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bone stimulator for broken implant in hammertoe?

Hello Dr.


I have had an implant put in my second toe to repair a hammertoe surgery that never worked and from which I ended up with mallet toe (the second surgery was done by a different surgeon). Unfortunately, the implant which is made of cadaverous bone is broken. I am nine weeks out from surgery. The surgeon is considering whether to put in a metal implant. Would you think a bone stimulator plus taping the toe to keep it straight would work? The tendon in the tip of the toe is pulling the top of the toe toward the floor (though not as bad as when I had the mallet toe). There is now a halo around the implant in the top part of the toe (it wasn't there five weeks after surgery).

Thank you

RESPONSE

Hello,

Well, problem number one is that bone stimulators, stimulate live bone to create more live bone in order to bridge the gap between the ends of a broken bone. You have cadaver bone which obviously is dead bone and therefore will not be able to stimulate the formation of new bone.

When you refer to implant that usually suggests something implanted into a toe to create an artificial joint. Cadaver bone and metal materials are not used to create artificial joints, so from your narrative, the best I can come up with is bone was implanted into the toe to keep the toe straight after a failed hammertoe surgery.

Because cadaver bone was put into the toe, I can only assume the first surgeon removed too much bone and you ended up with issues because either the toe was too "floppy" or too short. As a result of this failed surgery you also ended up with a tendon imbalance, where the flexor tendon, the tendon on the bottom of the toe now over powers the tendon on top of the toe and you have ended up with a mallet toe.

I am also making the assumption that the toe hurts you. I say that because just because the toe has become deformed at the distal joint, does not mean it has to be "fixed". The only reason you would consider having further surgery is if there is now pain as a result of the mallet toe.

You want to take the last paragraph very seriously for the simple reason that you have already had two surgeries on one toe. In surgery there is a point of diminishing returns with correcting, or trying to correct, the same problem multiple times. In regards to your lesser toes, repeated surgery will at some time cause vascular compromise to the toe, in the form of either diminished blood flowing into the toe, or the inability of blood to properly leave the toe.

The toe may also become chronically swollen, known as a "sausage toe" and this condition in most cases is permanent.

Every time you have surgery on this toe there is damage that is being done to the toe in terms of scar tissue and "man-handling" of the tissue within the toe. The end result is that the toe could end up "looking better" but still be a source of continuing pain simply because of all the surgical trauma done to it. I have seen this countless times in my career.

You have heard the old saying, "sometimes less is more".

So the only reason you would even consider a third surgery would be if there is continuing pain and you have tried conservative measures such as physical therapy, or modifying your shoe selection in an effort to protect the toe.

If conservative measures fail to alleviate your pain and your pain is severe enough, then you may be forced to consider a third procedure.

If your mallet toe is easily straightened by just pulling the end of the toe upwards, then you may want to ask your surgeon about a simple soft tissue procedure known as a flexor tenotomy, where under local anesthesia, (we do them in the office), the flexor tendon, which is over powering the tendon on top of the toe, is cut. This along with a flexor capsulotomy will make the end of the toe straight.

Yes, it is a surgical procedure, but it is one with minimal trauma to the toe, requires just a couple of sutures and should not set you back in terms of moving on with your life.

This suggestion would be predicated on the assumption that your pain is at the end of the toe and not where the broken cadaver bone is located. In theory broken dead bone should not be a source of pain, since it is dead bone and does not have nerve sensation.

Speak to your surgeon about your options and if not satisfied with the answers, seek a second opinion from another surgeon in your area.

Marc Mitnick DPM
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Sep 03, 2014
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many thanks
by: Anonymous

Thanks very much for your thoughtful reply. The mallet toe I had developed after the first failed surgery caused pain at every (other) step. A pt developed a shoe insert for me and taped my toe twice a week for about 10 months in an effort to relieve the pain. But my skin began to degrade regardless of the various tapes he used and the PT thought I risked infection. He also thought I would never stop favoring my good foot and leg until I fixed the mallet toe. Hence the second surgery.

You are correct, the cadaverous implant was meant to add length to my shortened toe. The toe is now a shade redder and puffy on the top half and feels full, warm and a bit painful. on the top portion It is also floppy at the tip end. The surgeon originally suggested the tendon release you mentioned, but when he saw the implant is broken he said he though it would be insufficient. In his view the toe will get floppier and I will develop a new, again very painful , mallet toe. The toe is already moving in that mallet direction, though I can wear a surgical shoe with little pain.

I had thought to go forward with the new implant which was also a second opinion view. But would it be better to leave as is and just see if it gets worse? grateful --

Hi,
I have probably gone as far as I can with this problem since I have not had the luxury of actually examining you.

It becomes a quality of life issue. If the present pain is bearable and you can function, then living with it the way it is, is an option.

I do not remember if I mentioned this in your original post, but you have to be careful about having multiple surgeries in the same area, particularly in toes. Since you are already dealing with a problematic toe as a result of previous surgery, there is always the chance that additional surgery will make it worse.

They do sell all sorts of "contraptions" that you can wear on your toe for a mallet toe deformity. Perhaps trying one of those might improve you situation and you can then live with what you've got. Try footsmart.com and search for "mallet toe" and see what is available.

Good luck.
Marc Mitnick DPM

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