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

Other messages in this thread:

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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