Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

194. Butler Procedure for Overlapping Fifth Toe

B. David Horn

DEFINITION

images Overlapping fifth toe is a congenital condition where the fifth toe is rotated and overrides the fourth toe.

images It is frequently bilateral.

images Males are affected as frequently as females.

ANATOMY

images There are six main components:

images The fifth toe may be smaller than normal.

images The fifth toe is adducted toward the fourth toe.

images The fifth metatarsophalangeal joint has a dorsiflexion contracture.

images The phalanges of the fifth toe are rotated laterally.

images The fifth extensor digitorum longus tendon is shortened.

images The fifth metatarsophalangeal joint is dislocated dorsally.

PATHOGENESIS

images 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

images This condition rarely causes pain or difficulty in shoe wear in children less than 10 years of age.

images In older children and adolescents there will be painful dorsal callosities about 50% of the time.

images There may also be difficulty in finding shoes that fit appropriately in older children and adolescents.

images Parents are frequently concerned about the cosmetic appearance of the foot.

PATIENT HISTORY AND PHYSICAL FINDINGS

images The fifth toe will be dorsiflexed, adducted, and laterally rotated. It will not be passively correctable into a neutral position.

images A careful neurovascular examination should be performed and documented.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Plain anteroposterior (AP), lateral, and oblique radiographs may be obtained and will demonstrate a dorsolaterally subluxated fifth metatarsophalangeal joint.

NONOPERATIVE MANAGEMENT

images Conservative treatment (eg, stretching, splinting, taping) is ineffective in the treatment of this condition.

SURGICAL MANAGEMENT

images Surgery is indicated when nonoperative treatment fails, such as failure to find comfortable shoes, or when there is intractable pain from shoes.

Positioning

images The patient is supine, preferably with a bolster beneath the ipsilateral hemipelvis to make the lateral foot more accessible.

images A tourniquet should be used during the procedure.

TECHNIQUES

BUTLER PROCEDURE FOR OVERLAPPING FIFTH TOE

images  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).

images  The plantar handle should be slightly longer than the dorsal handle and directed slightly laterally.

images  The skin flaps are elevated and the tight extensor tendon is exposed.

images  Care should be taken to preserve the neurovascular bundles (TECH FIG 1B).

images  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).

images  The toe should freely move plantarward and laterally into its corrected position (TECH FIG 1D).

images There should be no tension on the toe, and the toe should rest within the plantar handle of the racquet incision.

images  Interrupted sutures are then used to hold the toe reduced in place (TECH FIG 1E).

images  A cast or hard-soled shoe can be used postoperatively.

images

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.

images

POSTOPERATIVE CARE

images Postoperative care includes sterile dressings, and allowing mobilization and weight bearing as tolerated.

OUTCOMES

images This procedure has a high patient satisfaction rate (about 90%) in various studies.

images Black et al1 reported 94% good or excellent results.

COMPLICATIONS

images Incomplete correction

images Neurovascular compromise

images Scar contracture

images 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.



If you find an error or have any questions, please email us at admin@doctorlib.info. Thank you!