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Dr. Connor: Our program continues this afternoon with Dr. Chris Bromley who I introduced before, so I'm not going to do that again. And he's going to be talking about current hammer toe techniques.

Dr. Christopher Bromley: Thank you, Dr. Connor [phonetic]. Alright. Thank you for coming back, and thank – the whole present staff for having us here this year and having me back. So, the evolution of hammer toe correction evolves in what we talked about this morning. We talked about what we need to do to evaluate metatarsalgia and what role the biomechanics play in that and how we're going to decide to fix it. When I finished residency training in 1992, we had two options. It was in arthroplasty with a K-wire or not or a peg-in-hole, or the end-to-end arthrodesis was also there. But the evolution of hammer toe has really sped up as we got into all the different types of implants, and we're going to go through those implant choices, and the fundamentals about what works for me and how that might work for you, and then where we're going.

So, because of – disclosure, I work with a number of companies. None of them are associated with this particular lecture today. Objectives today is just to understand current trends, and for hammer toe correction, explore your different options of fixation, and what new fixation options we have and how that plays into our choices. Because this is a resident summit meeting, we will spend a little bit more time on the didactics than we would at another meeting. Again, understanding and reviewing from a board's perspective what are the ideology of hammer toe. What role does flexor stabilization, those patients who have global extensor substitution across the board?

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And maybe they have a cavus foot or neuromuscular issue. And then, what role does flexor substation play? And again, this all plays back into the conversation we have this morning with Dr. Sean House [phonetic] about flat foot and what's going on with the biomechanics. How does this foot become unstable, and how do we correct the hammer toe correction? Remembering, it's not just a hammer toe, it's related to all of the other biomechanics things that are going. It didn't occur in a vacuum.

So, the most common pathologic contracture is it obviously occurs in late stance, phase and propulsion due to pronation. So, we talked about that this morning. What will happen is we have FDL and FDB fire earlier and longer to stabilize the hypermobile flatfoot, overpowering the interossei and the resultant dislocation of the MTP joint. And then, the subsequent contracture of the PIP. I think that it was Dr. Sean House this morning who talked about the relationship of the cuboid and the hallux, and that angular relationship as they are parallel in that flexible flatfoot. And we see once those, we lose that sort of intrinsic stabilization, we see that goes on in this flexor stabilization, we see commonly in adductovarus fourth and fifth toes.

In extensor substitution, these are patients who have or typically present, they have a pes cavus, a totally different presentation. Then, we saw in the previous example, they may or may not have foot drop, anterior compartment. The EDL is overpowering the lumbar Kellie during the swing phase, causing deformity at the MTP joint and subsequent contracture at the PIP J, and it causes buckling. So again, this is a swing phase deformity versus the prior which was a stance phase.

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And last but not the least, the least common cause of digital contracture is the weakness in the triceps surae, deep – once your muscle group compensates, this again overpowers the interossei during stance and particularly during propulsion. And then, we see the digits contract at the sagittal plane with minimal varus rotation because we don't have – it's a flexor substitution versus the other deformities that we saw.

Treatment alternatives, obviously, one of the things that we talked about today at lunch today and we've talked about in many other meetings, is that what separates us from our orthopedic colleagues who are doing foot and ankle treatment, is our understanding of biomechanics and our ability to use all of the different alternatives, a great orthotic, the right shoe, the right splint. That's what separates us. So many of our young graduates were coming, "I'm a three-year trained fellowship foot and ankle surgeon." Yes, you may be, but what's separates you from the orthopedics across town is the fact that you understand all the conservative things that you can do to manage this patient. Because everybody that's coming in to see you does not want to have an arthrodesis at their toe or something else.

They really want to talk about what you can do conservatively. And once those conservative measures have failed, then we can talk about this surgical intervention. So that's really for the students that are residents that are in the room, the most important thing to remember is you want to treat these patients as the way you would want to be treated or your mom, or your sister, or your brother, or your dad, and explore all those conservative alternatives. We're not going to focus on those. We're going to focus on surgery. Surgical intervention, again, like we've talked about this morning, understanding and evaluating the MTP joint. If the MTP joint is dislocated or pre-dislocated as Dr. Yu [phonetic] used to say, look at the flexor plate. Look at the collaterals. And then, figure out how you're going to stabilize this whole complex. Because if you fix the toe and you haven't fixed the MTP joint, obviously, and you haven't stabilized the biomechanics, you're not going to be able to go on and be successful at the arthrodesis, if that's what you so choose to do.

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So, in general, multiple digital stabilizations at the PIP and MTP joint are indicated if you've got an advanced digital contracture and lots of different things going on. These deformities really need to be looked at. It's more than just a corn.

The transverse plane deformities are present. They typically we see that second toe start to move over towards the hallux. It's just very difficult to treat. We look at the ultrasound this morning in that lecture, if you look at the plant or capsular structure, when you see that second toe start to drift over toward the hallux, it's very difficult to correct. It's one of my least favorite things to correct because I've got to do something to stabilize that joint. You've got to fix the toe. You've got to fix the MTP. You got to get it down and move it back over toward the third which is tough. The soft tissue anchors that. We alluded too this morning the procedure that we – the ToeTac that we looked at, and we're doing some work now investigating different ways to use anchors to do the same thing, soft tissue anchor, because we're looking to be able to stabilize that whole plantar construct.

So, if you take a second toe that's contracted at the MTP joint and you fixed that PIP, it's now sitting up in the air, if you haven't corrected that component. That's why these two lectures go together so well. When I was coming out of school, there was the sequential release. So, the sequential release typically may have longitudinal incision. Eventually, we did semi-electricals that are longitudinal. We did a long extensor hood resection, the extensor tenotomy. It was either usually transverse. And then, we started 15 blade or a dissection around the PIP to release that. And then, if the toe was still contracted to the PIP, we went back and addressed the MTP joint.

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And then, that suggested that maybe we do a flexor plate release with the McGlamry elevator and then – and so forth, performing this push up test at each level. I said to you this morning, and I will say it to you again, I don't use McGlamry elevators. I don't think the MTP joint needs to be released. It's already too loose. And the only thing you're going to do if you perform that is make it worse. So again, we talked about this morning about how important that is and how dynamic this deformity is, so you have to make sure. You still go through this sequential release but making sure you understand that you have to have that sort of preplanned flexor plate that you're going to address. Hopefully, you've talked about it in the preop setting. And then, also talk about whether or not you're going to reconstruct that or do one of the soft tissue anchoring procedures that we talked about to stabilize the MTP joint.

Arthrodesis again is indicated if you got multiple trauma. I do arthrodesis. Universally, I don't perform arthroplasties and I certainly don't do peg-in-holes. And those are sort of old-school. Flexor tendon transfer, we alluded to a little bit this morning, they were sort of popular for a while. But if you looked at the amount of dissection and the amount of swelling that resulted in the toe, and the amount of correction you got, it was a good idea. But it's just really difficult to execute and get consistent results. If there are folks in the room that do them well, my hats off to you.

The implant alternatives, sort of going back to when I finished my training, this is what we – our typical toe look like. You've got a nice K-wire with a little pin on the end, and this is what you looked at. The downside of doing this is obviously when you removed it at two and a half to four weeks, whatever your window was, the toe usually popped up back where it was before, because we didn't fix the soft tissue. It was Gerard Yu [phonetic] who convinced me to use 65 instead of the 45 K-wire, and I'm glad he taught me to do that, because they were much easier to get out.

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But we don't do that much anymore. So, what implant or alternatives do we have? There are gazillion different implants out there. What we saw was way back when in the early '90s, we had the Orthosorb pins. And then, the Orthosorbs were popular for a while. And then, they faded, because patients ended up with these granular reactions. They really didn't arthrodise that well.

And then, we went through a phase where we had a Smart Toe and then maybe not so Smart Toe. And then, all of these different metal implants, and we'll go through some of the ones that we're familiar with and have experience with. And then, what I see now is sort of the trend, we have those allografts. The Solana products were the first to market, and we've seen a number of different aversions of those come back into phase. I think a lot of us that did the metal implants when the patients either broke their toe or re-injured their toe, or we've lost, we didn't get – we end up taking a lot of those metal ones out if they failed. The nice thing about the absorbable ones is if they fail, you didn't have to take them out. You could just hopefully get along with the way the toe was.

So, some of these implants I like were – I put this one in there particularly. I like this implant as sort of my second favorite of the metal implants because it had multiple component sizes. Many of you I'm sure in this room who've done arthrodesis before, if the inside of the metal fillings is really cavernous, it's a small bone to bone, it's really soft in there, one of the things I like about this particular implant was it was angulated at 10 degrees. It clicks together. It unclicks, so you can get it out. And if you had – if you did the drilling, and many of you I'm sure you've had this experience where you go ahead and you put the drill into the metal fillings, and that just drops in there. It's really, really soft. So, the advantage of this particular system over some of the other systems is you can – you have different sizes and it's very easy to use.

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And you can get it out just by screwing it out as opposed to having to work with any of the nitinol or the expanded implants. The Link implant is probably the implant that we've used the most. I typically use a 10 degree. The implant is placed into the proximal fillings and into the middle fillings. And then, you use a tool to compress the center. When you do that, it deploys the proximal and distal barbs and creates pressure against the internal surface and gives you the fixation that you're looking for. And typically, after you do that, there's a little bit of a gap, and you push it close. And you get a bone to bone positions. I've had great success with this particular implant. I think the instrumentation is better than many of the others. It's very exact thing. And they key pearls to this implant, like any of the other metal implants, is I typically no matter how many thousands of these that I've done, is that I will always pre-drill with a 45 K-wire into the proximal fillings, take a picture to make sure I'm exactly where I need to be.

And again, use the same K-wire, drill into the middle fillings, take a picture, and then go ahead and hand drill to put the implant in, knowing that the drill bit will likely go where my K-wire was. And it gives me a much lower risk of error in the position. These small toes are more difficult than even doing a bunion, distal bunion with screws, because the margin for error in the fillings is very small. I typically prepare the joints, use a sagittal saw or a rongeur just to remove the cartilage to try to prevent over-shortening.

Some of the other implants that are out there, are there are some poly implants that are available, straight, and angulate, and the ones that are now available I think from Paragon are cannulated.

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So, you can use that K-wire if you need to stabilize the toe to the fillings. But again, like we said this morning, the K-wire is really not the treatment of choice. The treatment of choice is to fix the soft tissue instability at the MTP joint with or without your osteotomy so that you can maintain the correction. Because obviously, once you remove the wire from that particular toe, it's going to have a tendency to drift back up, which is all the reason the patient came in the first place.

These absorbable implants have come back into the market. I like them as opposed to some of the metal implants because they're going to promote diffusion. They're very easy to use. And if there's a failure, if you don't get your arthrodesis or the patient, like the one of mine who was camping and tripped over a bunch of rocks that were creating a fireplace, if they crack this or they disturb you, it should release, just dissolve and go away, I will typically again always use the 10-degree implant so the toe is not perfectly straight. Normal toes, PIP joint is about somewhere between 15 and 17 degrees. So, the 10-degree is a good start. We can angle our cut at the arthrodesis too to make it a little bit more natural. The last thing you want to do is have somebody who comes in for their second toe correction, and all of their other toes have that normal contracture. Now, they have a rigidly straight second toe that doesn't look really good.

The CrossTIE and some of the other Vicryl implants are available. I've never done them, but I put them in there for completeness, the idea of creating this canal and being able to thread that through and pull it in just seems to be overkill for me.

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Again, this is one of the more – this one came from Paragon. The hammer toe implant is obviously a PEEK implant that has some titanium spray, and it helps with the bone, the advantage of being able to use it. It is cannulated. It does accept the K-wire and it comes in two different sizes. Obviously, they do have an angular offering but you can't use the wire with the angular offering. These allografts, this is their N2 bones again for completeness. We mention everybody, they mentioned this one has come back on and slightly different than the Solana one that we talked about earlier.

When we do these, typically, all implants, I typically want to remove as little bone as possible. As I mentioned, I usually will also angular this cut, a little sort of dorsal distal or plantar proximal, so that I can get more of that natural – we've taken a little bit more bone here than we do dorsally. And we want to be able to get a little bit more of a natural articulation when we do get infusion. This is an example from a procedure perspective using that small K-wire to find a medullary canal and then go ahead and drill in that hole. Again, this is a good example because this is a patient who has a very small proximal fillings width here, mid-fillings. These are ones you want to drill very carefully by hand. Most of the drill guides, they have the proximal line here, and then they have middle fillings you're going to drill to the line. Again, you want to – if you've done the wire, typically, and you're doing this by hand, always, will go down and find that canal where you need to be.

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This particular implant has some instrumentation which is nice so you can grab it and click it, and not drop it on the floor as many as we've done. I've done that once but it does happen. Typically, you can slide that implant in. Whenever you do these allografts, whether it's this brand or another brand, they have a tendency sometimes to be a little bit tight when you go to push them in. I don't force them in. Typically, what I do is take the drill bit and take it off the hand piece. I just pass it in and pass it out one or two times. And that clears that canal out, any of the bone debris that might have been in the way. And if you do that, then this implant slides in very nicely here. You can see that where I bias this cut from dorsal, distal, plantar, proximal. And then, when you got this 10-degree implant and you've got a few degrees here, you're getting that toe with a nice articulation.

Again, doing this by hand, it's going to follow – you're going to go to this line. You'll see it fits right in there and press it very, very nicely. We're a little too ahead of ourselves. Okay.

So, this is a salvage case. This young lady came in and this is what she had left. One of my colleagues in town performed an arthroplasty. You could see the toes got a deformity here at the MTP joint and she's got basically a flail toe, not particularly happy with this. She doesn't like the fact that it's short. And I really didn't want to operate on her. I tried to convince her. You can just tell by the look of this foot, this is not a foot that has great, great tissue quality. So, what we did was we went to try to get this back out to length. We opened this up, squared off the edges, pre-drilled with a 35, and then hand-drilled and out the allograft in.

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And then, we used a small bone, a piece of allograft over top of the implant to create a space and we got that toe out to line. And it looked fantastic for about eight weeks, and then the patient got up in the middle of the night and tripped over her cat, and basically destroyed this whole thing. But she wasn't mad at me, she was mad at the cat, so things ended well.

Overall key to this lecture to remember, the correct surgical choice, again, based on the pathology. We talked about whether or not it was a flatfoot versus cavus foot. We talked about addressing the biomechanics. We talked about correlating what we talked about this morning for the MTP joint, and then performing the sequential reduction minus the McGlamry elevator. It says, address the MTP joint, address the flexor plate deformity. Avoid creating a new one with the McGlamry elevator. So again, you don't want to disarticulate the collaterals and then the proximal flexor plate attachment. Incorporating the metatarsal osteotomy, really important to do if you feel comfortable. I do more while than anything if I need to. And then, don't rely on a K-wire to hold your toe where it needed to be.

Again, the key for the bone work is that there's very little margin for error in the toe. Use the C-arm. I use the 35 or 45 wire, depending on the size of the patient to pre-drill the proximal and middle fillings to make sure that we get the drill bit to go where I want it to go. And then overall, my typical choice is whatever implant you'd like to do, I typically use the 10-degree implant so I don't overly – get overly straight toes. And then, I do that slight bias on the bone to make sure that we get a good correction.

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So overall, that wraps up hammer toe, 2019. If you have questions, I'll be here for the rest of the weekend, and I thank you for your attendance.

Dr. Connor: Thank you, Chris. I just want to emphasize something which I neglected to do when I talked about phasic activity and muscle, which is a pain in the ass of a talk. But when you look at hammer toes, and Chris says, impressed upon us the significance of understanding the biomechanics leading to deformation, you have to realize that the intrinsic muscles of the sole of the foot start with the lumbricals which insert into the proximal fillings. You have interosseous muscles which insert into the proximal fillings, both plantar and dorsal interossei. You have a flexor digitorum brevis inserting into the middle fillings, all to try to stabilize that toe against the supporting surface when the ground is pushing up.

And as long as that's a rigid beam on those two segments, then the long flexor tending comes flying down the entire area into the distal fillings, that little thing at the end at the top. So, if there's any disruption of intrinsic activity and buckling of the digit, the long flexor tendon becomes a major abnormal force. So, it's incredible to watch the interaction of intrinsic muscles and extrinsic stabilizing the digits and the propulsive phase, and that's biomechanics.


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