Butler's procedure has been used since 1968 to correct congenital varus (overriding) 5th toe deformity. The authors reviewed 48 procedures in 36 patients followed for 1-16 years. Results were good to excellent in 93.75% of patients. Age did not significantly affect results, so the procedure can be used for all age groups. It remains the gold standard technique for correcting this deformity.

1. Original Article
Butler's procedure for
congenital varus 5th toe:
evaluation with long-term
follow-up
Freih Odeh AbuHassan, Akram Shannak and Frank McManus
Butler's procedure has been advocated for the correction of congenital varus (over-riding) 5th
toe deformity since 1968. We reviewed 48 procedures in 36 healthy children and young
adolescents. The patients were followed for 1±16 years, and the results have been good to
excellent in 93.75% of the patients. There was no statistically significant effect of the age
on the results of this technique (P ˆ 0.6550), thus it can be performed at any age group and
remains the gold standard technique. ß 2001 Harcourt Publishers Ltd
Introduction
Congenital varus 5th toe is a deformity in
children and young adolescents which is
sometimes familial. It can be bilateral; the toe is
hyperextended, externally rotated and may
overlap the 4th toe. The metatarsophalangeal
joint is subluxed dorsomedially, the volar
capsule adherent to the head of the metatarsal,
the extensor tendon is short, and displaced
medially. The 4th web space is contracted
(Cockin 1968, Morris et al. 1982, Johnson &
Huger 1983, Black et al. 1985). The deformed
toe causes cosmetic concern or pain in about
half of the patients (Scrase 1954, Hulman
1964). Conservative treatment for
symptomatic patients usually fails, and
surgery is necessary.
Of the many surgical procedures described,
two are commonly practised: Butler's and V-Y
arthroplasty. This procedure was originally
designed by Butler and described by Cockin in
1968. We found only two reports in the English
literature (Black et al. 1985, De Boeck 1993). We
have reviewed the results of 49 procedures
performed by the authors in the last 20 years
from two countries.
Patients and methods
From June 1980 to March 2000 , 48 Butler's
procedures for congenital varus 5th toe were
performed in 36 patients at the Children's Hospital
in Dublin and Jordan University Hospital in
Amman. There were 27 females and 9 males.
Twelve had bilateral procedures. Ages ranged
from 4 to 14 years with mean age 9.2 years.
Twenty-four patients (30 feet) were followed for
4±16 years (average 10.5 years), 5 patients ( 7 feet)
for 1±4 years (average 2.5 years) and 7 patients
(11 feet) had follow-up for 1±2 years (average
1.2 years). Nineteen patients (25 feet) were called
for review in a special assessment clinic, after
clinical examination, and an assessment sheet
was completed by the ®rst author. Eleven patients
(12 feet) were sent the assessment sheet by mail
to be completed. Seven patients (11 feet) could
not be contacted and their results were assessed
from medical records. The assessment of results
depending on overlapping, rotation, scaring and
range of movement of the 5th toe. Each foot was
given a grade: excellent, good, or poor.
A similar operative procedure had been
performed in all cases. A circumferential dorsal
racquet incision with a short handle and a plantar
Freih Odeh
AbuHassan FRCS
(Eng.), FRCS
(Tr&Orth.),
Assistant Professor
of Orthopaedics,
Jordan University
Hospital. P.O Box
73, Jubaiha 11941,
Jordan. E-mail: freih
@joinnet.com.jo;
Tel/fax: ‡962 6 51
61 346
Akram Shannak
FRCS, FRCS (Orth.),
Professor of
Orthopaedics,
Jordan University
Hospital, Amman,
Jordan
Frank McManus
M.Ch, FRCSI, Senior
Consultant
Orthopaedic
Surgeon, Children's
Hospital, Dublin,
Ireland`
132 The Foot (2001) 11, 132±135 ß 2001 Harcourt Publishers Ltd
doi: 10.1054/foot.2001.0697, available online at http://www.idealibrary.com on

2. incision with long handle were based slightly
lateral to the midline of the toe; after raising the
¯aps the extensor tendon was divided, there
was dorsomedial capsulotomy of the
metatarsophalangeal joint, and dissection of the
volar capsule from the metatarsal head. Once
the toe rested freely, the skin closed without
tension, and no wiring was needed to support
the toe, but the toe was strapped down 10 days
postoperatively for 6 weeks.
A one-way analysis of variance (ANOVA) was
used for analysis of the effect of age on the result of
the operation as dependent variable (P < 0.05).
Results
Thirty patients (37 feet) out of thirty-six (48 feet)
were assessed through clinical examination or
postal information. The clinical results were
classi®ed as excellent, good or poor. An excellent
result was considered to be one in which there was
absent overlap , normal toe rotation, faint scar and
full range of movement. Good results were those
with mild overlap, mild rotation, slight scar or
subnormal movement. Cases with severe
overlap, severe rotation, contracture in the scar,
or restricted movement were considered poor
results.
Eighteen patients (22 feet, 59.46%) were graded
good. Their mean age 9.3 years. Eleven patients
(13 feet, 35.1%) were graded excellent. Their mean
age were 8.6 years. One patient with bilateral
surgery (5.4%) was graded poor as a result of
recurrence of the deformity (Fig. 1).
There were no statistical difference between the
groups as regards the effect of age at operation
on the end result (P ˆ 0.6550). There were no
wound infections or neurovascular damage.
All 30 patients were very satis®ed with the result
of the operation. They indicated that they would
recommend the operation to a relative or friend.
They were all wearing normal footwear, even the
recurrent case.
Seven patients (11 feet) were not contactable but
their follow-up was limited to chart review, which
indicates a satisfactory, straight toe, which was
asymptomatic, with no deformity or scarring. Six
patients (10 feet) were graded good (mean age 8.53
16
14
12
10
8
6
4
2
0
Age
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Consecutive feet
Good group Excellent group Poor group
Fig. 1 Age at operation of different groups.
Butler's procedure for congenital varus 5th toe
ß 2001 Harcourt Publishers Ltd The Foot (2001) 11, 132±135 133

3. Chart follow-up feet
years). One patient was graded poor because of
recurrence in the ®rst 6 months postoperatively
(Fig. 2). Over all 27% of the feet had an excellent
result, 67% had a good result, and 6% had
a poor outcome (Fig. 3).
Discussion
Many operations has been described for the
correction of the congenital varus deformity. Soft
tissue excision, tenotomy and dorsal capsulotomy
(Morris et al. 1982, Hulman 1964), V-Y Plasty
(Wilson 1953), transfer of the extensor tendon to
the plantar of the toe aspect of the toe and transfer
to abductor digiti minimi (Lapidus 1942), and
transfer of the extensor tendon to the neck of
the 5th metatarsal (Lantzounis 1940). V-Y plasty
is a popular operation because it is simple but the
results is disappointing due to high recurrence
rate and ugly scaring (Scrase 1954, Paton 1990).
Other operations are more invasive, dif®cult
to perform with the risk of morbidity and
complications which may make the situation
worse than the disability itself (De Boeck 1993).
Feet
The potential problem with the Butler's operation
is damage to the circulation of the toe, but this is
not reported in the literature (Cockin 1968, Black
et al. 1985, De Boeck 1993). If the operation is
performed with attention to detail, it is unlikely
to cause any damage.
Our short- and long-term results support
previously published series for effectiveness of
16
14
12
10
8
6
4
2
0
Age
1 2 3 4 5 6 7 8 9 10
Good group Poor group
Fig. 2 Age at operation of chart follow-up groups.
Excellent
27%
Poor
6%
Good
67%
Excellent Good Poor
Fig. 3 Outcome of all feet.
Butler's procedure for congenital varus 5th toe
134 The Foot (2001) 11, 132±135 ß 2001 Harcourt Publishers Ltd

4. Butler's procedure for congenital varus 5th toe
this procedure. From the review of our series, and
protracted follow-up, we feel the Butler's
procedure is safe, and very effective for all age
groups, with no serious complications, and is
preferable to other operations to correct the
deformity.
Conclusion
Butler's procedure is a useful surgical technique
for the treatment of symptomatic congenital
varus (overriding) 5th toe deformities. The
operation has a high rate of success of any age
below 14 years.
References
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arthroplasty for correction of the adducted fifth toe:
a retrospective study of 36 operations between 1968
and 1982. J Pediatr Orthop 5: 439 ± 41
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De Boeck H 1993 Butler's operation for congenital
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Johnson C P, Huger D W 1983 A literature review of
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Lantzounis L A 1940 Congenital subluxation of the fifth toe
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Wilson J N 1953 V-Y correction for varus deformity of the
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ß 2001 Harcourt Publishers Ltd The Foot (2001) 11, 132±135 135