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

Developing and analyzing a Nanocomposites coated material for hammertoe implants

Hammertoe implants, frequently used for arthroplasty or proximal interphalangeal joint arthrodesis, have serious drawbacks because of bacterial colonization and material corrosion, which can result in infections and other problems. This study creates a new nanocomposite covering to improve the corrosion resistance, antibacterial qualities, and biocompatibility of 316L stainless steel (SS). 316L SS was treated with a nanocomposite made of graphene oxide (GO), zirconia (ZrO₂), and hydroxyapatite (HAp). The coating's structural and functional characteristics were examined using Fourier-transform infrared spectroscopy (FTIR), scanning electron microscopy (SEM), and energy-dispersive X-ray spectroscopy (EDX). Standard assays were used to evaluate the coated material's antibacterial activity, and simulated bodily fluid (SBF) was used to assess corrosion resistance in vitro. Biocompatibility was verified using assays for cell survival. Apatite layer formation during SBF immersion indicated increased bioactivity and the results showed that the HAp-ZrO₂-GO nanocomposite coating greatly increased the corrosion resistance of 316L SS. The coating showed anti-inflammatory and potent antibacterial qualities, successfully preventing bacterial colonization. Additionally, cell survival tests verified the coated material's biocompatibility, indicating that it would be safe for use in biomedical applications. This work presents a scalable and reasonably priced process for creating bioactive nanocomposite coatings for medical implants. The HAp-ZrO₂-GO coating addresses important drawbacks of conventional implant materials by improving physico-chemical interactions and providing better performance. With significant ramifications for developing biomedical engineering and enhancing patient outcomes, these results demonstrate the potential of the HAp-ZrO₂-GO nanocomposite as a workable option for long-lasting, antimicrobial, and biocompatible bioimplant coatings.

Implants for proximal interphalangeal joint arthrodesis of the lesser toes: Where are we? A systematic review

INTRODUCTION

Proximal interphalangeal joint (PIPJ) arthrodesis is indicated for the treatment of lesser toe deformities. K-wires have traditionally been the standard of care for PIPJ arthrodesis, however intramedullary implants may be superior. This systematic review evaluates the union rate and outcomes of implants for PIPJ arthrodesis.

METHODS

MEDLINE, CENTRAL, EMBASE and Google Scholar databases were reviewed for studies reporting on outcomes of intramedullary implants for PIPJ arthrodesis in hammer or claw toe. The primary outcome measure was union rate. Secondary outcome measures included pain scores, functional improvement, patient satisfaction, quality of life and complications.

RESULTS

12 studies comparing 12 different implants in 797 patients with 1118 treated toes were reviewed. Fusion rates ranged from 22.2 % to 96 % with the highest fusion rates demonstrated with Ossiofiber (96 %, n = 24), Smart toe (43.6-93.8 %, n = 217) and Nextra (84.44 %, n = 47) respectively. 4 studies compared 3 implants to K-wire (Smart toe, Tenfuse and Nextra) with improved union rates demonstrated compared to K-wire (p < 0.05). Function, pain relief, patient satisfaction and quality of life all improved following PIPJ arthrodesis with implants, however these outcomes were equivocal to K-wire. All studies were rated as high or critical risk of bias.

CONCLUSION

A definitive judgement on the best implant for PIPJ arthrodesis is currently unobtainable due to the high risk of bias in the reviewed studies. Given the high cost of intramedullary implants and equivocal functional outcomes to K-wire, further comparative study with randomised control trials is advised to establish the standard of care for PIPJ arthrodesis.

The effect of absorbable collagen suture for oral implant repair on wound healing and inflammation factors of gingival crevicular fluid

Background

To investigate the clinical value of absorbable collagen suture in the treatment of oral implant restoration.

Methods

A prospective, randomized, single-blind trial was conducted in patients undergoing dental implant restoration in our hospital. The patients were divided into an absorbable group (incision closure with absorbable collagen suture) and a conventional group (incision closure with conventional suture). The incision healing time, postoperative pain degree, incision healing grade, patient satisfaction, and the levels of tumor necrosis factor-a (TNF-a), interleukin-8 (IL-8) and interleukin-6 (IL-6) in gingival crevicular fluid were compared between the two groups.

Results

The absorbable group had faster incision healing times and lower postoperative pain scores on days 1 and 2, all with significant differences (P<0.05). Wound healing in the absorbable group was notably better, with a Grade A healing rate of 96.88% and a Grade B healing rate of 3.13%. In contrast, the conventional group had a Grade A healing rate of 81.25%, a Grade B healing rate of 17.19%, and a Grade C healing rate of 1.56%. These differences favored the absorbable group significantly (P<0.05). Before surgery, there were no statistically significant differences in the levels of TNF-a, IL-6, and IL-8 in gingival crevicular fluid between the absorbable and conventional groups (P>0.05). However, 3 days after surgery, the absorbable group showed significantly lower levels of TNFa, IL-6, and IL-8 compared to the conventional group (P<0.05). Patient satisfaction rates for stability, aesthetics, chewing function, and pronunciation were similar between the two groups (P>0.05). However, patients in the absorbable group reported significantly higher comfort levels compared to those in the conventional group (P<0.05). Moreover, the complication rate in the absorbable group was significantly lower at 6.25% compared to 18.75% in the conventional group (P<0.05).

Conclusions

Absorbable collagen suture for oral implant prosthesis after suture, beneficial to wound healing and reduce postoperative pain and inflammation.

Classical Surgical Alternatives for the Treatment of Lesser Toe Deformities

Lesser toe deformities are the second most common deformities around the foot and ankle. Early reports of procedures for lesser toe correction date back to the 1880s. Lesser toe deformities have a high variability of appearance. Thorough assessment of the joints involved in the deformity is necessary. Numerous techniques of soft tissue and osseous interventions are available and need to be included for individual correction. Osseous corrections are usually accompanied by soft tissue procedures. Kirschner-wire fixation is still an effective method of fixation, but internal fixation is probably the way to go for the future if cost-effectiveness can be improved.

A Primer on Cost-Effectiveness Analysis

A cost-effectiveness analysis (CEA) is a type of health economics model that uses a systematic approach to simplify the complexities that exist in health-care decision-making. A CEA aids in medical decision-making by considering both the costs of a treatment and how effective that treatment is for at least 2 competing strategies. This article reviews major concepts of CEA including results interpretation, key attributes of CEA that make it differ from cost analysis, uncertainty surrounding analysis, and how/why CEA is an important contributor to the medical literature.

Arthrodesis of the interphalangeal joints of the hand by two-dimensional intraosseous wiring

BACKGROUND

Numerous techniques for arthrodesis have been described to fix interphalangeal (IP) joints, and the fixation method should be considered on a case-by-case basis. This study aimed to investigate the availability of IP joint arthrodesis of the hand, using a two-dimensional intraosseous wiring (two-DIOW) method.

METHODS

A total of 43 joints (19 thumb IP joints, 9 proximal finger interphalangeal (PIP) joints and 15 distal interphalangeal (DIP) joints in 29 patients with a mean age of 66 years (range, 24-85 y) were retrospectively analyzed. All operations were performed with two-DIOW method. We evaluated the bone union rate, correction loss, presence of any surgical complications, and oral steroid use in cases of joint fixation using the two-DIOW method.

RESULTS

Of these 43 digits, 42 achieved bone union (97.7%). Non-union was seen in a thumb IP joint of mutilans rheumatoid arthritis. Mean correction loss of deviation was 1.0°, and flexion or extension angulation was 1.6° in the direction of extension. Surgical complications included mild nail deformity in 2 digits and wire irritation necessitating wire removal in 2 digits. Oral steroids were used for 18 of the 43 digits, including 2 digits complicated by nail deformities. There was no infection and skin necrosis in all digits with or without steroid use.

CONCLUSIONS

The two-DIOW method appears to offer an effective method of IP joint fixation, but caution should be exercised in digits of severe joint destruction and in the treatment of wire knot.

Double Row Fixation is More Costly and Does Not Have Clinical Benefit Over Single Anchor for Insertional Achilles Tendon Surgery

Surgical repair of insertional Achilles tendinosis is indicated in the face of failed conservative measures. Several methods for this repair have been described, and the optimal method is not universally agreed upon. In addition, the cost of medical care is important, and should be considered when determining the surgical repair for each patient. The purpose of this study is to compare implant costs between a single anchor or 4 anchor, double row repair, and evaluate associated outcomes. A retrospective comparative trial was performed for this purpose. The entire study encompassed 110 patients, 78 with a single anchor repair, and 32 with a double row repair. The average implant cost of the single anchor repair was $391.18 ± $272.10 and the double row repair was $1811.2 9 ± $169.47, p < .001. The groups did not have a statistically significant difference in complications (9% with single anchor vs 6.3% with double row, p = 1.0) or revisions 6.4% with single anchor vs 3.1% with double row, p = .67). The only difference in demographics between the groups was that the single anchor group had a higher percentage of female patients (p = .04). While the double row repair has been shown to have favorable biomechanical results, the present study did not show a benefit in complications or revisions and was a more costly repair technique. Surgeons should take these findings in consideration when choosing the repair technique when surgery is indicated.

Symptomatic Hammertoes Treatment Comparison: Peg-in-Hole Arthrodesis Versus End-to-End Screw Fixation

Proximal interphalangeal (PIP) arthrodesis technique utilizing the peg-in-hole arthrodesis was founded to avoid the use of retained internal fixation implants and thereby potentially decrease the concern of hardware complication. The specific aim of this study was to report the complication rates of the modified peg-in-hole arthrodesis technique and the end-to-end arthrodesis with single screw fixation technique for correcting symptomatic hammertoe deformities in lesser digits. This retrospective chart review included patients who underwent surgical hammertoe correction of lesser digits between the dates of January 2012 and December 2019. Patient demographic data and charts were reviewed to evaluate need for revision including screw/pin removal and complications related to corrective surgery. Five hundred ninety-three symptomatic hammertoe deformity cases (443 female, 150 male) were identified, with 113 cases (88 female, 25 male) treated with peg-in-hole arthrodesis technique and 480 cases (355 female, 125 male) treated with end-to-end arthrodesis with a single screw technique. The deformity recurrence rate was not significantly different between the two techniques (peg-in-hole: 10%, end-to-end: 13%, p = .428). There were 97 cases with postoperative complications that required re-operation (peg-in-hole: 7 cases, end-to-end: 90 cases) with the majority detected at <6 months. There was no statistically significant difference in reoperation rate between the peg-in-hole technique and the end-to-end arthrodesis technique reoperated with reasons excluding simple screw removal (p = .068). This study tended to show these two arthrodesis techniques have equivalent risks and similar success in bone healing; however, the peg-in-hole arthrodesis technique offers an advantage that does not result in retained hardware.

Relative Strengths of Intramedullary K-Wire Techniques for Digital Deformities

Hammertoe deformity correction surgery is one of the most common procedures performed by foot and ankle surgeons. Recent foot and ankle medical literature presents conflicting opinions regarding the optimal intramedullary fixation device and techniques for use in digital deformity correction. There are a number of varying fixation constructs of intramedullary Kirschner wire fixation reported for proximal interphalangeal joint arthrodesis; however, there are no reports of relative loading strength of the fixations. In this study, 90 sawbone models were divided equally into 3 groups of different intramedullary Kirschner wire fixation techniques: Group A- single straight, Group B- single bent, Group C- double bent. Each fixation construct underwent controlled axial loading and failure points were observed. Results showed no significant difference in load failure from all 3 groups with mean maximum force of Group A = 20N, Group B = 19.1N, and Group C =17.5N. We conclude that all Kirschner wire fixation options for digital deformity correction, will provide similar resistance to sagittal plane axial loads.

Matched retrospective analysis of three different fixation devices for chevron osteotomy

Chevron osteotomy with consecutive fixation is a commonly performed operative treatment option for hallux valgus deformities. The present retrospective study aims to compare the clinical and radiological outcome of novel bioabsorbable magnesium screw fixation with metal screw and Kirschner wire fixation. Eighteen matched triplets were assembled according to the following criteria: female gender, age difference less than 5 years, date of operation within 4 months, difference in preoperative intermetatarsal angle less than 5°, and equal experience of the first and second surgeon. These patients, between 18 and 85 years of age and with a minimum follow-up period of 12 months, were invited to a follow-up examination, of which only 16 matched triplets of patients entirely kept the appointment. Thus, 48 feet of 44 patients were clinically evaluated using the American Orthopaedic Foot & Ankle Society scale, Foot Function Index, University of California and Los Angeles Activity Score, as well as a visual analogue scale for pain, satisfaction, cosmetic results, and functional impairment. Radiographical assessment included measuring intermetatarsal angle and first metatarsophalangeal angles. All occurring complications and revision surgeries were noted. Significant differences were observed for postoperative intermetatarsal angle between magnesium screw and pin fixation (p = 0.009). Moreover, patients receiving magnesium screw were significantly more prone to undergo the same procedure again (p = 0.03). In conclusion, if the advantages of bioabsorbable magnesium screws outweigh the drawbacks of increased costs and a higher surgical demand, this implant might serve as possible chevron osteotomy fixation method. Compression screws and Kirschner wires also show comparable satisfactory outcomes. LEVEL OF EVIDENCE: III retrospective comparative study.

Ideal implant choice for proximal interphalangeal joint arthrodesis in hammer toe/claw toe deformity correction: A systematic review

Intramedullary devices have been developed to reduce the problems associated with Kirschner (K)-wire fixation in proximal interphalangeal joint (PIPJ) arthrodesis. The purpose of this systematic review is to compare the surgical outcomes of K-wires versus novel internal fixation devices in PIPJ arthrodesis in claw/hammer toe surgery. The databases searched were PubMed, Scopus, Cochrane, and Embase with keywords "claw toe OR hammer toe" AND "proximal interphalangeal OR PIP" AND "fusion OR arthrodesis." Clinical trials published in English with evidence levels I, II, and III were included. Five studies, including one randomized controlled trial and four case-controlled studies, were identified to meet the inclusion criteria. Overall, the studies showed promising results in union rates using the novel internal devices compared to K-wires. However, the novel internal devices seem not to present advantages in clinical parameters such as pain levels, patient satisfaction, foot-related function, or surgical complication rates.

Cost-effectiveness of interventions for musculoskeletal foot and ankle conditions: a systematic review

OBJECTIVE

Musculoskeletal conditions of the foot and ankle are common, yet the cost-effectiveness of the variety of treatments available is not well defined. The aim of this systematic review was therefore to identify, appraise and synthesise the literature pertaining to the cost-effectiveness of interventions for musculoskeletal foot and ankle conditions.

METHODS

Electronic databases were searched for studies presenting economic evaluations of non-surgical and surgical treatments for acute or chronic musculoskeletal conditions of the foot and ankle. Data on cost, incremental cost-effectiveness and quality-adjusted life years for each intervention and comparison were extracted. Risk of bias was assessed using the Drummond checklist for economic studies (range 0-35).

RESULTS

Thirty-six studies were identified reporting non-surgical interventions (n=10), non-surgical versus surgical interventions (n=14) and surgical interventions (n=12). The most common conditions were osteoarthritis, ankle fracture and Achilles tendon rupture. The strongest economic evaluations were for interventions managing end-stage ankle osteoarthritis, ankle sprain, ankle fracture, calcaneal fracture, and Achilles tendon rupture. Total ankle replacement and ankle arthrodesis for end-stage ankle osteoarthritis, in particular, have been demonstrated through high-quality studies to be cost-effective compared to the non-surgical alternative.

CONCLUSION

Selected interventions for musculoskeletal foot and ankle conditions dominate comparators, whereas others require thoughtful consideration as they provide better clinical improvements, but at an increased cost. Researchers should consider measuring and reporting costs alongside clinical outcome to provide context when determining the appropriateness of interventions for other foot and ankle complaints to best inform future clinical practice guidelines.

The Two-Component Implant for Interphalangeal Fusion in Toe Deformities

BACKGROUND

Although Kirschner wire implantation is popular for treating toe deformities, complications frequently occur. To prevent pin-tract infection and difficult Kirschner wire extraction, several implants have been developed to improve treatment outcomes.

METHODS

Patients who had undergone an interphalangeal fusion by two-component implant for the treatment of toe deformities were included. Thirty-one toes of 21 patients were evaluated retrospectively. American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores were used in clinical evaluation.

RESULTS

The mean operation duration per toe was 16.4 min (range, 13-26 min). The average AOFAS forefoot score was 42.76 (range, 23-57) preoperatively and 88.76 (range, 70-95) at 34.4 months (range, 26-46 months) after surgery. Mean follow-up was 14.8 months (range, 12-19 months). Compared with before surgery, the AOFAS score was increased significantly after surgery (P = .03 by t test). Three minor complications were encountered. In one patient an infection was observed. After the implants were removed (first month) she was treated successfully by debridement and antibiotic agents and, finally, Kirschner wire placement. The second patient had a fissure fracture at the proximal phalanx, but routine follow-up did not change. In the third patient, the locking mechanism had become loose (detected on day 1 radiography); it was remounted under fluoroscopy without opening the wound. No patients had a cutout, loss of alignment, recurrence, or persistent swelling.

CONCLUSIONS

Outcomes of arthrodesis using the two-component implant were found to be safe and reliable, especially for hammer toe and fifth toe deformities.

Managing Severe Foot and Ankle Deformities in Global Humanitarian Programs

The severe foot and ankle deformities the authors' organization has encountered in humanitarian programs worldwide are more complicated than those surgeons treat in daily practice in developed countries. Severity of deformity, patients' economic limitations, patients' expectations and realistic needs in life, availability of surgical instrumentation, the local team's understanding of foot and ankle surgery and their ability to do consultation for patients postoperatively, and compliance of patients all account for success of the surgery. Regardless of the effort surgeons make, complications and recurrence occur. Educating and training local surgeons to take over medical care are the most important goals of the programs.

Mallet Toes, Hammertoes, Neuromas, and Metatarsophalangeal Joint Instability: 40 Years of Development in Forefoot Surgery

BACKGROUND

Today's foot and ankle surgeon has an enhanced understanding of forefoot pathology and treatment options compared to surgeons who practiced in previous decades. This paper summarizes developments in forefoot surgery in the past 40 years, specifically in treatments for mallet toe, hammertoe, neuroma, and metatarsophalangeal joint instability.

MATERIALS AND METHODS

A review of the literature was conducted using the PubMed search engine, with key terms including, "mallet toe," "hammertoe," "neuroma," "metatarsophalangeal joint instability," "plantar plate," and "forefoot surgery." Chapters in major orthopaedic textbooks covering these topics were also reviewed. We then chronicled the history of the diagnosis and treatment of these pathologies, with a focus on the past 40 years.

CONCLUSIONS

There have been major advances in understanding and treating forefoot pathologies in the past four decades; however, there remain areas for improvement both in the diagnosis and treatment of these problems.

LEVEL OF EVIDENCE

Level V, meta-synthesis.

Radiographic and Clinical Comparison of Proximal Interphalangeal Joint Arthrodesis Between a Static and Dynamic Implant

Hammertoe deformation is a frequent motive for consultation in forefoot surgery, and proximal interphalangeal joint arthrodesis is a classic treatment for fixed deformation, which tends to be achieved more and more thanks to specific implants. This work evaluated and compared clinical improvement, radiologic fusion, and complication rates between dynamic (Difuse®) and static (TinyFix®) implants from Biotech Ortho. A total of 95 patients (110 feet and 166 toes; 97 static and 69 dynamic implants) were included. Mean age was 63.6 (±12.6) years in the dynamic group and 62.3 (±14.01) years in the static group. Epidemiologic and intraoperative radiologic data were collected. Pain, toes deformity, complications, and radiologic findings (bone fusion and osteolysis) were recorded at 4 months postoperatively and at the last follow-up. Mean follow-up was 11.5 (range 4 to 28) months, and the position of the implants was more often satisfying in the dynamic group (p = .01). Fusion rates at 4 months were 67% and 80% in the dynamic and static groups, respectively (p = .05). Radiologic osteolysis occurred more frequently in the dynamic group (p = .05 at 4 months), and pain was still present in 3% in the dynamic group at the last follow-up compared with 7% in the static group. Complication rate was 7% in the dynamic group (implant fractures) and 4% in the static group. Revision was considered more often in the dynamic group (p = .01). The static titanium implant seems superior to the dynamic memory shape implant in Nitinol alloy with regard to fusion (p = .04), complications (p = .03), and revision rates (p = .01). The literature review seems to support the good results of static implants compared with the rest of the available arthrodesis implant solutions.

Proximal Interphalangeal Arthrodesis of Lesser Toes Utilizing K-Wires Versus Expanding Implants: Comparative Biomechanical Cadaveric Study

BACKGROUND:

Lesser toe proximal interphalangeal (PIP) joint arthrodesis is one of the most common foot and ankle elective procedures often using K-wires for fixation. K-wire associated complications led to development of intramedullary fixation devices. We hypothesized that X Fuse (Stryker) and Smart Toe (Stryker) would provide stronger and stiffer fixation than K-wire fixation.

METHODS:

12 cadaveric second toe pairs were used. In one group, K-wires stabilized 6 PIP joints, and 6 contralateral PIP joints were fixed with X Fuse. A second group used K-wires to stabilize 6 PIP joints, and 6 contralateral PIP joints were fixed with Smart Toe. Specimens were loaded cyclically with extension bending using 2-N step increases (10 cycles per step). Load to failure and initial stiffness were assessed. Statistical analysis used paired t tests.

RESULTS:

K-wire average failure force, 91.0 N (SD 28.3), was significantly greater than X Fuse, 63.3 N (SD 12.9) ( P < .01). K-wire average failure force, 102.3 N (SD 17.7), was also significantly greater than Smart Toe, 53.3 N (SD 18.7) ( P < .01). K-wire initial stiffness 21.3 N/mm (SD 5.7) was greater than Smart Toe 14.4 N/mm (SD 9.3) ( P = .02). K-wire failure resulted from bending of K-wire or breaching cortical bone. X Fuse typically failed by implant pullout. Smart Toe failure resulted from breaching cortical bone.

CONCLUSION:

K-wires may provide stiffer and stronger constructs in extension bending than the X Fuse or Smart Toe system. This cadaver study assessed stability of the fusion site at time zero after surgery.

CLINICAL RELEVANCE:

Our findings provide new data supporting biomechanical stability of K-wires for lesser toe PIP arthrodesis, at least in this clinically relevant mode of cyclic loading.