Current And Emerging Insights On Hammertoe Correction

Start Page: 34
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Author(s): 
Christopher F. Hyer, DPM, FACFAS, and Ryan T. Scott, DPM

   The surgeon first inserted the intramedullary implant (in this case the Pro-Toe) into the proximal phalanx and then impacted the fin into the middle phalanx. Despite the rather poor bone quality, the medullary device captured well in the second and fourth toes. The middle phalanx on the third toe, however, would not retain the serrated fin in an acceptable fashion.

   At this point, the options included “upsizing” the internal device (if available), converting to a cannulated screw from the tip of the toe or going to a percutaneous K-wire. The surgeon chose to utilize the K-wire because it would not sacrifice the distal interphalangeal joint like a screw would.

   Unfortunately, at that time, an upsize of the medullary implant was not available. Though the patient was initially disappointed to have the percutaneous fixation, she understood the rationale and all three toes healed uneventfully.

Case Study Two: When There Is Post-Op Drift Of The Second Toe At The Proximal Interphalangeal Joint

A 46-year-old female previously had hammertoe correction via a condylectomy of the second proximal interphalangeal joint with percutaneous K-wire fixation. The initial procedure and postoperative course were unremarkable. Protected weightbearing occurred until K-wire removal at six weeks postoperatively. Gradually over a three-month period, the patient noted a drift of the second toe at the proximal interphalangeal joint laterally toward the third toe. The surgeon attempted conservative care but this ultimately failed to realign the toe.

   Typically, pseudofibrosis at the arthroplasy site maintains stabilization of the toe following K-wire removal but this was not the case for this patient. In this case, with mobilization of the fibrosis, the toe destabilized at the proximal interphalangeal joint and a valgus deformity occurred. Surgical options included a repeat K-wire stabilization, a trans-distal interphalangeal/proximal interphalangeal screw or an intramedullary device. In this case, use of the Pro-Toe salvaged and stabilized the proximal interphalangeal joint deformity.

In Conclusion

As technology drives the world of foot and ankle surgery, there will be many more devices developed for the correction of digital deformity. Each of the aforementioned devices has its own pros and cons. However, the most important aspect in hammertoe correction is selecting the appropriate implant for each individual patient. Different implant usage will also vary according to the comfort level of the surgeon. As we proceed forward in practice, the role of K-wire fixation has decreased due to the obvious apparent risks these wires carry. However, K-wires do and always will have an appropriate place in the foot and ankle surgeon’s armamentarium for digital correction.

   When we consider the evolution occurring with hammertoe correction and surgical implants, it is important to be comfortable with multiple devices and techniques. As with any surgical procedure, one must tailor implant selection to each patient’s specific individual anatomic constraints. Simply said, there may not be one hammertoe implant or fixation that covers every patient.

   Dr. Hyer is a board-certified foot and ankle surgeon in Columbus, Ohio. He and his colleagues founded FootSourceMD.com to provide patients across the country with convenient access to reliable resources and products recommended by physicians. Dr. Hyer also contributes to medical education and research through frequent presentations and publications. He also serves on the editorial boards of the Journal of Foot and Ankle Surgery, and Foot and Ankle Specialist.

   Dr. Scott is an Associate of the American College of Foot and Ankle Surgeons. He completed a comprehensive one-year advanced foot and ankle fellowship at The Orthopedic Foot and Ankle Center in Westerville, Ohio.

References

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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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