The Journal of Foot & Ankle Surgery 53 (2014) 59–61
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
An Unusual Case of Postaxial Polydactyly of the Foot Treated by Metatarsal Transfer Seung Hwan Han, MD, PhD 1, Jae Ho Cho, MD, PhD 2, Yu Sang Lee, MD 1 1
Division of Foot and Ankle Surgery, Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Kyounggi-do, Korea Division of Paediatric Orthopaedics and Deformity Correction, Division of Paediatric Foot and Ankle Surgery, Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Kyounggi-do, Korea 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Postaxial polydactyly is a relatively rare congenital deformity. We present a unique unusual fourth metatarsal type polydactyly in which the extra bone from the fourth metatarsal bone articulated with the most lateral ray proximal phalanx. We discuss the surgical management of this problem using a bone transfer from the extra metatarsal bone within the midfoot. This is the first reported case of fourth metatarsal-type polydactyly treated by bone transfer of the extra metatarsal bone and internal plate fixation to recover normal articulation. The normal orientation of the metatarsophalangeal joint, alignment, and cosmesis are important determinants when selecting the bone to be excised in cases of lateral ray foot polydactyly. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: congenital deformity digit foot lateral ray toe
Polydactyly is a rare congenital condition of the foot (1,2). Postaxial polydactyly is defined as a supernumerary digit on the lateral aspect of the foot and can be classified into 7 types: the middle phalangeal, proximal phalangeal head, proximal phalangeal medial, proximal phalangeal lateral, floating, fifth metatarsal, and fourth metatarsal types (3). We report a rare case of polydactyly with an unclassifiable, unusual lateral duplication of the fourth metatarsal with abnormal articulation to the lateral ray phalangeal bone. We attempted to overcome that problem by metatarsal transfer within the midfoot. Case Report A 19-year-old male presented with a history of right foot deformity and increasing pain on the lateral ray of the right foot (Fig. 1). Physical examination revealed postaxial polysyndactyly of the right foot with mild swelling. He had consistent walking pain and intermittent pain at rest. Malorientation of the metatarsophalangeal joint (MPJ) was present. The MPJ range of motion was 20 of dorsiflexion and 10 of plantar flexion. Callosity was present on the fifth toe with pain. The patient had had no previous medical illness or other orthopedic or systemic anomalies, and his family history was unremarkable. The findings from the remainder of the lower extremity examination were normal. Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jae Ho Cho, MD, PhD, Division of Paediatric Orthopaedics and Deformity Correction, Division of Paediatric Foot and Ankle Surgery, Department of Orthopedic Surgery, Ajou University School of Medicine, San 5 Wonchon-dong, Youngtong-gu, Suwon, Kyounggi-do 443-721, Korea. E-mail address: [email protected] (J.H. Cho).
Radiographs of the right foot revealed an extra bone originating laterally from the fourth metatarsal bone. The extra bone had formed new articulations from the shaft of the fourth metatarsal bone to the fifth metatarsal head and with the fifth proximal phalanx. The most lateral ray distal phalanx was also duplicated (Fig. 2). The preoperative lesser toe score (American Orthopaedic Foot and Ankle Society) was 52 (4). The main surgical indications were pain and limitation of MPJ motion, as well as a cosmetic problem. Surgery was decided. The proximal portion of the extra metatarsal bone was exposed using a dorsal zigzag incision along the lateral side of the fourth metatarsal. Fibrous interossei muscle was present. The base of the extra metatarsal was connected to the midshaft of the fourth metatarsal by articular cartilage. To preserve the articulation between the extra metatarsal and the fifth proximal phalanx, the
Fig. 1. View from top of (A) both feet and (B) right foot, with deformity visible.
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2013.09.003
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S.H. Han et al. / The Journal of Foot & Ankle Surgery 53 (2014) 59–61
Fig. 2. (A and B) Radiographs and (C) model showing articulation of deformity.
extra metatarsal was transposed to the fifth metatarsal shaft. Extra bone from the excised fragments was used as bone graft material. Internal fixation was performed with a plate and screws (Fig. 3). Two years after surgery, the implant was removed. Other than minimal bony spur formation on the medial side of the new fused fifth metatarsal bone, adequate bone union had been achieved. Postoperatively, the patient remained symptom free. The radiograph showed a normal orientation of MPJ. After normalization of the MPJ direction, the MPJ range of motion was 40 of dorsiflexion and 20 of plantar flexion with decreasing pain. The final lesser toe score was 95 (Fig. 4). Discussion During treatment of lateral ray polydactyly, the selection of the toe (medial or lateral) to excise is one of the most important issues (3,5). Lee et al (3) suggested a classification method for postaxial polydactyly of the foot and appropriate treatment options according to
Fig. 3. Radiographs (anteroposterior views) showing, by numbered segments, which bone was excised, transferred, and internally fixated. (A) Preoperative and (B) early postoperative radiographs.
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the morphologic, radiographic, and operative findings. The choice of the digit to excise should be determined by considering the site of origin, the state of fusion, and axial alignment. For fourth metatarsal types, the medial accessory fifth digit should be excised according to the classification scheme of Lee et al (3). Uda et al (6) reported that alignment, circulation, postoperative pain, and overall cosmesis must be considered when deciding between medial or lateral excision. They derived an algorithm for toe selection based on the consideration of such issues (6). In cases of metatarsal-type polydactyly, the radiographically nondominant metatarsal should be excised. In the present case, the fifth metatarsal was radiographically dominant. However, extra bone from the fourth metatarsal bone had articulated with the base of the fifth proximal phalanx. To preserve the metatarsophalangeal articulation of the extra metatarsal with the fifth proximal phalanx, the extra metatarsal bone was transposed to the shaft of the fifth metatarsal bone, instead of the distal portion of the original fifth metatarsal bone. Extra bone from the excised fragments was used as bone graft material. Internal fixation was performed with a plate to maintain placement of the transferred bone. The main surgical indication was pain in our patient. The possible causes of pain included the limitation of motion by bridging bone, the abnormal orientation of the MPJ, pain from the abnormal pseudoarticulation on the base of the bridging bone, and the large abnormal articulation on the MPJ area. We overcame this problem by metatarsal transfer within midfoot. The present case experience suggests that when selecting the bone to be excised in lateral ray polydactyly, normalization of the MPJ and the level of this joint will be important determinants, along with alignment and cosmesis. References
Fig. 4. Final radiographic view of right foot 2 years postoperatively.
1. Phelps DA, Grogan DP. Polydactyly of the foot. J Pediatr Orthop 5:446–451, 1985. 2. Watanabe H, Fujita S, Oka I. Polydactyly of the foot: an analysis of 265 cases and a morphological classification. Plast Reconstr Surg 89:856–877, 1992. 3. Lee HS, Park SS, Yoon JO, Kim JS, Youm YS. Classification of postaxial polydactyly of the foot. Foot Ankle Int 27:356–362, 2006. 4. Kitaoka HB, Patzer GL. Analysis of clinical grading scales for the foot and ankle. Foot Ankle Int 18:443–446, 1997. 5. Morley SE, Smith PJ. Polydactyly of the foot in children: suggestions for surgical management. Br J Plast Surg 54:34–38, 2001. 6. Uda H, Sugawara Y, Niu A, Sarukawa S. Treatment of lateral ray polydactyly of the foot: focusing on the selection of the toe to be excised. Plast Reconstr Surg 109:1581–1591, 2002.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
An Unusual Case of Postaxial Polydactyly of the Foot Treated by Metatarsal Transfer Seung Hwan Han, MD, PhD 1, Jae Ho Cho, MD, PhD 2, Yu Sang Lee, MD 1 1
Division of Foot and Ankle Surgery, Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Kyounggi-do, Korea Division of Paediatric Orthopaedics and Deformity Correction, Division of Paediatric Foot and Ankle Surgery, Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Kyounggi-do, Korea 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Postaxial polydactyly is a relatively rare congenital deformity. We present a unique unusual fourth metatarsal type polydactyly in which the extra bone from the fourth metatarsal bone articulated with the most lateral ray proximal phalanx. We discuss the surgical management of this problem using a bone transfer from the extra metatarsal bone within the midfoot. This is the first reported case of fourth metatarsal-type polydactyly treated by bone transfer of the extra metatarsal bone and internal plate fixation to recover normal articulation. The normal orientation of the metatarsophalangeal joint, alignment, and cosmesis are important determinants when selecting the bone to be excised in cases of lateral ray foot polydactyly. Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: congenital deformity digit foot lateral ray toe
Polydactyly is a rare congenital condition of the foot (1,2). Postaxial polydactyly is defined as a supernumerary digit on the lateral aspect of the foot and can be classified into 7 types: the middle phalangeal, proximal phalangeal head, proximal phalangeal medial, proximal phalangeal lateral, floating, fifth metatarsal, and fourth metatarsal types (3). We report a rare case of polydactyly with an unclassifiable, unusual lateral duplication of the fourth metatarsal with abnormal articulation to the lateral ray phalangeal bone. We attempted to overcome that problem by metatarsal transfer within the midfoot. Case Report A 19-year-old male presented with a history of right foot deformity and increasing pain on the lateral ray of the right foot (Fig. 1). Physical examination revealed postaxial polysyndactyly of the right foot with mild swelling. He had consistent walking pain and intermittent pain at rest. Malorientation of the metatarsophalangeal joint (MPJ) was present. The MPJ range of motion was 20 of dorsiflexion and 10 of plantar flexion. Callosity was present on the fifth toe with pain. The patient had had no previous medical illness or other orthopedic or systemic anomalies, and his family history was unremarkable. The findings from the remainder of the lower extremity examination were normal. Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Jae Ho Cho, MD, PhD, Division of Paediatric Orthopaedics and Deformity Correction, Division of Paediatric Foot and Ankle Surgery, Department of Orthopedic Surgery, Ajou University School of Medicine, San 5 Wonchon-dong, Youngtong-gu, Suwon, Kyounggi-do 443-721, Korea. E-mail address: [email protected] (J.H. Cho).
Radiographs of the right foot revealed an extra bone originating laterally from the fourth metatarsal bone. The extra bone had formed new articulations from the shaft of the fourth metatarsal bone to the fifth metatarsal head and with the fifth proximal phalanx. The most lateral ray distal phalanx was also duplicated (Fig. 2). The preoperative lesser toe score (American Orthopaedic Foot and Ankle Society) was 52 (4). The main surgical indications were pain and limitation of MPJ motion, as well as a cosmetic problem. Surgery was decided. The proximal portion of the extra metatarsal bone was exposed using a dorsal zigzag incision along the lateral side of the fourth metatarsal. Fibrous interossei muscle was present. The base of the extra metatarsal was connected to the midshaft of the fourth metatarsal by articular cartilage. To preserve the articulation between the extra metatarsal and the fifth proximal phalanx, the
Fig. 1. View from top of (A) both feet and (B) right foot, with deformity visible.
1067-2516/$ - see front matter Ó 2014 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2013.09.003
60
S.H. Han et al. / The Journal of Foot & Ankle Surgery 53 (2014) 59–61
Fig. 2. (A and B) Radiographs and (C) model showing articulation of deformity.
extra metatarsal was transposed to the fifth metatarsal shaft. Extra bone from the excised fragments was used as bone graft material. Internal fixation was performed with a plate and screws (Fig. 3). Two years after surgery, the implant was removed. Other than minimal bony spur formation on the medial side of the new fused fifth metatarsal bone, adequate bone union had been achieved. Postoperatively, the patient remained symptom free. The radiograph showed a normal orientation of MPJ. After normalization of the MPJ direction, the MPJ range of motion was 40 of dorsiflexion and 20 of plantar flexion with decreasing pain. The final lesser toe score was 95 (Fig. 4). Discussion During treatment of lateral ray polydactyly, the selection of the toe (medial or lateral) to excise is one of the most important issues (3,5). Lee et al (3) suggested a classification method for postaxial polydactyly of the foot and appropriate treatment options according to
Fig. 3. Radiographs (anteroposterior views) showing, by numbered segments, which bone was excised, transferred, and internally fixated. (A) Preoperative and (B) early postoperative radiographs.
S.H. Han et al. / The Journal of Foot & Ankle Surgery 53 (2014) 59–61
61
the morphologic, radiographic, and operative findings. The choice of the digit to excise should be determined by considering the site of origin, the state of fusion, and axial alignment. For fourth metatarsal types, the medial accessory fifth digit should be excised according to the classification scheme of Lee et al (3). Uda et al (6) reported that alignment, circulation, postoperative pain, and overall cosmesis must be considered when deciding between medial or lateral excision. They derived an algorithm for toe selection based on the consideration of such issues (6). In cases of metatarsal-type polydactyly, the radiographically nondominant metatarsal should be excised. In the present case, the fifth metatarsal was radiographically dominant. However, extra bone from the fourth metatarsal bone had articulated with the base of the fifth proximal phalanx. To preserve the metatarsophalangeal articulation of the extra metatarsal with the fifth proximal phalanx, the extra metatarsal bone was transposed to the shaft of the fifth metatarsal bone, instead of the distal portion of the original fifth metatarsal bone. Extra bone from the excised fragments was used as bone graft material. Internal fixation was performed with a plate to maintain placement of the transferred bone. The main surgical indication was pain in our patient. The possible causes of pain included the limitation of motion by bridging bone, the abnormal orientation of the MPJ, pain from the abnormal pseudoarticulation on the base of the bridging bone, and the large abnormal articulation on the MPJ area. We overcame this problem by metatarsal transfer within midfoot. The present case experience suggests that when selecting the bone to be excised in lateral ray polydactyly, normalization of the MPJ and the level of this joint will be important determinants, along with alignment and cosmesis. References
Fig. 4. Final radiographic view of right foot 2 years postoperatively.
1. Phelps DA, Grogan DP. Polydactyly of the foot. J Pediatr Orthop 5:446–451, 1985. 2. Watanabe H, Fujita S, Oka I. Polydactyly of the foot: an analysis of 265 cases and a morphological classification. Plast Reconstr Surg 89:856–877, 1992. 3. Lee HS, Park SS, Yoon JO, Kim JS, Youm YS. Classification of postaxial polydactyly of the foot. Foot Ankle Int 27:356–362, 2006. 4. Kitaoka HB, Patzer GL. Analysis of clinical grading scales for the foot and ankle. Foot Ankle Int 18:443–446, 1997. 5. Morley SE, Smith PJ. Polydactyly of the foot in children: suggestions for surgical management. Br J Plast Surg 54:34–38, 2001. 6. Uda H, Sugawara Y, Niu A, Sarukawa S. Treatment of lateral ray polydactyly of the foot: focusing on the selection of the toe to be excised. Plast Reconstr Surg 109:1581–1591, 2002.
