Case 108: Salvage of an Infected Hammer Toe with a Nail

At age 59, this man was an active smoker and an insulin-dependent diabetic for 26 years. His referring physician reported he had no pedal pulses for 16 years and had had x-ray evidence of atherosclerosis in his femoral vessels for 6 years. He was referred to Bryn Mawr from Virginia because of an indolent ulcer over the proximal interphalangeal joint of his right second toe. .

His x-ray showed a dislocation and a hammer toe deformity of his 2nd toe.

A portion of infected bone was protruding through the skin. A culture grew out Pseudomonas aeruginosa. The blood pressures in the dorsalis pedis and posterior tibial were respectively 58% and 82% of his brachial pressure. His pulse volume at the ankle was diminished. He was begun on intravenous antibiotics and Mini-Boot therapy.

Our orthopedic consultant was asked how he would handle this patient if his joint were sterile and he were nondiabetic. He would fuse it, he said. After a week of local and intravenous antibiotics, the toe appeared sterile and on the 9th hospital day it was nailed.

He was continued on antibiotics a few days and discharged with the nail in place

The nail did get infected and it was removed at a subsequent hospitalization. He eventually healed.

He returned at his second hospitalization with a swollen toe again infected with Pseudomonas. Again he was given intravenous antibiotics while gentamicin was injected into the sinus tract in his toe. After the injection, he received Mini-Boot therapy to disseminate the antibiotic around the toe and foot and to maintain the blood flow in his foot. The latter procedures were associated with a reduction in the redness and swelling of his foot within two days. He was subsequently discharged on oral antibiotics and did well..

Comments: Standard therapy for an infected hammer toe deformity in most centers is toe amputation. The gap between the toes may be filled with a rubber piece to prevent the adjacent toes from being dislocated over time as they bend into the gap. He had no such gap and a relatively normal foot posture. Our local use of gentamicin was effective and did not alter his diminished renal function. He eventually found himself on dialysis in Virginia and died a few years later. His feet served him to his end..