A long-term follow-up on proximal phalangectomy for hammer toes

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.

Meta-analysis of flexor tendon transfer for the correction of lesser toe deformities

BACKGROUND

Transfer of the flexor digitorum longus tendon is one of the surgical techniques described to treat lesser toe deformities. A global analysis of the benefits of this procedure has not been presented in the literature to date. The aim of this meta-analysis was to evaluate the clinical benefit of transfer of the flexor digitorum longus tendon regarding patient satisfaction.

METHODS

A reviewer formally trained in meta-analysis abstraction techniques searched several databases to identify relevant published studies. Initially, 203 citations were identified and evaluated for relevance. Abstract screening produced 112 articles to be read in their entirety, of which 17 articles studying 515 procedures with a mean ± SD follow-up of 54.21 ± 20.64 months met all of the inclusion criteria necessary for analysis.

RESULTS

Overall crude patient satisfaction after flexor digitorum longus tendon transfer was 86.7% (95% confidence interval, 81.7%-90.5%). A low grade of heterogeneity across studies (Q = 24.458, I(2) =34.583, P = .080) and no influence of the individual studies on overall estimation were found. When adjusting for higher-quality prospective studies, overall patient satisfaction increased to 91.8%, although it did not reach statistical significance. Additional a priori sources of heterogeneity (age, sex, studies with <3 years of follow-up, percentage of patients lost to follow-up, and year of publication) were evaluated by subgroup analysis and meta-regression, but no statistical significance was found. This adjustment also significantly decreased heterogeneity across studies (crude Q = 24.458, high-quality studies Q = 1.504).

CONCLUSIONS

Regarding patient satisfaction, this comprehensive analysis provides supportive evidence of the clinical benefit of flexor digitorum longus tendon transfer.

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 crossover toe and valgus toe deformity

Second toe problems are among the most common of all forefoot complaints. Its proximity to the hallux combined with limited motion at the second tarsometatarsal joint likely contributes to the second MTP joint being the most common to experience both pain and deformity. Many causes have been linked to this problem, which has lead to many surgical techniques to correct this deformity. Although many techniques have been described, a systematic approach relying first on soft tissue releases and plication followed by osteotomies as necessary has lead to satisfactory outcomes in the treatment of this difficult problem.

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.

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.

Outcomes after the Stainsby procedure in the lesser toes: an alternative procedure for the correction of rigid claw toe deformity

Clawing of the digits is a deformity seen both in patients with and without rheumatoid arthritis, resulting in pain and deformity in the forefoot. After failure of conservative treatment, the Stainsby procedure is one surgical option for severe clawing and metatarsalgia in both rheumatoid and nonrheumatoid feet. Results from the originating authors (G.D. Stainsby and P.J. Briggs) are consistent and reliable; however, there is little material outside of the originating center. This article reviews our experience in the Western Sussex Hospitals NHS Trust. Sixteen consecutive patients who underwent Stainsby procedure between 2006 and 2009 were reviewed. All operations were performed by a single consultant surgeon, the senior author (S.P.). All patients were scored using the Manchester Oxford Foot and Ankle score preoperatively and postoperatively. Minimum follow-up was 6 months, with a mean follow-up of 14 months. Significant improvements in all scores were seen postoperatively. Walking scores dropped from a mean of 22 preoperatively to 12.7 postoperatively (p = 0.007). Pain scores dropped from a mean of 13.3 to 7.1 (p = 0.001). Social scores dropped from a mean 11 to 6 (p = 0.001). Overall patient satisfaction was high. The Stainsby procedure has been shown to improve function and reduce pain in patients from its originating center in both rheumatoid and nonrheumatoid feet. This study demonstrates this simple technique is reproducible and effective in reducing morbidity.

Opinions on lesser toe deformities among Dutch orthopaedic departments

BACKGROUND

Wide variations in definitions of lesser toe deformities exist. In addition, a general consensus regarding treatment of lesser toe deformities is lacking. The objective of this study was to evaluate of the definitions, current concepts, and treatment protocols for lesser toe deformities among orthopaedic departments in The Netherlands.

METHODS

A questionnaire with statements regarding lesser toe deformities was sent to all 101 Dutch departments of orthopaedic surgery.

RESULTS

In total 76 (75%) completed forms were analyzed. A wide variation regarding definitions, concepts, and treatment strategies of lesser toe deformities was reported among the Dutch orthopaedic departments. Only half of all responding departments had a protocol or consensus in the treatment.

CONCLUSIONS

The definitions of lesser toe deformities used in Dutch orthopaedic departments do not coincide. This might explain the variations in indications and the various performed interventions for different deformities. The differences of opinion among the Dutch orthopaedic departments may have important clinical consequences because an indication for surgery depends on the correct diagnosis. To correctly interpret and improve treatment results, a consensus on this topic should be introduced.

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.

Hemiphalangectomy and syndactylization for treatment of osteoarthritis and dislocation of the second metatarsal phalangeal joint: an outcome study

End-stage osteoarthritis or severe dislocation at the second metatarsophalangeal joint typically presents with chronic pain and is often unrelieved by conservative treatment. The aim of this article is to review the preliminary outcomes of surgery involving resection of the base of the second proximal phalanx with syndactylization to the third toe for stability. Thirteen patients (13 feet) with second metatarsophalangeal osteoarthritis and 15 patients (15 feet) with a dislocated second toe underwent the procedure and were reviewed after a mean 12.4 months (range, 5-25 months). Patients were evaluated preoperatively and postoperatively with the American Orthopedic Foot and Ankle Society's scoring system and clinical review. A patient questionnaire was devised to yield information regarding toe alignment, cosmesis, and reflection on the procedure. Pain and activities were significantly improved in both subgroups (P < .01). Eighty-two percent were very satisfied or satisfied with the reduction in symptoms, with 11% satisfied with reservations and 7% not satisfied. Seventy-nine percent were very satisfied or satisfied with the appearance. Thirty-nine percent stated the outcome was better than expected, 14% as expected, and 14% felt the result was worse than expected. Twenty-three patients (82%) had no postoperative cosmetic concerns, and 7 patients (25%) felt there was a moderate or severe difference in the alignment with respect to the other toes. In conclusion, syndactylization can significantly improve pain and activity levels and was found to be cosmetically acceptable.

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.

Complications of lesser toe surgery

Surgical procedures for lesser toe problems are among the most common surgeries done on the foot. In a shoe wearing population, the incidence of lesser toe pathologic disorders is high. The complications associated with lesser toe surgery can be troublesome for patients and physicians. Understanding the possible common complications and how to avoid them is essential to maximizing satisfactory clinical results.

Operative repair of the fixed hammertoe deformity

Sixty-three patients (118 toes) were evaluated at an average 61 month follow-up following PIP resection arthroplasty for a fixed hammertoe deformity. The deformity involved the second toe in 35%, the third toe in 21%, the fourth toe in 24%, and the fifth toe in 20%. The involved toe averaged 2 mm. greater length than the adjacent toes and was longer in 49/94 (52%). Seventy-eight percent of patients complained of pain preoperatively due to the hammertoe deformity and 49% complained of callus formation. Following a resection arthroplasty technique with intramedullary Kirschner wire fixation, fusion of the PIP joint occurred in 81% of toes. A fibrous union resulted in the remaining 19% of cases. Patients rated subjective alignment as acceptable in 86% of cases and radiographic alignment was rated as good in 79%. Malalignment and numbness were the major factors associated with an unsuccessful result. Pain was relieved in 92%of patients and subjective satisfaction was noted by 84% of patients. Minor complications occurred in 5%. The average postoperative AOFAS score was 83 points. Resection arthroplasty of the proximal interphalangeal joint with intramedullary Kirschner wire fixation as a technique for correction of a fixed hammertoe deformity is a reliable technique that consistently gives a high level of satisfactory results.

Treatment of the atypical lesser toe deformity with basal hemiphalangectomy

Eighty-six lesser toe basal hemiphalangectomies were performed in 52 patients. The surgical technique included an oblique dorsal incision, resection of 8 mm of bone, and an extensor tenotomy. Minimum follow-up was 2 years (range 2-6/1/2 years). Sixty percent of the patients had total relief of pain. Twenty-nine percent stated that they would not have the surgery again, and we categorized these patients as dissatisfied. An extensor tenotomy increased the satisfaction rate and was found to decrease the radiographic sagittal angulation of the toe. The preoperative diagnosis was significant to the outcome of the surgery. Patients with metatarsophalangeal joint synovitis and rheumatoid toe deformities had high rates of satisfaction; those with transverse deviation, metatarsalgia, and hammertoes with metatarsophalangeal joint subluxation/dislocation had lower rates of satisfaction. Seventy percent of the dissatisfied patients were dissatisfied because of persistent flexion deformity of the PIP joint or pain under the metatarsal head. We now add a PIP fusion if any flexion deformity, even a mild deformity, is present at the PIP joint and a plantar metatarsal condylectomy for metatarsalgia.

Silicone implant arthroplasty for second metatarsophalangeal joint disorders with and without hallux valgus deformities

Subluxation or dislocation of the second metatarsophalangeal joint (MTPJ) is usually associated with a hammertoe deformity and, frequently, with a significant hallux valgus deformity. Although the joint itself may be painful, there is also pain in the hammertoe deformity, especially when the patient is wearing closed shoes. A painful intractable plantar keratosis is usually present. We reviewed all of our patients with second MTPJ subluxation or dislocation, in whom a double-stem silicone implant had been used to relocate the joint. In 31 feet of 28 patients, 32 implants were used. All but six feet with advanced degenerative joint disease secondary to Freiberg's infraction had severe associated forefoot pathology that necessitated surgical correction. Several feet had previous bunion operations as well as operations on the second toe. In addition to the second toe, we performed hallux valgus corrections in 23 feet, seven of which were revision procedures. At an average follow-up time of 37 months, good results were seen in 20 feet (63%), good results with reservations in eight feet (25%), and failure in four feet (12%). Transfer metatarsalgia was the most frequent complication. The implants remained stable, and in only one was there a suspected fracture. More optimum results might have been achieved had there been better correction of the hallux valgus deformities, more frequent correction of the hammertoe deformity, and less resection of the second metatarsal head. These patients with pathology usually involving both the first and second MTPJ are difficult to treat, therefore. Their results are less predictable and not as favorable as those achieved for patients with isolated similar deformities.