How To Reduce Complication Risk In Hammertoe Surgery

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Ten Keys To Minimizing Complication Risk

We have found the following pearls to be beneficial in avoiding or reducing the risk of common complications.

1. Ensure proper preoperative antibiotic prophylaxis.
2.  Knowledge of the relevant anatomy and careful dissection technique will help us avoid damage to the small vessels and nerves in the digits.
3. Allow the toes to have ground purchase by removing as little bone as possible. This allows the flexor tendons to have adequate pull.
4.   Consider addressing first ray disorders that may be influencing the lesser toes.
5.  If we are correcting the second and third digits, we will tend to correct all the toes to prevent the fourth and fifth toes from appearing hammered in comparison.
6.  Correct the adductovarus deformity of the fifth digit with a derotational arthroplasty.
7.  Perform flexor tenotomies to prevent mallet toes. This is especially important if the etiology of the digital deformity is neurological in nature.
8. If blue toe or white toe occurs, this will be apparent at the completion of the procedure or upon deflation of the tourniquet immediately after the procedure. One needs to address these complications immediately postoperatively.
9.  We use betadine-soaked gauze around digital procedures in an attempt to stabilize and minimize postoperative edema. Emphasize to the patient the importance of keeping the dressing clean, dry and intact to limit the risk of postoperative infection. Patient adherence with postoperative rest, ice and elevation is also very important.
10. Keep internal fixation in place for six weeks if possible to allow for complete fusion.

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Author(s): 
Kerry Zang, DPM, FACFAS, Shahram Askari, DPM, Mia Horvath, DPM, and Janna Kroleski, DPM

Given the common malady of hammertoe deformities, these authors share their experience and pertinent pearls for proactive prevention of common complications with hammertoe surgery.

Lesser digital deformities are one of the most common disorders podiatrists treat surgically in the lower extremity. They may exist as isolated contractions or in conjunction with deformities of the hallux. In the literature, there are many methods to address hammertoe deformities but there is no current absolute correction. The success or failure of surgical treatment depends on the surgeon’s understanding of the etiology of each deformity.

   As surgeons, we have the belief that digital deformities occur at the metatarsophalangeal as well as the interphalangeal joint levels. We further believe that the osseous structures and misalignments/joint deviations and muscle functioning out of phase can have a contributing effect. The best way to reduce complications is to do the correct surgical procedure the first time. It is essential to know the type of deformity you are attempting to correct and the etiology of that deformity. Once that is apparent, one can choose the proper procedure and determine the surgical incision planning. Postoperative pearls will help reduce other common surgical complications.

Keys To The Diagnostic Workup

Clinicians should assess the patient weightbearing and non-weightbearing during the initial exam. In regard to weightbearing radiographs, the AP and lateral films will aid in classifying the severity and level of deformity, and identify the planes (sagittal, frontal and/or transverse planes) of the deformity. It is also necessary to examine each digit for callus formation and areas of pressure. In order to select an appropriate surgical procedure, one should evaluate the metatarsophalangeal joint for instability and pain.

   Prior to proceeding with surgical intervention, one must evaluate the patient’s neurovascular status. Noninvasive vascular studies could help eliminate possible complications such as non-healing wounds, infections, and blue or white toe. It will also allow you to weigh the potential risks and benefits of surgery with your patient in deciding the proper course of treatment. Considering any patient comorbidities as well as his or her expectations after surgery will aid in patient satisfaction after surgery.

   The lifestyle and activity level of the patient are also very important. For elderly patients who are non-ambulatory, an arthroplasy would be the surgical procedure of choice. However, in younger active patients, one must consider the need for stabilization of flexor and extensor musculature over time.

   A proper physical examination is essential to find the correct deforming forces. For example, the physical examination of a patient with a swing phase etiology will reveal tight extensor tendons dorsally and prominent metatarsal heads plantarly. Orthoses function during the stance phase of gait and therefore would not be useful in treating a swing phase condition. If you were to perform an arthroplasty on this patient, it would only be a temporary treatment and would result in a higher risk of recurrence due to the lack of neutralization of the deforming forces. In this situation, an arthrodesis should be the procedure of choice.

Selecting The Appropriate Surgical Procedure

Knowing the etiology and neutralizing it with a sequential stepwise approach is the idea behind sequential reduction and the Kelikian push-up test.

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