How To Handle Complications Of Hammertoe Surgery

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

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.      One must be aware of the angular position of hammertoe correction. This can come in many forms. Inappropriate angular resection of the head of the phalanx, angular position of arthrodesis and postoperative influence by adjacent toes can lead to poor alignment. It is important to create the proper alignment intraoperatively and maintain that position postoperatively. Utilizing intraoperative K-wire fixation, Steristrip splintage bandaging and postoperative strapping and taping techniques can help maintain proper alignment.      The most common positional complication is positioning the toe in too straight an alignment. A toe that is too straight can cause many problems. It may not fit in proper alignment with the other toes of the foot and become irritated. It may also lead to a mallet toe deformity or even a reverse or swan neck deformity. The most common cause of this positional complication is placing K-wires with the toe hyperextended.      Using the Steristrip splintage provides superior results in maintaining a correct alignment without the fear of over-straightening the toe. Steristrips allow one to put the toes in physiological flexion while still maintaining excellent stability. Utilizing Steristrips instead of K-wires also allows patients to return to bathing and closed shoes at one week after surgery.

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