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Syndactylization of the lesser toes
SYNDACTYLIZATION OF THE LESSER TOES ERIC BARTEL, MD
Syndactylization is a simple and effective technique for the treatment of recurrent soft corns and as a salvage procedure for flail toes. It is used as an adjuvant procedure in the correction of cock-up fifth toe deformities, rheumatoid forefoot deformities, or severe hammertoes in addition to the primary soft tissue releases and/or bone resections. Though simple, the technique requires meticulous soft tissue handling and closure to avoid complications. KEY WORDS: syndactylization, soft corn, flail toe
Multiple surgical procedures have been proposed to deal with common deformities of the lesser toes. 1-13 It is clearly evident that no single operative procedure can satisfactorily correct every deformity. The orthopaedic surgeon is then faced with the challenge of matching the appropriate surgical procedure with the underlying pathology. TypicallN this results in a combination of surgical techniques individualized to the patient. Syndactylization is a relatively simple soft tissue procedure that may be used alone or in combination with other soft tissue balancing techniques or bony procedures. Syndactylization tends to be performed most commonly on the fourth and fifth toes, although it may be used on any of the lesser digits. It allows correction of both primary and secondary deformities by providing stability to the digits. It also directly addresses web space pathology. Initially described by McFarland, 9 Scrase, 12 and Kelikian 6 and subsequently Leonard and Rising, 7 these authors describe excellent results for a variety of deformities, particularly involving the fifth toe. Kelikian et al6 has the most complete work regarding syndactylization. He describes the use of syndactylization for an array of disorders ranging from gigantism of the second toe, cleft foot, congenital curly toe, overlapping fifth toe, congenital, and acquired hammertoes to interdigital clavus. He reported excellent results for each of these deformities. Depending on the deformity, he would perform either an isolated syndactylization or an associated bone resection if the deformity was not correctable by a soft tissue procedure alone. He described using a crossed incision technique in the web space without any resection of skin. McFarland 9 and Scrase 12 described a similar technique with excellent results for correction of fifth toe deformities. In all cases, additional bone resection was performed. Leonard and Rising 7 described a U-incision between the fourth and fifth toes with a resection of tissue involved. They reported excellent results in nearly 100% of their patients without :recurrence using syndactylization only for correction of overlapping fifth toe. Correction of rheumatoid forefoot disorders have been extensively treated by From Fox Valley Orthopedic Associates, Geneva, IL. Address reprint requests to Eric Bartel, MD, Fox Valley Orthopedic Associates. 2525 Kaneville Road, Geneva IL 60134. Copyright © 1999 by W.B. Saunders Company 1048-6666/99/0901-0004510.00/0
syndactylization. Daly and Johnson, 2 Saltzman et al, ~° Saltzman, n and Jahss 5 reported variable results in correction of forefoot deformities. In all cases, they used bone resection, primary partial proximal phalangeal resection with or without metatarsal head resection, and syndactylization for stabilization of the toes after bone resection. Cosmesis was the only complication directly attributable to the syndactylization portion of the procedure. Syndactylization as an isolated procedure has also been proposed for salvage of flail toe, 1,4 treatment of interdigital soft corns, s.6 and treatment of chronic tinea pedis, s The reports have been excellent for control of the deformity without recurrence, with occasional cosmesis complaints being the major complication.
INDICATIONS Instability of a toe is a primary indication for isolated syndactylization. Chronic instability may be secondary to recurrent dislocations of the fifth digit either at the proximal interphalangeal (PIP) or metatarsophalangeal (MTP) joints. The main iatrogenic cause of flail toe is excessive bone resection, particularly of the proximal phalanx originally performed for fixed deformities of the fifth toe. In cases of either iatrogenic or posttraumatic instability, the toe clinically tends to catch on footwear or receive repeated trauma when the patient walks barefooted. Repeated dislocations can become irreducible if left untreated. This can be quite physically distressing and cosmetically unsatisfactorv. Stabilization can be achieved with syndactylization. A second indication for isolated syndactylization is m the treatment of recurrent interdigital soft corns. This is commonly found in the fourth web space due to high pressure areas from constricting footwear. Failing conservative treatment, syndactylization is an excellent alternative to traditional DeVries condylectomies. The pain is relieved with syndactylization by removing the corn and all skin under compression in the web space. Recurrence due to inadequate bone resection is not seen with this technique. Postoperative instability from over-exuberant condylar shaving techniques at the base of the proximal phalanx is also avoided. In conjunction with bone resection, syndactylization gives added stability postoperatively and often precludes the need for postoperative pin fixation. It is used for
Operative Techniques in Orthopaedics, Vol 9, No 1 (January), 1999: pp 51-54
51
treatment of severe idiopathic hammertoe and rheumatoid forefoot deformities where large amounts of bone are resected to obtain full correction. The syndactylization is typically performed between digits 2 and 3 or 4 and 5 to give maximal stability.
CONTRAINDICATIONS As with other procedures involving the toes, syndactylization is contraindicated in the face of severe peripheral vascular disease, infection, or severely fragile soft tissue. Significant concerns about cosmesis are the primary contraindication for isolated syndactylization and preoperative counseling, preferably with photographs of past surgeries, can help avoid unrealistic patient expectations. Additionall~ adjacent toes with uncorrected deformities will cause progressive deformity in the syndactylized toes and are a relative contraindication unless this is taken into consideration and both toes are corrected at the same time.
TECHNIQUE The patient is positioned supine on the operating room table with the foot and ankle draped out in the standard fashion. Typically, an ankle block anesthetic with ankle tourniquet hemostasis is used during the case. Intravenous (IV) sedation is usually desirable with use of an ankle tourniquet. An Esmarch bandage is used to exsanguinate the foot with tourniquet being inflated to approximately 200 to 250 m m of Mercury. With the toes separated, a marking pencil is used to outline the incision starting with the shorter "fifth" toe (Fig 1). A line is drawn midline between the dorsal and plantar aspects of the toe erring plantar rather than dorsal. Typicallj6 the length of incision is to the level of the middle phalanx. In cases of gross instability at the PIP joint or complete lack of a proximal phalanx secondary to a previous total resection, the incision is carried out to the base of the distal phalanx. While the ink is still moist, the adjacent two toes are brought together in a cosmetically acceptable position with the nails aligned. This leaves a faint ink line on the adjacent toe (Fig 2). The line is darkened to complete the "V"-incision in the web space. Dorsally the line can be extended proximally between the adjacent metatarsal heads to form a Y-shaped incision. This
Fig 1. Incision outlined on shorter toe.
52
Fig 2. Mirror image incision on longer toe after placing toes in corrected position.
proximal extension will allow access to the MTP joint or web space to correct coexisting deformities. Using a no. 15 blade, the incision is made along the lines drawn. Full thickness flaps are developed in the web space (Fig 3). Because the proper digital nerves are plantar and dorsal to the midline incision, they are protected, along with soft tissue, when elevated with the flaps. Skin hook retractors are placed. A wedge shaped section of tissue may be resected from the web space using a second set of incisions inferior to the midline cuts. These second incisions are taken through dermis only with care to protect the proper digital nerves and vessels during removal of the tissue. Within the resected tissue would be any soft corns present. By resecting tissue, increased stability and closer approximation of the adjacent toes is obtained postoperatively. If correction of a fused PIP contracture is necessar)~ an appropriate amount of bone can be resected from the distal aspect of the proximal phalanx after subperiosteal dissection is performed (Fig 4). Hemostasis is achieved with bipolar cautery to avoid postoperative hematoma, which can lead to late wound dehiscence. If additional bone resection is to be performed at the MTP joint, soft tissue is cleared from the base of the proximal phalanx. Small Hohmann retractors are used to protect the neurovascular bundle, flexor, and extensor tendons. Resection of the base of the proximal phalanx is accomplished with an oscillating saw. If complete excision of the proximal phalanx is required, this is done with meticulous sharp dissection subperiosteally with a scalpel blade. Of note, equivalent resections should be performed
Fig 3. Full thickness flaps placed midline in the web space. ERIC BARTEL
Fig 4. (A) Correction of PIP contracture, (B) subperiosteal dissection of the proximal phalanx, after bone resection.
on the adjacent toes to be syndactylized. If unequal lengths are removed, the toes will shorten by two differing lengths and give unaccep~:able cosmetic results. K wire fixation may be required depending on the bone resection procedure. Closure is the most meticulous and time-consuming portion of the case. Absorbable sutures may be used, but a nonabsorbable suture such as a 4.0 prolene or nylon is preferred because less local suture reaction in the web space is created. Gentle soft tissue handling is essential to avoid w o u n d healing problems (Fig 5). Simple interrupted sutures are started plantarly at the apex of the web space with skin edges ew,~rted. Sutures are placed every 2 to 3 mL apart to keep tissue tension evenly distributed (Fig 6). The sutures are carried distally on the plantar flap then back proximally on the dorsal surface to finish closure of the wound. Sutures wJLllbe visible where the incision extends between the metatarsals, but less so in the web space (Fig 7). There should be an infolding of the dorsal flap if the incision has been placed correctly in the midline. This makes the syndactPylization slightly less obvious and more cosmetically acceptable. In addition, the adjacent nails
Fig 5. A traumatic handling of soft tissue flaps with skin hooks. SYNDACTYLIZATION OF THE LESSER TOES
should remain parallel after closure without tilting inward or outward from the syndactylization. A soft bulky dressing is used with 4 × 4 gauze and 2' Kling wrap for slight compression. Minimal gauze is placed between the syndactylized toes at the tips. The toes should lie in the desired final position with the dressings in place. If delayed capillary refill occurs after deflation of tourniquet, the dressings may need to be gently teased from around the toes to release excessive compression. POSTOPERATIVE
CARE
The patient is encouraged to rest and elevate the foot immediately postoperatively. Weight-bearing is allowed only in a postoperative shoe with a flat foot gait. Initial dressings are changed in 3 to 5 days, as some bleeding is not uncommon. Sutures are removed at 3 weeks to avoid wound dehiscence associated with early suture removal. At the time of suture removal and K wire removal the patient is allowed back into normal supportive footwear. Initially, wide athletic shoes are usually manageable, but normal swelling precludes fashion shoe wear for up to 2 to 3 months postoperatively.
Fig 6. Skin closure with multiple interrupted sutures. 53
salvage t e c h n i q u e for flail toes. It offers a n alternative for the t r e a t m e n t of r e c u r r e n t soft corns t h a t d o e s n o t require b o n e resection or risk late instability. In addition, it continu e s to h a v e a limited, b u t i m p o r t a n t , role in the t r e a t m e n t of severe h a m m e r t o e d e f o r m i t i e s w h e n u s e d in conjunction w i t h o t h e r p r o c e d u r e s .
REFERENCES
Fig 7. Dorsal view after skin closure.
COMPLICATIONS C o m p l i c a t i o n s attributable directly to s y n d a c t y l i z a t i o n i n c l u d e infection, h e m a t o m a , a n d w o u n d dehiscence. Careful soft tissue h a n d l i n g a n d m e t i c u l o u s closure w i t h h e m o s t a s i s will d i m i n i s h c h a n c e s of these p r o b l e m s . Instability can o c c u r if the w e b b i n g is n o t carried distally e n o u g h . I n cases of intractable soft corns or relatively stable deformities, s u b t o t a l w e b b i n g to the level of the m i d d l e p h a l a n x is a d e q u a t e , h o w e v e r , for m o r e distal flail toes, w e b b i n g s h o u l d be carried o u t to the base of the distal phalanx. C o s m e t i c c o n c e r n s can be a v o i d e d w i t h t h o r o u g h p r e o p erative c o u n s e l i n g a n d a p p r o p r i a t e p a t i e n t expectations. Careful p l a c e m e n t of m i d l i n e incisions will h e l p a v o i d rotational m a l a l i g n m e n t .
DISCUSSION S y n d a c t y l i z a t i o n is a s i m p l e p r o c e d u r e , w h i c h h a s previo u s l y b e e n d e s c r i b e d for the c o r r e c t i o n of a m u l t i t u d e of deformities. As an isolated p r o c e d u r e , it is a n excellent
54
1. Coughlin MJ, Mann RA: Lesser toe deformities, in Mann RA (ed): Surgery of the Foot and Ankle (ed 6, vol 2). St. Louis, MO, Mosb~ 1993, pp 401-403 2. Daly PJ, Johnson KA: Treatment of painful subluxation or dislocation at the second and third metatarsophalangeal joints by partial proximal phalanx excision and subtotal webbing. Clin Orthop 278:164-170, 1992 3. Goldstein N, Woodward GS: Surgery for Tinea Pedis. Arch Deformity 99:701-704, 1969 4. Jahss MH: Chronic and recurrent dislocations of the fifth toe. Foot Ankle 5:275-278, 1981 5. Jahss MI-I:Disorders of the Foot and Ankle (ed 2, vol. 2). Philadelphia, PA, Saunders, 1991, pp 1190-1194, 1215-1217, 1225-1227 6. Kelikian H, Clayton L, Loseff H: Surgical syndactylia of the toes. Clin Orthop 19:208-231,1961 7. Leonard MH, Rising EE: Syndactylization to maintain correction of overlapping 5th toe. Clin Orthop 43:241-243, 1965 8. Marek L, Giacopelli J, Granoff B: Syndactylization for the treatment of fifth toe deformities. J Am Podiatr Med Assoc 81:248-252, 1991 9. McFarland B: Congenital deformities of the spine and limbs, in Platt H (ed): Modern Trends in Orthopaedics. New York, NY, Hosher, 1950, pp 107-108 10. Saltzman CL, Johnson KA, Donnelly RE: Surgical treatment of mild deformities of the rheumatoid forefoot by partial phalangectomy and syndactylization. Foot Ankle 14:325-329, 1993 11. Saltzman CL: Rheumatoid forefoot reconstruction, in Johnson RA (ed): Master Techniques in Orthopaedic Surgery: The Foot and Ankle. New York, NY, Raven, 1994, pp 197-211 12. Scrase WH: The treatment of dorsal adduction deformities of the fifth toe. J Bone Joint Surg 36B:146, 1954 13. Teasdall RD: Resection arthroplasty of the second & third toes, in Johnson RA (ed): Master Techniques in Orthopaedic Surgery: The Foot and Ankle. New York NY, Raven, 1994, pp 149-160
ERIC BARTEL
Syndactylization is a simple and effective technique for the treatment of recurrent soft corns and as a salvage procedure for flail toes. It is used as an adjuvant procedure in the correction of cock-up fifth toe deformities, rheumatoid forefoot deformities, or severe hammertoes in addition to the primary soft tissue releases and/or bone resections. Though simple, the technique requires meticulous soft tissue handling and closure to avoid complications. KEY WORDS: syndactylization, soft corn, flail toe
Multiple surgical procedures have been proposed to deal with common deformities of the lesser toes. 1-13 It is clearly evident that no single operative procedure can satisfactorily correct every deformity. The orthopaedic surgeon is then faced with the challenge of matching the appropriate surgical procedure with the underlying pathology. TypicallN this results in a combination of surgical techniques individualized to the patient. Syndactylization is a relatively simple soft tissue procedure that may be used alone or in combination with other soft tissue balancing techniques or bony procedures. Syndactylization tends to be performed most commonly on the fourth and fifth toes, although it may be used on any of the lesser digits. It allows correction of both primary and secondary deformities by providing stability to the digits. It also directly addresses web space pathology. Initially described by McFarland, 9 Scrase, 12 and Kelikian 6 and subsequently Leonard and Rising, 7 these authors describe excellent results for a variety of deformities, particularly involving the fifth toe. Kelikian et al6 has the most complete work regarding syndactylization. He describes the use of syndactylization for an array of disorders ranging from gigantism of the second toe, cleft foot, congenital curly toe, overlapping fifth toe, congenital, and acquired hammertoes to interdigital clavus. He reported excellent results for each of these deformities. Depending on the deformity, he would perform either an isolated syndactylization or an associated bone resection if the deformity was not correctable by a soft tissue procedure alone. He described using a crossed incision technique in the web space without any resection of skin. McFarland 9 and Scrase 12 described a similar technique with excellent results for correction of fifth toe deformities. In all cases, additional bone resection was performed. Leonard and Rising 7 described a U-incision between the fourth and fifth toes with a resection of tissue involved. They reported excellent results in nearly 100% of their patients without :recurrence using syndactylization only for correction of overlapping fifth toe. Correction of rheumatoid forefoot disorders have been extensively treated by From Fox Valley Orthopedic Associates, Geneva, IL. Address reprint requests to Eric Bartel, MD, Fox Valley Orthopedic Associates. 2525 Kaneville Road, Geneva IL 60134. Copyright © 1999 by W.B. Saunders Company 1048-6666/99/0901-0004510.00/0
syndactylization. Daly and Johnson, 2 Saltzman et al, ~° Saltzman, n and Jahss 5 reported variable results in correction of forefoot deformities. In all cases, they used bone resection, primary partial proximal phalangeal resection with or without metatarsal head resection, and syndactylization for stabilization of the toes after bone resection. Cosmesis was the only complication directly attributable to the syndactylization portion of the procedure. Syndactylization as an isolated procedure has also been proposed for salvage of flail toe, 1,4 treatment of interdigital soft corns, s.6 and treatment of chronic tinea pedis, s The reports have been excellent for control of the deformity without recurrence, with occasional cosmesis complaints being the major complication.
INDICATIONS Instability of a toe is a primary indication for isolated syndactylization. Chronic instability may be secondary to recurrent dislocations of the fifth digit either at the proximal interphalangeal (PIP) or metatarsophalangeal (MTP) joints. The main iatrogenic cause of flail toe is excessive bone resection, particularly of the proximal phalanx originally performed for fixed deformities of the fifth toe. In cases of either iatrogenic or posttraumatic instability, the toe clinically tends to catch on footwear or receive repeated trauma when the patient walks barefooted. Repeated dislocations can become irreducible if left untreated. This can be quite physically distressing and cosmetically unsatisfactorv. Stabilization can be achieved with syndactylization. A second indication for isolated syndactylization is m the treatment of recurrent interdigital soft corns. This is commonly found in the fourth web space due to high pressure areas from constricting footwear. Failing conservative treatment, syndactylization is an excellent alternative to traditional DeVries condylectomies. The pain is relieved with syndactylization by removing the corn and all skin under compression in the web space. Recurrence due to inadequate bone resection is not seen with this technique. Postoperative instability from over-exuberant condylar shaving techniques at the base of the proximal phalanx is also avoided. In conjunction with bone resection, syndactylization gives added stability postoperatively and often precludes the need for postoperative pin fixation. It is used for
Operative Techniques in Orthopaedics, Vol 9, No 1 (January), 1999: pp 51-54
51
treatment of severe idiopathic hammertoe and rheumatoid forefoot deformities where large amounts of bone are resected to obtain full correction. The syndactylization is typically performed between digits 2 and 3 or 4 and 5 to give maximal stability.
CONTRAINDICATIONS As with other procedures involving the toes, syndactylization is contraindicated in the face of severe peripheral vascular disease, infection, or severely fragile soft tissue. Significant concerns about cosmesis are the primary contraindication for isolated syndactylization and preoperative counseling, preferably with photographs of past surgeries, can help avoid unrealistic patient expectations. Additionall~ adjacent toes with uncorrected deformities will cause progressive deformity in the syndactylized toes and are a relative contraindication unless this is taken into consideration and both toes are corrected at the same time.
TECHNIQUE The patient is positioned supine on the operating room table with the foot and ankle draped out in the standard fashion. Typically, an ankle block anesthetic with ankle tourniquet hemostasis is used during the case. Intravenous (IV) sedation is usually desirable with use of an ankle tourniquet. An Esmarch bandage is used to exsanguinate the foot with tourniquet being inflated to approximately 200 to 250 m m of Mercury. With the toes separated, a marking pencil is used to outline the incision starting with the shorter "fifth" toe (Fig 1). A line is drawn midline between the dorsal and plantar aspects of the toe erring plantar rather than dorsal. Typicallj6 the length of incision is to the level of the middle phalanx. In cases of gross instability at the PIP joint or complete lack of a proximal phalanx secondary to a previous total resection, the incision is carried out to the base of the distal phalanx. While the ink is still moist, the adjacent two toes are brought together in a cosmetically acceptable position with the nails aligned. This leaves a faint ink line on the adjacent toe (Fig 2). The line is darkened to complete the "V"-incision in the web space. Dorsally the line can be extended proximally between the adjacent metatarsal heads to form a Y-shaped incision. This
Fig 1. Incision outlined on shorter toe.
52
Fig 2. Mirror image incision on longer toe after placing toes in corrected position.
proximal extension will allow access to the MTP joint or web space to correct coexisting deformities. Using a no. 15 blade, the incision is made along the lines drawn. Full thickness flaps are developed in the web space (Fig 3). Because the proper digital nerves are plantar and dorsal to the midline incision, they are protected, along with soft tissue, when elevated with the flaps. Skin hook retractors are placed. A wedge shaped section of tissue may be resected from the web space using a second set of incisions inferior to the midline cuts. These second incisions are taken through dermis only with care to protect the proper digital nerves and vessels during removal of the tissue. Within the resected tissue would be any soft corns present. By resecting tissue, increased stability and closer approximation of the adjacent toes is obtained postoperatively. If correction of a fused PIP contracture is necessar)~ an appropriate amount of bone can be resected from the distal aspect of the proximal phalanx after subperiosteal dissection is performed (Fig 4). Hemostasis is achieved with bipolar cautery to avoid postoperative hematoma, which can lead to late wound dehiscence. If additional bone resection is to be performed at the MTP joint, soft tissue is cleared from the base of the proximal phalanx. Small Hohmann retractors are used to protect the neurovascular bundle, flexor, and extensor tendons. Resection of the base of the proximal phalanx is accomplished with an oscillating saw. If complete excision of the proximal phalanx is required, this is done with meticulous sharp dissection subperiosteally with a scalpel blade. Of note, equivalent resections should be performed
Fig 3. Full thickness flaps placed midline in the web space. ERIC BARTEL
Fig 4. (A) Correction of PIP contracture, (B) subperiosteal dissection of the proximal phalanx, after bone resection.
on the adjacent toes to be syndactylized. If unequal lengths are removed, the toes will shorten by two differing lengths and give unaccep~:able cosmetic results. K wire fixation may be required depending on the bone resection procedure. Closure is the most meticulous and time-consuming portion of the case. Absorbable sutures may be used, but a nonabsorbable suture such as a 4.0 prolene or nylon is preferred because less local suture reaction in the web space is created. Gentle soft tissue handling is essential to avoid w o u n d healing problems (Fig 5). Simple interrupted sutures are started plantarly at the apex of the web space with skin edges ew,~rted. Sutures are placed every 2 to 3 mL apart to keep tissue tension evenly distributed (Fig 6). The sutures are carried distally on the plantar flap then back proximally on the dorsal surface to finish closure of the wound. Sutures wJLllbe visible where the incision extends between the metatarsals, but less so in the web space (Fig 7). There should be an infolding of the dorsal flap if the incision has been placed correctly in the midline. This makes the syndactPylization slightly less obvious and more cosmetically acceptable. In addition, the adjacent nails
Fig 5. A traumatic handling of soft tissue flaps with skin hooks. SYNDACTYLIZATION OF THE LESSER TOES
should remain parallel after closure without tilting inward or outward from the syndactylization. A soft bulky dressing is used with 4 × 4 gauze and 2' Kling wrap for slight compression. Minimal gauze is placed between the syndactylized toes at the tips. The toes should lie in the desired final position with the dressings in place. If delayed capillary refill occurs after deflation of tourniquet, the dressings may need to be gently teased from around the toes to release excessive compression. POSTOPERATIVE
CARE
The patient is encouraged to rest and elevate the foot immediately postoperatively. Weight-bearing is allowed only in a postoperative shoe with a flat foot gait. Initial dressings are changed in 3 to 5 days, as some bleeding is not uncommon. Sutures are removed at 3 weeks to avoid wound dehiscence associated with early suture removal. At the time of suture removal and K wire removal the patient is allowed back into normal supportive footwear. Initially, wide athletic shoes are usually manageable, but normal swelling precludes fashion shoe wear for up to 2 to 3 months postoperatively.
Fig 6. Skin closure with multiple interrupted sutures. 53
salvage t e c h n i q u e for flail toes. It offers a n alternative for the t r e a t m e n t of r e c u r r e n t soft corns t h a t d o e s n o t require b o n e resection or risk late instability. In addition, it continu e s to h a v e a limited, b u t i m p o r t a n t , role in the t r e a t m e n t of severe h a m m e r t o e d e f o r m i t i e s w h e n u s e d in conjunction w i t h o t h e r p r o c e d u r e s .
REFERENCES
Fig 7. Dorsal view after skin closure.
COMPLICATIONS C o m p l i c a t i o n s attributable directly to s y n d a c t y l i z a t i o n i n c l u d e infection, h e m a t o m a , a n d w o u n d dehiscence. Careful soft tissue h a n d l i n g a n d m e t i c u l o u s closure w i t h h e m o s t a s i s will d i m i n i s h c h a n c e s of these p r o b l e m s . Instability can o c c u r if the w e b b i n g is n o t carried distally e n o u g h . I n cases of intractable soft corns or relatively stable deformities, s u b t o t a l w e b b i n g to the level of the m i d d l e p h a l a n x is a d e q u a t e , h o w e v e r , for m o r e distal flail toes, w e b b i n g s h o u l d be carried o u t to the base of the distal phalanx. C o s m e t i c c o n c e r n s can be a v o i d e d w i t h t h o r o u g h p r e o p erative c o u n s e l i n g a n d a p p r o p r i a t e p a t i e n t expectations. Careful p l a c e m e n t of m i d l i n e incisions will h e l p a v o i d rotational m a l a l i g n m e n t .
DISCUSSION S y n d a c t y l i z a t i o n is a s i m p l e p r o c e d u r e , w h i c h h a s previo u s l y b e e n d e s c r i b e d for the c o r r e c t i o n of a m u l t i t u d e of deformities. As an isolated p r o c e d u r e , it is a n excellent
54
1. Coughlin MJ, Mann RA: Lesser toe deformities, in Mann RA (ed): Surgery of the Foot and Ankle (ed 6, vol 2). St. Louis, MO, Mosb~ 1993, pp 401-403 2. Daly PJ, Johnson KA: Treatment of painful subluxation or dislocation at the second and third metatarsophalangeal joints by partial proximal phalanx excision and subtotal webbing. Clin Orthop 278:164-170, 1992 3. Goldstein N, Woodward GS: Surgery for Tinea Pedis. Arch Deformity 99:701-704, 1969 4. Jahss MH: Chronic and recurrent dislocations of the fifth toe. Foot Ankle 5:275-278, 1981 5. Jahss MI-I:Disorders of the Foot and Ankle (ed 2, vol. 2). Philadelphia, PA, Saunders, 1991, pp 1190-1194, 1215-1217, 1225-1227 6. Kelikian H, Clayton L, Loseff H: Surgical syndactylia of the toes. Clin Orthop 19:208-231,1961 7. Leonard MH, Rising EE: Syndactylization to maintain correction of overlapping 5th toe. Clin Orthop 43:241-243, 1965 8. Marek L, Giacopelli J, Granoff B: Syndactylization for the treatment of fifth toe deformities. J Am Podiatr Med Assoc 81:248-252, 1991 9. McFarland B: Congenital deformities of the spine and limbs, in Platt H (ed): Modern Trends in Orthopaedics. New York, NY, Hosher, 1950, pp 107-108 10. Saltzman CL, Johnson KA, Donnelly RE: Surgical treatment of mild deformities of the rheumatoid forefoot by partial phalangectomy and syndactylization. Foot Ankle 14:325-329, 1993 11. Saltzman CL: Rheumatoid forefoot reconstruction, in Johnson RA (ed): Master Techniques in Orthopaedic Surgery: The Foot and Ankle. New York, NY, Raven, 1994, pp 197-211 12. Scrase WH: The treatment of dorsal adduction deformities of the fifth toe. J Bone Joint Surg 36B:146, 1954 13. Teasdall RD: Resection arthroplasty of the second & third toes, in Johnson RA (ed): Master Techniques in Orthopaedic Surgery: The Foot and Ankle. New York NY, Raven, 1994, pp 149-160
ERIC BARTEL