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.
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.
Remember, hammertoe deformity is defined as plantarflexion of the PIPJ with dorsiflexion of the metatarsophalangeal joint. Claw toe deformity occurs with dorsiflexion of the metatarsophalangeal joint and plantarflexion of the distal interphalangeal joint and proximal interphalangeal joints. Mallet toe deformity occurs with plantarflexion of the distal interphalangeal joint.
Recurrences happen for many reasons. They may be the result of poor physical examination, not understanding the true cause of each digital deformity before proceeding, correction of the deformities at the wrong levels and even poor surgical technique. Another major factor causing complications with any surgical procedure is a patient’s realistic expectations of the outcome. After the surgical consultation, it is important for the patient to have a comfortable grasp of what the surgical procedures will be able to do for him or her.
We personally believe that surgery should truly be the last option. We further believe that the major criteria for surgery, other than the common conservative treatment failure, should be concentrated on increasing function and reducing pain. When speaking to most surgeons, there is an alarming increase in the number of patients who like to proceed with surgery simply due to the appearance of their toes. This is the most dangerous, yet common, recipe for disaster. More and more surgeons are now performing cosmetic foot procedures. In our experience, there is no such thing. Every surgical procedure should be addressing a specific problem with the goals of increasing the patient’s function and reducing his or her pain.
This is especially true since there is no way that the surgery and subsequent healing cycle will ever be able to fully replace and restore the original function of the toes. If we can assume the previous statement to be true, one can also conclude that no final outcome will ever be satisfactory to the cosmetic expectations of most patients. We can only hope to approach the desired function to improve everyday lifestyles.
Before considering surgery, consider the patient’s overall medical history and comorbidities. Do a full exam and order the appropriate studies before proceeding with surgical intervention. Discuss the risks and benefits with your patients, and allow them to make an educated decision on their treatment. There are very few absolute contraindications for surgical correction of hammertoes. These include active skin infection, impaired neurovascular status and comorbid medical conditions.
Dr. Zang is a Diplomate of the American Board of Podiatric Surgery, and a Fellow of the American College of Foot and Ankle Surgeons. He is an Adjunct Professor of Surgery at Midwestern University in Phoenix. Dr. Zang is in private practice at the Arizona Institute of Footcare Physicians.
Dr. Askari is in private practice at the Arizona Institute of Footcare Physicians. He is board-qualified by the American Board of Podiatric Surgery.
Dr. Horvath is board-qualified by the American Board of Podiatric Surgery. She is in private practice at the Arizona Institute of Footcare Physicians.
Dr. Kroleski is board-qualified by the American Board of Podiatric Surgery. She is in private practice at the Arizona Institute of Footcare Physicians.
For related articles, see “Removing Failed Hammertoe Implants Following Nonunion” in the May 2012 issue of Podiatry Today, “How To Handle Complications Of Hammertoe Surgery” in the September 2005 issue, the November 2010 DPM Blog, “Secrets To Navigating Hammertoe Surgery On The Fifth Toe” by William Fishco, DPM or “Current And Emerging Insights On Hammertoe Correction” in the February 2012 issue.