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Fifth-Toe Deformities Treatment & Management

  • Author: Stephen M Schroeder, DPM, FACFAS; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
 
Updated: May 02, 2016
 

Approach Considerations

Surgical correction is indicated for chronically painful hard and soft corns in cases where conservative treatment fails. Patients with neuropathy may also choose surgery for prophylaxis against chronic lesions that may lead to ulceration and other morbidity. This has also proved beneficial for treating patients with chronic ulcerations to prevent amputations.[9]  Surgical correction is also indicated for progressively painful hammertoes or over- or underlapping toes if conservative treatment fails.

Contraindications for surgery include adequate control with conservative treatment, poor circulation, underlying infection, or any systemic condition that would inhibit healing of the surgical site.

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Medical Therapy

Medical therapy is commonly considered conservative care. Conservative treatment for hard corns and soft corns involves periodic shaving by a healthcare professional using a scalpel or paring device. This is reinforced by regular use of a pumice stone or callus file during or after bathing.

Protective padding can be used over hard corns to decrease shoe irritation, and toe spacers are available to ease pressure on soft corns. To decrease pressure, multiple devices such as gel pads, foam, felt, devices with cutouts to accommodate lesions, and moleskin are available over the counter. Wearing wider shoes is a simple way to decrease pressure placed on hammertoes or other rotational deformities. Modifying and stretching the shoes can accomplish the same goals.

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Surgical Therapy

Surgical therapy depends on the type and level of the deformity. One must determine the underlying pathology and the degree of bone and soft-tissue involvement.

Angular deformities can be corrected with a combination of bone cuts and derotational skin incisions. Areas with contracted skin or tendons may require lengthening procedures and/or tenotomy.[10, 11]

Hard corns

Hard corns are probably the most common fifth-toe deformities and yield the most options for treatment. These lesions occur most frequently on the dorsum of the proximal interphalangeal joint (PIPJ) as a result of a hammertoe deformity or on the dorsolateral aspect of the PIPJ as the result of a hammertoe with varus rotation. Corrective procedures include the following:

  • Partial condylectomy
  • Exostectomy
  • Hemiphalangectomy
  • PIPJ arthroplasty with resection of the proximal phalangeal head
  • Some combination of the above

A derotational skin plasty is often included for the varus-rotated toe, and a flexor tenotomy or extensor lengthening can be included for a straight hammertoe deformity.

Soft corns

Surgical correction for soft corns involves resection of the appropriate bony prominence. This usually involves a combination of condyles from the fourth and fifth digits. A rotational deformity may also be present in the fifth toe, which should be addressed. Typical surgical options are as follows:

  • Resection of the lateral condyle on the base of the fourth toe proximal phalanx and the medial condyle on the head of the fifth toe proximal phalanx
  • Resection of the prominent condyles at the lateral aspect of the fourth PIPJ and the medial aspect of the fifth distal interphalangeal joint (DIPJ)

Web-space incisions should be avoided to prevent infections and painful scarring.[12]

Hammertoe, claw-toe, cock-up fifth-toe deformities

Surgical approaches vary, depending on the severity of the deformity. The simplest hammertoe is one that is completely reducible with no bony obstruction to straightening. This is clinically determined by manually straightening the toe. If a very mild deformity is completely reducible, a soft-tissue procedure with proper splinting of the digit may be all that is needed for correction. Examples of these are extensor tendon lengthening, dorsal metatarsophalangeal joint (MTPJ) capsulotomy, and flexor-tendon release.[13, 14]

PIPJ arthroplasty is added to the soft-tissue releases in more advanced cases that are semireducible or nonreducible. Most surgeons favor PIPJ arthroplasty as a primary procedure because it resolves a contracted PIPJ and functionally lengthens the extensor and flexor tendons, decompressing the MTPJ and DIPJ. After this is performed, the foot is put into a simulated weightbearing position by pushing up on the fifth metatarsal head.

The dorsal contracture at the MTPJ should resolve, and the toe should straighten. If residual contracture at the MTPJ is present, dorsal capsulotomy is performed and lengthening of the extensor tendon should be considered. Arthrodesis is described for correction of hammertoes but should not be performed in the fifth digit; it leaves the toe too straight, and this causes irritation when shoes are worn.

The Ruiz-Mora and syndactylization procedures are commonly described salvage options for severe or recurrent cock-up fifth-toe deformities.[15] The original Ruiz-Mora procedure involved removing the entire proximal phalanx, which left the toe somewhat shortened and unstable. Janecki described the modification more commonly used today, which calls for a subtotal proximal phalangectomy.[16] Patients should be advised that a good deal of shortening occurs, which may not be cosmetically appealing. (See the images below.)

Fifth-toe deformities. This Image and the followin Fifth-toe deformities. This Image and the following 3 Images demonstrate the surgical course for a severe fifth digit cock-up deformity. Note the dorsal contracture in this preoperative photo.
Fifth-toe deformities. Planned incision with arms Fifth-toe deformities. Planned incision with arms for the Z-plasty skin-lengthening flap drawn in. The central arm of the Z-plasty is along the line of skin contracture.
Fifth-toe deformities. Exposure showing a severely Fifth-toe deformities. Exposure showing a severely contracted extensor digitorum longus tendon. This is lengthened during the procedure.
Fifth-toe deformities. Postoperative photo showing Fifth-toe deformities. Postoperative photo showing a corrected fifth digit.

The initial step of the Ruiz-Mora procedure is the removal of an ellipse of skin plantar to the proximal phalanx curving slightly medial at the proximal margin of the incision. The flexor tendons are dissected and retracted to expose the PIPJ. A transverse capsulotomy is performed, the collateral ligaments are released, and a subtotal phalangectomy is performed at the head of the proximal phalanx. If a large portion of the bone is removed, the flexor and extensor tendons are held together with purse-string sutures of 2-0 nonabsorbable material. The skin is closed in such a way as to allow correction of the toe in a plantar-medial direction.

Complications of the Ruiz-Mora procedure include the following:

  • Instability of the toe
  • Fourth digit hammertoe formation
  • Callus formation
  • Bunionette deformity

Postoperatively, the patient is allowed to ambulate in a stiff-soled shoe, and the toe is splinted or taped in the corrected position for 6 weeks.

Syndactylization of the fifth toe to the fourth is generally reserved as a salvage procedure or to resolve a painfully fibrosed web-space lesion secondary to long-standing soft corns. Syndactylization provides excellent stability for an unstable or flail fifth toe.[17] With this procedure, the skin incisions on the fourth and fifth toes should be mirror images of each other. A good technique is to scribe the initial incision on the fifth digit with a surgical pen and then press the two digits together where they are to be joined. The ink is transferred to the fourth digit in the precise area where the incision should be placed.

The island of tissue created with the incision is carefully dissected to remove only the skin and to leave the subcutaneous tissue intact. Meticulous hemostasis is practiced, and a needle-tipped electrocautery device should be used for precision. Bone work and isolated tendon balancing can be performed through the open sulcus if needed. The skin is closed by placing all of the sutures throughout the site prior to tying the knots. This allows easier and more accurate passage of the needle through the skin margins of the toes. Sutures are left in for 1 extra week (total, 3 weeks), and the digits are splinted for an additional 2-3 weeks.

Underlapping and overlapping fifth-toe deformities

Many procedures have been described for the correction of an overlapping fifth toe. The deformities range from moderate to more severe, and the procedure chosen should address the existing contractures. The surgical treatment often includes the following:

  • Lengthening of the contracted skin and tendon and release of the tight capsular structures
  • Resection of redundant skin and soft tissue

Osseous contractures, if present, also must be addressed by means of ostectomy, arthroplasty, or both.

The images below illustrate one technique for correcting a painful overlapping fifth-toe deformity. Schuh et al described their experiences with the Butler technique.[18]

Fifth-toe deformities. This Image and the ones tha Fifth-toe deformities. This Image and the ones that follow demonstrate an operative technique for a painful overlapping fifth-toe deformity.
Fifth-toe deformities. Painful overlapping fifth-t Fifth-toe deformities. Painful overlapping fifth-toe deformity.
Fifth-toe deformities. When the toe is derotated a Fifth-toe deformities. When the toe is derotated and plantarflexed into the correct position, the dorsal skin "tents up," showing the exact location of the skin contracture.
Fifth-toe deformities. A Z-plasty is performed in Fifth-toe deformities. A Z-plasty is performed in this case to lengthen the contracted skin. Length is achieved along the central arm of the "Z" so it is placed along the line of contracture. Adjunctive procedures such as metatarsophalangeal joint release and extensor digitorum longus tendon lengthening should be performed through the same incision. An alternative to the Z-plasty is a V-Y flap.
Fifth-toe deformities. After rotation of the "Z" f Fifth-toe deformities. After rotation of the "Z" flaps and soft tissue release, the toe is reevaluated. The toe is down, and the proximal phalanx is in excellent position, but the distal portion of the toe has a varus rotation at the proximal interphalangeal joint. A proximal interphalangeal joint arthroplasty with derotational skin plasty is then performed to address this portion of the deformity.
Fifth-toe deformities. This Image and the one belo Fifth-toe deformities. This Image and the one below were taken 5 days postoperatively with the contractures addressed and the toe in good position.
Fifth-toe deformities. Five days after surgery, th Fifth-toe deformities. Five days after surgery, the contracture is addressed and the toe is in good position.

The DuVries procedure is indicated for correcting a mildly overlapping fifth toe. The area over the fourth interspace is longitudinally incised from the base of the toe to just proximal to the fifth metatarsal head. The MTPJ contractures are released via medial capsulotomy and release of the medial collateral ligament. The extensor digitorum longus (EDL) tendon is then released or lengthened to achieve the final release. The toe is placed into an overcorrected plantar and lateral position, and the skin is closed in this orientation. Dog-ears are removed when they occur.

Wilson described a modification to the procedure incorporating a V-Y skin advancement to lengthen the contracted skin dorsomedially.[19] Similar releases of the capsule and tendon are performed through the V-Y incision to complete the procedure. The authors use a Z-plasty advancement technique to lengthen the contracted skin dorsomedially. This affords greater lengthening potential, and the results are more cosmetically appealing than would be the case without the modification. PIPJ arthroplasty with appropriate capsule balancing completes the procedure, resulting in an excellent correction.

Lapidus described using a tendon transfer to correct severely overlapping fifth toes.[20] He transferred the EDL under the MTPJ and into the abductor digiti quinti. Other modifications have been described, including transfer of the EDL into the metatarsal neck, Z-plasty, dorsal capsulotomy with plantar capsulorraphy, and PIPJ arthroplasty. When possible, extensive dissection should be avoided because the toes tend to become postoperatively edematous, leading to pain and difficulty fitting shoes.

Underlapping fifth toes typically have a contracted plantar MTPJ capsule and flexor digitorum longus (FDL) with an attenuated EDL and a redundant dorsal MTPJ capsule. Underlapping fifth toes are usually flexible deformities in the pediatric population; tenotomy at the FDL and the flexor digitorum brevis (FDB) with appropriate splinting typically offers good results. However, as with the other conditions mentioned, the degree of deformity must be accounted for, and the appropriate adjunct procedures should be performed.

The Thompson technique is widely used and offers good results.[21, 22] Thompson described a Z-type incision over the proximal phalanx with the distal limb laterally oriented and the proximal limb medially oriented. Dissection extends to the PIPJ, where the head of the proximal phalanx is freed of soft-tissue attachments and resected using a microsagittal saw. The amount of head resection depends on the severity of the deformity, but care should be taken not to remove too much because this makes the toe unstable.

The soft tissue is appropriately augmented, the toe is derotated, and the flexor and extensor tendons are held together with purse-string sutures by using 2-0 nonabsorbable material. In less severe deformities, the purse-string suture can be left out and the capsule simply closed in a standard fashion. Adding a Kirschner wire (K-wire) across the PIPJ for 3-4 weeks or splinting with dressings for the same period can provide stability.

Finally, the Z-incision is reversed and closed with 4-0 nylon. A variation of the Thompson procedure involves a derotational skin plasty by creating a tissue island with a converging semielliptical incision over the PIPJ oriented from distal-dorsal-medial to proximal-plantar-lateral. As with the other procedures, the patient is allowed to ambulate in a postoperative shoe and is gradually transitioned to a roomy athletic-style shoe. The toe should be splinted in the corrected position for 6 weeks.

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Complications

The most common complication involving fifth-toe procedures is the development of a flail toe. Other potential problems include vascular embarrassment, undercorrection, recurrence, and prolonged edema. Meticulous dissection and tissue handling are the best defenses against vascular problems or prolonged edema. Proper planning should decrease the chance of recurrence or undercorrection.

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Contributor Information and Disclosures
Author

Stephen M Schroeder, DPM, FACFAS Foot and Ankle Surgeon, Sports Medicine Oregon

Stephen M Schroeder, DPM, FACFAS is a member of the following medical societies: American College of Foot and Ankle Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Peter A Blume, DPM, FACFAS Assistant Clinical Professor of Surgery, Department of Surgery, Yale University School of Medicine; Assistant Clinical Professor of Orthopedics and Rehabilitation, Department of Orthopedics and Rehabilitation, Section of Podiatric Surgery, Yale University School of Medicine

Peter A Blume, DPM, FACFAS is a member of the following medical societies: American Association of Hospital and Healthcare Podiatrists, American College of Foot and Ankle Surgeons, American Podiatric Medical Association, International College of Angiology, American Diabetes Association

Disclosure: Nothing to disclose.

Raymond O'Hara, DPM Chief Resident, Department of Orthopedic Surgery, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Enzo Sella, MD Chief, Orthopedic Foot and Ankle Surgery, Yale-New Haven Hospital; Associate Clinical Professor, Department of Orthopedics and Rehabilitation, Yale University School of Medicine

Enzo Sella, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association, North American Spine Society, Academy of Medical Royal Colleges

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Vinod K Panchbhavi, MD, FACS Professor of Orthopedic Surgery, Chief, Division of Foot and Ankle Surgery, Director, Foot and Ankle Fellowship Program, Department of Orthopedics, University of Texas Medical Branch School of Medicine

Vinod K Panchbhavi, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Orthopaedic Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Styker.

Additional Contributors

John S Early, MD Foot/Ankle Specialist, Texas Orthopaedic Associates, LLP; Co-Director, North Texas Foot and Ankle Fellowship, Baylor University Medical Center

John S Early, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Orthopaedic Trauma Association, Texas Medical Association

Disclosure: Received honoraria from AO North America for speaking and teaching; Received consulting fee from Stryker for consulting; Received consulting fee from Biomet for consulting; Received grant/research funds from AO North America for fellowship funding; Received honoraria from MMI inc for speaking and teaching; Received consulting fee from Osteomed for consulting; Received ownership interest from MedHab Inc for management position.

References
  1. Ellington JK. Hammertoes and clawtoes: proximal interphalangeal joint correction. Foot Ankle Clin. 2011 Dec. 16(4):547-58. [Medline].

  2. Dereymaeker G, van der Broek C. Biphalangeal fifth toe. Foot Ankle Int. 2006 Nov. 27(11):948-51. [Medline].

  3. Gallart J, González D, Valero J, Deus J, Serrano P, Lahoz M. Biphalangeal/triphalangeal fifth toe and impact in the pathology of the fifth ray. BMC Musculoskelet Disord. 2014 Sep 5. 15:295. [Medline].

  4. Bevans JS, Bosson G. A comparison of electrosurgery and sharp debridement in the treatment of chronic neurovascular, neurofibrous and hard corns. A pragmatic randomised controlled trial. Foot (Edinb). 2010 Mar. 20(1):12-7. [Medline].

  5. Ely LW. Hammertoe. Surg Clin N Am. 1926. 6:433.

  6. Higgs SL. Hammertoe. Med Press. 1931. 131:473.

  7. Mills GP. The etiology and treatment of claw-toe. J Bone Joint Surg. 1924. 6:142.

  8. Schnepp KH. Hammertoe and claw foot. Am J Surg. 1933. 36:351.

  9. Kim JY, Kim TW, Park YE, Lee YJ. Modified resection arthroplasty for infected non-healing ulcers with toe deformity in diabetic patients. Foot Ankle Int. 2008 May. 29(5):493-7. [Medline].

  10. Jacobs R, Vandeputte G. Flexor tendon lengthening for hammer toes and curly toes in paediatric patients. Acta Orthop Belg. 2007 Jun. 73(3):373-6. [Medline].

  11. Togashi S, Nakayama Y, Hata J, Endo T. A new surgical method for treating lateral ray polydactyly with brachydactyly of the foot: lengthening the reconstructed fifth toe. J Plast Reconstr Aesthet Surg. 2006. 59(7):752-8. [Medline].

  12. Coughlin MJ, Kennedy MP. Operative repair of fourth and fifth toe corns. Foot Ankle Int. 2003 Feb. 24(2):147-57. [Medline].

  13. Bouché RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. J Foot Ankle Surg. 2008 Mar-Apr. 47(2):125-37. [Medline].

  14. Konkel KF, Sover ER, Menger AG, Halberg JM. Hammer toe correction using an absorbable pin. Foot Ankle Int. 2011 Oct. 32(10):973-978.

  15. Ruiz-Mora J. Plastic correction of overriding 5th toe. Orthop Lett Club. 1954. 6:6.

  16. Janecki CJ, Wilde AH. Results of phalangectomy of the fifth toe for hammertoe. The Ruiz-Mora procedure. J Bone Joint Surg Am. 1976 Oct. 58(7):1005-7. [Medline].

  17. Lamm BM, Ades JK. Gradual digital lengthening with autologous bone graft and external fixation for correction of flail toe in a patient with Raynaud's disease. J Foot Ankle Surg. 2009 Jul-Aug. 48(4):488-94. [Medline].

  18. Schuh A, Werber S, Zeiler G, Schraml A. [Experiences with the Butler procedure for overlapping fifth toe]. Zentralbl Chir. 2005 Apr. 130(2):153-6. [Medline].

  19. Wilson JN. V-Y correction for varus deformity of the fifth toe. Br J Surg. 1953 Sep. 41(166):133-5. [Medline].

  20. Lapidus P. Transplantation of the extensor tendon for correction of the overlapping 5th toe. J Bone Joint Surg. 1942. 24:555.

  21. Thompson FM, Hamilton WG. Problems of the second metatarsophalangeal joint. Orthopedics. 1987 Jan. 10(1):83-9. [Medline].

  22. Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle. 1993 Sep. 14(7):385-8. [Medline].

 
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Fifth-toe deformities. Example of a hard corn. They commonly occur on the dorsal lateral aspect of the proximal interphalangeal joint, but they can also occur in the same location over the distal interphalangeal joint.
Fifth-toe deformities. Example of a soft corn deep in the web space. Intrinsic pressure develops between adjacent condyles of the lateral fourth proximal interphalangeal joint abutting the medial fifth distal interphalangeal joint, or the lateral fourth metatarsophalangeal joint abutting the medial fifth proximal interphalangeal joint. The lesions can develop on the skin over the lateral fourth proximal interphalangeal joint, medial fifth distal interphalangeal joint, medial fifth proximal interphalangeal joint, or deep in the web space.
Fifth-toe deformities. This Image and the one below are examples of kissing corns. They are 2 calluses that rub against each other on adjacent toes and are usually painful when squeezed together.
Fifth-toe deformities. Example of a kissing corn. These corns are 2 calluses that rub against each other on adjacent toes and are usually painful when squeezed together.
Fifth-toe deformities. This Image and the one below are further examples of kissing corns. Maceration is often noted in the web space and may contribute to their development. When they occur, other common problems, such as fungal infections or verruca, need to be ruled out. These lesions may develop into ulcerations in the neuropathic population if untreated, as is seen in this case.
Fifth-toe deformities. Example of kissing corns. Maceration is often noted in the web space and may contribute to their development. When they occur, other common problems, such as fungal infections or verruca, need to be excluded. These lesions may develop into ulcerations in the neuropathic population if untreated, as is seen in this case.
Fifth-toe deformities. Example of a hammertoe with a dorsiflexion contracture at the metatarsophalangeal joint and plantarflexion contracture at the proximal interphalangeal joint. Note the irritated skin secondary to shoe pressure.
Fifth-toe deformities. This Image and the one below represent an overlapping fifth toe. It is dorsally hyperextended at the metatarsophalangeal joint with a varus rotation and medial deviation onto the top of the fourth digit. Contractures develop dorsomedially at the metatarsophalangeal joint and eventually form in the extensor digitorum longus tendon and the dorsomedial skin overlying the metatarsophalangeal joint.
Fifth-toe deformities. Overlapping fifth toe. It is dorsally hyperextended at the metatarsophalangeal joint with a varus rotation and medial deviation onto the top of the fourth digit. Contractures develop dorsomedially at the metatarsophalangeal joint and eventually form in the extensor digitorum longus tendon and the dorsomedial skin overlying the metatarsophalangeal joint.
Fifth-toe deformities. This image and the one below are examples of an underlapping fifth toe, or curly toe. It is plantarflexed at the metatarsophalangeal joint, rotated into a varus position, and positioned under the fourth digit. A contracture typically occurs at the plantar-medial metatarsophalangeal joint capsule and flexor digitorum longus tendon.
Fifth-toe deformities. Underlapping fifth toe, or curly toe. It is plantarflexed at the metatarsophalangeal joint, rotated into a varus position, and positioned under the fourth digit. A contracture typically occurs at the plantar-medial metatarsophalangeal joint capsule and flexor digitorum longus tendon.
Fifth-toe deformities. This radiograph shows a prominent fifth-toe proximal phalanx medial condyle contacting the base of the proximal phalanx on the fourth toe, creating increased pressure and an interdigital clavi.
Fifth-toe deformities. This radiograph shows the distal phalanx of a varus-rotated fifth toe contacting the proximal phalanx on the fourth toe, creating another area of increased pressure and interdigital clavi.
Fifth-toe deformities. This Image and the following 3 Images demonstrate the surgical course for a severe fifth digit cock-up deformity. Note the dorsal contracture in this preoperative photo.
Fifth-toe deformities. Planned incision with arms for the Z-plasty skin-lengthening flap drawn in. The central arm of the Z-plasty is along the line of skin contracture.
Fifth-toe deformities. Exposure showing a severely contracted extensor digitorum longus tendon. This is lengthened during the procedure.
Fifth-toe deformities. Postoperative photo showing a corrected fifth digit.
Fifth-toe deformities. This Image and the ones that follow demonstrate an operative technique for a painful overlapping fifth-toe deformity.
Fifth-toe deformities. Painful overlapping fifth-toe deformity.
Fifth-toe deformities. When the toe is derotated and plantarflexed into the correct position, the dorsal skin "tents up," showing the exact location of the skin contracture.
Fifth-toe deformities. A Z-plasty is performed in this case to lengthen the contracted skin. Length is achieved along the central arm of the "Z" so it is placed along the line of contracture. Adjunctive procedures such as metatarsophalangeal joint release and extensor digitorum longus tendon lengthening should be performed through the same incision. An alternative to the Z-plasty is a V-Y flap.
Fifth-toe deformities. After rotation of the "Z" flaps and soft tissue release, the toe is reevaluated. The toe is down, and the proximal phalanx is in excellent position, but the distal portion of the toe has a varus rotation at the proximal interphalangeal joint. A proximal interphalangeal joint arthroplasty with derotational skin plasty is then performed to address this portion of the deformity.
Fifth-toe deformities. This Image and the one below were taken 5 days postoperatively with the contractures addressed and the toe in good position.
Fifth-toe deformities. Five days after surgery, the contracture is addressed and the toe is in good position.
 
 
 
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