Current And Emerging Insights On Hammertoe Correction

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Author(s): 
Christopher F. Hyer, DPM, FACFAS, and Ryan T. Scott, DPM

How Effective Are Absorbable Pins?

Absorbable pins became a popular alternative to the traditional K-wire for the fixation of digital contractures. This is because this device’s functions are identical to the K-wire in its mechanical role. One can either cut and bury the absorbable pin within the proximal and middle phalanx, or drive the pin the entire length of the digit. Despite its mechanical strength, there is a flaw in the breaking point of this device. There was a common failure point of breakage as surgeons initially inserted the pin and drove it distally. Other possible flaws include production of sinus tracts with the potential for secondary bacterial infection within the digit.9

   Konkel and colleagues found that complete bone union occurred in 38 of the 48 toes (73 percent).11 The authors noted no wound infection or toe swelling at final follow-up when using absorbable pin fixation.

Pertinent Pearls On Using Cannulated Screws For Fixation

Recently, surgeons have used small cannulated screws for fixation. Although this surgical procedure sacrifices the distal interphalangeal joint to treat the proximal interphalangeal joint, it significantly reduces the risks of residual toe angulation, mallet toe deformity and nonunion of the proximal interphalangeal joint. Cannulated screws also reduce postoperative shoe restrictions.

   Disadvantages of this technique are the risks of having to perform a second operation related to persistent pain at the tip of the toe caused by the head of the screw as well as breakage.8 Another disadvantage is the lack of bone purchase in larger proximal phalanges. This may cause pistoning of the screw and/or backing out of the implant, which increases the amount of swelling present in the digit as well as an increase in the risk of infection.

   We have also found that screw length can pose a significant problem. In a few cases, we have noted screw threads in either the distal interphalangeal joint or proximal interphalangeal joint distracting the joint. When this occurs, we leave the guide wire in place and drive the screw into the proximal aspect of the phalanx. Note that one should not drive these wires across the MPJ as there is a high risk of breakage due to the small diameter of the wire.

Case Study One: Percutaneous K-Wire Salvage In A Case Of Osteoporotic Bone 

A healthy 56-year-old female underwent hammertoe correction of the second, third and fourth toes with MPJ release and capsular tendon balancing. Preoperatively, the surgeon and patient discussed fixation options and due to the patient’s desire to avoid percutaneous fixation, they selected an intramedullary option.

   The surgeon used a transverse elliptical incision over the proximal interphalangeal joint of the second, third and fourth toes, and performed a condylectomy of the proximal phalanx. The bone was osteoporotic and quite soft in nature. The surgeon prepared the middle phalanx portion of the proximal interphalangeal joint and used a broach to prep the medullary canal.

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Dr. Nallisays: February 6, 2012 at 11:31 am

Gentlemen,

I read your article and I just don't see the complications you are talking about. I have never had an infection using a K-wire in the toe. Implants have a much higher failure rate (positioning, failure, prolonged swelling, etc).

Performing many hammertoe corrections a year with K-wires (in for 3 weeks), I have to suggest that maybe your pre-op discussions and post-operative care don't have patient buy-in or compliance.

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Dr. Scantlinsays: February 6, 2012 at 1:32 pm

I agree with Dr. Nalli. I rarely have an issue with pin tract infection or patient anxiety. My biggest concern with any of these implantable devices is that they don't address the dorsal contracture at the MPJ, and thus I have seen too many "floating toes." I never have that problem when I use K-wires. Out of curiosity, for those surgeons who do use them, what are surgeons doing to prevent floating toes? Skin plasty's?

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Joshuasays: February 9, 2012 at 5:32 am

Great article.

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Ed Davis, DPMsays: February 22, 2012 at 11:46 pm

I agree with Dr. Scantlin concerning the need to adequately address the deformity at the MTP joint. The various PIPJ implant devices do a good job of holding the joint in alignment but do so in rigid alignment. Fusion of the PIPJ yields a straight toe but one that is often painful in shoegear.

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