Big Toe Hammer Toe Surgery
In this episode of The PODdoctors podcast, Dr. Damien Dauphinee, a board-certified foot and ankle surgeon, and Dr. Raafae Hussain, a fellowship-trained foot and ankle surgeon, discuss the surgical correction of big toe hammertoe, a condition that, while seemingly benign, can pose significant risks for individuals with neuropathy, particularly those with diabetes. The Doctors discuss the complexities of treating this condition and share insights from a specific case involving a high-risk diabetic patient, highlighting the delicate balance between managing diabetes and ensuring proper foot health. The episode covers surgical techniques, including the use of screws for fixation, and the recovery process, which allows for quick weight-bearing activities post-surgery.
Top Takeaways:
- The podcast episode discusses the significant advancements in diabetic limb preservation over the last 20 years, highlighting new technologies and treatment options.
- Doctor Damian Dauphine emphasizes the importance of understanding complex cases in diabetic patients to prevent amputations.
- The surgical correction of big toe hammertoe, particularly its complications in patients with neuropathy.
- The risks associated with untreated hammertoe deformities can lead to dangerous ulcers, especially in diabetic patients.
- The anatomy of the big toe and the surgical procedures involved in correcting contractures.
- The importance of post-operative care and recovery strategies for patients undergoing foot surgery.
Resources:
Visit our website: https://thepoddoctors.com/
Transcript
The pod doctors is brought to you by the Kindle book saving limbs, saving lives advanced treatments to prevent amputations in diabetic populations.
Speaker A:This book by Doctor Damian Dauphine discusses specific patient cases in diabetic limb preservation, which highlight the modern use of wound care technology that has exploded in the last 20 years.
Speaker A: advanced therapy available in: Speaker A:Doctor Dauphine distills these options down to show patients and physicians treating these patients how combinations of these products can be used to save limbs and save lives.
Speaker A:Welcome to the pod doctors.
Speaker A:I'm Doctor Damian Dauphine, board certified foot and ankle surgeon.
Speaker A:My partner, Doctor Rafa Hussain, fellowship trained podiatric surgeon and we are the pod doctors.
Speaker A:Each week, the pod doctors will be discussing aspects of podiatric medicine and surgery to educate our audience on common foot and ankle problems and the latest treatment options available.
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Speaker A:Welcome to the podoctors.
Speaker B:I'm Doctor Damian Dauphine and I'm here.
Speaker C:With my partner, Doctor Rafi Hussein.
Speaker B:And we are going to talk about the big toe Hammertoe, which sounds like a benign problem, but if you have neuropathy, this is not a benign problem.
Speaker C:Oh yeah.
Speaker C:So what is a hallux malleus, aka big toe?
Speaker C:Hammered toe?
Speaker C:Hammered hallux toe bite in.
Speaker C:What happens is the big toe has a contracture deformity and at the tip of the toe people can get sores, calluses, etcetera.
Speaker C:It tends to be tender, painful, and if they're neuropathic, at risk for getting wounds and sores and ulcers and such.
Speaker B:And we can even see them underneath the first met head too.
Speaker B:So first metatarsal head, quite often we'll.
Speaker C:See them both spots right there because.
Speaker B:Of that retrograde force where the toe is literally sitting on top of the metatarsal head, shoving it down through the bottom of the foot.
Speaker B:So they'll end up with a callus there as well.
Speaker B:There you go.
Speaker B:And the, you know, the sesmoids can get involved.
Speaker B:So those two little bones on the bottom of that joint can become pressure points.
Speaker B:And you can see ulceration there as well.
Speaker B:So I have to do one of these tomorrow on a diabetic patient who is extraordinarily complex.
Speaker B:He has a defibrillator installed, so he's got serious cardiovascular disease.
Speaker B:I've had him cleared by his cardiologist.
Speaker B:He's on blood thinners.
Speaker B:He's kind of a train wreck.
Speaker B:But he's a powerlifter and teaches powerlifting to high school kids.
Speaker C:Wow.
Speaker B:And so we're fixing his toe because he keeps getting an ulceration at the tip of the toe, which we talked about in his situation.
Speaker B:With diabetes being pseudo controlled, he ranges in the seven to eight a one c range.
Speaker B:Every time he gets one of these ulcers, it's as dangerous as colon cancer.
Speaker B:And so, for him, the risks of the surgery far are far less than.
Speaker B:Far less than the risks of the daily risks that he sustains from the wound itself.
Speaker C:Yeah.
Speaker C:As far as things know, the anatomy for this is very straightforward.
Speaker C:You're dealing with the distal phalanx and the proximal phalanx of your big toe.
Speaker C:Your hallux soft tissue structures you may encounter are the extensor tendons and the neurovascular structures that may come across there.
Speaker C:Incisions for this, it's very user dependent.
Speaker C:I kind of go between one of two things.
Speaker C:I typically will do a transverse incision for the most part, or I'll do a lazy s type incision.
Speaker C:It just depends on how much exposure I need sometimes.
Speaker C:In this case, you'll see I did an ellipse because they'll have a lot of extra tissue there sometimes.
Speaker C:So we'll bring that tissue back so they don't have so much soft tissue pushing up on the skin.
Speaker C:Young male, really bad contractor.
Speaker C:Deformity, tip of his toe, callused.
Speaker C:We did the crest pads, we did the padding.
Speaker C:We did all the adjustments, and it just wouldn't get better.
Speaker C:I think he was a.
Speaker C:Some type of mechanical engineer or something like that.
Speaker C:So he's always on his feet.
Speaker C:So what we did first you saw was an s mark.
Speaker C:We squeezed the foot, push all the blood out of it.
Speaker C:I do my elliptical type of incision.
Speaker C:I'm just going through skin at this point, and all we're doing is taking that extra skin out of the equation, you know?
Speaker B:And that video also shows he's got some nail changes.
Speaker C:Oh, yeah.
Speaker B:And, you know, those are usually a direct result of pressure and friction and trauma to the nail plate, which can lead to a fungal infection.
Speaker B:So, you know another area that is a direct result of the deformity.
Speaker C:Yeah.
Speaker C:That's how people get that nail dystrophy that you probably heard us talk about a couple times.
Speaker C:So what I'm doing here is I just resected out the extensor tendon, and now I'm freeing the IPJ, the interphalangeal joint there.
Speaker C:So I go transverse across the top, and then I drop my blade, and I release the soft tissue structures along the margin, and I'll show you what they look like.
Speaker C:And we try to do that on both sides and alleviate the extensor from both ends slightly.
Speaker C:So when we take away the bone, we don't have to worry about that.
Speaker C:The tendon holding onto it, pretty much the same.
Speaker C:It's literally.
Speaker B:Yeah.
Speaker B:Any other.
Speaker B:Exactly.
Speaker B:Any other hammer toe.
Speaker B:But the structures are bigger, and it's a little easier to do.
Speaker B:I agree.
Speaker C:So now my assistant retracts the tendon.
Speaker C:I use a sagittal saw.
Speaker C:It reciprocates just like a drywall saw, but smaller.
Speaker C:The nice thing about these reciprocating saws are if you do touch soft tissue, the soft tissue just wiggles.
Speaker C:So very, very low chance of injuring tissue.
Speaker C:So I don't to worry about.
Speaker C:I mean, I still worry, but I don't necessarily worry about catching the flexor tendon at the bottom half of that.
Speaker C:So I'm resecting out the cartilage off of that IPJ, small, little wafer.
Speaker C:And this is the time that if he had an angular deformity, I would cut that bone on an angle if I needed to correct it in certain planes.
Speaker C:So now I'm just taking off the base of the distal phalanx.
Speaker C:So all the cartilage off of there will be gone.
Speaker C:So you see it's just little wafers.
Speaker C:And take my little Ron dure, pull.
Speaker B:That out, and this guy wasn't diabetic.
Speaker C:He has some type of neuropathy, if I'm not mistaken.
Speaker C:This is an old case.
Speaker C:I can't remember who it was, but I do remember he had some type of neuropathy contractor deformity that he dealt with.
Speaker C:I think it was just idiopathic, if I'm not mistaken.
Speaker C:So, the anatomy, like we talked about, these are the soft tissue structures that you're looking at.
Speaker C:You have your lateral, medial, lateral collateral ligaments, your sesmodal ligaments.
Speaker C:If we're back here, this is where it would be.
Speaker C:The sesmodal.
Speaker C:Back in this area.
Speaker C:Back here, we're in this area.
Speaker C:So no sesmodal ligaments.
Speaker C:And then you have the flexure tendon and or the plantar plate across there, across the top of here.
Speaker C:We already talked about you'd have your extensor hallucis longus, and you can see.
Speaker B:The shape of that distal phalanx.
Speaker B:It's not a problem when the toes in the right position, but as soon as that contracture becomes rigid, you're not designed a weight bear on the tip of the toe.
Speaker B:There's little fat there, so you get callus and ulceration pretty easily.
Speaker C:I resected my bone out just like the hammertoes.
Speaker C:If you do the K wire technique or implants, quite often, we'll run a wire, and in this case, I'm running a guide wire for my screw.
Speaker C:I'm doing a screw on this.
Speaker C:You can do a lot of options, staples, pins, wires, circlash wire.
Speaker C:There's bigger hammertoe implants that you can put across there.
Speaker C:I like to stick with the screw.
Speaker C:I think it's a little bit more sturdier because it is the big toe.
Speaker C:So you are pushing off of there.
Speaker C:So I always try to err on the side of caution for these, but bring my c arm in.
Speaker C:I'm getting a couple of different views, making sure that that wire is running dead center of the big toe here.
Speaker B:And you're typically using some bone graft?
Speaker C:Yeah, if the facility approves of it.
Speaker C:Great.
Speaker C:I try to use as much as I can.
Speaker C:My job is to fix this problem in one go and never have to deal with this again.
Speaker C:Sometimes the facilities won't allow it.
Speaker C:So we have to make sure that we have good apposition of that bone.
Speaker C:I will drill at fish scale if I needed to, and then if you really need to, you can take some of the bone that you took out and curette away the soft, spongy bone, the cancellous bone, and pack that into the surgical site.
Speaker C:So now I drove that wire distally to the point where I can almost feel the cortical bone, the hard, stiff bone, the dense bone in the toe.
Speaker C:So this is the area you kind of get to because obviously you don't want to go into the metatarsal phalange joint.
Speaker C:So these are the different ways that you can fixate these.
Speaker C:I'm doing your classic screw method here, but there's.
Speaker C:I don't know, there's straight k wires.
Speaker C:This kind of fell out of favor because you get the gapping there.
Speaker C:Obviously, there's nothing holding it together.
Speaker C:Circlage wire, still a great option, but they have better options.
Speaker C:Crossing k wires was kind of a big technique.
Speaker C:I even learned it back in training.
Speaker C:Before all these fancy things got approved by all insurances.
Speaker C:The crossing k wires, the only caveat to that was you'd have to compress that osteotomy site by hand, and then you'd run those k wires.
Speaker C:So, as you can see, this one looks like it's kind of gaps some.
Speaker B:And looks like they missed it.
Speaker C:Looks like they had whiffed on one.
Speaker B:Of the k wires.
Speaker B:Yeah.
Speaker C:Crossing the screws perfectly fine.
Speaker C:I do a straight screw, but I do what's called a Herbert screw or a headless screw, so it'll bury it into the bone just in case, God forbid, they don't feel at the distal end.
Speaker C:This is a.
Speaker C:What is it called?
Speaker C:Conical screw.
Speaker C:Whatever they call it.
Speaker C:The taper on the screw is graduated, so it catches more distally.
Speaker C:So it compresses more, and it catches less proximally.
Speaker C:Excuse me.
Speaker C:I said that backwards.
Speaker C:It catches more proximally or wherever the end of the screw is, and it catches less at the head of the screw distally in this case, and it'll compress that osteotomy size.
Speaker B:If you look really close to the screw, there's wider screw screw pitch.
Speaker C:Yeah.
Speaker B:At the bottom of the screw and tighter at the top.
Speaker B:So exactly what you're saying.
Speaker C:It's staples.
Speaker C:Staples are a good option, too.
Speaker C:Everyone has their technique.
Speaker C:And then the new implants.
Speaker C:Now, some of these are not the big toe.
Speaker C:I couldn't find great pictures.
Speaker C:These are.
Speaker C:I think this is a thumb.
Speaker C:This is a thumb, and this is a thumb.
Speaker C:No, this is not a thumb.
Speaker C:This is a tongue.
Speaker C:This is a thumb.
Speaker C:Yeah, it's all the same stuff.
Speaker C:So check my x ray.
Speaker C:Everything looks good.
Speaker C:Now I'm doing a little stab incision.
Speaker C:Obviously, we're putting a screw in there, and I don't want to stretch the skin out.
Speaker C:Use a little hemostat.
Speaker C:Open up that soft tissue.
Speaker C:Make sure that the head of my screw does not pull any soft tissue into the surgical site.
Speaker C:I am countersinking now.
Speaker C:It's a reamer type device that will make sure that the head of my screw will sit nice and low.
Speaker C:I'm just checking how deep I'm countersinking, making sure it's the appropriate depth.
Speaker C:Let me see.
Speaker C:Jump ahead.
Speaker C:I'm measuring the screw.
Speaker C:We use a measuring device, but, you know, if I have the screw in hand, I'll lay it on top of the bone and just get an x ray.
Speaker C:That way, make sure it's appropriate length.
Speaker C:Make sure the threads cross that area of the osteotomy site.
Speaker C:Because if the threads don't cross the osceonomy site, we're not going to compress.
Speaker B:Correct.
Speaker C:So now I'm putting the screw in.
Speaker C:It takes a good few minutes.
Speaker B:I got one of these at 930 tomorrow, if you want to come do it for me.
Speaker C:And then I get my final x rays, and if everything looks good, I pull that wire out and call it a day.
Speaker B:There you go.
Speaker C:So that's kind of what the x rays.
Speaker C:This is the actual patient that I did.
Speaker C:This is the x rays.
Speaker C:I lost all the other pictures.
Speaker B:I didn't say that's perfect placement, though.
Speaker C:But, yeah, threads across the osteotomy site.
Speaker C:The thread stop here.
Speaker C:Osteo site here.
Speaker C:Screws buried in the bone.
Speaker C:I mean, there's a little bit of a lip here, but you'd never feel it.
Speaker B:That's not going to be a problem.
Speaker B:Yeah.
Speaker B:And you've got a little bend to the toe, which is natural and normal and appropriate.
Speaker C:Yeah.
Speaker B:They're not going to be walking on the tip any longer.
Speaker B:They won't be walking on the incision line.
Speaker B:So.
Speaker B:Yeah, that, that should do.
Speaker B:That should do really well.
Speaker C:All right, so closing part, we irrigate.
Speaker C:Obviously, we don't want to, you know, close a dirty site.
Speaker C:And I'm just going to jump ahead, re approximate the tendon.
Speaker C:You'll see that when I threw my first stitch, I put it underneath the tendon.
Speaker C:I've said this a couple times.
Speaker C:Obviously, we don't want our stitches to feel on the patient.
Speaker C:Today, literally today I had that guy that you sent over, the cavus foot guy.
Speaker B:Yeah.
Speaker C:You felt the side of his peroneal tendons.
Speaker C:Right.
Speaker C:And, I mean, you could feel every single knot on his tendon.
Speaker C:It was whoever did the surgery.
Speaker B:I mean, I'm pretty sure they used non absorbable sutures and they used, like, big knots.
Speaker C:Yeah.
Speaker C:It's just they did an injustice.
Speaker C:Really?
Speaker C:Because he said he had pain for years and years and years.
Speaker B:Yeah.
Speaker C:And then they went in and they ablated the nerves over that area rather than fixing the original problem.
Speaker C:And I'm just like, all right, solution to a problem that could have been avoided to begin with.
Speaker C:Yeah, but it is what it is.
Speaker C:All right, so layer closure.
Speaker C:We talked about this.
Speaker C:I do my deep stitches, and then I do my superficial.
Speaker C:I'm just going to jump ahead because I'm sure you don't want to see me stitch for.
Speaker C:Hold on, let me say that again.
Speaker C:You don't want to see my first assist stitch because their heads in the way, but I do absorbable stitches.
Speaker C:The patient will never feel it.
Speaker C:And then the aftermath, obviously.
Speaker C:Brand new toe.
Speaker B:Looking good.
Speaker C:There we go.
Speaker C:So recovery for this, they'll be in a surgical boot for give or take, six weeks.
Speaker C:The recovery on this is very, very easy.
Speaker C:Surgical shoe or boot?
Speaker C:I like the boot.
Speaker C:I think it's easier to walk in, rest, ice and elevate as much as possible and make sure you get enough calcium and vitamin D.
Speaker C:Typically you'll be walking on this.
Speaker C:I tell patients to keep the pressure towards the heel but they should be fine regardless.
Speaker B:Yeah, these don't become non unions very often.
Speaker B:Pretty limited risk there.
Speaker B:Well, that's terrific.
Speaker B:Like I said, this is a common problem.
Speaker B:Worse, it's certainly a really difficult and sometimes detrimental issue in diabetic patients because they can't feel it and the ulcers are really dangerous for them.
Speaker B:And so fixing this, you know, one time solution is a really, really good option.
Speaker B:That looks like it hurts, but that's terrific.
Speaker B:So yeah, the big toe Hammertoe, pretty easy fix you can weight bear afterwards.
Speaker B:It doesn't require cast immobilization for weeks and weeks and weeks and non weight bearing.
Speaker B:So yeah, pretty easy recovery.
Speaker B:And these patients, if you're diabetic and it solves the wound problem and for all this is a tremendous procedure for that.
Speaker C:So no limitations.
Speaker C:After the surgery they can run crossfit, whatever they want?
Speaker B:Pretty much, yep.
Speaker B:Excellent.
Speaker B:Well, thank you, Doctor Hussain.
Speaker B:That was a terrific primer on the big toe Hammertoe and the surgery to correct it.
Speaker B:We will see you next time on the pod.
Speaker C:Thank you for listening to the pod, doctors.
Speaker C:We appreciate all of our listeners and subscribers.
Speaker C:If you'd like to hear more, follow us on Facebook, Twitter and watch our videos on YouTube.
Speaker C:Like thumbs up, subscribe.
Speaker C:Be safe.
Speaker C:See y'all next time.
Speaker C:Bye.
