Removing Failed Hammertoe Implants Following Nonunion

Author(s): 
Desiree M. Scholl, DPM, Cynthia R. Cernak, DPM, and Alex R. Scholl, DPM

These authors offer insights on removing failed hammertoe implants from a 53-year-old-female who presented with a chief complaint of continued pain and swelling localized to her right and left fourth toes.

   Hammertoe deformity is the most common deformity of the lesser toes, consisting predominantly of flexion contracture at the proximal interphalangeal joint (PIPJ) with associated compensatory hyperextension of the metatarsophalangeal joint (MPJ) and distal interphalangeal joint (DIPJ).

   Subsequently, hammertoe repair is one of the most commonly performed procedures that foot surgeons do. Various researchers The literature has documented numerous procedures for hammertoe correction that are widely accepted, including arthroplasty, tendon transfers, arthrodesis and in the extreme circumstance, amputation.1-19 Digital arthrodesis alone has a wide range of currently acceptable options, including peg-and-hole or end-to-end constructs with simple percutaneous pin fixation versus buried intramedullary devices.1,2,4,6-9,12-14,17,19

   In this article, we describe the case of an adult female who presented with continued focal pain and swelling after another surgeon performed hammertoe surgery using implants. Clinical and imaging examinations revealed the presence of failed implants. We determined the pain was a result of nonunion at the proposed digital arthrodesis site with associated internal fixation device failure. We proceeded to remove the failed implants and performed a revisional arthroplasty. The patient responded well and was ambulatory with a return to normal activities six weeks postoperatively.

Pertinent Insights On The Patient Presentation

The patient, a 53-year-old-female, presented with a chief complaint of continued pain and swelling localized to her right and left fourth toes. The pain was aggravated by standing and walking. Additional subjective reports included perceived “grinding” with walking or simple movements of the affected toes. Although there was no history of recent trauma, she did have prior surgical interventions by another surgeon for what began as painful hammertoe deformities.

   The patient underwent initial surgery for the second, third and fourth toes on the left foot three months prior to her first visit for a second opinion with subsequent revision occurring approximately six weeks later. At the time of the revision, she also chose to have similar repair of painful hammertoes of the second, third and fourth toes on the right foot.

   No complications arose in the immediate postoperative course. She returned to supportive tennis shoes with her custom orthotics and took prescription anti-inflammatory medications for continued pain and residual edema. She also used icing and extremity elevation, limited her activities, and attended physical therapy with only minimal pain relief.

   Her past medical history included obesity, sleep apnea, hypertension and hyperlipidemia. The surgical history included heart surgery at the age of 5, recent multiple, bilateral foot surgeries, a hysteroscopy with ablation and a hemorrhoidectomy. She had previously smoked for 25 years but quit smoking approximately 10 years before presenting to our clinic. The social history was otherwise unremarkable. Her family history included heart disease and lung cancer.

   The physical examination of the symptomatic digits revealed significant focal tenderness to palpation over the proximal interphalangeal joint (PIPJ) with mild varus rotation distally over the left distal interphalangeal joint (DIPJ) region. All skin incisions were well healed and adjacent skin was of normal coloration and appearance. Soft tissue edema was present in all post-surgical lesser toes but noticeably intensified over bilateral fourth toes.

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