Orthopedics - Oleksa A.P. 2006

Congenital and Acquired Deformities of the Lower Extremity
Orthopedic Foot Deformities
Congenital Deformities of the Toes

Among congenital toe malformations, Syndactyly is the most common. Fusion of adjacent toes can be either soft-tissue or osseous. Since parents are typically distressed by the deformity immediately after the child's birth, the physician should reassure them, explain The Nature of the pathology, and discuss the timing and scope of Surgical Treatment.

It is worth noting that parents and, subsequently, patients often decline surgery because syndactyly does not impair FOOT function, and the cosmetic defect causes no concern as it is concealed by footwear.

Surgical treatment consists of separating the fused toes. If radiographic examination reveals a soft-tissue fusion, it is advisable to first stretch the soft Tissues to ensure an adequate Skin reserve for closing the wound edges on the toes without tension or complications.

The surgical technique does not differ from that used for hand syndactyly. On the foot, wound edges must not be sutured under tension, as this leads to skin necrosis and wound dehiscence. In such cases, autodermoplasty must be employed to ensure normal wound healing.

In cases of osseous syndactyly, surgery can be performed in one or two stages. Surgeons most commonly perform a single-stage Procedure, which involves separating the toes while excising excess bone Phalanges and covering the wounds with autografts. To prevent recurrence of toe fusion at the base, the interdigital web space must be properly reconstructed using a graft or the Z-plasty technique.

Accessory Toes

Congenital accessory toes in polydactyly may be anatomically and functionally fully developed, or they may present as rudimentary structures attached by a soft-tissue pedicle.

Radiographically, polydactyly reveals the presence of additional Metatarsal Bones connected to the accessory toe. Their number may vary, but a single accessory toe is most frequently observed.

The rudimentary toe may include one or two bone phalanges and is mobile due to its significantly thinner soft-tissue pedicle.

It should be borne in mind that infants are highly sensitive to Blood loss; therefore, surgical intervention should not be rushed. Although the excision of a rudimentary toe is a minimally invasive procedure, it should be performed when the child is physically stronger, i.e., no earlier than six months of age. The toe pedicle is transected at its base with immediate hemostasis, ensuring sufficient skin is preserved to close the wound without tension. In cases of polydactyly, a foot radiograph must be obtained to determine whether additional metatarsal bones are present in relation to the toes

and to establish their spatial arrangement. We believe that surgery for polydactyly involving an additional metatarsal bone should not be performed before the child reaches three years of age.

The operation is performed under general anesthesia with a tourniquet applied to the lower leg. The function of all toes is visually assessed to determine which toe, along with the distal part of the accessory metatarsal bone, can be excised with minimal impact on foot cosmetics and function.

However, the accessory toe is most commonly located on the lateral aspect of the foot, which simplifies both the surgical decision-making and the procedure itself.

Polyphalangia and Brachydactyly

These are Congenital Malformations that are rarely encountered in clinical practice. Polyphalangia is most frequently observed in the hallux (first toe), manifesting as an accessory distal bone phalanx closely connected to the main phalanx by soft tissues. Consequently, the distal part of the toe is broad, and a separate nail may develop for each bone phalanx, although hallux function remains unimpaired. This cosmetic defect is the primary reason patients, particularly women, seek medical consultation.

The surgery is performed under general anesthesia or regional block using a 1% novocaine solution. Tissue incision is planned to provide adequate access and yield a cosmetic scar that will not cause discomfort when wearing footwear. The bone phalanx is first dissected and removed; subsequently, guided by the available skin reserve, the edges are trimmed and a normal first toe is reconstructed. When Nails are fused, it is crucial to separate them correctly and excise the nail matrix from the accessory phalanx. The edges of the surgical wound are meticulously apposed and sutured.

Brachydactyly—underdevelopment or a reduced number of phalanges—can affect any toe and is most commonly associated with other congenital anomalies, such as longitudinal cleft foot, amniotic bands, and others. Brachydactyly as an isolated pathology is generally not treated surgically. Surgery is performed only for associated congenital malformations that impair weight-bearing capacity or in the presence of a pronounced cosmetic defect.