Republication of "Congenital Dislocation of the Fifth Metatarsophalangeal Joint in Adults: Operative Technique".

Congenital dislocation of the fifth metatarsophalangeal (MTP) joint can cause significant limitations in a patient's ability to wear a closed shoe. Historic treatment has involved amputation of the digit or attempts at reconstruction. These techniques have had limited success with unreliable correction and/or unacceptable cosmesis. The authors present a detailed, methodical approach to reconstruction of this deformity with a stepwise algorithm that addresses both the bony and soft tissue components of the deformity. With this modern technique, reliable and satisfactory results can be expected.

Separated muscle belly of the flexor digitorum brevis for the fifth toe: a case report.

This case report describes a variation of the flexor digitorum brevis (FDB) with a separated muscle belly and tendon at the fifth toe. The narrow tendon and muscle belly for the fifth toe arose from the intermuscular septum between the FDB and abductor digiti minimi adjacent to the arising fibers of the FDB, separating from its other fibers. The tendon and muscle belly for the fifth toe became wider at the base of the metatarsal bones and narrower as it coursed toward the toes in a fusiform shape. The tendon and muscle belly for the fifth toe became thin at the midfoot and coursed just beneath the flexor digitorum longus tendon and entered the digital tendinous sheath. FDB variations including that described herein should be considered when performing various surgical procedures and evaluating the biomechanics of the foot.

Fetal presentation of chondrodysplasia with joint dislocations, GPAPP type, caused by novel biallelic IMPAD1 variants.

Biallelic IMPAD1 pathogenic variants leads to deficiency of GPAPP (Golgi 3-prime phosphoadenosine 5-prime phosphate 3-prime phosphatase) protein and clinically causes chondrodysplasia, which is characterized by short stature with short limbs, craniofacial malformations, cleft palate, hand and foot anomalies, and various radiographic skeletal manifestations. Here we describe prenatal presentation of GPAPP deficiency caused by novel biallelic pathogenic variants, 2 base pair duplication in exon 2 of IMAPD1 gene in a patient of Asian-Indian origin. Further we report on diagnostic clues of prenatal presentation of GPAPP deficiency through ultrasonography, fetal MRI, and postmortem findings. We also provide evidence of pathophysiology of underlying GPAPP deficiency in the form of disorganization and dysplastic chondrocytes and reduced sulfation of glycoproteins through histopathology of cartilage similar to that described in mice IMPAD1 homozygous mutant model.

Pediatric Forefoot Deformities.

This article explores different pediatric forefoot deformities including syndactyly, polydactyly, macrodactyly, curly toe, and congenital hallux varus. The epidemiology and genetic background are reviewed for each condition. Preferred treatment options and recommended surgical techniques are discussed with review of the current literature.

Surgical Outcomes and Predictive Factors of Medial Toe Excision for Polysyndactyly of the Fifth Toe.

BACKGROUND: We aimed to report surgical outcomes and analyze prognostic factors of medial toe excision for polysyndactyly of the fifth toe. METHODS: We reviewed the details of 139 consecutive patients who underwent surgery for postaxial polydactyly of the foot from 2009 to 2018. Among these, 83 patients (90 feet) with polysyndactyly of the fifth toe, treated by medial toe excision (between the duplicated toes) and reconstruction of the fourth web space using a dorsal rectangular flap, were included. The toe alignment and stability were restored by chondroplasty and soft tissue balancing without an osteotomy. A full-thickness skin graft was performed in 52 feet. The mean age at surgery was 27.1 ± 17.5 months and the mean duration of follow-up was 42.8 ± 24.9 months. RESULTS: At the last follow-up, a relatively small size of the reconstructed toe was observed in 19 feet (19/90, 21.1%). Proximal duplication level (metatarsal or proximal phalanx type) and preoperative hypoplasia of the remaining toe were related to the small postoperative size. Valgus deformity of the remaining toe was observed in 2 feet (2/90, 2.2%). We observed 17 cases with delayed healing or early postoperative wound infection. Among these, 7 cases (7/90, 7.8%) showed postoperative thickening or advancement of the web, which was not observed in cases without wound problems. No cases had functional disturbance or pain. CONCLUSION: The overall surgical outcomes were satisfactory without an osteotomy. Patients with a proximal duplication level or preoperative hypoplasia of the remaining toe should be informed of its possible small size postoperatively. LEVELS OF EVIDENCE: Level IV, retrospective case series.

Double little toenails: Report of 4 familial cases.

Double little toenails, or accessory nails of the fifth toe, are a rare and particular deformity distinct from other nail dysplasias. We describe 4 cases of female patients, including a 6-year-old girl, experiencing this bilateral condition after birth. The nail anomaly shows an autosomal-dominant type of transmission that affects only female individuals. The subjects examined were from a family without marriages between blood relatives and without neuroectodermal hereditary diseases. The 4 patients had no bone alterations of the terminal phalanges of the fifth toe or alterations of the joints of the toes or hair. One patient had nail deformity associated with epilepsy; another patient, associated with an infection of an accessory nail.

Ainhum, a rare mutilating dermatological disease in a female Cameroonian: a case report.

BACKGROUND: Ainhum is an idiopathic dermatological disease characterized by a progressive constricting ring usually on the fifth toe, which may lead to spontaneous auto-amputation of the affected toe. Timely diagnosis and treatment are the key elements to avert amputations with resultant mutilating deformities, permanent handicaps and psychological sequelae. Though common in African descents, this pathology has not been described in the Cameroonian literature. Herein, we report the case of an adult Cameroonian woman presenting with ainhum. CASE PRESENTATION: A 54-year old Cameroonian was admitted to our primary healthcare centre with a 6-month history of a painful constriction band developing at the base of her right fifth toe. Her past history was uneventful. Based on the absence of trauma and spontaneous onset of the condition, the diagnosis of ainhum was most suggestive. She was managed surgically by excision of the band, disarticulated at right fifth metatarsophalangeal joint and skin closure. Her post-operative course after 1 year was uneventful. CONCLUSION: Here we presented a case of ainhum, a rare dermatological disease with few reports. In view of the serious complications of ainhum such as mutilating deformities with permanent physical disabilities and psychological trauma, we draw clinicians' attention, especially wound care specialists to this rare but potentially handicapping disease, for timely diagnosis and management.

The incidence of biphalangeal fifth toe: Comparison of normal population and patients with foot deformity.

BACKGROUND: Pedal biphalangism, which was also defined as symphalangism, is seen at a frequency that cannot be ignored; however, no study can be found in the literature evaluating biphalangism in normal population in comparison to those who have foot disorders. The aim of this study was to evaluate the incidence of the pedal fifth toe symphalangism in normal population and in patients with foot deformity including hallux valgus, pes planus, pes cavus, and pes equinovarus. We hypothesized that pedal fifth toe symphalangism may be a predisposing factor or an accompanying structural variation for foot deformity. MATERIALS: Patients admitted to the emergency department of our center in October and November 2016 were defined as the control group, and patients with the diagnosis of hallux valgus, pes planus, pes cavus, and pes equinovarus treated between 2011 and 2016 in our department were defined as the foot deformity group. Individuals who had anteroposterior, oblique, and lateral radiographs of foot were included in the study. RESULTS: One thousand and four patients participated in the cross-sectional observational study. Biphalangeal fifth toe was found in 328 of 1004 (32.7%) patients. In foot deformity group ( n = 672), 222 patients (33%) had biphalangeal fifth toe. In the control group, 106 (31.9%) of the 332 patients had biphalangeal fifth toe. There was no statistically significant difference in the incidence of biphalangeal fifth toe between the two groups ( p = 0.72). CONCLUSIONS: According to the results of this study, biphalangeal fifth toe is a common pedal anatomical variant seen approximately in one-third of the population who have either foot deformity or not. This information may be valuable for podiatrist undertaking the conservative or surgical treatment of fifth toe-related disorders.

Additional muscular slip of the flexor digitorum longus muscle to the fifth toe.

Despite the fact that there are numerous reports on muscular variations in the sole of the foot, routine dissection in a formaldehyde-fixed cadaver revealed an accessory flexor digiti quinti muscle, which to the best of our knowledge is a very unusual variant. This was in the form of a slender, 38 mm long muscular slip, with a proximal and distal tendon extending from the common flexor digitorum longus tendinous plate out to the distal phalanx of the fifth toe. An associated finding was the absence of the musculotendinous portion of the flexor digitorum brevis to the same toe. A developmental explanation for this variation is presented. Clinical implications with regard to this anatomical condition may result in clawing of the fifth toe.

Percutaneous osteotomy of the fifth metatarsal for symptomatic bunionette.

The bunionette is a lateral prominence of the fifth metatarsal head. Operative correction of a symptomatic bunionette is indicated if conservative treatment has failed to relieve the symptoms. Although numerous bony or soft tissue surgical procedures have been described, the ideal treatment has not yet been identified. The aim of the present study was to retrospectively evaluate the results of a series of 15 feet affected by symptomatic bunionette deformity treated by percutaneous osteotomy of the fifth metatarsal. From January 2009 to December 2009, 15 feet in 12 patients with symptomatic type 2 and 3 bunionette deformities were treated with percutaneous fifth metatarsal osteotomy, alone or combined with percutaneous shaving of the fifth metatarsal head. The mean patient age was 44 (range 18 to 56) years at surgery. The mean follow-up duration was 24 (range 16 to 28) months. The average lesser toe American Orthopaedic Foot and Ankle Society scale score increased from 61.8 ± 11.1 points preoperatively to 100 points at the last follow-up visit (p < .0001). The mean fifth metatarsophalangeal angle decreased from 18.8° ± 3.6° (range 13° to 26°) preoperatively to 1.7° ± 1.4° (range -2° to 4°) at the final follow-up visit, and this difference was statistically significant (p < .0001). The average 4-5 intermetatarsal angle was 11.2° ± 1.7° (range 9° to 15°) before surgery and 3.1° ± 1.3° (range 1° to 5°) after surgery, and this difference was also statistically significant (p < .0001). The mean interval to radiographic union was 9 (range 8 to 12) weeks postoperatively. The complications included 1 case of wound dehiscence. In conclusion, percutaneous osteotomy of the fifth metatarsal is an effective and safe technique for the treatment of painful bunionette.

Percutaneous correction of congenital overlapping fifth toe in paediatric patients.

The various available surgical methods for correcting congenital overlapping fifth toe deformity consistently require a skin plasty step, which can result in complications (necrosis, tight scar, unbecoming appearance). Here, we describe a percutaneous technique involving extensor tenotomy combined with release of the dorso-medial capsule and ligaments. No skin plasty is required. Percutaneous osteotomy of the first phalanx can be performed if needed. From 2006 to 2010, we used this technique in 16 patients (27 toes) with a mean age of 12.6years (range, 6-17years). Mean follow-up at last evaluation was 2.1 years. Osteotomy of the first phalanx was performed for 13 toes. The outcome was very good for 21 toes and good for six toes. No relapses or complications were recorded. This simple and safe technique deserves consideration in children with congenital overlapping fifth toe.

Plastia de Lapidus en el tratamiento quirúrgico del quinto ortejo supra aducto / Lapidus procedure for treatment of overlapped fifth toe

The varus fifth toe pathology, in spite of its relative frequency and clinical relevance, has been barely studied in relation to the treatment results. 28 overlapped fifth toes operated according to the Lapidus Technique were evaluated retrospectively, corresponding to 17 patients, age average 28 years, opered since year2003. The minimum follow up time was 6 months. The surgical technique consisted on a dorsal approach in "italic s" on the 5° metatarsophalangic joint, capsulotomy and transference of the EDL to the digiti quinti abductor. Preoperative Hallux Metatarsophalangeal-lnterphalangeal AOFAS Scale average was 88,1 and varied to 99,4 points to the six months of pursuit. 100% of the patients showed complete satisfaction with the result. Only 2 patients presented minor postoperative complications (wound infection and dehiscence), which were handled ambulatory. Lapidus Procedure is a safe procedure and effective in the correction of overlapping fifth toe.

La patología del 5° ortejo varo, a pesar de su relativa frecuencia y relevancia clínica ha sido escasamente estudiada en relación a los resultados de tratamiento. Se evaluaron retrospectivamente 28 quintos ortejos supra aducto flexibles operados según la técnica de Lapidus, correspondientes a 17 pacientes, edad promedio 28 años, operados desde el año 2003. El seguimiento mínimo fue de 6 meses. La técnica quirúrgica consistió en abordaje dorsal en "s" itálica sobre la 5° articulación metatarsofalángica, capsulotomía y transferencia del EDL al abductor digiti quinti. El promedio de la Escala AOFAS para antepie preoperatoria fue de 88,1 y varió a 99,4 puntos a los seis meses de seguimiento. 100 por ciento pacientes mostraron satisfacción completa con el resultado. Sólo 2 pacientes presentaron complicaciones menores posoperatorias (infección de la herida y dehiscencia) que se manejaron ambulatoriamente. La plastia de Lapidus es un procedimiento seguro y eficaz en la corrección del quinto ortejo varo flexible.

Genetic and Environmental Factors of Two-phalanged Fifth Toe in Korean / 체질인류학회지

Anatomically, we have known that the first toe is composed of 2 phalangeal bones (proximal and distal phalanx) and the second, third, fourth, fifth toe are composed of 3 phalangeal bones (proximal, middle, and distal phalanx). But in Korean the 5th toe is commonly seen as 2 phalangeal bones in foot plain X-ray. In this study, we observed the numbers of phalangeal bones of fifth toe in Korean and analyzed the relation with several environmental factors and genetic factor. The data of occupation, age, body weight and foot length as well as the foot radiograph were obtained in 175 persons without any foot lesion. With the coorperative persons among them showing triphalangeal 5th toe as the index cases, radiograph of 12 family were studied to analyse the pedigree. As result, total frequency of the 5th toe symphalangism was 74.29% (male 74.2%, female 73.36%). There was no statistical difference between male and female. The bilaterality of the symphalangism was 98.46%. The occupation group were farmer, labor, self-support, white collar, student, housewife, there was no correlation between the kind of occupation and the frequency of the symphalangism. Also there was no correlation between body weight or foot length and the symphalangism. In conlusion, the two-phalanged fifth toe might be related with genetic factor rather than several environmental factors such as sex, age, occupation, body weight and length of foot. From the pedigree study we concluded the genetic trait of the triphalangism might be the autosomal recessive.

Two-phalanged Fifth Toe in Korean Children / 체질인류학회지

Radiographic research was performed to know the frequency of two-phalanged fifth toe and its relation to presence of the ossification centers in normal Korean children. Previous study showed more than 74% of the incidence in adulthood and less than 30% in childhood. Fifty children (33 male and 17 female, aged 2 to 15; mean age 9.6) were studied by plain foot radiographs focused on the fifth toe. In the 3~8 yr old 20 subjects, secondary ossification center of distal phalangeal bone was seen as a ossicle (small bone) placed at proximal to the distal phalanx. Secondary ossification center of middle phalangeal bone and the bony shaft of the phalanx was hard to distinguish. So keeping up the objectivity, regardless of distinguishable ossification center or the bony shaft of phalanges, ossicles seen on the 5th toe was counted to classify the presumptive type of the toe. Epiphyseal ossification center of proximal phalanx was excluded from the count. There were three types of the fifth toe which has 2 ossicles to 4 ossicles. Overall incidence of the type of 2 ossicles was 24% (12/50). Above 12 yr old group the incidence was 61% (11/18), and above 13 yr old group the incidence was 75% (9/12). The incidence of biphalangism came closer to the adult's after late childhood. This finding represent that progress of biphalangealization completed after late childhood. It seems that the progress starts earlier than 3 yr old. We made the hypothesis by the incidence of 30% (6/20) of the type which has 4 ossicles on the fifth toe at 3~8 yr old group. Four ossicles might be a secondary ossification center of distal phalanx and the bony shaft of distal, middle and proximal phalanx. They might form a distal interphalageal joint and the triphalangeal toe. To know more about the morphogenesis of biphalalngeal 5th toe, further progressive study in childhood is needed.

Congenital deformities of the foot.

A few selectec metric and numeric malformations of the foot (Fibular deficiency, vertical talus, coalition, syndactylism, macrodactylism, metatarsal malformation, cleft foot, overriding fifth toe) are discussed to demonstrate, that concepts for their treatment should be developed as early as possible in order to allow for bringing those structures that are developed in optimum use. Besides function cosmetic aspects of the foot also deserve being respected.

Two-Phalanged Fifth Toe in Korean / 체질인류학회지

Except for the hallux, the human toes classically present three phalanges, distal, middle and proximal. However in 5th toe, only two phalanges are frequently observed. In this condition, known as synarthrosis of the distal interphalangeal joint, the middle and distal phalanges are fused together to appear as symphalangism or biphalangeal 5th toe. Phalanges of 5th toe was investigated in 1,187 cases of Korean radiographs. The incidence of symphalangism was found to be 74% in 1,150 adult. The bilaterality was 99%. To prove proove the genetic basis of the symphalangism, pedigree studies were performed. The symphalangism of the 5th toe was supposed to be an autosomal dominant trait. As an phenotype of recessive homozygote the triphalaneal subjects were traced to investigate their families. Pedigrees of four families in which both parents had triphalangea of 5th toe showed that their offsprings always showed the triphalangea. Therefore, it suggests the symphalangism inherit as a Mendelian dominant trait and it seems to be an example of microevolution or genetic adaptation to bipedalism.