Is It Time To Look For An Alternative To Digital Arthroplasty For Hammertoes?

Hammertoe surgery is generally thought of as a simple procedure, which consistently gives good results with very few complications. Since an arthroplasty is technically easy to perform, it is usually the first surgery residents will perform in their training.

However, the digital arthroplasty is not necessarily a benign procedure. I am not talking about the overriding contracted second toe which can drive us crazy. I am talking about seemingly simple hammertoes.

Recently, I performed an arthroplasty to correct hammertoe contractures of the third, fourth and fifth toes. The hammertoes were semi-rigid and painful. When I reduced these hammertoes, they were long. There was contracture at the proximal interphalangeal joints (PIPJs) and at the metatarsophalangeal joints. This is a typical presentation.

I resected an appropriate amount of the head of the proximal phalanx and inserted 0.045 Kirschner wires. This procedure usually provides good alignment, especially with adjacent arthroplasties. Clinically and radiographically, the results were excellent. All of the toes were straight and on the same plane. I removed the K-wires approximately two and a half weeks after the surgery.

Although the toes were swollen, the patient was pleased with the results. Four weeks after surgery, the toes were stiff and still swollen. I reassured her that everything would be fine. I instructed her on range of motion (ROM) exercises and using elevation and ice when resting.

Four weeks later, the swelling had reduced slightly but the toes had that thick fusiform appearance from the dense fibrous tissue at the PIPJ. The ROM exercises had not been successful.

While the toes were not painful, the patient was not happy. I blocked the toes and performed manipulation to break adhesions. This helped and, gradually, the fibrosis reduced to a more acceptable level.

Why do the stiffness and swelling with excessive scar tissue occur? Are these complications or is this how the toes heal? Not all of my patients have these problems.

I have examined my technique. My dissection is clean and meticulous. I perform the appropriate tendon/capsule balancing and resect the correct amount of bone. The stiffness can occur even when I do not use k-wires or whether I use joint spacers/implants.

If these problems are inherent to the procedure, why didn't I previously hear of other surgeons having these problems? When I recently asked my colleagues about this, several of them told me they do have these problems and just accepted the swelling and stiffness as potential complications of hammertoe surgery.

Granted, surgeons have used the digital arthroplasty procedure for decades because it does correct a painful hammertoe. However, the procedure clearly has some potential postoperative problems. Is it time we look for a new procedure to correct this common forefoot pathology?



Anonymoussays: July 9, 2009 at 12:36 pm

Thank you for raising this topic, Dr. Fallat. I seem to have run into this scenario particularly with 4th toes. Where does this fibrosis come from, and what is the best way to address and prevent this? Do not use a tourniquet? Use Epinephrine (which I avoid at all cost usually). We know what is there to begin with: skin, tendon, and bone- what makes up this fusiform swelling! This problem begins between the 3-6 week mark and is frustrating. I will sometimes give a corticosteroid injection, but often with unsatisfying results and pain. I will watch for future information on this topic, but would be interested in some form of collaborative "look into" cause and/or treatment.

Georgeanne Botek, DPM
botekg@ccf.org

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Anonymoussays: July 12, 2009 at 9:00 am

I have used Coban wraps for each toe for four to six weeks post-op and that seems to really reduce the swelling. Also, Decadron phosphate at the end of the case, as well as utilizing proximal ankle or preferably sciatic blocks (the anesthesiologists truly love doing these-they're fun to do) blocks to reduce the scarring and fibrosis is tremendously helpful for all ankle and foot procedures. The volume of local blows apart all the tissue planes, so I avoid local infiltration.
George Tellam DPM
a_ankle@bellsouth.net

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Anonymoussays: July 20, 2009 at 2:04 pm

There are a few patients that seem to have little or no swelling at all around the PIPJ after an arthroplasty, but a fair number of patient's that I have seen enevitabley end up with prolonged swelling no matter what methods I employ to combat this problem. In addition to the tips of performing proximal nerve blocks, careful tissue dissection, pinning or nonpinning of toes, I have found that the majority of arthroplasty patients that I see are geriatric and on aspirin. The bleeding from the end of the resected proximal phalanx is what really leads to the fibrous of the area. Excessive bleeding and hence post op swelling from patients who have "forgotten" to stop their aspirin is a sure bet.

Joseph Kibler, DPM
foot.doctor@hotmail.com

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Anonymoussays: July 22, 2009 at 7:03 pm

I apply Fabco wrap around the digit immediately post-op. I remove sutures at 10 days and have the patient apply coban for 1-2 weeks afterwards. I have only had a sausage toe or swelling when the Fabco had been removed by the patient. I do not have the fusiform swelling or fibrosis as a complication. I also employ an MIS technique for my procedures.

Glenn S. McPhillips, DPM

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Anonymoussays: July 29, 2009 at 9:04 pm

I agree with the bleeding out of the phalanx and hematoma formation theory. I tend to use bone wax, even on my
Austins, to reduce chances of hematoma. Although, I have still seen a sausage, or two...I see them in about 5% of my cases. I also use coban on particular patients. It seems the diabetic and elderly and darker skinned individuals tend to be predisposed to this tubular fibrosis. I also think compliance and limited return to activity have rolls in post-op swelling.

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Chase R. Stuart, DPMsays: April 10, 2011 at 8:56 am

I agree with the need to apply compression around the digit but I have had a few patients that develop a deep crease where the 1 inch Coban was wrapped around their toe. Once they experience the pain from accidentally wrapping their toe/toes too tightly, it is difficult to convince them to continue wrapping the toe. Lesson: It is very important to educate and spend the extra time with the patient explaining how to properly apply the compression around the toe.

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