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Foot & Ankle International Foot & Ankle International http://fai.sagepub.com/ Hammer Toe Correction Using an Absorbable Intramedullary Pin Kurt F. Konkel, Andrea G. Menger and Sharon Ann Retzlaff Foot Ankle Int 2007 28: 916 DOI: 10.3113/FAI.2007.0916 The online version of this article can be found at: http://fai.sagepub.com/content/28/8/916 Published by: http://www.sagepublications.com On behalf of: American Orthopaedic Foot & Ankle Society Additional services and information for Foot & Ankle International can be found at: Email Alerts: http://fai.sagepub.com/cgi/alerts Subscriptions: http://fai.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav >> Version of Record - Aug 1, 2007 What is This? Downloaded from fai.sagepub.com at American Orthopaedic Foot & Ankle Society on December 17, 2013 FOOT &ANKLE INTERNATIONAL Copyright © 2007 by the American Orthopaedic Foot & Ankle Society, Inc. DOI: 10.3113/FAI.2007.0916 Hammer Toe Correction Using an Absorbable Intramedullary Pin Kurt F. Konkel, M.D.; Andrea G. Menger, O.T.C.; Sharon Ann Retzlaff, R.N. Menomonee Falls, Wisconsin ABSTRACT bring patients into the orthopaedic office for effective solu- tions. When nonoperative treatment fails, surgery often is Background: Fixed flexion deformity of the proximal interpha- recommended. Many operative options have been recom- langeal joint with or without hyperextension of the metatar- mended over the years. These include but are not limited sophalangeal joint is one of the most common foot deformities. to (1) arthrodesis with pins, wires, bone dowels, and screws, Many operative options have been recommended. Complaints (2) implants, (3) resection arthroplasty and (4) tendon trans- after operative procedures include a too straight toe, floating , , , , , , , , , , , fers.1 3 4 6 7 11 12 15 16 19 22 23 Over the years in our practice toe, painful toe recurvatum, mallet toe, pin track infection, broken hardware, and the necessity of removing hardware. patients have complained about a too straight toe, a floating A proximal interphalangeal joint arthrodesis for hammertoe toe, painful toe recurvatum, mallet toe, pin track infec- deformity using a 2-mm absorbable pin for internal fixation tions, broken hardware, and hardware removal after surgery is described. Methods: The results of 48 toe arthrodeses in 35 using the above techniques. Absorbable implants have been , , patients were reviewed. Followup ranged from 16 to 58 (average used successfully in other areas,17 20 21 and Sirlin et al.20 38.5) months. Results: The procedure is simple and safe for the in 2001 reported 59 patients who were followed for up to correction of painful rigid hammertoe deformities. Patient satis- 36 months after osteochondral bone grafting for osteochon- faction was high, complications were minimal, and followup dral defects using absorbable polydioxanone pins for fixation. required no pin management or removal. Conclusions: This The patients were followed clinically and with MRI of the procedure can be used for hammer toe deformities requiring operative area. Previous studies have indicated that polydiox- surgery when the metatarsophalangeal joint is stable, the skin is anone degrades in the body “by hydrolysis and nonspecific not compromised, and the intramedullary canal of the proximal enzymatic activity” and that the “in vivo synthetic debris phalanx is 2.0 mm or less. It also has been useful in stabilizing 20 hammertoe correction when there are severe pre-existing metal is cleared predominantly by tissue macrophages.” The allergies. process was slower than in polyglycolic acid implants that have been associated with osteolytic changes. Biodegradable polydiozanone pins usually absorbed completely within 24 Key Words: Absorbable Pin; Arthrodesis; Fusion; Hammer Toe; Lesser Toe; Proximal Interphalangeal Joint months, and marrow edema, probably representing inflam- mation related to pin resorption, occurred infrequently and tended to resolve. The cartilage defects that were caused by INTRODUCTION pin placement also healed spontaneously.20 Over the past 5 years we have used a polydiozanone absorbable pin in the Fixed flexion deformity of the proximal interphalangeal operative treatment of hammertoe deformity. joint with or without hyperextension of the metatarsopha- langeal joint is one of the most common foot deformities. The second toe is most frequently involved, with the third MATERIALS AND METHODS and fourth toes less frequently affected. Pain, calluses, corns, sores, and difficulty finding symptom-relieving footwear Fifty-nine patients with hammertoe deformity were treated operatively using an absorbable pin (Orthosorb Resorbable Corresponding Author: Pin poly-P-Dioxanone [PDS] and D&C Violet #2 distributed Kurt F. Konkel, M.D. Advanced Healthcare, Inc. by DePuy, Ace Medical, 700 Orthopaedic Drive, Warsaw, Orthopaedics IN) from January, 2001, to June, 2004. Two patients N84W16889 Menomonee Avenue died before followup leaving 57 potential patients available Menomonee Falls, Wisconsin 53051 E-mail: [email protected] for followup. All surgeries were carried out by the prin- For information on prices and availability of reprints, call 410-494-4994 X226 cipal author. (K.F.K.) Thirty-five patients returned for final 916 Downloaded from fai.sagepub.com at American Orthopaedic Foot & Ankle Society on December 17, 2013 Foot & Ankle International/Vol. 28, No. 8/August 2007 HAMMER TOE CORRECTION 917 followup (62%) at an average of 38.5 (range 16 to 58) months bend and curl the absorbable pin until its distal tip entered from their surgery. All 35 patients were women with an the drill hole in the proximal phalanx. The raw bone ends of average age of 69 (range 37 to 93) years. Five patients came the middle phalanx and proximal phalanx were opposed as back after their foot healed to have their other foot operated. the pin was placed into the proximal phalanx. The toe was There were 43 second toes, three third toes, and two fourth released and checked for position. Because the absorbable pin toes operated. The average age of the patients was 69 (range had some plasticity, usually a few degrees of flexion were 37 to 93) years. Patients with unstable metatarsophalangeal present at the proximal interphalangeal joint. This gave the joints were treated by another method and were not included toe a more natural appearance. The foot and ankle were then in this study. brought into standing position. If the operative toe was hyper- extended at the metatarsophalangeal joint, a percutaneous Operative Technique extensor tenotomy was done proximal to the metatarsopha- All operations were done outpatient. Mild to moderate langeal joint with a No. 11 blade scalpel. If the operative sedation with an ankle block and an Esmarch ankle tourni- toe was flexed, the Esmarch tourniquet was released before quet were used for all patients. Complete extremity prepa- closure to relax flexion. A flexor tendon release was never ration, double gloving, no touch technique, and thorough required. The wound was closed in layers using 3-0 Dexon intraoperative irrigation were used for each case.10,13 A3/4- for the extensor hood and subcutaneous tissue. The skin in dorsal longitudinal incision was made over the proximal was closed with a running 4-0 nylon suture. A soft dressing interphalangeal joint. The initial incision was carried down was applied, with a 4-in elastic wrap keeping the toe in the to bone. The extensor hood, capsule, synovium and collateral corrected position. ligaments were released. The volar plate was not cut, and the flexor tendon was not exposed or released. A mini-oscillating Postoperative Care saw was used to cut the cartilage and subchondral bone from An open-toe postoperative shoe was used constantly for the distal proximal phalanx at a right angle to the longitu- the first 2 weeks. The patient was advised to elevate the dinal axis of the proximal phalanx and removed from the foot above the heart for the first 48 hours as much as field. The toe was flexed, and the proximal middle phalanx possible and to keep the dressings clean, dry, and intact was dorsally subluxed. The cartilage and subchondral bone during the first 2 weeks. After the first 2 weeks, a light were cut using the mini-oscillating saw at right angles to the dressing was worn until all eschars were gone and the longitudinal axis of the middle phalanx. This piece also was wound was completely healed. There were no restrictions in removed from the field. If the proximal interphalangeal joint weightbearing imposed during recovery. The first visit was was easily corrected with the bone ends opposed without 10 to 14 days after surgery for the first dressing change, tension no further resection was necessary; if not easily suture removal, and steri-strip application. Ten days after corrected, more of the distal proximal phalanx was removed suture removal showers were allowed with air-drying. No as needed to correct the deformity completely without force. soaking or tub baths were allowed for the first 6 weeks. Excessive resection was avoided to minimize the risk of The patient was next seen routinely 6 to 8 weeks from an unstable construct. A 2.0-mm drill was used antegrade surgery for followup and radiographs. Comfort shoes with to open the intramedullary canal of the proximal phalanx extra depth were recommended and encouraged for the next (avoiding drilling the subchondral plate proximally). The 2.0- 4 to 6 weeks. Any shoes were allowed thereafter (usually mm drill was then used retrograde to drill through the middle at 10 to 14 weeks). The final checks were recommended 6 phalanx and into the distal phalanx. Care was taken to avoid months from surgery and then 1 year later. drilling through the tuft of the distal phalanx. It is important The patients were called back for this study. A patient to hold the distal phalanx straight and aligned to the longitu- satisfaction survey was completed, and toe radiographs were dinal axis of the middle phalanx during retrograde drilling.
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