Hammertoe Implants

[Shiyuan]

Rarely use them, but might need one on a future revision. Any recommendations? I tried the ProToe before but it wasn’t the greatest. Thanks y’all!

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[FedPod]

Don’t use staples

 

[Feli]

K-wires, buried or rarely out of the toe, are all I've ever used.

I did hundreds of Smart Toe, Hammer Lock, allo plug, absorbing, various other copy cats in training. No advantage to the $500+ ones over a $5 k-wire in my eyes... the former is a lot harder to remove or revise. As for the "rotational stability" nonsense, that's called two sutures in the EDL and proper pt education.

 

[SouthPod7]

In residency we fooled around a bit with other implants but in practice I've only ever used k-wires in practice. They are cheap, readily available, come in multiple sizes depending on patient, and they just work.

 

[air bud]

Hammer toes heal as long as the bones are in the same zip code. I have never actually done buried k wires have only really done k-wire with a ball. As long as it doesn't cross the mpj walk on it right away remove it ideally in 4 weeks but if it comes out in 2 weeks due to irritation or loosening usually not a big deal. Have maybe seen a 2 to 5% complication with hammer toes I can think of maybe one or two in my career that I've had to revise. Very rarely use implants they just take up way too much time and cost too much money. Kwires are so incredibly fast and do the job. It's a pipj not an mpj. I am fast to put the wire across the mpj when there is significant contracture although I do not repair the plantar plate. If other surgeries allow for immediate weight bearing I allow the patient to immediate their even with it crossing the mpj. I have tried those bendy wires from arthrex they are stupid and do not work like they are supposed to and are way too hard to put in and not worth the money.

The other big disadvantage of implants is the amount of tissue trauma that occurs. The less you touch that toe the less pissed off it gets. Using some device to strike the end of the toe to properly engage some two-part implant makes that toe really mad. And then when you don't like it's initial position and you have to take it apart and put some muscle into it you are further traumatizing that toe.

And when you are dealing with cost, a good way to get what you want in terms of hardware for the first Ray is by cutting costs on the lesser toes they're much more likely to allow you to use whatever expensive plate and screw construct on the first Ray if you tell them you will knock out another 4 to 8 procedures on the lesser toes and only use suture and wires.

 

[Shiyuan]

Thanks all!

 

[CutsWithFury]

I did a lot of Arthrex 2.5 screws buried in the toes for hammertoes. They work well but sometimes if its not absolutely perfect it can be a pain to get them buried into the middle phalanx to fixate the PIPJ. I've had a couple heart attacks where I got stuck trying to get across the DIPJ with the head of the screw. Don't ask me how to get them out.

I have transitioned back to K-wires.

 

[wakaflocka88]

K-wires all the way. How often have we all dealt with a skinny proximal phalanx bone and an implant would blow it out?

On a side note, how often are y’all doing a Weil in conjunction with your hammertoe repair versus just pinning across MPJ if there is still contracture?

 

[CutsWithFury]

K-wires all the way. How often have we all dealt with a skinny proximal phalanx bone and an implant would blow it out?

On a side note, how often are y’all doing a Weil in conjunction with your hammertoe repair versus just pinning across MPJ if there is still contracture?

Any residual dorsal contracture gets a weil. The toe will sit down perfectly. Still dorsal contracture? Then flexor tendon transfer and EDL tendon lengthening. Deviating to right or left? Then capsulotomies of whatever side collaterals you are trying to free up. Then put the K-wire across the met head.

 

[air bud]

K-wires all the way. How often have we all dealt with a skinny proximal phalanx bone and an implant would blow it out?

On a side note, how often are y’all doing a Weil in conjunction with your hammertoe repair versus just pinning across MPJ if there is still contracture?

Maybe 50%? I like weils less and less these days. Obviously now add in cost but I love the idea of the biomet weil plate thing. Don't touch the joint and stable fixation right away.

Ok how about closure? I do 1 4-0 monocryl in the tendon then 3-0 prolene for closure. I close prolene ps2 for everything.

And incision? I almost always do 2 semi elliptical incisions lengthwise. I see people do other orientation and wish I did that sometimes. Obviously do DIPJ that way, not sure why don't use for PIPJ.

And can't stress enough to residents....hammer toes heal if the bones are in the same zip code. Don't waste your time repositioning wires and damaging the soft tissue. Asking for sausage toes. Don't even look at the toe the wrong way.

 

[SouthPod7]

Any residual dorsal contracture gets a weil. The toe will sit down perfectly. Still dorsal contracture? Then flexor tendon transfer and EDL tendon lengthening. Deviating to right or left? Then capsulotomies of whatever side collaterals you are trying to free up. Then put the K-wire across the met head.

Any issues with your wire running into your screw for the weil? Do you advance the wire into the met head and stop when you hit the screw?

I had an attending in residency that wouldn't even use a screw for a weil and simply ran the wire from the hammertoe correction into the metatarsal shaft and that was his fixation. Pull out in 4-6 weeks. Seemed to do okay.

 

[Pronation]

I would be fine with never doing another hammertoe surgery again.

They usually get a k-wire, but the only implant that I’ll sometimes use is a screw.

 

[air bud]

Any issues with your wire running into your screw for the weil? Do you advance the wire into the met head and stop when you hit the screw?

I had an attending in residency that wouldn't even use a screw for a weil and simply ran the wire from the hammertoe correction into the metatarsal shaft and that was his fixation. Pull out in 4-6 weeks. Seemed to do okay.

Seems like a good idea but probably I won't do that. The wire just bounces right off and skives off and is just fine.

 

[DYK343]

Any issues with your wire running into your screw for the weil? Do you advance the wire into the met head and stop when you hit the screw?

I had an attending in residency that wouldn't even use a screw for a weil and simply ran the wire from the hammertoe correction into the metatarsal shaft and that was his fixation. Pull out in 4-6 weeks. Seemed to do okay.

My biggest gripe with weil is not the floating toe but dislocation when a K-wire is placed across the MTPJ and the patient walks early (I havent personeally had much issues with the kwire hitting the screw, it just bounced off and takes a slightly different course if it does hit it)

Ive had at least a few dislocate from early weightbearing against medical advice. One of which required revision.

My biggest fear in general is dead toe with hammertoe surgery. I think Airbud nailed it. Gotta be really gentle and non constrictive bandages post op.

 

[air bud]

I hate true edl lengthenings I think I'm probably just doing it wrong though

 

[DYK343]

Buried K wire with peg and hole is the best hammertoe system there is.

 

[Pronation]

Buried K wire with peg and hole is the best hammertoe system there is.

That’s a real thing? Thought it was a podiometric myth

 

[CutsWithFury]

Any issues with your wire running into your screw for the weil? Do you advance the wire into the met head and stop when you hit the screw?

I had an attending in residency that wouldn't even use a screw for a weil and simply ran the wire from the hammertoe correction into the metatarsal shaft and that was his fixation. Pull out in 4-6 weeks. Seemed to do okay.

I don't know how he controls the head of the metatsarsal if they are driving the K-wire through it with no screw fixation. Just asking for severe shortening of the met head.

I just bounce the wire off the screw. If you push hard enough it finds it way.

 

[air bud]

That’s a real thing? Thought it was a podiometric myth

lol true. i know a few people who do it. Trilliant and some others make reamers for hammertoes, seems like a good idea but no interest in doing it.

My biggest gripe with weil is not the floating toe but dislocation when a K-wire is placed across the MTPJ and the patient walks early (I havent personeally had much issues with the kwire hitting the screw, it just bounced off and takes a slightly different course if it does hit it)

Ive had at least a few dislocate from early weightbearing against medical advice. One of which required revision.

My biggest fear in general is dead toe with hammertoe surgery. I think Airbud nailed it. Gotta be really gentle and non constrictive bandages post op.

Never killed a toe*
I don't have a problem with weils walking right away. If the rest of the surgery allows it then fine with me.

 

[CutsWithFury]

The chances of killing a toe go down significantly if you do a generous resection of the PIPJ (shortening of the toe). Of course patient selection is critical.

 

[Utvolsdpm]

That’s a real thing? Thought it was a podiometric myth

One of my attendings did a peg in hole during residency it was great. I always wanted to do it myself but never sacked up enough to actually do it.

 

[NatCh]

I like to bend and bury a K wire. They’re easy to remove under local anesthesia in the office later if the patient wants/needs it out. I always angle the “hook” part laterally so it’s easy to locate during removal

 

[Feli]

K-wires all the way. How often have we all dealt with a skinny proximal phalanx bone and an implant would blow it out?

On a side note, how often are y’all doing a Weil in conjunction with your hammertoe repair versus just pinning across MPJ if there is still contracture?

Weil is my central hammertoe repair in probably 80% of central hammertoes... only about a quarter of hammertoes get PIPJ arthrodesis anymore (almost always in conjunction with a Weil). Fifth digits are obviously a plasty.

It's funny because in my training, we did bunionectomy with various osteotomy (many A/A) and PIPJ fusions in 90% of bunion/hammertoe feet... and now out in practice, I probably do Lapidus or MPJ1 fusion and Weils in 90% of them.

Weil accomplishes the tendon lengthening and MPJ slack indirectly and lets the toes lay down well enough unless uber rigid, where they need both might need Weil + PIPJ fusion or Weil + PIPJ fusion+ some MPJ/EDL work. That is only your real real severe HAV, cavus, flatfoot, RA/psoriatic, etc. For 80% of normal bunions or hammertoes, Weil(s) alone seem to do the job fine in my hands. A lot of the time, with recurrence and floater toes after the stupid barbed/screw implants for hammertoes, you can't go through the PIPJ anyways (without totally de-vasc whatever's left of the digit), so you can just do Weils.

 

[Pronation]

I wonder how much longer it’ll be until insurances bundle a Weil with a hammertoe, just like an Akin is bundled with other 1st ray procedures.

 

[heybrother]

I wonder how much longer it’ll be until insurances bundle a Weil with a hammertoe, just like an Akin is bundled with other 1st ray procedures.

Already happening in, wait for it, private practice.

 

[PlainsPod]

I’ve used them all over the years. My preference is still a good old K-wire

 

[DYK343]

I did so many hammertoes in residency. It was an unhealthy amount of lesser toe surgery. 5-10 a day, every day, at least.

We had 2 die in residency

I had one on my own 1st year out I thought as gonna die. Pulled the pin, injected with lido, and kept a close eye. Turns out she was a heavy smoker and lied. The toe did live.

I had a 2nd one that had a dissecting hematoma and the whole thing turned black in a ~18yo kid. at 1st bandage change. Puckered pretty hard on that one but was able to salvage the toe. Watching that epithelium flake off with healthy pink toe underneath was glorious.

IMO if you do enough hammertoe surgery some day you will lose one.

I discuss this extensively in preop risk discussion. RIsks are close to zero but not zero.




Peg and hole might be a regional thing. A lot of my attendings do them where I trained and now subsequently I do them because they fuse really really well. End to end i just dont get the fusion rate I see with peg and hole. Not that true fusion in PIPJ really matters though.

 

[dtrack22]

I don't know how he controls the head of the metatsarsal if they are driving the K-wire through it with no screw fixation.

Just make the met osteotomy extra-capsular. If you don’t destabilize dorsal. Medial, and lateral MPJ capsule then the met head won’t be unstable.

 

[Redsting]

I tried a few implants. Most of them suck.
Despite what FedPod said. I like the hammer toe staple. No rotation. Easy to remove if needed (haven't needed to). I've a had a handful early on I fixated with Kwires that rotated or person bent them so the toe wasn't as pretty as it should have been. I am better at selection who to use stable on vs kwire now.

I had an attending that burried a kwire for all hammer toes then 6 or however many weeks later he would take it out in clinic. Practice management I guess.

 

[CutsWithFury]

I like to bend and bury a K wire. They’re easy to remove under local anesthesia in the office later if the patient wants/needs it out. I always angle the “hook” part laterally so it’s easy to locate during removal

View attachment 361867View attachment 361868

Do patient's complain about feeling the end of the K-wire ever even though it is bent?

 

[NatCh]

Do patient's complain about feeling the end of the K-wire ever even though it is bent?

If the hook hugs the bone they don't feel it. If the wire migrates distally then they will, in which case I'll remove it in the office.

Procedure:
1. Drill pilot hole in proximal phalanx with the wire
2. Send the wire distally through middle and distal phalanges
3. Retrograde the wire into the proximal phalanx all the way then reduce the hammertoe
4. Distract the wire out about 5mm-10mm
5. Bend wire where it exits the skin then cut to size
6. Make small incision laterally at the tip of the toe
7. Drive wire back into the toe and tamp. The tamping seats the hook of the wire against the distal phalanx and at the same time ensures that the PIPJ arthrodesis surfaces are in firm contact.

 

[air bud]

If the hook hugs the bone they don't feel it. If the wire migrates distally then they will, in which case I'll remove it in the office.

Procedure:
1. Drill pilot hole in proximal phalanx with the wire
2. Send the wire distally through middle and distal phalanges
3. Retrograde the wire into the proximal phalanx all the way then reduce the hammertoe
4. Distract the wire out about 5mm-10mm
5. Bend wire where it exits the skin then cut to size
6. Make small incision laterally at the tip of the toe
7. Drive wire back into the toe and tamp. The tamping seats the hook of the wire against the distal phalanx and at the same time ensures that the PIPJ arthrodesis surfaces are in firm contact.

What do you use to tamp?

 

[NatCh]

What do you use to tamp?

Something like this tamper if they have one, otherwise I say, "Give me something to tamp this in with" and let the Tech figure it out (they usually hand me a Key elevator).

Sklar Bone Tamper

Sklar Bone Tamper

www.medicaldevicedepot.com

 

[air bud]

Something like this tamper if they have one, otherwise I say, "Give me something to tamp this in with" and let the Tech figure it out (they usually hand me a Key elevator).

Sklar Bone Tamper

Sklar Bone Tamper

www.medicaldevicedepot.com

I see a future medical device product development in your future....the NatCh wire tamper™️

 

[NatCh]

I see a future medical device product development in your future....the NatCh wire tamper™️

Do I get to go on the lecture circuit?

For real though, about 15 years ago I modified a piece of hardware that Arthrex adopted but made me sign an NDA. Never saw a cent out of it, lol. Whatever...