B. David Horn
DEFINITION
Overlapping fifth toe is a congenital condition where the fifth toe is rotated and overrides the fourth toe.
It is frequently bilateral.
Males are affected as frequently as females.
ANATOMY
There are six main components:
The fifth toe may be smaller than normal.
The fifth toe is adducted toward the fourth toe.
The fifth metatarsophalangeal joint has a dorsiflexion contracture.
The phalanges of the fifth toe are rotated laterally.
The fifth extensor digitorum longus tendon is shortened.
The fifth metatarsophalangeal joint is dislocated dorsally.
PATHOGENESIS
The exact pathogenesis is unknown, but the condition is believed to be secondary to a congenital contracture of the fifth extensor digitorum longus tendon.
NATURAL HISTORY
This condition rarely causes pain or difficulty in shoe wear in children less than 10 years of age.
In older children and adolescents there will be painful dorsal callosities about 50% of the time.
There may also be difficulty in finding shoes that fit appropriately in older children and adolescents.
Parents are frequently concerned about the cosmetic appearance of the foot.
PATIENT HISTORY AND PHYSICAL FINDINGS
The fifth toe will be dorsiflexed, adducted, and laterally rotated. It will not be passively correctable into a neutral position.
A careful neurovascular examination should be performed and documented.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Plain anteroposterior (AP), lateral, and oblique radiographs may be obtained and will demonstrate a dorsolaterally subluxated fifth metatarsophalangeal joint.
NONOPERATIVE MANAGEMENT
Conservative treatment (eg, stretching, splinting, taping) is ineffective in the treatment of this condition.
SURGICAL MANAGEMENT
Surgery is indicated when nonoperative treatment fails, such as failure to find comfortable shoes, or when there is intractable pain from shoes.
Positioning
The patient is supine, preferably with a bolster beneath the ipsilateral hemipelvis to make the lateral foot more accessible.
A tourniquet should be used during the procedure.
TECHNIQUES
BUTLER PROCEDURE FOR OVERLAPPING FIFTH TOE
A dorsal racquet incision is made about the toe with a second handle to the racquet added on the plantar aspect of the toe (TECH FIG 1A).
The plantar handle should be slightly longer than the dorsal handle and directed slightly laterally.
The skin flaps are elevated and the tight extensor tendon is exposed.
Care should be taken to preserve the neurovascular bundles (TECH FIG 1B).
The extensor tendon is divided, and a dorsomedial release of the fifth metatarsophalangeal joint is performed. If needed, the plantar aspect of the fifth metatarsophalangeal joint may be dissected off the metatarsal head and divided to increase joint mobility (TECH FIG 1C).
The toe should freely move plantarward and laterally into its corrected position (TECH FIG 1D).
There should be no tension on the toe, and the toe should rest within the plantar handle of the racquet incision.
Interrupted sutures are then used to hold the toe reduced in place (TECH FIG 1E).
A cast or hard-soled shoe can be used postoperatively.
TECH FIG 1 • A. A racquet incision with plantar and dorsal extensions is used. B. Deep dissection is performed, preserving the neurovascular bundles. An extensor tenotomy is performed. C. A capsular release is performed. D. The toe should now reside in its corrected position. E. The incisions are closed with interrupted sutures. They help provide stability to the reconstruction.
POSTOPERATIVE CARE
Postoperative care includes sterile dressings, and allowing mobilization and weight bearing as tolerated.
OUTCOMES
This procedure has a high patient satisfaction rate (about 90%) in various studies.
Black et al1 reported 94% good or excellent results.
COMPLICATIONS
Incomplete correction
Neurovascular compromise
Scar contracture
Infection
REFERENCES
· Black GB, Grogan DP, Bobechko WP. Butler arthroplasty for correction of the adducted fifth toe: a retrospective study of 36 operations between 1968 and 1982. J Pediatr Orthop 1985;5:439–441.
· De Boeck H. Butler's operation for congenital overriding of the fifth toe: retrospective 1to 7-year study of 23 cases. Acta Orthop Scand 1993;64:343–344.
· Cockin J. Butler's operation for an over-riding fifth toe. J Bone Joint Surg Br 1968;50B:78–81.