal site of the diaphysis to prevent delayed union. A proximal dome-shaped osteotomy corrects the deformity and relieves the symptoms, but careful attention should be paid to the osteotomy site.     

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.     

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.     

A nonclassified preaxial polydactyly of the foot

Polydactyly of the foot has been classified according to anatomic differences in bony structures, external appearance of involved digits and associated anomalies. A new subtype of the metatarsal type of the medial ray (preaxial) polydactyly of the foot is presented. This includes triplication of the first metatarsal triplication of the tendons and three separate big toes. In addition, associated anomalies were present: short tibia and pes varus.     

The foot in Apert syndrome

Foot deformity in Apert syndrome is very characteristic and predictable. Progressive synostosis occurs on what is presumably an unsegmented cartilaginous mass. The first ray shortens with medial deviation of the great toe, secondary to growth abnormality and a delta phalanx. The two phalanx digits characteristically go on to fusion, with maintenance of minimal motion at the metatarsal phalangeal joints. The midfoot and hindfoot progress to characteristic fusion in a supinated position. There is prominence of the fifth metatarsal with callosities under the fifth and third metatarsal heads in all patients. Orthotic and surgical management of these conditions is necessary to ensure maximal function in the symptomatic Apert patient.     

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.     

Effect of the First Tarsometatarsal (Modified Lapidus) Arthrodesis on Hindfoot Alignment

The purpose of this study is to demonstrate the effect of first tarsometatarsal (modified Lapidus) arthrodesis on hindfoot alignment. We reviewed the radiographs of 39 patients, 40 feet (16 right feet and 24 left feet in 6 males and 34 females; mean age 43 years) who underwent hallux valgus reconstruction and isolated first tarsometatarsal arthrodesis. Patients who had ancillary osseous procedures were excluded from the study, with the exception of proximal phalangeal osteotomy to address hallux interphalangeus.The mean time to follow up was 33.78 weeks (8.45 months), median 21.5 weeks. Statistically significant differences were found between preoperative and postoperative measurements for talar declination (?3.3 ± 3.5), lateral talocalcaneal angle (?3.1 ± 3.9), lateral Meary's angle (?4.2 ± 4.9), medial cuneiform height (3.5 ± 4.6), medial cuneiform to fifth metatarsal distance (4.7 ± 4.5), AP talocalcaneal angle (?2.8 ± 5.3), and percentage of talar head uncovering (?6.6 ± 7.6). Our results suggest that first tarsometatarsal arthrodesis can affect hindfoot alignment on AP and lateral radiographs.     

Isolated hexadactylia: A rare case of central polydactyly of the foot

BackgroundCentral polydactyly of foot is uncommon form of polydactyly but it usually causes intermetatarsal widening because of metatarsal bifurcation. Central polydactyly associated with T shaped bifurcation of metatarsal in vertical plane has not been reported yet.CaseWe present a 4 year male child with extra toe on the dorsal aspect of right foot with complains of difficulty in wearing footwear and poor cosmesis. The extra digit was fully developed with bifurcation of 2^nd metatarsal bone proximal to the head without any intermetatarsal widening. The angular deviation was 45° to the longitudinal axis of foot and in a plane vertical to the transverse arch of foot. The child was operated with excision of extra toe without any residual bony deformity.ConclusionThe central polydactyly is rare type of polydactyly of foot. Central polydactyly with metatarsal extension causing intermetatarsal widening has been well described entity. But the previous classifications need to be modified to include central polydactyly with vertical oriented T bifurcation of metatarsal bone without intermetatarsal widening.