Minimizing The Risk Of Failed Hammertoe Surgery

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Author(s): 
Johanna Richey, DPM, and Graham Hamilton, DPM, FACFAS

Case Study Two: When A Patient Presents With Predislocation Syndrome

A patient initially presented with symptoms of pain and dysfunction of the second toe that were consistent with predislocation syndrome. She had significant biomechanical pathologies that accounted for her deformity.

   First and most importantly, she had insufficiency of the first ray with metatarsus primus elevatus and a subsequent functional hallux limitus. This prevented appropriate propulsion off the first ray with transfer to the second MPJ. She also had a gastroc equinus manifested by significant extensor substitution during gait analysis and flexor stabilization secondary to her compensatory pronated foot. This contributed to her symmetric hammertoe deformity of digits two through four with adductovarus deformity of the fifth digit.

   She had a positive Lachman’s test of the second digit (a “pull up test” to evaluate for capsulitis), which was indicative of MPJ capsulitis and likely attenuation of the plantar plate. Her second digit had more dorsal subluxation clinically than her other hammertoes, which is also suggestive of plantar plate attenuation.

   Accordingly, the surgical planning was based on addressing the deforming forces encountered in her biomechanical exam. The surgeons first performed first MPJ fusion with an endoscopic gastroc recession in order to provide a stable platform for propulsion during gait and eliminate the equinus deformity.

   Subsequently, the surgeons performed a plantar plate repair of the second digit with extensor tendon transection at the level of the PIPJ with PIPJ arthrodesis. During the PIPJ arthrodesis, the surgeons transferred the FDL to the dorsal aspect of the proximal phalanx to provide tendon balancing. Next up was a standard arthrodesis of the third and fourth digits with transection of the EDL at the PIPJ with MPJ release. The surgeons subsequently performed a standard arthroplasty of the fifth digit with derotational skin plasty to remove the varus angulation.

   The patient was completely satisfied with the results two years postoperatively.

   Dr. Richey is a second-year resident with the Kaiser San Francisco Bay Area Foot and Ankle Residency Program at Kaiser Permanente Medical Center in San Francisco, Oakland and Walnut Creek, Calif.

   Dr. Hamilton is a Fellow of the American College of Foot and Ankle Surgeons. He is a Staff Podiatric Surgeon and Attending Staff with the Kaiser San Francisco Bay Area Foot and Ankle Residency Program at the Kaiser Permanente Medical Centers in Oakland, Calif., San Francisco and Walnut Creek, Calif.

   For further reading, see “How To Handle Complications Of Hammertoe Surgery” in the September 2005 issue of Podiatry Today or “Emerging Concepts In Hammertoe Surgery” in the September 2009 issue. Also see the Podiatry Today blog “Secrets To Navigating Hammertoe Surgery On The Fifth Toe” by William Fishco, DPM, at http://bit.ly/dkD76j .




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