08/13/2012 Richard Gosnay, DPM
Painful Bunion and Hammertoe (Mario Dickens, DPM)
I completely agree with Dr. Sullivan's opinion
that we need more information in order to
conclusively propose a solution to this case.
Information that we must know includes the
patient's medical history and med list, the
active patient's goals and expectations with
respect to activities and shoes, the patient's
ability to go non-weight-bearing if necessary,
possible hypermobility of the 1st metatarsal-
cuneiform joint, possible pain at the site of
plantar plate ruptures, possible 1st metatarsal
elevatus, possible equinus, and any other gross
foot deformity.
But we do know several important facts regarding
this case. The A/P view shows-a skew-foot, which
is notoriously difficult to comprehensively
correct (impossible in a 69 year-old). The A/P
also shows the sort of medial angulation of the
1st metatarsal-cuneiform joint often seen with
hyper-mobile first ray pathology. Although the
degradation of the 1st MTPJ is not terribly
impressive on radiographs, we know that there is
pain and crepitus on range of motion.
We can see that the second metatarsal is long.
There appear to be small periarticular erosions
in the lesser MTPJ's and a medial cyst in the
first metatarsal head, which are incidental
findings unless an autoimmune disorder is
confirmed in the medical history.
Because she is active, I will assume that her
medical history is insignificant and that she
has no contraindications to surgery. I will also
assume that she has the ability to recover from
surgery and use crutches or a walker. Because of
the painful crepitus and the A/P radiograph, I
will assume that the pain is from both the
medial eminence and arthritis of the 1st MTPJ
(although minimal arthrosis is seen on
radiographs).
Hammertoe pain is typically at the tip of the
toe (which is ground into the weight-bearing
surface), the dorsal PIPJ (which rubs on shoes)
and the plantar surface of the metatarsal head
(which could be metatarsalgia from retrograde
pressure or rupture of the plantar plate).
Because of the long 2nd metatarsal, I will
assume that the hammertoe pain is at all of
these sites.
Since one should never say never, I will stop
short of concluding that 1st MTPJ implants
should never be placed. But if there is a
hypothetical patient who would benefit more from
a first MTPJ implant than from other procedures
and therapies, this woman is not she. The
pathologic forces from the skew-foot that have
contributed to the forefoot deformity would
certainly ruin even the best possible immediate
post-op outcome. And the painful crepitus and
angular appearance of the 1st metatarsal
cuneiform joint on the A/P film suggest to me
that there is a functional or structural
elevatus that would jam the artificial joint.
I am also dubious about the prospect of joint
sparing procedures because of the painful
crepitus. Of course we can easily restore
mechanical motion to almost any joint with
enough remodeling of the bone segments. But, in
this case, it would be painful motion. The goal
is not simply to restore motion. The goal is
primarily to relieve pain. Further, lets assume
that the patient was examined on a particularly
bad day, and that she does not really have
painful crepitus; Decompressing the joint with a
shortening osteotomy would still be problematic
because it would exacerbate the long second
metatarsal and associated painful hammertoe.
The same can be concluded about the Keller
arthroplasty. It would only make the second ray
pain worse.
This reasoning leaves me with a first MTPJ
fusion as the best treatment for this patient.
This procedure would eliminate the painful joint
and create a long, stable first ray for
propulsion that would likely remove some stress
on the second ray. It would also reduce the
transverse plane bunion deformity. A Weil
osteotomy on the second metatarsal should be
considered if there is plantar pain at the
second MTPJ or the 2nd metatarsal head.
A typical PIPJ arthrodesis will correct the
hammertoe. If there is a torn plantar plate, a
Girdlestone tendon transfer in addition to the
hammertoe correction and the Weil osteotomy will
stabilize the toe. If the patient has equinus,
gastrocnemius or the entire Achilles tendon
should be lengthened in accordance with findings
during the Silverskiold test.
Finally, orthotic control of a skew foot can be
difficult because it is a compensated foot.
Correcting one segment can cause exaggerated
deformity of the neighboring segment. So if the
talo-navicular joint rests on the floor in
stance, I would put some semi-rigid arch support
in the patient's shoes. But I would be careful
not to correct her hindfoot and midfoot so much
that the resulting metatarsus adductus makes it
impossible for her to walk without tripping. All
of these ideas are contingent on my assumptions
being correct. And I did make several
assumptions.
Richard Gosnay, DPM, Danbury, CT,
glabroushead@gmail.com
08/10/2012 Tip Sullivan, DPM
Painful Bunion and Hammertoe (Mario Dickens, DPM)
Many things cannot be conveyed in a forum
setting, like what are the patient's goals? What
is her general medical status? What are her
activities of daily living? What does her gait
look like? The xrays provided do not include a
weight-bearing lateral.
Given the data available, and in the most
general terms. I strongly discourage using an
implant in a structurally compromised foot. In
my younger years, I thought that perhaps I could
get away with an easier procedure and perhaps
control the foot well enough in an orthoses to
prevent rapid recurrance. Sometimes it worked
sometimes it didn’t. I spent years trying to
become adept enough to know exactly what the
best procedure would be. For me, it is an art
with a little science thrown in.
Well I finally figured out that as theoretically
palatable orthoses and scientifically valid
studies may be, the actuality is quite different
when it comes to individual patients. I can
guarantee you that if I put an implant in this
foot the patient would have a fairly rapid
recurrence with or without biomechanical
assistance.
There may be others out there that would feel
comfortable doing that and perhaps there is some
trick I have not learned but in my hands an
implant would be wrong. My plan would be as
follows: if the patient was a medically
reasonable candidate for surgery: 1) assess the
joint-salvagable or not? 2) if salvageable,
perform aneck osteotomy of some sort with of
modification for moving in transverse and
saggital planes (perhaps planarflexory
(Austin/Youngswick)) modification. If non-
salvageable, performarthrodesis with a locking
plate and early weight-bearing. Given the data
presented I do not think a base osteotomy or the
more “popular” Lapidus would be needed.
Tip Sullivan, DPM, Jackson, MS,
tsdefeet@MSfootcenter.ne
04/26/2010 Todd Lamster, DPM
Hallux Hammertoe/Varus in an 8 Y/O (Mark Aldrich, DPM)
This is a very interesting case, with multiple
issues occurring simultaneously. First, let’s
look again at the radiographs. The 1st ray is
large, especially on the right, as compared to
the other lesser metatarsals and normal 1st
metatarsals in the same age group. It is wide,
has increased bone mineralization and density
and is longer than the other metatarsals. The
proximal and distal phalanges of both halluces
are also huge in comparison. Therefore, I
believe this to be a case of congenital
macrodactyly. Is this deformity static or is it
dynamic? If static, surgery now may produce good
long term results. If not, any procedure
performed now may fail due to continued growth
of the affected bones, at least until the
patient completes puberty.
Other interesting features include significant
hypertrophy of the lateral growth plate on
proximal 1st metatarsal creating adduction.
Also, look carefully at the head of both 1st
metatsarsals: is there a secondary growth plate?
If not, what are those translucent lines running
transversely across both heads? Chronic
impaction injuries from retrograde pressure from
the contracted halluces? I honestly don't know.
It also appears as though there has been joint
accommodation from this congenital defect,
specifically at the HIPJ B/L. Which brings up
how this patient functions. Is the HIPJ in a
fixed contracture, or is this deformity
completely flexible? Can you reduce both joints
into a straight alignment?
Surgically, one would have to address the
metatarsal, the MTPJ and the HIPJ with
associated soft tissue contractures. If the
present treatment includes surgery, one may opt
to perform a lateral epiphysiodesis on the 1st
met and an HIPJ release with lengthening/release
of any contracted structure. I would pin the
associated joints for 4 weeks or longer, if
possible. A closing wedge osteotomy on the
metatarsal can be done instead. If you decide to
wait and allow the patient to reach skeletal
maturity, then I would be left with performing a
Lapidus (to correct the angular deformity and
decrease length of the 1st ray to realign the
met parabola) with an HIPJ fusion. This could be
done if significant damage hasn't already
occurred to the 1st MTPJ.
With respect to Dr. Weil, this would preserve
1st MTPJ ROM and allow you to perform a single
stage procedure. The fusion of the HIPJ would
also decrease the length and size of the toe
which would be very important in shoe gear. Once
you straighten the hallux, it will appear
extremely long and large as compared to the
lesser digits. It will also make wearing shoes
difficult and most likely painful. Wait for
skeletal maturity and perform the definitive
procedures.
Todd Lamster, DPM, Phoenix, AZ,
tlamster@gmail.com
04/24/2010 Gino Scartozzi, DPM
Hallux Hammertoe/Varus in an 8 Y/O (Mark Aldrich, DPM)
This is an unusual case that Dr. Aldrich
presents. Lateral view radiographs would be
helpful to assess the sagittal plane components
to the deformity development (i.e., extensor
tendon contracture about the first ray.) I would
approach this surgical intervention with
attention to two regions of deformity present:
1. The first metatarsal-phalangeal joint reveals
adductive cartilaginous changes of the first
metatarsal surface. The medial aspect of the
first metatarsal head reveals an "impaction"
appearance which appears to contribute to the
varus orientation of the halluces at the first
metatarsal-phalangeal level. The first procedure
at this level one may consider is to address is
an abductor hallucis release.
The second procedure that one may want to
consider is to address would be dependent on the
first metatarsal-phalangeal positional function.
If there is noted to be a negative proximal
articular set angle, an abductory wedge
osteotomy at the neck of the first metatarsal
(proximal to the epiphysis that is patent on the
radiograph) can be utilized to orient the
capital fragment of the first metatarsal thus
reducing the varus deformity contributed at this
region of the foot. Fixing the osteotomy can be
accomplished by percutaneous fixation with K-
wire driven in a distal-dorsal-lateral to
proximal-plantar-medial direction with a bend
placed at the end of the Kirschner wire for
eventual removal if required.
2. The interphalangeal joint of the hallux in
all likelihood is a compensatory reaction to the
varus orientation at the first metatarsal-
phalangeal joint. The hallux interphalangeaus
deformity would be approached by addressing the
extensor hallucis longus tendon by means of Z-
plasty lengthening if noted that a "tightening"
of the tendon is contributory to the
interphalangeus deformity. A lateral capular
release of the interphalangeal joint of the
hallux may be considered with placement of a
Kirschner wire through the distal and proximal
phalanx of the hallux maintaining a rectus
position for approximately 6 weeks.
Gino Scartozzi, DPM, New Hyde Park, NY,
Gsdpm@aol.com
11/19/2008 Barry Mullen, DPM
Varus 5th Hammertoe in a 12 Year Old (Richard Frost, DPM)
The majority of this deformity is at the PIPJ,
therefore, de-rotational arthroplasty of 5th
proximal phalangeal head via oblique semi-
elliptical skin incision oriented from proximo-
lateral to disto-medial is the procedure of
choice. Ensure enough bone is excised past the
surgical neck (most active area of bone growth)
into the tubular portion of the shaft of the 5th
proximal phalanx, because bone regeneration from
under resection is more prevalent in children.
Difficult to tell w/ only 1 isolated DP x-ray as
no "gun barrell" sign observed; but if
significant digital flexion contracture also
exists, a flexor set at the apex of that
contracture would also be indicated.
5th toe arthroplasties rarely need K-wire
splintage, but in this case, if you feel
compelled I'd have little issue splinting this
correction with an .045 K-wire, and for two
reasons:
The majority of this deformity is at the PIPJ,
therefore, de-rotational arthroplasty of 5th
proximal phalangeal head via oblique semi-
elliptical skin incision oriented from proximo-
lateral to disto-medial is the procedure of
choice. Ensure enough bone is excised past the
surgical neck (most active area of bone growth)
into the tubular portion of the shaft of the 5th
proximal phalanx, because bone regeneration from
under resection is more prevalent in children.
Difficult to tell w/ only 1 isolated DP x-ray as
no "gun barrell" sign observed; but if
significant digital flexion contracture also
exists, a flexor set at the apex of that
contracture would also be indicated. 5th toe
arthroplasties rarely need K-wire splintage, but
in this case, if you feel compelled I'd have
little issue splinting this correction with
an .045 K-wire, and for two reasons:
1) It's diameter is not likely to create
significant growth plate damage anyway (assuming
you nail it w/ 1 try)
2) This is a 12 year old female, not a young
child. Bone maturation occurs sooner than in
males, so there's very little bone growth left
in this female anyway, evidenced by her nearly
closed 4th proximal phalangeal base and 2nd
metatarsal head growth plates. Even if one
created minor growth plate damage, how much
further shortening or angulation deformity are
you likely to create at this point? I'd also
remodel the EDL tendon to reflect the new
digital alignment created by shortening its
lateral side prior to closure.
Lastly, unless there is a significant
contracture or transverse plane deformity at the
MTP(not visualized in your DP x-ray), when
performing digital arthroplasty, there's rarely
any need to pin through that joint, so no
worries about that growth plate. Besides, I'd be
more concerned about damage to the cartilagenous
surface of the metatarsal head than the growth
plate. Pins should stop at the subchondral bone
of the base of the proximal phalanx. In healthy
bone, if you take your time, you should be able
to feel the resistance of the pin against
subchondral bone.
If you are still concerned, you'd likely still
achieve satisfactory splintage by stopping the
pin just distal to the growth plate, as a
healthy 12 year old's bone is strong, so the pin
would likely seat itself anyway. When compared
to subchondral bone, when reaching the distal
part of the metaphysis, the feel of resistance
is much more subtle, but still noticeable.
There's always fluro, but frankly, for an
arthroplasty, I think that is "overkill" as I'd
be more concerned about radiation exposure in a
young female than exact pin placement locale. In
surgery, the "kiss" approach is often best, as I
believe it is here.
Barry Mullen, DPM, Hackettstown, NJ,
yazy630@aol.com
05/16/2006 Larry Schuster, DPM, Marc Katz, DPM
Hallux Hammertoe Patient on Anti-Rejection Meds (S Werter, DPM)
RE: Hallux Hammertoe Patient on Anti-Rejection
Meds (S Werter, DPM)
From: Larry Schuster, DPM, Marc Katz, DPM
Many of my patients have immune issues and it is
more dangerous for
them to walk around with an open "hole" in their
foot than have
surgery as long as the vascular status is okay.
As for fusion
arthroplasty can be just as effective. Two semi
elliptical
transverse incisions excising skin and capsule
dorsally to correct
the contracture, excise the head of the proximal
phalange. Then
strip the cartilage from the base of the distal
phalange easily by
swiping the saw over it a few times. It may
fuse, fibrous or not but
the shortening of the proximal phalange and the
capsular tightening
dorsally will surely prevent ulcer recurrence.
Internal or external
fixation is nice but not necessary.
After the arthroplasty, debride the ulcer well
if it is still open
and culture it (do this last) if necessary take
a bone specimen to
rule out osteo. Your idea of relieving pressure
to cure the ulcer is
correct and may be the only way to cure him if
compliance and shoe
gear have failed.
Larry Schuster, DPM, Parsippany, NJ,
lschus@comcast.net
For this type of ulcer arthroplasty can work on
the hallux. You
could keep his toe splinted and not use fixation.
Alternatives to consider: a simple flexor tendon
release. Even if
the toe is not completely flexible it may relief
enough pressure to
heal the ulcer. Another option is removing
distal bone to decrease
the pressure.
Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com
05/15/2006 Scott Werter DPM
Hallux Hammertoe Patient on Anti-Rejection Meds
Query: Hallux Hammertoe Patient on Anti-
Rejection Meds
From: Scott Werter DPM
I have a 52 y/o male patient with a hallux
hammertoe and a chronic
ulcer at the tip of the toe. He is s a heart and
kidney transplant
patient on anti-rejection meds. I have tried to
heal this lesion
with off-loading without success. He would be a
great candidate for
IP fusion, however his transplant docs do not
want me to use any
type of hardware as they are concerned about
infection. Does anyone
do arthroplasties of the hallux IP joint? Any
thoughts or ideas.
Scott Werter, DPM, Myrtle Beach, SC,
swerter@coastalpodiatry.com
02/01/2006 Deb Carr, CCS
Billing Multiple Hammertoe Repairs on One Toe
Query: Billing Multiple Hammertoe Repairs on One
Toe
If patient has a hammertoe deformity at both
proximal interphalangeal joint and distal
interphalangeal joint of the toe, can CPT 28285
be billed twice or only one time per toe to
correct the contracture deformities?
Deb Carr, CCS, Enola, PA
>
Response: CPT 28285 is defined as a "hammertoe
correction" - that's the toe. It is used once
per toe to correct the deformed toe, whether one
or two inter-phalangeal joints are involved or
treated.
Mark Schilansky, DPM, Catskill, NY
07/22/2005 Greg Amarantos, DPM
Pediatric Hammertoe (Greg Cohen, DPM)
RE: Pediatric Hammertoe (Greg Cohen, DPM)
From: Greg Amarantos, DPM
My son was born with a similar condition. He is
now 16 years old,
and runs cross country. I tried tape and splints
when he was an
infant, to no avail. He is comfortable, so tell
mom..."if it ain't
broke, don't fix it" When the child is older,
then a decision can be
made.
Greg Amarantos, DPM
Chicago, NY
07/21/2005 Mark Robson, DPM
Pediatric Hammertoe (Greg Cohen, DPM)
RE: Pediatric Hammertoe (Greg Cohen, DPM)
From: Mark Robson, DPM
I have used a DIPJ flexor tenotomy on children
as young as 18 months old for reducible digital
contracture. Used on two adjacent toes, under
lapping is usually resolved as well as the
sagittal plane deformity. I let the parents know
that it will hopefully prevent the need for bony
surgery in the future. I prefer to do the
procedure in the office with the patient awake
so I can confirm the effectiveness of the
release. Children of that age will need to be
done under anesthesia at a hospital or surgery
center. Obviously a child 2 years old has a
small toe, you have to be careful.
Mark Robson, DPM
Austin TX
07/20/2005 Greg Cohen, DPM
Pediatric Hammertoe
Query: Pediatric Hammertoe
I had a 2 year old girl present the other day
with a flexion contracture of the left 3rd digit
which underlaps the 2nd toe. The deformity is
reducible and resolves on weight-bearing. The
mother was mostly concerned about the
appearance. She also has a mild degree of
femoral anteversion with in toeing gait.
Orthopedic exam is otherwise unremarkable.
The question is, should the flexion contracture
be treated and if so how? I am having the mother
splint the toe with silk tape at night for the
time being. Any suggestions are much appreciated.
Greg Cohen, DPM
Brooklyn, NY
10/07/2004 Steven H. Goldstein, DPM
Coding Hammertoe Correction with Implant
Query: Coding Hammertoe Correction with Implant
What would be the appropriate CPT-4 code for the
insertion of the Weil Silastic digital implant
for a hammertoe correction?
Steven H. Goldstein, DPM
Livingston, NJ
Codingline Response: The correction of a
hammertoe deformity is coded as CPT 28285. This
code is defined as "Correction, hammertoe (eg,
interphalangeal fusion, partial or
total phalangectomy)." The parenthetical
examples are just that - examples of what
technique or components could be used to resolve
the deformity. They are not met to be absolute.
It is my opinion, as well the opinion of many
others, that preparation of the site and
insertion of an interdigital implant is
surgically not a technically greater procedure
than fusion of the IPJ. Both techniques are
designed for hammertoe correction. And both
would be billed as CPT 28285 (with the
appropriate "T" modifier).
Codingline Expert Panelist: Harry Goldsmith, DPM
09/07/2004 Steven Abramow, DPM
Bundling Hammertoe & Bunionectomy Surgery
Query: Bundling Hammertoe & Bunionectomy Surgery
I performed a bunionectomy and hammertoe
correction on digits 2, 3, 4, and 5 right foot.
When I received payment, the insurer, HealthNet,
paid the allowance for the bunionectomy, but
denied the reimbursement for the hammertoe
corrections. Following an appeal, I received a
letter from the medical director that upheld the
denial based on the rationale that "28285 is a
component of the procedure code 28296 upon
review of the CCI (pg. 165-Musculoskletal)".
[The Medicare CCI (Correct Coding Initiative)
lists comprehensive codes and bundled component
codes] I have never encountered this response
before, and wonder whether this is an incorrect
determination made by the medical director.
Steven Abramow, DPM
New York, NY
Codingline Response: The Correct Coding
Imitative (CCI) edits do, in fact, bundle CPT
28285 (hammertoe correction) into CPT 28296
(bunionectomy with osteotomy) as "standard
medical/surgical practice". Don't ask me who
they relied on to define it as such.
Although it takes an extra effort, the CCI edits
do allow you to legitimately bypass the edit
using modifiers.
I would think that either you submitted your
claim to HealthNet (who has decided to use
Medicare's CCI edits to process their claims)
without the appropriate modifiers, or the
HealthNet/its medical director does not
understand that modifiers (per the CCI’s) will
allow payment.
You should appeal, based on CCI’s and
appropriate use of modifiers (if you did not
append the appropriate "T" codes to the
hammertoe procedures [or the "T" codes plus "-
59" modifiers - I don't know if HealthNet
requires both], correct your claim and include
it with an op report on the appeal. And be sure
to ask for peer review.
If you believe you coded and modified the codes
correctly, you should try to speak to the
medical director, and discuss the procedures and
billing. If you still have problems with
HealthNet or its medical director, assuming you
are member of the APMA, contact the staff person
for the Health Systems Committee (800 275-2762)
for assistance.
Tony Poggio, DPM
Alameda, CA
05/01/2004 Nat Chotechuang, DPM
Hallux Hammertoe
RE: Hallux Hammertoe
I have a patient with a first metatarsal
elevatus who has developed a hammered hallux.
Her metatarsal is approximately 3mm elevated at
the head, and is approximately 4mm shorter than
the second metatarsal. Her first proximal
phalanx is dorsiflexed approximately 20 degrees
from the ground at rest and does not reduce to
normal position under forefoot loading. The 1st
MTPJ can dorsiflex to 45 degrees, but can
plantarflex only to 20 degrees dorsiflexed. Is
there a biomechanical explanation for the
hammering, or is scar tissue the cause?
Nat Chotechuang, DPM
Bend, OR
natchot@hotmail.com
03/24/2004 Multiple Respondents
Amputation for Hammertoe Deformity? (Kevin Kirby, DPM)
RE: Amputation for Hammertoe Deformity? (Kevin
Kirby, DPM)
From: Multiple Respondents
In the Australian community of podiatric
surgeons it is uncommon for 2nd hammertoe
deformities to be primarily treated by
amputation in a healthy individual. Exceptions
to this practice include gangrene or significant
vascular incompetence. With hammertoe
deformities involving severe contracture or
dislocation, it may be argued that straightening
the toe could present a significant risk of
vascular compromise due to vascular elongation.
In such cases the surgeon and patient would need
to discuss the benefits versus the risks of each
option, but amputation is not a commonly
performed treatment for this deformity.
Litigation defence usually includes comparison
with standard practices, and the selection of
expert witnesses and their opinions in any one
case can often determine an outcome. Amputation
may equate with a shorter period of
convalescence for the primary procedure, but may
involve a prolonged period of morbidity if
secondary pathology develops.
Andrew Kingsford
Melbourne, Australia
drk@netspace.net.au
When the deformity is due to HAV, correction of
the deformity at the 1st met. is not required.
On elderly pts. and with some flexibility to the
2nd digit still available, performing a phalanx
osteotomy with NO dissection into the MPJ
provides space for the 2nd digit. I was always
concerned about creating a painful 1st MPJ, due
to change in mechanics, but in 22 years it never
occurred. The post-op disability in minimal.
Rigid post-op shoe for 4-6 weeks. Simple to
perform, little disability, sometimes removing
the 2nd digit can create more deformity and
problems down the road on ambulatory pts.
Jeffrey Trantalis, DPM
Deerfield Beach, FL
trantalis@bellsouth.net
I have performed several 2nd toe amputations.
Number one, it is not a common procedure. But in
an elderly patient with chronic, recurrent
infections/ulcerations that fails to be managed
with appropriate shoes, padding, etc., it is a
good procedure. I had a sixty-ish year old
active female who loved to walk. She had a large
bunion (IM angle 18 degrees) and a 2nd
digit "hammertoe from hell." The hallux was
laterally deviated against the 3rd toe as the
2nd toe was up and out of the way.
I was all set to fix the bunion and the 2nd toe
with an arthroplasty and PIPJ fusion when she
came in for her pre-op visit. She sheepishly
mentioned that a friend of hers was an
orthopedic surgeon who looked at her foot
informally. He asked her what really bothered
her. She replied that the 2nd toe was the
problem. The bunion really didn't bother her. He
then suggested to her to just have the 2nd toe
amputated. She asked me what I thought. After
consideration, I decided that amputating the 2nd
toe wouldn't be a bad idea. The hallux was
already maximally laterally deviated so it
wouldn't be going anywhere. So, I amputated the
toe. Post-op was uneventful until she came in 5
weeks after her surgery saying her foot was a
little sore. It turns out that was because she
had walked 6 miles the day before!
We are taught that amputations are bad and that
if we have to do one, that means we lost the
battle. I still think that is true. But in
properly selected cases, it is not a bad
procedure.
Possible complications that I can think of would
include contracture of the 3rd toe, transfer
lesion plantarly, and bunion formation.
Doug Milch, DPM
Asheville, NC
LDMilch@cs.com
Although it is my understanding that the action
is more common amongst the orthopedic community
as opposed to the podiatric community, the
amputation of the strongly deformed and
contracted 2nd digit is done and has been done
by me as well in several instances. The question
is whether the patient is best served by the
contracted digit with the pain and potentially
open wound at the PIPJ or by an attempted
correction. If the patient's age and inability
to comply with the off-loading of the site deems
them a poor candidate for arthrodesis and MTPJ
reconstruction/fusion then the patient may be
better served by having the toe removed. Once
the site is healed, I recommend a silicon toe-
filler to maintain spacing at the site. I would
also like to hear other opinions on this as I've
seen a number of orthopods amputating the 2nd
digit over the years.
David Secord, DPM
Corpus Christi, TX
David5603@POL.net
I am one of those "certain" podiatrists who does
offer this surgical option to a select group of
patients. I have had excellent results with
incredible patient satisfaction. It is a simple
procedure, less potential for post-op
complications and recuperation as compared to a
sequential reduction of the hammertoe with
arthrodesis and K-wire fixation. These types of
patients are usually elderly, have a rigidly
contracted 2nd digit that is overriding the
hallux, and the metatarsophalangeal joint is
completely subluxed dorsally. They have
inability to wear a regular shoe due to the toe
sticking up dramatically. Concomitant
ASYMPTOMATIC hallux valgus is present. They
never complain of the bunion. It is just the
2nd toe that is the problem.
These are my criteria. The first patient I
offered this procedure as a simple common sense
approach, at first was reluctant. I asked her to
think about it and she ultimately accepted it.
In 2 weeks she was back in a shoe with no
problems. Soon after, she requested I amputate
the other 2nd toe with the same problem. She
was delighted with the outcome as have many
patients since.
Generally, there is always hallux valgus present
with the hallux underriding the 2nd toe. If a
surgeon were to "correct" the 2nd toe with
accepted standard of sequential reduction of the
deformity with arthrodesis, he would have to
address the hallux valgus deformity to allow the
space needed to bring the toe to anatomical
reduction. This would entail a bunion procedure
on an asymptomatic deformity with added
potential complications and post operative
recuperation.
In these situations, I am hard pressed to sell a
bunion surgery to an elderly patient I feel does
not need it. The 2nd digit is just "hanging" on
top of the foot, is subluxated and the reduction
is more complex. I thought about this long and
hard and see the amputation procedure as the
best solution for this problem . I give these
types of patients this option as well as the
standard arthrodesis approach. They have never
been unhappy with the results and were thankful
afterwards. So , when you see this type of
patient again....give this option a thought.
Carlos I. Montes, Jr., DPM
W. Melbourne, FL
cimontesjr@aol.com
03/23/2004 Multiple Respondents
Amputation for Hammertoe Deformity? (Kevin Kirby, DPM)
RE: Amputation for Hammertoe Deformity? (Kevin
Kirby, DPM)
From: Multiple Respondents
A digital amputation of a deformed but otherwise
healthy digit under the right circumstances is
an appropriate procedure. I have utilized it in
usually elderly patients with a severe, though
often asymptomatic bunion deformity and an
overlapping second toe. The second toe is often
developing ulcerations from shoe irritation.
There is no good way to correct the contracted
digit without also correcting the bunion. The
digit is already functionally useless. Fixing
the bunion would require prolonged
immobilization and sharply increases the risks.
In contrast, a digital amputation in that group
has a very short term disability and much lesser
risks with no loss in function compared to their
starting point.
Alan Kalker, DPM
Middleton, WI
In cases where a bunion is causing a deformity
in the 2nd toe that is symptomatic, and because
of their age or other reasons the patient
doesn't want to have the HAV deformity repaired,
I have removed the 2nd toe. I remove the head of
the proximal phalanx and the distal toe, leaving
the remaining proximal phalanx to act as a
spacer. This works very well. I've only done
this 2 or 3 times, and its hard for me to
envision other scenario's that don't involve
infection or ischemia that justify amputation.
Scott Hughes, DPM
Monroe, MI
Yes, I do this procedure with indications as
noted. Though I do not condone the habit of
amputating any structural part it is usually the
second digit that is subluxed and/or abscessing
by bunion pressure. Additionally, the patient
is usually elderly and compromised by PVD and
osteoporosis, therefore, any Keller and/or
digital fusion is risky. I explain the benefit
of healing just an incision wound with an
ambulatory status without any altered gait
pattern. I average only one a year.
Wayne A. Vetter, D.P.M.
Portland, OR
The first time I performed a second toe
amputation for the treatment of hammertoe
deformity I too was uncomfortable about the
approach. Everything we had been taught in
school was to preserve the digit if possible.
The patient was an elderly woman, caring for a
husband with Alzheimer's Disease, no extended
family, good peripheral circulation, with a
large asymptomatic hallux valgus deformity, and
a very painful crossover second hammertoe
deformity.
I offered the patient the options of HV and HT
second correction with internal fixation and the
usual 6 - 8 weeks of limited ambulation, or a
second toe amputation. (We had also discussed
and documented non-surgical option - molded
shoes, as well.) She choose the amputation. I
documented why the amputation was advantageous
in this individual case. I performed the
amputation and she was up ambulating after 24
hours with no pain, and very pleased with the
overall result and lack of disability.
Since this time I find I perform these digital
amputations for a variety of patients with
various toe deformities. Most recently a
rheumatoid patient came to my office from an
orthopedic surgeon, s/p fusion 1st MTP joint,
2nd, 3rd, and 4th toes. The 2nd, 3rd, and 4th
toes had subluxed laterally and the 4th toe was
over riding the 5th toe with a painful
interdigital lesion. She was "not going to go
through those pins again." So we amputated the
4th toe, and she was very pleased and back in
shoes after 3 weeks.
I always document why the amputation is the
advantageous procedure (minimal post-op
disability compared with the alternatives) and
the risks of further digital deformities. I find
digital amputation to be a satisfactory
alternative to hammertoe correction surgery,
when the patient does not want the prolonged
disability of an arthrodesis, and the
arthroplasty is doomed to failure. One pearl I
have found for second toe amputations, where I
am concerned about lateral drift of the hallux
is to leave the base of the proximal phalanx of
the second toe, which continues to serve as a
buttress.
David Arkin, DPM
Big Flats, NY
03/22/2004 Kevin A. Kirby, DPM
Amputation for Hammertoe Deformity?
Query: Amputation for hammertoe deformity?
It has come to my attention that there are
certain podiatrists both here in the States and
abroad who will occasionally perform 2nd digit
amputations for 2nd digit hammertoe deformities
in patients that are otherwise healthy in order
to avoid the prolonged healing from a PIPJ
arthrodesis procedure or other hammertoe
correction procedures. Even though I have
never performed a digital amputation for a
hammertoe, my curiosity has been aroused
sufficiently to pose this set of questions to
the talented podiatric surgical contributors of
PM News:
1. How common is the practice of 2nd digit
amputation for 2nd digit hammertoes in your
medical community?
2. If this procedure was performed and the
patient developed, for example, a bunion
deformity as a result, would this be considered
grounds for malpractice in your medical
community?
3. What are the benefits and risks of 2nd digit
amputation versus hammertoe correction?
Kevin A. Kirby, DPM
Sacramento, CA
kevinakirby@comcast.net
03/10/2004 Brian Connor, DPM
Repair Plantar Plate and Hammertoe
Query: Repair Plantar Plate and Hammertoe
I am looking for some help in coding the repair
of a plantar plate in conjunction with a flexor
tendon transfer/hammertoe repair (the digit is
crossed over an adjacent toe). Specifically,
does anyone have a recommendation on a CPT to
use for the repair of the plantar plate with the
hammertoe correction?
Brian Connor, DPM
Altamonte Springs, FL
Codingline Response: Most insurance companies,
whether it seems reasonable or not, will bundle
all soft tissue and bone procedures related to
repair of hammertoe into CPT 28285 (hammertoe
correction, e.g., interphalangeal fusion,
partial or total phalangectomy).
Since there is no specific code for repair of
flexor plate, I suggest adding modifier "-22" to
CPT 28285 indicating that this procedure was
greater than the usual code, and deserves more
compensation. By sure to include an operative
report, and request peer review with your
insurance claim.
Howard Zlotoff, DPM
Camp Hill, PA
01/10/2004 Deb Carr, CCS
Hammertoe Repair with Fasciotomy
Query: Hammertoe Repair with Fasciotomy
When coding surgery on a toe, can I code both
CPT 28285 (hammertoe correction) and CPT 28008
(fasciotomy) - performed through the same
incision? I checked both the CCI edits and AAOS
Global Service Data, and do not see them
bundled. The surgeon's also did an extensor
tendon release for contracture which I know is
bundled into CPT 28285..
Deb Carr, CCS
Enola, PA
Codingline Responses: The soft tissue release
(especially on the toe itself) performed during
hammertoe correction is considered to be bundled
within CPT 28285, hammertoe correction. I would
like to see specific description of the "toe
fasciotomy." Releasing the plantar fascia on a
toe without a flexor tenotomy or capsulotomy (or
both) doesn't quite sound right.
Tony Poggio, DPM
Alameda, CA
Most likely your surgeon performed a hammertoe
correction with IPJ capsulotomy and/or
tenotomy. This component procedure, CPT 28272,
would not be separately billable from the CPT
28285 global. The coding would only be CPT 28285.
Rick Horsman, DPM
Olympia, WA
11/05/2003 Alex Dellinger, DPM
Hammertoe Repair with Fx Bone Excision
Query: Hammertoe Repair with Fx Bone Excision
I did surgery on a diabetic patient who had a
severely contracted hammertoe with recurrent
ulcer on the dorsal proximal phalangeal joint on
the 3rd toe, right foot. The patient also had an
old fracture fragment at the base of the
proximal phalanx (medial condyle) on the same
toe. The procedure included a hammertoe repair
with excision of the fracture fragment (same
incision). Am I allowed to bill both procedures
separately, or are they included in the single
CPT 28285 allowance?
Alex Dellinger, DPM
Little Rock, AR
Codingline Response: No. Both CPT 28124 (partial
excision [craterization, saucerization,
sequestrectomy, or diaphysectomy] bone [e.g.,
osteomyelitis or bossing]; phalanx) and CPT
28022 (arthrotomy, including exploration,
drainage, or removal of loose or foreign body;
metatarsal-phalangeal joint) effectively
includes the removal of bone or loose body are
bundled per CCI within CPT 28285. The AAOS
Complete Global Services Data for Orthopedic
Surgeon, likewise, includes these procedures
within CPT 28285.
Chris P. Galeziewski; CPC, CMIS
Kelsey-Seybold
Houston, TX
07/01/2003 Steven H. Goldstein, DPM, Brian Kashan, D.P.M.
Hammertoe (Bruce Lebowitz, DPM)
RE: Hammertoe (Bruce Lebowitz, DPM)
This really presents a challenge because in
order to attempt to correct this toe a lot of
shortening can take place. First start at the MPJ
and try the standard releases of the extensor
wing, sling, dorsal capsule, collateral ligaments
and lengthen the long extensor if necessary by Z
plasty. Ideally I think you will have to do a
double arthrodesis at the PIPJ and DIPJ the cuts
on the cartilage may need to be in an angular
fashion to reverse the transverse plane
deformities. Again inform the patient of the
shortening that will take place. You will have to
drive a K wire through the DIPJ, PIPJ and MPJ for
6 weeks or so. You may want to place the patient
in the Darco Incline shoe which will keep her for
bearing any weight on the forefoot. I have also
seen some patients who have had the toe
syndactylized to the third digit but it does not
look well from a cosmetic standpoint but it does
give added stability.
Steven H. Goldstein, DPM
Livingston, NJ
One word answer to your dilemma. Fusion....
of both the DIPJ and PIPJ with
appropriate tendon/soft tissue release.
Brian Kashan, D.P.M.
Baltimore, MD
03/05/2003 Ray McClanahan, DPM, BS Ed., Lowell Scott Weil, Sr., DPM
Young Athlete With Severe Hammertoes (Robert Kelsey, DPM)
RE: Young Athlete With Severe Hammertoes (Robert
Kelsey, DPM)
From: Ray McClanahan, DPM, BS Ed., Lowell Scott
Weil, Sr., DPM
Regarding Dr. Kelsey's 16 yo female
basketball player with forefoot deformity. It
would be extremely helpful to know what types of
conservative care have been tried on his patient
thus far. It would also be helpful to know where
her pain is located. Dorsal PIPJ level? Distal
digital level? Plantar metatarsal head level?
Without having seen this athlete, I would
recommend:
1. Measure her feet for length and width and
compare to her shoes. Look at her wear pattern
on the insole of her shoe to determine where her
toes are functioning ( or not functioning if they
are clawing ). Very likely her shoes are too
small and probably have been for years.
2. I would enlist her in an aggressive stretching
protocol for her extensor hood mechanisms by
having her do a stretch I call toe extensor
stretch. The patient puts the tops of their toes
on the ground and applies a stretch to the
extensor hood and extensors by pushing their
toes in under their foot.
I suspect she also has some level of equinus
associated with her other deformities. Nite
splints may help with this and keeping her out of
heels should be paramount.
3. I would take a felt medial longitudinal pad
and apply it to her insole in the same location
you would place a met pad, round side forward,
long tapered side following the course of the
plantar fascia. This will give her flexors a bit
of an advantage to pull the toes down
towards the ground.
4. Multiple types of digital pads are available
for pain at a variety of digital levels.
5. Get her in to see a podiatrist that
specializes in treating athletes.
6. I would not operate on her until a concerted
effort of conservative care failed. Not enough
information was given to determine if this is the
case.
First, do no harm.
Ray McClanahan, DPM, BS Ed.
Longview , WA
footdr@nwfootankle.com
-------------
Over the years, I have had the opportunity
to treat many professional athletes with the most
horrendous looking feet imaginable. Unless the
condition interfered with their ability to play
at the highest level, I reserved surgery until
after their college or professional career ended.
Appropriate accommodations in a roomy basketball
shoe will usually suffice to relieve symptoms.
Having said that, one should not hesitate to
perform an arthroplasty or arthrodesis of the
most symptomatic toe or toes. I would caution
doing across the board hammertoe repairs with
bilateral bunionectomies. The time to recovery
could influence the ability of a college prospect
to gain a scholarship. Proceed with caution and
do to the athlete what you would do to your
daughter.
Lowell Scott Weil, Sr., DPM
Des Plaines, IL
WEIL4FEET@aol.com
03/04/2003 Robert Kelsey, DPM
Young Athlete with Severe Hammertoes
RE: Young athlete with severe hammertoes
From: Robert Kelsey, DPM
My partner has a 16 year old female basketball
player who suffers from severe bunions and
hammertoes (actually more of a claw toe
deformity). This young lady has a promising
basketball future ahead of her with Division 1
college scholarships almost certain. She and her
family have decided to pursue surgical correction
(after conservative treatments and living with
painful toes for several years). Do any readers
have experience with how athletes do after
arthroplasty vs.
arthrodesis for the correction of the
hammertoes? Is jumping or running ability
affected by digital fusions? Any advice
regarding advantages or pitfalls one might expect
with either procedure in this type of athlete
would be appreciated.
Robert Kelsey, DPM
Dubuque, IA
blkelsey@juno.com
09/25/2002 Mark A. Aldrich, DPM
Bunionectomy/Hammertoe Denials
Query: Bunionectomy/Hammertoe Denials
From: Mark A. Aldrich, DPM
We recently did a Silver-type bunionectomy (CPT
28290) right, and also hammertoe corrections on
the 2nd and 3rd toes right foot (CPT 28285-51
x2). Medicare allowed for the bunionectomy
procedure, but denied the hammertoe corrections,
stating that they were included in the global
allowance for the bunionectomy. Why was this
denied?
Four weeks later, we took the patient
back to surgery and performed the exact same
procedures on the left foot - all the procedures
were denied with an explanation that they were
included with the right foot bunionectomy
allowance. Why?
Mark A. Aldrich, DPM
Antigo, WI
-----------Codingline(L) Response -----------
It is important to add the appropriate "T"
modifiers to each hammertoe procedure to
delineate that each was performed on a separately
identifiable anatomical site. Additionally, I
would personally also add the "-59" modifier to
each of the hammertoe procedures.
R. Murphy Hanley, DPM – Codingline(L) participant
Hollywood, FL
09/05/2002 Mark A. Aldrich, DPM
Bunionectomy-Hammertoe Coding
Query: Bunionectomy-Hammertoe Coding
From: Mark A. Aldrich, DPM
We recently did a Silver-type bunionectomy (CPT
28290) right, and also hammertoe corrections on
the 2nd and 3rd toes right foot (CPT 28285-51
x2). Medicare allowed for the bunionectomy
procedure, but denied the hammertoe corrections,
stating that they were included in the global
allowance for the bunionectomy. Why was this
denied?
Four weeks later, we took the patient back to
surgery and performed the exact same procedures
on the left foot - all the procedures were denied
with an explanation that they were included with
the right foot bunionectomy allowance. Why?
Mark A. Aldrich, DPM
Antigo, WI
----------------
Codingline(L) Responses
When doing procedures on different toes at the
same sitting, you must use the toe modifiers to
indicate that the hammertoes ("T" codes) are
separate from the bunionectomy procedure. In
addition, I also use the "-59" modifier to
indicate a separate site.
If you don't use the toe modifiers, Medicare will
bundle them all together.
Walter J Pedowitz, MD- Codingline Expert Panelist
New Jersey
-------------
It appears that you need modifiers to let the
carrier know that you are working on different
toes.
For the hammertoe procedures, you need to append
the "T6" modifier for the right second toe, "T7"
modifier for the right third toe, along with "-
59" modifiers (noting they are separate and
distinct from the bunion procedure). The
modifier "RT" should be added to the bunionectomy
code.
When you took the patient back and essentially
performed the same procedures on the left foot -
all within the global period of the right foot -
you needed to let the carrier know that the
procedures performed during this surgical session
were unrelated to those performed on the previous
surgical session. For the hammertoe procedures,
you need to append the "T1" modifier for the left
second toe, "T2" modifier for the left third toe,
along with "LT" added to the bunionectomy code.
Then, after those modifiers, you need to append
modifier "-79" to each code thereby alerting the
carrier that the patient had procedures (left
foot) NOT related to those of the first surgical
session (right foot) that initially began the
global period.
Margie S Vaught, CPC – Codingline(L) Participant
Ellensburg, WA
