How To Address Complications Of Hammertoe Surgery

By Molly Judge, DPM

Residual MPJ subluxation. Neuritis. Flail toe. Hypertrophic scars. These are just some of the complications that can occur with hammertor surgery. Accordingly, this author offers proactive pointers for reducing the risk of complications and facilitation optimal outcomes.

A host of potential complications may result from hammertoe surgery and the most common list includes but is not limited to: infection, neuritis, painful or unsightly scarring, chronic swelling, malunion or nonunion of bone, and recurrence of deformity. While these untoward results can occur, they are unlikely if both the surgeon and the patient follow the basic principles of surgery and postoperative care. Other complications of hammertoe surgery are possible and many of these are the result of technical failures in performing the procedure.

   Complications in hammertoe surgery often have more to do with a failure to recognize the biomechanical influences that caused the deformity than an actual failure in performing the procedure. This can occur when one fails to identify the apex of the digital deformity accurately. For example, correction of a sagittal plane deformity at the proximal interphalangeal joint will fail if the surgeon does not address the ill effects of a taut extensor digitorum longus tendon and extensor hood apparatus, a long metatarsal bone, metatarsophalangeal joint (MPJ) subluxation or the subtle combination of both that often complicate a hammertoe deformity.

   An obvious but often overlooked error in procedure selection is the tendency to perform “chief complaint” surgery without identifying and eliminating associated functional or structural insufficiency of the first ray segment. The natural history of first ray insufficiency and hallux abductovalgus deformity includes forefoot imbalance and an overloading of the lesser rays as a consequence. For example, the outward signs of a subtle metatarsus primus elevatus are easy to overlook and this can lead to an imbalance that exacerbates a hammertoe deformity.

Pertinent Tips On Resolving Residual MPJ Subluxation

In regard to residual MPJ subluxation, this deformity may be the result of an insufficient release of the extensor hood apparatus. In these cases, one will often see a residual biplane deformity. Residual elevation and transverse plane luxation at the metatarsophalangeal joint are common. In these cases, the flexor tendon power to stabilize the MPJ has not been restored while continued contracture at this level remains a very powerful and unrestrained deforming force.

   Revisional surgery for these deformities is relatively straightforward. It typically includes a MPJ capsulotomy to eliminate residual subluxation while achieving a neutral position in both the transverse and sagittal planes.

   One should complete a careful evaluation of the position of the long flexor tendon in this setting. Should there be any displacement either medially or laterally, this will contribute to a recurrent transverse plane deformity.1,2 The surgeon can suture the long flexor tendon into the MPJ capsule to anchor the tendon in position and maintain a more appropriate direction of pull, facilitating enhanced plantar stabilization.

   When the apex of the sagittal plane deformity is persistent at the proximal interphalangeal joint (PIPJ) level, a flexor tendon transfer can be very effective for reducing the deformity and stabilizing the ray. A flexor to extensor transfer is a popular approach and the surgeon can complete it successfully via a variety of incisional approaches.

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