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Jarrod Shapiro, DPM
Practice Perfect Editor
Assistant Professor
Dept. of Podiatric Medicine
Surgery & Biomechanics
College of Podiatric Medicine
Western University of Health
Sciences, St. Pomona, CA |
Here ye, here ye. I'm calling this trial to order!
Judge Annie Podiatrist presiding over the case of the lesser toe arthroplasty. This venerable surgery, going by the old name Post Procedure, has been a staple of the foot surgeon for many a year. All podiatrists, from the moment they learn about surgery of the toes are taught this fundamental procedure. All of us have, at one time or another utilized this for its supposed benefits. To this day many podiatric professionals provide profound publications pertinent to this procedure.
 However!
However, my kind audience, the question before you today is this:
Should the lesser toe arthroplasty be put to death?
I submit to you, the jury, that this so called "benign" surgery is neither anatomically nor mechanically appropriate in most circumstances. Additionally, with the advent of newer technologies not previously available, the toe arthroplasty has become outdated and should be put to death.
Or should it?
In certain patient populations, the digital arthroplasty retains its usefulness as a tool in the foot and ankle surgeon's toolbox and should be spared an ignominious death. Instead, it should be considered an ancillary procedure and should not be used alone.
Let us be specific, my colleagues, about that procedure for which we speak. The lesser digital arthroplasty consists of an incision (longitudinal or transverse) over the proximal interphalangeal joint – that oh so bothersome joint when not adequately aligned in the sagittal or transverse plains. The capsular tissue is incised and dissected, revealing the proximal phalangeal head – that shining bone upon a hill (sorry, I couldn't help the Ronald Reagan reference). That osseous article is then resected and discarded with nigh a care in the world. This, my friends, is the procedure on trial today.
As a result of this heinous procedure, many patients are left with a flail toe...that fat, floppy, flappy phalanx that fails to feel the ground. In other cases, chronic edema, the enigmatic, exasperating error ensues. Patients dislike the appearance of this toe and sometimes complain of pulsating, palpable, pain.
(What, you don't like my consonance and assonance? – Ok, ok I'll stop sounding so smug).
Ahem. Sorry about that. Got out of control. Moving on.
Perhaps the most significant problem with this procedure is its failure to correct the biomechanics of the digital deformity. Recall that the etiology of the digital deformity generally occurs due to muscular and tendinous imbalances that cause the digits to lose their stabilized and rectus position. If the intrinsic muscles, plantar plate, or other ligamentous structures fail to balance the powerful extrinsic extensor and flexor muscles, digital deformity will occur. Removing the proximal phalangeal head in isolation does nothing to rebalance this.
Put a K-wire in that sucker, you say? Let the "joint" scar in over six or so weeks, you advocate? We've all seen what happens with this procedure when the pin comes out: recurrence! A sad return to that prior state of affairs, though perhaps to a lesser degree than without. Don't forget that old adage, the correction on the table is the correction with which the patient will live.
Fusing the proximal interphalangeal joint is a biomechanically superior procedure in that the contracture is removed without the residual movement that allows for hammertoe recurrence. However, the toe becomes much more rigid with the increased possibility of a mallet toe deformity.
I submit to you Exhibit B (since Exhibit A was all the biomechanical stuff), an interesting, and, dare I say, important lecture by one Lawrence DiDomenico, DPM on the PRESENT website entitled:
Dr. DiDomenico argues that effective hammertoe repair, in flexible deformities, is best performed by focusing on rebalancing the tendon imbalances around the toe. His procedure of choice is a modified Hibbs, but regardless of the specific procedure, the point he makes is well demonstrated in this lecture. That is that it is unnecessary to destroy otherwise functional joints. Instead, we should focus on fundamental principles. For example, we are well aware that the flexor digitorum longus tendon is normally a plantarflexor of the toe at the metatarsophalangeal (MTP) joint. But with loss of the intrinsics activating the extensor complex, it becomes a dorsiflexor via retrograde plantarflexion on the other digital joints. A simple flexor tendon transfer to the base of the phalanx converts this muscle back to a plantarflexor of the toe at the MTP joint.
I now submit for your consideration our final piece of evidence, exhibit C, two images of patients of your prosecutor who underwent digital arthroplasty procedures for neuropathic toe ulcers.
The image on the left is a patient that underwent arthroplasty of toes three and four due to ulceration of the tip of the 3rd digit. Due to concern for possible bone infection, no K-wires were used. At three weeks postop, the patient's ulcer healed, but you'll notice edema and recurrent contracture of both the 3rd and the 4th toe (the 4th toe ulcer was due to the patient dropping something on the digit – it healed without issue).
Compare this to the image on the right. This patient underwent an arthroplasty with MTPJ release and a flexor tendon transfer on the 2nd toe. Notice the improved rectus appearance of the toe. Again, due to the risk of underlying infection (the ulcer was on the dorsal PIP joint), no K-wire was used.
A much better appearance for the second case. A true comparison is impossible due to the differences in ancillary procedures and the time difference (the one on the right is intraoperative). Despite these differences, it is clear that the tendon rebalancing procedure was superior.
In conclusion, it appears the classic isolated lesser toe arthroplasty has outlived its usefulness and is only necessary for a very narrow indication. It fails to address the biomechanical imbalances and often leads to other complications. Add to this the newer procedures and technologies that allow for strong repair of the plantar plate and we have a procedure whose useful life has come to an end. To you, the jury, I charge you with the final decision for your patients. Sentence the isolated arthroplasty to death! Or at least consider tendon rebalancing for your hammertoe procedures.
I rest my case.
Best wishes,
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
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