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.    Perhaps the most commonly discussed approach involves a plantar incision at the level of the distal interphalangeal joint (DIPJ) to release the flexor digitorum longus (FDL) tendon from its enthesis. One would pull this free end of the tendon through a plantar incision at the PIPJ level where the surgeon subsequently splits the tendon longitudinally in preparation for transfer. Then the split tendon ends are pulled up into the dorsal digit and the tendon ends are attached to the dorsum of the proximal phalanx, one medially and one laterally, to complete a Girdlestone-Taylor type of flexor transfer.    In the event that one has overlooked a defect in the plantar plate, the residual contracture at the MPJ will perpetuate the original deformity and may result in continued contracture with a progressive loss of flexibility if it is left unchecked. Some authors have advocated direct repair of the plantar plate and the procedure has been described using either a dorsal or plantar incision approach.3-8 The plantar approach is the most direct and has been discussed and illustrated well in the current literature.9,10    Plantar plate repair and subsequent stabilization of the MPJ via K-wire is a standard approach. One should be sure to remove the K-wire after approximately three to four weeks in order to avoid unusual stiffness and residual metatarsalgia at this level. Restoring range of motion at the MPJ level should be an immediate goal after removal of the fixation device as it will expedite a return to more normal weightbearing and ambulation. Some patients may require physical therapy to aid in this rehabilitation process.    When the complications of residual stiffness and degenerative joint disease of the second MPJ occur after hammertoe surgery, one can entertain a joint destructive procedure to eliminate the painful range of motion. Karlock has demonstrated findings and discussed arthrodesis of the second MPJ in the current literature as a viable option to achieve this goal in appropriate candidates.11   When a surgeon performs hammertoe surgery via resection of the phalangeal base, a residual sagittal plane deformity may occur at the metatarsophalangeal joint. The decrease in cubic content of bone at the MPJ level lends a higher advantage to the extensor hood apparatus and the pull of the extensor hood apparatus overcomes the combined action of the short and long flexor tendons. This destabilization results in flexion contractures at the PIPJ and DIPJ levels. These contractures perpetuate the retrograde force or reverse buckling that causes dorsiflexion of the proximal phalangeal stump on the metatarsal head.    The primary option for reconstruction of this complication includes MPJ capsulotomy with stabilization of the PIPJ via an end-to-end arthrodesis. Once one has stabilized the PIPJ, the surgeon can enhance the pull of the flexor tendons by anchoring the flexor digitorum longus (FDL) into the residual stump of the proximal phalanx.12

Correcting Residual Transverse Plane Deviation: What You Should Know

Residual transverse plane deviation may result as a consequence of disruption of a collateral ligament about the PIPJ in isolation or in combination with disruption of a collateral ligament of the MPJ.13,14 The interdigital splaying and subsequent metatarsalgia that results from lateral destabilization of both the PIPJ and MPJ can be worse than the original hammertoe deformity. A primary repair of the collateral ligament is the best defense against more progressive deformity if the PIPJ is the apex of deformity. If both joint levels, the PIPJ and MPJ, are affected, then it is important to ensure there is not residual contracture of a component of the extensor hood apparatus due to an incomplete release.    Release of this structure and evaluation of the condition of the plantar plate should precede the use of internal splintage using a K-wire crossing the MPJ. Effective K-wire stabilization requires purchase of the wire within the proximal metatarsal base. If the wire falls short of this region, it will simply vacillate within the cancellous bone of the medullary canal of the metatarsal and will likely migrate out of the toe with weightbearing. This results in an unstable construct. Digital splintage via K-wire is typically required for three to four weeks. If the splintage is maintained for too long, a residual metatarsalgia may result with subsequent stiffness at the MPJ that can be difficult to rehabilitate.    After surgery for an isolated hammertoe deformity, a patient may have continued progression of lateral deviation of the digit until the digit crosses over or under the adjacent toe. If this condition is left unchecked, it may ultimately result in a rigid or semi-rigid crossover toe deformity, perhaps the most challenging of the digital deformities. In some extreme instances, a salvage reconstruction may not successfully eliminate pain or subsequent digital dysfunction. The decision to move forward with a digital amputation is a viable option when salvage procedures have been met with failure.    When numerous lesser digits suffer from postoperative complications, forefoot imbalance and unrelenting metatarsalgia may result. In this scenario, a panmetatarsal head resection may be warranted. One should avoid benign neglect when it comes to complications of hammertoe surgery. The decision not to treat, the watch-and-wait approach, is only an option after you have fully educated the patient about the natural history of the deformity and then the patient decides not to pursue treatment.

When Patients Develop Flail Toe

When complications from hammertoe surgery result in the development of a flail toe, there are two primary options for salvage of the destabilized digit.    Syndactylization to the adjacent digit may provide a more stable appendage that is less susceptible to inadvertent trauma. Such a procedure employs a basic plastic surgery technique in which one removes an ovoid section of skin that extends from the PIPJ level of the affected digit into the web space and continues onto the mirror image location of the adjacent toe. In this procedure, meticulous skin resection is required to avoid disruption of neurovascular structures. Thereafter, one can complete a simple dermal closure in a single layer.    Most often, a flail toe is the result of a significant decrease in the cubic content of bone. This can occur after the removal of an excessive amount of a digital phalanx. It can also happen after a surgeon has performed a total phalangectomy. One can entertain the use of a bone graft to restore length of the affected phalanx.15 This requires a thoughtful perioperative plan and extensive patient education as there is a significant risk of nonunion when working with the small bones of the digit. Once a reasonable attempt at reconstruction of a flail toe has failed, the option of amputation is perhaps the most viable.

How To Treat Neuritis

Neuritis can present as a transient postoperative condition or may be the result of frank nerve transection or entrapment. The simplest of strategies includes applying a topical heating agent three to four times per day. Peripheral nerves release substance P in response to a painful stimulus. If the nerve is repeatedly exposed to an agent that aggravates this chemical release, then the nerves’ store of substance P can be exhausted and symptoms will remit. For some, there is a welcome relief and the therapy may only be required for the short term. Others may not be able to tolerate frequent applications of the topical agent due to sensitivity. In these cases, one may consider an alternate dosing scheme.    The patient can apply a single nighttime application of a deep heating agent under occlusion (under the cover of cling wrap works best). The occlusive material prevents the heating agent from evaporating or rubbing off, and affords patients numerous hours of deep heat therapy while they sleep.    Unfortunately, not all patients can tolerate topical heat. When treating these patients, the physician may consider alternative medications, topical or oral, for the relief of neuritic pain. Many topicals contain an extract of jalapeño pepper. Do not add since over-stimulation of the nerve is the goal in this type of therapy.    Clinicians have used tricyclic antidepressants such as amitriptyline, anticonvulsants such as gabapentin, and other neurologic agents with varying success. Nerve pain can be very frustrating as it can disturb the patient’s sleep/wake cycle and result in emotional upheaval. In order to facilitate successful treatment, it is essential to identify this condition promptly, provide emotional support and encourage the patient that there are numerous ways to treat this condition. Also be sure to remind the patient that patience will be required while you explore the options to find the best remedy for him or her.

Insights On Managing Hypertrophic Scars, Keloids And Cicatrix Contractures

Early identification of a hypertrophic scar, keloid or cicatrix contracture is paramount to minimizing the ill effect of this complication. There are various topical agents available for reducing the localized edema and discoloration that accompany these conditions. Topical steroids and over-the-counter topical scar care agents are among the first-line agents of choice to relax and reduce the prominence of localized scar irritation. Deep fiber massage may be required in the event of adhesion and contracture, and vigorous massage should be performed numerous times a day for the best effect.    Some have advocated the use of a well-placed steroid injection to reduce associated fibrous adhesions and minimize the ill effect of chronic inflammatory change and contracture.16 Exercise caution when using steroids in the small appendages of the feet as there is a genuine risk for dermal atrophy and this may be detrimental to the health of the toe.    A single well localized injection can undermine the cicatrix while the pressure of the injected fluid separates the hypertrophic fibrous tissue from healthy subcutaneous tissue. This maneuver can release the adhesion while relaxing the surrounding skin and relieving associated digital contracture. Educate the patient and have him or her sign a consent form for such a procedure in order to ensure his or her understanding and agreement of the treatment plan.

Addressing The Complications Of Sausage Digit And Chronic Edema

The development of chronic swelling that interferes with normal venous return and lymphatic flow commonly occurs after digital surgery. The soft tissue envelope about the digits is relatively small so the volume available for expansion is minimal. Given the fact that there are four neurovascular bundles in each digital sleeve, the risks of venous congestion, chronic stasis and lymphatic dysfunction are quite high. Therefore, meticulous dissection and careful management of soft tissue retraction are paramount to success in digital surgery. In the face of postoperative complications, it is likely that a certain degree of vascular compromise has already occurred. Therefore, a history of failed hammertoe surgery increases the risk of complications should one pursue a reconstruction procedure.    Given this fact, one should use caution when approaching a second digital surgery as further compromise after an attempt at salvage surgery may result in the need for digital amputation. This end result is often met by a discouraged and dissatisfied patient. A good preemptive strike against this complication is to treat the vascular compromise aggressively with local measures prior to entertaining a plan for a second surgery.    Conservative treatment measures include continuous compression with malleable, removable silicone sleeves, deep fiber massage and range of motion exercises at the MPJ to enhance venous return and increase the patency of lymphatic channels. One can perform such therapy with the benefit of a physical therapist to ensure proper performance of these maneuvers and the patient can continue therapy at home thereafter. Have the patient continue these maneuvers for numerous weeks prior to subsequent surgical consultation. The post-rehab condition of the digit may well be improved in comparison to the initial evaluation, and may put the patient in a better position to undergo the risks of surgery.    Often, the patient’s ability to be compliant in following these instructions and reporting for care is reflective of the postoperative compliance that one can expect should further surgery be pursued. Should the patient fail to comply with simple conservative measures, it may be prudent to encourage second or even third opinion consultations. When a patient shows poor compliance with simple conservative measures, it may be prudent to discourage the surgical option altogether. Dr. Judge is the Director of Externship Programs and the Coordinator of Residency Selection and Marketing for the St. Vincent Charity Hospital in Cleveland. She completed a three-year surgical residency program in major reconstructive surgery for the leg, foot and ankle under the auspices of the late Gerard V. Yu, DPM. Dr. Judge has offices in Port Clinton, Ohio and Lambertville, Mich. Dr. Judge is the Official Foot and Ankle Physician for the Jamie Farr Owens Corning LPGA Classic.



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