Surgical Management of Digital Deformities

All too frequently, a painful and deformed digit may be diagnosed under the commonly used terminology of "hammer toe”, when in fact it may not be a hammer toe at all. Digital deformities vary widely in their presentation, severity, and etiology. To choose the best possible surgical procedure for correction of the deformity, it is critical that certain aspects of the deformity be clearly identified. Digital deformities involving the second, third, fourth, and fifth toes can be classified and described using a number of parameters (Fig. 26-1; Table 26-1). The deformities can occur on the sagittal, transverse, or frontal planes or any combination of these planes. They may be static or dynamic and may occur singularly or as part of a group in which all lesser digits display the abnormality. They may have no planal abnormalities, that is, display no contraction or rotation, yet exhibit painful pressure lesions. If contraction or rotation is present, the contraction may be flexible and reducible, or it may be rigid and nonreducible. Etiologies of digital deformities vary widely, and may be congenital or acquired, simple or complex, the result of surgical failure or naturally occurring. The extensive history of digital surgery includes soft tissue procedures only, osseous procedures involving partial or total resection of bone, fusions and amputations, and an untold number of combinations of these. Soft tissue procedures include tendon releases and lengthenings, capsulotomies, extensor hood apparatus releases, ligament releases, and tendon transfers. Tenotomies with or without capsulotomies as isolated procedures are rarely indicated. Extensor and flexor tenotomy and capsulotomy find greatest application in the older patient in whom more definitive reconstructive surgery is not possible. Tendon transfers have been reported for a number of purposes. In 1928, Forrester-Brown used transfer of the long flexor tendon to the extensor tendons to replace lost intrinsic function to the hallux. In 1942, Lapidus described transfer of the extensor tendon for correction of the overlapping fifth toe. In 1947, Girdlestone transferred flexor digitorum longus tendons into dorsal expansions of the extensor tendons in the hope that intrinsic function that had been lost would be restored. Sgarlato performed flexor tendon transfer to itself and to the extensor tendons for contracted digits. In 1984, Barbari and Brevig performed the previously mentioned Girdlestone-Taylor with Parrish's modification. In 1980, Kuwada and Dockery reported a modification of the flexor transfer in which the flexor tendon was brought through a drill hole in the anatomic neck of the proximal phalanx. In 1988, Kuwada followed with a retrospective analysis of modification of the flexor tendon transfer for correction of hammer toe deformities, as a long-term look back at those performed previously. Osseous procedures include partial resection of phalanges, 1-5,16,17 total resections of phalanges, and digital amputations. All parts of the phalanx have at one time or another been removed, including condyles, the head, the base, and the diaphyseal shaft. In 1910, Soule described the first arthrodesis procedure of the proximal interphalangeal joint (PIPJ). Other modifications have included the "spike" and hole of Higgs in 1931 and the truncated cone-shaped design