BUTLER`S OPERATION FOR AN OVER

BUTLER’S
OPERATION
FOR
AN
J. COCKIN,
Frau,
The dorsally
adducted
fifth
in half of the affected
patients.
capsule
of
the
OVER-RIDING
OXFORD,
U,zitec/
tile
metatarso-phalangeal
joint
an
extended,
adducted,
lateral
This paper describes
an operation
of Cambridge
and has been used
TOE
ENGLAND
Bristol
toe is a common
The phalanges
FIFTH
Hospitals
familial
deformity
of the fifth toe are
is contracted
on
the
which
laterally
dorsal
causes
rotated
aspect.
disability
and the
The
toe
rotation
deformity
at the
metatarso-phalangeal
for this deformity
which was devised
by Mr R. Weeden
in the United
Bristol
Hospitals
for the past seventeen
has
joint.
Butler
years.
OPERATION
The
skin
is incised
to the racquet
than
the dorsal
by a dorsal
on the plantar
handle,
and
tight
The
extensor
extensor
joint
into
phalangeal
(Fig.
correct
joint
In most
5).
position
(Fig.
6).
metatarso-phalangeal
the
The
metatarsal
toe
downwards
securely
Treatment
operation
day
78
and
in
into
(Figs.
after
without
normal
its
by
the
10).
any
activity
to
tension.
the
A second
handle
handle
should
Skin flaps are
is then
toe
may
and
the
without
of the
incision;
of the
splints
are
The
sutures
will
not
leaving
needed
are
now
2
swing
rotate
freely
a slight
of the
head.
This
toe
plantar
compare
length
the
able
removed
of
to
(Fig.
the
sutured
are
illustrated
lies
between
the
metatarsal
the
metatarso-
capsule
freely
having
round
of
it holds
at
tenth
the
from
(Fig.
been
in Figures
correctly
the
and
is separated
rotate
8),
skin
toe
at
capsule
4).
downward
around
part
tension
and the
operation
freely
incongruity
adherent
is then
any
as
added
be a little longer
raised
to reveal
a
bundles
are carefully
preserved
(Fig.
capsule
of the metatarso-phalangeal
toe
adherence
mechanics
operation-No
cases
metatarsal
position
handle
The
dorsal
hinge,
dissection
corrected
plantar
9 and
may
is due
to the
blunt
fully
the
but
This
joint
head
lies
I).
FIG.
(Fig.
3).
The neurovascular
to the toe is cut and the
divided
the
(Fig.
The plantar
laterally.
I
laterally
into the correct
position.
If the deformity
is longstanding
head
incision
(Fig.
2).
be inclined
dorsal
aspect
ofthe
incision.
Note
the length
ofthe
dorsal
incision
and
length
in Figure
9. Figure
2-The
plantar
aspect
of the incision.
Compare
of plantar
handle
with
final length,
Figure
10.
tendon
tendon
is widely
aspect
should
1
FIG.
Figure
I-The
this with
its
racquet
7).
moved
it there
11 to
the
end
of
and
fourteenth
14.
the
is allowed.
TIlE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
BUTLER’S
OPERATION
FOR
AN
OVER-RIDING
FIFTH
4
FIG.
Figure
3-Skin
flaps
Figure
5-Wide
dorsal
FIG.
FIG.
Figure
capsule
VOL.
SOB,
elevated.
1, FIBRUARV
4-Neurovascular
preserved.
bundles
5
and extensor
nietatarso-phalangeal
tenotomy.
joint
Figure
surfaces.
7
1968
identified
FIG.
capsulotomy
of the
7- The incongruity
of
adhesions.
Compare
NO.
Figure
and
carefully
6
6-Showing
FIG.
metatarso-phalangeal
joint
has disappeared
the position
of the toe with
its position
Position
of the toe before
skin suture.
79
TOE
incongruity
8
after
separating
plantar
in Figure
6.
Figure
8----
J. COCKIN
80
RESULTS
From
1953
patients.
The
fifty-five
patients
congenital
to
1963,
age
were
five
at
operation
was
under
fifteen
adducted
Follow-up--Patients
fifth
were
from
years
toe
and
examined
of the operations
five years before.
plantar
eleven
for
aspect
showing
that
the
male
forty-five
dorsally
of
toe
can
of
12
be
years;
adducted
one
thirty-six
to
ten
female
forty-five
of
were
fifth
or more
years
the toe after
of the toe after
swung
and
operations
toe
the
done
with
for
clawing.
years
after
operation.
before
and
twenty-one
10
FIG.
FIG.
position
to
three
position
final position
of the
nineteen
Fifty-nine
period
done
11
FIG.
1 I-Initial
age.
a
been
on
months
of
after
had
done
FIG.
9
dorsal aspect of the final
Figure 9-The
Figure
operations
were
dorsally
Forty-three
more
than
seventy
suturing.
suturing.
Figure
FIG. 13
downwards
within
the
head.
Figure
12-Adherent
10-The
FIG. 14
elliptical
skin
incision,
plantar
capsule
of
the proximal
phalanx
gliding
smoothly
over
the metatarsal
the metatarso-phalangeal
joint causing
the toe to hinge at the joint,
producing
incongruity
of the articular
surfaces
and preventing
full correction
of the deformity.
Figure
13-After
release
of the plantar
capsule
the toe glides freely around
the metatarsal
head and the deformity
is fully corrected.
Figure
14-Showing
how correction is held by skin sutures.
Results
sixty-four
surgeon
were
graded
and
A fair
satisfactory
patient,
result
to
“good,”
(91 per
operations
with
was
the
full
The
and
of the
in four
had
an
“failed.”
criterion
correction
recorded
patient,
“fair”
cent).
was
good
result
which
was
was
obtained
satisfactory
to
in
both
deformity.
patients
(6 per
element
A
a result
of
cent).
deformity
This
was
a toe which,
uncorrected,
usually
although
a rotational
deformity.
There
sixteen
with
rapidly
within
were
two
failures
congenital
a year
(3 per
dorsal
and
was
cent).
adduction
then
treated
These
two
deformity.
by
failures
The
were
in girls
deformity
in
of thirteen
both
cases
and
recurred
amputation.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
BUTLER’S
OPERATION
Wound
infection
occurred
was delay
in wound
healing.
of fourteen
days.
Circulation
and
skin
cases
texture
being
was
hardly
also
FOR AN OVER-RIDING
in two cases (3 per
This occurred
when
in all toes examined
normal.
There
were
FIFTH
81
TOE
cent).
In a further
three operations
there
the sutures
were removed
at ten instead
at follow-up
was normal
and sensation
no
cases
of keloid
formation,
the
scar
in all
visible.
DISCUSSION
Many
of
drawbacks.
the
operations
Probably
significant
number
(Scrase
described
the
result
most
in an
for
widely
ugly
the
correction
practised
scar
and
keloid
of
V-Y
is
this
plastic
formation
deformity
have
serious
elongation
of the
skin.
recurrence
of the
deformity
and
A
1954).
McFarland’s
operation
of
of the proximal
phalanx
of proximal
phalangectomy
results
replace
one deformity
Practically
all
syndactyly
of
fifth toes and excision
1954),
and
the Ruiz-Mora
(Straub
1951),
whilst
fourth
operations
require
of the base
operation
giving
good
and
(McFarland
1950,
Scrase
with
plantar
syndactylism
by another.
immobilisation
after
operation,
including
those
of
Lapidus
(1942)
and Colonna
(1950).
Butler’s
operation
can be likened
to changing
gear in a car.
The whole
toe is swung
downwards
and laterally
to lie in the plantar
part of the wound.
It is not simply
a combined
dorsal
V-Y and plantar
Y-V plastic
procedure,
but a complete
realignment
of the whole
toe.
It is to be stressed
of
the
deformity
on
the
neurovascular
to
the
circulation
against
this
In this
splints
of the
are
without
bundles
unnecessary
if adduction
toe.
This,
after
tension.
It
correct
the
is,
however,
at the
from
and
operation
damage
possible
this
is usually
A full and normal
circulation
release
of the tourniquet.
The
joint
surface
alignment
adherent
plantar
capsule
Butler’s
however,
is severe
and is careful
to guard
against
it.
series
there
has been no circulatory
not been a problem.
to two minutes
after
because
separating
that
is obtained
can
to
correction
produce
traction
produce
temporary.
to the
as full
embarrassment
Butler
toe
and
(1964)
wound
usually
returns
in the toe
two failures
almost
certainly
metatarso-phalangeal
the metatarsal
joint
was
not
healing
warns
has
within
one
occurred
obtained
by
head.
SUMMARY
I.
Butler’s
2.
It is a simple
operation
3.
The
results
and
for the
safe
of seventy
correction
of the
operation
not
needing
operations
performed
I am
dorsally
adducted
splints,
over
and
ten
years
fifth
toe
giving
good
are
studied.
is described.
reliable
grateful
to the orthopaedic
surgeons
of the Bristol clinical area for permission
to study
R. Weeden
Butler and Mr A. L. Eyre-Brook
for their help, encouragement
and kindly
I am particularly
indebted
to Mr Butler for the drawings.
to
Mr
results.
their patients;
criticism
; and
REFERENCES
R. W. (1964) : Personal
communication.
COLONNA,
P. C. (1950):
Regional
Orthopedic
Surgery,
p. 492.
Philadelphia
and London:
W. B. Saunders
Company.
LAPIDUS,
P. W. (1942): Transplantation
of the Extensor
Tendon
for Correction
of the Overlapping
Fifth Toe.
Journal of Bone and Joint Surgery,
24, 555.
MCFARLAND,
B. (1950):
Congenital
Deformities
of the Spine and Limbs.
In Modern
Trends
in Orthopaedics,
p. 107. Edited by Sir Harry
Platt.
London:
Butterworth
& Co. (Publishers)
Ltd.
SCRASE,
W. H. (1954): The Treatment
of Dorsal
Adduction
Deformities
of the Fifth Toe.
Journal
of Bone
and Joint Surgery,
36-B, 146.
STRAUB,
L. R. (1951): Orthopedic
Surgery.
In The Specialities
in General
Practice,
p. 60. Edited
by R. L. Cecil.
Philadelphia
and London:
W. B. Saunders
Company.
BUTLER,
50 B,
\‘OL.
F
NO.
1,
FEBRUARY
1968