One of my first blogs, over a year ago, discussed treatment of a pediatric underlapping toe (see http://www.podiatrytoday.com/blogged/when-a-child-presents-with-an-under...  ). Since then, I have operated on the patient’s contralateral toe and I thought it would be nice to provide a follow-up of how things went for this young patient.
After her first correction, her toe did extremely well. She had no remaining symptoms on that side and continued to wear her custom orthotics to good effect. Wouldn’t you know though as soon as her one side starting feeling better, her contralateral side starting bothering her. Of course, we tried conservative management first with splinting, but since the first procedure went so smoothly, her parents wanted the toe “fixed.”
As we all know, the second side never goes quite like the first and this was no different. I went in expecting to do a simple flexor tenotomy and found out quickly that I would likely have to do some creative plastic surgery to get that toe where I thought it should be (not where I wanted mind you).
After performing the flexor tenotomy, the toe itself was just not sitting right in my eyes or hands. I decided to do a V-Y plasty on the plantar medial side, taking very great care to avoid the neurovascular bundle in the area. I could have used some lopes on that one.
Finally, I was happy with how this toe was sitting. After employing one stitch to hold the most distal aspect in place and a Steri-Strip, I was done. The patient had a nice, straight toe.
One of the challenges of treating the pediatric population is sometimes dealing with a very cranky young person in the office and dealing with parents who bring their kids in at the worst possible time of day. This young patient’s parents brought her in after waking her up from her nap so I could remove that one stitch.
To make a very long story short, I ended up asking the parents to remove the one stitch at home and they did this successfully. I called them a couple of days later to verify that the patient was doing well and that the stitch was removed. I wish they would have called and just rescheduled that visit for a time of day when the patient had not just gotten up from a nap. I would have slept better for a couple of nights if they had.
Ultimately, the other toe healed beautifully. The patient is almost 5 years old now. She runs and plays with her friends as if she never had a problem. She continues to wear the custom orthotics and will likely need a new pair very shortly.
One of the real hurdles to overcome is the almost complete lack of evidence-based data to support much of what we do with our pediatric population. I will address this in a future blog. However, one thing is undeniable. This young patient was happy. She said to me, “I have my feet back!” That is all the evidence I need.