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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

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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 metatarsophalangeal 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 hyperextended 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. obtained and evaluated for status of healing and final toe A 2-mm smooth spike was then used proximally and distally position. An American Orthopaedic Foot and Ankle Society to slightly over-ream the areas of previous drilling (failure forefoot evaluation form was completed. to over-ream would have made later rod insertion impos- sible). The lengths of the drillings were carefully measured RESULTS with a depth gauge, and a 2-mm absorbable pin was cut and beveled as needed to attain proper length and to avoid sharp None of the patients had wound infection or toe swelling. edges. The absorbable pin was then inserted into the middle Complete bone union occurred in 38 of the 48 toes (73%) phalanx. The dorsal phalanx was held straight in relationship seen at final followup (Figure 1). Five toes with initial to the middle phalanx, and the distal absorbable pin was slid fibrous unions at 6 weeks progressed to solid bone unions through the intramedullary canal of the middle phalanx and and 12 initial delayed bone unions at 6 weeks advanced to into the distal phalanx until the distal interphalangeal joint solid bone unions at final followup. Nine toes (19%) had was straight and the pin was secure in the distal phalanx. A fibrous unions on radiographs. Clinically, there was some moderately-sized needle holder or hemostat was then used to motion on mild stress of the proximal interphalangeal joint

Downloaded from fai.sagepub.com at American Orthopaedic Foot & Ankle Society on December 17, 2013 918 KONKEL ET AL. Foot & Ankle International/Vol. 28, No. 8/August 2007

Fig. 1: Thirty-seven months after proximal interphalangeal joint arthrodesis Fig. 3: Thirty-ﬁve months after proximal interphalangeal joint arthrodesis left second toe with absorbable pin and solid fusion. of the right third and fourth toes with absorbable pins, delayed fusion occurred in the third toe.

area (Figure 2), and five toes had delayed bone unions on radiographs (Figure 3). Clinically, no motion occurred with mild stress of the proximal interphalangeal joint area (8%). No patient had a hyperextension deformity of the proximal interphalangeal joint; therefore, no painful toe recurvatums occurred. Two patients had hyperextension deformities of the distal interphalangeal joint (21 degrees and 15 degrees). The 21-degree hyperextended distal interphalangeal joint resulted in an 11-mm floating toe. The toe with 15 degrees hyperextension at the distal interphalangeal joint was not floating or causing any problems. The amount of fixed proximal interphalangeal joint flexion averaged 20.5 degrees and distal interphalangeal joint flexion averaged 11.3 degrees. Floating toes occurred nine times. Four (patients 2, 24, 30, and 50) were associated with Weil metatarsal osteotomies on the same toe.14 One patient with a 16-month followup still had some wound tightness and a 5-mm floating asymptomatic toe. A 95-year-old woman (patient 10) had some gradually increasing hallux valgus with mild encroachment of the great toe on the second toe. This resulted in a 3-mm floating second toe, which caused her no problems. Three 3-mm floating toes occurred for unknown reasons. There were seven medial angulations and one lateral angulation. One patient who had a stroke had a 42-degree Fig. 2: Twenty-two months after right second toe proximal interphalangeal apex medial angulation of the distal interphalangeal joint. joint arthrodesis with absorbable pin, fibrous union is present. The tip of the second operated toe crossed under the third toe. Another patient had 26 degrees apex medial angulation

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 919 of the proximal interphalangeal joint and a hypertrophic resection arthroplasty or tendon transfers are dissatisfied distal interphalangeal joint with soft corns. One patient because of excessively short toes, malposition, floppiness, developed a solid bone fusion with a hypertrophic medial or hyperextension of the proximal interphalangeal joint with condyle and a 30-degree medial angulation in the proximal symptomatic calluses under the distal proximal phalanx interphalangeal joint after surgery with a painful soft corn. (painful toe recurvatum). No hyperextended toes at the One year after her initial surgery she had removal of proximal interphalangeal joint occurred in our series and the prominent condyle with complete relief of her painful no painful toe recurvatum. Providing stable fixation for soft corn. One patient developed a pseudarthrosis at the over 6 months with the absorbable pins decreased the proximal interphalangeal joint with 30 degrees of apex possibility of hyperextension of the toes at the proximal lateral angulation. She had no pain, swelling, or problems interphalangeal joint arthrodesis site and gave the toes overall with her toe. Two patients developed 21 and 27-degree a normal appearance.20 Unsuccessful results of hammer-toe medial angulation, that conformed to their hallux valgus correction have been reported by several authors (5% to interphalangeus and was asymptomatic. One patient had 50%).2,8,13,18 There were 8% unsuccessful results after an a fibrous union with an asymptomatic 35-degree medial average followup of 39 months in this study. angulation. Patients do not like the pins sticking out of their toes. The There were three mallet toes in the same patient. The technique used in this study leaves nothing penetrating the second and third toes had calluses on the dorsum of the skin and nothing to remove. Furthermore, activity level was distal interphalangeal joint requiring careful choices when severely restricted until the pins were taken out and the toe buying shoes. The fourth toe distal interphalangeal joint wounds were healed (no eschars or drainage present). The mallet deformity did not bother her and had no calluses or only activity level restrictions in our study were related to the corns. Corrective surgery was offered, but she refused. primary wound healing. Even with successful proximal inter- Three patients were dissatisfied (five toes, 8%) and would phalangeal joint arthrodesis, 8% to 44% of operatively treated not have the procedure again. Two mallet toes in the same lesser toes develop symptomatic mallet toe deformities.3,4,5 patient were callused and intermittently painful, depending Symptomatic mallet toe deformities occurred in 4% in this on the shoe worn. One patient with third toe involvement series at an average followup of 39 months. There have had a deviated toe tip at the distal interphalangeal joint been reports that a toe “too straight, hyperextended, or with it crossing under the third toe and one patient with not touching the ground” leads to greater dissatisfaction two operated toes had some thickness of the scar about the among patients.14 Floating toes not associated with the Weil proximal interphalangeal joint and some tenderness when osteotomy or progressive hallux valgus with encroachment walking at 2 years after srugery. The tenderness while on the second toe occurred in 8% of toes in this series. The walking prevented her from walking more than 1 mile at amount of floating ranged from 3 to 11 mm, an average 4 mm a time. when standing barefoot. No absorbable pins were removed in The overall success rate was 91% (25 extremely satisfied this study group. There was no evidence that the Orthosorb patients, five very satisfied, and two satisfied). The AOFAS resorbable pin used in this study to stabilize the toes during Lesser Toe Scale range was 68 to 95 with an average score healing caused any problems with the adjacent bone or soft of 92.9 Most patients would have the surgery again (91%). tissue. Some of these patients had hammertoe surgery of the lesser After reviewing our results, one shortcoming of this proce- toes of the opposite foot using Kirschner wires or resection dure was identified. The size of the absorbable pin in larger arthroplasties. They greatly preferred the hammertoe surgery toes contributed to the medial-to-lateral angulations noted in with the absorbable implant, because the toes appeared more seven toes. Some larger toe lengths and intramedullary diam- natural and no secondary procedures were required. eters exceeded the 2.0 mm diameter and length of the implant available. When this happened the implant would toggle in DISCUSSION the intramedullary canal and was not as long as desired to stabilize the distal interphalangeal joint. Another absorbable The incidence of hammertoe deformity increases with pin size, 10% to 15% wider and longer than currently avail- age, and a second toe deformity commonly is associated able might result in a stiffer construct with less opportunity with hallux valgus. Proximal interphalangeal joint arthrodesis for the larger toes to yield to any deforming forces at the first described by Soule almost 100 years ago is still the proximal interphalangeal joint or distal interphalangeal joint accepted treatment.7 Kirschner wires, screws, bone dowels, during healing. and 26-gauge wire sutures have all been used to keep the The described technique is a simple, safe procedure for the proximal interphalangeal joint straight until arthrodesis or correction of painful hammertoe deformity. Patient satisfac- stability has been assured.16 Metal pins, wires, and screws are tion was high, and followup required only wound precautions subject to infection, bending, breakage, pain, and premature and no pin management or pin removal. This procedure extrusion. In our series, breakage or hardware problems is used by the principal author for hammer-toe deformi- using absorbable pins did not occur. Many patients with ties requiring surgery when the metatarsophalangeal joint is

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