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
How To Treat The ‘Sausage’ Toe
A swollen or “sausage” toe is the most common complication following hammertoe surgery. Damage to the lymphatic and/or venous circulation can account for this postoperative edema. Chronically swollen toes can also be the result of a symptomatic non-union at an attempted arthrodesis site.4 In some cases, toes will stay swollen for an inordinate amount of time and usually will stay swollen for a longer duration than one might see with other, more complicated procedures of the forefoot. It is not uncommon for a hammertoe correction to stay swollen longer than an osteotomy that one performs to correct a bunion at the same time. Given that it is difficult to create compression with shoe gear, toes typically will remain swollen for up to six months following surgery. It has been our experience that toes tend to remain swollen longer with arthroplasty procedures as opposed to arthrodesis or implant arthroplasty procedures, which tend to have the least amount of postoperative swelling. Utilizing some type of compressive taping or strapping method postoperatively can reduce swelling. We commonly utilize the Silipos or silicone hammertoe pads. Getting patients into closed shoe gear as quickly as a week after surgery can also help minimize post-op swelling. It is very important to be patient with this swelling. Most post-op swelling will resolve. Becoming aggressive with cortisone shots and other invasive procedures will only prolong the swelling.
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.
Addressing Nonunions And Other Complications Involving K-Wires
Nonunions can be quite common when it comes to performing an arthrodesis procedure. Since these nonunions are usually not symptomatic and function as a pseudoarthrosis, they rarely need revision. Inadequate bone resection or bone-to-bone apposition are common causes of nonunions. Additionally, K-wires can maintain a separated position of the fusion site, which can lead to the nonunion. When revision is necessary, resecting the nonunion to an arthroplasty with or without an implant can be a simple solution. Utilizing bone graft and additional fixation can become a hazardous and traumatic event for the frequently operated upon toe. One may see other complications that involve K-wires. Pin tract infections, K-wire migration and loss of fixation can all occur. Utilizing alternative forms of stability such as Steristrips or bandaging techniques may offer better solutions than K-wires. We have found that placing one or two 1/4-inch Steristrips longitudinally from the distal pulp of the toe and secured to beyond the metatarsophalangeal joint dorsal proximally allows for the same stability without the inherent complications associated with K-wire fixation.
Proactive Tips For Minimizing Post-Op Complications With Implants
Hammertoe implants have received negative publicity over the last 20 years but they offer an excellent alternative to many surgical procedures for hammertoes. Hammertoe implants can offer a happy medium of increased stability over an arthroplasty without the stiff, immobile joint of an arthrodesis. Patient satisfaction rates are very high both in the literature and in our experience. While complications are not common with implants, they do occur. According to the literature, the most common complications were bony regrowth, prolonged edema, limited range of motion, poor toe purchase and implant removal.5 In our experience, the most common complications with hammertoe implants are breakage of the implant with chronic pain and swelling of the toe. In regard to breaking of the implant, the causes are unknown and rare. However, they may be due to excessive angular force or trauma on the toe and implant. When an implant breaks, removing or replacing it is a predictable solution. While implant engulfment is a very rare complication, it can lead to pain in the joint. Removing and/or replacing the implant may also be necessary in that situation.
What You Should Know About Other Complications
Dorsal contracture can be a frustrating complication. It can occur when the surgeon has failed to address a more proximal etiology of the hammertoe such as metatarsophalangeal joint contracture. However, one may also see a dorsal contracture occur as a response to the body’s natural healing and scar contracture of a dorsally placed longitudinal incision. Employing a medial longitudinal approach can avoid this complication. However, surgeons can often use scar contracture to their advantage — especially when dealing with mallet toe deformities — by making a transverse elliptical incision across the distal interphalangeal joint. In cases of postoperative dorsal contracture recalcitrant to conservative care such as massage or physical therapy, we find it helpful to manipulate the joint under anesthesia to mobilize the joint. Floppy toes can result from excessive bony resection of a hammertoe. Patients often find this to be the most intolerable complication. They complain of discomfort, a feeling of uneasiness when putting on a sock and a feeling of insufficient function with ambulation. Employing more minimal resection intraoperatively, fusing the toe or utilizing an implant can prevent this complication. However, when floppy toes occur, it may be necessary to revise an existing implant, perform syndactylization or proceed with an amputation. Vascular compromise is the most severe complication one may see with hammertoe correction. Ensuring a proper preoperative assessment of vascular integrity is obviously the most important preventive measure. Excessive dissection can be an additional cause of vascular compromise. Excessive straightening of the toe maintained by K-wires is another common etiology of vascular problems. Changing the position of the wire intraoperatively or removing the K-wire early in the postoperative period when indications are present can help this problem. However, when a vascular compromise occurs, one should wait for demarcation to occur before pursuing definitive procedures.
Hammertoe repairs offer predictable, gratifying outcomes for the surgeon and patient. When performing these procedures, ensuring proper preoperative planning and intraoperative and postoperative management can reduce the incidence of complications. However, when complications arise, surgeons must address them in a proper and timely fashion. Dr. Weil is the Fellowship Director of the Weil Foot and Ankle Institute in Des Plaines, Ill. He is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Schilling is a Fellow at the Weil Foot and Ankle Institute, and is an Associate of the American College of Foot and Ankle Surgeons.
1. Harmonson, JK, Harkless, L: Operative procedures for the correction of hammertoe, claw toe, and mallet toe: a literature review. Clin Podiatr Med Surg. 1996 Apr;13(2):211-20.
2. ACFAS Preferred Practice Guidelines Committee: Hammer Toe Syndrome. J Foot Ankle Surg. 1999 Mar-Apr;38(2):166-78.
3. Caughlin, MJ et al: Operative repair of the fixed hammertoe deformity. Foot Ankle Int. 2000 Feb;21(2):94-104.
4. Yu, GV, et al.: Techniques of digital arthrodesis: revisiting the old and discovering the new. Clin Podiatr Med Surg. 2004 Jan;21(1):17-50.
5. Sgarlatto, TE, Tafuri, SA: Digital Implant Arthroplasty. Clin Podiatr Med Surg. 1996 Apr;13(2):255-62