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.
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.
We performed this via two 2-mm incisions; one on the dorsal lateral aspect of the fifth MPJ and one in the midline plantarly at the level of the proximal phalangeal base.
It has been well established that employing soft tissue procedures in digital correction surgery rarely overcomes the osseous adaptation, which will remain present without adjuvant osseous correction. As one can see in the photos of the serial radiographs, the patient achieves complete osseous union even though there is a significant gap at the level of the osteotomy at the time of surgery, which is required for adequate correction.
The final photos show that the cosmetic result is excellent. The patient is pain free and can wear any shoe.
Dr. Barrett is an Adjunct Professor within the Arizona Podiatric Medicine Program at the Midwestern University College of Health Sciences. He is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Rascon practices in Midland, Texas
1. Wagreich CR. Congenital deformities. In: Banks AS, Downey MS, Martin DE, Miller SJ (eds): McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, 3rd Ed, Lippincott Williams & Wilkins, 2001. Chapter 42, pp. 1449-55.