What are Hammertoes?
• Classic Hammertoe– MPJ is cocked upward
and PIPJ is downward• Claw Toe
– MPJ is upward, PIPJ and DIPJ are downward
• Mallet Toe– DIPJ is downward
What Causes Hammertoes?
• Hammertoes are primarily caused by a muscle imbalance during gait
• There is also evidence that poor fitting shoes can contribute
Muscles Involved
• Extrinsic Muscles:– Flexor Digitorum Longus– Extensor Digitorum Longus– Flexor Hallucis Longus– Extensor Hallucis Longus– Tibialis Anterior– Tibialis Posterior– Peroneus Longus– Peroneus Brevis
• Intrinsic Muscles– Lumbricales
• Plantarflexory force across MPJ/Proximal phalanx
– Quadratus Plantae– Interossei
• Plantarflexory force across MPJ, stabilization in transverse plane
– Extensor Digitorum Brevis– Flexor Digitorum Brevis
Gait Patterns
• Flexor Stabilization– Most common, FDL/FDB overpower the interossei
• Flexor Substitution– Caused by weak Tendo-Achilles where PB, PL, TP,
FDL, FHL try to make up for the weak calf muscles and again overpower the interossei
• Extensor Substitution– EDL overpowers the lumbricales, usually seen in high
arched foot and/or ankle equinus
How do we Treat Crooked Toes?
• We can try to accommodate the hammertoes with non-surgical treatment such as:
• Orthotics• Metatarsal pads• Soft toe caps• Wide, Extra-depth shoes• Digital spacers• Taping/Splinting• Crest Pads
When non-surgical methods fail, we start thinking about surgical options.
We need to decide what techniques and products work best for our patients.
So what’s out there…
Smooth K-Wire
• Advantages:– Quick application– Cheap– Able to cross the MPJ if
needed
• Disadvantages:– Pin is sticking out of toe
and can catch on things– No compression– Increased risk of infection– Toe can rotate– Wire can bend
Screw Fixation
• Advantages:– Not sticking out of skin– Provides compression
• Disadvantages:– Toe is completely
straight and can’t bend at DIPJ
– Can still rotate– More difficult to
remove than a wire if needed
Absorbable Pins
• Advantages:– Internal– Cost efficient
• Disadvantages:– No compression– Toe can rotate– Patient can have a
reaction to the material
Stay Fuse• Advantages:
– Internal– Provide some compression– Different sizes
• Disadvantages:– 2 pieces– Costly– Higher chance for error
Biomet Weil-Carver Implant
• Advantages:– Resorbable with Lactosorb:
poly-L-lactic/polyglycolic acid copolymer
– Retains strength 6-8wks, degrades approx 12 mos
– Partially threaded, barbed to prevent pistoning
• Disadvantages:– Toe can still rotate– Doesn’t provide complete
compression
Smart Toe
• Advantages:– Internal– Provides some
compression– Prevents rotation– Also comes with an
angled version
• Disadvantages:– Must be cooled prior to
implantation– Costly
Orthopro I Fuse
• New product in development
• Comes in Screw-Barb and Barb-Barb configurations
• Small and Large sizes
• Also comes either angled at 10 degrees or straight
Summary
• As reps you have more influence on doctors than you know. However:
• Once you can get surgeons to break out of their “old habits” they will:
• 1. Use the quickest implant to insert.• 2. The implant that has minimal complications, high
fusion rate and high patient satisfaction.
• Note: In my opinion, the best implant as far as a rep is concerned is one that has a high degree of “dummy factor”. If the implant is easy to put in: ie. Doesn’t require dry ice etc. then the rep doesn’t have to be present for every case. (Earning income while golfing)