Is It Time To Look For An Alternative To Digital Arthroplasty For Hammertoes?
- Lawrence Fallat DPM FACFAS
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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?