How To Handle Complications Of Hammertoe Surgery
- Volume 18 - Issue 9 - September 2005
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How To Treat The ‘Sausage’ Toe
A swollen or “sausage” toe is the most common complication following hammertoe surgery. Damage to the lymphatic and/or venous circulation can account for this postoperative edema. Chronically swollen toes can also be the result of a symptomatic non-union at an attempted arthrodesis site.4 In some cases, toes will stay swollen for an inordinate amount of time and usually will stay swollen for a longer duration than one might see with other, more complicated procedures of the forefoot. It is not uncommon for a hammertoe correction to stay swollen longer than an osteotomy that one performs to correct a bunion at the same time. Given that it is difficult to create compression with shoe gear, toes typically will remain swollen for up to six months following surgery.
It has been our experience that toes tend to remain swollen longer with arthroplasty procedures as opposed to arthrodesis or implant arthroplasty procedures, which tend to have the least amount of postoperative swelling. Utilizing some type of compressive taping or strapping method postoperatively can reduce swelling. We commonly utilize the Silipos or silicone hammertoe pads. Getting patients into closed shoe gear as quickly as a week after surgery can also help minimize post-op swelling.
It is very important to be patient with this swelling. Most post-op swelling will resolve. Becoming aggressive with cortisone shots and other invasive procedures will only prolong the swelling.
How Malpositioning Can Lead To Further Problems
Malposition is the most common complication that causes long-term problems. Malposition can be caused by:
• excessive shortening;
• inadequate resection or shortening;
• failure to address deformities or length problems with other toes;
• incorrect angulation of correction; or
• positioning the toe too straight.
Excessive shortening is a result of overly aggressive bony resection or, in rare cases, resorbtion of the medullary bone. Proper preoperative evaluation and intraoperative care can minimize this problem.
However, when one sees this complication, performing a fusion with an interpositional bone graft can rectify the situation. In our experience, performing an implant arthroplasty to gain length and stability provides the most consistent results. Occasionally, it may be necessary to perform syndactylization in the extremely flail toe in order to create a more proper alignment.
Inadequate resection or shortening can lead to a toe that remains excessively long and painful with a high incidence of hammertoe recurrence. It is very important to align the toe that one is correcting with the other toes of the foot. One should not correct any toe in isolation without considering its place among the other toes. When significant shortening is necessary, resecting both the proximal phalanx head and middle phalanx head can solve this difficult problem. Using an implant can also help enhance stability of the shortened toe.
In some cases, podiatric surgeons will encounter a deformity that is more prominent than others in the foot. Unfortunately, correcting the primary deformity can unmask less noticeable deformities. It is important during preoperative planning to assess how the primary hammertoe repair will affect other toe deformities. Maintaining a stepladder-like relationship of toes two through five is critical.