HALLUXINTERPHALANGEALJOINTARTHRODESIS …

1 INTRODUCTIONH allux interphalangeal joint (HIPJ) arthrodesis is afrequently performed surgery for the treatment of pain,deformity, arthritis, hallux malleus, and a variety of otherconditions affecting the HIPJ. The most common surgi-cal techniques for fusion of this joint includeintramedullary screw fixation and Kirschner wires (K-wires). Other less popular fixation techniques haveincluded a single crossed screw, staples, intramedullarydevices, and an external fixator. There are no reportsdetailing a double crossed screw technique for fusion ofthe HIPJ. The use of crossed K-wires is an effective meansfor HIPJ arthrodesis because they are easy to remove,prevent rotation, may be used in osteoporotic bone, andare minimally invasive. Disadvantages of the crossedK-wire technique include the lack of compression acrossthe fusion site, and the fact that the exposed K-wiresare external, making return to work difficult for somepatients.

2 Pins also carry a risk of pin tract infectionor migration, and therefore may have a lower single intramedullary screw has become popular forthis procedure because the fixation remains internal andtherefore may be more accepted by the patient and becauseit provides compression across the fusion site. However, thistechnique has its own known disadvantages, which includepossible loss of fixation or adequate screw purchase and thepossibility for frontal plane rotation. Screw head prominenceat the tip of the hallux can also be problematic, which has ledsome authors to use headless screws in the area. Headlessscrews however rely on the screw design for its compressionand may be difficult to remove should this be screws may not work well in osteoporoticbone, may require removal, and the authors feel that theyare overall more invasive as they occupy a significant portionof the intramedullary canal. If the intramedullary screw doesrotate, it is possible for the screw to back out causingulceration or pain at the tip of the toe due to the screw head,or the screw threads may hold open the fusion authors have used the crossed K-wire techniquepopularized by Gerard Yu, DPM in the Podiatry Institute1998 Update Textbook with good success.

3 However thetechnique is limited in that it does not provide compressionacross the fusion site and leaves exposed K-wires that maybe problematic or be an unattractive option for somepatients. In this article, the authors will introduce a crossedscrew technique utilizing cannulated screws that parallels inmany parts the crossed K-wire technique as described by (1,2). The authors feel that the crossed screw fixation ofthe HIPJ combine the advantages of the two most popularfixation techniques, the intrameduallary screw and crossedK-wires, while limiting the disadvantages. Crossed screwfixation allows compression of the fusion site, providesinternal fixation, which has a higher patient acceptance andavoids pin tract infection, prevents axial rotation, providesbicortical fixation, which is strong, is a relatively simpletechnique, and overall is felt to be less invasive than anintramedullary screw. Where the screw heads are placed thereis little prominence felt by the patient and therefore there isless chance of fixation pain requiring removal.

4 The crossedscrew technique as described by the authors does have somedisadvantages, these include the use of cannulated screws,which may be cost prohibitive for some patients or notavailable, works best in conjunction with C-arm fluoroscopy,and is a partially blind technique. It also may not be sufficientin osteoporotic bone in which the crossed K-wire techniquemay be TECHNIQUEThe incisional approach to the HIPJ is surgeon dependentand not critical to the performance of the a dorsal linear incision can be used, the proximity tothe nail bed becomes a concern. As such, the authorsprefer either a double semi-elliptical transverse incisionover the joint or lazy S/double L-type incision (Figure1A). After the incision, a transverse extensor tenotomy andcapsular incision is performed gaining exposure to theHIPJ articular surfaces. The cartilage and subchondralHALLUX INTERPHALANGEAL JOINT ARTHRODESISBY CROSSED SCREW TECHNIQUEA nnette Filiatrault, DPMTodd Haddon, DPMCHAPTER4bone is removed by hand instrumentation or sawresection (Figure 1B).

5 Saw resection is typically used whenangular correction is necessary with the correctionperformed mostly through the proximal phalanx boneresection with minimal resection of the distal phalangealbase. Otherwise, the authors prefer hand instrumentationfor bone removal to provide a rougher surface ofcancellous bleeding bone for the bone is prepared for fusion and good positionand bone apposition is noted, the joint is ready for this point, Dr. Yu described retrograding two in a crossing fashion driven from the base of thehallux distal phalanx distally to the medial and lateralcurvatures of the proximal phalanx base with one wire drivenmore superior than the other wire to avoid collision of thewires and therefore the screws. In the crossed cannulatedscrew technique, instead you substitute the guide pins forthe screws for the K-wires, but they are driven in a similarfashion (Figures 1C-1D).Of note, many cannulated screw systems do not havedouble pointed guide pins, in these cases it is helpful to drivethe guide wire or similar sized K-wire all the way outthrough the distal phalanx, remove the pin than pass theblunt-sided portion of the guide pin out distally so that whenthe guide pin is driven proximally the pointed end canpenetrate the proximal cortex medially and laterally, thusstabilizing the guide pin prior to screw placement.

6 Once theblunt side of the 2 guide pins are passed distally such thatthe pointed surface no longer sticks out of the base fusionsite, the distal phalanx base is positioned in rectus alignmentagainst the proximal phalanx distal fusion surface. The guidepins are than passed proximally into the proximal phalanxideally exiting the medial and lateral cortices of the proximalphalanx diaphysis (Figure 1E). Alternatively, the guide pinscan capture the subchondral bone plate at the base ofthe proximal phalanx, but this is not as ideal. Guide wireplacement and fusion apposition can be confirmed usingintraoperative the fusion site apposition and guide pin placementis deemed appropriate, a small incision is created at the guidepin exit sites distally and widened slightly to allow passing ofthe cannulated screws. The cannulated screws, typically partially threaded screws, may than be placed instandard fashion (Figures 1F-1G).

7 Again, screw placementand length may be checked by C-arm. Since this is a partiallyblind technique as far as screw placement, there are a fewpearls to avoiding problems. The authors recommendutilizing intra-operative fluoroscopy as these smaller screwscan sometimes be difficult to tell when full contact of thescrew head to bone has occurred. Additionally, take care notto lose engagement of the screwdriver to the screw head asagain these small cannulated screws often have cruciate headsand it may be difficult to re-engage the screwdriver to thehead of the screw blindly when only partially driven into thebone, it is also important to avoid stripping the screw headwhich will be more likely each time the surgeon attempts tore-engage the screw. Once compression of the fusion site isachieved and the screw placement is completed, the guidepins may be removed and closure of the wound in layers maycommence at the HIPJ.

8 This will include reapproximatingthe extensor tendon, prior to closure of the subcutaneousand skin layers per surgeon preference. Often just onesimple interrupted suture is required to close the distal screwinsertion sites. A dressing is applied and typically the patientis weightbearing to tolerance in a surgical CAREThe dressing is changed within the first week and inspectedfor complications or infection. A new dry sterile dressing isthen applied and the patient may be followed per surgeonpreference with serial screws to achieve fusion is not a new conceptand has been utilized by the authors and other surgeonsfor many sites in the foot and ankle, including the firstmetatarsophalangeal joint. The authors are simply applyingCHAPTER 420 Figure 1. Illustration demonstrating the overallcrossed screw technique for HIPJ fusion. Of note,the authors prefer to slightly stagger the insertionof the guide wires as depicted in 1C in both thedorsal to plantar and medial to lateral planes inattempt to avoid collision of the 421 Figure 2.

9 Case sequence of the HIPJ fusion crossed screw technique,patient concept to the HIPJ. The crossed screw technique hasthe advantage of avoiding potential rotation of the distalphalanx on the proximal phalanx with the single axialcompression screw technique, but affords the compressionthat the crossed K-wire technique does not. The authorshave presented a comprehensive technique in applying crossscrew fixation to fuse the 422 Figure 423 Figure 14. Pre-operative radiograph for HIPJ fusion (patient B).Figure15. Preoperative radiograph for HIPJ fusion (patient B), thepatient has an old fracture fragment medially and painful HIPJ 16. Intraoperative screw placement of patient B with goodbone apposition Yu GV, Vargo FE, Brook JW. Arthrodesis of the interphalangeal jointof the hallux: a simple and effective technique. J Am Podiatric MedAssoc 2001;91 Yu GV, Vargo FE. hallux interphalangeal arthrodesis: a simpletechnical pearl.

10 The Podiatry Institute 1998 Update, (Tucker, GA):1988. 424 Figure 18. Full fusion and final long-term postop-erative radiograph of patient 20. Preoperative radiograph, patient 19. Post operative radiograph of patient 21. Postoperative radiograph, patient C.