Operative repair of the fixed hammertoe deformity

Minimally invasive surgery for pedal digital deformity: an audit of complications using national benchmark indicators

Background

There is increasing global interest and performance of minimally invasive foot surgery (MIS) however, limited evidence is available in relation to complications associated with MIS for digital deformity correction. The aim of this prospective audit is to report the surgical and medical complications following MIS for digital deformity against standardised clinical indicators.

Methods

A prospective clinical audit of 179 patients who underwent MIS to reduce simple and complex digital deformities was conducted between June 2011 and June 2013. All patients were followed up to a minimum of 12 months post operatively. Data was collected according to a modified version of the Australian Council of Healthcare standards (ACHS) clinical indicator program. The audit was conducted in accordance with the National Research Ethics Service (NRES) guidelines on clinical audit.

Results

The surgical complications included 1 superficial infection (0.53%) and 2 under-corrected digits (0.67%), which required revision surgery. Two patients who underwent isolated complex digital corrections had pain due to delayed union (0.7%), which resolved by 6 months post-op. No neurovascular compromise and no medical complications were encountered. The results compare favourably to rates reported in the literature for open reduction of digital deformity.

Conclusion

This audit has illustrated that performing MIS to address simple and complex digital deformity results in low complication rates compared to published standards. MIS procedures were safely performed in a range of clinical settings, on varying degrees of digital deformity and on a wide range of ages and health profiles. Further studies investigating the effectiveness of these techniques are warranted and should evaluate long term patient reported outcome measures, as well as developing treatment algorithms to guide clinical decision making.

Correction of Hammer Toe Deformity of Lateral Toes With Subtraction Osteotomy of the Proximal Phalanx Neck

Existing techniques for surgical treatment of hammer toe commonly combine skeletal and soft tissues interventions to obtain a durable correction of the deformity, balance the musculotendinous forces of flexion and extension of the toe, and normalization of the relations between interosseous muscles and metatarsal bones. The most common surgical techniques can provide the correction of the deformity through arthroplasty with resection of the head of the proximal phalanx or arthrodesis of the proximal interphalangeal joint. In most cases, these 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 evaluated a series of 40 patients, aged 18 to 82 years, who underwent surgery from January 2008 to December 2010. All patients were evaluated clinically and radiographically pre- and postoperatively and underwent examination at a mean final follow-up point of 24.4 (minimal 12, maximal 36) months. For the clinical evaluation, we used the American Orthopaedic Foot and Ankle Society score. The rate of excellent and good results was >90%. Compared with other techniques, this technique led to considerable correction, restoration of the biomechanical and radiographic parameters, and an adjunctive advantage of preserving the integrity of the proximal interphalangeal joint. Thus, our results have caused us to prefer this technique.

Extensor apparatus of the lesser toes: anatomy with clinical implications--topical review

Lesser toe deformities are one of the most common conditions faced by orthopedic surgeons. Knowledge of the anatomy of the lesser toes is important for ensuring correct diagnosis and treatment of deformities, which are caused by factors such as muscle imbalance between the extensor apparatus and flexor tendons. However, this apparatus has not received sufficient attention in the literature. In addition, the large number of inaccurate and erroneous descriptions means that gaining an understanding of these structures is problematic. The objective of the present article is to clarify the anatomy of the extensor apparatus by means of a pictorial essay, in which the structures involved will be grouped and discussed in detail. The most relevant clinical implications will be addressed.

LEVEL OF EVIDENCE

Level V, expert opinion.

[Arthodesis of the proximal and distal interphalangeal joint]

OBJECTIVE

Elimination of the fixed lesser toe deformity by arthrodesis of the proximal or distal interphalangeal joints (PIP and DIP, respectively).

INDICATIONS

Painful fixed deformity. PIP joint: fixed hammer toe or clawtoe. DIP joint: fixed mallet toe. Relative indication: flexible hammer toe, clawtoe or mallet toe.

CONTRAINDICATIONS

General operative contraindications. Relative contraindications also include severe deformities affecting the metatarsophalangeal (MTP) joint, for which the arthrodesis should combine an operative procedure of the MTP joint.

SURGICAL TECHNIQUES

PIP arthrodesis: Dorsal incision centered over the PIP joint, exposure of the PIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles, resection of the head of the proximal phalanx and the articular surface of the middle phalanx. The arthrodesis should be stabilised in mild plantar flexion. The tip of the toe should have contact with the surface when the push up test is done. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed. DIP arthrodesis: dorsal incision centered over the DIP joint, exposure of the DIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles. Resection of the head of the middle phalanx and the articular surface of the distal phalanx. The arthrodesis should be stabilised in straight position. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed.

POSTOPERATIVE MANAGEMENT

Postoperative full weight bearing for 3-6 weeks, depending on the arthrodesis technique used.

RESULTS

Stabilisation of the toe with adequate alignment is achieved by arthrodesis of the affected joint. In general, digital fusion of the fixed lesser toe pathology shows a high subjective satisfaction rate among the patients, although the rate of pseudarthrosis in attempted PIP or DIP arthrodesis is quite high. Major reasons for postoperative dissatisfaction were swelling, wound necrosis, pin infection, floating toe, shortening and angulation of the toe.

Retrospective comparative study of operative repair of hammertoe deformity

BACKGROUND

The purpose of this study was to compare the outcomes of patients with second hammertoe deformities who underwent correction using either joint resection arthroplasty, proximal interphalangeal joint (PIP) arthrodesis without osteotomy, or interpositional implant arthroplasty.

METHODS

Medical records from patients who underwent second PIP correction from July 1999 to December 2008 were retrospectively reviewed. A total of 114 patients (136 second toes) were the basis for this retrospective comparative study. The average final follow-up with weight-bearing radiographs of the 136 procedures at the second toe was 53.8 months.

RESULTS

All 3 groups had significantly reduced VAS scores postoperatively (P < .01). Also, all groups had significant radiographic correction in the average measured lateral angle of the second PIP joint (P < .01). However, the interpositional implant group had significantly corrected the second PIP joint in the axial plane, with an average postoperative anterior-posterior (AP) angle of 2.9° (P < .01). The postoperative AP angle was also significantly different compared with the postoperative AP angles of the other 2 groups (P < .01).

DISCUSSION

Our study confirms that all 3 techniques provide adequate pain relief and radiographic sagittal plane correction. However, interpositional implant arthroplasty provides significant radiographic correction in the axial plane.

LEVELS OF EVIDENCE

Therapeutic Level III, Retrospective comparative study.

A modified technique for flexor-to-extensor tendon transfer to correct residual metatarsophalangeal extension in the treatment of hammertoes

A variety of surgical procedures exist for the correction of hammertoe deformities, and several different methods of flexor tendon transfer have been described for the correction of hammertoes associated with extension contracture of the corresponding metatarsophalangeal joint. In the present report, we have described a variation of flexor tendon tenodesis we have found useful.

Prospective study of hammertoe correction with an intramedullary implant

BACKGROUND

Operative correction of a hammertoe deformity is often accomplished by excision of the articular surface of the proximal interphalangeal joint (PIP) and fixation across the joint. This study aimed to prospectively evaluate clinical and radiographic outcomes of hammertoe operative correction utilizing an internal implant and assess its ability to maintain postoperative alignment.

METHODS

Twenty-nine patients (53 toes) with a painful rigid hammertoe deformity were prospectively enrolled and operatively treated with resection arthroplasty of the PIP joint and fixation with an implant. Five patients were lost to follow-up, and 24 patients (42 toes) returned at an average of 12 months for final clinical and radiographic evaluation. All patients were evaluated pre- and postoperatively by AOFAS and Visual Analog Pain Scale (VAS) scores. On physical exam, the location and magnitude of the deformity, callosities, and digit circumference were recorded. Radiological parameters evaluated were digital alignment, successful union, implant position, and bone reaction.

RESULTS

All patients reported satisfaction at final follow-up, with an average improvement of AOFAS score from 52 (range, 24-87 points) to 71 (range, 42-95 points) points. The mean VAS pain score improved from 5 points (range, 2 to 10) preoperatively to 1 point (range, 0 to 5) postoperatively. Of patients, 87% reported an ability to return to their preoperative activities without limitations. Regarding digital alignment, there were no recurrent deformities or transverse plane deformities; 1 toe presented with a minor digital rotational deformity at final follow-up. Postoperative radiographs indicated 100% of proximal interphalangeal (PIP) joints with good alignment, and 81% demonstrated bony union.

CONCLUSION

Our results suggest that utilization of an internal implant for hammertoe correction was safe and provided acceptable alignment, pain reduction, and improved function at final follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

Stabilization of proximal interphalangeal joint in lesser toe deformities with an angulated intramedullary implant

BACKGROUND

Hammertoe and claw toe are among the most common foot deformities. Proximal interphalangeal (PIP) joint realignment can be performed using specifically designed intramedullary implants. The aim of this study was to assess the clinical outcome of patients with lesser toes deformities undergoing PIP joint realignment using an intramedullary implant.

METHODS

Patients requiring PIP joint realignment were included in this prospective multicenter observational study and followed for 12 months. A total of 156 toes, in 117 patients were implanted with the implants. Complications and radiological and functional outcome were assessed.

RESULTS

The proportion of joints fused on X-rays was 83.8% (95% CI: 77.8, 89.7) after 1 year. American Orthopaedic Foot and Ankle Society lesser metatarsophalangeal-interphalangeal scale (AOFAS-LMIS) improved from 40.4 (SD = 18.3) preoperatively to 85.5 (SD = 9.2) after 1 year. The proportion of patients with pain was 15.5% after 6 weeks and decreased to 4.7% after 1 year. Of the patients, 98% were satisfied about the operation. In patients with incomplete fusion of the PIP joint after 1 year, AOFAS-LMIS improved from 36.7 (SD = 18.9) preoperatively to 84.2 (SD = 10.1) 1 year postoperatively, while pain was reported by 2 patients (8.3%) after 1 year. Toe malalignment and lack of toe pulp-contact were reported slightly more frequently than for the whole group of patients, but not for the majority of the cases. Overall, complications were reported intraoperatively in 1.3% of the patients (2 cases) and postoperatively in 3.2% (5 cases). Revision was required in 1 case. Mallet toe deformity was found in 2.0% of the patients after 1 year.

CONCLUSION

This study showed that the use of an intramedullary implant for PIP realignment led to a high rate of fusion and a good outcome. No need of reoperation was reported for patients with incomplete joint fusion who had a stable joint with no pain.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot

Forefoot pain in the adult often alters mobility and has a negative impact on quality of life. Metatarsalgia describes pain localized to the forefoot. Forefoot pain may be caused by conditions of the lesser toes themselves (eg, hammertoes, mallet toes, claw toes). The pathophysiology of lesser toe deformities is complex and is affected by the function of intrinsic and extrinsic muscle units. In addition to lesser toe and metatarsal abnormality, forefoot pain can be attributed to interdigital neuritis, disorders of the plantar skin, and gastrocsoleus contracture. Treatment of these conditions may include shoe modifications, appliances, therapeutic exercises, and surgical repair.

High heritability of hallux valgus and lesser toe deformities in adult men and women

OBJECTIVE

To estimate the heritability of 3 common disorders affecting the forefoot, i.e., hallux valgus, lesser toe deformities, and plantar forefoot soft tissue atrophy, in white adult men and women.

METHODS

Between 2002 and 2008, a trained examiner used a validated foot examination to document the presence of hallux valgus, lesser toe deformities, and plantar soft tissue atrophy in 2,446 adults from the Framingham Foot Study. Among these, 1,370 participants with an available pedigree structure were included. Heritability was estimated using pedigree structures by the Sequential Oligogenic Linkage Analysis Routines package. Results were adjusted for age, sex, and body mass index.

RESULTS

The mean age of the participants was 66 years (range 39-99 years) and 57% were women. The prevalence of hallux valgus, lesser toe deformities, and plantar soft tissue atrophy was 31%, 29.6%, and 28.4%, respectively. Significant heritability was found for hallux valgus (range 0.29-0.89, depending on age and sex) and lesser toe deformity (range 0.49-0.90, depending on age and sex). The heritability for lesser toe deformity in men and women ages >70 years was 0.65 (P = 9 × 10(-7)). Significant heritability was found for plantar soft tissue atrophy in men and women ages >70 years (H(2) = 0.37, P = 3.8 × 10(-3)).

CONCLUSION

To our knowledge, these are the first findings of heritability of foot disorders in humans, and they confirm the widely-held view that hallux valgus and lesser toe deformities are highly heritable in white men and women of European descent, underscoring the importance of future work to identify genetic determinants of the underlying genetic susceptibility to these common foot disorders.

Digital arthrodesis with a one-piece memory nitinol intramedullary fixation device: a retrospective review

A 1-piece memory Nitinol intramedullary fixation device (Smart Toe; Stryker Corporation, Kalamazoo, MI) was used for proximal interphalangeal joint arthrodesis for correction of painful hammertoes in digits 2, 3, and 4. Sixty-five implants were placed in 35 patients. The mean age of our patients was 62.2 years (range = 27-82; standard deviation = 12.5). Mean follow-up time was 27 months (range = 12-40 months; standard deviation = 7). Overall, a 93.8% fusion rate was noted. Complications were noted in 4 patients (6.1%): 1 asymptomatic nonunion (1.5%), 2 hardware failures (3%), and 1 implant displacement (1.5%). To date, no patients required revisional surgery or hardware removal.

LEVEL OF EVIDENCE

V.

StayFuse for proximal interphalangeal joint fusion

BACKGROUND

Proximal interphalangeal (PIP) joint fusion is a commonly performed procedure for lesser-toe deformities. There are various techniques described to accomplish it. We report the results of PIP joint fusion carried out with an intramedullary fusion device in 150 consecutive toes. The aim of our study was to evaluate the outcomes of PIP joint fusion with this technique.

METHOD

A total of 150 toes in 140 consecutive patients who underwent PIP joint fusions of the lesser toes with a StayFuse implant were included in our study. The mean age of the patients was 69.5 years, and the mean follow-up was 18 months. Clinical, radiologic, and subjective evaluations as well as preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores were carried out.

RESULTS

Of the PIP joints, 95.3% were clinically asymptomatic, but the radiologic fusion was 73%. The mean preoperative AOFAS score improved from 22.9 to 81.6 at follow-up. There were implant-related complications in 8 toes. Ninety-five percent of the patients were satisfied with the procedure, and 3.3% of the patients needed revision surgery.

CONCLUSION

This technique maintained PIP joint alignment and provided rotational and angular stability with high patient satisfaction and low complication and reoperation rates. We conclude that this is a reproducible technique and an alternative for PIP joint fusions.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Pinning across the metatarsophalangeal joint for hammertoe correction: where are we aiming and what is the damage to the metatarsal articular surface?

Kirschner wire (K-wire) fixation across the metatarsophalangeal joint (MTPJ) is commonly used in hammertoe repair surgery. The purpose of the present study was twofold: (1) to determine where the K-wire penetrates the metatarsal articular surface to achieve a rectus digit; and (2) to quantify the percentage of cartilage disruption to better understand the consequences of K-wire transfixation of the MTPJ. Arthrodesis was conducted on the second, third, and fourth proximal interphalangeal joints of 10 below-the-knee cadaver specimens, using a 1.6-mm K-wire. Digital alignment was confirmed with simulated weightbearing intraoperatively and radiographically. The K-wire was removed, and the MTPJ was dissected until the metatarsal head was fully exposed. The penetration point was plotted on a quadrant system with deviation noted from the epicenter. Center was defined as the point equidistant from the medial-to-lateral and superior-to-inferior edges on the distal surface of the metatarsal head, excluding the plantar condyles. Statistically significantly deviations were found in the K-wire placement from the center (35.9% ± 17.5%, p < .001), medial-to-lateral width (22.2% ± 19.2%, p < .001), and dorsal-to-plantar height (15.8% ± 25.0%, p = .002). Relative to the center, the K-wire was superior in 22 (79%), inferior in 6 (21%), medial in 22 (79%), and lateral in 6 (21%) of the cadaveric MTPJs. The mean percentage of disruption of the articular cartilage was 1.8% ± .4% and was similar for the second, third, and fourth MTPJs (p = .13) and for the left and right feet (p = .75). This information could be used to guide surgeons when they transfixate the MTPJ during hammertoe correction and might contribute to preservation of the articular cartilage.

Revisiting the tailor's bunion and adductovarus deformity of the fifth digit

Correction of the fifth digit deformity and Tailor's Bunion can be rewarding as well as challenging for a foot and ankle surgeon. Immense care should be taken when performing these reconstructive surgical procedure, especially to avoid and minimize complication rates and mainly to prevent neurovascular damage. Appropriate surgical procedure selection for the fifth digit deformity and Tailor's Bunion is necessary in order to obtain a long term predictable outcome.

Digital arthrodesis

For lesser toe deformities, fusion of the proximal interphalangeal joint offers good long-term correction and predictability. Digital arthrodesis has been described for longer than 100 years in the literature, and current techniques closely resemble those described in early accounts. However, many implants currently being used take advantage of the latest metallurgic and polymeric innovations, with implants being composed of nitinol, polylactic or polyglycolic acids, and polydioxanone. Newer implants offer easy insertion and good stability, with no percutaneous wires. Pin-tract infection rates from exposed Kirschner wires may be as high as 18%, and newer implants help to mitigate this problem.

Smart toe® implant versus buried Kirschner wire for proximal interphalangeal joint arthrodesis: a comparative study

The surgical correction of hammer digits offers a variety of surgical treatments ranging from arthroplasty to arthrodesis, with many options for fixation. In the present study, we compared 2 buried implants for arthrodesis of lesser digit deformities: a Smart Toe® implant and a buried Kirschner wire. Both implants were placed in a prepared interphalangeal joint, did not violate other digital or metatarsal joints, and were not exposed percutaneously. A retrospective comparative study was performed of 117 digits with either a Smart Toe® implant or a buried Kirschner wire, performed from January 1, 2007 to December 31, 2010. Of the 117 digits, 31 were excluded because of a lack of 90-day radiographic follow-up. The average follow-up was 94 to 1130 days. The average patient age was 61.47 (range 43 to 84) years. Of the 86 included digits, 48 were left digits and 38 were right. Of the digits corrected, 54 were second digits, 24 were third digits and 8 were fourth digits. Fifty-eight Smart Toe® implants were found (15 with 19-mm straight; 2 with 19-mm angulated; 34 with 16-mm straight; and 7 with 16-mm angulated). Twenty-eight buried Kirschner wires were evaluated. No statistically significant difference was found between the Smart Toe® implants and the buried Kirschner wires, including the rate of malunion, nonunion, fracture of internal fixation, and the need for revision surgery. Of the 86 implants, 87.9% of the Smart Toe® implants and 85.7% of the buried Kirschner wires were in good position (0° to 10° of transverse angulation on radiographs). Osseous union was achieved in 68.9% of Smart Toe® implants and 82.1% of buried Kirschner wires. Fracture of internal fixation occurred in 12 of the Smart Toe® implants (20.7%) and 2 of the buried Kirschner wires (7.1%). Most of the fractured internal fixation and malunions or nonunions were asymptomatic, leading to revision surgery in only 8.6% of the Smart Toe® implants and 10.7% of the buried Kirschner wires. Both the Smart Toe® implant and the buried Kirschner wire offer a viable choice for internal fixation of an arthrodesis of the digit compared with other studies using other techniques.

Using a bone allograft to fixate proximal interphalangeal joint arthrodesis

Digital contractures are a very common deformity of the foot and ankle that require surgical correction. It has been shown that arthrodesis provides a better long-term result than arthroplasty of the interphalangeal joints. Arthroplasties usually require K-wire fixation that presents potential complications, such as pin tract infection. This study presents a new cadaveric bone matrix allograft to be used as rigid internal fixation for proximal interphalangeal joint arthrodesis. The purpose of using the allograft as a fixation device is to achieve solid bone fusion and avoid the potential complications of external pin fixation. Arthrodesis of the proximal interphalangeal joint was performed on 63 toes in 32 patients using TenFUSE (Solana Surgical, Memphis, TN), a sterile bone matrix allograft. The authors found 97% fusion rate with no complications reported to this date. It was concluded that this bone matrix allograft provides excellent results and is a suitable alternative fixation device for correction of hammer toe deformity.

LEVEL OF EVIDENCE

Level V.

How many joints does the 5th toe have? A review of 606 patients of 655 foot radiographs

BACKGROUND

It is a common understanding that the fifth toe has three bones with two interphalangeal joints. However, our experience shows that a significant number have only two phalanges with one interphalangeal joint.

METHODS

We identified 676 patients listed as having had a foot radiograph, during an eight week period, of which 606 radiographs were available for the assessment. The radiographs were then assessed counting the number of phalanges in the fifth toe.

RESULTS

The patients consisted of 344 females and 262 males. Bilateral radiographs had been performed in 49 patients. 362 radiographs (55.3%) were found to have 3 phalanges in their 5th toe, with 291 (44.4%) having only two phalanges.

CONCLUSIONS

We have demonstrated the presence of two phalanges is a common anatomical variant. This finding has clinical implications with regard to the treatment of deformities of the fifth toe and the type of internal fixation device used.

Lesser toes proximal interphalangeal joint fusion in rigid claw toes

Treatment of rigid claw toe is still subject to discussion and evolution. Arthrodesis or arthroplasty of the PIPJ is apparently the most reliable procedure. K wire seems be the most reliable way to solve this clinical issue, but different implants specifically created to treat PIPJ deformities are being developed, and still have to be tested clinically. The use of screws to fix the PIPJ is a valid alternative, although some problems remain to be solved, specifically pain in relation to the tip of the screw. Longer follow-up studies are needed to increase our knowledge of the treatment of this specific deformity.

Hammertoe surgery: arthroplasty, arthrodesis or plantar plate repair?

In cases of painful complex hammertoe deformity, there is no single approach that can be used in all circumstances. If conservative care fails, surgical management may include interphalangeal joint arthroplasty, arthrodesis, and/or plantar plate repair. The best and most pragmatic surgical plan must be patient-centered, taking the age, activity level, expectations of the patient, and precise etiology of the hammertoe deformity into account.

Treatment of hammertoe deformity using a one-piece intramedullary device: a case series

Hammertoes are common deformities that are often surgically treated using arthrodesis or arthroplasty of the proximal interphalangeal joint with percutaneous, temporary Kirschner wire fixation. However, percutaneous Kirschner wire fixation is associated with potential complications, including wire migration, breakage, and pin tract infection. Furthermore, the complications of pseudoarthrosis and nonunion are seen using this technique owing to a lack of rotational control of the Kirschner wire. Another drawback of this implant is the need for wire removal and the associated patient anxiety with this in-office procedure. In the present series of 7 toes in 3 patients, we describe an alternative method of hammertoe fixation using a permanently implanted, 1-piece intramedullary device used to stabilize the proximal interphalangeal interface. The potential advantages of this prosthesis include elimination of wire migration and breakage, enhanced control and stability of the digit, elimination of potential pin tract infection, and decreased patient anxiety since hardware removal is not required. The patients were followed up for approximately 1 year after the surgery, and no intraoperative or postoperative complications were observed. The implant maintained proper clinical and radiographic alignment throughout the observation period, without implant failure or breakage. All patients were satisfied with the cosmetic appearance of their surgically corrected toes and were able to perform all activities of daily living without the use of assistive devices. Also, their postoperative pain and function were acceptable. The implant used in the patients described in the present report appears to be a viable alternative for the treatment of hammertoe.

Early complications and recurrence rates after Kirschner wire transfixion in lesser toe surgery: a prospective randomized study

BACKGROUND

Prolonged percutaneous Kirschner wire transfixion after correction of lesser toe deformities has been associated with an increased rate of complications such as infection, wire breakage or loosening. Currently, the duration of wire transfixion is based on the surgeons' opinion rather than on evidence. We hypothesized that a transfixion time of 3 weeks when compared to 6 weeks would decrease complication rates without an increase in the rate of recurrent deformity.

METHODS

We prospectively randomized 52 lesser toes corrected for a moderate hammer- or claw toe deformity by means of resectional arthroplasty of the proximal interphalangeal joint into two groups with 3 and 6 weeks of Kirschner wire transfixion, respectively. Kirschner wire-associated complication rates and incidence of early recurrence of malalignment in a short term followup of three months were assessed. Forty-six toes, 23 in each group, were available for final followup.

RESULTS

No statistically significant differences were found in pre- and postoperative total AOFAS scores between the groups. No Kirschner wire associated complications occurred. Recurrent malalignment was more often documented in the group with 3 weeks of transfixion (11 of 23 toes, 47.8%) when compared to 6 weeks (two of 23 toes, 8.7%) at 3 months followup. Interphalangeal joint motion was significantly reduced with prolonged Kirschner wire transfixion, indicating a more stable fibrous union (p = 0.038).

CONCLUSION

At short-term followup, Kirschner wire transfixion of 6 weeks as opposed to 3 weeks showed a lower rate of recurrent malalignment without an increase in Kirschner wire associated complications.

Master techniques in digital arthrodesis

This is a comprehensive review of various techniques of digital fusion. Evolution of the technique has afforded today's surgeons a valuable repertoire of surgical options. Ultimately, patient factors and surgeon preference determine the most appropriate method of fixation.

Hammertoes/Clawtoes: metatarsophalangeal joint correction

Clawing of the lesser toes is not uncommon, can arise from a number of causes, and is often associated with other forefoot abnormalities. There is still some confusion in the nomenclature of lesser toe deformities affecting the MTPJ and PIPJ although the resulting deformities are probably part of the same pathologic process and thus treated in a similar manner. Many will be successfully treated with nonoperative methods, but if they fail a number of surgical options are available depending on the severity of the deformity and whether the deformity is fixed or flexible. Correction at the MTPJ can be achieved using a stepwise progression of soft-tissue procedures alone, bony procedures, or a combination of both.

The use of flexor to extensor transfers for the correction of the flexible hammer toe deformity

Flexor to extensor transfer is a useful means for the correction of a flexible hammer toe deformity. Although satisfaction rates have varied in the literature, this technique remains a useful tool in the surgeon’s armamentarium to improve toe deformity, decrease pain, and aid in shoe wear.

Prospective review of medium term outcomes following interpositional arthroplasty for hammer toe deformity correction

BACKGROUND

Hammer toe is a common lesser toe deformity that is usually found to affect the second toe. A number of procedures have been applied in its surgical management with varying results but there is still no consensus on the best technique.

MATERIALS AND METHOD

We prospectively reviewed a consecutive series of patients treated with interpositional arthroplasty, early mobilisation and with a minimal follow up of 6 months. We measured outcome using the Manchester Oxford foot and ankle questionnaire and a global impression of change score.

RESULTS

There was a high level of satisfaction with the resulting pain relief and the type of footwear worn thereafter. We had no complications in terms of infection or chronic pain. There were no early recurrences within our follow up period.

CONCLUSIONS

Overall we demonstrate good to excellent results with this surgical tactic allowing pain relief, early mobilisation and a low risk of infection.

Hammertoes and clawtoes: proximal interphalangeal joint correction

Hammertoe and clawtoe deformities are common forefoot problems. The deformity exists owing to the underlying pathoanatomy. Hallux valgus, longer metatarsals, and intrinsic imbalance are the most common etiologies. Understanding the cause of the deformity is important to be able to successfully treat the condition, whether nonoperative or with operative intervention. When nonoperative measures fail, PIP correction is best obtained through arthroplasty or arthrodesis. The key to successful PIP correction is obtaining a well-aligned toe and reducing pain as demonstrated by Coughlin and Mann.15 When choosing a technique, the author prefers PIP joint arthrodesis because it has several advantages, including a decreased risk of recurrence and a more predictable toe posture. The authors prefers an intramedullary device to avoid the well-known complications of K-wires. The best surgical correction and fixation techniques are still to be determined. Each patient much be evaluated thoroughly and treatment should be tailored to the patient’s deformity, comorbidities, expectations and surgeon’s experience.

Hammer toe correction using an absorbable pin

BACKGROUND

Fixed flexion deformity of the proximal interphalangeal joint with or without hyperextension of the metatarsaophalangeal joint, hammertoe, is one of the most common foot deformities. Many surgical options have been recommended including the use of a more flexible PDS Orthosorb absorbable pin for fixation. The authors, using the PDS pin technique, reported some coronal angulations with painful soft corns requiring surgical correction. A new proximal interphalangeal joint arthrodesis procedure for hammer toe deformities utilizing a stiffer poly L-lactate 2-mm absorbable pin for internal fixation is presented.

METHODS

Forty-seven toe procedures were done on 29 patients followed for an average of 18 (range, 10 to 36) months. Final evaluation included: physical exam, X-rays, MRI scan, AOFAS score, and a patient satisfaction survey.

RESULTS

Utilization of the stiffer poly-L-lactate absorbable pin resulted in minimal coronal angulations, no soft corns, high fusion rates and patient satisfaction.

CONCLUSION

The stiffer poly-L-lactate absorbable pin technique in this study was found to be superior to the published results using other methods of fixation including the more flexible PDS absorbable pin.

Digital arthrodesis: current fixation techniques

Several hammertoe implant devices have recently been introduced in an attempt to provide optimal fixation for proximal interphalangeal joint arthrodesis. This article reviews these implants individually, and discusses their advantages and disadvantages. There is a lack of research with long-term follow-up available for these devices. Percutaneous Kirschner-wire fixation persists as a time-honored and effective method of fixation. The buried Kirschner-wire technique is also an effective, cost-conscious option, with many of the same advantages as newer implantable devices.

Lesser toe deformities

Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various appliances. Surgical management is reserved for patients who fail nonsurgical treatment. Options include soft-tissue correction (eg, tendon transfer) as well as bony procedures (eg, joint resection, fusion, metatarsal shortening), or a combination of techniques.

Bone block lengthening of the proximal interphalangeal joint for managing the floppy toe deformity

The short floppy toe, an iatrogenic condition in which the digit lacks structural stability, results from excessive resection of the distal aspect of the proximal phalanx during correction of claw or hammer toe deformity. The involved toe is much shorter than the adjacent digit, which it will often overlap. Little attention has been given to the cause and treatment of the floppy toe deformity in the literature. As an iatrogenic condition, the best treatment is prevention. This article discusses the various procedures for the surgical correction of the floppy toe deformity.

Interphalangeal joint lengthening arthrodesis for the treatment of the flail toe

BACKGROUND

Flail toe is a bothersome complication following PIP resection arthroplasty, usually as a result of excessive bone resection. Patients complain of toe instability and catching on socks or shoes. We describe a PIP joint lengthening arthrodesis using structural bone graft for treatment of this condition.

MATERIALS AND METHODS

The results of 13 toe lengthening arthrodesis procedures in 13 patients were reviewed. Twelve patients were available for final followup, ranging from 6 to 70 (average, 31) months.

RESULTS

Relief of instability symptoms occurred in all of the patients. The union rate was 75% (9/12 toes). Infection occurred in four patients, all treated successfully with oral antibiotics and pin removal when necessary. Two patients presented with ischemic complications in the tip of the toe which resolved spontaneously with good final results. Eleven of 12 patients were satisfied with the procedure and stated that they would do the surgery again.

CONCLUSION

We believe toe lengthening arthrodesis is a good salvage operation for a flail toe following PIP resection arthroplasty.

Digital surgery: current trends and techniques

Digital deformities continue to be a common ailment among many patients who present to foot and ankle specialists. When conservative treatment fails to eliminate patient complaints, surgical correction remains a viable treatment option. Proximal interphalangeal joint arthrodesis remains the standard procedure among most foot and ankle surgeons. With continued advances in fixation technology and techniques, surgeons continue to have better options for the achievement of excellent digital surgery outcomes. This article reviews current trends in fixation of digital deformities while highlighting pertinent aspects of the physical examination, radiographic examination, and surgical technique.

Radiographic analysis of proximal interphalangeal joint arthrodesis with an intramedullary fusion device for lesser toe deformities

BACKGROUND

Lesser toe deformities are frequent and bothersome conditions. Many options exist for the treatment of hammertoes and clawtoes. The purpose of this study was to review our experience with the use of an intramedullary fusion device.

MATERIALS AND METHODS

An IRB approved retrospective review was performed to identify 38 toes in 27 patients treated with the StayFuse (Nexa Orthopaedics) device with a mean followup of 31 months. The indications for surgery were primary deformity in 12 toes and recurrent deformities in 26 toes.

RESULTS

Union occurred in 23 of 38 (60.5%). The union rate was nine of 12 for primary procedures and 53.8% (14/26) for revisions. Coronal PIP alignment demonstrated no change in 33 of 38 cases (86.8%) and changed in five of 38 (13.2%). Sagittal PIP alignment demonstrated no change in 36 of 38 cases (94.7%), and changed in 2/38 (5.3%). Including nonunion, the overall complication rate was 55.3% (21/38) (15 nonunions; three hardware failures (two (bent) not requiring intervention and one (broke) leading to a rotational deformity requiring revision), one intraoperative fracture (without sequelae), one requiring MP surgery, and one requiring a larger implant. The index surgery for all three of the patients that required a second surgery was for a recurrent deformity. All three patients requiring a second surgery occurred in the nonunion group.

CONCLUSION

The StayFuse intramedullary fusion device was efficacious in maintaining PIP alignment in the treatment of lesser toe deformities with a relatively low reoperation rate at mid-term followup.

Muscle imbalance and reduced ankle joint motion in people with hammer toe deformity

BACKGROUND

Multiple factors may contribute to hammer toe deformity at the metatarsophalangeal joint. The purposes of this study were to (1) compare the ratio of toe extensor/flexor muscle strength in toes 2-4 among groups with and without hammer toe deformity, (2) to determine correlations between the ratio of toe extensor/flexor muscle strength in toes 2-4, and metatarsophalangeal joint deformity (3) to determine if other clinical measures differ between groups and if these measures are correlated with metatarsophalangeal joint angle.

METHODS

Twenty-seven feet with visible hammer toe deformity and 31 age matched feet without hammer toe deformity were tested. Toe muscle strength was measured using a dynamometer and the ratio of toe extensor muscle strength to flexor muscle strength was calculated. Metatarsophalangeal joint angle was measured from a computerized tomography image. Ankle and subtalar joint range of motion, and tibial torsion were measured using goniometry.

FINDINGS

Extensor/flexor toe muscle strength ratio was 2.3-3.0 times higher in the hammer toe group compared to the non-hammer toe group, in toes 2-4. The ratios of extensor/flexor toe muscle strength for toes 2-4 and metatarsophalangeal joint angle were highly correlated (r=0.69-0.80). Ankle dorsiflexion and metatarsophalangeal joint angle were negatively correlated for toes 2-4 (r=-0.38 to -0.56) as were eversion and metatarsophalangeal joint angle.

INTERPRETATION

These results provide insight into potential risk factors for the development of hammer toe deformity. Additional research is needed to determine the causal relationship between hammer toe deformity and the ratio of toe extensor/flexor muscle strength in toes 2-4.

The laterality of the surgical correction of forefoot pathology

Lateral prevalence has not been traditionally attributed to the development and presentation of pathologic forefoot complaints. The objective of this study was to determine if a laterality prevalence exists for surgically corrected forefoot deformities. All cases performed at the Inova Fairfax Hospital Ambulatory Surgery Center over a 76-month period were reviewed and classified into the following categories: hallux abductovalgus deformity correction, hallux limitus deformity correction, specific digital deformity correction, neuroma surgery, and combinations of these categories (n = 1821). Our analyses indicated no laterality difference in the surgical correction of most common forefoot pathologies. A measure of all examined surgical corrections (hallux abductovalgus, hallux limitus, digital deformity, and/or neuroma) did not demonstrate a difference between the surgical correction of the right and left extremities (chi(2) = 0.003; P = .94). There was also no significant difference in the surgical correction of the right and left extremities when studying the individual categories of any hallux abductovalgus correction (chi(2) = 0.416; P = .52), any hallux limitus correction (chi(2) = 2.050; P = .15), any digital deformity correction (chi(2) = 1.251; P = .26), or any neuroma surgery (chi(2) = 0.784; P = .38). Only the surgical correction of hallux limitus deformity without surgical correction of digital deformity or neuroma demonstrated a significant laterality with surgical correction of the right lower extremity being more common (chi(2) = 4.600; P = .03).

LEVEL OF EVIDENCE

2.

Epidemiological aspects of the surgical correction of structural forefoot pathology

The aim of this study was to associate structural forefoot surgical correction with theories related to the etiology of structural forefoot pathology. All forefoot surgical cases performed at the Inova Fairfax Hospital Ambulatory Surgery Center over a 76-month period (January 2001 through April 2007) were reviewed and classified according to the following surgical categories: hallux abductovalgus, hallux limitus, lesser digital deformity, and combinations of these categories (N = 1684 procedures in 1592 patients). The results suggested that the etiology of lesser digital deformity was associated with the etiology of hallux abductovalgus more so than it was with hallux limitus. In fact, a patient undergoing surgical correction of a hallux abductovalgus deformity displayed 4.63 times greater odds of undergoing surgical correction of a digital deformity, or deformities, compared to a patient undergoing surgical correction of hallux limitus (OR = 4.63, 95% CI 2.81-7.71, P < .0001). Furthermore, medial (second or second and third) toe deformity correction was statistically significantly associated with hallux abductovalgus surgery (OR = 3.34, 95% CI 2.52-4.44, P < .0001), whereas lateral (fifth or fourth and fifth) toe deformity correction was statistically significantly associated with cases that did not involve hallux abductovalgus surgery (OR = 0.27, 95% CI 0.20-0.37, P < .0001). The concept of flexor hallucis longus stabilization is introduced as a possible mechanical explanation for these results.

LEVEL OF EVIDENCE

2.

Hammer toe correction using an absorbable intramedullary pin

BACKGROUND

Fixed flexion deformity of the proximal interphalangeal joint with or without hyperextension of the metatarsophalangeal joint is one of the most common foot deformities. Many operative options have been recommended. Complaints after operative procedures include a too straight toe, floating toe, painful toe recurvatum, mallet toe, pin track infection, broken hardware, and the necessity of removing hardware. A proximal interphalangeal joint arthrodesis for hammertoe deformity using a 2-mm absorbable pin for internal fixation is described.

METHODS

The results of 48 toe arthrodeses in 35 patients were reviewed. Followup ranged from 16 to 58 (average 38.5) months.

RESULTS

The procedure is simple and safe for the correction of painful rigid hammertoe deformities. Patient satisfaction was high, complications were minimal, and followup required no pin management or removal.

CONCLUSIONS

This procedure can be used for hammer toe deformities requiring surgery when the metatarsophalangeal joint is stable, the skin is not compromised, and the intramedullary canal of the proximal phalanx is 2.0 mm or less. It also has been useful in stabilizing hammertoe correction when there are severe pre-existing metal allergies.

Transfer of the flexor digitorum longus for the correction of lesser-toe deformities

BACKGROUND

This study reviewed the results, complications, and patient satisfaction rates of a modified technique of flexor-to-extensor tendon transfer for correction of lesser-toe deformities.

METHODS

Records of 38 patients (79 toes; 46 feet) were identified and reviewed retrospectively. The mean duration of clinical followup was 33 (range 6 to 121) months. The average age of patients was 65 (range 27 to 82) years; 32 were women (84%) and six were men.

RESULTS

In 89% of the toes (70 toes; 34 patients; 42 feet) patients were satisfied with the procedure and would have it again.

CONCLUSIONS

The technique described for flexor-to-extensor transfer for correction of lesser-toe deformities resulted in few complications, no "floating" toes and high patient satisfaction.

Joint and skeletal deformities in Parkinson's disease, multiple system atrophy, and progressive supranuclear palsy

The objective of this study is to characterize clinical features of joint and skeletal deformities in Parkinson's disease (PD), multiple system atrophy (MSA), and progressive supranuclear palsy (PSP). Clinical information including age, gender, presence of deformity, initial symptom side, neuropsychological and motor features, family history, and treatment with levodopa/dopamine agonists was collected on consecutive patients with PD, MSA, and PSP evaluated at the Movement Disorders Clinic at Baylor College of Medicine. In this series of 202 patients, 36.1% had deformities of the limbs, neck, or trunk, including 33.5% of PD, 68.4% of MSA, and 26.3% of PSP patients. "Striatal" hand and foot deformities were present in 13.4%, involuntary trunk flexion in 12.9%, anterocollis in 9.4%, and scoliosis in 8.4% of all patients. Patients with these joint and skeletal deformities had higher mean Unified Parkinson's Disease Rating Scale scores (57.4 vs. 46.6; P < 0.01) and were more often treated with levodopa (69.9% vs. 50.4%; P < 0.01) than patients without deformity, independent of disease duration. Patients with striatal deformity were younger than patients without deformity (mean 60.4 vs. 68.6 years; P < 0.01), and they tended to have an earlier age of onset of initial parkinsonian symptoms (mean 54.7 vs. 62.5 years; P < 0.01). Furthermore, the side of striatal deformity correlated with the side of initial parkinsonian symptoms in all patients (100%) with striatal hand and in 83.3% of patients with striatal foot. Joint and skeletal deformities are common and frequently under-recognized features of PD, MSA, and PSP that often cause marked functional disability independent of other motor symptoms.

A bioabsorbable fixation implant for use in proximal interphalangeal joint (hammer toe) arthrodesis: Biomechanical testing in a synthetic bone substrate

The surgical correction of hammer toe deformity of the lesser toes is one of the most commonly performed forefoot procedures. In general, percutaneous Kirschner wires are used to provide fixation to the resected proximal interphalangeal joint. Although these wires are effective, issues such as pin tract infections as well as difficult postoperative management by patients make alternative fixation methods desirable. This study biomechanically compared a threaded/barbed bioabsorbable fixation implant made of a copolymer of 82% poly-L-lactic acid and 18% polyglycolic acid with a 1.57-mm Kirschner wire using the devices to fix 2 synthetic bone blocks together. Constructs were evaluated by applying a cantilever load, which simulated a plantar force on the middle phalanx. In all cases, the failure mode was bending of the implant, with no devices fracturing. The stiffness (approximately 6-9 N/mm) and peak load (approximately 8-9 N) of the constructs using the 2 systems were equivalent. Accelerated aging at elevated temperature (47 degrees C) in a buffer solution showed that there was no reduction in mechanical properties of the bioabsorbable system after the equivalent of nearly 6 weeks in a simulated in vivo (37 degrees C) environment. These results suggest that the bioabsorbable implant would be a suitable fixation device for the hammer toe procedure.

Removal of the second toe for severe hammertoe deformity in elderly patients

BACKGROUND

Our hypothesis was that amputation of an isolated, painful second hammertoe is beneficial and has less morbidity than forefoot reconstruction when other associated deformities are not clinically painful. The objective was to evaluate the clinical outcomes of elderly patients undergoing amputation of painful second hammertoes instead of advanced reconstructive procedures.

METHODS

We retrospectively reviewed all cases of removal of the second toe through the MTP joint for painful hammertoe deformities from May, 1998 to May 2004. Amputation for ischemic disease was excluded from the study. No patient had a concurrent hallux valgus reconstruction. The study group included 12 patients (17 amputations). A clinical questionnaire was used to determine patient satisfaction and postoperative changes in forefoot alignment.

RESULTS

Ten patients were satisfied with the results, and the other two were satisfied with reservations. The activity level improved for nine patients. Eight patients noted continued valgus drift of the great toe. Nine patients would have the procedure again, and 11 thought that it met their expectations and would recommend it. No important complications were noted.

CONCLUSIONS

Amputation of the second toe in elderly patients is acceptable for complaints of pain related solely to the hammertoe. The morbidity associated with more advanced reconstruction is avoided, while eliminating pain and improving shoe-wear and function. Patient satisfaction was high, and complications were minimal. Drift of the great toe into valgus did not appear to be a clinical problem.

Review of proximal interphalangeal joint excisional arthroplasty for the correction of second hammer toe deformity in 100 cases

BACKGROUND

The main bony procedures used in the treatment of second hammertoe are excisional arthroplasty and arthrodesis of the proximal interphalangeal (PIP) joint. While a number of studies have reported the outcomes after PIP joint arthrodesis, there are few reports of the outcome of excisional arthroplasty of the PIP joint for the correction of second hammertoes. The purpose of this study was to evaluate the long-term outcome of PIP joint excisional arthroplasty.

METHODS

Seventy-five patients (100 toes) who had excisional arthroplasty of the PIP joint for the correction of second hammertoe were reviewed at an average followup of 44 months. All patients were seen in clinic and were physically examined to assess the alignment and function of each digit. The radiographs were evaluated preoperatively. The AOFAS clinical rating scale was used preoperatively and at final followup. Patients were asked to rate their satisfaction on a scale of 0 to 10 and were asked if they would be happy to have the surgery under similar circumstances again.

RESULTS

The mean preoperative AOFAS clinical rating scale was 46. At final followup this increased to 94, showing an average improvement of 48 points (p < 0.0001). The mean satisfaction on a scale of 0 to 10 (with 0 equaling complete dissatisfaction and 10 complete satisfaction) was 9.3 (SD 1.3). One patient would not have been happy to undergo outpatient surgery again, because of a change in her social circumstances.

CONCLUSION

In a group of 75 patients who had PIP joint arthroplasty for the correction of second hammertoe, high levels of satisfaction were achieved. No serious complications were encountered, and revision surgery was required in just two cases. Floating toe was the most common complication encountered, and although this did decrease the level of patient satisfaction in seven patients it was not a cause of footwear irritation or pain in any patient.

Arthrodesis of the toe joints with an intramedullary cannulated screw for correction of hammertoe deformity

Twenty-four patients (37 feet, 51 toes) affected by hammertoe deformity of the lesser toes and treated surgically by arthrodesis of the proximal interphalangeal joint, stabilized with an intramedullary titanium cannulated screw, were reviewed 1-4 years after the operation. At follow-up, the arthrodesis was fused in 48 toes; three toes showed an asymptomatic radiographic nonunion, and in one of them the screw was broken. In seven toes, the cannulated screw was removed because of persistent pain at the tip of the toe where the head of the screw was located. In one case only, there was a late infection, with toe malalignment. All the patients were able to use street shoes 2 weeks after surgery. The average AOFAS score at follow-up was 86.54 points. Compared to the conventional temporary stabilization with an intramedullary Kirschner wire, the stabilization with a cannulated screw decreases the risk of infection, of radiographic nonunion, and of mallet toe deformity.