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.     

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.     

Hallux valgus and first ray mobility. A prospective study

BACKGROUND: There have been few prospective studies that have documented the outcome of surgical treatment of hallux valgus deformities. The purpose of this investigation was to evaluate the effect of operative treatment of hallux valgus with use of a proximal crescentic osteotomy and distal soft-tissue repair on the first metatarsophalangeal joint. METHODS: All adult patients in whom moderate or severe subluxated hallux valgus deformities had been treated with surgical repair between September 1999 and May 2002 were initially enrolled in the study. Those who had a hallux valgus deformity treated with a proximal crescentic osteotomy and distal soft-tissue reconstruction (and optional Akin phalangeal osteotomy) were then invited to return for a follow-up evaluation at a minimum of two years after surgery. Outcomes were assessed by a comparison of preoperative and postoperative pain and American Orthopaedic Foot and Ankle Society scores; objective measurements included ankle range of motion, Harris mat imprints, mobility of the first ray (assessed with use of a validated calibrated device), and radiographic angular measurements. RESULTS: Of the 108 patients (127 feet), five patients (five feet) were unavailable for follow-up, leaving 103 patients (122 feet) with a diagnosis of moderate or severe primary hallux valgus who returned for the final evaluation. The mean duration of follow-up after the surgical repair was twenty-seven months. The mean pain score improved from 6.5 points preoperatively to 1.1 points following surgery. The mean American Orthopaedic Foot and Ankle Society score improved from 57 points preoperatively to 91 points postoperatively. One hundred and fourteen feet (93%) were rated as having good or excellent results following surgery. Twenty-three feet demonstrated increased mobility of the first ray prior to surgery, and only two feet did so following the bunion surgery. The mean hallux valgus angle diminished from 30 degrees preoperatively to 10 degrees postoperatively, and the mean first-second intermetatarsal angle decreased from 14.5 degrees preoperatively to 5.4 degrees postoperatively. Plantar gapping at the first metatarsocuneiform joint was observed in the preoperative weight-bearing lateral radiographs of twenty-eight (23%) of 122 feet, and it had resolved in one-third (nine) of them after hallux valgus correction. Complications included recurrence in six feet. First ray mobility was not associated with plantar gapping. There was a correlation between preoperative mobility of the first ray and the preoperative hallux valgus (r = 0.178) and the first-second intermetatarsal angles (r = 0.181). No correlation was detected between restricted ankle dorsiflexion and the magnitude of the preoperative hallux valgus deformity, the post-operative hallux valgus deformity, or the magnitude of hallux valgus correction. CONCLUSIONS: A proximal crescentic osteotomy of the first metatarsal combined with distal soft-tissue realignment should be considered in the surgical management of moderate and severe subluxated hallux valgus deformities. First ray mobility was routinely reduced to a normal level without the need for an arthrodesis of the metatarsocuneiform joint. Plantar gapping is not a reliable radiographic indication of hypermobility of the first ray in the sagittal plane.     

Classification of postaxial polydactyly of the foot

BACKGROUND: The origins and shapes of accessory digits in postaxial polydactyly of the foot were analyzed morphologically and radiographically, and their characteristics were determined. A simple classification method was then devised to assist in determining the most appropriate treatment options. METHODS: We evaluated 113 feet of 95 patients who had surgery for the treatment of postaxial polydactyly between 1998 and 2002. Based on the morphologic, radiographic, and operative findings, the cases were classified according to the origin of the accessory digit: middle phalangeal, proximal phalangeal, floating, fifth metatarsal, or fourth metatarsal. The proximal phalangeal type was further divided into three subtypes: proximal phalangeal lateral type, proximal phalangeal medial, and proximal phalangeal head. RESULTS: Of the 113 feet, 36 were middle phalangeal type, 45 were proximal phalangeal type, 5 were floating type, 15 were fifth metatarsal type, and 12 were fourth metatarsal type. Of the proximal phalangeal types, 15 were laterally duplicated supernumerary sixth digits, and 17 were medially duplicated supernumerary fifth digits. The duplicated digits of the remaining 13 originated at the distal portion of the proximal phalanx. In the middle phalangeal, proximal phalangeal head, proximal phalangeal medial, and fourth metatarsal types, the medial accessory fifth digit was an abnormally duplicated digit, which was excised. In the proximal phalangeal lateral, floating, and fifth metatarsal types, the lat eral accessory sixth digit was excised. For the children in this study, we did not perform reconstruction of the deep transverse metatarsal ligament or collateral ligament. Also, we did not use longitudinal pin fixation. Skin necrosis occurred in 10 feet that resolved, and in five of the 15 feet of the 5th metatarsal medial deviation occurred. CONCLUSIONS: Based on the morphologic, radiographic, and operative findings, we suggest a classification method of postaxial polydactyly of the foot. We believe this is a straightforward and useful method for the treatment of postaxial polydactyly.     

Surgical management of Darier's disease affecting the feet

Darier's disease is an autosomal dominant condition of variable severity affecting the skin, nails and mucosa. A 37-year-old man with Darier's disease on the soles of both feet was medically managed with oral retinoids, but areas of disease continued to fissure and cause excruciating pain. Surgical management with excision of diseased skin and resurfacing with split skin grafting was successful. There has been no disease recurrence at 6-month follow-up. This is the first reported case of excision and skin grafting for Darier's disease in the foot, a notoriously difficult area to operate on successfully. It also adds further evidence to the beneficial outcomes of surgical management in Darier's disease. Level of Evidence: Level V, therapeutic study.     

Spring ligament insufficiency and hallux valgus as an independent risk factors for first ray instability

IntroductionFirst ray instability (FRI) arising from failed plantar/interosseous ligaments is strongly associated with planovalgus, leading to synovitis and deformity. Our hypothesis is that proximal spring ligament insufficiency (SLI) drives secondary FRI in the absence of hallux valgus (HV) and may be an independent risk factor.MethodsPatients with FRI, screened by Klaue’s test, were recruited. Patients’ normal contralateral feet with previous radiographs were included as controls. First ray dorsal translation was measured with a digital Klauemeter. Spring ligament integrity was assessed using lateral translation distance as an indirect measure of spring ligament strain. Intermetatarsal angle and hallux valgus angle were recorded to classify the severity of HV.ResultsSeventy feet included, 54 had symptomatic FRI and 16 were asymptomatic contralateral feet included as control. Twenty-three feet had moderate/severe HV and 47 had mild/normal HV. Moderate/severe HV was associated with FRI (OR, 10.31; p = 0.029). Forty-five feet with SLI had a strong association with FRI (OR, 100.7; p < 0.0001). SLI without moderate/severe HV was the most prevalent group (31/54), followed by SLI with moderate/severe HV, 29.63% (16/54). Moderate/severe HV without SLI was prevalent in 11.1% (6/54) and 1.85% (1/54) had no SLI or moderate/severe HV. In a multivariate logistic regression analysis model, both SLI and severe/moderate HV were independent predictors of FRI.ConclusionThis is the first study that links SLI and HV as independent risk factors to FRI. 98.15% of FRI can be attributed to SLI, HV or both. First ray instability may allude to the strong presence of spring ligament insufficiency in the absence of hallux valgus.Level of evidenceLevel III, retrospective cohort study.     

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.     

Arthroscopic triple arthrodesis in patients with Müller Weiss disease

BackgroundMüller Weiss disease is a rare disease characterized by collapse of the lateral part of the navicular, outwards protrusion of the talar head and peri-navicular osteoarthrosis. We review the result of six patients treated by arthroscopic triple arthrodesis.MethodsSince 1998, arthroscopic triple arthrodesis was performed in six feet with Müller Weiss disease. The arthroscopic findings were analyzed. The feet were graded by the pre-operative X-rays according to Mareira classification. The consolidation of the triple arthrodesis was assessed by the post-operative X-rays of the operated feet. The clinical outcome was assessed by the modified AOFAS ankle–hindfoot scale.ResultsAll the operated feet fused solidly. The average time for solid fusion was 21 weeks (16–22 weeks). The overall American Orthopaedic Foot and Ankle Society (AOFAS) ankle–hindfoot score was 81.5.ConclusionsArthroscopic triple arthrodesis is an alternative surgical treatment in management of Müller Weiss disease resisted to conservative treatment.Level of evidenceLevel 4 therapeutic study.     

Feet deformation treatment in children with arthrogryposis multiplex congenita (AMC)--evaluation of the results]

In Arthrogryposis Multiplex Congenita (AMC) feet deformations are frequent. They have form of talipes equinovarus, or less frequently of plano-valgus. The study included influence of various surgical techniques on final result of foot treatment in arthrogryposis. The aim of the study was to analyse errors in classification and surgical technique influencing the final result. Between 1986 and 2004 21 AMC children were surgically treated. In all of the patients the disease was accompanied by heavy feet deformations: 38 talipes equinovarus deformations and 1 plano-valgus. Age of the treated children was between 7 months and 4 years. All feet required surgery. Follow-up period was 3 to 20 years, mean 12.5 years. During the follow-up examination the following elements were evaluated: foot appearance, gait mechanics, foot load level, wearing commercial shoes or orthopaedic equipment. Additionally radiography of feet in AP and lateral projection was performed. Posterior liberation was performed in 21 feet, peritarsal reposition in 18 feet. In case of 13 feet the primary correction was satisfactory. In the remaining 26 feet re-surgeries were necessary, including astrogolectomy in 9 feet. 13 good results were obtained--in which feet were properly loaded, adapted to common shoes and painless. 15 satysfying results were obtained--the feet required orthopaedic shoes; and 11 bad results, where temporary foot pain additionally occurred. Excessively conservative primary surgery in case of heavy foot deformations was a cause for multiple re-surgeries.     

An unusual case of fibular (postaxial) polydactyly: extrametatarsal head with fused duplication of the proximal phalanx

Polydactyly of the foot is a congenital anomaly characterized by the appearance of all or part of 1 or more additional rays. A number of morphologically and anatomically based classifications exist. We present an unusual case of fibular (postaxial) polydactyly characterized by an extrametatarsal head with fused duplication of the proximal phalanx. We describe the method of surgical correction and emphasize the need for careful preoperative planning to achieve a good functional and cosmetic outcome.     

Onychomatricoma: a case report with literature review

Onychomatricoma (OM) is a fibroepithelial tumor of nail matrix that occurs in the digits of both the hands and feet. This was first reported by Baran and Kint. They initially described 3 cases, all of which demonstrated a filamentous tumor of matrix tissue that resulted in a thickened funnel-shaped nail. Although apparently benign, it is subject to recurrence, and long-term follow-up is recommended because it is not known whether there is a conversion to malignancy. Even though this neoplasm was first described more than 18 years ago, there remains a dearth of case reports (currently fewer than 50) in the literature. This is a single case report and literature review. Levels of Evidence : Therapeutic, Level IV.     

The treatment of congenital foot abnormalities

With the exception of club foot, flat foot and claw foot, this paper gives a review of principal foot malformations at birth, proceeding from the available radiographical and clinical findings, and also from the facts found during surgery. In addition, there is suggested a classification of various deformities, and there are defined major guidelines and instructions for treatment. As far as the rather frequent polydactylies are concerned, the author distinguishes between a distal phalanx type, an interphalanx type, a proximal phalanx type, a metatarsal type and a tarsal type, depending on the "level", each, where distal/proximal web separation between the fingers stops. It is possible to include also rather particular forms, such as the rudimentary type and the so-called multiplications in this classification. The major indications for the surgical treatment of polydactylies are problems in finding adequate shoes, and also the aesthetic appearance. The principal concern of surgical treatment is to remove additional toes. When there is in parallel a syndactyly or a congenital hallux varus, this may require great skill in the applied surgical technique. Various approaches of surgical treatment are demonstrated by a few examples. Feet oligodactylies are primarily encountered with fibula dysplasia or aplasia, or in cleft feet. In very severe cases it is possible to find just one toe. The actual deformities alone rarely require surgical treatment, but they often "hint at" further malformations in the reach of the root of the foot (synostosis) and of the lower limb. Cleft feet are also frequently impaired in form and function, with these deformities including less severe hypoplasia of a middle toe, e. g. with a somewhat deeper web separation, toe aplasia, metatarsus hypoplasia and aplasia, synostosis, and transversal bones, and even monodactylies with only ray V existing. Additional toes in the cleft foot is one of the rare exceptions. However, the combination of cleft feet and cleft hands is rather frequently encountered. Many cleft feet are nevertheless highly efficient, even without any surgical treatment. That is why there are only indications for a surgical treatment when there are severe foot deformities or most inconvenient misalignments of peripheral toes. Some of the "lobster like" feet are so wide that it is just not possible to wear normal shoes. In this case it is recommended to have surgical correction and to close the cleft. Feet of congenital giant growth are extremely rare, but they raise most complex problems as to adequate treatment. In many cases, an amputation of the additional parts cannot be avoided.(ABSTRACT TRUNCATED AT 400 WORDS)     

Shortening of the first metatarsal as a complication of metatarsal osteotomies

There have been few reports of shortening of the first ray of the foot because of damage to the physis of the first metatarsal during the performance of metatarsal osteotomy for residual metatarsus adductus. In a retrospective study of twenty-seven feet in twenty patients who underwent this procedure, eight feet in seven patients were noted to have some degree of residual shortening of the first ray. This is an incidence of 30 per cent. The follow-up period after osteotomy ranged from two years to seven years and four months (average, four years). We could find no clear correlation between the occurrence of shortening and the patient's age at osteotomy, sex, or race, or the etiology of the adduction for which the osteotomy had been done. A clear correlation was found, however, with the surgical technique that had been employed. In two of the eight feet with a short first ray, the osteotomy had been done within the physis of the first metatarsal. In the other feet the procedure had employed an osteotomy site close to the physis or extensive periosteal dissection, or both. The results in our patients implicate subperiosteal dissection of the first metatarsal as an important, previously unreported cause of damage to the physis and of the resultant shortening. We recommend radiographic determination of the relationship of the osteotomy site to the physis before dissection is performed.     

Macrodactyly of the foot

BACKGROUND: The purpose of this study was to focus on the problems associated with macrodactyly of the foot and to formulate guidelines for optimum treatment. METHODS: Seventeen feet (fifteen patients) with macrodactyly formed the basis of this retrospective review. The feet were classified into one of two groups, depending on whether the macrodactyly involved only the lesser toes (group A) or involved the great toe with or without involvement of the lesser toes (group B). Toe amputation or ray resection was usually done to reduce the length and width of the foot in group A, whereas the length of the first ray was reduced by epiphysiodesis or amputation of the phalanx in four of the five feet in group B. In both groups, soft-tissue debulking was an integral part of the treatment. The severity of the macrodactyly and the effect of treatment were documented radiographically by measurement of the so-called metatarsal spread angle. At the latest follow-up evaluation, each foot was graded with regard to pain and shoe wear. RESULTS: Toe amputation was performed in six of the twelve feet in group A and toe shortening was performed in two, but only three of those procedures had a good result. Ray resection was performed in five feet (as an initial or secondary procedure) in Group A, and all had a good result. The mean reduction of the metatarsal spread angle was 10.0 degrees following resection of a single ray in Group A. In Group B, four of the five feet were rated as having only a fair result because shortening alone did not effectively reduce the size of the great toe. The macrodactyly of the great toe was not treated in the fifth foot, which also had a fair result. CONCLUSIONS: Toe amputation, which is cosmetically unappealing, is not effective for treating macrodactyly of the lesser toes and does not address the enlargement of the forefoot. Ray resection results in the best cosmetic and functional outcomes in feet with involvement of the lesser toes. When the great toe is involved, the result is often only fair, and repeated soft-tissue debulking may be necessary.     

Transverse laxity of the forefoot

BackgroundSplay of the forefoot reflects the loss of tension in the soft tissues and indicates failure of the biomechanics of the tie-bar system. By identifying and quantifying the soft tissue structures involved in the destruction of forefoot stability we could increase the understanding of forefoot pathologies.MethodsWe investigated the transverse forefoot laxity on healthy feet, feet with forefoot pathology and cadaveric feet undergoing sequential dissection.ResultsStatistical difference in transverse laxity was seen between healthy feet (n = 160) and feet with symptomatic forefoot pathology requiring surgery (n = 29). Presence of lesser ray pathology is associated with increased transverse laxity.For the dissected cadaveric feet (n = 9) sequential sectioning the plantar plate causes a progressive evolution of transverse laxity. The repair of plantar plates greatly improves transverse stability.ConclusionsForefoot pathology causes increased transverse laxity. In case of a major transverse laxity of the forefoot a plantar plate lesion should be suspected.     

Sliding oblique osteotomy for the treatment of hallux abducto valgus associated with functional hallux limitus.

This is a retrospective study of 27 patients (35 feet) with hallux abducto valgus associated with hallux limitus who underwent a sliding oblique osteotomy for surgical treatment between August 1997 and June 1998. Radiographic analysis and range-of-motion measurements were evaluated with an average follow-up of 65 days (range, 26-100). Preoperative criteria included < 45 degrees of dorsiflexion of the first metatarsophalangeal joint with weightbearing, no evidence of degenerative joint disease at the first metatarsocuneiform joint, and no previous surgical procedures on the first ray. The average preoperative intermetatarsal angle was 9 degrees, hallux abductus angle 17 degrees, and first metatarsal declination angle 15 degrees. The average postoperative intermetatarsal angle was 6.6 degrees, hallux abductus angle 10.3 degrees, and first metatarsal declination angle 21.7 degrees. Eighteen patients (22 feet) had a follow-up of over 6 weeks, and the first metatarsophalangeal joint was evaluated. The average gain in postoperative range of motion with weightbearing was 22.3 degrees.     

第1跖列稳定术联合第2-5跖骨头切除术治疗晚期类风湿关节炎前足畸形

目的:介绍第1跖列稳定联合第2-5跖骨头切除术治疗晚期类风湿关节炎(rheumatoid arthritis,RA)前足畸形的手术方式并对中短期临床疗效进行评价。方法:2006年10月至2010年8月收治的晚期RA前足畸形97例患者进行回顾性分析。其中,男9例,女88例;单足65例,双足32例;年龄36～67岁,平均54岁;病程6～32年,平均17年。所有病例存在严重的拇外翻同时合并第1跖跗关节不稳,第2-5跖趾关节脱位及僵硬。采用第1跖列稳定联合第2-5跖趾关节成形术对其进行治疗。通过影像学资料测量拇外翻角(Hallux valgus angle,HVA),跖骨间角(intermetatarsal angle,IMA),并采用JSSF(Japanese Society for Surgery of the Foot)评分对临床疗效进行评估。结果:97例患者中失访5例(7足),平均随访37个月(6～52个月),其中1例术后1年因急性心肌梗死死亡。术前JSSF评分(33.2±8.2)分,末次随访时改善至(67.3±3.1)分(P<0.01);HVA由术前(50.0±11.8)°纠正至术后(21.2±3.2)°(P<0.01);IMA由术前(15.5±3.6)°纠正至术后(9.7±6.6)°(P<0.01)。发生跖趾关节骨不连4足;术后8～11月摄片发现第1楔骨内高密度改变3足;出现拇内侧切口延迟愈合9足;跖趾关节内固定感染2足;跖跗关节内固定感染1足;第2-5跖趾关节术后16足畸形复发。结论:晚期RA患者的前足病变涉及范围广,畸形严重。采用第1跖趾关节融合联合Lapidus术式重建第1跖列的外形及稳定性,跖骨头切除术纠正第2-5跖趾关节畸形的方式重建前足疗效可靠。该术式适用于重度拇外翻合并IMA增大及第1跖跗关节不稳,同时存在第2-5跖趾关节僵硬性半脱位的患者。