How To Handle Complications Of Hammertoe Surgery

By Lowell Weil Jr., DPM, MBA, and Richard A. Schilling, DPM

           Offering insights and pearls from their experience, these authors discuss essential preoperative and intraoperative steps for reducing the risk of complications from hammertoe surgery. They also offer salient advice for rectifying complications when they occur.      There are several reasons why patients undergo hammertoe surgery. While pain is the most common indication for hammertoe surgery, one cannot separate pain and cosmesis in many of these cases. Certainly, there are severe deformities associated with hammertoes and in many instances, one may be able to manage these problems with roomier shoe gear. However, when the symptoms are not relieved by shoe gear modifications, surgery is often a very viable option.      Hammertoe surgery is one of the most successful and gratifying procedures for surgeons and patients alike. Over 300,000 hammertoe surgeries are performed each year. Patients usually have few complications and are able to resume their daily activities without significant interference.      Given these consistent findings, expectations for a smooth recovery are extremely high for all involved. However, complications can occur. Given the added burden of providing cosmetic improvement in addition to providing pain relief and functional improvement, these complications can come in many forms. Patients may have relief of their symptoms and still be unhappy with the result because of the appearance of their toes. Additionally, a cosmetically appealing toe may not provide the functional capacity for activity levels and support.      Surgeons must consider multiple deformities when evaluating hammertoes. Concomitant pes cavus, hallux valgus, hallux interphalangeus and lesser metatarsophalangeal deformities all can play important roles in the development and correction of hammertoes, and factor into complications from hammertoe surgery as well.

A Quick Overview Of Common Hammertoe Procedures

     Arthroplasty, arthrodesis and implant arthroplasty are the three most common procedures we employ to correct hammertoe deformities. All offer benefits as well as potential complications. Podiatric surgeons also commonly utilize additional soft tissue procedures to help correct the hammertoe deformity.      According to the literature, the most common complications of arthrodesis procedures are medial or lateral deviation of the toe at the proximal interphalangeal joint, metatarsalgia, pin tract infections, residual anesthesia and lack of toe purchase. The most common complications of arthroplasty procedures are lack of toe purchase, recurrence, shortness of the digit and flail toe. The most common complications of implant arthroplasty are pain, lesion recurrence, infection, implant failure, implant rejection and bone damage. For soft tissue procedures such as a tenotomy and a capsulotomy, the most common complications include residual deformity, metatarsalgia, recurrence, reduction in range of motion and hyperextension at the metatarsophalangeal joints.1      According to the American College of Foot and Ankle Surgeons preferred practice guidelines, persistent edema, recurrence of deformity, residual pain and excessive stiffness were the most common complications following hammertoe surgery. However, other less commonly reported complications include numbness, flail toe, symptomatic osseous regrowth, malposition of toe, malunions/non-union, implant fatigue, failure or intolerance, infection, vascular impairment and gangrene.2      Coughlin, et. al., reported on a large series of arthroplasties in which swollen or sausage toe was not a problem. However, they did see complications that included vascular impairment, hyperextension at the proximal phalangeal joint and postoperative numbness.3

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