Surgical Correction of Hammertoes

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Surgical Correction of Hammertoes
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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

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What Causes Hammertoes?

• Hammertoes are primarily caused by a muscle
  imbalance during gait
• There is also evidence that poor fitting shoes
  can contribute

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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

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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

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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

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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 whats out there
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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

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Screw Fixation

• Advantages
• Not sticking out of skin
• Provides compression
• Disadvantages
• Toe is completely straight and cant bend at DIPJ
• Can still rotate
• More difficult to remove than a wire if needed

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Absorbable Pins

• Advantages
• Internal
• Cost efficient
• Disadvantages
• No compression
• Toe can rotate
• Patient can have a reaction to the material

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Stay Fuse

• Advantages
• Internal
• Provide some compression
• Different sizes
• Disadvantages
• 2 pieces
• Costly
• Higher chance for error

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Biomet Weil-Carver Implant

• Advantages
• Resorbable with Lactosorb poly-L-lactic/polyglyco
  lic acid copolymer
• Retains strength 6-8wks, degrades approx 12 mos
• Partially threaded, barbed to prevent pistoning
• Disadvantages
• Toe can still rotate
• Doesnt provide complete compression

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Smart Toe

• Advantages
• Internal
• Provides some compression
• Prevents rotation
• Also comes with an angled version
• Disadvantages
• Must be cooled prior to implantation
• Costly

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X Fuse

• Advantages and Disadvantages comparable to the
  Smart Toe

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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

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Screw-Barb Configuration
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Barb-Barb Configuration
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Pins
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Broach with AO Quick Connect
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Drivers
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Implant in Bone Model
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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. Doesnt require dry ice etc. then the
  rep doesnt have to be present for every case.
  (Earning income while golfing)