Foot and Ankle Surgery 2002 8:49-52

V-Y arthroplasty for congenital overriding fifth a retrospective study of 34 operations between 1986 and 2000

toe:

F.O. ABU HASSAN,* A. SHANNAK* AND M. S T E P H E N S t *Jordan University Hospital, Amman, Jordan and ~Children's Hospital, Dublin, Ireland

Summary A total of 32 children and adolescents who had undergone V-Y arthroplasty for the correction of overriding fifth toe by multiple surgeons was reviewed retrospectively. Bilateral operations were performed on six patients, giving a total of 38 operations. Patients were followed for 1-13 years (average 8.07 years). A total of 12 patients (15 feet) were clinically examined. The remaining 16 patients (19 feet) completed the assessment sheet by mail. Excellent results were obtained in 7 feet, good results in 16 feet and poor results in 11 feet. All the poor results related to the age at the time of surgery (P = 0.0047). A total of 37% of the patients were not satisfied with the results of the operation. With a third of the patients having a poor result, serious consideration should be made in recommending this form of surgery, especially in adolescent children.

Keywords: overriding fifth toe; varus fifth toe; V-Y arthroplasty; little toe deformity; adducted fifth toe

Introduction

Overriding fifth toe is a relatively common condition in which the little toe overlaps the adjacent fourth toe associated with the following abnormalities: hypo- plasia of the fifth toe, short, contracted extensor digitorum longus tendon hypoplasia of the fourth web space, dorsomedial subluxation of the fifth metatarsophalangeal joint, external rotation deform- ity of the little toe, contracture of the dorsomedial fifth metatarsophalangeal joint capsule and adhesion of the volar plate to the head of the fifth metatarsal [1-7].

The deformity can be a cosmetic problem; footwear problems in the ~dolescent patients are usually symptomatic in half of the patients [1,2,4,7]. In 1948, Stamm described the operation of V-Y plasty and in 1953, Wilson [8] reported the results of seven cases.

Correspondence: Freih Odeh Abu Hassan, PO Box 73/Jubaiha 11941, Jordan (e-mail: freih@joinnet.com.jo).

Reports on the results of this operation in the literature are very few. Paton [6] and Scrase [7] reported bad results of this operation. This encouraged us to review our patients to assess the results of this procedure.

Patients and methods

At the Children's Hospital in Dublin and the Jordan University Hospital in Amman, between January 1986 and March 2000, 32 healthy patients underwent V-Y arthroplasty by the authors to correct sympto- matic and overlapping deformity of the fifth toe through a V-shaped incision based distally on the abnormal skinfold of the fourth web space and the dorsum of the toe, followed by division of the extensor tendons, dorsomedial capsulotomy and closure of the skin in a Y-shape; in eight of the feet, the toe was fixed with a Kirschner wire for 4 weeks. There were 25 girls, seven boys, and six bilateral,

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50 F .O. A B U H A S S A N E T A L .

giving a total of 38 procedures . The mean age for the girls was 10 years (range 4-15 years), and the mean age for the boys was 8.3 years (range 2.7-14.3 years). Four patients were uncontactable as a result of a change of their address , leaving 28 patients (with 34

feet) for the final review. They were fol lowed for 1- 13 years (average 8.07 years).

The patients were evalua ted for the results of the operat ion by assessing overlap, rotation, scarring, range of m o v e m e n t and pat ient satisfaction. Each pat ient was given one of three grades: excellent, good or poor (Table 1).

A total of 12 pat ients (42.85%), wi th 15 feet (44.11%), were recalled into a special assessment clinic and, after clinical examinat ion, the assessment sheet (Table 2) was comple ted by the first author. The remain ing 16 patients, wi th 19 feet, comple ted the assessment sheet by mail; seven of these pat ients were contacted by te lephone for clarification of their answers to the questionnaire.

Table 1 Scoring criteria

Excellent Good Poor

Overlap Absent Mild Severe Rotation Normal Mild Severe Scar Faint S l igh t Contracture Range of movement F u l l Subnormal Restricted/stiff

Result 7 feet 16 feet 11 feet

Complicat ions included one superficial w o u n d infection, which was treated by antibiotics and g raded as a good result in the final fol low-up, and

one accidental wi thdrawal of the Kirschner wire, which caused relapse of the deformi ty and was

g raded 'poor ' . In a fur ther single case, there was delay in w o u n d

heal ing due to early suture removal ; the case was

g raded as ' good ' at the final follow-up. A one -way analysis of var iance (aNOVA) was used

for analysis of the effect of age on the results as a d e p e n d e n t variable.

R e s u l t s

Out of the 34 feet, seven feet scored an excellent result (20.6%), 16 feet scored good results (47%), and 11 feet scored poor results (32.4%) (Figure 1). Of those wi th excellent results, their age range at the t ime of the operat ion was be tween 2.7 and 10 years (mean 6.71 years); the age range of those wi th good results was be tween 4 and 12 years (mean 9.48 years), and for those wi th poor results the range was be tween 8 and 15 years (mean 11.62 years)

(Figure 2). The ANOVA revealed a statistically significant

relat ionship be tween the age at opera t ion and the end result (P = 0.0047), the poor results noted in the older age group. A total of 13 feet of the total g roup

Patient personal details: Name: Date of birth: Sex: Date of operation: (a) Do you recommend the operation for a relative? (b) Are you satisfied with the results of the operation? (parents" or patients' opinion) (c) Do you have problems with shoe wear after the operation? Result of the operation: 1. Completely normal toe:

(a) Non-visible scar (faint) (b) No overlap of the toe on the 4th toe (c) Normal rotation of the toe (d) Full range of movement of the toe

2. Nearly normal toe: (a) Visible scar not causing any concern (b) Mild overlap not causing any concern (c) Mild rotation not causing any concern (d) Mild restriction of the movement of the toe

3. Abnormal toe: (a) Skin contracture or keloid (b) Severe overlap as before (c) Severe rotation as before (d) Stiff toe

Table 2 Assessment sheet

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V-Y ARTHROPLASTY FOR C O N G E N I T A L OVERRIDING TOE 51

Excellent 21%

Overall 37% of the patients were not satisfied with the final results (Figure 3). Despite this, all were able to wear normal shoes. A total of 11 out of 23 patients (47.8%) would not recommend the opera- tion for a relative or a friend.

Po(

32 °

Figure 1 End results of V-Y arthroplasty.

was noticed to have a tendency to early recurrence in the first 6 weeks after the operation, which was treated by strapping the toe down in the corrected position. Seven had poor results, four had good results and two had excellent results. Out of the eight feet which were supported by a Kirschner wire to keep the toe in corrected position, only two feet had an excellent result; three had good results and three had poor results.

D i s c u s s i o n

V-Y arthroplasty is performed by many orthopaedic surgeons because it is a simple and easy operation. As the deformity is associated with many structural abnormalities, conservative treatment is unlikely to achieve correction. Giannestras [9] described the use of adhesive tape splinting that is changed daily but it did not correct the deformity.

Jordan and Caselli [10] described modification of the Giannestras technique, although their technique was simple but it did not achieve long-term correction.

Numerous other surgical procedures have been described to treat this condition: soft tissue proce- dures (Butler's procedures, Hulman procedure, V-Y arthroplasty, extensor tenotomy, extensor tendon transplantation, capsular release or surgical

16-

14-

12-

c-

O_ 8 O

< 6

• Excellentgroup

• Good group

[ ] Poorgroup

1 2 3 4 5 6 7 8 9 10

Consecutive feet

Figure 2 Age distribution of the various groups.

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52 F .O. A B U H A S S A N E T A L .

in 3%, whereas De-Boeck [14] repor ted sat is factory results in 22 out of 23 procedures.

The H u l m a n p rocedure is simple, safe and gave sat is factory long- te rm results in all 32 p rocedures [4], mo reove r there are no b o n y resect ions and the scar is h i dden [5].

Paton [6] repor ted the results of 20 p rocedures of V-Y p las ty and s h o w e d good results in 70% on short- te rm fo l low-up, wh ich d r o p p e d to 30% in 2 years.

We found that the results of this p rocedu re are d i rect ly related to the age at the t ime of surgery ; poo r resul ts in this series were not iced in the o lder age g r o u p whereas the younge r ch i ldren scored ' g o o d ' to 'excel lent ' (P = 0.0047). Therefore, this su rgery shou ld be r e c o m m e n d e d wi th caut ion and shou ld no t be carr ied out in ado lescent chi ldren.

There was no consensus in the l i terature to ei ther the best p rocedure or any techn ique par t icu lar ly su i ted for a specific age group.

Figure 3 Despite the good correction, the patient was not satisfied, due to scarring at the site of surgery.

syndacty l ism) m a y lead to excessive scarr ing and recurrence, wh ich is cosmet ica l ly unacceptab le and causes disabi l i ty, except for the But ler 's p rocedure [1-8,11,14].

Soft t issue associated w i th b o n y resect ion (proxi- ma l pha langec tomy, ex tensor t endon transfer to the neck of the fifth metatarsal) p roduces good results bu t is technical ly diff icult, mo re extensive, p roduces new deformi t ies and requi res a long per iod of immobi l i za t ion [12,13].

The But ler 's p rocedure , wh ich addresses the soft t issues at the dorsal med ia l and the p lantar aspect of the toe, a l lows for correct ion of the st ructura l abnormal i t ies and gives consistent results, p rov ided care is taken not to p roduce excessive tension on the neurovascu la r bund le w h e n full correct ion is obta ined [1,2,14].

Black et al. [1] repor ted their good- to-excel lent results in 34 out of 36 operat ions. Cock in [2] repor ted good results in 90% of pat ients, fair in 6%, and poor

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R e f e r e n c e s

1 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 (4): 439-41.

2 Cockin J. Butler's operations for overriding fifth toe. J Bone Joint Surg-Br 1968; 50: 78-81.

3 Lapidus PC. Transplantation of the extensor tendon for correc- tion of the overlapping fifth toe. J Bone Joint Surg 1942; 24: 555.

4 Hulman S. Simple operation for the overlapping fifth toe. Br Med ] 1964; 11: 1506-7.

5 Morris EW, Scullion JE, Mann TS. Varus fifth toe. J Bone Joint Surg-Br 1982; 64 (1): 99-100.

6 Paton RW. V-Y plasty for correction of varus fifth toe. J Pediatr Orthop 1990; 10 (2): 248-49.

7 Scrase WH. The treatment of dorsal adduction deformities of the fifth toe. J Bone Joint Surg-B 1954; 36: 146.

8 Wilson JN. V-Y correction for varus deformity of the fifth toe. Br J Surg 1953; 41: 133-5.

9 Bouchard JL. Congenital deformities of the forefoot. In: McGlamry DE Ed., Comprehensive Textbook of Foot Surgery. Baltimore: Williams & Wilkins, 1987: 580-606.

10 Jordan RP, Caselli MA. Overlapping deformity of the digits of the digits in the pediatric patient: a conservative approach to treatment. J Am Podiatry Assoc 1978; 68: 503-505.

11 Kelikian H, Clayton L, Loseff H. Surgical syudactylia of the toes. Clin Orthop 1961; 19: 208.

12 DePalma L, Zancoli G. Zancoli procedure for overlapping fifth toe: retrospective study of 18 cases followed for 4-17 years. Acta Orthop Scand 1998; 69 (5): 505-7.

13 Dyal CM, Davis WH, Thompson FM et al. Clinical evaluation of the Ruiz-Mora procedure: long-term follow-up. Foot Ankle Int 1997; 18 (2): 94-7. De Boeck H. Butler's operation for congenital overriding of the fifth toe: retrospective 1-7 year study of 23 cases. Acta Orthop Scand 1993; 64: 343-4.

© 2002 Blackwell Science Ltd, Foot and Ankle Surgery 2002, 8, 49-52