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Following are X-rays of 8 y/o with supernumary digits.
The patient has 6 toes on each foot, only the left has six metaheads.
His complaint is pain in the sixth toe with shoes.
As you can see from the soft tissue outline the sixth digit is somewhat of a
macrodactyly with the fifth somewhat undersized.
I do not have a photo of the foot itself, but I will take it pre operatively and
post it here.
Treatment option suggestions?
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Following are X-rays of 8 y/o with supernumary digits.
The patient has 6 toes on each foot, only the left has six metaheads.
His complaint is pain in the sixth toe with shoes.
As you can see from the soft tissue outline the sixth digit is somewhat of a
macrodactyly with the fifth somewhat undersized.
I do not have a photo of the foot itself, but I will take it pre operatively and
post it here.
Treatment option suggestions?
Steve
Probably the best result will come from a 6th toe amputation and removal of the lateral/ 6th metatarsal head. I guess the major problems with this could be that you could alter the growth plate of the 5th and you'd be leaving the boy with a small 5th toe, but it'd fit in the shoe, stop the pain and get him up and about relatively quickly.
Another, more technically demanding option would be to remove the 5th toe, 5th metatarsal head and do an osteotomy to reduce the lateral bowing of the 6th metatarsal head. It's more surgery, not guaranteed to give a better result than the former and has all the risks of the other procedure and a few more.
Any interdigital corns? Where's the pain coming from? Is it a rub on the shoe? I presume conservative care has been exhausted/ explored.
Looking forward to the clinical photo.
Hi Bob:
"Probably the best result will come from a 6th toe amputation and removal of the lateral/ 6th metatarsal head."
That's what I'm planning. I'm more concerned with bone callus formation of the distal 1/3 of the 5th meta shaft after I remove the 6th metahead.
Thanks again
Steve
Steve:
Your surgical plan sounds very reasonable. I would be more concerned about a possible stress fracture after removal of the lateral-distal half of the 5th metatarsal shaft than bone callous formation. You may want to consider putting the patient in a cast or walking brace for 4-6 weeks after the case since the surgery will weaken the 5th metatarsal by making it more susceptible to bending moments from ground reaction forces acting on the 5th metatarsal head during weightbearing activities. Interesting case! Thanks for sharing.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Hi Kevin:
Good point.
The patient is a rather "small" Asian 8 year old. Hopefully this will decrease the possibility of a stress fracture.
I'll watch for it though
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Hi Bob:
"Probably the best result will come from a 6th toe amputation and removal of the lateral/ 6th metatarsal head."
That's what I'm planning. I'm more concerned with bone callus formation of the distal 1/3 of the 5th meta shaft after I remove the 6th metahead.
Thanks again
Steve
Yes, but there's not 100% chance of that happening, so I guess it's a wait and see job as ever. Same goes for the orthosis/ stress fracture thing. You'll have to get your resection just right to avoid not taking enough (leaving a prominence) or reducing width too much (Kevin's stress fracture) - bit of a Goldilocks procedure really, but there's nothing new there!
Have you planned your incision yet? Be nice to see how you manage the flaps and the post op scar.
Good luck with getting it 'just right'. Hope the little guy has a good return to normal. Like your post by the way - especially because you agreed with me! Ha haa.
Interesting case. I would concur that the easiest route would be to simply amputate the 6th toe/most lateral toe and resect the lateral aspect of the 5th metatarsal. The growth plate may not be disrupted because it appears as if there are two articular surfaces.
My concern would involve post operative hemostasis, since you are basically removing one cortical surface (the lateral cortex) and exposing medullary/cancelllous bone when you resect the lateral portion of the metatarsal. Naturally, this will result in bleeding and not the most structurally strong bone during the initial healing.
(Remember the "old" days when we used bone wax?!)
Therefore, as per Kevin's concern regarding a stress fracture, I would opt on the conservative side and probably keep this 8 y/o non-weightbearing for a few weeks.
Here are the Digital photos I promised.
The patient is scheduled for this week.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
OK:
Intra op and a 1 week post op.
The patient is doing very nicely.
I'm happy with the cosmetic appearance.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
The Following User Says Thank You to drsarbes For This Useful Post:
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Wow.
That looks fantastic.
Excellent work.
I have done 2 similar cases, but both patients were women in their 20's...
I am sure you have made the patient and his parents very happy.
Do you have him in a cast/CAM walker? NWB? Thank you for the pics-
-John
__________________
Dr. John G. Fasick II
Clinical Insructor, LSU School of Medicine
Advanced Foot & Ankle Center of East Jefferson footankledoc2@gmail.com
This would make a very nice case report paper for Cases Journal, an open access journal published by Biomed Central, the publishers of Journal of Foot and Ankle Research. JFAR links to all open access foot and ankle case reports here:
He was in a CAM walker for 3 weeks. He did not put any weight on the foot the first week although I told him it was OK. He was in a tennis shoe at three weeks.
Kids..gotta love the way they heal.
Dr. Menz: I'll try.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Interesting case #4 - 6 toes
Re: Interesting case #4 - 6 toes
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