The Journal of Foot & Ankle Surgery 54 (2015) 1116–1118
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Tips, Quips, and Pearls “Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle SurgeryÒ, which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providing better care.
Stabilization of Fifth Digit Derotation Arthroplasty With an Absorbable Fixation Pin Joel W. Brook, DPM, FACFAS, Mark J. Drake, DPM Surgeon, Dallas Podiatry Works, Dallas, TX
a r t i c l e i n f o
a b s t r a c t
Keywords: flail toe hammertoe phalanx surgery Trim-ItÔ pin
Derotation arthroplasty is the time-tested procedure for the repair of a symptomatic adductovarus deformity of the fifth toe. However, the procedure can result in an unstable floppy toe. A technique is described to stabilize this arthroplasty using an absorbable poly-L-lactic acid pin. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Fifth digit derotation arthroplasty is a common surgical procedure for the correction of an adductovarus fifth digit. It is a timetested procedure for alleviating the symptoms associated with this deformity. The most commonly reported complications specific to derotation arthroplasty are recurrence of the deformity and an unstable or flail toe (1). The primary method of stabilization with arthroplasty has been deep suture and skin closure. Secondary stabilization, if needed, traditionally has been done with a Kirschner wire inserted across the proximal interphalangeal joint arthroplasty, but this procedure is rarely performed now because it can increase the risk of secondary infection and lead to fibrous pseudoarthrosis and irritation of the fifth toe against the break angle of the toe box (2). Another adjunctive stabilization technique is splinting of the fifth digit, incorporated as a part of the postoperative dressing. It has been our experience that stabilizing the fifth digit arthroplasty with a 1.5-mm poly-L-lactic acid (PLLA) absorbable pin without a swaged metallic cutting tip is a very successful adjunct to the procedure. Not only does this method provide the stabilization needed, but it also eliminates the risk of infection associated with the skin portal and the potential hyperrigidity created by a Kirschner wire.
transverse tenotomy and capsulotomy is performed, exposing the head of the proximal phalanx and the base of the middle phalanx. Removal of the head of the proximal phalanx is achieved using an oscillating bone saw or bone cutting forceps. Addressing the articular surface of the middle phalanx is not needed. Next, the proximal phalanx is stabilized using a phalangeal clamp. We use a 1.5-mm Trim-ItÔ pin (Arthrex, Inc., Naples, FL). It comes in a prepackaged kit that includes a 1.5-mm diameter (100 mm in
Surgical Technique A standard oblique elliptical skin incision is used, centered over the dorsolateral aspect of the fifth proximal interphalangeal joint. A Address correspondence to: Joel W. Brook, DPM, FACFAS, Dallas Podiatry Works, 16226 Red Cedar Trail, Dallas, TX 75248. E-mail address: [email protected] (J.W. Brook).
Fig. 1. Stabilization of the middle phalanx with full visualization of the base.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.12.016
J.W. Brook, M.J. Drake / The Journal of Foot & Ankle Surgery 54 (2015) 1116–1118
1117
Fig. 2. Drill wire measurement of the proximal and middle phalanx plus about another 3 mm.
Fig. 4. View of the toe after a standard closure technique.
length) drill wire with graduated hash marks every 10 mm. This drill wire enables a good visual reference point on which to measure the implant length. Using the prepackaged 1.5-mm drill wire, a hole is drilled from distal to proximal into the medullary canal of the proximal phalanx until resistance has been encountered from the subchondral bone proximally. The depth should be measured using the graduated hash marks on the wire. Next, the middle phalanx should be stabilized and full visualization of the base ensured (Fig. 1). Measuring the depth is important for ensuring correct placement of the drill hole, which should align with the corresponding hole in the proximal phalanx. The initial drill hole should be placed centrally in the base of the middle phalanx and continued until the subchondral bone in the head has been encountered. The measurement of the drill wire in the middle phalanx should be recorded. The drill wire measurement of the proximal and middle phalanx should be summed plus about another 3 mm, and the PLLA absorbable pin should be cut to correspond to this length (Fig. 2).
For cutting the PLLA absorbable pin, we have found that bone cutting forceps, held at an oblique angle, yield the least amount of pin deformation. The cut end of the pin is then crimped with a
Fig. 3. Insertion of the pin using a needle driver first into the proximal phalanx.
Fig. 5. Radiographic view of the most common complication associated with fifth digit derotation arthroplasty, a flail digit.
1118
J.W. Brook, M.J. Drake / The Journal of Foot & Ankle Surgery 54 (2015) 1116–1118
heavy needle driver to narrow any thickened or deformed regions caused by cutting the pin. Once cut to appropriate length, the pin should be inserted into the proximal phalanx with a needle driver (Fig. 3). Next, the middle phalanx should be distracted and plantarflexed, and the distal aspect of the pin should be bent using the needle driver and inserted into the middle phalanx. The arthroplasty should then be assessed for stability (Fig. 4). The primary author (J.W.B.) contends that no additional splinting will be necessary to stabilize the digit. If this is performed as an isolated procedure, the patient should be placed in a postoperative shoe, with weightbearing allowed, as tolerated. Discussion The primary benefit of using this procedure to stabilize the arthroplasty is a lower risk of complications such as a flail digit (Figs. 5 and 6). We have also found that the PLLAF5 F6 absorbable pin acts as an internal stabilizer while providing some flexibility, thus reducing the probability of recurrent hyperkeratosis or pain related to shoe pressure. The interval to pin degradation varies depending on physiologic factors and implant properties (3), but the pin generally maintains full strength for approximately 24 weeks, and degradation will be complete by 12 to 18 months postoperative (4). References
Fig. 6. Radiographic view of correction of flail digit using the 1.5-mm Trim-ItÔ pin.
1. Strash W. Arthroplasty for 5th toe deformity. Clin Podiatr Med Surg 27:625–628, 2010. 2. Good J, Fiala K. Digital surgery: current trends and techniques. Clin Podiatr Med Surg 27:583–599, 2010. €stman O, Hirvensalo E, M€ €la € H, 3. Rokkanen P, Bo akel€ a EA, Partio EK, P€ atia €€ €rma €l€ Vainionpa a SI, Vihtonen K, To a P. Bioabsorbable fixation in orthopaedic surgery and traumatology. Biomaterials 21:2607–2613, 2000. €stman O, Hirvensalo E, To €rm€ 4. Pihlajamaki H, Bo al€ a P, Rokkanen P. Absorbable pins of self-reinforced poly-L-lactic acid for fixation of fractures and osteotomies. J Bone Joint Surg Br 74-B:853–887, 1992.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Tips, Quips, and Pearls “Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle SurgeryÒ, which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providing better care.
Stabilization of Fifth Digit Derotation Arthroplasty With an Absorbable Fixation Pin Joel W. Brook, DPM, FACFAS, Mark J. Drake, DPM Surgeon, Dallas Podiatry Works, Dallas, TX
a r t i c l e i n f o
a b s t r a c t
Keywords: flail toe hammertoe phalanx surgery Trim-ItÔ pin
Derotation arthroplasty is the time-tested procedure for the repair of a symptomatic adductovarus deformity of the fifth toe. However, the procedure can result in an unstable floppy toe. A technique is described to stabilize this arthroplasty using an absorbable poly-L-lactic acid pin. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Fifth digit derotation arthroplasty is a common surgical procedure for the correction of an adductovarus fifth digit. It is a timetested procedure for alleviating the symptoms associated with this deformity. The most commonly reported complications specific to derotation arthroplasty are recurrence of the deformity and an unstable or flail toe (1). The primary method of stabilization with arthroplasty has been deep suture and skin closure. Secondary stabilization, if needed, traditionally has been done with a Kirschner wire inserted across the proximal interphalangeal joint arthroplasty, but this procedure is rarely performed now because it can increase the risk of secondary infection and lead to fibrous pseudoarthrosis and irritation of the fifth toe against the break angle of the toe box (2). Another adjunctive stabilization technique is splinting of the fifth digit, incorporated as a part of the postoperative dressing. It has been our experience that stabilizing the fifth digit arthroplasty with a 1.5-mm poly-L-lactic acid (PLLA) absorbable pin without a swaged metallic cutting tip is a very successful adjunct to the procedure. Not only does this method provide the stabilization needed, but it also eliminates the risk of infection associated with the skin portal and the potential hyperrigidity created by a Kirschner wire.
transverse tenotomy and capsulotomy is performed, exposing the head of the proximal phalanx and the base of the middle phalanx. Removal of the head of the proximal phalanx is achieved using an oscillating bone saw or bone cutting forceps. Addressing the articular surface of the middle phalanx is not needed. Next, the proximal phalanx is stabilized using a phalangeal clamp. We use a 1.5-mm Trim-ItÔ pin (Arthrex, Inc., Naples, FL). It comes in a prepackaged kit that includes a 1.5-mm diameter (100 mm in
Surgical Technique A standard oblique elliptical skin incision is used, centered over the dorsolateral aspect of the fifth proximal interphalangeal joint. A Address correspondence to: Joel W. Brook, DPM, FACFAS, Dallas Podiatry Works, 16226 Red Cedar Trail, Dallas, TX 75248. E-mail address: [email protected] (J.W. Brook).
Fig. 1. Stabilization of the middle phalanx with full visualization of the base.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.12.016
J.W. Brook, M.J. Drake / The Journal of Foot & Ankle Surgery 54 (2015) 1116–1118
1117
Fig. 2. Drill wire measurement of the proximal and middle phalanx plus about another 3 mm.
Fig. 4. View of the toe after a standard closure technique.
length) drill wire with graduated hash marks every 10 mm. This drill wire enables a good visual reference point on which to measure the implant length. Using the prepackaged 1.5-mm drill wire, a hole is drilled from distal to proximal into the medullary canal of the proximal phalanx until resistance has been encountered from the subchondral bone proximally. The depth should be measured using the graduated hash marks on the wire. Next, the middle phalanx should be stabilized and full visualization of the base ensured (Fig. 1). Measuring the depth is important for ensuring correct placement of the drill hole, which should align with the corresponding hole in the proximal phalanx. The initial drill hole should be placed centrally in the base of the middle phalanx and continued until the subchondral bone in the head has been encountered. The measurement of the drill wire in the middle phalanx should be recorded. The drill wire measurement of the proximal and middle phalanx should be summed plus about another 3 mm, and the PLLA absorbable pin should be cut to correspond to this length (Fig. 2).
For cutting the PLLA absorbable pin, we have found that bone cutting forceps, held at an oblique angle, yield the least amount of pin deformation. The cut end of the pin is then crimped with a
Fig. 3. Insertion of the pin using a needle driver first into the proximal phalanx.
Fig. 5. Radiographic view of the most common complication associated with fifth digit derotation arthroplasty, a flail digit.
1118
J.W. Brook, M.J. Drake / The Journal of Foot & Ankle Surgery 54 (2015) 1116–1118
heavy needle driver to narrow any thickened or deformed regions caused by cutting the pin. Once cut to appropriate length, the pin should be inserted into the proximal phalanx with a needle driver (Fig. 3). Next, the middle phalanx should be distracted and plantarflexed, and the distal aspect of the pin should be bent using the needle driver and inserted into the middle phalanx. The arthroplasty should then be assessed for stability (Fig. 4). The primary author (J.W.B.) contends that no additional splinting will be necessary to stabilize the digit. If this is performed as an isolated procedure, the patient should be placed in a postoperative shoe, with weightbearing allowed, as tolerated. Discussion The primary benefit of using this procedure to stabilize the arthroplasty is a lower risk of complications such as a flail digit (Figs. 5 and 6). We have also found that the PLLAF5 F6 absorbable pin acts as an internal stabilizer while providing some flexibility, thus reducing the probability of recurrent hyperkeratosis or pain related to shoe pressure. The interval to pin degradation varies depending on physiologic factors and implant properties (3), but the pin generally maintains full strength for approximately 24 weeks, and degradation will be complete by 12 to 18 months postoperative (4). References
Fig. 6. Radiographic view of correction of flail digit using the 1.5-mm Trim-ItÔ pin.
1. Strash W. Arthroplasty for 5th toe deformity. Clin Podiatr Med Surg 27:625–628, 2010. 2. Good J, Fiala K. Digital surgery: current trends and techniques. Clin Podiatr Med Surg 27:583–599, 2010. €stman O, Hirvensalo E, M€ €la € H, 3. Rokkanen P, Bo akel€ a EA, Partio EK, P€ atia €€ €rma €l€ Vainionpa a SI, Vihtonen K, To a P. Bioabsorbable fixation in orthopaedic surgery and traumatology. Biomaterials 21:2607–2613, 2000. €stman O, Hirvensalo E, To €rm€ 4. Pihlajamaki H, Bo al€ a P, Rokkanen P. Absorbable pins of self-reinforced poly-L-lactic acid for fixation of fractures and osteotomies. J Bone Joint Surg Br 74-B:853–887, 1992.
