An Unusual and Nonclassified Central Polydactyly of the Foot

Rotational osteo-onychocutaneous flap for central polydactyly of the foot: A novel technique for correction of the deformity

Eccentric location of two nails like eyes of a bird are frequently observed in central polydactyly of the foot. A novel technique of rotational osteo-onychocutaneous (OOC) flap procedure is introduced to correct this deformity. Six children with central polydactyly of the foot who showed eccentric locations of nails were operated by this technique. Four patients were distal phalangeal type, and two middle phalangeal type. Preoperatively the angulation deformity of distal phalangeal type was average 16.8 (range, 2.3-48.0) degrees, and middle phalangeal type 10.3 (range, 2.9-17.7) degrees. The rotational OOC flap procedure was performed at average 24 (range, 12-51) months of age. Cosmetic and radiographic assessments were done after an average of 42 (range, 6-79) months of follow-up. All patients and their parents were satisfied with the cosmetic results. The angulation deformity was improved to average 4.2 (range, 0.5-11.2) degrees in distal phalangeal type, and 5.9 (range, 2.0-9.8) degrees in middle phalangeal type, respectively. Postoperative residual angulation deformity measured by simple radiographs were less than 5° in all patients. Complications such as partial necrosis of the flap were not found. In conclusion, our novel technique of rotational OOC flap procedure resulted in satisfactory outcome for patients with 'eyes of a bird' type toe nail deformity of central polydactyly of the foot. It corrected the angulation and rotational deformity of the toe nail of the main digit without causing any complications.

Polydactyly of the Foot: A Review

Pediatric foot polydactyly presents in a wide variety of deformities from single extra digits attached only by a narrow soft-tissue connection to complex central foot duplications with tarsal bone duplication. The goal of surgical reconstruction is a stable, mobile, pain-free foot with five cosmetically appealing toes that allows for normal footwear and painless ambulation. This review covers the incidence, genetics and embryology, classification, presentation and natural history, physical examination, radiographic assessment, and surgical intervention for all types of foot polydactyly.

Central polydactyly of the foot: surgical management with plantar and dorsal advancement flaps

BACKGROUND

Central polydactyly is the least common form of foot polydactyly, and the intercalary location of the duplicated ray makes the surgical exposure, excision, and closure more complex. For these reasons there is little consensus concerning the optimal technique for surgical management.

METHODS

A retrospective case series of 22 patients with 27 feet with central polydactyly, treated surgically by the dorsal and plantar advancement flap technique, was performed. Change in width of the forefoot was measured from radiographs by the metatarsal gap ratio. Functional outcomes were assessed by the Foot and Ankle Ability Measure.

RESULTS

Signficant narrowing of the forefoot, as measured radiographically by the metatarsal gap ratio, was achieved after surgery (P<0.0001). This radiographic narrowing was maintained with growth after a mean follow-up of 8 years (P=0.0001). In 7 of the unilateral cases, the mean forefoot radiographic width of the affected side, after surgical resection and reconstruction of the central polydactyly, was 2% greater than the contralateral, uninvolved side. Persistent clinical widening of the forefoot after surgery was reported in the majority (82%) of cases. The Foot and Ankle Ability Measure results showed near-normal functional outcomes in itemized activities of daily living, itemized sports, and overall function categories. The few reports of less than normal foot function were related to shoe wear issues and incisional scarring that was painful or cosmetically unappealing.

CONCLUSIONS

The radiographic and functional outcomes after surgical management of central polydactyly with the dorsal and plantar advancement flap technique are excellent. The technique successfully narrows the forefoot on radiographs, and this narrowing is maintained with growth over time. However, families should be advised that persistent perceived widening of the forefoot relative to normal is common, despite successful radiographic narrowing after surgery.

LEVEL OF EVIDENCE

IV.

An eight-toed foot: a rare pedal polydactyly

Polydactyly is a fairly common congenital condition of the foot and is characterized literally by supernumerary toes (digit or metatarsal). The frequency of polydactyly varies widely among populations. It may be an isolated condition or part of a congenital syndrome. Eight-toed polydactyly is a distinctly rare congenital foot anomaly. In this report, an 18-month-old child with pre-axial 8-toed right foot had been treated with excision of the excess rays with muscular, tendentious, and ligamentous reconstructions. The patient had presented a good postoperative result. Through monthly follow-up visits for 1 year, the parents expressed excellent cosmesis, shoe fit, and walking function.

Indications for amputations

Amputation may take a psychological toll on a patient. Proper documentation is paramount along with a lucid informed consent. Various pathologies may lead to an amputation. Tools to aid in the decision to amputate, in choosing the levels of amputation, and in the selection of the type of procedure are available. The key to any amputation is to be at a level that is most definitive.