Butler Procedure for Overlapping Fifth Toe

 

 

 

 

DEFINITION

Overlapping fifth toe is a congenital condition where the fifth toe is rotated and overrides the fourth toe.1,

2, 3

 

It is frequently bilateral.

Males are affected as frequently as females.

 

 

ANATOMY

 

There are seven main components:

 

 

The fifth toe may be smaller than normal.

 

The fifth toe is adducted toward the fourth toe.

 

 

The fifth metatarsophalangeal joint has a dorsiflexion contracture. The phalanges of the fifth toe are rotated laterally.

 

 

 

The fifth extensor digitorum longus tendon is shortened. The fifth metatarsophalangeal joint is dislocated dorsally. The skin in the fourth web space is contracted.

PATHOGENESIS

 

The exact pathogenesis is unknown, but the condition is believed to be secondary to a congenital contracture of the fifth extensor digitorum longus tendon.1

NATURAL HISTORY

 

 

This condition rarely causes pain or difficulty in shoe wear in children younger than 10 years of age. In older children and adolescents, there will be painful dorsal callosities about 50% of the time.

 

There may also be difficulty in finding shoes that fit appropriately in older children and adolescents.

 

 

 

FIG 1 • A,B. Frontal and lateral image of overlapping fifth toe. (Picture courtesy of Richard Davidson, MD.)

 

 

Parents are frequently concerned about the cosmetic appearance of the foot.

 

PATIENT HISTORY AND PHYSICAL FINDINGS

 

The fifth toe will be dorsiflexed, adducted, and laterally rotated. It will not be passively correctable into a neutral position (FIG 1A,B).

 

A careful neurovascular examination should be performed and documented.

 

IMAGING AND OTHER DIAGNOSTIC STUDIES

 

Plain anteroposterior (AP), lateral, and oblique radiographs may be obtained and will demonstrate a dorsolaterally subluxated fifth metatarsophalangeal joint.

 

NONOPERATIVE MANAGEMENT

 

Conservative treatment (eg, stretching, splinting, taping) is ineffective in the treatment of this condition.1, 2

 

SURGICAL MANAGEMENT

 

Surgery is indicated when nonoperative treatment fails, such as failure to find comfortable shoes or when there is intractable pain from shoes.

 

Positioning

 

The patient is supine, preferably with a bolster beneath the ipsilateral hemipelvis to make the lateral foot more accessible.

 

A tourniquet should be used during the procedure.

 

 

P.1043

TECHNIQUES

• Butler Procedure for Overlapping Fifth Toe

   

  A dorsal racquet incision is made about the toe with a second handle to the racquet added on the plantar aspect of the toe (TECH FIG 1A).

   

   

  The plantar handle should be slightly longer than the dorsal handle and directed slightly laterally. The skin flaps are elevated and the tight extensor tendon is exposed.

   

  Care should be taken to identify and protect the neurovascular bundles (TECH FIG 1B).

   

   

   

  TECH FIG 1 • A. A racquet incision with plantar and dorsal extensions is used. B. Deep dissection is performed, preserving the neurovascular bundles. An extensor tenotomy is performed. C. A capsular release is performed. D. The toe should now reside in its corrected position. E,F. The incisions are closed with interrupted sutures. They help provide stability to the reconstruction.

   

   

  The extensor tendon is lengthened, and a dorsomedial release of the fifth metatarsophalangeal joint is performed. If needed, the plantar aspect of the fifth metatarsophalangeal joint may be dissected off the metatarsal head and divided to increase joint mobility (TECH FIG 1C).

   

  The toe should freely move plantarward and laterally into its corrected position (TECH FIG 1D).

   

  There should be no tension on the toe, and the toe should rest within the plantar handle of the racquet incision.

   

   

  Interrupted sutures are then used to hold the toe reduced in place (TECH FIG 1E). A cast or hard-soled shoe can be used postoperatively.

   

   

  PEARLS AND PITFALLS

  • The surgeon should assess the plantar capsule for tightness as well as the

   

  dorsal capsule.

  Incomplete release of soft tissues

   

  Neurovascular compromise

• The neurovascular bundles should be protected during the procedure, and traction on the fifth toe is avoided. Circumferential dressings about the toe are avoided.

 

POSTOPERATIVE CARE

 

Postoperative care includes sterile dressings and allowing mobilization and weight bearing as tolerated.

OUTCOMES

This procedure has a high patient satisfaction rate (about 90%) in various studies. Black et al1 reported 94% good to excellent results.

 

 

COMPLICATIONS

Incomplete correction Neurovascular compromise Scar contracture

Infection

 

 

REFERENCES

1. Black GB, Grogan DP, Bobechko WP. Butler arthroplasty for correction of the adducted fifth toe: a retrospective study of 36 operations between 1968 and 1982. J Pediatr Orthop 1985;5:439-441.

    

    

2. Cockin J. Butler's operation for an over-riding fifth toe. J Bone Joint Surg Br 1968;50(1):78-81.

    

    

3. De Boeck H. Butler's operation for congenital overriding of the fifth toe. Retrospective 1- to 7-year study of 23 cases. Acta Orthop Scand 1993;64:343-344.