A dorsally elevated fifth toe can be a challenge to treat. When evaluating the fifth toe, I look at frontal plane rotation, the degree of proximal interphalangeal joint (PIPJ) contracture and, most importantly, whether the fifth toe is “riding high” with respect to the other lesser toes. If so, a PIPJ arthroplasty alone will not work.
With the other lesser toes, there is a decision to make: arthrodesis versus arthroplasty. For the fifth toe, it is rare that we ever fuse the toe so the decision making is pretty simple. Most of us will look at the frontal plane position of the toe and do a derotational skin plasty if necessary. One of the most important maneuvers that we often forget is to evaluate the sagittal plane position of the fifth toe preoperatively and intraoperatively with the Kelikian push-up test.
Assuming that you are dealing with a typical PIPJ contracture hammertoe, the standard stepwise approach to the fifth toe should be:
1. If there is a frontal plane deformity (i.e. adductovarus deformity), then perform skin plasty. If not, then perform a linear midline incision over the PIPJ.
2. If the toe is riding high after the arthroplasty is done, proceed to do a metatarsophalangeal joint (MPJ) release by doing an extensor hood recession and dorsal MPJ capsulotomy.
3. If the toe is still riding high, then proceed to extend your skin incision and covert it to a V-Y skin plasty.
4. If the toe is still riding high after the V-Y skin plasty, then consider a plantar wedge resection of skin to reduce excess plantar skin tissue.
5. If the toe is still riding high, then cut it off (just kidding). The very last maneuver is going to be a flexor to extensor tendon transfer, which I find is very rarely needed.
Give the fifth toe the decision making and time that it deserves. As we have all learned the hard way, there is more to the fifth toe than just an arthroplasty.