Current And Emerging Insights On Hammertoe Correction

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

   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.

   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.

Comments

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.

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?

Great article.

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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