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Arthrodesis of the PIP Joint Using a Headless Intramedullary Screw

William Granberry M.D.

Presented at: 2007 AOFAS Annual Summer Meeting Toronto Canada

Introduction: Standard fixation for arthrodesis of the PIPJ in hammertoe surgery has been a smooth k-wire. Reliable arthrodesis is difficult using a smooth wire alone. Nonunion and malunion rates vary from 20% to 60%. Dissatisfaction with surgery is primarily related to nonunion and malunion. This report describes an intramedullary fixation technique that provides reliable maintenance of alignment and ultimate fusion of the PIPJ. This study explores the viability of more permanent fixation to ensure alignment and a higher fusion rate to improve patient satisfaction.

Conclusions: Intramedullary fixation of the PIPJ using a headless self-compression screw provides reliable radiographic and subjective results when used for hammertoe reconstruction. Refinement in techniques and screw design will make fixation of the PIPJ even more simple and reliable.

Methods: A consecutive series of 19 patients who had hammertoe surgery from July 2004 through December 2005 using intramedullary fixation of the PIPJ were included in this study. All patients had resection of the distal end of the proximal phalanx and removal of the articular cartilage from the middle phalanx. A headless self-compression screw was then used to fixate and compress the joint. The screw was placed retrograde using a specially designed screwdriver. It was inserted past the distal phalanx and DIPJ to immobilize only the PIPJ. Additional procedures were done in each patient as determined by the deformities present.  Postoperative management allowed for immediate weight bearing and the use of a hammertoe splint to prevent MTP extension for 6 weeks. Follow up examination included clinical and radiographic exam.

Results: A total of 19 patients (32 toes) were available for review. The average age was 62 years (range 58 to 72). Average follow up was 11 months (minimum 6 months). There were 22 second toes, 6 third toes and 4 fourth toes. Preoperatively, patients complained primarily of pain, callusing and difficulty with shoes. Additional surgery was performed on 18 feet. There were 6 bunionectomies, one MTP fusion, 2 plantar condyectomies and 9 Weil metatarsal shortening osteotomies. There were no acute postoperative complications. All but one of the toes were solidly fused by 3 months. Alignment improved in all of the cases. Preoperative flexion of the PIPJ averaged 53.5 degrees (range 20 to 115 degrees). Postoperatively the average alignment was 3 degrees of flexion (range 0 to 18 degrees). The average correction was 50 degrees (range 20 to 115 degrees). Axial alignment improved as well. The deviation in the AP plane ranged from 45 degrees of varus to 68 degrees of valgus. Postoperatively only one toe was more than 10 degrees (28 degrees of valgus) from straight. MTP hyperextension averaged 23 degrees (range 10 to 48 degrees) and improved in all the toes as well. One patient had frank dislocation of the MTP preoperatively. Only 4 toes had 20 degrees or more of residual MTP extension. All patients were satisfied with the postoperative result. The appearance of hyperextension of the PIPJ was noted in 4 patients, however they remained satisfied and no additional surgery was required.