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Polydactyly of the Foot Treatment & Management

  • Author: Cara Novick, MD; Chief Editor: Dennis P Grogan, MD  more...
 
Updated: Nov 11, 2014
 

Surgical Therapy

Surgical treatment consists of excision of the duplicated digit and reconstruction of any associated abnormalities in the remaining rays (eg, longitudinal epiphyseal bracket).[3, 11, 12, 13] A thorough preoperative examination should be undertaken, including evaluation of radiographs, to formulate an operative plan. Most patients have good-to-excellent results after surgery (see the images below). Careful surgery helps to ensure better cosmetic and functional outcomes.

Postoperative view of 1-year-old child who had pos Postoperative view of 1-year-old child who had postaxial polydactyly and excision of the sixth toe demonstrates a good result with straight lateral border.
Postoperative radiograph of a 1-year-old child wit Postoperative radiograph of a 1-year-old child with preaxial polydactyly who had significant varus of the duplicated toe demonstrates a good result after resection and metatarsal narrowing.
Postoperative radiograph of an 8-year-old boy with Postoperative radiograph of an 8-year-old boy with a history of bilateral preaxial polydactyly and excision of the duplicated digits at an outside institution. He required additional surgery because of residual deformity. A good result is depicted following combination of the first metatarsal base with the second metatarsal shaft, creating a 5-digit foot.
Radiograph depicting a patient who had a history o Radiograph depicting a patient who had a history of bilateral preaxial polydactyly and excision of bilateral duplicated digits at an outside institution. He required additional surgery at age 8 years. Good results were obtained following combination of the first metatarsal base with the second metatarsal shaft, creating a 5-digit foot. At 20-year follow-up, the patient is doing well.
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Intraoperative Details

Most medial digits in preaxial polydactyly and most lateral digits in postaxial polydactyly are usually resected. This allows the foot to be narrow, with a straight medial or lateral border.

Postaxial polydactyly

In postaxial polydactyly, a racquet-shaped or oval incision is made at the base of the most lateral digit and carried through skin and fascia. Tendons are divided as distally as possible. The capsule of the metatarsophalangeal (MTP) joint is divided, and the digit is disarticulated. Care is taken to remove T or Y extensions of the metatarsal head or to reshape an expanded metatarsal head. The capsule is repaired, the skin closed, and a bandage or cast applied.

Park et al conducted a retrospective study to evaluate the operative treatment of postaxial polydactyly in 27 patients.[20] For excision of the medial toe, dorsal rectangular flap and full-thickness inguinal skin grafting were used; for excision of the lateral toe, a racket-shape incision was used. The investigators concluded that satisfactory functional and cosmetic results were obtained with dorsal rectangular flap and full-thickness inguinal skin grafting for medial toe excision and with the toe selection algorithm that was employed.

Preaxial polydactyly

In preaxial polydactyly, the medial toe is usually excised. The toe is again removed through disarticulation. Care must be taken to appropriately balance the abductor and adductor hallucis muscles and to minimize hallux varus. Correction of an associated longitudinal bracket epiphysis helps to prevent the development of hallux varus and an excessive short first metatarsal. The capsule is repaired as accurately as possible.

If the more lateral toe is hypoplastic and is excised, the intermetatarsal ligament must be reapproximated. A Kirschner wire (K-wire), in place for 4-6 weeks, may be helpful in maintaining position and avoiding varus deformity. A soft dressing or cast may be used.

Central polydactyly

In central polydactyly, a dorsal racquet-shaped incision is made at the base of the duplication. The extra digit is excised through disarticulation. The intermetatarsal ligament is reapproximated prior to closure. A cast or orthosis may be useful postoperatively to minimize a residual widened forefoot. A careful plastic skin closure is used in all patients, as cosmesis is a concern.

Osborn et al conducted a retrospective case series review of 22 patients (27 feet) who underwent surgical treatment of central polydactyly using the dorsal and plantar advancement flap technique.[21] Significant narrowing of the forefoot was achieved after surgery. This radiographic narrowing was maintained with growth after a mean follow-up of 8 years. However, persistent clinical widening of the forefoot after surgery was reported in the majority of cases (82%).

The researchers concluded that the dorsal and plantar advancement flap technique provides excellent radiographic and functional outcomes in the treatment of central polydactyly: It successfully narrows the forefoot on radiographs, and this narrowing is maintained with growth over time.[21] They advised that families be made aware that it is common for patients to experience persistent widening of the forefoot relative to normal, despite successful radiographic narrowing after surgery.

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Postoperative Details

A cast or soft dressing is used. If a K-wire is used, it is usually left in place for 4-6 weeks. A walking cast allows the small child to be active and at the same time protects the surgical incision.

The patient must be monitored and evaluated for residual or future deformity.

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Complications

The most common complication in preaxial polydactyly is hallux varus. This may cause pain and difficulty with shoe wearing, warranting subsequent surgical correction.

Failure to correct a longitudinal bracket epiphysis that may be associated with a duplicate great toe can result in the development of hallux varus. The deformity should be addressed when noted. The bracket can be resected to allow for untethered growth, and the varus can be corrected with capsulorrhaphy and K-wire fixation at the metatarsophalangeal (MTP) joint. Resection and metatarsal osteotomy may occasionally be needed in the older child.[22]

Patients with postaxial polydactyly may have residual angular deformity, including angulation at the MTP joint and bowing of the metatarsal. This is usually not clinically significant.

In patients with central polydactyly, a widened forefoot is a common complication.

All patients are at risk for developing MTP joint subluxation or angular deformity and residual deformities of the metatarsal head. Incomplete excision of elements that are not yet ossified may also lead to future problems or deformity.

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Future and Controversies

Accurate understanding of the involved anatomy leads to better clinical results. Radiographs obtained after ossification of the involved bones allow for definitive treatment of the duplicated parts and all associated abnormalities. Recent better appreciation of the longitudinal bracket epiphysis, often seen in the first metatarsal in children with preaxial polydactyly, and descriptions that allow for earlier diagnosis and correction of this abnormality lead to better outcomes.

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Contributor Information and Disclosures
Author

Cara Novick, MD Consulting Surgeon, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Cara Novick, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Pediatric Orthopaedic Society of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Dennis P Grogan, MD Clinical Professor (Retired), Department of Orthopedic Surgery, University of South Florida College of Medicine; Orthopedic Surgeon, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Dennis P Grogan, MD is a member of the following medical societies: American Medical Association, American Orthopaedic Association, Scoliosis Research Society, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association

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.

George H Thompson, MD Director of Pediatric Orthopedic Surgery, Rainbow Babies and Children’s Hospital, University Hospitals Case Medical Center, and MetroHealth Medical Center; Professor of Orthopedic Surgery and Pediatrics, Case Western Reserve University School of Medicine

George H Thompson, MD is a member of the following medical societies: American Orthopaedic Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons

Disclosure: Received none from OrthoPediatrics for consulting; Received salary from Journal of Pediatric Orthopaedics for management position; Received none from SpineForm for consulting; Received none from SICOT for board membership.

Chief Editor

Dennis P Grogan, MD Clinical Professor (Retired), Department of Orthopedic Surgery, University of South Florida College of Medicine; Orthopedic Surgeon, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Dennis P Grogan, MD is a member of the following medical societies: American Medical Association, American Orthopaedic Association, Scoliosis Research Society, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association

Disclosure: Nothing to disclose.

Additional Contributors

Charles T Mehlman, DO, MPH Professor of Pediatrics and Pediatric Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Director, Musculoskeletal Outcomes Research, Cincinnati Children's Hospital Medical Center

Charles T Mehlman, DO, MPH is a member of the following medical societies: American Academy of Pediatrics, American Fracture Association, Scoliosis Research Society, Pediatric Orthopaedic Society of North America, American Medical Association, American Orthopaedic Foot and Ankle Society, American Osteopathic Association, Arthroscopy Association of North America, North American Spine Society, Ohio State Medical Association

Disclosure: Nothing to disclose.

References
  1. Venn-Watson EA. Problems in polydactyly of the foot. Orthop Clin North Am. 1976 Oct. 7(4):909-27. [Medline].

  2. Beaty JH. Polydactyly. In: Operative Pediatric Orthopaedics. 2nd ed. Mosby-Year Book. 1995:112-114.

  3. Hart ES, Grottkau BE, Rebello GN, Albright MB. The newborn foot: diagnosis and management of common conditions. Orthop Nurs. 2005 Sep-Oct. 24(5):313-21; quiz 322-3. [Medline].

  4. Herring JA. Polydactyly. In: Tachdjian's Pediatric Orthopaedics from the Texas Scottish Rite Hospital for Children. 3rd ed. WB Saunders Co. 2001:1021-1024.

  5. Jones KL. Smith's Recognizable Patterns of Human Malformation. 5th ed. WB Saunders Co. 1997.

  6. Lee HS, Park SS, Yoon JO, Kim JS, Youm YS. Classification of postaxial polydactyly of the foot. Foot Ankle Int. 2006 May. 27(5):356-62. [Medline].

  7. Turra S, Gigante C, Bisinella G. Polydactyly of the foot. J Pediatr Orthop B. 2007 May. 16(3):216-20. [Medline].

  8. Morrison BE, D''Mello SR. Polydactyly in mice lacking HDAC9/HDRP. Exp Biol Med (Maywood). 2008 Aug. 233(8):980-8. [Medline]. [Full Text].

  9. Auyeung J, Bhattacharya R, Birla R, Hide G, Henman P. The occult toe: an unusual case of polydactyly in the foot. J Pediatr Orthop B. 2009 Aug 24. [Medline].

  10. Klaassen Z, Shoja MM, Tubbs RS, Loukas M. Supernumerary and absent limbs and digits of the lower limb: A review of the literature. Clin Anat. 2011 Jan 3. [Medline].

  11. Lim YJ, Teoh LC, Lee EH. Reconstruction of syndactyly and polysyndactyly of the toes with a dorsal pentagonal island flap: a technique that allows primary skin closure without the use of skin grafting. J Foot Ankle Surg. 2007 Mar-Apr. 46(2):86-92. [Medline].

  12. Morley SE, Smith PJ. Polydactyly of the feet in children: suggestions for surgical management. Br J Plast Surg. 2001 Jan. 54(1):34-8. [Medline].

  13. Mubarak SJ, O'Brien TJ, Davids JR. Metatarsal epiphyseal bracket: treatment by central physiolysis. J Pediatr Orthop. 1993 Jan-Feb. 13(1):5-8. [Medline].

  14. Jenkins S, Morrell DS. Ellis-van Creveld syndrome: case report and review of the literature. Cutis. 2009 Jun. 83(6):303-5. [Medline].

  15. Sund KL, Roelker S, Ramachandran V, Durbin L, Benson DW. Analysis of Ellis van Creveld syndrome gene products: implications for cardiovascular development and disease. Hum Mol Genet. 2009 May 15. 18(10):1813-24. [Medline]. [Full Text].

  16. Yucel A, Kuru I, Bozan ME, Acar M, Solak M. Radiographic evaluation and unusual bone formations in different genetic patterns in synpolydactyly. Skeletal Radiol. 2005 Aug. 34(8):468-76. [Medline].

  17. Adam MP, Hudgins L, Carey JC, Hall BD, Coleman K, Gripp KW, et al. Preaxial hallucal polydactyly as a marker for diabetic embryopathy. Birth Defects Res A Clin Mol Teratol. 2009 Jan. 85(1):13-9. [Medline].

  18. Belthur MV, Linton JL, Barnes DA. The spectrum of preaxial polydactyly of the foot. J Pediatr Orthop. 2011 Jun. 31(4):435-47. [Medline].

  19. Seok HH, Park JU, Kwon ST. New classification of polydactyly of the foot on the basis of syndactylism, axis deviation, and metatarsal extent of extra digit. Arch Plast Surg. 2013 May. 40(3):232-7. [Medline]. [Full Text].

  20. Park GH, Jung ST, Chung JY, Park HW, Lee DH. Toe component excision in postaxial polydactyly of the foot. Foot Ankle Int. 2013 Apr. 34(4):563-7. [Medline].

  21. Osborn EJ, Davids JR, Leffler LC, Gibson TW, Pugh LI. Central polydactyly of the foot: surgical management with plantar and dorsal advancement flaps. J Pediatr Orthop. 2014 Apr-May. 34(3):346-51. [Medline].

  22. Nelman K, Weiner DS, Morscher MA, Jones KC. Multiplanar supramalleolar osteotomy in the management of complex rigid foot deformities in children. J Child Orthop. 2009 Feb. 3(1):39-46. [Medline]. [Full Text].

 
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The Venn-Watson classification of polydactyly is based on the anatomic configuration of the metatarsal and the duplicated bony parts.
Postaxial polydactyly in a 1-year-old child. In this case, the duplicated sixth toe was excised (dotted line), and the broad distal fifth metatarsal was narrowed.
Postoperative view of 1-year-old child who had postaxial polydactyly and excision of the sixth toe demonstrates a good result with straight lateral border.
Preoperative photograph of a 1-year-old child with preaxial polydactyly and significant varus of the duplicated toe.
Postoperative radiograph of a 1-year-old child with preaxial polydactyly who had significant varus of the duplicated toe demonstrates a good result after resection and metatarsal narrowing.
Preaxial polydactyly with longitudinal bracket epiphysis.
Mother and son with polydactyly. The patterns of deformity are different.
Image of an 8-year-old boy with a history of bilateral preaxial polydactyly. He had excision of bilateral duplicated digits at an outside institution.
Postoperative radiograph of an 8-year-old boy with a history of bilateral preaxial polydactyly and excision of the duplicated digits at an outside institution. He required additional surgery because of residual deformity. A good result is depicted following combination of the first metatarsal base with the second metatarsal shaft, creating a 5-digit foot.
Radiograph depicting a patient who had a history of bilateral preaxial polydactyly and excision of bilateral duplicated digits at an outside institution. He required additional surgery at age 8 years. Good results were obtained following combination of the first metatarsal base with the second metatarsal shaft, creating a 5-digit foot. At 20-year follow-up, the patient is doing well.
 
 
 
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