A patient presents to the office with fifth toe pain and it has been over six months since the patient had surgery with another provider. This is a situation I often find myself in and I have to assume I am not alone.
Sometimes, the toe appears to have healed well with radiographs showing a seemingly appropriate resection of the proximal phalangeal head and proper toe position. Other times, a floppy or cocked-up deformity is apparent with too little or too much bone resection. This failure to achieve resolution of symptoms can happen for obvious reasons but often without any at all.
What is it about the fifth toe that leads so many to this place of surgical revision? This most common digital deformity occurs primarily in the sagittal plane to the other toes but at the fifth toe, there is often frontal plane rotation and adduction. While resection of the proximal phalanx head reduces the pull of the long flexor, the patient may need a skin plasty to correct the varus position.1 Skin plasty and transposition skin flaps can release dorsal skin contracture as can metatarsal-phalangeal joint capsular release.2,3
When the result of the fifth toe surgery is not as hoped, steps toward revision are often similar to the original choices. Some may consider partial syndactylization but many surgeons will go back to more bone resection and skin plasty.4
Too much bone resection in repeat surgery and the resultant floppy toe are very real concerns. This is the fear that first led me to try a silicone stabilizing rod implant for revision almost a decade ago. This simple implant (InterPhlex, Osteomed®) utilizes a ball at the joint with a stem into the middle phalanx and the remaining proximal phalanx. Once one has corrected the deforming forces, the surgeon drills the medullary canal on both sides. After employing a trial sizer for confirmation of size and fit, the surgeon can subsequently place the implant.5
I was reminded a few weeks ago how much I really like this little implant. On the same day, I saw a patient who had the implant procedure six months ago and another patient who had the procedure seven years ago. In each case the patient presented for an unrelated issue and is pain-free at the joint where the implant resides. In regard to the man who had this fifth toe revision six months ago, it was the type of case where there was no clear reason for continued pain after the original procedure. The woman from seven years ago had significant deformity and obviously poor surgical results from the original procedure. In each of these cases, the pre-operative situation was very different. In the end, stabilizing the fifth toe in an improved position with reduction of deforming forces and without loss of length was achievable in a surprisingly simple way.
Dr. Schwartz is the Scientific Conference Chair and a Past President of the American Association for Women Podiatrists. She is board-certified in foot surgery by the American Board of Foot and Ankle Surgery, and is in private practice with Foot and Ankle Specialists of the Mid-Atlantic in Washington, DC and Chevy Chase, MD.
1. DiDomenico L, Baze E, Gatalyak N. Revisiting the tailor’s bunion and adductovarus deformity of the fifth digit. Clin Podiatr Med Surg. 2013;30:397-422.
2. Simsek T, Yosma E, Abdullayvev A, Demir B, Aksakal IA. Correction of overlapping fifth toe deformity with combination of z-plasty and transposition skin flap. Surg Curr Res. 2015;5:2.
3. Murgier J, Knorr J, Soldado F, Bayle-iniguez X, Sales de Gauzy J. Percutaneous correction of congenital overlapping fifth toe in paediatric patients. Orthop Trauma Surg Res. 2013;99(6):737-740.
4. Vispo-Seara JL, Ettl VS, Krauspe R. The Ruiz-Mora procedure: a surgical treatment of the cock-up deformity of the fifth toe. Foot Ankle Surg. 1998;4(3):145-149.
5. Osteomed InterPhlex flexible stabilization rod surgical technique guide. Available at: http://www.osteomed.com/Literature/OsteoMed-InterPhlex-Surgical-Guide.pdf . Accessed February 12, 2020.