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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Postoperative care
Various precautions may be taken by the physician to prevent postop
erative problems such as recurrence, pain, infection, or prolonged
drainage. These preventative principles include the use of single
uninterrupted incisions, good illumination and visualization of
the surgical site, careful differentiation of tissue levels, proper use of
instrumentation, elimination of exostosis discovered during the
toenail surgery, and incorporation of adjacent toes in the postopera
tive bandages.
Alternatives to incision closure include the use of 18 inch to 14 inch
sterile paper tape strips (Steri-Strips) rather than sutures to close the
incisions. They are left on from 7 to 14 days to allow complete healing,
and the author suggests they be placed on the incisions without
tension. The larger 12 inch (13 mm) Steri-Strips may be better in
some patients when there is adequate incision size to accommodate
the tapes.
After the procedures are completed, the incisional areas are covered
with petrolatum impregnated Adaptic gauze, sterile 2 × 2 gauze and
the dressings are then covered with a firm compression bandage
that is removed in 5–8 days. In most cases, once the sutures are
removed, the patient is instructed to begin warm water and Epsom
salts foot soaks followed by bandaid coverage until healing is
complete.
well as the possibility of epidermoid cysts and recurrences of nail
spicules (Fig. 24.36). All of these may be unacceptable cosmetically
and unnecessary when other, more effective total matrixectomies are
available. I believe that this radical procedure for nail conditions is
performed far too widely and should not be performed when there
are less traumatic procedures available (such as phenol chemical
matrixectomies) that will accomplish the same results. Having said
that, it is still an important procedure when all of the indications are
present for its use.
Figure 24.24 Total nail avulsion. (A) A simple elastic toe tourniquet is
applied and the nail is freed from nail bed attachments. (B) The nail is
completely avulsed.
A
B
Figure 24.25 Final dressings and elastic cohesive bandage over toe.
Figure 24.26 The illustrated Winograd procedure for partial matrixectomy.
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| 24 |
Figure 24.27 Winograd partial matrixectomy procedure for relief of onychocryptosis. (A) The ingrown part of the toenail and a section of the nail fold
and matrix have been resected by removing a wedge of tissue. (B) Final closure with good appearance of remaining nail.
A
B
Figure 24.28 Winograd procedure for treatment of recurrent ingrown
lateral fifth toenail.
Figure 24.29 Long-term appearance of bilateral Winograd wedge
resection for severe recurrent ingrown toenail with chronic hypertrophied
nail borders.
Figure 24.30 Schematic Frost partial matrixectomy procedure (modified with suture closure).
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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 24.31 Schematic Zadik total matrixectomy procedure. The incision is planned in an H-shape to encompass the toenail and create a proximal
flap. The nail is avulsed and the matrixectomy is performed. The hyponychium is removed and the distal and proximal skin flaps are undermined and
sutured together in the original H design.
Figure 24.32 Zadik total matrixectomy. (A) The toenail is avulsed. (B) The H-incision is made and the distal flap is created with excision of the
hyponychium. (C) The proximal flap is created and a total matrixectomy is performed. (D) The nail bed is remodeled so that it is flat and the medial
and lateral folds are undermined. (E) The proximal and distal flaps are apposed and sutured along with the borders. (F) Final appearance at 3 months
postoperatively.
A
B
C
D
E
F
CONCLUSION
The formation and anatomical aspects of toenails and adjacent struc
tures and the associated pathological changes that may involve these
tissues has been reviewed. It is obvious that a great deal of information
has been published regarding conditions involving toenails, which
tends to indicate the frequent presentation of these problems. The
treatment of onychomycosis has taken on a new perspective with the
advent of safer oral antifungal drugs, such as terbinafine HCl. Because
onychocryptosis appears to be one of the most frequently reported
conditions, the principles and general techniques of surgical nail care
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| 24 |
Figure 24.33 Schematic terminal Syme operation for total nail removal. The incision is planned similar to the Zadik approach, but the distal cross
incision is made just under the tip of the toenail, which must be removed first. The medial, lateral and proximal nail folds, as well as the nail bed and
nail matrix, are excised and the distal 13 to 12 of the phalanx is removed. The distal plantar flap is then sutured to the proximal skin incision.
Figure 24.34 Terminal Syme operation. At 1-year follow-up of hallux
procedure with good results.
Figure 24.35 Terminal Syme operation. Uncommon use of the procedure
for a second toe condition.
Figure 24.36 Terminal Syme operation. Excessive shortening and bulbous
end of hallux left the patient very unhappy with the end-results.
were presented as a background for the discussion of several of the
most commonly employed surgical procedures.
It should not be overlooked that most patients have a significant
level of fear of having surgical procedures performed on their toenails.
There is an underlying feeling that this causes severe pain and possible
disability. Thorough and careful explanation of the treatment plans
and expectations, as well as good anesthesia techniques, are required
for complete patient acceptance. With this background information
the physician treating the lower extremity should be able to approach
conditions of the toenail both conservatively and surgically and be
able to offer the patient the best possible management for their toenail
problems.
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| 25 |
CHAPTER CONTENTS
Introduction
307
Etiology of digital conditions
308
Digital skin incisions
308
Digital lesions
309
Acquired digital fibrokeratoma
309
Angioleioma
310
Cutaneous horn
311
Dermal neuroma
311
Dermatofibroma
311
Glomus tumor
312
Helomata
312
Hemangioma
313
Lipoma
314
Mucoid cysts
314
Nevi
317
Osteochondroma
317
Osteophyte (subungual exostosis)
318
Pyogenic granuloma
318
Verruca
322
Soft tissue digital angular correction
322
Planes of deformity
322
Tenotomy
323
Toe tendon lengthening
324
Toe tendon transfers
325
Skin procedures for flexible toe correction
329
Skin wedges for toe alignment
329
Skin Z-plasty for toe alignment
329
Osseous digital correction
329
Arthroplasty
330
Arthroplasty or arthrodesis with flexor tendon
transfer
330
Treatment of elongated toes
331
Staged-combined procedures
333
Digital syndactylization
334
Mini webbing procedure
337
Partial webbing procedure
337
Fusiform webbing procedure
337
Full-length webbing procedure
338
Modified syndactylization
338
Digital desyndactylization
339
Rectangular flap desyndactylization procedure
340
Z-flap desyndactylization procedure
344
Fusiform graft desyndactylization procedure
344
Other unique methods
344
Digital amputations
344
Distal digital amputation
349
Partial digital amputation
350
Total digital amputation
352
Conclusion
352
INTRODUCTION
This chapter is devoted to soft tissue and simple osseous procedures
in and around the toes, and is not about the variety of procedures
for the osseous structural correction of the metatarsals or complex
digital deformities. This implies that most of the positional or
malalignment conditions discussed will be flexible in nature. As
with all other procedures that are discussed in this text, it is impor
tant to understand the anatomy and function of the digits before
surgery is undertaken. Topics will include skin incisions, digital
lesion excision, angular and malalignment repair, digital tendon
procedures, syndactylization and desyndactylization, and digital
amputations.
©2012 Elsevier Ltd.
Digital procedures
G. Dock Dockery
Chapter
25
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not always possible. Passing over flexion and extension lines should
be avoided unless the incisions are curved to compensate for contrac
ture (Fig. 25.1). When a curved incision is planned on two adjacent
digits, it is prudent to draw them on the toes with a skin marker
and make them in the same direction for the best overall appearance
(Fig. 25.2).
Straight incisions over two successive joints, such as over the first
metatarsophalangeal joint and the hallux interphalangeal joint, can
cause an unsightly scar that may contribute to dorsal contracture (Fig.
25.3). Often, this increase in scar formation is due to early motion,
which is necessary in many joint procedures to prevent stiffness.
Adjustments or modifications of incision placement over two joints
may reduce this excessive scar formation (Fig. 25.4).
ETIOLOGY OF DIGITAL CONDITIONS
There are a number of reasons for maladies of the digits. Congenital
deformities frequently involve the lesser toes, especially the fourth and
fifth digits. Biomechanical abnormalities cause a significant number
of digital problems and are the basis for a considerable number of
surgical procedures for these conditions. Neuromuscular defects also
cause problems with the toes and most of these conditions need
extensive deliberation before being treated surgically. Trauma is an
obvious cause of many toe problems and the treatment is usually very
straightforward. Metabolic and inflammatory conditions such as rheu
matoid arthritis, gout, diabetes, other arthritides, such as Reiter’s
syndrome, spondylitis, psoriatic arthritis, and any number of other
systemic conditions, can also result in toe deformities. Finally, there
is a large group of conditions that simply fit into the group classifica
tion of idiopathic. Included in this rather ubiquitous category are skin
lesions, tumors, and unusual toe conditions that cannot easily be
placed into specific etiologic classes.
Pain is often the initiating reason for most patients to seek medical
attention regarding toe problems but not always. In some instances,
the reason for the concern is the abnormal appearance, unsightly
manifestation, or functional difficulties arising from the condition.
The patient may be having difficulty fitting into their regular shoes or
they may be embarrassed by the appearance of the condition. A note
of caution is due at this point. If the patient is concerned about the
appearance of a condition, and has no other symptoms, it is extremely
important that the surgeon seriously evaluate the need for surgery in
the first place and carefully outline the alternatives, procedure goals,
and potential risks in great detail.
DIGITAL SKIN INCISIONS
The ultimate location for an elective skin incision is within the
relaxed skin tension lines (RSTLs) or at right angles to the direction
of muscle-tendon pull. Following natural crease lines, however, is
Figure 25.1 Illustration of sample skin incision planning. Skin incisions
over the digits are frequently curved to compensate for the relaxed skin
tension lines or tendon pull.
(Reproduced with permission from: Miller, S.J., 1986. The art of making an incision.
Clin Pod Med Surg 2: 225–233).
A
B
Figure 25.2 When incisions on adjacent digits are planned, it is wise
to make them in the same general shape for similar appearance
postoperatively.
Figure 25.3 A linear scar over two successive joints may allow excessive
scar formation and dorsal scar contracture may restrict motion.
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309
| 25 |
blade, or even with the tip of the blade, is very inefficient and allows
for variability in the depth of the incision. Additionally, there is a
tradition in surgery that the initial skin blade needs to be discarded
as soon as it has been used and replaced with a new deep blade. This
is unnecessary and the only reason to change the blade is when it
becomes slightly dull or is of the wrong size. However, a frequent
change of the surgical blade during a surgical procedure does assure
smoother incisions and increases the surgeon’s control of the cuts
during the case. A dull surgical blade tends to cause the surgeon to
press harder on the scalpel blade and, therefore, increases the risk of
slipping or cutting adjacent tissues.
It is important to complete the incision, once it is initiated, with
one smooth deliberate stroke through the epidermis and all or a
portion of the dermis while keeping the blade perpendicular to the
skin. A long, smooth continuous stroke of the surgical blade is essen
tial to obtain the best incision and reapproximation at the time of
closure. An incision composed of multiple short slices is one that
produces a considerable amount of damage and results in ragged and
uneven edges that the body will have to try to repair during the post
operative healing phase of recovery.
The primary difference between the smooth deliberate incision and
the short multiple slices incision is usually one of surgeon confidence
in the technique and the underlying anatomy. When there is underly
ing neurovascular structures, or other anatomy that must be protected,
the first incision should not completely penetrate the deep dermis. A
second incision is made through the deep dermal layer and subcuta
neous to expose the dermal and subdermal vessels and nerves. At this
level, bleeding vessels may be clamped or cauterized as needed. Very
little, if any, undermining is performed until the subcutaneous layer
is opened completely. If, in contrast, there are no underlying neurov
ascular or anatomical structures of concern, then the incision may be
made to the deepest level necessary to perform the planned procedure
(Fig. 25.5).
DIGITAL LESIONS
There are numerous cutaneous and soft tissue lesions that may be
found on the toes. Many of these are benign, asymptomatic and never
bother the patient. Others may be premalignant, malignant, painful,
unsightly or in some way bothersome for the patient. In most cases,
any suspicious lesion should be removed by biopsy to be evaluated
by a board-certified dermatopathologist. In fact, any time a lesion is
surgically removed it should be sent to pathology to protect the
patient and be assured of an accurate diagnosis. Simple excision of
the lesion is generally all that is required. Whenever a lesion is located
in an area where motion or flexion is needed, it may be necessary
to perform a curvilinear incision, unconventional approach or skin
flap in order to preserve this function. A few of these lesions will be
subsequently reviewed.
Acquired digital fibrokeratoma
These uncommon flesh-colored lesions may resemble cutaneous
horns, acrochordons (skin tags), or fibromas and may occur on the
toes or other areas such as the fingers, palms, soles or heels (Fig. 25.6).
The growth is solitary and occurs as a nodular to dome-shaped fibrotic
or keratotic lesion that may be warty or pedunculated. They may also
be surrounded by a collarette of elevated skin. Treatment of acquired
digital fibrokeratoma is with simple shave excision and cautery. It may
also be removed by surgical excision with fusiform approach and
suture closure. Recurrence after removal is very rare.
When making an incision over digits the initial incision is made
with the smallest scalpel blade size that is appropriate for the size
of the surgical site. In other words, a smaller scalpel blade might
be more appropriate for a patient with a fifth toe deformity and
a large scalpel blade might be better for a patient with a first toe
deformity. This concept also applies for intricate or detailed flaps or
procedures.
The initial incision is initiated with the tip or point of the blade
and then the surgical scalpel is held in such a manner as to allow the
cutting edge of the blade, the belly, to contact the skin. The incision
should then be ended with the tip of the blade. This is a very accurate
method of creating a skin incision with a more consistent skin-
incision depth. Performing the entire incision with the belly of the
Figure 25.4 Modified incision placement when two joints are involved.
(A) A 3-week postoperative incision for a dorsal first metatarsal head
procedure is curved medially and then brought back over the hallux
interphalangeal joint. (B) Another similar incisional placement with a
medial first metatarsal head procedure and hallux IP joint procedure
at 3 months postoperative.
A
B
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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
solitary in nature, and the most striking feature is intense pain.
Pain usually occurs spontaneously and may be paroxysmal in nature.
Solitary angioleiomas are encapsulated and contain numerous
blood vessels. Leiomyomas of non-vascular origin are unencapsu
lated tumors of smooth muscle bundles. Angioleiomyomas are
Angioleioma
Angioleiomas, leiomyomas, and angioleiomyomas represent benign
tumors derived from cutaneous smooth muscle (Fig. 25.7). Most of
these lesions are misdiagnosed. Lower extremity lesions are generally
Figure 25.5 Precise, full-depth incision. (A) Angular deformity of the hallux. (B) Initial incision is medial to the extensor tendon and full-depth to the
underlying bone to be cut. (C) Osseous procedure is performed. (D) Skin closure with subcuticular suture and Steri-Strip tape.
A
B
C
D
Figure 25.6 Acquired digital fibrokeratoma. An uncommon lesion
located on the lateral aspect of the hallux resembles a cutaneous horn,
the base of which is surrounded by a collarette of elevated skin.
Figure 25.7 Angioleiomyoma. Typical location on the lesser toe. This one
was on the base of the fourth digit.
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to light touch and, unlike plantar keratotic lesions, do not respond
to local debridement. In fact, most attempts at local care will make
the symptoms worse. Treatment includes aperture padding of the
area to off-weight pressure, 4% alcohol injections to create a chemical
neurolysis, or surgical excision of the lesion and attached nerve tissue
(Fig. 25.11).
Dermatofibroma
Also known as solitary histiocytomas, these common benign lesions
are usually asymptomatic to slightly pruritic. They are frequently
found on the lower legs and occasionally on the toes (Fig. 25.12).
These firm, raised, round-to-oval, elevated, pigmented lesions retract
Figure 25.8 Leiomyoma. (A) Extremely painful lesion located on plantar
base of the third toe. (B) The lesion was completely excised with a
fusiform incision.
A
B
Figure 25.9 Cutaneous horn. This hard conical projection composed
mostly of keratin located on the fifth toe will extend outward until
damaging adjacent tissues.
Figure 25.10 Dermal neuroma. This extremely painful dermal neuroma
formed at the plantar aspect of an incision on the weight-bearing aspect
of the foot.
encapsulated and show many blood vessels with thick muscular walls
(Fig. 25.8). Since most of these lesions are solitary, the treatment of
choice is surgical excision.
Cutaneous horn
This is generally a conical hyperkeratotic lesion of various sizes com
posed of keratin and resembling an animal horn (Fig. 25.9). These
lesions commonly form on the toes, feet, ears and hands. Warts, sebor
rheic keratoses, stucco keratoses, actinic keratoses, solar keratoses, and
keratoacanthomas may all retain keratin at their base and produce
cutaneous horns. Microscopic evaluation shows compacted keratin
layers with a base characteristic of one of the previously listed condi
tions. Surgical excision with a 1-mm border is curative in most cases.
Dermal neuroma
This dermal lesion is poorly recognized and frequently misdiagnosed.
Dermal neuromas often result from a superficial skin injury or surgery
with exposure of dermal nerves that are subsequently trapped within
the resultant scar formation (Fig. 25.10). Lesions may be flat, slightly
elevated, or papular. They are usually smooth and skin-colored to pink
and may show a slight scaling or hyperkeratotic ring around the
periphery. In some cases, nerve endings may be seen through a trans
lucent layer of keratin that has formed over them. A thin callus may
form over the dermal neuroma. These lesions are exquisitely tender
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beneath the skin surface when they are squeezed from either side
(Fitzpatrick dimple sign). They vary from 2 mm to 2 cm in diameter.
The lesion may be removed with a deep-shave excision or, if excised,
a wide margin with full depth must be performed in order to prevent
recurrence.
Glomus tumor
Solitary glomus tumors are small, soft-to-firm, red-to-blue papules,
most frequently found on the lower extremities. Common locations
for the glomus tumors are subungual, at the distal nail bed (Fig.
25.13) and on the lesser toes (Fig. 25.14). These lesions are charac
teristically very tender and have paroxysmal pain. Glomus tumors are
hamartomas of glomus bodies and blood vessels that are richly inner
vated. This combination of neurovascular structures provides the col
oration seen below the skin and the painful symptoms reported by
the patients. Treatment is complete surgical excision.
Helomata
The discrete digital helomas, also called corns or calluses, may be
found in several different forms, including heloma durum (hard
corns), which are usually found at the ends of the toes or over the
dorsal aspect of the lesser digits (Fig. 25.15); heloma molle’ (soft
corn), which are seen between the digits (Fig. 25.16); heloma unguium
Figure 25.11 Dermal neuroma. (A) The dermal neuroma and old scar are outlined with the fusiform incision. An unrelated proximal phalanx
osteotomy is also planned. (B) The dermal neuroma and attached scar tissue are excised as one unit. (C) The incisions are closed with subcuticular
absorbable sutures and Steri-Strips. (D) The postoperative appearance at 3 weeks.
A
B
C
D
Figure 25.12 Dermatofibroma on hallux. Early lesions may be small and
have a well-defined border, with an elevated irregular red surface.
Pigmentation begins at the periphery and usually does not reach the
center of the lesion.
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cence by excision and by removal of any underlying osseous patho
logic process (Figs 25.19–25.24).
Hemangioma
These vascular lesions are frequently located on the trunk, legs or toes.
They are well-defined and raised and have a dome-shaped surface.
They are usually bright red to purple in color, which suggest the diag
nosis in most cases. Cherry hemangiomas, also known as Campbell
de Morgan spots (Fig. 25.25) and senile angiomas (Fig. 25.26), are
found commonly in elderly patients, but may develop early in adult
life. Multiple lesions may be present ranging from 1 to 3 mm in
diameter. Lesions on the digits may be larger than those seen on the
trunk or lower legs. Most of these lesions do not require removal, but
smaller lesions may be removed by electrodesiccation, shave excision
(callused nail groove), which are found on the edge of toenails, espe
cially the border of the fifth toenail (Fig. 25.17); and the heloma
hallux (pinch callus), which is found on the medial and plantar
border of the hallux (Fig. 25.18). Treatment ranges from trying to
control the underlying pressure problem or biomechanical imbalance,
to simple debridement and padding, to topical keratolytics to surgical
treatment. The surgery should be directed at removal of the excres
Figure 25.13 Glomus tumor. Common location at the distal or
subungual region of the hallux.
Figure 25.14 Glomus tumor. Located at the distal medial aspect of the
fifth toe. Diagnosis was confirmed with surgical excision and biopsy.
Figure 25.15 Heloma durum. The most common location for this hard
corn is over the dorsal aspect of the lesser toes.
Figure 25.16 Heloma molle of second toe. The soft corn is usually
located on the deep web-space between the toes.
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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
are more likely to be affected by ordinary lipomas of the lower extrem
ities. The fat masses are encapsulated and composed of adipose tissue
with a slight increase in the size of the individual fat cells. Surgical
excision is warranted if the lesion causes symptoms or is unsightly.
The recurrence rate after excision is very low.
Mucoid cysts
Digital mucoid cysts are soft, dome-shaped, smooth, oval-to-round,
translucent, white-to-pink structures occurring intradermally on the
dorsal surface of the distal aspect of the digits. This condition has a
greater frequency in females (3 : 1 ratio) and is uncommon in younger
patients. This slow-growing and well-localized lesion is almost always
or with simple fusiform excision. Shave excision allows delicate
removal of the lesion by a blade and histologic confirmation of the
diagnosis. When the lesion is irritated from pressure and begins to
bleed it is wise to remove it. Hemostasis following removal may be
obtained by chemical means (aluminum chloride) or by performing
electrocautery.
Lipoma
The lipoma is one of the most common mesenchymal tumors and
they may be seen on any part of the lower extremity. Lipomas are
common on the trunk and extremities, especially around the ankles.
Digital lipomas are, however, relatively unusual (Fig. 25.27). Women
Figure 25.17 Heloma unguium. The callused nail groove may be seen
on the border of any toenail but is common on the fifth toe. This is
usually easy to differentiate from a nail spicule.
Figure 25.18 Heloma hallux. This distinct pinch callus is secondary to
increased pressure from biomechanical abnormalities and is common on
the medial and plantar aspect of the hallux.
Figure 25.19 Excision of distal heloma durum. (A) A fusiform excision is performed around the distal heloma durum. (B) The incision is closed with
simple interrupted nylon sutures. (C) The postoperative appearance at 6 weeks.
A
B
C
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A
B
Figure 25.20 Excision of dorsal heloma durum. (A) Transverse excision
of heloma over the second distal interphalangeal joint. (B) Transverse
excision of heloma over the second proximal interphalangeal joint.
(C) Transverse excision of heloma over the fifth proximal interphalangeal
joint.
C
Figure 25.21 Treatment of heloma durum fifth digit without excision
of lesion. (A) Medial incision with removal of proximal phalanx head.
(B) Suture closure of medial incision. Removal of the underlying bony
prominence will frequently resolve the lesion.
A
B
solitary and favors the fingers and toes (Fig. 25.28). The cyst is a soft
and fluctuant mass that contains a clear viscous jelly-like fluid, which
will extrude if broken or punctured (Fig. 25.29). There are two varia
tions of cyst, one located over the interphalangeal joint and the other
at the proximal nail fold. The treatments include injection of either a
cortisone solution or 4% alcohol mixture (Fig. 25.30), fusiform exci
sion of the cyst (Fig. 25.31), or complete excision and rotational skin
flap closure (Fig. 25.32). This final approach gives the best long-term
results. When performing the Schrudde single-lobe flap following
excision of the digital mucoid cyst, it is advisable to design the flap
in such a way that it has a good potential blood supply to the pedicle
after it has been rotated into place. This planning will also assure
that the flap defect is then closed within the RSTL of the digit (Figs
25.33, 25.34).
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Figure 25.22 Treatment of heloma durum fifth digit with excision of lesion. (A) A painful heloma durum with underlying bursa formation on fifth toe.
(B) The lesion is excised and the underlying bursa is removed. (C) The underlying bony prominence is reduced. (D) Appearance at suture removal 3
weeks postoperative. (E) Final appearance at 6 weeks.
A
B
C
D
E
Figure 25.23 Heloma unguium (callused nail groove). (A) The adjacent nail is avulsed. (B) The callused nail groove is removed with a wedge excision
down to the underlying phalanx. Bony exostosis may be removed as necessary. No undermining of the skin edge is usually necessary. (C) The incision is
closed with simple nylon sutures.
A
B
C
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A
B
Figure 25.24 Treatment of heloma hallux with rotation flap. (A) A large
pinch callus that was unresponsive to conservative care. (B) Planned
Schrudde-type single-lobe rotation flap. (C) Postoperative appearance at
8 weeks.
C
Figure 25.25 Hemangioma. Small cherry hemangioma (Campbell de
Morgan spot) located on the medial aspect of the hallux. This lesion was
chronically irritated and was removed with simple excision.
Figure 25.26 Hemangioma. Larger cherry hemangioma (senile angioma)
located on the distal aspect of the second toe. This lesion was not
treated due to the extensive nature of the involvement.
Nevi
Compound melanocytic nevi are slightly elevated, flesh-colored-to-
dark-brown, smooth-to-rough-surfaced lesions commonly seen on
the hands and feet, including the toes (Fig. 25.35). They may be round
or slightly irregular and they may become more elevated with increas
ing age. Usually they are nodular, smooth, and uniformly pigmented.
On occasion, they may be flat, warty and irregular in shape and color,
making the clinical diagnosis more difficult (Fig. 25.36). Histological
evaluation of the compound melanocytic nevus shows collections of
nevocytes within the dermis and the junctional zone (Fig. 25.37).
Treatment is not usually necessary unless there are changes in the
appearance or size of the lesion or if the lesion is >6 mm in diameter;
then it should be biopsied with the shave technique for dermat
opathologic diagnosis (see Ch. 12).
Osteochondroma
The solitary osteochondroma is frequently seen in patients between
10 and 20 years of age, and it is often misdiagnosed as a skin tumor
or subungual exostosis. The osteochondroma is characterized by a
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contributory factor in the development of the ingrown or pincer
toenail deformity. The subungual exostosis is different than an osteo
chondroma in its relatively smaller size (<0.5 cm in diameter), its
fibrocartilaginous cap instead of a purely hyaline cartilaginous cap,
and its very low recurrence rate after treatment. It appears to be much
more common in cases following trauma to the toenail. The treatment
of choice is surgical excision of the subungual exostosis through a
distal fish mouth incision at the tip of the digit (Fig. 25.42) or, if too
large to resect by the previous method, by removal of the toenail and
incision through the nail bed to gain exposure (Fig. 25.43).
Another variation of the exostosis is seen around the interphalan
geal joints (Fig. 25.44), which may be associated with arthritis or dry
synovitis. Treatment is surgical excision with complete removal of the
involved bone. Care must be taken to prevent injury directly to the
joint itself. In most cases, a curvilinear skin incision around the lesion
is preferable to a straight incision.
Pyogenic granuloma
This misnamed entity is neither infectious nor granulomatous but this
name appears to be one that is well-known and still in common use.
These rapidly growing, pink-to-bright-red vascular tumors may be
hyaline cartilaginous capped osseous protrusion, most often located
at the metaphysis of long bones, especially around the knee and at
the subungual area of the distal phalanges (Fig. 25.38). This lesion is
composed primarily of bone and is produced by progressive endo
chondral ossification of the growing cartilage cap. The treatment of
choice is surgical excision. Subungual lesions usually require nail
avulsion and surgical excision of the entire tumor (Fig. 25.39).
Osteophyte (subungual exostosis)
The slow growing, solitary osteophyte, called a subungual exostosis,
has a predilection for the dorsomedial aspect of the hallux distal
phalanx (Figs 25.40, 25.41). It is most common in adults between the
ages of 20 and 40 years. Because of its typical location it may be a
Figure 25.27 Digital lipoma. A relatively large lipoma of the hallux. This
mass made shoe fitting difficult and was excised through a linear lateral
hallux incision.
Figure 25.28 Digital mucoid cyst. Typical location and appearance.
Figure 25.29 Digital mucoid cyst. A thick viscous fluid will extrude when
the cyst is punctured or broken.
Figure 25.30 Digital mucoid cyst. Injection of 1 : 1 mixture of
corticosteroid and local anesthetic agent or a 4% diluted alcohol
solution.
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Figure 25.31 Digital mucoid cyst. (A) Cyst located on the distal lateral interphalangeal joint of second toe. (B) A fusiform incision is made over the
lesion and it is removed. (C) The incision is carried down to the deep layers and the stalk is removed into the joint. (D) The incision is closed full-depth
with simple nylon sutures.
A
B
C
D
A
B
Figure 25.32 Digital mucoid cyst. (A) Large cyst at the distal lateral aspect of second toe. (B) Complete excision of lesion with design of the single-
lobe rotation flap.
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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
(C) Flap transferred and sutured into place. (D) Final appearance at 6 weeks postoperative.
C
D
Figure 25.32, Continued
Figure 25.33 Digital mucoid cyst. (A) The flap is designed proximal to the cyst in such a manner as to rotate distal and medial. (B) The position after
rotation has good potential proximal blood supply to the base of the flap.
A
B
Figure 25.34 Digital mucoid cyst. (A) The flap is designed across the toe within the relaxed skin tension lines. (B) The closure shows that the flap has
a good potential proximal blood supply and the donor site closure is within the skin folds.
A
B
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Figure 25.35 Compound nevus. The distal edge is elevated and darker
pigmented than the majority of the lesion.
Figure 25.36 Compound nevus. The center is elevated, and the lesion is
less pigmented than usually seen. Confirmation is by shave biopsy.
Figure 25.37 Compound nevus. Photomicrograph shows both junctional
and dermal nevus cell nests. (H&E, ×40.)
Figure 25.38 Osteochondroma. The typical appearing lesion was present
under the third toe and had been previously diagnosed as a wart.
Figure 25.39 Osteochondroma. (A) The toenail is avulsed exposing the cartilaginous cap of the lesion. (B) The nail bed and soft tissue is retracted
from the lesion to the underlying phalanx. The osteochondroma is removed well into the bone and the base is curetted. (C) Appearance at 6 weeks
postoperative. The nail is already regrowing.
A
B
C
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includes shave excision with electrocautery or silver nitrate application
of the base or complete surgical excision with suture closure.
Verruca
Digital warts are relatively common and may be of several different
types. The most frequently found wart is the verruca vulgaris, or
common wart (Fig. 25.46). Subungual and periungual warts, filiform
warts, plane warts, and plantar warts may also be found on the toes.
Verrucae are caused by the human papillomaviruses (HPV), which are
listed numerically by their DNA composition for identification pur
poses. The treatment for warts ranges from simple acids or cryotherapy
to blunt dissection and curettage removal.
SOFT TISSUE DIGITAL
ANGULAR CORRECTION
A number of surgical procedures have been described for the correc
tion of lesser digital deformities. Most of the procedures are designed
to correct malaligned toes and decrease symptoms and a few are
intended to change the angle or appearance of the toes. In most of
the cases that will be discussed, the toes are flexible and the correction
will be aimed at the cause, whether it is contracture of the skin, exten
sor or flexor tendon tautness, or bony malalignment deformity.
Planes of deformity
Primary sagittal-plane deformities consist of the typical hammertoe
(Fig. 25.47), clawtoe (Fig. 25.48) and mallet-toe deformities (Fig.
25.49). In most cases, these deformities involve the second, third,
fourth and occasionally the fifth digits (Fig. 25.50). Isolated sagittal-
plane hammertoe deformities most often involve the second digit and
isolated mallet-toe deformities frequently occur on the fourth digit.
Clawtoes, in contrast, usually affect more than one toe and can often
involve all lesser toes.
Coronal (frontal) plane deformities, varus or valgus rotation with
concomitant medial or lateral deviation of the digits, may involve any
toe, but usually affect the fourth and fifth digits (Figs 25.51, 25.52).
mistaken for malignant growths. The painful lesions usually occur in
children and young adults. They frequently arise in areas of minor
trauma and next to ingrown toenails (Fig. 25.45). The pedunculated
lesion is very fragile, bleeds easily, and ranges from a few millimeters
to several centimeters in diameter. The base of the pyogenic granu
loma may have a ring of thick epidermis, called a collarette. Treatment
Figure 25.40 Subungual exostosis. Common location arising at the distal
medial subungual area of the great toe.
Figure 25.41 Subungual exostosis. X-rays confirm the typical appearance
of subungual exostosis arising from the dorsomedial aspect of the distal
phalanx.
Figure 25.42 Schematic of fish-mouth incision to gain access to
subungual exostosis without removal of the toenail.
Figure 25.43 Subungual exostosis. The nail has been avulsed and a
longitudinal incision is made in the distal half of the nail bed overlying
the exostosis, which is then excised completely. The nail bed is then
closed with fine sutures.
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The technique for a simple extensor tenotomy involves making
a small puncture incision with a mini-Beaver blade scalpel just pro
ximal to the metatarsophalangeal joint on the side of the tendon
(Fig. 25.57). The surgical blade is held flat and is placed subcutane
ously below the extensor tendon and the toe is then straightened at
the same time that the blade is rotated upward toward the tendon
allowing the tendon to be cut during this process. The blade is returned
to the flat position and withdrawn from the incision. A simple
suture or single Steri-Strip may be used, but often there is no need
to close such a small incision at all. When isolated tenotomies are
performed, it is essential to hold the toe in the corrected position
for 4 weeks in order to maintain the acceptable alignment while
healing occurs.
The technique for performing the flexor tenotomy involves making
a small incision along the side of the involved toe or at the plantar
aspect of the toe just below the interphalangeal joint (Fig. 25.58). The
blade is placed flat between the phalanx and the flexor tendon. The
blade is then turned down toward the flexor tendon as the toe is
placed into extension, which allows for severing of the tendon. There
is usually a palpable snap as well as an audible sound as the tendon
is released. In most instances, the toe will show an immediate improve
ment in position. This procedure works well for the mallet-toe and is
also used in the other sagittal plane toe deformities. Patients may lose
a slight amount of purchase of the toes during stance-phase of gait,
but in most cases this is a small concession for the flexion deformity
that was present (Fig. 25.59).
Figure 25.44 Exostosis of interphalangeal joints. (A) X-ray showing the extent of the exostosis at the distal interphalangeal joint of the hallux. (B) A
curvilinear incision is made over the dorsomedial hallux. (C) The incision is deepened and the exostosis is completely excised. (D) Closure with running
nylon suture.
A
B
C
D
The condition is frequently referred to as digitus adductus or an adduc
tovarus deformity of the toes.
Transverse (horizontal) plane deformities involve medial or lateral
deviation of the longitudinal axis of the phalanges compared with the
long axis of the metatarsal without rotational deviation. Most often,
this condition seems to involve the hallux (Fig. 25.53), called hallux
varus or valgus, or the second digit with medial subluxation (Fig.
25.54). When this second toe transverse plane deformity is severe and
crosses over the dorsal aspect of the hallux it is referred to as the cross-
over second toe (Fig. 25.55). In very young children, this transverse
plane deformity of the toes may be in a lateralward direction rather
than the typical medial direction (Fig. 25.56). This condition is some
times referred to as digitus abductus and represents a congenital
deformity.
Tenotomy
The surgical release of a taut tendon is referred to as a tenotomy and
it may involve the extensor or the flexor digitorum longus tendon.
This can be done as an isolated procedure or performed in multiple
toes and it may be combined with skin procedures as well. In many
cases, this procedure is thought to be a temporary measure since the
recurrence of tautness of the tenotomized tendon will frequently
return. This procedure is indicated in pediatric and elderly patients,
or for anyone in whom a more complicated procedure is not
warranted.
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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
A
B
Figure 25.45 Pyogenic granuloma. (A) Located on the base of the
plantar aspect of the hallux. (B) Located at the distal end of the fourth
toe. (C) Typical location at the border of an ingrown toenail.
C
Figure 25.46 Verrucae vulgaris. The common wart is frequently found
on the digits.
Figure 25.47 Hammertoe deformity. This condition has sagittal-plane
deformity with dorsiflexion of the proximal phalanx, plantarflexion of
the intermediate phalanx and hyperextension of the distal IP joint. IP,
interphalangeal.
Figure 25.48 Clawtoe deformity. There is dorsiflexion of the proximal
phalanx and plantarflexion of both the intermediate and distal phalanx.
Toe tendon lengthening
In this case, the term tendon lengthening with regards to the toes
infers lengthening of the extensor digitorum longus tendon. This
procedure is most often used in conjunction with osseous hammertoe
procedures of the digit or in conjunction with metatarsal procedures.
Unlike the tenotomy procedure, in which the tendon is severed com
pletely, the tendon lengthening procedure is truly elongated by using
a Z-lengthening technique (Fig. 25.60). The procedure begins with a
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Figure 25.49 Mallet-toe deformity. This primarily results from
plantarflexion of the distal phalanx only.
Figure 25.50 Multiple toe deformity. (A) Contracted hammertoes. (B) Clawtoes. (C) Mallet-toes.
A
B
C
Figure 25.52 Coronal plane adductovarus. Clinical example of the fourth
and fifth toe deformity.
Figure 25.51 Coronal plane adductovarus. Schematic illustration of
deviated and rotated fourth and fifth toes.
small incision placed over the metatarsal area at some point that is
proximal to the extensor hood apparatus. The tendon is exposed and
a small flat instrument, such as a spatula, is placed under the tendon
allowing full visual inspection. A Z-incision is then made into the
extensor tendon and controlled lengthening is then performed. Once
the right amount of correction has been achieved, the tendon ends
are then sutured together with simple interrupted stitches and the
incision is closed.
Toe tendon transfers
In cases where the simple extensor or flexor tenotomy does not seem
appropriate, or where the hammertoe deformity is moderate to severe
but still flexible, the tendon transfer procedures may be more appro
priate. This particular section will discuss only the various types of
flexor tendon transfer procedures. These procedures may be done as
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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 25.53 Transverse plane deviation. Hallux varus condition.
Figure 25.54 Transverse plane deviation. Moderate transverse plane
deformity with medial subluxation of the second toe.
Figure 25.55 Severe transverse plane deformity of the second toe (the
cross-over second toe).
Figure 25.56 Pediatric transverse plane toe deformity with lateral
deviation.
Figure 25.57 Long extensor tenotomy procedure. The mini-Beaver scalpel blade is used to make a small incision adjacent to the extensor tendon
proximal to the metatarsophalangeal joint. The blade is passed below the tendon and then rotated upward toward the tendon to sever it. A single
Steri-Strip is all that is usually necessary to close the incision.
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absorbable sutures, while the toe is held in the corrected and slightly
plantarflexed position compared to the adjacent digits. This procedure
does not allow for an arthroplasty or arthrodesis procedure without
considerable modifications. Once the procedure is completed as
described, the toe is usually not pinned with a K-wire afterwards but
is maintained in a splint-type dressing for 3–4 weeks or at least until
the sutures are removed.
The Schuberth flexor tendon transfer involves transferring the long
flexor toe tendon through a drill hole in the base of the proximal
phalanx rather than at the anatomic neck (Fig. 25.61C). Everything else
about the procedure is the same as in the Kuwada–Dockery procedure.
This procedure allows for the arthroplasty or arthrodesis procedure of
the proximal interphalangeal joint and may provide a better fulcrum
for plantarflexion of the digit at the metatarsophalangeal joint.
Figure 25.58 Long flexor tenotomy procedure. The small incision is placed at the side of the toe, or plantar aspect, just below the interphalangeal
joint using a mini-Beaver scalpel blade. The blade is positioned between the phalanx and the tendon and then turned downward toward the tendon
to sever it. In many cases no form of incision closure is needed.
independent procedures or combined with digital arthroplasty or
digital fusion procedures in more rigid deformities.
The Girdlestone toe tendon procedure involves transferring the
flexor digitorum longus (FDL) and brevis (FDB) tendons onto the top
of the proximal phalanx, where it is sutured to the dorsal expansion
of the extensor tendons. The Sgarlato modification of this procedure
involves transferring the split flexor digitorum longus tendon over the
dorsum of the proximal phalanx and suturing it to itself and into the
periosteum (Fig. 25.61A). The toe may or may not be pinned with a
K-wire to maintain stability of the toe position while healing occurs.
The Kuwada–Dockery flexor tendon transfer involves transferring
the long flexor toe tendon through a drill hole in the anatomic neck
of the proximal phalanx (Fig. 25.61B). The tendon is then sutured
medially, laterally and centrally, into the extensor tendon, using
Figure 25.59 Flexor tenotomy procedure. (A) Contracted flexor digitorum longus tendons of the lesser toes. (B) Post-release of long flexor tendons
shows immediate improvement in the contracted position. The patient is instructed that they may lose some flexor function needed for gripping the
toes.
A
B
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Figure 25.60 Extensor tendon lengthening. A small incision is made proximal to the extensor hood apparatus and the extensor digitorum longus
tendon is exposed and a Z-lengthening is performed.
Figure 25.61 Flexor tendon transfers. (A) Sgarlato split flexor longus transfer. (B) Kuwada–Dockery flexor transfer into distal drill hole in proximal
phalanx. (C) Schuberth flexor transfer into proximal drill hole in proximal phalanx.
A
B
C
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All of the flexor toe tendon transfer procedure may result in swollen
toes postoperatively. Most of the edema will resolve within the first 3
months. Massage and compression wrapping will help to decrease the
residual swelling and speed final healing. Additionally, many of these
toes are stiff after surgery and it is important to tell the patients about
this effect. We have frequently called this a ‘soft fusion’ with the infer
ence that the toe will function much like an arthrodesis.
SKIN PROCEDURES FOR FLEXIBLE
TOE CORRECTION
When the flexible deformity or malalignment seems to be mostly due
to soft tissue and skin contracture, it is possible to realign the digits
by doing skin procedures rather than by transferring tendons or oste
otomizing the osseous structures. In some cases this soft tissue correc
tion is very simple to perform and in other cases it is more involved.
Nonetheless, each procedure must be designed to provide the greatest
benefit to risk ratio and give the patient the appropriate end result.
Skin wedges for toe alignment
Skin wedges are the easiest soft tissue procedures to perform and are
designed to reduce redundant skin or help in the repositioning of a
malaligned digit. The wedge may simply be designed in an oblique
fashion to help straighten an under-riding fifth digit that is in an
adductovarus position (Fig. 25.62). This same type of wedge can be
made transversely at the distal and dorsal aspect of a flexible mallet-
toe (Figs 25.63, 25.64). When there are multiple malaligned toes,
especially when the toes are going in different directions, the skin
wedge technique may be very useful in realigning all of the digits (Fig.
25.65). Another way to use the skin-wedge procedure is to narrow an
enlarged toe (Fig. 25.66). In this example there is not so much of an
angular correction, but the size of the toe will be remarkably reduced
in diameter making it much more comfortable in shoe gear.
Skin Z-plasty for toe alignment
The Z-plasty skin procedure is a powerful technique for lengthening
the taut skin that deforms the lesser toes. This procedure may be used
on any toe that has soft tissue or scar contracture as the main deform
ing force. Additional procedures, such as osseous techniques, may also
be performed at the same time. The most common use for the Z-plasty
with malaligned toes is for the dorsally contracted and overlapping
fifth digit (Fig. 25.67). This technique is also useful for dorsally con
tracted and elevated second toes (Fig. 25.68) (See Chapter 16).
OSSEOUS DIGITAL CORRECTION
Even though it was stated earlier that the discussion in this section
would center on the soft tissue correction of the digits, there is still a
need to review the more common osseous procedures briefly. These
Figure 25.62 Skin wedge procedure. (A) An oblique wedge of tissue is designed on the dorsolateral aspect of the adductovarus toe. (B) The skin
wedge is resected along with underlying subcutaneous and capsular material. (C) The entire incision area is sutured with simple nylon sutures.
(D) At first week follow-up there is noticeable repositioning of the under-riding toe.
A
B
C
D
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Figure 25.63 Skin wedge procedure. (A) A transverse skin wedge is
taken at the dorsal and distal aspect of the fifth toe mallet condition.
(B) Appearance at time of suture closure with correction of the deformity.
A
B
A
B
Figure 25.64 Skin wedge procedure. (A) Mallet-toe deformity of the
third toe. (B) A transverse skin wedge is designed at the dorsal and distal
aspect of the third toe mallet condition. (C) Appearance at time of suture
closure with correction of the deformity.
C
procedures are used for a variety of different conditions involving
the toes and may range from simple joint resection arthroplasty to
more complex procedures with skin, tendon and bone procedures
combined.
Arthroplasty
The simple arthroplasty is one that has been a popular procedure
for many years. It is well noted that when this procedure is done on
the second or third toes alone, with no other stabilizing procedures,
there may be a problem of malposition of the toes after surgery.
This operation, as an independent procedure, is much more accepted
on the fourth and fifth toes and, occasionally, the third digit as well
(Fig. 25.69).
A simplified variation of the standard arthroplasty was developed
in the mid-1960s by Dr KH Lau called the ‘24-hour hammertoe opera
tion’ (Dr Lau 1969, pers comm). This technique was reserved for the
fourth and, especially, fifth toes (Fig. 25.70). The name came from the
fact that patients could ambulate in soft shoes within 24 h following
the operation. Once the procedure is completed and the incision is
closed, a small sterile bandaid is applied and covered with an elastic
cohesive bandage. This is usually sufficient to prevent postoperative
bleeding and edema.
Arthroplasty or arthrodesis with flexor
tendon transfer
This combination of an osseous and a tendon procedure is common
on the second and third digits. In these toes, stability and position
appear to be more important than in the fourth and fifth toes (Fig.
25.71). This does not mean that this procedure is not acceptable for
the fourth toe, and on occasion is utilized, however, these procedures
are rarely performed on the fifth toe.
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Figure 25.65 Skin wedge procedure. (A) Multiple malaligned toes going in different directions on the same foot. (B) Appearance at time of suture
removal with correction of all toes using skin wedge technique.
A
B
Treatment of elongated toes
In cases where some of the toes are too long, there are techniques for
non-joint-destructive shortening procedures (Fig. 25.72). If some toes
are too short on the same foot, bone removed from the longer
toes may be transferred to the shorter toes to give them length. If the
toes are elevated, a flexor tendon transfer may be performed at the
same time. The Kuwada–Dockery procedure for correction of elon
gated toes involves performing diaphysectomies in the proximal
phalanx and, if needed, in the intermediate phalanx of each elongated
toe. For shortened toes, the proximal phalanx is cut and the section
removed from the long digit is placed into the osteotomy of the short
phalanx. K-wires are placed through the phalanges to reapproximate
and maintain the corrected position of the toes (Fig. 25.73).
Figure 25.66 Skin wedge procedure. (A) A relatively wide wedge is designed longitudinally on the enlarged fifth digit. (B) The wedge of skin and
subcutaneous tissue is removed and the underlying tendon is remodeled. (C) Final closure with significant reduction in the diameter of the enlarged toe.
A
B
C
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Figure 25.67 Z-plasty skin lengthening. (A) Dorsally contracted and overlapping fifth digit deformity. (B) Postoperative appearance at time of suture
closure with correction of deformity.
A
B
Figure 25.68 Z-plasty skin lengthening. (A) Dorsally contracted and elevated second digit deformity. (B) Appearance at time of suture closure with
correction of deformity.
A
B
Figure 25.69 Arthroplasty procedure. (A) Typical hammertoe condition with overlying heloma durum on the fourth toe. (B) A transverse skin wedge
excision of the lesion and underlying soft tissue is followed by resection arthroplasty of the proximal phalanx head.
A
B
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Frequently, the K-wire fixation is not passed into the metatarsal head
and, in most of these cases, two K-wires are placed into each digit to
provide stability and prevent rotation from occurring (Fig. 25.74).
When the K-wire is passed into the metatarsal it is advisable to keep
the patient non-weight bearing until the pins are removed in order to
prevent them from bending. When the pins are in the toes only, the
patient may weight bear much sooner. In either case, the K-wires are
kept in place for 4–6 weeks and then removed in the office. In most
cases, the wires can be simply rotated and removed without the need
for anesthesia.
Staged-combined procedures
Combined procedures performed on a single foot are sometimes
staged. This merely means that parts of the procedures are performed
first and when everything is healed the next part of the surgery is then
Figure 25.70 Modified arthroplasty. Called the 24-h hammertoe operation. (A) A full-depth dorsomedial linear skin incision is made over the fifth toe.
(B) The medial capsule and collateral ligaments are severed at the proximal interphalangeal joint, exposing the phalanx head. No other undermining or
soft tissue dissection is performed (C) The proximal phalanx head is carefully freed of the lateral collateral ligament. (D) The proximal phalanx head is
resected with bone forceps and the phalanx is checked for sharp edges. (E) The toe is relocated and the incision is closed with a few interrupted
sutures.
A
B
C
D
E
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Figure 25.71 Arthroplasty with flexor tendon transfer. (A) The skin is marked for a skin wedge resection of a dorsal heloma along with a small incision
for tendon lengthening and metatarsophalangeal capsulotomy of the second digit. (B) The deep soft tissues are retracted and the proximal phalanx
head is exposed and resected. (C) The flexor longus tendon is exposed, split and transferred to the top of the toe where it is sutured to the soft
tissues. (D) The incision is closed with simple sutures.
A
B
C
D
Figure 25.72 Kuwada–Dockery correction of elongated toes. Marked
areas of bone are resected and K-wire fixation stabilizes the digits in the
corrected position. If there are short toes present, the bone resected from
the long toes can be used as graft for lengthening of the shorter toes. If
the toes are elevated, a flexor tendon transfer may be added to the
procedure.
performed. In some cases, this is necessary because of doctor or
patient concerns about too much surgery at once, or it may be impor
tant to evaluate the healed position before determining what addi
tional corrections are needed.
In most cases, it is recommended to do the more complicated or
involved procedures first and then do the less complicated or easier
operations last. An example of this staged procedure for the toes
would be to do the shortening or realignment osteotomy of the hallux
in the first stage and then the lesser digits in the second stage (Fig.
25.75). Another example would be when a complex first ray procedure
is needed with multiple osteotomies or fusion, this is performed
during the first stage and severe contracted toes are repaired during
the second stage (Fig. 25.76). There are those that would argue that
all surgical procedures should be done at the same surgical setting.
Others would suggest that it is sometimes better to separate significant
procedures by adequate healing time before proceeding with further
surgery. Surgeons must use their own best judgment for what is best
for that particular patient and the selected procedures.
DIGITAL SYNDACTYLIZATION
In foot surgery, the original descriptions of surgical syndactylization
of the lesser digits were for unstable toes following the resection of
the metatarsal head or base of the proximal phalanx. Both of these
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Figure 25.73 Kuwada–Dockery correction of elongated toes. (A) Elongated and contracted first, second and third digits along with a short fourth toe
caused the patient discomfort and embarrassment on the left foot. The right foot appeared normal. (B) Following shortening of the second and third
toes, lengthening of the fourth toe and fusion of the hallux. Extensor tenotomies and flexor transfers were also performed. K-wires are used to
stabilize the three middle toes until healing has occurred.
A
B
Figure 25.74 Kuwada–Dockery correction of elongated toes. (A) Preoperative X-rays of symptomatic long second and third toes. (B) Immediate
postoperative views of shortened toes with double K-wires to prevent rotation during healing. (C) Postoperative X-ray at 6 weeks. (D) Appearance of
foot following digital repositioning.
A
B
C
D
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Figure 25.75 Staged-combined surgery. (A) Preoperative malaligned
toes. (B) Postoperative. In the first stage, the hallux was shortened and
realigned and 6 months later, in the second stage, the second toe was
fused, a small V–Y plasty was done at the joint and tenotomies of the
lesser toes was performed.
A
B
Figure 25.76 Staged-combined surgery. (A) Preoperative malaligned
toes. (B) 1 year postoperative reconstructive procedures with Lapidus
arthrodesis and bunion correction and several months later an arthrodesis
of second toe with flexor transfer and lesser digit tenotomies were
performed.
A
B
procedures have decreased in popularity and, as a result, the use of
digital syndactylization has diminished but is still utilized for other
conditions. Patients must be well aware of the final results and appear
ance of a planned syndactylization procedure. In cases where there
has been an interdigital infection present, the infection must be totally
resolved prior to performing a syndactylization.
It is not recommended to syndactylize the third and fourth toes
independently because of the potential for functional problems with
this webbing. This is due to intrinsic motion between the medial and
lateral columns of the foot during gait, which passes between the third
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and fourth ray. Webbing of the third and fourth toes appears to com
promise the balance of the patient’s forefoot and creates a high rate
of failure of the syndactylization of these two toes. There does not
appear to be the same stress on webbing procedures between the first
and second toes, the second and third toes or between the fourth and
fifth toes.
There are four main styles of syndactylization described and they
include the mini webbing, frequently performed for soft corns; the
partial webbing, used primarily for fourth and fifth toe procedures;
the fusiform webbing, mainly for first and second toe conditions; and,
the full-length webbing, used whenever the entire digit needs to be
stabilized.
Mini webbing procedure
This is the simplest of the webbing techniques and the smallest area
of tissue is syndactylized. This procedure is frequently performed for
soft corns located within the base of the interdigital space (Fig. 25.77).
With a surgical marking pen, the soft corn is outlined between the
fourth and fifth toes and then the toes are pressed together. This
creates a pattern on both toes that is then incised along the outermost
outline. Only the skin at the base of the web space is excised, leaving
the subcutaneous layer intact. The wound is then sutured with inter
rupted nylon sutures. A running suture may also be performed to
speed closure. This procedure is not suitable for flail or floppy toes
since it does not stabilize the adjacent toe adequately.
Partial webbing procedure
This version of the syndactylization technique is used primarily for
fourth and fifth toe procedures (Fig. 25.78), but may obviously be
used on any digits. It typically is performed in order to give the
Figure 25.77 Mini webbing procedure. With the marking pen, the lesion is outlined and the toes are pressed together in the position of correction.
The marking is then transferred and the outer marking is incised and the deep web skin and lesion are excised leaving the subcutaneous layer intact.
The wound is then closed with simple sutures.
appearance of a more normal digit and not one that necessarily has
been webbed. With a surgical marking pen, the soft corn or proximal
web space is outlined with a U-shaped drawing on the medial border
of the fifth toe, and then the fourth and fifth toes are pressed together.
This transfers the U-shaped ink drawing from the fifth toe to the lateral
aspect of the fourth toe and creates a matching pattern on both toes
that is then incised along the outline. A small crescent of plantar skin
is taken out when doing this webbing so as to avoid creating a small
dog-ear on the plantar aspect of the webbed area. Again, the subcuta
neous layer is left intact unless there is some other reason to excise it.
The wound is then closed utilizing a running suture of either absorb
able or non-absorbable suture material. Multiple interrupted sutures
may also be used, but the running suture technique is much faster
and the end results are equal. Additionally, the removal of multiple
sutures is much more tedious and uncomfortable for the patient. If
the non-absorbable suture is used, the ends of the stitch are cut first
and the loops are then pulled out using a small skin hook.
Fusiform webbing procedure
This variation of the partial webbing technique is employed mainly
for first and second toe conditions but, again, may also be used on
the fourth and fifth toes (Fig. 25.79). The procedure involves drawing
a V-shaped image on the lateral aspect of the hallux and then the first
and second toes are pressed together. This leaves a mirror image
impression of the drawing on the medial aspect of the second toe.
When performed on the fourth and fifth toes the original V-shaped
drawing is placed on the medial aspect of the fifth toe first, and then
transferred to the lateral aspect of the fourth toe. As in the partial
webbing procedure, the skin is then incised along the line and the
section of tissue is excised leaving the subcutaneous layer intact. The
wound is then closed as described earlier.
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Figure 25.78 Partial webbing procedure. With a marking pen the U-shaped drawing outlines the lesion on the medial aspect of the fifth toe. The toes
are pressed together in the corrected position and the drawing is transferred to the lateral fourth toe. The web is incised along the outline and a small
crescent is cut into the plantar aspect to facilitate better closure plantarly. A running suture is then placed from the plantar aspect to the dorsal
surface. Once all of the sutures are placed they may be tightened in sequence and the final knot is tied superiorly.
Figure 25.79 Fusiform webbing procedure. The marking pen is used to mark a V-shaped outline on the medial aspect of the fifth toe. The fourth and
fifth toes are pressed together and the corresponding fusiform mark is then excised from the web space. Closure of the wound creates the webbing.
Full-length webbing procedure
This is used when the entire digit needs to be stabilized or for
the treatment of chronic recurrent web-space infections (Fig. 25.80).
In cases of web-space infections or interdigital maceration condi
tions it is important that these problems be resolved completely
before the webbing procedure is performed. This procedure is espe
cially useful when excessive bone has previously been removed from
the fifth toe resulting in a flail toe. The full-length technique is an
extension of the partial or fusiform webbing procedure, which is
expanded to include the entire interdigital space in the syndactyliza
tion procedure.
Modified syndactylization
This technique of syndactylization is the only one that does not resect
tissue from the interdigital space. The procedure entails making a
Y-shaped incision between the involved toes (Fig. 25.81). The skin is
first marked with a straight line on the inside aspect of the shortest
toe. The two adjacent toes are pressed together producing a matching
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Figure 25.80 Full-length webbing procedure. This is essentially the same as the partial webbing procedure with the exception that the tissue is excised
as high up on the shortest toe as is possible. This is a preferred procedure in flail or floppy toes.
Figure 25.81 Modified webbing procedure. The first linear line is drawn at the midline of the shortest toe. The adjacent toes are pressed together and
the subsequent V-shape is noted. The base of the Y is then drawn onto the dorsum of the foot and the drawing is then incised into the subcutaneous
layer. Closure is from the plantar aspect proceeding to the dorsum by either interrupted or running sutures.
V-shaped line. The stem of the Y is then drawn on the dorsal aspect
of the foot at the intermetatarsal space. The lines are then incised into
the subcutaneous tissue. Soft tissue releases, capsulotomies, tenoto
mies or bone work can then be done as needed. Both skin and sub
cutaneous layers are reflected and then closed starting at the plantar
aspect and continuing the closure dorsally. Running or simple inter
rupted sutures of absorbable or non-absorbable suture material may
be used.
This modification is quick and easy but does create a more
visible scar dorsally on the foot than the other procedures. It is not
considered the webbing procedure of choice for the correction of
interdigital space maceration or chronic recurrent infection. Addi
tionally, in some cases, this type of syndactylization procedure creates
unstable webbing if it is not brought out to the tip of the shortest toe.
The current application of these various forms of surgical syndac
tylization includes: a flail fifth toe (Fig. 25.82); chronic heloma molle
(Fig. 25.83); chronic unstable hammertoes (Fig. 25.84); overlapping
fifth toes (Fig. 25.85); following bone removal due to osteomyelitis
(Figs 25.86, 25.87); chronic web-space infection (Fig. 25.88), and
stabilization of the great toe after hallux varus repair (Figs 25.89,
25.90) or hallux malleus repair (Fig. 25.91).
DIGITAL DESYNDACTYLIZATION
Congenital syndactyly, in which webbing persists between adjacent
digits from birth, and acquired syndactyly, in which webbing between
adjacent digits results from injury or surgery, are considered to be
cosmetic problems in most cases since this usually causes little or no
functional loss in the foot. Recommendations for the surgical correc
tion of digital syndactyly of the foot usually list the reasons for
the surgery as a relief of emotional or psychological problems and
cosmetic concerns. Because of this, it is imperative that the patient
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Figure 25.82 Webbing for flail toe. (A) This extremely short and flail fifth toe would catch in the patient’s sock but the patient refused amputation. (B)
Full-length webbing procedure stabilized the toe and preserved it for appearance purposes.
A
B
Figure 25.83 Mini webbing for soft corn. (A) Soft corn in base of web space. (B) The lesion and adjacent tissues are excised to include a portion of
the medial skin of the fifth toe. (C) Final closure with mini webbing procedure. (Courtesy of Dr Doug Ichikawa.)
A
B
C
understand the potential risks of desyndactylization procedures. Since
cosmesis is a very high priority, the resultant potential for scarring,
recurrence and possible loss of digit due to vascular embarrassment
must be clearly spelled out.
The basic classifications of syndactyly are the incomplete (webbing
does not extend full length of the involved digits) and complete
(webbing extends to the ends of the involved digits). Additionally, the
syndactyly may be simple (soft tissue connection only) or complex
(involved phalanges that are abnormal in size, shape, number or are
connected). The complex form may have significant sharing of nerves,
blood vessels and other anatomical structures making this type more
difficult to separate surgically. The easiest form to treat consequently
is the simple, incomplete version of syndactylism. There are many
different repairs recommended for the correction of syndactyly,
ranging from very simple to extremely complicated. The simplest of
these surgical repairs is considered to be the safest type of treatment
with the least risks.
Rectangular flap
desyndactylization procedure
This involves the design of two broad rectangular flaps, one on the
dorsal aspect of one toe and the other on the plantar aspect of the
opposite toe (Fig. 25.92). Use of a broad flap for closing the dorsal
host site will lead to incomplete coverage of the plantar host site. The
plantar host site may be further covered with a wound graft material,
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Figure 25.84 Fusiform webbing for unstable hammertoe. (A) The third
digit was very unstable and would dorsally dislocate following excessive
bone removal. (B) A fusiform webbing procedure to the second toe
added significant stabilization.
A
B
Figure 25.85 Partial webbing procedure for overlapping fifth toe. The
proximal phalanx was removed from the overlapping fifth digit and it
was syndactylized to the fourth toe. The fourth toe also had a transverse
skin wedge procedure.
Figure 25.86 Partial webbing procedure. (A) Chronic osteomyelitis
complicated the distal second toe along with severe joint disease of the
metatarsophalangeal joints. (B) Webbing of the first and second toes
following partial amputation of the distal second toe and joint
destructive procedure of the first metatarsophalangeal joint.
A
B
Figure 25.87 Full-length webbing procedure. The patient had complete
resection of the fifth metatarsal due to chronic osteomyelitis but wanted
to keep his fifth toe for cosmesis.
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A
B
C
D
E
Figure 25.88 Fusiform full-length webbing procedure for chronic web infection. (A) The patient had a recurrent and chronic web space infection
between the fourth and fifth toes. Once the infection was brought under full control the procedure was scheduled. (B) A fusiform drawing was placed
on the full side of the medial fifth toe and the web skin was excised. (C) Appearance of the running sutures from the plantar aspect. (D) Appearance
of the running sutures from the dorsal aspect. (E) Tightening of the plantar running sutures. (F) Final closure with tightening of the dorsal sutures.
F
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Figure 25.89 Fusiform webbing procedure for hallux varus. (A) Unstable hallux varus condition. (B) Intraoperative fusiform webbing of first and second
toes. (C) Appearance 3 weeks postoperative.
A
B
C
Figure 25.90 Modified webbing procedure for hallux varus. (A) Congenital hallux varus condition. (B) The base of the Y incision was brought onto the
plantar surface rather than the dorsal surface for the webbing. (C) Immediate postoperative closure of modified webbing procedure. The webbing was
added to help prevent recurrence of the varus deformity.
A
B
C
Figure 25.91 Mini webbing procedure for hallux malleus. (A) Hallux malleus condition. (B) Plantar view of mini webbing with running sutures. The
webbing was added to the surgical repair of the hallux malleus for additional stability of the great toe.
A
B
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Figure 25.92 Rectangular flap desyndactylization procedure. A dorsally placed rectangular flap is made across the syndactyly to cover the majority of
the conjoined tissues and advancing to approximately the midpoint of the opposite toe. On the plantar surface a similar mirror image rectangular flap
is created within the conjoined tissue. Each individual flap is then carefully dissected free and rolled around the toe to which it is attached. Care must
be taken to suture the flaps in place without tension. A compression bandage is applied to each toe.
pinch grafts from the arch or allowed to granulate and fill over 3
weeks. Use of a flexible ruler to obtain exact measurements for the
plantar flap is recommended, but always add an additional 2–4 mm
(10%) of flap width to allow for postoperative swelling. This will
prevent flap tension and avoid flap loss. The flaps are closed with
simple interrupted sutures so that tension can be controlled better and
sutures may be removed in a staged process as needed. A folded silk
dressing or other fine mesh dressing is placed in the proximal inter
space to prevent resyndactylism of the proximal interspace fold. This
dressing is maintained for 3 weeks. When performed properly, this
flap creates a functional and esthetic appearance for the toes (Fig.
25.93). This alternate flap design looks relatively simple to design but,
if not performed perfectly, the orientation of the flaps may not provide
adequate coverage and there is a high rate of vascular embarrassment
postoperatively secondary to too much tension on the wound inci
sions. Additionally, the scar contracture postoperatively may be high
due to the straight-line healing of the final incision.
Z-flap desyndactylization procedure
The drawing of this approach is more complex and requires a well-
thought-out diagrammed approach (Fig. 25.94). The Z-plasty design
is used in an attempt to reduce the inadequate-coverage and scar-
contracture problems of the rectangular flap design (Fig. 25.95). The
dorsal flaps are planned so that there are two triangular flaps medially
and one laterally or vice versa. The plantar flaps are designed with the
opposite configurations of the dorsal flaps. The scar contracture is
greatly reduced; however, there are potential problems with survivabil
ity of each of the triangular flaps. Simple interrupted suture placement
and reduction of tension on the tips of the flaps are all crucial. After
suture removal, the toes should be wrapped with mild compression
tape for up to 2 months to prevent swelling and scar contracture.
Fusiform graft
desyndactylization procedure
This procedure is one of the most simple to plan, design and
carry out. Therefore, it tends to have fewer problems with scar forma
tion, tension, and vascular complications. The procedure involves
separating the two conjoined toes with a surgical scalpel followed by
grafting the resultant defect (Fig. 25.96). The graft may be with a
porcine xenograft (Fig. 25.97), a split-thickness skin graft, a form-fit
full-thickness skin graft from the patient’s sinus tarsi region (Fig.
25.98) or other forefoot areas. Porcine xenografts or the full-thickness
skin grafts are recommended over split-thickness grafts, because the
split-thickness grafts are more likely to contract and to deform the
digits. Additionally, there is no secondary scar from the porcine graft
and the scar from the primary closure of the fusiform donor site of
the full-thickness graft is usually much more cosmetically appealing
than the scar from the split-thickness skin-graft donor site.
To use the porcine xenograft or full-thickness skin graft, a template
is made of the interdigital defect with sterile paper or surgical drape
material and this is used to obtain the proper fit of graft. An autoge
nous full-thickness graft obtained from the lateral sinus tarsi region
is within the natural RSTLs making primary closure straight-forward
or a full-thickness skin graft from an adjacent toe can also be designed
(Fig. 25.99). The full-thickness graft may be partially debulked by
removing excessive subcutaneous fat so that it will fit properly between
the toes. When using a porcine xenograft it is covered with sterile
gauze and compression tape to hold it into place while the full-
thickness skin graft is sutured into place and covered with standard
graft bandaging.
Other unique methods
Although surgical desyndactylization is a relatively simple procedure
to perform some patients may elect to have a tattoo created to func
tionally camouflage the syndactylism instead of undergoing surgery.
Some simply have the web space created with the tattoo, while others
may have more elaborate decorations created (Fig. 25.100).
DIGITAL AMPUTATIONS
Although it may be said that surgical amputation of a toe is tanta
mount to failure of good reconstruction or surgeon failure, this is far
from reality in most cases. In reality, digital amputation is sometimes
a necessary procedure in medicine and surgery. It should be consid
ered as a reconstructive procedure rather than a medical predicament.
Whether the initiating factors leading to the need for amputation are
neuropathy, trauma, ulceration, infection, ischemia, gangrene, or dys
function, surgical removal of the toe should be considered a crucial
step in returning the patient to their best functional status possible.
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Figure 25.93 Lee rectangular flap desyndactylization procedure. (A) Preoperative view of syndactyly. (B) The plantar flap should be taken from the
larger girth or wider toe to allow complete coverage of the dorsal host site. Incomplete dorsal site coverage will lead to a thickened linear scar. The
transverse skin incisions should be at the proximal crease of the metatarsal parabola. (C) The linear incision of the dorsal flap should be almost into the
interspace to conceal the linear scar. (D) Use of simple interrupted 4–0 nylon sutures close both flaps. (E) Postoperative view.
(Courtesy of Dr David Lee, Arizona Institute for Restorative Foot & Ankle Surgery, Inc.)
A
B
C
D
E
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Figure 25.94 Z-flap desyndactylization procedure. A Z flap is created on the dorsum of the toes starting at the point of natural separation and
continuing to the base of the toe. On the plantar surface a mirror-image Z flap is created. Each of the Z flaps is then transferred into the appropriate
defect. Careful planning and design of the flaps is necessary to prevent uncovered areas. Again, the flaps are sutured without undue tension to
prevent failure.
Figure 25.95 Z-flap desyndactylization procedure. (A) Preoperative syndactyly dorsal view. (B) Preoperative syndactyly plantar view. (C) Postoperative
desyndactyly dorsal view at 6 weeks. (D) Postoperative desyndactyly plantar view at 6 weeks.
(Courtesy of Dr Stephen Schroeder.)
A
B
C
D
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Figure 25.96 Schematic of fusiform graft desyndactylization procedure. The syndactyly area is sharply divided with a scalpel trying to leave sharp
edges without bevels. A template is made from sterile paper or surgical drape material to exactly fit the defect. A full-thickness skin graft is then taken
from the sinus tarsi region of the same foot to match the template. The graft is then sutured into place and the toes are bandaged apart until healing
has occurred.
Figure 25.97 Fusiform desyndactylization procedure with porcine xenograft. (A) The syndactylized toes are separated and porcine is applied to all
exposed tissues. (B) Postoperative results at 4 months.
(Courtesy of Dr Steve LeBaron.)
A
B
Digital amputations can be performed at several different levels and
are classified as distal, partial, or total amputations. The incisions for
the amputation procedures can either be made medial-lateral, dorsal-
plantar or racquet-type depending on the surgeon’s choice (Fig.
25.101). Full-thickness skin flaps are usually then created for closure
after the amputation has been completed. The length of the incision
proximally depends on the amputation level and the need for addi
tional soft tissue or osseous procedures.
The extent of the complication, be it trauma, infection, tumor or
ischemia, will dictate the number of digital sites that require amputa
tion. If an infection has spread into surrounding tissues two or more
toes may require partial or total amputation. Also if a severe crush
injury of the toes has occurred, then all the digits may require amputa
tion. Consequently, the actual extent of digital amputations is often
predetermined by the precipitating events and will depend entirely on
the specific situation in each case.
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Figure 25.98 Fusiform desyndactylization procedure with full-thickness skin graft. (A) Previous webbing procedure of third and fourth toes with
painful scar, neuroma, hammertoe contracture and plantarflexed fourth metatarsal. (B) Fusiform desyndactylization with extension of incision for
neurectomy and metatarsal osteotomy. The fourth toe was also fused and pinned with a K-wire. (C) A sterile drape was folded and used to create a
template of the defect site between the toes. (D) The template was then used to obtain an exact fit full-thickness skin graft from the lateral sinus tarsi.
(E) The graft was then laid into the defect and sutured plantarly. (F) The graft was then sutured dorsally and the extended incision was closed.
A
B
C
D
E
F
A
B
C
Figure 25.99 Fusiform desyndactylization procedure with full-thickness skin graft. (A) Partial syndactyly of the 2nd and 3rd digits with partial
amputation of 4th toe. (B) Separation of the fused digits and template created from the deformed lateral aspect of the 3rd toe. (C) Application of the
full-thickness fusiform graft.
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(D,E) Final appearance with graft sutured into place.
D
E
Figure 25.99, Continued
Figure 25.100 Tattoo for camouflage of digital syndactyly. (A) Partial syndactyly of 2nd and 3rd digits. (B) Camouflage tattoo. (C) Close-up to show
the interdigital portion of the web tattoo. (Courtesy Dr. Robert Marra)
A
B
C
Before amputation is undertaken it is important to determine the
oxygen perfusion of the tissues at the proposed level of amputation,
since this is crucial for future healing. Additionally, it may be very
important to consider the mechanical function of the foot once the
planned amputation is completed, since this may determine the level
of amputation necessary for the best functional end result.
Distal digital amputation
The distal toe amputation is referred to as the terminal Syme proce
dure (discussed in Ch. 25), which is frequently performed for distal
osteomyelitis, chronic ingrown toenail or non-healing ulcerations at
the distal toe area. The procedure is performed by first removing the
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Figure 25.101 Incisions for digital amputation. Top: Medial-lateral
incision. Middle: Dorsal-plantar incision. Bottom: Racquet-type incision.
Figure 25.102 Distal Syme procedure. The nail is removed and an
elliptical wedge is excised to bone. The distal phalanx is removed and the
flap is closed.
Figure 25.103 Distal Syme procedure of the hallux.
Figure 25.104 Distal Syme procedure of the fifth digit.
toenail and then making a fish-mouth or fusiform incision down to
underlying bone. The distal portion of the phalanx is removed and
the incision is closed (Fig. 25.102). The distal Syme amputation is
primarily performed on the hallux (Fig. 25.103), but may be used for
any of the lesser digits as well (Fig. 25.104).
Partial digital amputation
For a partial amputation of the digit there are two main sites for bone
and soft tissue resection. The first is at the level of the phalanx and
the second being at the interphalangeal joint either proximal or distal.
When the procedure is performed through the phalanx, the bone is
cut with a power saw perpendicular to the weight-bearing surface at
the desired level. The wound is then closed with a fish-mouth effect
of the tissue flaps and sutured with simple interrupted technique
(Fig. 25.105).
On occasion, several toes may need to be partially amputated, and
when this occurs it is important that the amputations be done in a
compatible pattern for shoe gear to prevent excessive pressure on the
stumps (Fig. 25.106). Leaving the base of the toe or the proximal
portion of the proximal phalanx intact, serves to block the toes on
either side from gradually migrating toward each other. This is espe
cially important when an amputation is planned for the second toe,
since the hallux will tend to drift lateralward and the third toe tends
to drift medialward (Fig. 25.107).