Removing Failed Hammertoe Implants Following Nonunion

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

   Following removal of the failed implants and revisional arthroplasty at the PIPJ of bilateral fourth toes, the patient has progressed well. Her pain and edema were minimal at six weeks postoperatively and she was pleased with the overall cosmetic appearance. She is ambulatory and has returned to work on a full-time basis (10-hour days standing) without restrictions. Immediate postoperative radiographs revealed interval removal of fourth toe implants with arthroplasty and toes in rectus, anatomical alignment. She did however continue to have intermittent swelling and pain to the left fourth toe only. Due to the potential for recurrence of the deformity, we will continue to periodically monitor her for changes.

Final Notes

The exact mechanism for implant failure in this case remains unclear. Three of the six implants were visibly broken.1,17 Additionally, two of the three broken implants occurred on the fourth toes and were symptomatic to the point that they required revisional surgical intervention with removal of the failed implant and resection of the nonunion with arthroplasty.

   In regard to hammertoe surgery, researchers have reported that the general complication rate of hammertoe surgery is highest in the fourth toe with the most reports of residual pain, swelling and overall dissatisfaction.10 Although hammertoe surgery is a common procedure with numerous well-documented procedural selections that range from arthroplasty to amputation, we must always be aware of underlying biomechanical components when it comes to procedure selection.3,9-11,16,19

   Successful surgical outcomes are not only dependent on fixation but on properly identifying and addressing associated pathology and soft tissue imbalances that contribute to biomechanical instability and development of the hammertoe deformity. Ultimately, fixation is not the only factor in a successful surgery. One must properly understand and address the advantages and limitations of each method of fixation in relation to the patient’s pathology.1-19

   Dr. Desiree M. Scholl practices at Wisconsin Neuropathy Center in Kenosha, Wis.

   Dr. Cernak practices at Wisconsin Neuropathy Center in Kenosha, Wis.

   Dr. Alex R. Scholl practices at Wisconsin Neuropathy Center in Kenosha, Wis.

References

1. Augoyard M, Meusnier T, Peyrot J. Proximal interphalangeal arthrodesis using intramedullary bone fastener Smart Toe: Clinical and Xrays review [Clinical White Paper]. Lyon, France: Memometal technologies. 2007.

2. Briggs L. Proximal interphalangeal joint arthrodesis using the Stayfuse implant. Tech Foot and Ankle Surg. 2004; 3(1):77-84.

3. Bouche R, Heit E. Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joint: preliminary observations. J Foot Ankle Surg. 2008; 47(2):125-137.

4. Caterini R, Farsetti P, Tarantino U, Potenza V, Ippolito E. Arthrodesis of the toe joints with an intrameduallary cannulated screw for correction of hammertoe deformity. Foot Ankle Int. 2004; 25(4):256-261.

5. Coughlin M, Dorris J, Polk E. Operative repair of the fixed hammertoe deformity. Foot Ankle Int. 2000; 21(2):94-104.

6. Creighton R, Blustein S. Buried Kirschner wire fixation in digital fusion. J Foot Ankle Surg. 1995; 34(6):567-569.

7. Cuttica D, DeCarbo W, Smith B, Berlet G. New intramedullary implant for proximal interphalangeal joint arthrodesis. Tech Foot Ankle Surg. 2008; 7(3):203-206.

8. Ellington JK, Anderson R, Davis H, Cohen B, Jones C. Radiographic analysis of proximal interphalangeal joint arthrodesis with intrameduallary fusion device for lesser toe deformities. Foot Ankle Int. 2010; 31(5):372-376.

9. Edwards WH, Beischer AD. Interphalangeal joint arthrodesis of the lesser toes. Foot Ankle Clinics. 2002; 7(1):43-48.

10. Fishco W. Emerging concepts in hammertoe surgery. Podiatry Today. 2009; 22(9):34-39.

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