Surgical

 Correction  of  a  Unique  Non-­‐Classified  Pre-­‐Axial  Polydactyly  Case

Jonathon  Srour  BS,  Kurtis  Bertram  BS,  Juan  Martinez  BS,  Calvin  Davis  BS,  Aaron  Bradley  BS    

New  York  College  of  Podiatric  Medicine  

Presentation Classification  Systems Results Discussion

The patient was instructed to remain non-weight bearing in a surgical shoe
A retrospective chart and imaging review is presented on a 29 year-old for roughly 4 weeks assuming radiographs showed adequate healing. He
patient with a chief complaint of pain, swelling, and erythema over the presented to the clinic 1 week post-op with cramping in his left calf,
dorsal aspect of the IPJ of the left hallux. The patient stated that he was decreased light touch sensation at the forefoot, and sanguineous drainage
born with a deformity on his left foot and that his pain worsens with noted upon compression of the foot. Augmentin was prescribed for 1 week.
activity and has discomfort when wearing shoes. At 1.5 weeks post-op, the pain and the drainage did not decrease, the
patient presented to the ER and was admitted for 3 days. 1 day post-
Upon presentation to the clinic on March 9, 2015, a soft tissue mass discharge, he returned to the clinic. The patient complained that when he
encompassing an osseous interior was noted on the medial aspect near the bumped his foot, the wound bled excessively. The sutures were intact over
base of the 1st metatarsal. Additionally, the hallux was in a varus position the medial incision, but wound dehiscence was noted over the dorsal 1st
MPJ incision. Additionally, edema, erythema, and loss of sensation over
with hammering and a dorsal hyperkeratotic lesion at the IPJ. X-rays
confirmed an additional bone medial to the diaphysis of the 1st metatarsal the forefoot were noted. The patient was seen weekly for the following 5
as well as the varus and hammered attitude of the hallux. Furthermore, the months for debridement of the dorsal ulcer and sterile dressing of the
radiographs showed an accessory medial cuneiform. Vascular and wound.
neurological exams were unremarkable. At 1 month post-op, the patient complained of continued pain while
remaining non weight-bearing with crutches. Excessive sanguineous
The patient returned to the clinic on May 13 and expressed interest in drainage was produced from the dorsal incision site upon light palpation.
pursuing surgical options for pain relief and cosmesis. An eschar was noted on the dorsal aspect of the hallux measuring 2 cm x
1.7 cm.
At 5 weeks post-op, the ulcer showed no signs of clinical improvement and
.
-­‐ - Several structural and morphological classifications systems
exist in the literature for pedal polydactyly. Our case lacks the
criteria to be classified precisely using these established systems.
-­‐ - The SAM classification system, recently published in a South
Korean plastic surgery journal, provides a system that is intended
for pre-surgical planning.
-­‐ - Although our case does not completely conform to the SAM
classification system, we recommend that polydactyly cases, if
surgical correction is an option, be classified using SAM.
-­‐ - Since this case presents an extra digit arising from an accessory
medial cuneiform, we propose the creation of a new classification
system that accounts for tarsal bone duplication with digital
extension.

Statement  of  Purpose

X-rays portrayed osteopenia surrounding the area of plate fixation. References
Eventually, a bone stimulator was prescribed and used for 20 minutes per
day. • Blauth W, & A.T. Olason. (1988). Classification of polydactyly of the
In  this  case  report,  we  present  a  new  polydactyly  derivative  in   CRP's, ESR, and CBC were ordered and were within normal limits. hands and feet. Archives of Orthopaedic and Traumatic Surgery, 107,
334-344.
which  the  extra  digit  extends  from  an  accessory  medial  cuneiform.   At 4 months post-op, the patient consented to a 2nd procedure (which had • Chiang, H., & Huang, S. C. (1997). Polydactyly of the foot:
been recommended for several months) to remove the screws and Manifestations and treatment. Journal of the Formosan Medical

Literature  Review Procedure hardware, which were backing out from the 1st MPJ. The surgical site was
•
Association = Taiwan Yi Zhi, 96(3), 194-198.
Christensen, J. C., Leff, F. B., Lepow, G. M., Schwartz, R. I., Colon, P. A.,
packed with Calcium Phosphate and infused with Vancomycin powder.
Arminio, S. T., et al. (1981). Congenital polydactyly and
A  6  cm  curvilinear  incision  was  performed  proximal  to  the  left  1st   Amniotic barrier membrane was placed over the dorsal aspect of the polymetatarsalia: Classification, genetics, and surgical correction. The
-­‐ Polydactyly  is  characterized  by  the  presence  of  one  or  more   MPJ,  extending  distally  to  the  IPJ  of  the  left  hallux.  The  extensor   metatarsal before closing. The patient was placed on Bactrim (160-800). Journal of Foot Surgery, 20(3), 151-158.
supernumerary  digits.  These  supernumerary  digits  can  appear   hallucis  longus  tendon,  although  not  abnormal  on  pre-­‐op  MRI,   At 2 weeks s/p the hardware removal, the original incision had completely • Coppolelli, B. G., Ready, J. E., Awbrey, B. J., & Smith, L. S. (1991).
medially  (pre-­‐axial),  laterally  (post-­‐axial),  or  centrally.  1,3,4,6,8,10-­‐13 was  noted  to  be  bifid  and  then  tenotomized.  A  wedge  of  bone,   closed and there were radiographic signs of healing. A month after the Polydactyly of the foot in adults: Literature review and unusual case
presentation with diagnostic and treatment recommendations. The
-­‐ Most  classification  systems  for  polydactyly  are  based  on   including  hypertrophic,  degenerative  cartilage  was  removed  from   hardware removal, the patient denied pain and had returned to full weight Journal of Foot Surgery, 30(1), 12-18.
morphology  and  derive  from  either  metatarsal  or  phalangeal   the  1st  metatarsal  head.   bearing in a post-op shoe. • Farrell, D. J., Adamitis, J., & Skokan, S. J. (1996). Polydactyly in the
extension.  No  pre-­‐surgical  classification  system  exists  that   pre-adolescent foot: An unusual case presentation with impending
Next,  the  cartilage  at  the  base  of  the  proximal  phalanx,  head  of   pathologic fracture. The Journal of Foot and Ankle Surgery : Official
accounts  for  tarsal  bone  duplication  with  digital  extension:  1,3-­‐ Figure 3
6,8,10,12,13 the  proximal  phalanx  and  base  of  the  distal  phalanx  where   Figure 4 Publication of the American College of Foot and Ankle Surgeons, 35(1),
54-58.
removed.  An  adductory  contraction  at  the  MPJ  was  noted  and  
-­‐ While  Watanabe  and  Blauth  Olason  classification  schemes  do   • Kleanthous, J. K., Kleanthous, E. M., & Hahn, P. J.,Jr. (1998).
neutralized  through  a  transverse  tenotomy  of  the  abductor   Polydactyly of the foot. overview with case presentations. Journal of the
account  for  tarsal  extension,  these  were  based  on  either  a  
hallucis.   American Podiatric Medical Association, 88(10), 493-499.
rudimentary  digit  extending  from  the  navicular  or  1st metatarsal   • Masada, K., Tsuyuguchi, Y., Kawabata, H., & Ono, K. (1987). Treatment
without  tarsal  duplication  or  an  extra  digit  in  the  hand   The  1st  MTPJ  was  then  fused  using  a  lag  screw  and  a  dorsal  lacking   of preaxial polydactyly of the foot. Plastic and Reconstructive Surgery,
extending  from  a  duplicate  trapezoid.1,13 plate.   79(2), 251-258.
Figure  1 Figure  2 • McCarthy, G. J., Lindaman, L., & Stefan, M. (1995). Pedal polydactyly:
-­‐ It  is  recommended  that  surgery  should  not  be  delayed  beyond   An overview with case report. The Journal of Foot and Ankle Surgery :
walking  age.8,12,13 Official Publication of the American College of Foot and Ankle Surgeons,
34(6), 577-582.
-­‐ Surgical  correction  of  pre-­‐axial  polydactyly  is  considered  to  be  
• Meltzer, R. M. (1987). Polydactyly. Clinics in Podiatric Medicine and
challenging  with  complications  like  recurrent  hallux  varus  and   Surgery, 4(1), 57-62.
splaying  of  the  1st ray  or  1st metatarsal  which  does  not   • Morley, S. E., & Smith, P. J. (2001). Polydactyly of the feet in children:
sufficiently  bear  weight.5,7,8,9,11,12 Suggestions for surgical management. British Journal of Plastic
Surgery, 54(1), 34-38.
-­‐ The  main  complication  of  pre-­‐axial  polydactyly  surgery  is  a   • Phelps, D. A., & Grogan, D. P. (1985). Polydactyly of the foot. Journal of
resultant  hallux  varus.  To  avoid  this,  1st MTPJ  fusion  is  often   Pediatric Orthopedics, 5(4), 446-451.
performed  in  conjunction  with  removal  of  the  accessory  digit.   • Shaheed, N., Nealy, J. A., & Bituin, B. V. (2000). A rare occurrence of
2,7,9,11 polydactyly. Journal of the American Podiatric Medical Association,
90(8), 425-429.
-­‐ When  surgery  is  warranted,  the  most  important  consideration  is   • Watanabe, H., Fujita, S., & Oka, I. (1992). Polydactyly of the foot: An
the  choice  of  digit  to  remove.  This  is  often  based  on  X-­‐ray   analysis of 265 cases and a morphological classification. Plastic and
Reconstructive Surgery, 89(5), 856-877.
criteria.  3,4,8-­‐12
-­‐ While  radiographs  are  standard  imaging  for  evaluating  osseous  
deformity,  MRI  can  be  useful  for  assessing  the  locations  of  soft   Ackknowledgements
tissue  in  pre-­‐surgical  planning.  4,5 Figure  1:  Pre-­‐op  radiograph  visualizing  supernumerary  digit  and  accessory   Figure  3:    DP  radiograph  17  weeks  post-­‐op  showing  significant  osteopenia  
We would like to thank Dr. Johanna Godoy for her generous assistance in
medial  cuneiform. around  the  surgical  site.  
providing the surgical case and her expert input throughout the process. In
Figure  2:  Pre-­‐op  clinical  picture  showing  accessory  digit. addition we would like the thank April Yin for her hard work and time
Figure  4:  DP  radiograph  6 weeks  status  post  hardware  removal  suggesting  
osseous  healing. dedicated to creating the poster.

RESEARCH  POSTER   PRESENTATION  D ESIGN   ©  2 015

www.PosterPresentations.com