Does timing of surgery influence the long-term results of foot polydactyly treatment?

Surgical management of bilateral preaxial and postaxial polydactyly with syndactyly: A case report

INTRODUCTION AND IMPORTANCE

Polydactyly is the most common congenital malformation in the limbs. However, it is rare for a patient to exhibit concomitant preaxial and postaxial polydactyly alongside syndactyly in both limbs, and there are limited recommendations for such conditions. This report presents a case of bilateral preaxial and postaxial polydactyly with syndactyly of the feet.

PRESENTATION OF CASE

A 2-year-old girl was presented with an excess number of toes on both feet and an abnormal connection between the second and third toes. After a physical examination and plain radiography, the patient was diagnosed with bilateral preaxial and postaxial polydactyly with syndactyly. We performed a one-stage surgical correction consisting of ablation at the extra digit of bilateral great and little toes, followed by syndactyly release using z-plasty. The surgery was uneventful, and the parents were satisfied with the result.

DISCUSSION

A plain radiograph is necessary for pre-operative planning. We discarded the excess digits for cosmetics and soft and hard tissue for optimal function. It is necessary to preserve the soft tissues, remove the auxiliary digit, realign the digit, and restore the ligaments to preserve digit stability.

CONCLUSION

The complexity of this case required a meticulous surgical approach to address the structural abnormalities, restore functionality, and improve cosmetic appearance. In this case, the surgery can be performed in one procedure to minimize patient morbidity.

Lower Extremity Polydactyly Does Not Disturb Finding One's Feet

Little is known about functional outcomes in children with treated lower extremity polydactyly (LEP). No classification system has been shown to be prognostically useful for functional outcomes. This study investigates whether children with treated LEP learn to walk at an age comparable to the population and whether the SAM (severity of syndactyly, axis deviation and metatarsal involvement) classification system is prognostically useful. In a retrospective cohort of 18 patients, we tested for associations between patient characteristics and SAM scores, age at learning to walk, and ability to fit off-the-shelf shoes. The proportion of children with treated LEP able to walk at 18 months of age was compared with the general population. We found no association between the age at which the 17 participants learned to walk and the severity of syndactyly (p = .214), axis deviation (p = .723) and metatarsal involvement (p = .781), nor between the proportion of patients able to wear off-the-shelf shoes compared to those requiring extra wide off-the-shelf shoes and the severity of syndactyly (p = 1.000), axis deviation (p = 1.000) and metatarsal involvement (p = 1.000). We found a trend between older age at surgery and the need for extra wide off-the-shelf shoes (OR = 1.008, p = .080). We found no significant difference in the proportion of children able to walk at 18 months between our patients (proportion = 1.00) and the general population (proportion = 0.95) (p = 1.000). We found no significant association between different SAM scores and functional outcomes, and none in the proportion of children able to walk at 18 months between treated LEP patients and the general population.

Reconstruction of polysyndactyly of the fused fifth toe with the fourth toe

Polysyndactyly of the fused fifth toe with the fourth toe is a common subtype of postaxial polydactyly. The aim of the study was to present an operative technique for cosmetic improvement and reconstruction of polysyndactyly of the fused fifth toe with the fourth toe. We retrospectively reviewed the details of 22 patients with postaxial polydactyly treated from January 2018 to May 2021. The operation involved medial toe excision and web space reconstruction using a dorsal rectangular flap without skin grafting and simultaneous correction of a valgus deformity by chondroplasty and soft tissue balancing without an osteotomy. The web shape, scar, and aesthetic outcomes were evaluated on the criteria of the D'Arcangelo, Vancouver Scar Scale score, and satisfactory questionnaire, respectively. The patients were followed up for 7-43 months. At the last follow-up, valgus deformity was completely corrected without recurrence. On the basis of the criterion of D'Arcangelo, the height and width of the webs were good in 24 of the feet, fair in four of the feet, and poor in none of the feet. The mean Vancouver Scar Scale score was 1.55. All parents and patients were satisfied with the appearance and function. The described medial toe excision technique and reconstruction of the web space without a skin graft corrected the valgus deformity and were able to satisfy functional and cosmetic requirements.

Pathologizing Ugliness: A Conceptual Analysis of the Naturalist and Normativist Claims in "Aesthetic Pathology"

Pathologizing ugliness refers to the use of disease language and medical processes to foster and support the claim that undesirable features are pathological conditions requiring medical or surgical intervention. Primarily situated in cosmetic surgery, the practice appeals to the concept of "aesthetic pathology", which is a medical designation for features that deviate from some designated aesthetic norms. This article offers a two-pronged conceptual analysis of aesthetic pathology. First, I argue that three sets of claims, derived from normativist and naturalistic accounts of disease, inform the framing of ugliness as a disease. These claims concern: (1) aesthetic harms, (2) aesthetic dysfunction, and (3) aesthetic deviation. Second, I introduce the notion of a hybridization loop in medicine, which merges the naturalist and normative understanding of the disease that potentially enables pathologizing practices. In the context of cosmetic surgery, the loop simultaneously promotes the framing of beauty ideals as normal biological attributes and the framing of normal appearance as an aesthetic ideal to legitimize the need for cosmetic interventions. The article thus offers an original discussion of the conceptual problems arising from a specific practice in cosmetic surgery that depicts ugliness as the disease.

Examination of Postoperative Outcomes Using Morphological and X-Ray Classifications and Selection of the Toe to Be Excised in Postaxial Polydactyly of the Foot

The treatment of postaxial polydactyly requires excision of the medial fifth or lateral sixth toe, and separation of the adjacent fourth/fifth toes if the adjacent toes exhibit skin syndactyly. Morphological changes in the retained toes and reoperation are common problems after such surgery. This study examined the effects of preoperative classifications and selecting the medial fifth or lateral sixth toe for excision on the postoperative outcomes of surgery for postaxial polydactyly. From April 2006 to March 2019, surgery for postaxial polydactyly was performed on 55 feet in 49 patients. The patients' mean age at surgery was 28.8 months. Postoperative esthetic and bone alignment scores, the reoperation rate, and postoperative dysfunction were examined. The postoperative esthetic and bone alignment evaluations were performed by examining postoperative photograph and X-ray images using original scoring systems. The surgical procedure was chosen by the surgeon-in-charge during a preoperative conference after considering the toe growth and bone alignment. In the postoperative esthetic evaluation, excising the lateral sixth toe produced significantly better outcomes than excising the medial fifth toe. The morphological classification also indicated that excising the lateral sixth toe produced better outcomes, as it resulted in the bifurcated toes being clearly independent. Interestingly, the postoperative X-ray-based bone alignment score was not correlated with the esthetic score. The reoperation rate tended to be high after medial fifth toe excision. There were no postoperative functional complications. Lateral sixth toe excision for postaxial polydactyly of the foot produces good postoperative esthetic outcomes.

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.

Lower extremity postaxial polydactyly: Current literature status and future avenues

BACKGROUND

Despite lower extremity polydactyly (LEP) representing the most common congenital foot anomaly with functional and psychosocial implications, the literature is devoid of comprehensive, synthesizing reviews. The purpose of the current review is to identify an evidence-based approach to guide clinical management and shed light on reported functional and esthetic outcomes for postaxial polydactyly.

METHODS

A scoping systematic review of primary clinical studies was performed. Baseline patient characteristics, diagnostic, and surgical approaches were recorded. Main outcomes included immediate postoperative pain, infections, callouses, scar cosmesis, residual deformities, and difficulty with shoe-wear or mobility. A qualitative synthesis of outcomes was performed, and a therapeutic algorithm was developed.

RESULTS

Nine primary studies were identified representing 375 cases of LEP; mean age was 28.8 months (range: 20-40.6 months), and mean follow-up: 42.7 months (range: 1 month-41 years). Ray dominance and the presence of syndactyly were identified as the most important factors for surgical planning; age at surgery was insignificant. A lateral incision approach was used in 78% of cases. Postoperative callouses occurred in 22.1% of cases, infections in 2.5%, and intermittent pain in 11.9%. Significant issues with shoe-wear or mobilization and esthetic residual deformities were reported for 0.78% and 41.2% of cases, respectively. The incidence of residual valgus was 10.6%.

CONCLUSION

LEP is most commonly managed with excision of the non-dominant ray and carries excellent long-term functional outcomes, as presented herein. Numerous techniques are discussed to minimize the risk of esthetic sequalae, although the presence of residual valgus remains a concern. A therapeutic algorithm is proposed for the optimal management of LEP.