RECONSTRUCTIVE SURGERY
Primary On-top Plasty for Treatment of Short-type Postaxial Polydactyly of the Foot Satoshi Usami, MD,* Satoshi Kodaira, MD,† and Mutsumi Okazaki, MD, PhD* Background: Postaxial polydactyly of the foot is typically treated with medial or lateral toe ray resection. However, simple ray resection does not always give a natural postoperative appearance, especially for short-type polydactyly. The purpose of this article was to describe our primary operation with on-top plasty for lengthening of short-type postaxial polydactyly. Methods: Four patients (mean age, 11.3 months) underwent this procedure. Ray transfer was performed at the proximal phalangeal level. Lateral distal and middle phalanges were resected and the medial ray was transferred on top of the remaining lateral proximal phalanx. Preoperative and postoperative toe lengths and complications were evaluated by comparison with the contralateral side on x-ray. Results: All toes were lengthened by a mean of 115.1% from the tip of the distal phalanx to the bottom of the proximal phalanx relative to contralateral side. Appearances were very natural without valgus deformity and hypertrophic scar. And there was no remaining dysfunction in walking after a mean of 21.5 months follow-up. Conclusions: This on-top procedure is useful for improving toe lengthening and bone alignment correction with minimal functional disturbance. Key Words: on-top plasty, polydactyly, toe lengthening
Surgical Technique Before the operation, bone size and alignment on x-ray and nail form based on the visual appearance were evaluated to determine whether medial or lateral phalanges should be used as proximal and distal components. All operations were performed under general anesthesia. A dorsal wavy longitudinal incision was first made between the fourth and fifth toe. After dissection of soft tissue, the phalanges and metatarsal head were exposed. Ray transfer was performed at the proximal phalangeal level; that is, we separated and elevated the target toe with the neurovascular bundle in the metatarsophalangeal (MTP) joint (distal component) and then transferred the elevated toe ray on top of the neighboring remaining proximal phalanx (proximal component) after osteotomy. After toe ray transfer, the toe was pinned with single or double Kirschner wire. Remaining soft tissue around the ontop bone was sutured to maintain joint stability (Fig. 1). If the transferred toe-tip developed an ischemic skin color, we had only to shorten the on-top bone to stabilize the blood circulation of the transferred toe. After surgery, a below-knee splint was used to protect the affected toe for 4 to 6 weeks. Kirschner wire was removed at approximately 4 weeks postoperatively.
(Ann Plast Surg 2014;00: 00–00)
CASE REPORT
T
reatment of postaxial polydactyly does not always produce an ideal cosmetic outcome. Redundant medial or lateral toe ray resection is the standard treatment,1 but simple ray resection gives a poor postoperative appearance of toe length in a case in which the toes are short relative to the fourth toe. Several surgical procedures have been described that avoid skin grafting for postaxial polysyndactyly,2,3 but there have been few attempts to lengthen the toe bone in the primary operation.4 On-top plasty is broadly used for congenital anomalies5 or traumatic injuries6 of the hand region. The purpose of this article was to describe a primary operation with on-top plasty for lengthening of short-type postaxial polydactyly of the foot.
Case 1 The patient was an 11-month-old girl who had a right foot fifth ray duplication at the metatarsal level with a proximal component defect.7 She underwent resection of hypoplastic medial metatarsal and
PATIENTS AND METHODS Between February 2010 and October 2013, 4 patients (all females) underwent bone lengthening plasty for short-type postaxial polydactyly with on-top plasty. The mean age of the patients was 11.3 months (range, 11–12 months). Preoperative and postoperative toe lengths and complications were evaluated by comparison with the contralateral side on x-ray. Bone length was evaluated on x-ray by measurement of distances DP-PP and DP-MT (Fig. 1) and comparison of these distances between the affected and contralateral sides. Received June 5, 2014, and accepted for publication, after revision, October 6, 2014. From the *Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, Tokyo; and †Department of Plastic and Reconstructive Surgery, Saitama Hand Surgery Institute, Saitama Seikeikai Hospital, Saitama, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Satoshi Usami, MD, Department of Plastic Reconstructive Surgery, Graduate School of Science, Tokyo Medical Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/0000–0000 DOI: 10.1097/SAP.0000000000000385
Annals of Plastic Surgery • Volume 00, Number 00, Month 2014
FIGURE 1. The schema of on-top procedure based on the x-ray of case report and the 2 distances for assessment of toe bone length between preoperative and postoperative. DP-PP, The length from the tip of the distal phalanx to the bottom of the proximal phalanx. DP-MT, The length from the tip of the distal phalanx to the bottom of the metatarsal bone. www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
2
www.annalsplasticsurgery.com
117.7 105.9 112.2 102.8 118.8 104.9 111.6 102.3 24.8 68.3 14.7 46.8 19.1 50.9 17.2 44.4 6
12
19
29.2 72.3 16.5 48.1 22.7 53.4 19.2 45.4 49
117.5 105.6 116.2 106.3 139.8 109.3 102.5 101.9 81.7 92.2 96.2 99.5 89.1 96.3 72.2 85 17.1 44.9 10.5 36.6 12.8 40.8 15.8 41.3 20.1 47.4 12.2 38.9 17.9 44.6 16.2 42.1 11
12
11
11
1
2
3
4
Age, mo
DP-PP DP-MT DP-PP DP-MT DP-PP DP-MT DP-PP DP-MT
13.8 41.4 10.1 36.4 11.4 39.3 11.4 35.1
Pre On-Top, % Case
Length
Post On-Top, mm Pre On-Top, mm
TABLE 1. Improvement of Bone Length on X-ray
FIGURE 3. Postoperative view 49 months after the operation. Upper, The right fifth toe is lengthened and has a natural appearance. Lower, The epiphyseal line of the proximal phalanx was confirmed on x-ray and there was no impaired bone growth.
Preoperative and Intraoperative
lateral distal and middle phalanges. The medial proximal phalanx was then transferred to the top of the lateral proximal phalanx after partial osteotomy and pinned with Kirschner wire (Fig. 2). After surgery, her
Contralateral, mm
Affected/ Contralateral
FIGURE 2. Preoperative and intraoperative views in case 1. Upper left, Preoperative dorsal view. Upper center, Preoperative lateral view. Upper right, Preoperative bone alignment on x-ray. Lower left, After transfer of medial phalanges to the top of the lateral proximal phalanx. Lower right, Bone fixation with Kirschner wire.
Post On-Top, %
Follow-up Period, mo
Affected, mm
Contralateral, mm
Affected/ Contralateral Length
Postoperative
Postoperative, %
Annals of Plastic Surgery • Volume 00, Number 00, Month 2014
Usami et al
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery • Volume 00, Number 00, Month 2014
foot was covered with a below-knee splint and Kirschner wire was removed 4 weeks postoperatively. At 49 months postoperatively, the appearance of the foot was natural and the length of the affected toe was similar to that on the contralateral side. The epiphyseal line was confirmed on x-ray and there was no impaired bone growth (Fig. 3).
RESULTS On-top plasty was performed with medial phalanges transferred to the lateral proximal phalanx in all cases. The ratios of the affected to contralateral side preoperatively to postoperatively changed from 84.8% (72.2%–96.2%) to 115.1% (111.6%–118.8%) for DP-PP and from 93.3% (85%–99.5%) to 104% (102.8%–105.9%) for DP-MT. The DP-PP and DP-MT lengths were longer on the affected side intraoperatively and postoperatively (Table 1). There was no further surgery required and no notable complication during follow-up. Dislocation of the phalangeal bone, joint instability, and atrophy of the toes were not seen in any case. All fifth toes were well improved without valgus deformity and hypertrophic scar formation. None of the patients had persistent or occasional pain while walking or running during follow-up. This procedure was performed in few cases, but postoperative notable problems were not observed.
DISCUSSION Treatment of postaxial polydactyly of the foot should result in a natural postoperative appearance, especially in Japan where many people remain barefoot in daily life. To obtain a natural appearance after surgery, 2 points should be kept in mind throughout the operation: (1) to avoid valgus deformity1,8 and (2) to keep the remaining toe as long as possible. The on-top procedure is effective for lengthening of the total toe bone and correcting valgus deformity by changing the angle of osteotomy or fixation. In osteotomy, care should be taken not to damage the epiphyseal line, but this line is clearly visible under a microscope and the risk of epiphyseal line injury is low on the proximal phalangeal bone. Metatarsal level transfer,9 MTP joint level transfer,10 and middle phalangeal level transfer4 have been reported as switching methods. In the 4 cases described here, we used proximal phalangeal level on-top plasty for short-type polydactyly. As inclusion criteria for this procedure, it is necessary that MTP joint of proximal component keeps normal alignment for the postoperative walking function and nail form of distal component is not hypoplastic. If the cases that proper proximal and distal components belong in the same side or there is anomaly or hypoplasia of the neurovascular bundle in distal component, this method should not be applied. Additionally, by the intraoperative clinical findings, this procedure might be modified or abandoned. We consider only a few cases may be appropriate for this procedure; thus, between January 2010 and December 2013, we treated 15 patients (17 feet) with postaxial polydactyly of the foot, of whom only 4 had the indication for on-top plasty. The other patients underwent simple
© 2014 Lippincott Williams & Wilkins
On-top Plasty for Short-type Postaxial Polydactyly
medial or lateral ray resection. In our cases, all 4 patients underwent lateral distal and middle phalanges resection and the medial ray was used as a distal component. However, if there is syndactyly between the fourth and fifth toe, interdigital skin should be attached to the fifth toe and a skin graft is needed for covering the lateral aspect of the fourth toe. No patients had a postoperative functional problem that resulted in unsteady walking. The fifth toe itself only rarely serves a functional purpose in walking, in contrast to the metatarsal.1,4,9 Phalangeal level ray transfer has little effect on the MTP joint and normal joint mobility is retained. Therefore, our procedure should have little influence on walking ability, especially in children, who tend to have more joint flexibility. Postoperative hypertrophic scar formations are concerned because the force of skin traction is increased in this procedure. But hypertrophic scars were caused in our only 4 cases. We think these concerns could be prevented by using wavy or zigzag longitudinal incision, not making transverse incision as much as possible. And depending on cases, Z plasty or local flaps are effective for the prevention of hypertrophic scar formations.
CONCLUSIONS The procedure described in this report is effective for improving total bone length and correcting valgus deformity, and might be appropriate as a primary surgery for short-type postaxial polydactyly of the foot. REFERENCES 1. Uda H, Sugawara Y, Niu A, et al. Treatment of lateral ray polydactyly of the foot: focusing on the selection of the toe to be excised. Plast Reconstr Surg. 2002;109: 1581–1591. 2. Matsumine H, Yoshinaga Y, Morioka K, et al. A new surgical technique for lateral ray polydactyly without skin graft: the bell-bottom flap. Plast Reconstr Surg. 2010;125:134e–135e. 3. Hayashi A, Yanai A, Komuro Y, et al. A new surgical technique for polysyndactylyof the toes without skin graft. Plast Reconstr Surg. 2004;114:433–438. 4. Togashi S, Nakayama Y, Hata J, et al. A new surgical method for treating lateral ray polydactyly with brachydactyly of the foot: lengthening the reconstructed fifth toe. J Plast Reconstr Aesthet Surg. 2006;59:752–758. 5. Ogino T, Kato H, Ishii S, et al. Digital lengthening in congenital hand deformities. J Hand Surg Br. 1994;19:120–129. 6. Kelleher JC, Sullivan JG, Baibak GJ, et al. “On-top plasty” for amputated fingers. Plast Reconstr Surg. 1968;42:242–248. 7. Watanabe H, Fujita S, Oka I. Polydactyly of the foot: an analysis of 265 cases and a morphological classification. Plast Reconstr Surg. 1992;89:856–877. 8. Iba K, Wada T, Kanaya K, et al. An individualized approach to surgical reconstruction for lateral polydactyly of the foot with an emphasis on collateral ligament reconstruction. Plast Reconstr Surg. 2012;130:673e–680e. 9. Sahin O, Kuru I, Akgun RC, et al. Metatarsal transfer for the treatment of postaxial metatarsal-type foot synpolydactyly: a new technique that allows for comfortable shoe wearing. Bone Joint J. 2013;95-B:929–934. 10. Morley SE, Smith PJ. Polydactyly of the feet in children: suggestions for surgical management. Br J Plast Surg. 2001;54:34–38.
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3
Primary On-top Plasty for Treatment of Short-type Postaxial Polydactyly of the Foot Satoshi Usami, MD,* Satoshi Kodaira, MD,† and Mutsumi Okazaki, MD, PhD* Background: Postaxial polydactyly of the foot is typically treated with medial or lateral toe ray resection. However, simple ray resection does not always give a natural postoperative appearance, especially for short-type polydactyly. The purpose of this article was to describe our primary operation with on-top plasty for lengthening of short-type postaxial polydactyly. Methods: Four patients (mean age, 11.3 months) underwent this procedure. Ray transfer was performed at the proximal phalangeal level. Lateral distal and middle phalanges were resected and the medial ray was transferred on top of the remaining lateral proximal phalanx. Preoperative and postoperative toe lengths and complications were evaluated by comparison with the contralateral side on x-ray. Results: All toes were lengthened by a mean of 115.1% from the tip of the distal phalanx to the bottom of the proximal phalanx relative to contralateral side. Appearances were very natural without valgus deformity and hypertrophic scar. And there was no remaining dysfunction in walking after a mean of 21.5 months follow-up. Conclusions: This on-top procedure is useful for improving toe lengthening and bone alignment correction with minimal functional disturbance. Key Words: on-top plasty, polydactyly, toe lengthening
Surgical Technique Before the operation, bone size and alignment on x-ray and nail form based on the visual appearance were evaluated to determine whether medial or lateral phalanges should be used as proximal and distal components. All operations were performed under general anesthesia. A dorsal wavy longitudinal incision was first made between the fourth and fifth toe. After dissection of soft tissue, the phalanges and metatarsal head were exposed. Ray transfer was performed at the proximal phalangeal level; that is, we separated and elevated the target toe with the neurovascular bundle in the metatarsophalangeal (MTP) joint (distal component) and then transferred the elevated toe ray on top of the neighboring remaining proximal phalanx (proximal component) after osteotomy. After toe ray transfer, the toe was pinned with single or double Kirschner wire. Remaining soft tissue around the ontop bone was sutured to maintain joint stability (Fig. 1). If the transferred toe-tip developed an ischemic skin color, we had only to shorten the on-top bone to stabilize the blood circulation of the transferred toe. After surgery, a below-knee splint was used to protect the affected toe for 4 to 6 weeks. Kirschner wire was removed at approximately 4 weeks postoperatively.
(Ann Plast Surg 2014;00: 00–00)
CASE REPORT
T
reatment of postaxial polydactyly does not always produce an ideal cosmetic outcome. Redundant medial or lateral toe ray resection is the standard treatment,1 but simple ray resection gives a poor postoperative appearance of toe length in a case in which the toes are short relative to the fourth toe. Several surgical procedures have been described that avoid skin grafting for postaxial polysyndactyly,2,3 but there have been few attempts to lengthen the toe bone in the primary operation.4 On-top plasty is broadly used for congenital anomalies5 or traumatic injuries6 of the hand region. The purpose of this article was to describe a primary operation with on-top plasty for lengthening of short-type postaxial polydactyly of the foot.
Case 1 The patient was an 11-month-old girl who had a right foot fifth ray duplication at the metatarsal level with a proximal component defect.7 She underwent resection of hypoplastic medial metatarsal and
PATIENTS AND METHODS Between February 2010 and October 2013, 4 patients (all females) underwent bone lengthening plasty for short-type postaxial polydactyly with on-top plasty. The mean age of the patients was 11.3 months (range, 11–12 months). Preoperative and postoperative toe lengths and complications were evaluated by comparison with the contralateral side on x-ray. Bone length was evaluated on x-ray by measurement of distances DP-PP and DP-MT (Fig. 1) and comparison of these distances between the affected and contralateral sides. Received June 5, 2014, and accepted for publication, after revision, October 6, 2014. From the *Department of Plastic and Reconstructive Surgery, Graduate School of Science, Tokyo Medical and Dental University, Tokyo; and †Department of Plastic and Reconstructive Surgery, Saitama Hand Surgery Institute, Saitama Seikeikai Hospital, Saitama, Japan. Conflicts of interest and sources of funding: none declared. Reprints: Satoshi Usami, MD, Department of Plastic Reconstructive Surgery, Graduate School of Science, Tokyo Medical Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/0000–0000 DOI: 10.1097/SAP.0000000000000385
Annals of Plastic Surgery • Volume 00, Number 00, Month 2014
FIGURE 1. The schema of on-top procedure based on the x-ray of case report and the 2 distances for assessment of toe bone length between preoperative and postoperative. DP-PP, The length from the tip of the distal phalanx to the bottom of the proximal phalanx. DP-MT, The length from the tip of the distal phalanx to the bottom of the metatarsal bone. www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1
2
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117.7 105.9 112.2 102.8 118.8 104.9 111.6 102.3 24.8 68.3 14.7 46.8 19.1 50.9 17.2 44.4 6
12
19
29.2 72.3 16.5 48.1 22.7 53.4 19.2 45.4 49
117.5 105.6 116.2 106.3 139.8 109.3 102.5 101.9 81.7 92.2 96.2 99.5 89.1 96.3 72.2 85 17.1 44.9 10.5 36.6 12.8 40.8 15.8 41.3 20.1 47.4 12.2 38.9 17.9 44.6 16.2 42.1 11
12
11
11
1
2
3
4
Age, mo
DP-PP DP-MT DP-PP DP-MT DP-PP DP-MT DP-PP DP-MT
13.8 41.4 10.1 36.4 11.4 39.3 11.4 35.1
Pre On-Top, % Case
Length
Post On-Top, mm Pre On-Top, mm
TABLE 1. Improvement of Bone Length on X-ray
FIGURE 3. Postoperative view 49 months after the operation. Upper, The right fifth toe is lengthened and has a natural appearance. Lower, The epiphyseal line of the proximal phalanx was confirmed on x-ray and there was no impaired bone growth.
Preoperative and Intraoperative
lateral distal and middle phalanges. The medial proximal phalanx was then transferred to the top of the lateral proximal phalanx after partial osteotomy and pinned with Kirschner wire (Fig. 2). After surgery, her
Contralateral, mm
Affected/ Contralateral
FIGURE 2. Preoperative and intraoperative views in case 1. Upper left, Preoperative dorsal view. Upper center, Preoperative lateral view. Upper right, Preoperative bone alignment on x-ray. Lower left, After transfer of medial phalanges to the top of the lateral proximal phalanx. Lower right, Bone fixation with Kirschner wire.
Post On-Top, %
Follow-up Period, mo
Affected, mm
Contralateral, mm
Affected/ Contralateral Length
Postoperative
Postoperative, %
Annals of Plastic Surgery • Volume 00, Number 00, Month 2014
Usami et al
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery • Volume 00, Number 00, Month 2014
foot was covered with a below-knee splint and Kirschner wire was removed 4 weeks postoperatively. At 49 months postoperatively, the appearance of the foot was natural and the length of the affected toe was similar to that on the contralateral side. The epiphyseal line was confirmed on x-ray and there was no impaired bone growth (Fig. 3).
RESULTS On-top plasty was performed with medial phalanges transferred to the lateral proximal phalanx in all cases. The ratios of the affected to contralateral side preoperatively to postoperatively changed from 84.8% (72.2%–96.2%) to 115.1% (111.6%–118.8%) for DP-PP and from 93.3% (85%–99.5%) to 104% (102.8%–105.9%) for DP-MT. The DP-PP and DP-MT lengths were longer on the affected side intraoperatively and postoperatively (Table 1). There was no further surgery required and no notable complication during follow-up. Dislocation of the phalangeal bone, joint instability, and atrophy of the toes were not seen in any case. All fifth toes were well improved without valgus deformity and hypertrophic scar formation. None of the patients had persistent or occasional pain while walking or running during follow-up. This procedure was performed in few cases, but postoperative notable problems were not observed.
DISCUSSION Treatment of postaxial polydactyly of the foot should result in a natural postoperative appearance, especially in Japan where many people remain barefoot in daily life. To obtain a natural appearance after surgery, 2 points should be kept in mind throughout the operation: (1) to avoid valgus deformity1,8 and (2) to keep the remaining toe as long as possible. The on-top procedure is effective for lengthening of the total toe bone and correcting valgus deformity by changing the angle of osteotomy or fixation. In osteotomy, care should be taken not to damage the epiphyseal line, but this line is clearly visible under a microscope and the risk of epiphyseal line injury is low on the proximal phalangeal bone. Metatarsal level transfer,9 MTP joint level transfer,10 and middle phalangeal level transfer4 have been reported as switching methods. In the 4 cases described here, we used proximal phalangeal level on-top plasty for short-type polydactyly. As inclusion criteria for this procedure, it is necessary that MTP joint of proximal component keeps normal alignment for the postoperative walking function and nail form of distal component is not hypoplastic. If the cases that proper proximal and distal components belong in the same side or there is anomaly or hypoplasia of the neurovascular bundle in distal component, this method should not be applied. Additionally, by the intraoperative clinical findings, this procedure might be modified or abandoned. We consider only a few cases may be appropriate for this procedure; thus, between January 2010 and December 2013, we treated 15 patients (17 feet) with postaxial polydactyly of the foot, of whom only 4 had the indication for on-top plasty. The other patients underwent simple
© 2014 Lippincott Williams & Wilkins
On-top Plasty for Short-type Postaxial Polydactyly
medial or lateral ray resection. In our cases, all 4 patients underwent lateral distal and middle phalanges resection and the medial ray was used as a distal component. However, if there is syndactyly between the fourth and fifth toe, interdigital skin should be attached to the fifth toe and a skin graft is needed for covering the lateral aspect of the fourth toe. No patients had a postoperative functional problem that resulted in unsteady walking. The fifth toe itself only rarely serves a functional purpose in walking, in contrast to the metatarsal.1,4,9 Phalangeal level ray transfer has little effect on the MTP joint and normal joint mobility is retained. Therefore, our procedure should have little influence on walking ability, especially in children, who tend to have more joint flexibility. Postoperative hypertrophic scar formations are concerned because the force of skin traction is increased in this procedure. But hypertrophic scars were caused in our only 4 cases. We think these concerns could be prevented by using wavy or zigzag longitudinal incision, not making transverse incision as much as possible. And depending on cases, Z plasty or local flaps are effective for the prevention of hypertrophic scar formations.
CONCLUSIONS The procedure described in this report is effective for improving total bone length and correcting valgus deformity, and might be appropriate as a primary surgery for short-type postaxial polydactyly of the foot. REFERENCES 1. Uda H, Sugawara Y, Niu A, et al. Treatment of lateral ray polydactyly of the foot: focusing on the selection of the toe to be excised. Plast Reconstr Surg. 2002;109: 1581–1591. 2. Matsumine H, Yoshinaga Y, Morioka K, et al. A new surgical technique for lateral ray polydactyly without skin graft: the bell-bottom flap. Plast Reconstr Surg. 2010;125:134e–135e. 3. Hayashi A, Yanai A, Komuro Y, et al. A new surgical technique for polysyndactylyof the toes without skin graft. Plast Reconstr Surg. 2004;114:433–438. 4. Togashi S, Nakayama Y, Hata J, et al. A new surgical method for treating lateral ray polydactyly with brachydactyly of the foot: lengthening the reconstructed fifth toe. J Plast Reconstr Aesthet Surg. 2006;59:752–758. 5. Ogino T, Kato H, Ishii S, et al. Digital lengthening in congenital hand deformities. J Hand Surg Br. 1994;19:120–129. 6. Kelleher JC, Sullivan JG, Baibak GJ, et al. “On-top plasty” for amputated fingers. Plast Reconstr Surg. 1968;42:242–248. 7. Watanabe H, Fujita S, Oka I. Polydactyly of the foot: an analysis of 265 cases and a morphological classification. Plast Reconstr Surg. 1992;89:856–877. 8. Iba K, Wada T, Kanaya K, et al. An individualized approach to surgical reconstruction for lateral polydactyly of the foot with an emphasis on collateral ligament reconstruction. Plast Reconstr Surg. 2012;130:673e–680e. 9. Sahin O, Kuru I, Akgun RC, et al. Metatarsal transfer for the treatment of postaxial metatarsal-type foot synpolydactyly: a new technique that allows for comfortable shoe wearing. Bone Joint J. 2013;95-B:929–934. 10. Morley SE, Smith PJ. Polydactyly of the feet in children: suggestions for surgical management. Br J Plast Surg. 2001;54:34–38.
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
3
