Hammertoe Surgery Research Articles

How Important Is a Lesser Metatarsal Osteotomy in Preventing Second Hammertoe Recurrence?

Hammertoes with greater preoperative transverse plane deformity are more likely to recur after corrective surgery; however, it is unclear whether this represents an inherent (fixed, non-modifiable) risk, or whether steps can be taken intraoperatively to mitigate this risk. In this study, we examined whether transverse plane transposition and/or shortening of the 2nd metatarsal during 2nd hammertoe surgery influenced recurrence. We performed a secondary analysis of pre-existing data from patients that had previously undergone 2nd hammertoe surgery at our institution between January 1, 2011 and December 31, 2013. One hundred two patients (137 toes) were followed for a mean 28 ± 7.8 months postoperatively. Thirty-seven toes required, at the surgeon's discretion, an additional/concomitant Weil metatarsal osteotomy. Magnitude of transverse plane transposition and shortening of the 2nd metatarsal, and joint angular measurements were obtained from the 2nd metatarsophalangeal joint on weightbearing AP radiographs preoperatively and at 6-10 weeks postoperatively. Cox regression analysis was used to identify predictors of hammertoe recurrence using these new variables and a set of known predictors. In the final regression model, failure to establish a satisfactory postoperative metatarsal parabola (i.e., long 2nd metatarsal; Nilsonne values < -4mm, multivariate hazards ratio [HR] 1.96, P=0.097), and intraoperative lateral transposition of the metatarsal head (multivariate HR 3.45, P=0.028) seemed to confer additional risk for hammertoe recurrence. We conclude that shortening osteotomies may be assistive in some individuals, while further inquiry is still needed to determine whether similar benefits can be derived from medial head transposition in medial toe deformities. Level of Clinical Evidence: 3, comparative study Classification: Forefoot Reconstruction.

Minimally Invasive Versus Open Hammertoe Correction: A Retrospective Comparative Study

Hammertoe deformity is a common forefoot pathology, characterized by a progressive deformity with dorsiflexion of the proximal phalanx on the metatarsal head at the metatarsal phalangeal joint (MTPJ) and plantarflexion of the intermediate phalanx on the proximal phalanx at the proximal interphalangeal joint (PIPJ). While there is literature available discussing open techniques for hammertoe correction, there is a lack of publications discussing minimally invasive techniques, therefore the objective of this retrospective comparative study is to evaluate minimally invasive versus open hammertoe surgery in terms of time to osseous union, complications, recurrence, and return to full activity. Sixty eight feet among 41 patients met the inclusion criteria and were surveyed. Among the 68 feet, 54 feet (124 toes) underwent minimally invasive hammertoe correction and 14 feet (22 toes) underwent open hammertoe correction. Time to osseous union (weeks) in the MIS group was 8.76 ± 2.31 weeks with similar outcomes to the open group with union at 8.42 ± 2.31 (p = .65). Return to activity (weeks) was 10.47 ± 3.45 in the MIS group and 9.92 ± 3.03 in the open group with no statistical significance (p = .62). There was 4 recurrent hammertoe deformities in the MIS group (3.23%) with no recurrent hammertoes in the open group (0%). In the MIS group 5 hammertoes had unplanned hardware removal (4.03%) compared to 0 in the open group. There was no statistical significance for both recurrence and unplanned hardware removal (p = 1). Overall, we concluded that both techniques are equivocal with no detectable statistical difference.

PMD6 INFECTIONS AND REOPERATIONS AFTER HAMMERTOE SURGERY IN OLDER PATIENTS

This study evaluated the rates of infections and reoperations after hammertoe surgery and calculated one- and two-year incremental payments associated with infections and reoperations in older adults. This was a retrospective evaluation of medical claims from the United States Centers for Medicare and Medicaid Standard Analytic File (100%) sample. Patients aged ≥65 years with a diagnosis of hammertoe who underwent hammertoe procedure between 2015 and 2016 were included. Cumulative proportion of patients with a diagnosis of infection were reported 30-, 60-, 90-, 180-days and one- and two-years post-hammertoe procedure. All-cause reoperations defined as presence of an additional code for hammertoe surgery with and without known laterality were reported, one- and two-years post-surgery. Generalized linear regression models were used to evaluate the adjusted total payments for patients with and without infections and reoperations. The adjusted incremental payments associated with infection and ipsilateral reoperation were reported one- and two-years post-surgery. A total of 10,624 older adults (average age 73.4 years, 77.8% females, and 54.9% with Charlson Comorbidity Index ≥1) were identified. The proportion of patients with infections over 30-, 60-, 90-, 180-days and one- and two-years post-hammertoe procedure were 1.1%, 1.9%, 2.4%, 3.1%, 4.2% and 6.5%, respectively. All-cause reoperations were reported in 6.3% of which 1.7 % were ipsilateral, 1.9% were contralateral and 2.7% were of unknown laterality over one-year post surgery. For two-years post-surgery, the all-cause reoperation rate was 9.5%: 2.2% ipsilateral, 2.2% contralateral and 5.1% unknown laterality. The adjusted incremental payments for infection and ipsilateral reoperations were $28,595 and $6,753 at one-year and $50,791 and $15,614 at two-year post-surgery, respectively. Among older adults with hammertoe surgery the rates of infection and reoperations reached 6.5% and 9.5% over two-years post-surgery with increased payments. Treatment alternatives are needed to lower complications rates and financial burden to healthcare system.

PSU22 INFECTIONS AND REOPERATIONS AFTER HAMMERTOE SURGERY IN A NATIONWIDE US COMMERCIAL INSURANCE CLAIMS DATABASE

This study evaluated the rates of infections and reoperations after hammertoe surgery and calculated one- and two-year incremental payments associated with infections and reoperations in a nationwide US commercial insurance claims database.

Risk Factors for Failure in Hammertoe Surgery.

Hammertoe correction is perhaps the most common elective surgery performed in the foot, yet rates of symptomatic recurrence and revision surgery can be high. In this study, we aimed to identify patient and provider risk factors associated with failure after hammertoe surgery. Consecutive patients with a minimum of 6 months' follow-up undergoing hammertoe surgery within a single, urban foot and ankle practice between January 1, 2011, and December 31, 2013, served as the basis of this retrospective cohort study. Cox regression analysis was used to identify important predictor variables obtained through chart and radiographic review. One hundred fifty-two patients (311 toes) with a mean age of 60.8 ± 11.2 years and mean follow-up of 29.5 ± 21.2 months were included. Statistically significant predictors of failure were having a larger preoperative transverse plane deviation of the digit (hazard ratio [HR], 1.03 for each degree; P < .001; 95% CI, 1.02, 1.04), operating on the second toe (vs third or fourth) (HR, 2.23; P = .003; 95% CI, 1.31, 3.81), use of a phalangeal osteotomy to reduce the proximal interphalangeal (PIP) joint (HR, 2.77; P = .005; 95% CI, 1.36, 5.64), and using less common/conventional operative techniques to reduce the PIP joint (HR, 2.62; P = .03; 95% CI, 1.09, 6.26). Concomitant performance of first ray surgery reduced hammertoe recurrence by 50% (HR, 0.51; P = .01; 95% CI, 0.30, 0.87). We identified risk factors that may provide guidance for surgeons during preoperative hammertoe surgery consultations. This information may better equip patients with appropriate postoperative expectations when contemplating surgery. Level III, retrospective case series.

Radiographic Predictors for Adverse Outcomes Following Surgical Correction of Hammertoe Deformity

Category:Lesser ToesIntroduction/Purpose:Hammertoe deformities are common, often painful deformities of the lesser foot and are known to severely affect physical function. When patients seek surgical management, x-ray imagining is 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 their frequent use, no previous data support particular X-ray findings as being indicative of clinical presentation nor surgical outcomes. The aim of this study is to identify specific radiographic parameters that are predictive of pain and function outcomes after surgical correction of hammertoe deformity.Methods:Prospectively collected data was reviewed on 116 patients who underwent hammertoe correctional surgery. Patient demographics, comorbidities, and postsurgical complications were recorded from their electronic medical records. Clinical outcomes were assessed utilizing preoperative and postoperative pain Visual Analogue Scale (VAS) and Short Form Health Survey Physical Component (SF-36 PCS) scores with 1-year 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. Data was examined using chi-squared, t-test, and ANOVA analyses.Results:Preoperatively, 14.7% of patients had a deformity classified radiographically as mild, 37.1% as moderate, and 48.3% as severe. X-rays prior to surgery showed that 65.5% had MTP joint instability, 9.5% had joint dislocation, and 18.1% had joint arthritis. Postoperatively, 78.5% had PIP joint fusion, 38.8% had MTP joint arthritis, and 17.2% had MTP joint instability. A significant association was found between postoperative MTP joint instability and a lower 1-year SF-36 PCS (p=0.0032). There were no associations found between the other radiographic findings and postoperative outcomes, and no parameters were associated with pain VAS scores.Conclusion:After undergoing surgical correction of hammertoe deformity, the postoperative radiographic finding of MTP joint instability was determined to be predictive of physical function. However, neither metatarsophalangeal joint arthritis nor PIP fusion were predictive of outcomes. This work informs foot and ankle specialists that proper joint alignment and stabilization is critical to ensuring success in hammertoe surgery.

Clinical Comparison Between Shortening Osteotomy of the Proximal Phalanx Neck and Arthrodesis in Hammer Toe Surgery at Mid-TermFollow-Up

The treatment of hammer toe has been advocated for years, and many procedures have been proposed with skeletal and soft tissue intervention. The purpose of the present study was to compare arthrodesis of the proximal interphalangeal joint with shortening osteotomy of the proximal phalanx neck. In most cases, both procedures have been associated with elongation of the extensor apparatus, capsulotomy of the metatarsophalangeal joint, and stabilization with a Kirschner wire. To experiment with a technique that respects the anatomy and joint function, we used a distal subtraction osteotomy of the proximal phalanx neck. We compared a series of 78 patients, divided in to 2 groups: 38 (48.7%) treated with arthrodesis and 40 (51.3%) with shortening osteotomy. Patients were aged 22 to 78 years, with a mean final follow-up period of 56.6 (range 24 to 96) months. For clinical evaluation, we used the American Orthopaedic Foot and Ankle Society score, Foot and Ankle Outcome Score, and a subjective rating scale. The results were comparable between the 2 techniques; however, we report faster functional recovery in the group treated with shortening osteotomy (p < .0001), with an adjunctive advantage of preserving the integrity of the proximal interphalangeal joint. Thus, according to our results, this technique is comparable to arthrodesis.

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 &amp; 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 &amp; ankle specialists that healing of the PIP joint is critical to successful hammertoe surgery.

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.

Comparison between two techniques in hammertoe surgery after 5 years

Comparison between two techniques in hammertoe surgery after 5 years

StayFuse™ Intramedullary Implant Stabilization For Management of the Floppy Toe Following Hammertoe Correction Surgery

Category: Lesser Toes Introduction/Purpose: Though typically hammertoe correction surgery is successful, there are two possible outcomes that necessitate a second surgical procedure. Over time the hammertoe deformity may recur, or occasionally too much bone will be resected in the primary surgery resulting in an unstable or “floppy toe”. The floppy toe can be very difficult to manage, often requiring bone grafting to obtain fusion and stability. The StayFuse™ intramedullary implant is a two piece double ended screw device which can be implanted into the phalangeal remnants and interdigitated to permanently stabilize and align the toe in the correct position. The purpose of this study was to gather outcome data from patients treated with the StayFuse™ intramedullary implant in these revision procedures. Methods: Following IRB approval, a retrospective analysis of 32 patients who had been treated with the StayFuse™ intramedullary implant for unstable floppy toe deformities was undertaken. Demographic information collected included gender, age, time from initial hammertoe surgery, and number of previous procedures they had undergone on the involved foot, and involved toe. In addition, preoperative questionnaire scores were reviewed. The second toe was involved in 25 cases (78%), the 3rd toe in 11 cases (34%), and the 4th toe in 2 cases (6%). 6 required implantation in their 2nd and 3rd toes. Each patient underwent an average of 2.9 procedures during their revision surgery. Patients were evaluated at an average of 54 months post- surgery and completed a VAS Pain Score, Foot and Ankle Ability Measure (FAAM), Veterans Rand 12 Item Health Survey (VR-12), and a patient satisfaction survey. Univariate analysis was then performed. Results: The study population was 94% female with a mean age of 59.1 years. Patients had waited an average of 3.7 years before undergoing their revision procedure. At final follow-up, patients reported an average pain level of 2.7/10 in their involved toe as compared to 6.8/10 before implantation. The average final FAAM ADL score was 63.81/100, and Sports score 46.50/100. The average VR-12 Physical score was 40.84 and Mental score was 61.50. Six patients reported being “Extremely dissatisfied” with the outcome of their surgery, 3 were “Somewhat dissatisfied”, 4 were “Neither dissatisfied nor satisfied”, 6 were “Satisfied” and 12 were “Extremely satisfied”. Patients reporting being “dissatisfied” had undergone an average of 3.87 previous surgeries on their foot, compared to 2.84 previous surgeries in “satisfied” group (p &lt; 0.05) Conclusion: The floppy toe following an over-resected distal condylectomy of the proximal phalanx during a hammertoe correction remains a difficult problem to manage. By utilizing an intramedullary implant to stabilize the joint, the present study found that 56% (18/32) patients were satisfied with the outcome of their salvage surgery, while 13% (4/32) were neither dissatisfied nor satisfied. Unfortunately 28% (9/32) patients were dissatisfied. We conclude that the StayFuse™ intramedullary implant is a reasonable option for revision of unstable “floppy toes”. Patients should be counseled at length before consenting to surgery so that postoperative expectations may be better managed.

Lesser Toe PIP Joint Resection Versus PIP Joint Fusion: A Randomized Clinical Trial.

It is unclear whether proximal interphalangeal joint (PIPJ) resection or fusion leads to superior clinical outcome in patients undergoing hammertoe surgery. The purpose of this study was to prospectively evaluate a series of patients undergoing this surgery. Patients with one or more toes with rigid PIP flexion deformity were prospectively enrolled. These patients were randomly assigned to undergo either PIPJ resection or PIPJ fusion. In addition to the PIPJ procedure, a metatarsophalangeal joint (MTPJ) release was performed if deemed necessary. Follow-up was up to 1 year postoperatively. Twenty-six patients (39 toes) were included in the PIPJ resection group and 29 (50 toes) in the PIPJ fusion group. Thirty-four underwent an MTPJ release. No significant difference in foot outcome scores (American Orthopaedic Foot & Ankle Society scale, the Foot Function Index, and visual analog scale pain) could be detected after 1-year follow-up. A statistically significant difference was found regarding the toe alignment in the sagittal plane in favor of PIPJ fusion. Our randomized controlled study did not show any clinical outcome difference between PIPJ fusion and PIPJ resection. Both procedures resulted in good to excellent outcome in pain and activity scores. Level II, lesser quality RCT or prospective comparative study.

Hammertoe correction with k-wire fixation.

Kirschner wire (K-wire) fixation for correction of hammertoe deformity is a common, low-cost method for fixation of hammertoes after proximal interphalangeal (PIP) arthroplasty or fusion. Complications of this procedure include pin-tract infection, pin migration, pin bending or breakage, and recurrence of deformity. The investigators reviewed a large experience using K-wire stabilization for hammertoe correction. All hammertoe corrections performed by a single surgeon from 1999 to 2013 were retrospectively reviewed. A resection arthroplasty of the PIP joint or PIP fusion was performed and fixed with a K-wire. Follow-up duration, preoperative diagnosis, pin duration, concomitant procedures, recurrence rates, and complications were reviewed and analyzed. A total of 1,115 operations were performed on 876 patients, with correction of 2,698 hammertoes. There were 709 female and 167 male patients, with an average age of 57.5 years (range, 14-88 years), followed for an average of 20.8 months (range, 27 days to 12.7 years). Complications included 94 pin migrations (3.5%), 9 pin-tract infections (0.3%), and 2 pin breakages (0.1%). There were 150 recurrent deformities (5.6%) and 94 toes (3.5%) required revision hammertoe surgery. Malalignment was noted in 55 toes (2.1%). Vascular compromise occurred in 16 toes (0.6%), with 10 (0.4%) requiring amputation. Ninety-four toes (3.5%) required revision surgery because of symptomatic recurrence of deformity. The expected rates and rate ratios (RRs) of patients requiring revision hammertoe correction, compared with the study population as a whole, were statistically significantly higher in patients who underwent an metatarsophalangeal joint capsulotomy (3.10 vs 0.97; RR, 3.20) and those who experienced K-wire-related complications (5.10 vs 1.80, RR, 2.84). K-wire fixation for the treatment of hammertoe deformities led to good maintenance of correction with a relatively low complication rate, and we believe that it remains an effective, low-cost method of fixation for hammertoe correction. Level IV, retrospective case series.

Hammertoe Correction With Interphalangeal Joint Arthrodesis

Hammertoe deformities are a common clinical complaint and will on occasion require surgical repair. The goal of hammertoe surgery is to correct the apex of deformity to properly align the toe in the cardinal planes and relieve pain. The use of a Kirschner wire has historically been the fixation of c

Hammertoe Surgery and the Trim-It Drill Pin

Digital deformities are some of the most frequent complaints of patients seeking a surgical solution after the failure of conservative care. A thorough assessment of the actual level of deformity is important to ensure a lasting surgical correction. This article details the options for correcting hammertoe, clawtoe and mallet toe deformities with Trim it Drill pin and the Spin pin. Level 5.

Gradual Digital Lengthening with Autologous Bone Graft and External Fixation for Correction of Flail Toe in a Patient with Raynaud's Disease

Iatrogenic flail toe is a complication of hammertoe surgery that occurs when an overaggressive resection of the proximal phalanx occurs. This can cause both functional and cosmetic concerns for the patient. We present a case report of the correction of a flail second toe in a patient with Raynaud's disease. The correction was achieved by means of gradual soft tissue lengthening with external fixation and an interposition autologous bone graft digital arthrodesis. After 5 months, this 2-stage procedure lengthened, stabilized, and restored the function of the toe. 4.

Validation of a new outpatient orthopedic pain model utilizing ?Hammertoe? surgery: Statistical separation of an opioid combination and a Cox -2 inhibitor from placebo

Background/Aims Few outpatient orthopedic pain models exist. The purpose of this study was to assess the validity of a new outpatient orthopedic pain model using Hammertoe surgery. Methods The study design was a single dose, double-blind, randomized trial assessing the effect of two marketed analgesics for acute pain after Hammertoe surgery. Subjects underwent a primary unilateral hammertoe repair requiring open partial phalangectomy with/without fixation. Upon reaching moderate or severe post-operative pain, patients were randomized to: Celecoxib 200 mg (n=29), hydrocodone/acetaminophen 10/1000 mg (n=29) or placebo (n=13). Analgesic assessments over 8 hours included: TOTPAR, SPID & SPRID and Onset. Results Results indicated excellent assay sensitivity as the model separated both compounds from placebo: TOTPAR hours 4 & 8, p<.001 & p<.02 respectively; SPID hours 4 & 8 p<.001 & p<.01 respectively; SPRID hours 4 & 8 p<.005 & p<.009 respectively. Both agents achieved median onsets of .5 hours compared to placebo (p<.002). Data collected on post-dosing days 2–6 demonstrated that the majority of patients took supplemental analgesics over this period. Conclusion This study demonstrated assay sensitivity and utility of the Hammertoe model for the study of analgesics in acute pain and its potential for multi-day, multi-dose designs. Clinical Pharmacology & Therapeutics (2005) 77, P52–P52; doi: 10.1016/j.clpt.2004.12.089

Results of second toe amputation: for overriding second toe with asymptomatic hallux valgus and as a salvage procedure following failed hammer-toe surgery

We assessed the results of second toe amputation retrospectively from January 1990 to December 1999 in terms of patient satisfaction following primary second toe amputation for asymptomatic hallux valgus (AHV) with overriding second toe or severe hammer-toe deformity, and in a second group as a salvage procedure following failed corrective surgery for hallux valgus and second hammer-toe. A total of 25 out of 39 patients returned to the outpatient clinic and was assessed using the Maryland Foot Score Profile (MFSP), a subjective assessment of pain, function, cosmesis and motion: 20 (80%) patients had an excellent result (score: 90–100); five (20%) patients had good result (score: 75–89). Our results clearly indicate that second toe amputation is valuable and psychologically atraumatic as a primary procedure in the 70-plus age group for AHV with severe second toe deformity and as a salvage procedure. Benefits include simplicity and applicability to the day case setting with reduced operative risk and recovery time and good patient satisfaction.

Correction of Hammer Toe Surgery Deformity by Z-Plasty and Bone Graft

Correction of Hammer Toe Surgery Deformity by Z-Plasty and Bone Graft

The repair of bone following hammertoe surgery.

The repair of bone following hammertoe surgery.