Removing Failed Hammertoe Implants Following Nonunion

These authors offer insights on removing failed hammertoe implants from a 53-year-old-female who presented with a chief complaint of continued pain and swelling localized to her right and left fourth toes.

   Hammertoe deformity is the most common deformity of the lesser toes, consisting predominantly of flexion contracture at the proximal interphalangeal joint (PIPJ) with associated compensatory hyperextension of the metatarsophalangeal joint (MPJ) and distal interphalangeal joint (DIPJ).

   Subsequently, hammertoe repair is one of the most commonly performed procedures that foot surgeons do. Various researchers The literature has documented numerous procedures for hammertoe correction that are widely accepted, including arthroplasty, tendon transfers, arthrodesis and in the extreme circumstance, amputation.1-19 Digital arthrodesis alone has a wide range of currently acceptable options, including peg-and-hole or end-to-end constructs with simple percutaneous pin fixation versus buried intramedullary devices.1,2,4,6-9,12-14,17,19

   In this article, we describe the case of an adult female who presented with continued focal pain and swelling after another surgeon performed hammertoe surgery using implants. Clinical and imaging examinations revealed the presence of failed implants. We determined the pain was a result of nonunion at the proposed digital arthrodesis site with associated internal fixation device failure. We proceeded to remove the failed implants and performed a revisional arthroplasty. The patient responded well and was ambulatory with a return to normal activities six weeks postoperatively.

Pertinent Insights On The Patient Presentation

The patient, a 53-year-old-female, presented with a chief complaint of continued pain and swelling localized to her right and left fourth toes. The pain was aggravated by standing and walking. Additional subjective reports included perceived “grinding” with walking or simple movements of the affected toes. Although there was no history of recent trauma, she did have prior surgical interventions by another surgeon for what began as painful hammertoe deformities.

   The patient underwent initial surgery for the second, third and fourth toes on the left foot three months prior to her first visit for a second opinion with subsequent revision occurring approximately six weeks later. At the time of the revision, she also chose to have similar repair of painful hammertoes of the second, third and fourth toes on the right foot.

   No complications arose in the immediate postoperative course. She returned to supportive tennis shoes with her custom orthotics and took prescription anti-inflammatory medications for continued pain and residual edema. She also used icing and extremity elevation, limited her activities, and attended physical therapy with only minimal pain relief.

   Her past medical history included obesity, sleep apnea, hypertension and hyperlipidemia. The surgical history included heart surgery at the age of 5, recent multiple, bilateral foot surgeries, a hysteroscopy with ablation and a hemorrhoidectomy. She had previously smoked for 25 years but quit smoking approximately 10 years before presenting to our clinic. The social history was otherwise unremarkable. Her family history included heart disease and lung cancer.

   The physical examination of the symptomatic digits revealed significant focal tenderness to palpation over the proximal interphalangeal joint (PIPJ) with mild varus rotation distally over the left distal interphalangeal joint (DIPJ) region. All skin incisions were well healed and adjacent skin was of normal coloration and appearance. Soft tissue edema was present in all post-surgical lesser toes but noticeably intensified over bilateral fourth toes.

   All the above findings were more pronounced on the left foot. The affected toes also demonstrated no deviation in skin temperature, hydration or hair growth in comparison with the same areas on the other, asymptomatic post-surgical toes.

   The biomechanical evaluation demonstrated bilateral ankle equinus as well as flexible flatfoot. The remainder of the physical examination was unremarkable.

   We compared standard weightbearing radiographs of both feet to those taken in the initial, immediate postoperative period. Repeat imaging revealed continued soft tissue edema of bilateral fourth digits in addition to interval failure of the implant with evidence of nonunion at the PIPJ arthrodesis site of the third and fourth digits on the right foot and four on the left foot. No other complicating process or abnormality was visible. There was no evidence of periosteal reaction, adjacent cortical disruption, osteophytic proliferation or cystic formation within the affected joints.

What You Should Know About Implant Removal

Based on the progressive clinical symptomatology and imaging findings, we proceeded to the operating room for surgical inspection, attempted removal of failed implants and attempted bone biopsy. This was an effort to make an accurate diagnosis and to attempt to alleviate the initial complaint of pain, which we believed to be directly related to the failed internal fixation device and suspected nonunion.

   In the operating room, the surgeon made a linear longitudinal incision over the dorsal aspect of the PIPJ using prior skin incision sites. We noted extensive fibrous tissue surrounding the attempted PIPJ fusion site. Upon entry and exposure into the affected joints, no osseous union was visible. Upon further inspection, we noted that the retained metallic implants in the fourth toes were fractured at the lateral aspect of the distal arm with associated multiplanar mobility at the PIPJ. In the left foot, there was more significant sagittal and frontal plane rotation.

   The implants were relatively rigid and exhibited moderate resistance upon removal from the proximal and middle phalynx components. We fully removed the right device but the left was embedded within the middle phalynx. We could not visualize the lateral most aspect and remove it without aggressive osseous resection. We decided intraoperatively to allow this remnant to remain as complete removal might have resulted in further, unnecessary destruction as no evidence of the metallic implant was directly visible nor was impingement visible at the PIPJ upon movement.

   The remaining osseous tissue was normal in appearance and texture. We sent a specimen for pathologic examination to ensure that no evidence of osteomyelitis was present. The surgeon rasped the hypertrophied osseous prominence smooth. After copious irrigation, we placed bone putty within the voids from implant removal. Layered closure allowed for accurate approximation of the extensor tendon, subcutaneous tissues and skin with toes maintaining rectus alignment.

   The gross pathological examination of the specimens was “heavily mineralized, necrotic lamellar bone” with diffuse marrow fibrosis. There was no evidence of osteomyelitis. We feel this is likely due to nonunion resulting in micromotion and continual rotational stressors that ultimately led to device failure and further inflammation and pain.

   Following removal of the failed implants and revisional arthroplasty at the PIPJ of bilateral fourth toes, the patient has progressed well. Her pain and edema were minimal at six weeks postoperatively and she was pleased with the overall cosmetic appearance. She is ambulatory and has returned to work on a full-time basis (10-hour days standing) without restrictions. Immediate postoperative radiographs revealed interval removal of fourth toe implants with arthroplasty and toes in rectus, anatomical alignment. She did however continue to have intermittent swelling and pain to the left fourth toe only. Due to the potential for recurrence of the deformity, we will continue to periodically monitor her for changes.

Final Notes

The exact mechanism for implant failure in this case remains unclear. Three of the six implants were visibly broken.1,17 Additionally, two of the three broken implants occurred on the fourth toes and were symptomatic to the point that they required revisional surgical intervention with removal of the failed implant and resection of the nonunion with arthroplasty.

   In regard to hammertoe surgery, researchers have reported that the general complication rate of hammertoe surgery is highest in the fourth toe with the most reports of residual pain, swelling and overall dissatisfaction.10 Although hammertoe surgery is a common procedure with numerous well-documented procedural selections that range from arthroplasty to amputation, we must always be aware of underlying biomechanical components when it comes to procedure selection.3,9-11,16,19

   Successful surgical outcomes are not only dependent on fixation but on properly identifying and addressing associated pathology and soft tissue imbalances that contribute to biomechanical instability and development of the hammertoe deformity. Ultimately, fixation is not the only factor in a successful surgery. One must properly understand and address the advantages and limitations of each method of fixation in relation to the patient’s pathology.1-19

   Dr. Desiree M. Scholl practices at Wisconsin Neuropathy Center in Kenosha, Wis.

   Dr. Cernak practices at Wisconsin Neuropathy Center in Kenosha, Wis.

   Dr. Alex R. Scholl practices at Wisconsin Neuropathy Center in Kenosha, Wis.

References

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3. Bouche R, Heit E. Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joint: preliminary observations. J Foot Ankle Surg. 2008; 47(2):125-137.

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9. Edwards WH, Beischer AD. Interphalangeal joint arthrodesis of the lesser toes. Foot Ankle Clinics. 2002; 7(1):43-48.

10. Fishco W. Emerging concepts in hammertoe surgery. Podiatry Today. 2009; 22(9):34-39.

11. Gallentine J, DeOrio J. Removal of the second toe for severe hammertoe deformity in elderly patients. Foot Ankle Int. 2005; 26(5):353-358.

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13. Lane G. Lesser digital fusion with a cannulated screw. J Foot Ankle Surg. 2005; 44(2):172-173.

14. Lehman DE, Smith RW. Treatment of symptomatic hammertoe with a proximal interphalageal joint arthrodesis. Foot Ankle Int. 1995; 16(9):535-541.

15. Mereau TM, Ford T. Nitinol compression staples for bone fixation in foot surgery. J Am Podiatr Med Assoc. 2006; 96(2):102-106.

16. O’Kane C, Kilmartin T. Review of proximal interphalangeal joint excisional arthoroplasty for the correction of second hammertoe deformity in 100 cases. Foot Ankle Int. 2005; 26(4):320-325.

17. Roukis T. A 1 piece shape-metal Nitinol intrameduallary intramedullary internal fixation device for arthrodesis of proximal interphalangeal joint in neuropathic patients with diabetes. Foot Ankle Specialist. 2009; 2(3):130-132.

18. Smart Toe Intramedullary Memory Implant. Surgical Technique. MMI-USA Foot and Ankle brochure.

19. Zingas C, Katcherian DA, Wu K. Kirschner wire breakage after surgery of lesser toes. Foot Ankle Int. 1995; 16(8):504-509.