HAMMERTOES CAUSES AND CORRECTIONS Gregory J. Kramer, DPM, FACFAS Ankle and Foot Associates of Southern Georgia

Hammertoes Abnormal contracture of the joints of the lesser digits Anatomy Classification Etiology Treatment Surgical Arthroplasty vs. Arthrodesis OrthoPro Screw 2

ANATOMY Osseous Structures Soft Tissue Structures 3

Osseous Structures Articulations Metatarsal Phalanges Head Shaft Base Proximal Middle Distal Articulations Metatarsal Phalangeal Joint (MPJ) Proximal Interphalangeal Joint (PIPJ) Distal Interphalangeal Joint (DIPJ) 4

Soft Tissue Structures Tendons Extrinsic Extensor digitorum longus Flexor digitorum longus Intrinsic Extensor digitorum brevis Flexor digitorum brevis Dorsal and Plantar Interossei Lumbricles Quadratus plantae 5

Classifications Classic Hammertoe Claw Toe Mallet Toe Rigid Flexible 6

Classic Hammertoe 7

Claw Toe 8

Mallet Toe 9

Push Up Test 10

Etiology of Hammertoes Genetic Acquired Shoe gear Trauma Biomechanical Flexor Stabilization Flexor Substitution Extensor Substitution 11

Treatment Conservative Surgical 12

Conservative Shoe modification Accommodative padding Orthotic devices 13

Surgical Treatment “You have this” “We are going to give you this” “Is it really that simple?” 14

Surgical Treatments Soft Tissue Procedures Osseous Procedures Sequential Release 15

Soft Tissue Procedures Tenotomy Extensor tenotomy and capsulotomy Flexor tenotomy and capsulotomy Flexor tendon transfer 16

Osseous Procedures Resection of base of proximal phalanx Syndactylization Arthroplasty Arthrodesis 17

Sequential Release 18

Arthroplasty Most common procedure performed for hammertoe correction May or may not require fixation Usually requires addition of soft tissue procedures 19

Arthroplasty Types of fixation K-wire Absorbable rod Implants Shaw rod Ship implant 20

Arthrodesis Usually requires addition of soft tissue procedures Is not performed on the fifth digit Requires fixation Types of fixation K-wires (smooth or threaded) Screws Various implants 21

Types of Arthrodesis End to End Peg in hole Insitu 22

ARTHROPLASTY VS. ARTHRODESIS Athrodesis Most common procedure performed for hammertoe correction Technically easy procedure Some motion is retained Shortening of digit is inherent to procedure May be unstable Increased chance of recurrence of hammertoe deformity Fixation K-wire Implant Indications Flexible to semi – rigid deformity Not as common Technically more difficult procedure No motion, toe is rigid Maintains relative length of digit Stable Minimal chance of recurrence Longevity of correction Fixation Screw Threaded or Smooth K-wire Implant Indications: Loss of Intrinsic muscle stability Diabetes Neuromuscular conditions 23

ADVANTAGE OF ORTHOPRO SCREWS OVER K-WIRES OR IMPLANTS FOR USE IN DIGITAL ARTHRODESIS Technically easy No exposed K-wire Less chance of pin tract infection No need to remove the pin at a later date Less chance of bending or breaking of the pin Quicker return to bathing and shoe gear Provides superior compression Provides stability even in the face of pseudoarthrosis Stabilizes both distal and proximal interphalangeal joints 24

Quips and Tips Don’t try to be an expert on procedure choice Be the expert on your implant Know the technical aspects of your implant (i.e. lengths, diameter, etc.) 25