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

   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.

Final Notes

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.

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