A Closer Look At Suture Stabilization for Digital Arthrodesis

Offering a case review of six patients, these authors provide a guide to a novel in-bone suture stabilization method for digital arthrodesis, which may facilitate adequate reduction of hammertoes.

Digital arthrodesis is a common procedure performed by podiatric surgeons. Soule, in 1910, was probably the first to describe the use of proximal interphalangeal phalangeal joint (PIPJ) arthrodesis for hammertoe correction.¹ Schrier and colleagues showed that PIPJ arthrodesis and PIPJ resection demonstrated no significant differences at 3- and 12-months post-op with the exception of digital alignment being better on sagittal radiograph in the arthrodesis group.² Coughlin and coworkers noted union in 81 percent of those who had PIPJ arthrodesis with 92 percent improvement in pain.³ Glissans, who is often referred to as the father of arthrodesis, suggested complete removal of articular cartilage and interposing soft tissue with close fitting bone apposition and optimal anatomic joint positioning.⁴

The hardware for digital arthrodesis varies and surgeons frequently utilize hardware they are most comfortable with and what is readily available. The description of various techniques for digital arthrodesis by D’Angelantonio and colleagues is a great source of information when considering surgical options.⁵ Dayton and Smith used wide positional sutures to maintain toes in a rectus position.⁶ Doty and Fogleman suggest that implants are as effective as k-wires, but cost significantly more for digital surgery.⁷ Harris and coworkers describe the use of stainless steel cerclage wire to maintain reduction and hold bone apposition.⁸ Hood and colleagues propose the use of buried, slightly diverging k-wires for inexpensive PIPJ arthrodesis.¹ Comparing the strength of various techniques for digital arthrodesis, Vanik and coworkers found cerclage wire to be the strongest.⁹  

Step-By-Step Surgical Pearls

Using these concepts and in an attempt to create a stable inexpensive technique for digital arthrodesis, we developed the in-bone suture stabilization method.

First, one places a linear longitudinal incision centrally over the digit. Carry dissection down to the level of the extensor tendon and expose the PIPJ in the usual manner. Carefully dissect the dorsal head of the proximal phalanx and the dorsal base of the middle phalanx from the surrounding soft tissue. Use a sagittal saw to resect predetermined amounts of bone from either side of the joint. Proceed to make bone cuts to create a rectus toe and reduce any concomitant deformity. Then use a small dental bur to drill a hole approximately 2 to 3 mm from the bone cuts into intact cortical bone in both the dorsal distal phalanx and the dorsal proximal phalanx. One makes the drill hole to communicate with the medullary canal without passing through the opposite cortex. From the dorsal drill hole, pass 0-vicryl into the medullary canal of one phalanx and subsequently pass it into the medullary canal and out of the dorsal drill hole of the second phalanx. Run a k-wire anterograde and ultimately retrograde through the phalanges to create splintage. Press the phalanges together while tightening and tying the suture. The surgeon should be careful to tie the suture off without breaking the dorsal cortices of the phalanges. One can obtain closure in the usual fashion.

Although this technique requires a few extra steps, the time required to complete them is minimal and worthwhile. The suture is eventually hydrolyzed. We postulate that this leaves the medullary canals open for new bony ingrowth. The technique also prevents pistoning of the phalanges on the k-wire and, to a lesser degree, prevents rotational forces around the k-wire at the target site of arthrodesis, leading to suture stabilization.

What The Case Review Revealed

Although we have utilized the aforementioned technique for dozens of patients at our institution, we used billing codes (28285-hammertoe correction) to choose six patients at random in order to review outcomes and complications. Initially, we included patients if they had a digital arthrodesis with the aforementioned suture stabilization technique and were over the age of 18. The procedure must have included resection of bone from the PIPJ or DIPJ or both, and the use of a drill and suture to stabilize the arthrodesis site. We selected patients if their surgeries were performed at one hospital institution by the lead author.

Patient ages ranged from 58 to 73 years with the mean age being 65.2 years. The study included six patients (11 toes). Two patients had a history of type II diabetes mellitus. One patient had surgery on both feet. All of the surgeries in this study group were index procedures.

In assessing plain film radiographs, there was arthrodesis at the target surgical sites for nine of the 11 toes. The second and third toes of one patient did not show complete arthrodesis and went on to have a non-painful pseudarthrosis. This was likely due to patient non-compliance. All of the patients were, however, satisfied with surgical correction.

Final Notes

In conclusion, the suture stabilization technique for digital arthrodesis is a simple modification that requires little additional surgical time, is cost-effective and provides adequate reduction of non-reducible hammertoes. Additionally, we have used this technique successfully for revisional digital arthroplasties as well as revisional arthrodesis procedures. It is our hope that this suture stabilization technique can become another useful tool in our podiatric armamentarium of hammertoe deformity correction.

Dr. Greenfield is the Chief of Podiatric Surgery at Delaware County Memorial Hospital in Drexel Hill, Pa., and is in private practice in Havertown, Pa. He is board-certified in foot and ankle surgery by the American Board of Podiatric Surgery.

Dr. Cornell is board-certified in foot and ankle surgery by the American Board of Podiatric Surgery, and is in private practice in Havertown, Pa. She is affiliated with the Delaware County Memorial Hospital and its Center for Wound Healing in Drexel Hill, Pa.

Dr. Friis is a Chief Resident with the Crozer Keystone Health System in Pennsylvania.  

Dr. Stayman is a second-year resident with the Crozer Keystone Health System in Pennsylvania.

References
1. Hood CR, Blacklidge DK, Hoffman SM. Diverging dual intramedullary Kirschner wire technique for arthrodesis of the proximal interphalangeal joint in hammertoe correction. Foot Ankle Spec. 2016;9(5):432-437.
2. Schrier JC, Keijsers NL, Matricali GA, Louwerens JW, Verheyen CC. Lesser toe PIP joint resection versus PIP joint fusion: a randomized clinical trial. Foot Ankle Int. 2016;37(6): 569-575.
3. Coughlin MJ, Dorris J, Polk E. Operative repair of the fixed hammertoe deformity. Foot Ankle Int. 2000;21(2):94-104.
4. Glissan DJ. The indications for inducing fusion at the ankle joint by operation with description of two successful techniques. Aust NZ J Surg. 1949, 19(1):64-714.   
5. D'Angelantonio AM, Nelson-Rinaldi KA, Barnard J, Oware F. Master techniques in digital arthrodesis. Clin Podiatr Med Surg. 2012;29(1):21-40.
5. Dayton P, Smith D. Dorsal suspension stitch: an alternative stabilization after flexor tenotomy for flexible hammer digit syndrome. J Foot Ankle Surg. 2009;48(5), 602-605.
6. Doty JF, Fogleman JA. Treatment of rigid hammertoe deformity: permanent versus removable implant selection. Foot Ankle Clin. 2018;23(1):91-101.
7. Harris W, Mote GA, Malay DS. Fixation of the proximal interphalangeal arthrodesis with the use of an intraosseous loop of stainless-steel wire suture. J Foot Ankle Surg. 2009;48(3):411-414.
8. Vanik, RK, Weber RC, Matloub HS, Sanger JR, Gingrass RP. The comparative strengths of internal fixation techniques. J Hand Surg Am. 1984;9(2):216-221.