Tag Archives: Kirschner wire

Intramedullary rodding of a toe – hammertoe correction using an implantable intramedullary fusion device – a case report and review

by Christopher R. Hood JR, DPM, AACFAS1, Jason R. Miller, DPM, FACFAS2pdflrg

The Foot and Ankle Online Journal 9 (4): 1

Development of a hammertoe is a commonly encountered problem by the foot and ankle surgeon. In long-standing deformity, the pathologic toe becomes fixed with patient complaints of pain, corns, and calluses and, in the immunocompromised patient, ulceration with potential infection and amputation. A common correction of the deformity is through lesser toe interphalanageal arthrodesis, commonly performed at the proximal joint. There are numerous techniques and new devices on the market to help assist in holding position until fusion is achieved.  The author demonstrates a case report utilizing a fixation device that has characteristics similar to that of an intramedullary rod. Additionally, a retrospective, observational study involving 35 toes that have undergone an arthrodesis procedure of the proximal interphalangeal joint using an intramedullary fusion device to stabilize the fusion site is reviewed. This device imparts its stability in a manner similar to that of intramedullary rods in long bone fixation.

Keywords: ArrowLokTM, arthrodesis, digit(al), fusion, hammertoe, implantable device, intramedullary, surgery, Kirschner wire

ISSN 1941-6806
doi: 10.3827/faoj.2016.0904.0001

1 – Premier Orthopaedics and Sports Medicine, Malvern, PA, Malvern, PA
2 – Premier Orthopaedics and Sports Medicine, Malvern, PA, Fellowship Director, Pennsylvania Intensive Lower Extremity Fellowship, and Residency Director, Phoenixville Hospital PMSR/RRA, Phoenixville, PA
* – Corresponding author: Christopher R. Hood JR, DPM, AACFAS, crhoodjr12@gmail.com

The hammertoe deformity is one of the most common presenting problems and surgical corrections encountered and performed by the foot and ankle surgeon [1,2]. Correction through lesser interphalangeal (proximal interphalangeal joint, PIPJ, or distal interphalangeal joint, DIPJ) resection and fusion was first described by Soule in 1910 [1]. Since then many modifications have been made to the procedure from various methods of bone preparation at the fusion site to extramedullary (EM) Kirschner wires (KW) and intramedullary (IM) fusion devices (IMFD) to stabilize the fusion site until osseous healing has been achieved [1, 3-6].

The choice to adapt fixation from EMKW to IMFD buried inside the bone stemmed from the desire to improve surgical outcomes, namely decreasing surgical site infection (SSI) rates among other inherent problems with KW use [5]. Since their introduction onto the market, many of these new have held true in decreasing these complication rates, achieving similar outcomes regarding fusion rates, with the bonus of higher patient satisfaction and a decreased (almost eliminated) infection rate [2, 7-10].

Here we present an example of an IMFD, different in construct than others on the market, which has not yet been reported on. This device gives another option to the surgeon when it comes time for digital fusion procedures with the added versatility of various lengths when multiple digital joints need to be fused simultaneously. The construct of this device, unlike others, garners its strength and stability from its length, purchasing the subchondral bone plate and acting in a manner similar to an intramedullary rod used in other orthopaedic fixations scenarios.


Case Report

Our patient, a 49 year-old female, presented with a chief complaint of a right second toe deformity. Conservative measures of strapping, padding, and shoe modifications were attempted, but ultimately failed. She elected to proceed with arthrodesis of the digit. She was followed at post-op weeks 2, 4, and 8. At week 8, osseous bridging was noted across the osteotomy site (Figure 1). The patient had no complaints and was discharged. She returned to the office 2 years later for a different complaint and x-rays revealed fusion across the PIPJ with no loss in hardware fixation (Figure 2).

fig1a fig1b

Figure 1 Case report patient at (left) 2 weeks and (right) 8 weeks post-operation. Note fusion on medial side of arthrodesis site at 8 weeks.


Figure 2 Case report patient seen 2 years later. Complete fusion with no loss of fixation.


Surgical Technique

A #15 blade is used to make an incision across the PIPJ of the digit. This is dissected down to the deep capsule taking care to create a surgical plane between the superficial and deep fascial layers. Retraction is utilized to protect neurovascular structures located around the digit. A transverse tenotomy of the long extensor is performed just proximal to the PIPJ and soft tissues are freed up from the proximal phalanx head and middle phalanx base. Cartilage resection is performed with a sagittal saw at the head of the proximal phalanx and base of the middle phalanx.

Implantation of the IMFD is performed per the devices surgical technique guide. First, the IM canals of the proximal and middle phalanx are reamed with the supplied 1.6mm diameter reaming device down to but not through the subchondral plate into the adjacent joint. This position is checked on fluoroscopy and length is measured off of the wire, summing the proximal and middle phalanx measurements and choosing the sized implant available. Next the proximal phalanx is broached with the supplied 2.7mm broaching device. The depth of the broach is noted per the ruler on the device (7-10mm depth). The appropriate implant is positioned at the corresponding proximal phalanx reaming depth and placed within the proximal phalanx IM canal. The digit is then grasped and manipulated to place the distal end of the implant into IM canal of the middle phalanx. Once inserted, the implant can be released and the bones are manually compressed across the resection point. Closure consists of re-approximation of the extensor tendon and capsule around the fusion site for extra-medullary stability, and layered closure of the superficial fascia and skin.

Patient Audit

A CPT code audit of 28285 (correction hammertoe, eg. Interphalangeal fusion, partial, or total phalangectomy) from March 1, 2011, to July 15, 2015, was performed. Over that time period, the resulting search yielded 60 patients who had 89 digital surgeries. Patients that had arthroplasty, arthrodesis not performed with the studied device, the studied device plus KW, or isolated DIPJ arthrodesis were excluded. Ultimately, 35 toes in 23 patients had isolated PIPJ fusions using this technique.


The case patient was seen at post-operation weeks 2, 4, and 8. Signs of fusion were noted at week 4 and complete fusion was noted at week 8 radiographically. No loss of fixation was noted at any point. Patient satisfaction was high at discharge.

The CPT audit identified 35 toes that underwent PIPJ arthrodesis using the studied device. Average follow-up was 110 days. There was zero (0%) cases of hardware failure noted. In a single instance (2.8%), the device appeared to have rotated 90 degrees on its long axis, but fixation was still maintained. Two toes (5.7%) were misaligned with  slight medial angulation of the digit. There were zero occurrences of either a superficial or deep incisional infection as defined by the CDC [11]. No patient required revision surgery or a return to the operating room for a complication secondary to the index digital arthrodesis procedure.


One of the biggest problems with arthrodesis of the PIPJ can be attributed to the use of EMKW for temporary stabilization across the fusion site until osseous union is achieved. The use of KW for fixation was first described by Taylor in 1940 [1]. Since that time, surgeons have battled against the complications of this technique such as pin-tract infections, digital edema, delayed or non-union of the arthrodesis site due to lack of compression, rotational instability, bent or broken wires, and patient dissatisfaction and apprehension due to the protruding wire and its impending removal [2,10]. External wire exposure infection rates range from 0-18% [1,5,12]. Studies have reported 40% of the wire infections were related to external factors through irritation at the skin-pin interface secondary to trauma and water-contamination [5]. Because of this, Creighton et al (1995) first presented a new technique of the single buried KW in digital fusion [5]. In more recent times, various IMFDs have been manufactured to give the surgeon options of fixation other than the aging gold standard KW. Canales et al (2014) in a recent paper noted 68 IMFDs on the market as of February 1, 2014 [6]. Normal incidence of surgical site infection after foot and ankle surgery has been reported between 1% and 5.3% [13, 14]. Creighton et al (1955) reported an infection rate of 3.5% with his buried KW technique while more recent fusion products have reported similar results ranging from 0%-5% [2,5,7,10]. Our results were similar with a 0% superficial or deep infection rate for the 35 toes at average patient follow-up of 110 days.  No patient at any point or length of follow-up presented for care of digital infection.

One such product for IM digital fusion is the Arrow-LokTM Hybrid implant (Arrowhead Medical Device Technologies, LLC., Collierville, TN) and is the specific implant used by the senior author and reviewed in this article. The implant is made of one solid piece of ASTM F-138 stainless steel, has a core diameter of 1.5mm (0.059”) with a proximal 3-dimensional (3-D) barbed arrow-shaped head 3.0mm by 3.5mm or 2.5mm and distal 3-D arrow-shaped head 3.0mm by 3.5mm. It comes in variable lengths ranging between 13mm and 50mm and in 0° and 10° plantar bend angles [15-17] (Figure 3). There is no special handling or pre-operative storage restriction placing a handling time limitation on implementation [17]. Its use in various clinical situations (PIPJ and DIPJ arthrodesis) as well as surgical tips and tricks have been published on, but to the authors best knowledge no literature exists on loss of correction and infection rates [15,18].


Figure 3 Intramedullary fusion device comes in straight (top) or 10° angulation (bottom). Key regions include (A)overall length, 13-50-mm; (B) distal tip diameter, 3.5-mm; (C) proximal tip diameter, 2.5-mm or 3.5mm; (D) length of proximal angle segment, variable 6-9-mm; (E) length of proximal angle segment, variable 10-26-mm.


The theory of construct of the ArrowLokTM is similar to that of an intramedullary rod (IMR) in fracture care (Figure 4). One of the biggest benefits of the ArrowLokTM device is due to the various available lengths ranging from 13mm to 50mm, the largest identifiable span on the market. Both transfer loads across a break in long bones, whether it be a fusion (ArrowLokTM) or fracture (IMR) site [19]. This IM position is closer to the anatomic axis of the bone and aids to resist bending while the circular round construct resists loads equally in all planes. Mechanical load testing at a quarter of a million cycles at up to 89N showed no signs of wear or fatigue of the ArrowLokTM  or bone [16]. Furthermore, in instances where both PIPJ and DIPJ fusion is needed, one longer device can be used versus two separate devices to be squeezed into a tight space [15]. This results in a location of potential stress riser in the middle phalanx between the distal and proximal ends of the two implants as described in the above situation. This is important when a common results regarding digital fusion (either implanted devices and percutaneous k-wires), the bulk of the non-osseous fusions are made up of fibrous unions which rarely impact the outcome of the surgery and are still considered a surgical success [7,8]. When osseous fusion is not achieved and weaker fibrous tissue fills the fusion interface, much of the strength of the fusion lies in the inherent strength of the implant device.

fig4a fig4ab fig4c

Figure 4 Like an IM rod (left), the ArrowLokTM device (right) garners its strength through its length spanning the osteotomy site to transfer loads and end arrow tips acting as a locking screw, preventing rotation, shortening and gapping, all reasons for failure of fixation.



Figure 5 DIPJ arthrodesis with the ArrowLokTM device.

The 3-D arrow-ends of the ArrowLokTM act similar to proximal and distal locking screws in IMRs. This secures the device and prevents rotation, compression, shortening, or gapping, resulting in loss of fixation. Compared to a standard 1.6mm  (0.0062”) EMKW, the ArrowLokTM has comparable resistance to bending, increased resistance to pull-out (21x more resistant), and increased resistance to rotational forces (12x more resistant) [16]. These problems are inherent to EMKW use due to the design lacking IM compressive purchase and inability to prevent rotation, leading to potential non-solid fusion and mal- or non-union.

IMRs bending rigidity is based off of diameter and in solid, circular nails, is proportional to nail diameter to the third power [20]. Diameter also affects nail fit with a well fitting nail, reducing movement between the nail and bone, friction between the two maintaining reduction [20]. Reaming with the initial KW and broach help increase this contact relationship. With a 1.5mm core diameter, the ArrowLokTM is a tight fit within the phalangeal canal and increases bending rigidity and construct strength. The long, solid, one-piece design differs from others on the market in not having regions of thinner diameter metal and having two pieces that snap together at the junction of the fusion site – both which lead to sites of potential breakdown [9]. One study demonstrated a 20.7% rate in fracture at internal fixation site using Smart Toe® (Stryker Osteosythesis, Mahwah, NJ) versus 7.1% in 0.062-inch buried IMKW use [9].


The recent literature has demonstrated that utilization of these newer devices like the ArrowLokTM for correction of the hammertoe deformity provide a safe method with low complication rates similar to other products on the market.8 Furthermore, with the decrease and almost elimination of infection rates, despite the higher cost of the implant compared to a KW, the potential for infection complications and the associated cost is avoided. In our retrospective case review, ArrowLokTM showed a lack of hardware failure, zero infection rate, and high patient satisfaction. Due to its available lengths, IMR type construct, and ability to cross two fusion sites at once, this device offers another option for the surgeon in digital fusion.

Conflict of Interest

Dr. Jason R. Miller is a consultant for Arrowhead Medical. Arrowhead Medical Device Technologies had no knowledge or influence in study design, protocol, or data collection related to this report.


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  2. Angirasa AK, Barrett MJ, Silvester D. SmartToe® implant compared with kirschner wire fixation for hammer digit corrective surgery: a review of 28 patients. J Foot Ankle Surg. 2012;51(6):711-713. doi:10.1053/j.jfas.2012.06.013.
  3. Lamm BM, Ribeiro CE, Vlahovic TC, Bauer GR, Hillstrom HJ. Peg-in-hole, end-to-end, and v arthrodesis. A comparison of digital stabilization in fresh cadaveric specimens. J Am Podiatr Med Assoc. 2001;91(2):63-67.
  4. Miller JM, Blacklidge DK, Ferdowsian V, Collman DR. Chevron arthrodesis of the interphalangeal joint for hammertoe correction. J Foot Ankle Surg. 2010;49(2):194-196. doi:10.1053/j.jfas.2009.09.002.
  5. Creighton RE, Blustein SM. Buried kirschner wire fixation in digital fusion. J Foot Ankle Surg. 1995;34(6):567-570; discussion 595. doi:10.1016/S1067-2516(09)80080-X.
  6. Canales MB, Razzante MC, Ehredt DJ, Clougherty CO. A simple method of intramedullary fixation for proximal interphalangeal arthrodesis. J Foot Ankle Surg. 2014;53(6):1-8. doi:10.1053/j.jfas.2014.03.017.
  7. Basile A, Albo F, Via AG. Intramedullary fixation system for the treatment of hammertoe deformity. J Foot Ankle Surg. 2015:1-7. doi:10.1053/j.jfas.2015.04.004.
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Outcome after early open reduction and Kirschner wire fixation of Lisfranc joint injuries

by Irfan Ahmad Latoo (MS)1, Reyaz Ahmad Dar (MS)1, Mubashir Maqbool Wani (MS)1, Iftikhar Hussain Wani (MS)1, Mohammad Shafi bhat1pdflrg

The Foot and Ankle Online Journal 7 (1): 1

The study was a consecutive study conducted over a period of four years commencing in 2008 on Lisfranc joint injuries of feet. We studied the outcome of early open reduction and internal fixation of 20 cases of Lisfranc injuries using AOFAS-M score (American Orthopaedic Foot and Ankle Society-Midfoot score). Most patients were in the age group of 18-35 years. In our series the cause of injury was road traffic accidents in 50% cases followed by fall from height in 40% of cases. Most of Lisfranc fractures were of type B (60%) followed by type A. Most common associated injuries were metatarsal fracture (30% cases). The follow-up was 1-3 years with an average of 2 years. The mean AOFAS-M score was 78.36 with patients losing points to pain and decreased recreational function. Ours was not a comparative study but we strongly feel that early open reduction and Kirschner wire fixation of Lisfranc fracture dislocations within 24 hours of injury considerably improves functional outcome in these cases.

Key words: Lisfranc fracture, Kirschner wire

ISSN 1941-6806
doi: 10.3827/faoj.2014.0701.0001

Address correspondence to: Mubashir Maqbool Wani, Hospital for Bone and Joint Surgery Barzulla, India 190005.
Email: mubashirmaqboolwani@yahoo.co.in

The Lisfranc joint has been an eponym of tarsometatarsal joint injuries since Jacques Lisfranc, a field surgeon in Napoleon’s army described an amputation through the joint for gangrenous injuries of the forefoot [1]. Fracture dislocations of the Lisfranc (tarsometatarsal) joints of foot are uncommon but serious injuries with high potential for chronic disability. These injuries can easily be missed in the emergency department as radiographs may show only subtle incongruity of the joint [2].

In the treatment of fracture dislocation of tarsometatarsal joints, early accurate diagnosis combined with prompt anatomic reduction and stable internal fixation provides optimal results [3]. Closed reduction and percutaneous Kirschner wire fixation has been advocated by some [4,5], but the trend is towards open reduction and screw/Kirschner wire fixation [6,7].

The purpose of this study was to evaluate the functional outcome of patients with Lisfranc joint injuries treated with open reduction and internal fixation with Kirschner wires within 24 hours of injury.


Figure 1 X-ray right foot AP view showing C2 injury.

Materials and Methods

We performed a consecutive study of 20 patients with tarsometatarsal joint injuries at our hospital commencing in 2008 after approval by hospital ethics committee. An informed consent was taken from all the patients. Only those patients were included who presented < 24 hours of injury and were aged between 16 years and 65 years, the patients who were excluded from study were patients with open injuries, patients presenting > 24 hours of injury and polytrauma patients. The injuries were classified by Myerson’s modification of Hardcastle classification [8].


Figure 2 X-ray right foot oblique view of same patient as Figure 1.

Surgical Technique

A dorsal longitudinal incision was made between the first and second metatarsal. The extensor hallucis longus tendon, deep peroneal nerve and dorsalis pedis artery were identified and retracted as a unit.

Small irreducible fragments were debrided from the joint. The first tarsometatarsal joint was aligned by reducing the medial border of medial cuneiform to the medial border of the first metatarsal. The planter medial aspect of the joint was directly visualized to ensure that there was no planter gap. The second metatarsal was then reduced to the medial border of middle cuneiform. The joints were fixed with Kirschner wires. In some cases a second longitudinal incision was made centered over the fourth metatarsal and the third metatarsocuneiform joint was reduced. The fourth and fifth metatarsals usually reduced once the above three reductions were achieved and were held with one or two transarticular K-wires from the base of 5th metatarsal to the cuboid.


Figure 3 X-ray foot AP View of same patient 8 weeks after fixation.


Most patients (70%, n=14) were in age group of 18-35 years with a mean 33.2 years. Males (80%, n=16) outnumbered females (20% n=4). Both right and left foot were equally involved. Cause of injury were road traffic accidents in 50% cases (n=10), fall from height in 40% (n=8) and other causes in 10% (n=2).

Metatarsal fracture was the most common associated injury (30%, n=6). The injuries were classified by Myerson,s modification of Hardcastle classification [8]. The majority of injuries (60%, n=12) were type B followed by type A (20%, n=4). All the operations were done within 24 hours of injury.


Figure 4 X-ray foot AP view of same patient 1.5 years after fixation.

Following surgery a posterior splint was applied and left in place for 10-14 days. During this period alternate wound dressings were done. Stitches were removed at around 14 days and short leg cast was given at the time of removal of stitches. K-wires were removed at 8 weeks. Full weight bearing was allowed at 10-12 weeks. Anatomical reduction was obtained in 19 patients (95%).

There was one case of loss of reduction in our study. There were two cases of superficial wound infection in our series both of them responded to antibiotics. Primary closure of skin was done in 90% cases (n=18) while in two patients delayed primary closure was done. There was no case of compartment syndrome of foot in our series. Good to fair results were seen in 90% cases (n=18).


Figure 5 X-ray foot Lateral view of the same patient after 1.5 years of fixation.

The mean AOFAS-M score in our study was 78.36 with most patients losing points to pain and decreased recreational function. Eighty percent of patients were able to return to their original occupation, including 10 household or office workers and six laborers.


Lisfranc injuries result from high-energy injuries. In our study, motor vehicular accidents were the most common cause of injury, a finding consistent with the already available literature. Anatomic reduction and internal fixation has become standard principle governing treatment of tarsometatarsal fracture dislocations. Most authors agree stable anatomic reduction leads to optimal results [9]. The advantage of open reduction is that it allows direct visualization of the fracture dislocation for debridement of comminuted fracture fragments and osteochondral defects.

There is controversy about which method of fixation is best. There are proponents of k-wire fixation [10,11], while others rely on screw fixation [9,12]. In our study the age group ranged from 16-65 years with mean of 33.2 years.

In Goossens et al study [13], age groups ranged from 10-52 years with mean of 34 while as reported in Pereira et al [14], age group ranged from 17-50 years with mean of 31.53. The mean age group in our study was close to the study of Goossens et al [13]. Males outnumbered females in our study with ratio of 4:1 while as in Hesp et al [15], the male to female ratio was 2.3:1. The reason for higher male to female ratio in our study may be due to the fact that most of females in our setup are household sedentary workers. Both right and left feet were equally involved in our study.

The mode of injury was road traffic accidents (RTA) in majority of patients (50%) followed by fall from height which was consistent with Hardcastle et al [8], 40.3% RTA and Kuo et.al. [16], with RTA 42%. In our study most of the Lisfranc injuries (60%) were type Hardcastle type B followed by type A (20%). In Enríquez et al [17] series type B injuries were most common Lisfranc injuries (50%). While as in Pereira et al series [14], type B Lisfranc joint injuries constituted 80.94 percent of Lisfranc fracture dislocations. Metatarsal fracture were the most common associated injury in our study in 30% cases. In Goossens et al, series [13] metatarsal injuries were also the most common associated injuries (40%).

The mean duration of hospital stay in our series was three days. K-wire were removed at mean of 8 weeks in our study while as in Kuo et al [16] K-wires were removed at 6-8 weeks. There was no case of compartment syndrome in our study and primary closure was done in 90% cases. While two cases delayed primary closure was done. Complication in our study included loss of reduction in one case and two cases of superficial wound infection. Both cases occurred within one week of surgery and responded well to antibiotics and daily dressings. In Kuo et al series [16], there was no case of postoperative wound infection and one patient in their series required fasciotomy with split-thickness skin graft. There was one case of loss of reduction in our series.

The percentage of loss of reduction with K-wires was less in our series as we immobilized the foot for longer duration in short leg cast (mean 8 weeks). Molded arch support was given to patients after three months, which was discarded at 6 months in 70% cases while as 30% cases felt its need up to one year. In our study good to fair results were seen in 90% cases as per scale used by Pereira et al [14], with mean AOFAS score 78.23. Our mean AOFAS score was higher than Kuo et al [16], while as in Pereira et al [14] it was 77.36. Like this study most of our patients lost points to pain and decreased recreational function.

We believe that early open reduction and K-wire fixation considerably improves the functional outcome in these injuries. There is an added advantage that no second surgery for removal of hardware is required. The disadvantage is that this method needs longer period of immobilization in a cast. The limitation of our study is that there was no control group so that we could compare our results.


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