Case Study: Treating A Severe Fifth Digit Contracture Deformity

Author(s): 
Stephen L. Barrett, DPM, FACFAS, and Vincent P. Rascon, DPM, FACFAS

These authors present pertinent pearls on using minimally invasive techniques for a patient with a bilateral, congenitally contracted fifth digit.

Reconstructive surgery for a congenital overlapping and hyperextended fifth digit can be extremely difficult as it requires extensive surgical dissection and the deformity can vary with every presentation. Often, traditional open surgery results in less than desirable outcomes for the patient. Long postoperative periods of morbidity are common, especially with fifth digits, and swelling can be permanent. It can be a long time before the patient can return to regular shoe gear.

   A 21-year-old healthy male patient presented with an extremely severe bilateral, congenitally contracted fifth digit with an almost 90 degree angle of the proximal phalanx to the fifth metatarsal. The patient was unable to wear any regular shoes without modification (he would cut holes in his shoes so he could wear them) and was unable to work because of his requirement for steel toe safety boots.

   The traditional surgical approaches to the correction of this type of deformity have been well described, ranging from the Ruiz-Mora proximal phalangectomy to variations involving complex skin plasties. Corrections of the condition would usually involve some variation and combination of extensor tendon lengthening, flexor tenotomy/transfer, capsulotomy of the fifth metatarsophalangeal joint (MPJ), possible shortening of the fifth metatarsal, proximal phalangeal joint arthroplasty with head resection, V-Y skin plasty and K-wire stabilization of the digit.

   When one can fully assess and understand this deformity, there are always multiple factors to consider in planning the surgical approach in order to address all the relevant aspects to maximize outcome. Downey and Rubin described their “consolidated surgical approach” as cited in McGlamry’s text.1

   From a functional standpoint, remember that the first surgical technique described for this condition was amputation. The requirements for success with this deformity are acceptable cosmesis and the ability to wear normal shoe gear. It is unreasonable to expect any success with restoration of complete tendon function to provide a grasping ability of the fifth toe.

   While the original Ruiz-Mora surgical technique with complete proximal phalangeal resection addresses the longstanding bony adaptation that exists at the level of the MPJ, it frequently resulted in poor cosmetic results. The technique that we recommend addresses all of the multiple factors contributing to the deformity without the associated morbidity of a maximally invasive technique.

Achieving Results With Minimally Invasive Techniques

We addressed this correction with percutaneous minimally invasive techniques that included: an extensor tenotomy; a flexor tenotomy; capsulotomy of the fifth MPJ; and complete proximal phalangeal base osteotomy with displacement and no fixation.

Comments

Could this minimally invasive procedure be done as a revision for a failed arthroplasty, tendon lengthening and skin plasty of the 5th toe?

Yes, because the use of a phalangeal base osteotomy would allow for more correction and also takes in the fact that once the joint surfaces have been congruent for so long in the deformed position, trying to realign the deformity at the joint level is usually impossible and not long lasting.

Even though this is minimally invasive surgery, there is a steep learning curve and there are many esoteric nuances that predicate either success or a less than desirable outcome.

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