Hammertoe Deformity Research Articles

Floating toe

Category: Midfoot/Forefoot Introduction/Purpose: The Weil osteotomy (WO) is frequently used for treating metatarsalgia and metatarsophalangeal (MTP) instability. Nevertheless, it presents complications, being the floating toe the most frequent one. A modification has been proposed to decrease the beforementioned complication, removing a slice from the osteotomy (modified Weil osteotomy, MWO). Additionally, it has been proposed that stabilizing the toe interphalangeal joints when treating hammer toes may contribute to decrease the floating toe complication, given that all flexors contribute to MTP flexion. The objective of this research is to describe complications and functional score in patients operated with MWO with and without interphalangeal stabilization. Methods: 110 patients (250 toes) treated for metatarsalgia and hammer toe deformity were retrospectively collected and prospectively followed for 66 months (SD 15). 2 groups were studied, 45 adults with isolated MWO and 65 adults with MWO with toe stabilization. Average age 55. Patients with Diabetes, previous surgeries and infections were excluded. LEFS, AOFAS and satisfaction index were recorded. A physical examination looking for floating toe, MTP instability and metatarsalgia was performed. Statistical analysis included logistic regression spearmen correlation test, Mann-Whitney test and student T test. Results: LEFS and AOFAS scores were 70 and 73 respectively, with no differences between patients operated with isolated MWO or with toe stabilization. Satisfaction index average result was “minor reservations”. Floating toe incidence was 24%, with no difference between groups. There was no difference in functional scores and satisfaction index if floating toe was present or absent. There was no correlation between functional scores and satisfaction index. Metatarsalgia was present in 31% of patients, and there is a direct correlation of floating toe occurrence and pain (4 times more chance to have pain). Conclusion: There was no clinical significant consequence of floating toe on LEFS, AOFAS or satisfaction. There was no difference in complication rate, functional scores and patient satisfaction if the interphalangeal joint was fixed or not. Although floating toe didn’t influence on functional scores, it was associated with pain. It can be suggested that the scores utilized were not able to detect the negative influence of floating toe on every patient. The high prevalence of floating toe using the MWO should make us look for additional factors which we may be overlooking when treating metatarsalgia, such as plantar plate damage.

Comorbidities associated with poor outcomes following operative hammertoe correction in a geriatric population

Category: Lesser Toes Introduction/Purpose: Hammertoe deformities are one of the most common lesser foot deformities and are extremely prevalent in the geriatric population. When nonoperative treatment fails, surgical correction can improve functional status and pain. While complications following these surgeries are rare, older patients with comorbid conditions are often considered worse operative candidates due to an increased risk of adverse outcomes. The aim of this study is to determine if specific comorbidities or perioperative variables are associated with increased complications or unsuccessful outcomes following operative hammertoe correction in geriatric patients. Methods: Prospectively collected data was reviewed on 31 consecutive patients aged 60 or older who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, perioperative variables, and postoperative complications were recorded from their electronic medical records. Clinical outcomes were assessed utilizing preoperative and postoperative Visual Analogue Scale (VAS) and Short Form Health Survey Physical Component Score (SF-36 PCS) with a minimum of six-month follow-up. Data was examined using Fisher’s method and multivariable analysis. Results: 29.0% (9/31) of patients had a history of smoking, 61.2% (19/31) were on anticoagulant therapy, 19.4% (6/31) had osteoporosis, 16.1% (5/31) had rheumatoid arthritis, and 9.7% (3/31) had diabetes mellitus. The mean tourniquet and operative times were 65.7 (SE=6.2) and 95.4 (SE=7.4) minutes, respectively. Postoperative complications occurred in 12.9% (4/31) of patients with the most prevalent being wound infections that were treated with antibiotics in 9.7% (3/31). Impaired wound healing, joint nonunion, and the need for revision surgery each occurred in 3.2% (1/31) of patients. Mean 6-month improvement in VAS was 2.1 (SE=0.5) and mean improvement in SF-36 PCS was 10.2 (SE = 3.4). No significant association was found between comorbidities or perioperative variables and postoperative complications or improved outcomes. Conclusion: No specific comorbidities or perioperative variables were identified that increase the risk for unsuccessful surgical correction of hammertoe deformities. While comorbidities in the geriatric population have traditionally been thought to increase complication rates and lead to poor outcomes, further research in this area is warranted. Comorbidities should not necessarily be a deterrent for geriatric patients pursuing operative hammertoe correction.

Radiographic predictors for improved outcomes after hammertoe correction surgery

Category: Lesser Toes Introduction/Purpose: Hammertoe deformities are common, often painful deformities of the lesser foot and are known to severely affect daily activities. When patients seek surgical management, x-rays are utilized for diagnosis, evaluation for surgical candidacy, and selection of the operative technique. Postoperatively, radiographs are retaken to assess bone health, healing status, and alignment. Despite the frequent use of radiographs pre- and post-operatively, radiographic results are not necessarily indicative of clinical presentation or surgical outcomes. The aim of this study is to identify specific radiographic parameters that are predictive of improved pain and function after surgical correction of hammertoe deformity. Methods: Prospectively collected data was reviewed on 51 consecutive patients who underwent operative correction of hammertoe deformity. Patient demographics, comorbidities, and post-surgical complications were recorded from their electronic medical records. Clinical outcomes were assessed utilizing preoperative and postoperative Visual Analogue Scale (VAS) and Short Form Health Survey Physical Component (SF-36 PCS) scores with a minimum of six-month follow-up. Radiographs were scored by a foot & ankle fellowship-trained orthopaedic surgeon to assess preoperative severity, postoperative joint fusion, and both pre- and postoperative joint instability and arthritis. Data was examined using a multivariable analysis. Results: Preoperatively, 15.7% (8/51) of patients had a deformity classified radiographically as mild, 37.3% (19/51) as moderate, and 47.1% (24/51) as severe. Additionally, 60.8% (31/51) had joint instability, 17.7% (9/51) had joint dislocation, and 7.8% (4/51) had joint arthritis. Postoperatively, 74.5% had PIP joint fusion, 35.3% (18/51) had joint arthritis, and 9.8% (5/51) had joint instability. A significant association was found between PIP joint fusion and improved SF-36 PCS scores (p=.004). Preoperative anticoagulant therapy was associated with reduced rates of PIP joint fusion (p=0.02). There was no association found between the other demographic or radiographic parameters, and no parameters were associated with improvement in VAS scores. Conclusion: After undergoing surgical correction of hammertoe deformity, postoperative PIP joint fusion was the only variable determined to be indicative of improved physical function. However, pre- and postoperative metatarsophalangeal joint arthritis nor instability was predictive of outcomes. This work informs foot & ankle specialists that healing of the PIP joint is critical to successful hammertoe surgery.

Determination of minimum clinically important difference (MCID) in visual analog scale for pain scores after hallux valgus correction

Category: Bunion Introduction/Purpose: Surgical outcome studies rely on patient reported outcome measurements to assess the effectiveness of treatment. The concept of minimal clinically important difference (MCID) proposes a necessary threshold to achieve clinically significant treatment results, and refers to the smallest change in outcome measure important from the patient’s perspective. In the context of visual analog scale (VAS) questionnaires, MCID refers to a clinically significant change in pain score. Determination of MCID in patient-oriented outcome questionnaires is necessary to further evaluate the effectiveness of hallux valgus surgery. Further, MCID analysis of hallux valgus surgical outcomes could provide improved insight into post-operative patient satisfaction. The purpose of this study was to determine the MCID in pre- to post-operative VAS pain score in patients undergoing surgical treatment of hallux valgus. Methods: Adult patients undergoing surgical treatment of hallux valgus were retrospectively included. Pre- and post-operative VAS pain scores (0-10) and surveys inquiring about satisfaction with pain level after surgery were collected at a minimum of 1-year post-surgery. Patients were categorized as responders or non-responders based upon a completed 6-point pain satisfaction scale. Patients reporting satisfaction scores 0-3 were categorized as non-responders, and 4-6 as responders. Four MCID calculation methods were used that have been described in previous literature: the standard deviation (SD) approach, the average change approach, the minimally detectable change (MDC) approach, and the change difference approach. The total percentage of patients meeting the calculated VAS threshold score for each MCID method was determined. The likelihood of meeting the VAS threshold for each MCID method based on responder status, hallux valgus severity, and correction status of concomitant hammertoe deformity was also determined using bivariate analysis. Results: 170 patients were included with post-operative follow-up averaging 23.6 months. VAS MCID threshold scores were 1.77points (SD approach), 5.21points (average change approach), 1.98points (MDC approach), and 4.27points (change difference approach). The patient percentage meeting the VAS threshold score for each MCID approach was 73.5%, 40.6%, 73.5%, and 48.8%, respectively. Moderate deformity procedures (Ludloff) demonstrated greater likelihood than mild deformity procedures (Chevron, Modified McBride, Aikin, Silver) of meeting the average change, MDC, and change difference approach thresholds (p=0.036, 0.035, 0.034). Severe deformity procedures (Lapidus) demonstrated greater likelihood than mild deformity procedures of meeting the SD approach threshold (p=0.046). Hammertoe correction demonstrated greater likelihood than non-correction of meeting the average change approach threshold (p=0.038). Responders demonstrated greater likelihood than non-responders of meeting all MCID approach thresholds (p<0.001). Conclusion: This study demonstrated marked variability in determining VAS MCID for hallux valgus correction (range 1.77- 5.21 points). This study suggests an association between type of hallux valgus correction and likelihood of post-operative improvement, as there was greater chance of meeting MCID with correction of greater hallux valgus deformity or hammertoe deformity. MCID methods utilizing comparisons of responder status may not be appropriate for hallux valgus patients, as responders tended to improve with time and non-responders tended to decline. Additional investigation of the optimal MCID method for hallux valgus correction is necessary to narrow the range and determine surgical efficacy.

Reliability and validity of the Turkish version of the Foot Function Index in patients with foot disorders

Background/aim: The Foot Function Index (FFI) is a valid, reliable, and widely used self-reported questionnaire for the foot. The purpose of this study was to provide evidence for the validity and reliability of the Turkish version of the FFI (FFI-TR) among patients with foot disorders such as plantar fasciitis, hallux valgus, pes planus, and hammertoe deformities. Materials and methods: One hundred and fifty-nine patients with foot disorders were enrolled. The psychometric properties of the previously translated and adapted FFI-TR were assessed. The internal consistency and test-retest reliability were evaluated. Construct validity was examined for correlations with the Short Form-36 (SF-36) questionnaire. Results: Cronbach's alpha ranged between 0.821 and 0.938. Reproducibility was satisfactory, with intraclass correlation coefficient values between 0.960 and 0.985. Weak correlations were found between FFI-TR and some SF-36 subscales for validity (|rho| < 0.30). There was a ceiling effect for the activity limitation subscale. There were no floor effects for any items or application times. Good accuracy was determined for all scores. Conclusion: FFI-TR is a reliable and valid scale. This tool can be used in routine practice and clinical research for evaluating foot disorders and foot-related functional impairments.

Joint Preservation in the Rheumatoid Forefoot: Commentary on an article by Junichi Kushioka, MD, et al.: "Modified Scarf Osteotomy with Medial Capsule Interposition for Hallux Valgus in Rheumatoid Arthritis. A Study of Cases Including Severe First Metatarsophalangeal Joint Destruction".

Joint Preservation in the Rheumatoid Forefoot: Commentary on an article by Junichi Kushioka, MD, et al.: "Modified Scarf Osteotomy with Medial Capsule Interposition for Hallux Valgus in Rheumatoid Arthritis. A Study of Cases Including Severe First Metatarsophalangeal Joint Destruction".

Anatomic Reconstruction Versus Traditional Rebalancing in Lesser Metatarsophalangeal Joint Reconstruction

Traditional rebalancing techniques, such as capsulotomies and capsulorrhaphies, are commonly performed during complex hammertoe and lesser metatarsal osteotomy procedures involving metatarsophalangeal joint (MTPJ) contractures; however, floating toes, digital instability, and malalignment are concerns. We critically analyzed the outcomes after anatomic reconstruction of the plantar plate and collateral ligaments compared with those after traditional rebalancing techniques. A case-control study was conducted of 54 patients who had undergone surgical correction of lesser MTPJ imbalances due to complex hammertoe deformities (power 80%, type I error = 0.05). Cases were defined as consecutive patients treated with anatomic plantar plate and collateral ligament reconstruction. Controls had undergone traditional lesser MTPJ rebalancing and were matched to cases by age, gender, follow-up duration (minimum 12 months), and concomitant procedures of the same lesser ray. Multivariate logistic regression demonstrated that patients treated with anatomic reconstruction had greater digital stability (negative dorsal drawer and negative paper pull-out test findings) at final follow-up examination compared with the controls. American College of Foot and Ankle Surgeons (ACFAS) forefoot module scores were greater in the anatomic group in all domains (p ≤ .05). Controls had greater postoperative radiographic MTPJ angles than the cases, with no differences detected between the 2 groups in visual analog scale scores or proximal interphalangeal joint angles. The importance of restoration of the plantar plate and collateral ligament integrity as a digital stabilizer is generally accepted but has not been well studied. We found that anatomic reconstruction yielded greater digital stability, greater ACFAS Forefoot module scores, and better radiographic MTPJ alignment than controls. Additional studies are warranted to assess the long-term viability of anatomic lesser MTPJ reconstruction.

Free vascularized fibula grafting in the operative treatment of malignant bone tumors of the upper extremity: A systematic review of outcomes and complications.

Vascularized bone grafting after tumor resection can be an important component in the treatment of bony neoplasms of the upper extremity. The purpose of this study was to determine the outcomes of free vascularized fibula grafting (FVFG) in the treatment of upper extremity sarcomas. A systematic review of the literature of FVFG used in the treatment of upper extremity sarcomas was performed. A total of 56 studies were included in final analysis. The most common diagnosis was osteosarcoma (35.1%) and the most common recipient site was the humerus (57.3%). FVFG had a median union rate of 93.3%, with the median time to union being 5.0 months. The most common complications were fracture (11.7%), nerve injury (7.5%), infection (5.7%), and hammer toe deformity (3.3%). The reoperation rate was 34.5%. The most commonly reported standardized assessment of clinical outcomes following treatment was the Musculoskeletal Tumor Society Score, which had a median of 80% postoperatively. FVFG in the treatment of malignant bony neoplasms of the upper extremity has a high rate of union and good overall outcomes; however, postoperative complication rates are high. A greater degree of standardization is needed in the reporting of patient-centered outcomes to facilitate future comparative studies.

Percutaneous Kirschner Wire Versus Commercial Implant for Hammertoe Repair: A Cost-Effectiveness Analysis

Hammertoe deformities are one of the most common foot deformities, affecting up to one third of the general population. Fusion of the joint can be achieved with various devices, with the current focus on percutaneous Kirschner (K)-wire fixation or commercial intramedullary implant devices. The purpose of the present study was to determine whether surgical intervention with percutaneous K-wire fixation versus commercial intramedullary implant is more cost effective for proximal interphalangeal joint arthrodesis in hammertoe surgery. A formal cost-effectiveness analysis using a decision analytic tree model was conducted to investigate the healthcare costs and outcomes associated with either K-wire or commercial intramedullary implant fixation. The outcomes assessed included long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. Costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2017 price base. Our results found that commercial implants were minimally more effective than K-wires but carried significantly higher costs. The total cost for treatment with percutaneous K-wire fixation was $5041 with an effectiveness of 0.82 QALY compared with a commercial implant cost of $6059 with an effectiveness of 0.83 QALY. The incremental cost-effectiveness ratio of commercial implants was $146,667. With an incremental cost-effectiveness ratio of >$50,000, commercial implants failed to justify their proposed benefits to outweigh their cost compared to percutaneous K-wire fixation. In conclusion, percutaneous K-wire fixation would be preferred for arthrodesis of the proximal interphalangeal joint for hammertoes from a healthcare system perspective.

Complication Rates and Short-Term Outcomes After Operative Hammertoe Correction in Older Patients.

Hammertoe deformities are the most common lesser toe deformity. To date, no studies have looked at outcomes of operative management in the geriatric population, which may be at greater risk for complications or functional compromise because of comorbidities. Data on 58 patients undergoing operative correction of hammertoe deformities were prospectively collected. Clinical outcomes were assessed using preoperative and postoperative visual analogue scale (VAS) and Short Form Health Survey (SF-36) scores with a minimum of 6-month follow-up. Patients were divided into 2 groups on the basis of age at the time of surgery: younger than 65 and 65 and older. Complication rates and mean VAS and SF-36 improvement were compared. Forty-seven patients met inclusion criteria (7 men, 40 women), with 26 patients (37 toes) in the younger cohort and 21 patients (39 toes) in the older cohort. Overall, patients demonstrated significant improvement from baseline to 6 and 12 months postoperatively in VAS ( P < .001 and P < .001) and SF-36 ( P < .001 and P < .001) scores. Mean improvement in VAS and SF-36 scores was not significantly different between the groups at 6 and 12 months postoperatively. Complications occurred in 13.5% and 10.3% of patients in the younger and older cohorts, respectively. Outcomes of operative correction of hammertoe deformities in older patients were similar to outcomes in younger patients after greater than 6 months of follow-up. Overall improvement in VAS and SF-36 was statistically significant for both cohorts. There was no associated increase in complications for older patients. Level, III comparative series.

Comparative Study of Intramedullary Hammertoe Fixation.

Temporary Kirschner wire fixation (K-wire) is a widely used, low-cost fixation method for the correction of hammertoe deformity. Reported complications associated with K-wires prompted the development of new implants over the past decade. However, there is a lack of literature on comparative studies analyzing functional outcomes using validated questionnaires. The purpose of this study was to analyze functional outcomes in patients who had undergone proximal interphalangeal joint fusion using 2 types of intramedullary implant, the Smart Toe and the TenFuse, and to compare them with the outcomes in patients treated with standard K-wire fixation. A retrospective review of operative hammertoe correction by a single surgeon was performed in 96 patients followed for more than 12 months. Functional outcome was assessed using the Foot Function Index (FFI), the Short Form 36 (SF-36), and the 10-point visual analog scale (VAS) validated questionnaires. Complications and fusion rates were also evaluated. Several patients in the study underwent corrections in different toes; thus, a total of 186 toes were included in the study. From these, 65 toes (34.9%) were treated with K-wire fixation, 94 (50.5%) with Smart Toe titanium implant, and 27 (14.5%) with TenFuse allograft implant. No statistically significant differences in functional outcome and incidence of complications were observed among the 3 fixation groups, although the 2 intramedullary implants were associated with greater fusion rates and patient satisfaction. Breakage of the Smart Toe implant was significantly higher than that of the other fixations, with 10.6% of implants breaking within the first year postoperatively. SF-36 and VAS scores decreased 12 months after surgery for the 3 types of fixation, with no statistically significant differences observed. The use of Smart Toe and TenFuse implants provided operative outcomes comparable to those obtained using a K-wire fixation and slightly better patient satisfaction. Our results suggest that utilization of these implants for hammertoe correction was a reasonable choice that provided good alignment, pain reduction, and improved function at final follow-up. However, they are more expensive than K-wires. For this reason, in-depth cost-benefit studies would be required to justify their use as a standard treatment. Level III, comparative series.

Distal Syme Hallux Amputation for Tip of Toe Wounds and Gangrene Complicated by Osteomyelitis of the Distal Phalanx: Surgical Technique and Outcome in Consecutive Cases

Distal hallux gangrene and neuropathic ulceration associated with digit deformity frequently result in osteomyelitis of the distal phalanx. Ideal treatment would involve limited resection to preserve function. We describe our surgical technique and retrospective results for distal Syme hallux amputation with plantar flap closure. An institutional review board-approved review was conducted on cases performed over 8 years. A total of 15 consecutive patients (16 digits) with hallux soft tissue loss who had undergone distal Syme hallux amputation were included. In each case, initial resection removed the distal hallux wound, nail bed, and distal phalanx. The proximal phalanx tip was remodeled, allowing margin biopsy and reduction of prominence. Of the 16 digits, 5 (31.3%) had hammertoe deformity and 1 (6.3%) was excessively long. Positive probe-to-bone status was identified in 8 of the 16 digits (50.0%). All 8 ulcers (100.0%) that probed to bone had histologic or culture results consistent with distal phalanx osteomyelitis. A proximal margin biopsy was taken in 12 of 16 digits (75.0%), and proximal phalanx osteomyelitis was observed in 4 of 12 proximal margin biopsies (33.3%). Two digits (12.5%) failed to heal. Three digits (18.8%) required a more proximal amputation, and the remaining 13 (81.3%) were found to be well-healed and functional at the final follow-up examination. The mean follow-up period was 27.6 (range 8 to 97) months. We have found distal Syme hallux amputation to be an effective treatment when used judiciously for distal hallux gangrene and osteomyelitis associated with neuropathic ulceration. This procedure permits bone biopsy for early diagnosis, confirmation of clean margins, removal of nonviable tissue and the abnormal toenail, and some deformity correction.

Utilization of Retrofusion screw for PIP fusion for treatment of hammertoes

Category: Lesser Toes Introduction/Purpose: The rigid hammertoe deformity requires realignment of the proximal interphalangeal joint. Traditionally this has been achieved with resection arthroplasty with K-wire fixation of the joint. However, this method is prone to complications such as pin migration, pin tract infection, pin breakage, nonunion, and malunion. Recently, a variety of treatment options have been developed to achieve appropriate PIP joint fusion while minimizing these risks. This study investigates the fusion rate and outcomes of a novel internal fixation screw. Methods: A retrospective review was done to determine the short term fusion and satisfaction rate of hammertoe corrections performed by 2 surgeons utilizing a specifically designed longitudinal compression screw. A typical dorsal approach to the PIP joint was performed, followed by a resection arthroplasty, and the screw was inserted in the appropriate described manner. At the last follow up, the radiographs and clinical condition was observed. The fusion and alignment of the joint were then analyzed by an orthopaedic resident (PGY3), an orthopaedic attending, and a musculoskeletal radiologist. Clinical satisfaction and appearance was derived from chart review. A total of 55 screws were placed in 40 patients. Thirty-nine of these toes were second toes, 12 were third toes, and 4 were fourth toes. This implant was not designed for the fifth toe. The median final X-ray follow up was 10 weeks (range 5 to 40 weeks). Results: After evaluation of the post-operative X-rays by all 3 evaluators, at least 76% of these toes were definitively fused. About 13% of the joints were difficult to judge for radiological union based on the available X-rays. Approximately 11% of the joints went into nonunion or were not fused by final (typically asymptomatic) follow up. Two toes (3.6%) had persistent pain and swelling at the last visit. Two toes (3.6%) had slight misalignment (more than 5 degrees of varus/valgus), and only one was a cosmetic issue. No toes changed in alignment from the immediate post-operative position. There was no evidence of post- operative infection in the entire series. None of the toes required a return to the operating room for any reason. Conclusion: Compression screw fixation for the treatment of hammertoe deformities is a relatively effective method in that it demonstrates reasonable rates of radiographic union with very high rate of symptomatic relief. There were no complications associated with infection or loss of alignment. Furthermore, even in patients without firm evidence of bony union, the presence of an intramedullary implant maintains alignment while relieving symptoms.

Cuboid fracture: Epidemiology and treatment algorithm on 28 patients

Distal hallux gangrene and neuropathic ulceration associated with digit deformity frequently result in osteomyelitis of the distal phalanx. Ideal treatment would involve limited resection to preserve function. We describe our surgical technique and retrospective results for distal Syme hallux amputation with plantar flap closure. An institutional review board-approved review was conducted on cases performed over 8 years. A total of 15 consecutive patients (16 digits) with hallux soft tissue loss who had undergone distal Syme hallux amputation were included. In each case, initial resection removed the distal hallux wound, nail bed, and distal phalanx. The proximal phalanx tip was remodeled, allowing margin biopsy and reduction of prominence. Of the 16 digits, 5 (31.3%) had hammertoe deformity and 1 (6.3%) was excessively long. Positive probe-to-bone status was identified in 8 of the 16 digits (50.0%). All 8 ulcers (100.0%) that probed to bone had histologic or culture results consistent with distal phalanx osteomyelitis. A proximal margin biopsy was taken in 12 of 16 digits (75.0%), and proximal phalanx osteomyelitis was observed in 4 of 12 proximal margin biopsies (33.3%). Two digits (12.5%) failed to heal. Three digits (18.8%) required a more proximal amputation, and the remaining 13 (81.3%) were found to be well-healed and functional at the final follow-up examination. The mean follow-up period was 27.6 (range 8 to 97) months. We have found distal Syme hallux amputation to be an effective treatment when used judiciously for distal hallux gangrene and osteomyelitis associated with neuropathic ulceration. This procedure permits bone biopsy for early diagnosis, confirmation of clean margins, removal of nonviable tissue and the abnormal toenail, and some deformity correction.

Complication rates and short-term outcomes similar after hammertoe correction in older patients

Category: Lesser Toes Introduction/Purpose: Hammertoe deformities are common lesser toe deformities and multiple methods exist for surgical treatment. The population continues to age and to date, no studies have looked specifically at outcomes in the geriatric cohort, who are often at greater risk of complications or functional compromise due to increased co-morbidities. This study examines differences in short-term outcomes of pain, improvement of SF-36 scores, and complication rates in younger compared to older patients who underwent surgical correction of hammertoe deformities. Methods: 47 patients undergoing surgical correction of hammertoe deformities were prospectively followed. All surgical procedures were performed by a single surgeon and the specific surgical technique was tailored to each patient’s deformity. All patients were treated with early mobilization and progressive weight-bearing as tolerated. Subjective assessment of function was obtained using pre-operative and post-operative Visual Analogue Scale (VAS) and Short Form Health Survey (SF-36) scores with a minimum of six-month follow-up. 38 patients met inclusion criteria for length of follow-up (5 males, 33 females). Patients were divided into two groups based on age at the time of surgery (those younger than sixty years old, and those older than sixty years old). The improvements in mean (+/- SEM) VAS and SF-36 scores for patients younger than sixty years were compared to outcomes of patients older than sixty years of age, and results were assessed for statistical significance using a student’s t-test. Results: The mean age was 46.4 +/- 4.1 years in the younger patients and 68.0 +/- 1.2 years in the older cohort. The mean improvement in VAS score from pre-op to six months post-op was 2.8 +/- 0.8 and 2.8 +/- 0.6 (p = 0.95) in the younger and older cohorts, respectively (Table 1). The mean improvement in SF-36 Physical Component Score from pre-op to six months post-op was 8.6 +/- 6.7 and 6.7 +/- 4.4 (p= 0.81) in the younger and older cohorts, respectively. The mean improvement in SF-36 Mental Component Score was 1.5 +/- 3.7 and 1.4 +/- 4.2 (p=0.99) in the younger and older cohorts, respectively. One complication occurred in the younger cohort (0.11%) and no complications were reported in the older cohort. Conclusion: Outcomes of surgical correction of hammertoe deformities in older patients were similar to outcomes in younger patients at short-term follow-up. The study had sufficient power to detect differences in means as small as 5-8% depending on the specific outcome parameter. This study establishes a cohort of patients who will be followed to determine the effect of age on long-term outcomes of pain, SF-36 scores, and complication rates of surgical correction of hammertoe deformities. Future studies will also compare radiologic outcomes of hammertoe deformities preoperatively and postoperatively.

PIP resection arthroplasty vs PIP arthrodesis for fixed hammertoe deformity correction. A review

The Tactys® implant is a total anatomic gliding and modular prosthesis for proximal interphalangeal (PIP) arthritis. We report the clinical and radiographic results of this implant with a minimum follow-up of 12 months. Thirty-three implants in 27 patients with a mean age of 67 years were reviewed. Surgical approach was mid-line dorsal and trans-tendinous. Postoperative active motion was performed with a protective splint for 4 weeks. All patients were evaluated (pain, range of motion, strength, function through QuickDASH and PRWE scores, X-rays) by an independent examiner. The mean follow-up was 21 months (range: 12–30). Pain decreased from 7.4 to 1.6 on a VAS scale (P < 0.001). Flexion–extension range of motion increased from 32.1° to 59.2° (P < 0.001). Functional QuickDASH and PRWE improved from 64.5 and 67.1 to 25.5 and 19.5, respectively (P < 0.001). Grip and pinch strength increased from 15.1 and 1.8 to 24.2 and 2.4 kg/F, respectively (P < 0.001). At the last follow-up, a swan neck deformity was noticed in three patients, which was reducible in all cases. Four patients were reoperated: dorsal tenoarthrolysis in three cases and correction of swan neck deformity in one case. On X-rays, asymptomatic periprosthetic ossifications were noticed in 13 cases (39%). There were no signs of implant migration or loosening. Our results are comparable to those of other published studies of PIP arthroplasty. The modularity of the Tactys® implant allows the range of motion of the PIP joint to be maintained. It is a reliable alternative to other conventional PIP implants.Level 4, case series.La prothèse Tactys® est une prothèse anatomique totale, non contrainte, à glissement et modulaire utilisée dans le traitement de l’arthrose de l’articulation interphalangienne proximale (IPP). Nous rapportons les résultats préliminaires de cet implant avec un recul minimum de 12 mois. Trente-trois implants chez 27 patients d’âge moyen 67 ans (43–85) ont été posés au sein d’un même centre. Toutes les prothèses ont été implantées par voie dorsale trans-tendineuse. Une mobilisation activo-passive a été réalisée sous couvert d’une orthèse de protection pendant les 4 premières semaines. Une évaluation clinique (douleur, force, amplitudes articulaires), fonctionnelle (scores QuickDASH et PRWE) et radiologique a été réalisée par un examinateur indépendant. Le recul moyen à la révision était de 21 mois (12–30). Cliniquement, on notait une amélioration de la douleur (EVA 1,6 contre 7,4, p < 0,001), de l’arc de mobilité en flexion-extension de l’IPP (59,2° contre 32,1°, p < 0,001). Les scores fonctionnels QuickDASH et PRWE ont été également améliorés significativement (respectivement 25,5 et 19,5 contre 64,5 et 67,1, p < 0,001). Les forces palmo-digitale et digitale pure étaient aussi significativement améliorées (24,2 kg/F versus 15,1 et 2,4 kg/F versus 1,8, p < 0,001). Au dernier recul, trois patients (9 %) présentaient une déformation réductible en col-de-cygne. Quatre patients ont nécessité une réintervention : trois pour une ténoarthrolyse dorsale et un pour correction d’un col-de-cygne douloureux et gênant. Sur le plan radiologique, des calcifications périprothétiques dans 13 cas (39 %) étaient trouvées. Aucun descellement précoce, fracture ou enfoncement d’implant n’était noté. Nos résultats sont comparables à ceux de la littérature. Par sa modularité, la prothèse Tactys® semble autoriser le maintien d’une mobilité IPP fonctionnelle. Elle représente une alternative valable et fiable aux autres implants conventionnels existants.Niveau 4, étude de cas.

Gastrocnemius Recession Leads to Increased Ankle Motion and Improved Patient Satisfaction After 2 Years of Follow-Up

The isolated gastrocnemius contracture present in neurologic healthy patients results in a significant limitation of ankle dorsiflexion causing pathologic gait patterns and a greater risk of further foot disorders. Gastrocnemius recession is an established procedure to increase ankle dorsiflexion. However, little evidence is available of the use of gastrocnemius recession in these patients. Complication rates, recurrence of gastrocnemius contracture, and the prevalence of additional foot disorders needs further evaluation. A study group of 64 operated limbs undergoing gastrocnemius recession was evaluated to determine the prevalence of foot disorders, pre- and postoperative ankle dorsiflexion, and incidence of complications. A subgroup of 15 (23.4%) patients without additional operative procedures was examined regarding ankle dorsiflexion, strength (Janda method), sensitivity in the operated limb, and the pre- and postoperative Foot Function Index scores. The prevalence of foot disorders showed pes planus (41%), hallux valgus (38%), metatarsalgia (19%), hammertoe deformity (13%), and symptomatic Haglund exostosis (11%). At 31 months of follow-up, the patients had significantly benefited from increased ankle dorsiflexion of 13.3° ± 7.9° (p < .001). Postoperatively, 16% patients experienced complications. In the subgroup of 15 patients, the follow-up examination after 44 months showed ankle dorsiflexion of 14° ± 7.1°. The plantarflexion strength was 4 of 5 (Janda method). The Foot Function Index score had improved significantly from 65.4 ± 26.5 points to 33.4 ± 19.5 points (p < .001). Patients with isolated gastrocnemius contracture seem to have a high prevalence of symptomatic foot disorders. At a mid-term follow-up examination, gastrocnemius recession (Strayer) was shown to be an effective procedure to significantly improve ankle dorsiflexion, functionality, and pain symptoms. More attention should be given to the development of postoperative complications.

Correzione percutanea del dito a martello

A hammer toe deformity is defined as dorsiflexion at the MTPJ, plantarflexion at the PIPJ and either normal position or dorsiflexion at the DIPJ. A hammer toe, in addition to a sagittal plane deformity, may also have a medial or lateral deviation of the distal phalanx. Hammer toes may cause pain and callus formation. Multiple factors contribute to the development of this deformity, and the prevalence is higher in women and with advanced age. The terms “hammer toe” and “clawtoe” have often been interchangeable in the literature. Before surgical treatment, we have to discriminate between flexible/semirigid and rigid hammer toe.

Correction of Hammertoe Deformity With Novel Intramedullary PIP Fusion Device Versus K-Wire Fixation

K-wire fixation has been the most common method of fixation for hammertoe deformity. However intramedullary devices are gaining ground in both number of available choices and in procedures performed. This study aimed to compare the outcomes of hammertoe correction performed with K-wire fixation versus a novel intramedullary fusion device (CannuLink). A retrospective review of hammertoe correction by a single surgeon was performed from June 2011 to December 2013. Sixty patients (95 toes) underwent K-wire fixation and 39 patients (54 toes) underwent fusion with the CannuLink implant. Average age was 61.7 years and 61.4 years, respectively. Average length of follow-up was 12.9 and 12.3 months, respectively. Patients were evaluated for medical comorbidities, smoking status, inflammatory arthritis, peripheral vascular disease, peripheral neuropathy, pre- and postoperative visual analog pain scale, bony union percentage, revision rate, complications (hardware and surgery-related), and persistent symptoms at last follow-up. There was no significant difference in demographics or comorbidities between the 2 groups ( P > .05). In the K-wire group, 16 patients (18 toes) remained symptomatic at last follow-up (27%). Nine toes (9.5%) had recurrent deformity, 3 toes (3%) developed a late infection because of the recurrent deformity, and 1 toe (1%) developed partial numbness. One patient suffered a calf deep vein thrombosis (DVT) and peroneal nerve neuritis, 1 patient developed foot drop, and 3 patients continued to complain of pain. Five toes required revision surgery (5.3%). In the intramedullary group, 3 (7.7%) patients remained symptomatic and all were associated with a complication. One patient developed chronic regional pain syndrome in the foot, a calf DVT, and a nonfatal pulmonary embolus. A second patient developed a painless recurrent deformity. A third patient had wound dehiscence. Nobody had hardware failure or required a second operation. The CannuLink intramedullary device for hammertoe correction resulted in fewer complications, only 1 recurrent deformity, and no reoperations compared with K-wire fixation. Level III, retrospective comparative study.

Correction of Hammer Toe Deformity with Novel Intramedullary PIP Fusion Device versus K-Wire fixation

Category: Lesser Toes Introduction/Purpose: K-wire fixation is the most common operative procedure for hammertoe deformity today. However, intramedullary implants are gaining ground in both number of available choices and in procedures performed. This study aimed to compare the outcomes of hammertoe correction performed with K-wire fixation versus a novel intramedullary fusion device. Methods: A retrospective review of hammertoe correction by a single surgeon was performed from June 2011 to December 2013. Sixty patients (95 toes) underwent K-wire fixation and 39 patients (54 toes) underwent fusion with the intramedullary implant. Average age was 61.7 years and 61.4 years, respectively. Average length of follow up was 12.9 and 12.3 months, respectively. Patients were evaluated for medical comorbidities, smoking status, inflammatory arthritis, peripheral vascular disease, peripheral neuropathy, pre and postoperative visual analogue pain scale, bony union percentage, revision rate, complications (hardware and surgery-related), and persistent symptoms at last follow up. Results: There was no significant difference in demographics or comorbidities between the two groups (p&gt;0.05). In the K-wire group, sixteen patients (18 toes) remained symptomatic (27%). Nine toes (9.5%) had recurrent deformity, three toes (3%) developed a late infection due to the recurrent deformity and one toe (1%) developed partial numbness. One patient suffered a calf DVT and peroneal nerve neuritis, one patient developed a foot drop, and three patients continued to complain of pain. Five toes required revision surgery (5.3%). In the intramedullary group three (7.7%) patients remained symptomatic. One patient developed CRPS in the foot, calf DVT, and a non-fatal PE. A second patient developed a painless recurrent deformity. A third patient had wound dehiscence. Nobody suffered hardware failure or required a second operation. Conclusion: The intramedullary device for hammertoe correction resulted in less complications, recurrent deformity, and reoperations than K-wire fixation.