The Top Eleven Pearls For Hammertoe Surgery

By Michael D. Dujela, DPM, James L. Chianese, DPM, James R. Holfinger, DPM, and Richard J. Zirm, DPM

Digital contractures are among the most common deformities we see in podiatric practice. McGlamry described three etiologies for hammertoes: flexor stabilization, flexor substitution and extensor substitution.1 While each entity may exist independently, it is more likely you will see co-existing etiologies, particularly when you’re dealing with more complex deformities.
Most hammertoes in early stages primarily involve sagittal contractures. However, as the deformity progresses, transverse plane components may be unmasked. You may recognize transverse plane deformities early on as a subtle predislocation syndrome.2 Emphasizing aggressive treatment may help prevent frank dislocation.
When it comes to treating hammertoe deformities, therapy has ranged from simple orthodigital splinting devices to “reconstructive disarticulation.”3 Primary surgical treatments commonly involve arthroplasty or arthrodesis, although soft tissue repairs (ranging from simple flexor tenotomy to complex flexor tendon transfer) have also been advocated.
With this in mind, let’s take a closer look at a few surgical pearls and tips that have improved outcomes in treating digital deformities at our institution.

Is A Middle Phalangectomy Better Than The Proximal Interphalangeal Joint Arthoplasty For Fifth Digits?
The standard fifth digit arthroplasty is one of the most commonly performed podiatric procedures. The approach involves removing the head of the proximal phalanx at the surgical neck. Resecting the phalangeal head exposes cancellous bone, which continues to bleed for a period of time. Without meticulous dissection and hemostasis, blood may collect in the newly formed “dead space,” serving as a nidus for infection and promoting low-grade chronic inflammation.
Regardless of the osseous work you perform, the surgical intervention tends to result in interruption of venous and lymphatic channels, which creates a chronic “sausage digit.”
In select patients who have a small to medium-sized middle phalanx (particularly those without symphalangism), we have routinely performed middle phalangectomy to avoid bleeding cancellous bone exposure. When a prominent phalangeal condyle remains, we perform a condylectomy, although this negates some of the benefits inherent to performing just the phalangectomy.
Typically, we do a linear incision or two semi-elliptical converging incisions. Include a de-rotational component if it is required for neutral frontal plane positioning. There are a few caveats, though. When there is a large phalanx, take care to avoid middle phalangectomy, as this may sufficiently decrease the internal cubic content of the joint, resulting in a useless, floppy digit, similar to an aggressive arthroplasty. Additionally, you’ll find dissection becomes more difficult and often more traumatic when removing a large specimen through the standard converging semi-elliptical approach.
However, with appropriate procedure selection, middle phalangectomy often results in less swelling and greater stability, allowing earlier return to activity and normal shoe gear. You also may employ this procedure in the remaining lesser digits with diligence.

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