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.

Kerry Zang, DPM, FACFAS, Shahram Askari, DPM, Mia Horvath, DPM, and Janna Kroleski, DPM

1. Interphalangeal joint tenotomy and capsulotomy
2. Removal of bone from the interphalangeal joint
3. Extensor hood release (When releasing the extensor hood apparatus, be sure not to cut the lumbrical attachment on the proximal phalanx.)
4. Metatarsophalangeal joint capsule release
5. Flexor plate release

   One can classify digital deformities according to their flexibility with weightbearing. There are several parameters that clinicians must evaluate before deciding on the proper procedure. Let us discuss reducible deformities first.

   If the Kelikian push-up test allows the digit to straighten, a flexible deformity is present. When there is a reducible flexion deformity present at the interphalangeal joint, one may only need to perform a tenotomy of the long flexor tendon. If the skin is contracted, the surgeon may use a plantar incision for this procedure. Otherwise, one may employ a medial or lateral approach.

   When the extensor tendons are contracted along with the dorsal capsule of the metatarsophalangeal joint, this may be the only pathological entity that needs correction. It is necessary to lengthen both the short and long extensors, and one must take care to ensure there is no injury to the cartilage of the metatarsophalangeal joint when doing the capsulotomy.

   For digits in which the proximal interphalangeal joint (PIPJ) is buckled but reducible, surgeons may reposition the medial and lateral extensor slips dorsally on the digit to avoid resection of bone and shortening of the digit with subsequent complications (flail toe). With this procedure, there is very little motion at the interphalangeal joint.
Nonreducible deformities require fusion or implant at the level of the deformity. In patients with fixed digital deformity and instability at the metatarsophalangeal joint or weak intrinsic musculature, an arthrodesis is recommended.

   Whether the surgeon does an end-to-end arthrodesis or a peg-in-hole arthrodesis, one must ensure correct rectus position of the digit before fixation. Remember that you will get more shortening of the digit with a peg-in-hole arthrodesis. Accordingly, one should reserve this procedure for patients with long digits. Surgeons should also reserve the peg-in-hole arthrodesis for patients with good bone stock. One may perform a flexor tendon transfer in conjunction with both arthroplasty and arthrodesis, and the procedure is indicated for patients with metatarsalgia and floating toe. When doing surgical correction on multiple digits, one should consider doing arthrodesis on all digits (except the fifth digit) due to the lack of stability associated with arthroplasty, regardless of the flexibility of the deformity.

Addressing Complications, Recurrences And Patient Expectations

Over time, complications can be a common occurrence after digital surgical procedures. These complications may be due to the positioning of the corrected toe in comparison to the other digits. Sausage toes, floating toes, medial and lateral contractures, dislocations, hypertrophic reactive bone formation, implant failure (usually picking the wrong implant) and, last but not least, correcting the deformity at the wrong level could all be responsible for postoperative complications.

   Correcting the deformity at the wrong level will not only result in recurrence but other postoperative complications as well.

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