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Arthroplasty for Fifth Toe Deformity
A r t h ro p l a s t y f o r F i f t h To e D ef o r mi ty Walter W. Strash,
DPM
KEYWORDS Arthroplasty Fifth toe Hammertoe Footgear
Fifth toe positional problems typically cause irritation with various forms of footgear.1–3 The position of the toe causes irritation against the toe box of the shoe. There are 3 varieties of deformity, a cock-up deformity, a plantar flexion deformity, and an overlapping deformity, which occur at the fifth metatarsophalangeal joint of the fifth toe. Each deformity has different physical examination findings, causes, and treatment. With some deformities, conservative treatment can be successful in controlling a patient’s discomfort. The cock-up deformity is most commonly seen in older patients. The typical presentation is a dorsiflexed and abducted fifth toe. The onset is usually slow and insidious, and patients typically do not seek treatment until they have difficulties with all forms of footgear, including pain and callus formation. The plantar flexed and overlapping deformities more commonly occur in younger age groups and are often congenital. The signs and symptoms of this deformity are similar to those of the cock-up deformity, and patients have difficulty with shoes fitting properly. A corn (hyperkeratotic lesion) is often seen overlying the proximal interphalangeal joint of the fifth toe. Footwear is the often-cited cause because compression from the toe box creates irritation to the skin and an accumulation of hyperkeratotic tissue. With an abducted deformity, hyperkeratotic tissue can develop in the web space and become macerated creating a soft corn (heloma molle). This deformity often leads to infection because the moisture causes a breakdown of the skin and a portal for bacteria to enter the area. PHYSICAL EXAMINATION
The metatarsal phalangeal joint may be contracted with the proximal portion of the fifth toe in a cock-up position. There may be a varus component to the position of the fifth toe. In younger patients, the joint is flexible and may be easily reducible. With time, the capsule and extensor mechanism become contracted, and the fifth toe becomes tighter and less reducible. Often there is a palpable callus on the proximal interphalangeal joint (Fig. 1).
Private Practice - Alamo Family Foot & Ankle Care, San Antonio, TX, USA E-mail address: [email protected] Clin Podiatr Med Surg 27 (2010) 625–628 doi:10.1016/j.cpm.2010.08.001 0891-8422/10/$ – see front matter Ó 2010 Published by Elsevier Inc.
podiatric.theclinics.com
626
Strash
Fig. 1. Callus on the proximal interphalangeal joint.
With a plantar flexion deformity, the fifth toe is in a plantar flexed position and may be varus rotated. There is typically a flexion contracture of the flexor tendons of the fifth toe, and attempts at manually straightening the toe on examination are a challenge. The overlapping deformity may be congenital. The fifth toe is contracted and rests on the dorsal side of the adjacent fourth toe. The congenital deformity is fixed and irreducible. Most patients relate to a history of having the problem for as long as they can remember. In the early developmental deformity, the fifth toe can be reduced manually and brought back into a neutral position. However, with time, the developmental deformity becomes more rigid and fixed. Radiographic evaluation of the cock-up toe deformity shows the subluxation and dorsiflexion of the proximal phalanx on the head of the fifth metatarsal. A varus positioning of the proximal phalanx may be observed. There may also be a prominence or enlarged head of the proximal phalanx. In the case of the soft corn, an enlarged medial head of the proximal phalanx may be seen. SOLUTIONS
From a nonsurgical standpoint, taping and strapping of the toes are usually unsuccessful. Strapping of the fifth toe in a corrected position by buddy splinting to the fourth toe only allows for temporary correction because once the strapping is removed, the fifth toe returns to its prior position. Shoes with a wider and deeper toe box along with padding of the fifth toe may offer the elderly and patients with reduced physical demands some relief. Along with the debridement of the soft corn, the use of lamb’s wool and various soft toe spacer pads may reduce maceration to the interspace and provide patients with temporary relief. STANDARD OR BASIC HAMMERTOE PROCEDURE
Resection of the head of the proximal phalanx of the fifth toe or fifth toe arthroplasty is a common, relatively simple, and effective procedure for painful lesions of the proximal interphalangeal joint. This procedure relieves the flexion contracture of the proximal interphalangeal joint and may need to be combined with extensor and capsular release over the metatarsal phalangeal joint if extensor contracture at the metatarsal phalangeal exists. Temporary pinning of the toe may also be necessary as an adjunct to the hammertoe repair.
Arthroplasty for Fifth Toe Deformity
Frontal plane rotation of the fifth toe can be accomplished with this procedure, and proper semielliptical skin incision placement over the proximal interphalangeal joint is helpful in obtaining both sagittal and frontal plane correction. Most commonly, a dorsolinear incision is placed over the proximal interphalangeal joint. Alternatively, 2 semielliptical incisions may be made from proximal lateral to distal medial to aid in derotation and frontal plane correction. The hyperkeratotic lesion is excised within the skin wedge. The incision is deepened through the superficial fascia to expose the capsule and extensor tendon. At the level of the proximal interphalangeal joint, a transverse incision is made proximally to the base of the middle phalanx, leaving a small portion of extensor tendon. The proximal interphalangeal joint capsule and collateral ligaments are carefully incised with a 64-blade because the use of this blade is helpful in preventing an inadvertent buttonholing. The head of the proximal phalanx is now exposed and resected, using a small sagittal saw, with the amount of bone removed depending on the amount of flexion contracture at the proximal interphalangeal joint. The proximal phalangeal stump is then rasped smooth and the long extensor tendon is repaired. Stability of this repair is enhanced with the repair of the medial and lateral collateral ligaments to prevent the possibility of a flail toe (Fig. 2). The fifth toe is then held in a rectus position as the sterile dressing is applied. Patients’ feet are placed in a postoperative shoe for a 2-week period. After suture removal, further splinting of the fifth toe is helpful for an additional 2 to 3 weeks to support the soft tissues during healing and scar remodeling. This splinting aids in maintaining the corrected position of the fifth toe.
Fig. 2. Stability restored with the repair of medial and lateral collateral ligaments.
627
628
Strash
MANAGEMENT OF COMPLICATIONS
Shortening of the fifth toe occurs with the arthroplasty procedure, and instability manifests itself as a floppy toe. This complication is exaggerated if a large partial condylectomy is performed. Typically, there is no functional consequence other than the toe catching on socks. A solution to failed fifth toe arthroplasty is the application of a metal or Silastic lesser toe implant. If the toe is undercorrected, recurrence may arise. Placement of the toe in a corrected position with postoperative bandages or Kirschner wire fixation is helpful. However, pin placement for 3 to 4 weeks cannot correct a soft tissue deformity that has not been addressed at the time of surgery. The small area for the fifth toe arthroplasty requires protection of the neurovascular structures. Injury to a proper digital branch may lead to numbness of the toe. Preoperatively, the patient should be informed that the fifth toe will not have full function as a result of shortening and disruption of the extensor mechanism. SUMMARY
Although there are variations on the fifth toe arthroplasty, such as the derotational procedure, Z-plasty, and V-Y skin plasty techniques, the standard or basic arthroplasty offers the simplest approach and can be used with most fifth hammertoes. The concept discussed in this article is not difficult to perform and master, requiring minimal preparation with a high rate of patient satisfaction. REFERENCES
1. Root MC, Orien WP, Weed JH. Normal and abnormal function of the foot, clinical biomechanics. Los Angeles: Clinical Biomechanics Corporation; 1977. p. 457. 2. Dobbs BM. Arthroplasty of the fifth toe. Clin Podiatr Med Surg 1986;3(1):29–39. 3. Smith TF, Pfeifer KD. Surgical repair of fifth digit deformities. In: Banks AS, Downey MS, Martin DE, et al, editors. McGlamry’s comprehensive textbook of foot & ankle surgery. Lippincott Williams & Wilkins; 2001. p. 311–7.
DPM
KEYWORDS Arthroplasty Fifth toe Hammertoe Footgear
Fifth toe positional problems typically cause irritation with various forms of footgear.1–3 The position of the toe causes irritation against the toe box of the shoe. There are 3 varieties of deformity, a cock-up deformity, a plantar flexion deformity, and an overlapping deformity, which occur at the fifth metatarsophalangeal joint of the fifth toe. Each deformity has different physical examination findings, causes, and treatment. With some deformities, conservative treatment can be successful in controlling a patient’s discomfort. The cock-up deformity is most commonly seen in older patients. The typical presentation is a dorsiflexed and abducted fifth toe. The onset is usually slow and insidious, and patients typically do not seek treatment until they have difficulties with all forms of footgear, including pain and callus formation. The plantar flexed and overlapping deformities more commonly occur in younger age groups and are often congenital. The signs and symptoms of this deformity are similar to those of the cock-up deformity, and patients have difficulty with shoes fitting properly. A corn (hyperkeratotic lesion) is often seen overlying the proximal interphalangeal joint of the fifth toe. Footwear is the often-cited cause because compression from the toe box creates irritation to the skin and an accumulation of hyperkeratotic tissue. With an abducted deformity, hyperkeratotic tissue can develop in the web space and become macerated creating a soft corn (heloma molle). This deformity often leads to infection because the moisture causes a breakdown of the skin and a portal for bacteria to enter the area. PHYSICAL EXAMINATION
The metatarsal phalangeal joint may be contracted with the proximal portion of the fifth toe in a cock-up position. There may be a varus component to the position of the fifth toe. In younger patients, the joint is flexible and may be easily reducible. With time, the capsule and extensor mechanism become contracted, and the fifth toe becomes tighter and less reducible. Often there is a palpable callus on the proximal interphalangeal joint (Fig. 1).
Private Practice - Alamo Family Foot & Ankle Care, San Antonio, TX, USA E-mail address: [email protected] Clin Podiatr Med Surg 27 (2010) 625–628 doi:10.1016/j.cpm.2010.08.001 0891-8422/10/$ – see front matter Ó 2010 Published by Elsevier Inc.
podiatric.theclinics.com
626
Strash
Fig. 1. Callus on the proximal interphalangeal joint.
With a plantar flexion deformity, the fifth toe is in a plantar flexed position and may be varus rotated. There is typically a flexion contracture of the flexor tendons of the fifth toe, and attempts at manually straightening the toe on examination are a challenge. The overlapping deformity may be congenital. The fifth toe is contracted and rests on the dorsal side of the adjacent fourth toe. The congenital deformity is fixed and irreducible. Most patients relate to a history of having the problem for as long as they can remember. In the early developmental deformity, the fifth toe can be reduced manually and brought back into a neutral position. However, with time, the developmental deformity becomes more rigid and fixed. Radiographic evaluation of the cock-up toe deformity shows the subluxation and dorsiflexion of the proximal phalanx on the head of the fifth metatarsal. A varus positioning of the proximal phalanx may be observed. There may also be a prominence or enlarged head of the proximal phalanx. In the case of the soft corn, an enlarged medial head of the proximal phalanx may be seen. SOLUTIONS
From a nonsurgical standpoint, taping and strapping of the toes are usually unsuccessful. Strapping of the fifth toe in a corrected position by buddy splinting to the fourth toe only allows for temporary correction because once the strapping is removed, the fifth toe returns to its prior position. Shoes with a wider and deeper toe box along with padding of the fifth toe may offer the elderly and patients with reduced physical demands some relief. Along with the debridement of the soft corn, the use of lamb’s wool and various soft toe spacer pads may reduce maceration to the interspace and provide patients with temporary relief. STANDARD OR BASIC HAMMERTOE PROCEDURE
Resection of the head of the proximal phalanx of the fifth toe or fifth toe arthroplasty is a common, relatively simple, and effective procedure for painful lesions of the proximal interphalangeal joint. This procedure relieves the flexion contracture of the proximal interphalangeal joint and may need to be combined with extensor and capsular release over the metatarsal phalangeal joint if extensor contracture at the metatarsal phalangeal exists. Temporary pinning of the toe may also be necessary as an adjunct to the hammertoe repair.
Arthroplasty for Fifth Toe Deformity
Frontal plane rotation of the fifth toe can be accomplished with this procedure, and proper semielliptical skin incision placement over the proximal interphalangeal joint is helpful in obtaining both sagittal and frontal plane correction. Most commonly, a dorsolinear incision is placed over the proximal interphalangeal joint. Alternatively, 2 semielliptical incisions may be made from proximal lateral to distal medial to aid in derotation and frontal plane correction. The hyperkeratotic lesion is excised within the skin wedge. The incision is deepened through the superficial fascia to expose the capsule and extensor tendon. At the level of the proximal interphalangeal joint, a transverse incision is made proximally to the base of the middle phalanx, leaving a small portion of extensor tendon. The proximal interphalangeal joint capsule and collateral ligaments are carefully incised with a 64-blade because the use of this blade is helpful in preventing an inadvertent buttonholing. The head of the proximal phalanx is now exposed and resected, using a small sagittal saw, with the amount of bone removed depending on the amount of flexion contracture at the proximal interphalangeal joint. The proximal phalangeal stump is then rasped smooth and the long extensor tendon is repaired. Stability of this repair is enhanced with the repair of the medial and lateral collateral ligaments to prevent the possibility of a flail toe (Fig. 2). The fifth toe is then held in a rectus position as the sterile dressing is applied. Patients’ feet are placed in a postoperative shoe for a 2-week period. After suture removal, further splinting of the fifth toe is helpful for an additional 2 to 3 weeks to support the soft tissues during healing and scar remodeling. This splinting aids in maintaining the corrected position of the fifth toe.
Fig. 2. Stability restored with the repair of medial and lateral collateral ligaments.
627
628
Strash
MANAGEMENT OF COMPLICATIONS
Shortening of the fifth toe occurs with the arthroplasty procedure, and instability manifests itself as a floppy toe. This complication is exaggerated if a large partial condylectomy is performed. Typically, there is no functional consequence other than the toe catching on socks. A solution to failed fifth toe arthroplasty is the application of a metal or Silastic lesser toe implant. If the toe is undercorrected, recurrence may arise. Placement of the toe in a corrected position with postoperative bandages or Kirschner wire fixation is helpful. However, pin placement for 3 to 4 weeks cannot correct a soft tissue deformity that has not been addressed at the time of surgery. The small area for the fifth toe arthroplasty requires protection of the neurovascular structures. Injury to a proper digital branch may lead to numbness of the toe. Preoperatively, the patient should be informed that the fifth toe will not have full function as a result of shortening and disruption of the extensor mechanism. SUMMARY
Although there are variations on the fifth toe arthroplasty, such as the derotational procedure, Z-plasty, and V-Y skin plasty techniques, the standard or basic arthroplasty offers the simplest approach and can be used with most fifth hammertoes. The concept discussed in this article is not difficult to perform and master, requiring minimal preparation with a high rate of patient satisfaction. REFERENCES
1. Root MC, Orien WP, Weed JH. Normal and abnormal function of the foot, clinical biomechanics. Los Angeles: Clinical Biomechanics Corporation; 1977. p. 457. 2. Dobbs BM. Arthroplasty of the fifth toe. Clin Podiatr Med Surg 1986;3(1):29–39. 3. Smith TF, Pfeifer KD. Surgical repair of fifth digit deformities. In: Banks AS, Downey MS, Martin DE, et al, editors. McGlamry’s comprehensive textbook of foot & ankle surgery. Lippincott Williams & Wilkins; 2001. p. 311–7.