Taking A Novel Approach To Hammertoe Surgery
Hammertoes may have an etiology that is either congenital or acquired. Pain and cosmetic appearance are the leading factors for patients wanting surgical intervention for hammertoe deformities. While there are a variety of approaches for hammertoe correction, we have found success with a novel approach that emphasizes the use of medial and lateral incisions.
Typically, surgeons use dorsal linear, dorsal longitudinal semi-elliptical, dorsal transverse semi-elliptical, plantar longitudinal and medial/lateral incisions in hammertoe surgery.1 However, we feel the medial and lateral incisions provide adequate exposure to achieve the goal of deformity correction and facilitate cosmetic results that patients appreciate and prefer.
We typically perform medial incisions to the second and fifth digits, and opt for lateral incisions to the third and fourth digits. Incorporating these incisions addresses the longer aspect of the toe (i.e., medial or lateral) and prevents suture contracture. The procedures involve an arthroplasty or arthrodesis of the proximal interphalangeal joint (PIPJ) while leaving the extensor and flexor tendons intact. One may also perform a flexor tendon transfer depending on the severity of the deformity.
A Step-By-Step Guide To Surgery
When beginning the hammertoe procedure, one should evaluate the involved digit and anesthetize it with 3 to 4 cc of 0.5% bupivicaine in the traditional v-block fashion. Using a number 15 blade, make a 2 cm linear incision just distal to the PIPJ and ending before the web space on the medial/lateral aspect of the digit. Identify all neurovascular structures and retract them as necessary. Deepen the incision with sharp dissection to the capsule of the PIPJ.
One would then identify the extensor mechanism. Pass the blade between the extensor tendons and bone, separating the bone from the extensor hood. Then release the medial and lateral collateral ligaments, allowing access to the head of the proximal phalanx. Using a double action bone cutter, transect the phalangeal head at the surgical neck and remove it in toto.2 Use a bone rasp to smooth and remove any bone spicules.
If one has not achieved the correction, the surgeon should proceed to perform an arthrodesis. Using a 0.045-inch Kirschner wire, drive the wire retrograde through the medullary canal of the middle phalanx, exiting through the distal tip of the digit. One would then drive the Kirschner wire anterograde through the distal and middle phalange, and through the PIPJ.2
If the digit is subluxed, perform a flexor tendon transfer. Identify the flexor tendon and release the fully intact tendon from its capsular attachments. Transect the tendon as far distally as possible through the original incision. Split the tendon longitudinally in half and reapproximate it dorsally over the proximal phalanx.3,4
One can extend the incision proximally to allow for a metatarsophalangeal joint release without transecting either tendon. The surgeon can transect the collateral ligaments. Using a McGlamry elevator, one can free the metatarsal head dorsally.
Irrigate the surgical site with normal saline. If you have performed a flexor tendon transfer, you should reapproximate with 3.0 Vicryl. Close the skin using 4.0 nylon in a simple suture fashion. Dress the toe with a non-adherent dressing and use a Betadine sterile bandage to help splint the toe. Have the patient wear a postoperative shoe. Remove the sutures within 10 to 14 days and remove the Kirschner wire after four weeks.
How The Procedure Offers Key Benefits
The success of these procedures is due to the location of our incision and the minimal contact/pressure of the incision site. Neurovascular insult is always a concern. However, one can make the incision parallel to the neurovascular structures in order to minimize the risk of any trauma that could occur.