Surgical Correction of Hammertoes. What are Hammertoes? Classic Hammertoe –MPJ is cocked upward and PIPJ is downward Claw Toe –MPJ is upward, PIPJ and.

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)