Of late, it seems there are many companies developing new fixation devices. Specifically, for the purpose of this blog, I will limit the talk to hammer toe surgery. (feel free to discuss any body part.)

In the past, for the most part when performing a hammer toe repair one would chose to perform an arthroplasty or an arthrodesis. (Some, possibly even an amputation.)

For the arthroplasty, no fixation was needed. For the arthrodesis, one could perform a peg-in-hole fashioning the shapes from the bones themselves and this could also feasibly spare the need for internal fixation as the bone itself acts as the fixation. In my own personal experiences, I have not seen this done too much. My best friend in podiatry school had mentioned to me he performed this procedure while in his residency and I thought it was cool he had been able to see it.

I was pretty much trained on k-wires. I must say, they are quick and do the job. There is the benefit that you remove it and so no hardware is remaining in the body. However, I hate the fact it sticks out the foot. I worry over the patient bumping their foot. I worry about a pin tract infection. I have heard and read of horror stories of patient's developing osteomyelitis. patient's also "freak out" when they see them.

Newer options include absorbable pins, or metal devices that are inserted at the joint and are inserted into the proximal and middle phalanges and do not protrude from the digit like a k-wire. smarttoetoe

   To the left, is an x-ray with a Smart Toe implant (Stryker). Other, types or brands include the Stayfuse (Tornier), Pro-Toe (Wright.) Advantages, no metal sticking out the foot and hence no pin tract infection. Compression is given unlike when a K-wire is used. There is some technical skill involved and extreme care needs to be taken to stay centered otherwise one can blow out the cortical wall of the digit.

When, I ask how Smart is a Smarttoe device I don't mean to pick on this particular company. My real question becomes what happens when a problem arises and you need to remove the device for whatever reason. Reps are excellent at selling you a product and telling you how good it is. On the surface, this is good, but I have been to lectures and read articles seeing these devices broken, half in a toe etc.

When you put something in - you also know need to know how to get it out. A back-up or contingency plan is always needed. So - has anyone put these in and needed to get them out? how easy or hard was it? Would you or do you still use the devices? Please Share. 

  • Comments (24)
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  • I M unfortunately going to be taking the patient back to the OR for removal of smart toe implants from the bilateral 2nd toes.  This is the 1st time I have ever had to remove these implants.  He is reacting poorly to them and is resorbing bone around them.  He is continuing to have pain.  I do not think he has osteomyelitis as it would be extremely unlikely for him to have this on both feet.  I am considering.  However replacing the smart toe implants with the TENfuse devices so that he will still be able to have a fusion, but will hopefully not have the same type of reaction that he has had to these implants Since these implants are made of allograft rather than actual metal.

    I have seen a few instances where people have removed these implants and then converted simply to an arthroplasty.  I guess my concern is that because there is now denuded bone on both sides of the fusion site, with the patient not continue to have pain?  Patient absolutely refuses pin fixation and since the smart toe implants have been in place, I do not think these would hold anyhow.

    Any input would be greatly appreciated.

  • Since I am a fair guy, I would like to share a current article in JFAS 51 (2012) 711-713.Smarttoe implant compared with K wire fixation for hammertoe correction, surgery of 28 patients.The retrospective study compared the two procedures at various intervals and compared certain parameters like pain, infection, fusion of joint etc.The article concluded the Smarttoe device had better results on all parameters tested. Since, I questioned the effectiveness of the device previously, I wanted to balance out the other side.....as I just read the article today. Incidentally, Dr. Gottleib wrote a similiar blog with his experience with a hemi implant and difficulty taking it out. This is one of the reasons I personally am not a fan of the Smarttoe. I don't think it would be easy to take it out if one had to for whatever the reason.
  • The second incision to remove the k-wire is very small and minimally traumatic.  Sometimes a steri-strip is enough for closure. 

    Arthrex was the most recent absorbable pin I used, c.2007.  Before that it was around 2004 and I no longer recall which manufacturers I used, but I tried three or four different makes.  I just couldn't seem to avoid the induration from any of the bioabsorbables and went back to steel.  Hopefully you'll have better results.

    I think we all go with what's most comfortable for us.

     

  • Nat - you love those k-wires I see. I haven't had any sausage toes yet. I thought about your buried k-wire. But, I just don't like the idea of making a second Inchon to remove, and don't think I would have an easy time burying it. I guess people do what they find easy for them. What brand absorbable did you use when the sausages appeared?
  • I've tried a few absorbable pins but my patients always ended up with sausage toe and a less-than-satisfactory end result.

    An 0.045 k-wire is also malleable.

  • Chris - if you are still following this thread, I did 3 digital fusions this morning and I tried out the Osteomeed product instead of my usual Arthrex absorbable. I think I like the Osteomed rods much better. The reason is usually the rods come longer than they need to be and you have to cut them. The osteomed ones are so easy to trim shorter. I had difficulty with cutting the arthrex ones. On the flip side, the osteomed rods being easier to cut have a greater chance of being stressed when you need to bend it to get into the opposing bone....so you need to be careful. I think I am sold on the osteomed rods. The great thing about using absorbable rods is that once they are in you can still position the toe to where you want it because the rod is somewhat malleable even when it is in the toe. So if you feel you need to relocate the toe either transversally or in a slight plantarflex position you can do all of this. With a k-wire, smart toe or any other metallic implant there is no way of doing this.If anyone hasn't yet tried an absorbable rod - "try it, you'll like it". It is definately my prefered method of fusion. (Call it soft fusion - if you want, but it works.) If anyone reading this decides to try it - please come back and share your experience and outcomes.
  • Quote:

    Eric - since you mentioned you have had to take out smart toes etc, can you share how easy or hard it was? technique that you utilized? also, you stated that you revised with a headless screw, were there difficulties in doing so after removing the smart toe, another words if you had to make a dorsal window was there enough intact bone to put the headless compression screw in. Thanks in advance for any comments you might make.


    Jeff,

    In the course of removing a "few" of the type of implants we are discussing, I really need to qualify the comments made that these are "salvage" procedures -- not reconstruction.  Failed digital arthrodesis procedures should be thought of as salvage and not in the reconstruction models.

     

    In removing these types of implants, it is important to distinguish goals for the patients and as the surgeon.  Do not go lightly into a hardware removal case without having a prepared plan for salvage.  With this in mind, the primary focus is to protect the arthrodesis site as much as possible without exposing the bone to more damage.  The following is my technique for removal of a Smart Toe or other similar device:

    1) Give yourself plenty of operative field.  Don't try to be a hero and do it though a small incision.  Give yourself room to manipulate the bone, place instrumentation, etc.

    2)  Clamp the proximal end off first, attempt to detatch the "feet" from the inner cortex. I have found that a rotational movement while extricating the feet with compression tends to do it quickly.

    3)  Rotational extrication of the headed component using reverse techinque in Step 2.

    4)  DO NOT crack the dorsal cortex of the bone.

    5)  Recannulate the bone with a guidewire and throw in a medullary headless compression screw.  Use bone void filler as necessary.  Allografting usually isn't necessary...its a toe.  Bone void works well if you have a shaky screw site or the screw is wobbly.

    Hope this helps.

    Eric

  • Chris - I have had no complaints at all regarding stiffness of the DIPJ. I also do not go into the DIPJ. The procedure is done in the PIPJ joint. So you drill into the base of the middle phalanx and the head of the proximal phalanx and you don;t go beyond these toes. I have been using the Arthrex device. (they have 2 different types one I do believe goes thru the DIPJ joint) I think Osteomed makes a "twin" product.

    Eric - since you mentioned you have had to take out smart toes etc, can you share how easy or hard it was? technique that you utilized? also, you stated that you revised with a headless screw, were there difficulties in doing so after removing the smart toe, another words if you had to make a dorsal window was there enough intact bone to put the headless compression screw in. Thanks in advance for any comments you might make.

  • Quote:

    Great comments!  I previously wrote a similar blog on the Smart Toe device, which I abandoned because I had several DIPJ contractures develop after using these.  I agree that the K-wire is the cheapest and most effective way.  Most of us have probably tried using these devices for reasons including:

    1.  No one likes wire sticking out end of toe for 6 weeks

    2.  Sometimes, your toe was perfectly straight, you remove the wire and low and behold...your toe can re-contract

    3.  No compression

    4.  Pin tract infection?? How many have you really seen?  RARE with hammertoes

    5.  Patient can shower quicker

     

    I currently use the wires and sometimes the Pro-Toe device, which is also not perfect. The middle phalanx is sometimes too short, it is often difficult to broach the hard bone in the middle phalanx, the medullary canal in the shaft of the proximal phalanx can be too hollow, not allowing purchase of the threads and causing a loose fit..  I have learned several tricks to overcome these problems such as cutting the device, packing pieces of bone in the proximal phalanx, etc.. 

    I too have never taken out a Smart Toe but it would not be fun or easy and I doubt that after bone has grown around the legs of this device that it will contract with cool water.  I have seen Pro-toe devices dislodged but in general, I like the outcome of the straight toes and patients are thrilled because they have now wire sticking out.  K-wires are cheap!  I have seen people bury wires and make a variety of homemade internal devices using threaded and non-threaded wire.  Some of these devices are 600+ per toe or more.  Bad thing is that once you open the device and can't get it to fit or work, patient still charged and you STILL revert back to the old standby....K-Wire. I too leave mine in for 6 weeks.  I used balls on the tips and ALWAYS cover the toes once they pink up.  Most complication from k-wires in my opinion are related to patients moving them, catching them on thinks, pulling them out.  

    I have also tried 2.0 and 3.0mm screws down the shaft of the toe.  This is a bit technical and seems to often lead to an over extended toe, despite proper MPJ release and sequential reduction. The screws often back out too but can easily be removed in the office.  These devices (Pro-toe, Smart Toe) are internal splintage devices that seem to resist the over powering of the flexor tendon which will sometimes re contract the toe after wires removed so I believe that they have their place and I have used both of these with great outcomes.  Similarly, i have thousands of toes that i fixated with wires with good outcome.  I doubt that if you did a head to head study comparing wires to these devices that you would see a great significance in the outcome of the devices versus the good ole' k-wire.  

    Hopefully a perfect solution will come-out soon!

     

    Chris 


    Chris,

    I have had to take out a number of Smart Toe devices over the last couple of years that were placed by other colleagues of mine.  As a result, in most salvage cases, I have had to place a 2.4 or 3.0 headless compression screw as an alternative replacement without much complications post-operatively. 

    When i did liteature research regarding ORTHOPEDIC fixation for digital arthrodesis, the standard of care is a 2.0 to 3.0 cannulated compression screw.  No Smart Toe, Pro-Toe, HammerLock, etc.  Inasmuch as I want to be "different" than the orthopedists, they basically get this one right.  For digital arthrodesis, a cannulated headless compression screw will serve as your best single surgical plan.

    The age old problem with K-wire fixation is the same:  pin looseining, pull-out, pin tract infection, migration of capital fragment of toe, loss of purchase, etc.  Digital arthrodesis still is the best single fixative course procedure in the books.

    Eric

  • Jeff.  Which pin do you use?  How are your results lets say at about one year (just asking)?  Any complains about stiff DIPJ.  If so,  would you rather have that or straight toes?  

    Thanks!

     

    CHRIS

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