Surgical Correction of Hammertoes

What are Hammertoes?

• Classic Hammertoe– MPJ is cocked upward

and PIPJ is downward• Claw Toe

– MPJ is upward, PIPJ and DIPJ are downward

• Mallet Toe– DIPJ is downward

What Causes Hammertoes?

• Hammertoes are primarily caused by a muscle imbalance during gait

• There is also evidence that poor fitting shoes can contribute

Muscles Involved

• Extrinsic Muscles:– Flexor Digitorum Longus– Extensor Digitorum Longus– Flexor Hallucis Longus– Extensor Hallucis Longus– Tibialis Anterior– Tibialis Posterior– Peroneus Longus– Peroneus Brevis

• Intrinsic Muscles– Lumbricales

• Plantarflexory force across MPJ/Proximal phalanx

– Quadratus Plantae– Interossei

• Plantarflexory force across MPJ, stabilization in transverse plane

– Extensor Digitorum Brevis– Flexor Digitorum Brevis

Gait Patterns

• Flexor Stabilization– Most common, FDL/FDB overpower the interossei

• Flexor Substitution– Caused by weak Tendo-Achilles where PB, PL, TP,

FDL, FHL try to make up for the weak calf muscles and again overpower the interossei

• Extensor Substitution– EDL overpowers the lumbricales, usually seen in high

arched foot and/or ankle equinus

How do we Treat Crooked Toes?

• We can try to accommodate the hammertoes with non-surgical treatment such as:

• Orthotics• Metatarsal pads• Soft toe caps• Wide, Extra-depth shoes• Digital spacers• Taping/Splinting• Crest Pads

When non-surgical methods fail, we start thinking about surgical options.

We need to decide what techniques and products work best for our patients.

So what’s out there…

Smooth K-Wire

• Advantages:– Quick application– Cheap– Able to cross the MPJ if

needed

• Disadvantages:– Pin is sticking out of toe

and can catch on things– No compression– Increased risk of infection– Toe can rotate– Wire can bend

Screw Fixation

• Advantages:– Not sticking out of skin– Provides compression

• Disadvantages:– Toe is completely

straight and can’t bend at DIPJ

– Can still rotate– More difficult to

remove than a wire if needed

Absorbable Pins

• Advantages:– Internal– Cost efficient

• Disadvantages:– No compression– Toe can rotate– Patient can have a

reaction to the material

Stay Fuse• Advantages:

– Internal– Provide some compression– Different sizes

• Disadvantages:– 2 pieces– Costly– Higher chance for error

Biomet Weil-Carver Implant

• Advantages:– Resorbable with Lactosorb:

poly-L-lactic/polyglycolic acid copolymer

– Retains strength 6-8wks, degrades approx 12 mos

– Partially threaded, barbed to prevent pistoning

• Disadvantages:– Toe can still rotate– Doesn’t provide complete

compression

Smart Toe

• Advantages:– Internal– Provides some

compression– Prevents rotation– Also comes with an

angled version

• Disadvantages:– Must be cooled prior to

implantation– Costly

X Fuse

• Advantages and Disadvantages comparable to the Smart Toe

Orthopro I Fuse

• New product in development

• Comes in Screw-Barb and Barb-Barb configurations

• Small and Large sizes

• Also comes either angled at 10 degrees or straight

Screw-Barb Configuration

Barb-Barb Configuration

Pins

Broach with AO Quick Connect

Drivers

Implant in Bone Model

Summary

• As reps you have more influence on doctors than you know. However:

• Once you can get surgeons to break out of their “old habits” they will:

• 1. Use the quickest implant to insert.• 2. The implant that has minimal complications, high

fusion rate and high patient satisfaction.

• Note: In my opinion, the best implant as far as a rep is concerned is one that has a high degree of “dummy factor”. If the implant is easy to put in: ie. Doesn’t require dry ice etc. then the rep doesn’t have to be present for every case. (Earning income while golfing)