The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Correction of Hammer Toe Deformity of Lateral Toes With Subtraction Osteotomy of the Proximal Phalanx Neck Paolo Ceccarini 1, Alfredo Ceccarini 2, Giuseppe Rinonapoli 3, Auro Caraffa 4 1
Resident, Department of Orthopaedics and Traumatology, S.M. Misericordia Hospital, University of Perugia, Perugia, Italy Orthopaedic Surgeon, Department of Orthopaedics and Traumatology, S.M. Misericordia Hospital, University of Perugia, Perugia, Italy 3 Associate Professor, Department of Orthopaedics and Traumatology, S.M. Misericordia Hospital, University of Perugia, Perugia, Italy 4 Professor in Chief, Department of Orthopaedics and Traumatology, S.M. Misericordia Hospital, University of Perugia, Perugia, Italy 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
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. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: foot surgery forefoot hammertoe lesser toe deformity
Hammer toe (hammertoe) deformity of the lateral toes is characterized by flexion of the proximal interphalangeal joint (PIPJ), associated with the hyperextension of the metatarsophalangeal joint (MTPJ) and the neutral, sometimes hyperextended, position of the distal interphalangeal joint (1) (Fig. 1). The indications for surgery depend on the degree of the deformity and the severity of pain. The goals of surgery are to provide a durable correction of the deformity, restore the balance of flexion and extension musculotendinous forces of the toes, and restoration of the anatomic relationships between the interosseous muscles and the metatarsal bones. The classic surgical techniques included correction of the deformity using proximal interphalangeal arthrodesis, an arthroplasty, or, more recently, percutaneous techniques of osteotomy of the first and second phalanxes (2). Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Paolo Ceccarini, Department of Orthopaedics and Traumatology, S.M. Misericordia Hospital, University of Perugia, Perugia 06125, Italy. E-mail address: [email protected] (P. Ceccarini). 1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.11.013
Fig. 1. Hammer toe deformity.
2
P. Ceccarini et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 2. (A) With a transverse skin incision, the osteotomy is performed perpendicularly to the axis of the phalanx. (B) Subtraction osteotomy was performed.
The arthroplasty according to Duvries and Lelievre (3) consists of correction of the deformity with excision and removal of the head of the proximal phalanx. This resection has a width that varies according to the degree of the deformity and the width of the toe to be corrected, allowing for correction of the varus and valgus deviations. It is stabilized with a Kirschner wire. The resected bone is replaced by the formation of a more or less solid fibrous ankylosis, sufficient, according to most investigators, to maintain the alignment of the 2 phalanges. The limitations include anatomic changes, with alteration of the normal joint conformation, a possible limited duration of the correction, and imbalance of the musculotendinous forces with the possibility of recurrence and secondary deformities (4). Arthrodesis is characterized by the resection of the 2 articular ends (head of the proximal phalanx and basis of the middle phalanx) and stabilization with a Kirschner wire, which should be maintained for 4 to 6 weeks. The goals are to stabilize the joint and reduce the recurrence rate (5). Arthrodesis is indicated for severe and irreducible hammer toes. Regarding the various types of arthrodesis, the most commonly used has been the end-to-end procedure. The distal portion of the proximal phalanx is resected with a saw, and the articular surface of the middle phalanx is prepared, removing the cartilage with a small rongeur or curet. It is important to have a parallel PIPJ after bone resection to prevent varus–valgus or flexion–extension deformity. The bone resection should reduce the tension of the soft tissues and conserve an appropriate toe length. These arthrodeses tend to be physiologic but can usually require a long immobilization period
(6 weeks) with Kirschner wires. Such immobilization increases the risk of infection and a delay in the use of normal shoes. Thus, some investigators prefer stable internal fixation with screws or absorbable pins (6–8). Furthermore, we undertook a review of a series of patients upon whom we performed this procedure with the aim of determining clinical outcomes following subtraction arthroplasty. Regarding the occurrence of insufficient correction, additional operative times are often necessary at the level of the MTPJ, which consists of the release of the joint, lengthening of the extensor apparatus, and possible fixation of the MTPJ with a Kirschner wire. In a few cases, a percutaneous tenotomy of the long extensor according to McGlamry will be sufficient (5,9). The most common complications include infections and the partial collapse of the arthrodesis at the level of the PIPJ after involuntary removal of the Kirschner wire before the fifth week. Late complications have included nonunion, recurrence of the deformity, malalignment of the toe in the frontal plane at the level of PIPJ (surface not perpendicular to the axis of the phalanges), and rotational defects of the distal part of the toe on the frontal plane (5,10–12). Thus, we decided to perform subtraction osteotomy of the proximal phalanx neck to obtain stable and lasting correction of the deformity, preservation of the joint motion of the PIPJ, and bony union with the characteristics of minimal invasiveness. Furthermore, we reviewed a series of patients who underwent subtraction osteotomy of the proximal phalanx for treatment of hammer toe deformity, with the aim of determining clinical outcomes associated with this intervention.
Fig. 3. Passing the Kirschner wire out the tip of the toe.
Fig. 4. Kirschner wire fixation.
P. Ceccarini et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
3
Fig. 5. (A and B) Hammer toe correction with Kirschner wire fixation.
We were interested in finding a technique permitting us the correction of the hammer toe deformity and, at the same time, maintaining the PIPJ articulation and showing the same positive outcomes reported in literature. We hypothesized, therefore, that a shortening osteotomy would result in a stable and enduring correction of the deformity maintaining the joint of the PIPJ with miniinvasive surgery. Our main aim was to evaluate the conservation of the PIPJ and the satisfaction of our patients; our secondary aim was to assess the capacity of correction and the stability of the osteotomy. Therefore we evaluated a series of patients that had undergone this procedure to determine the clinical results obtained with this technique.
Patients and Methods We evaluated a group of 40 patients with a second hammer toe deformity (40 toes). We recruited both from our clinic and a coauthor’s private practice (A.C.). The mean age of the patients was 61.3 (range 18 to 82) years. Of the 40 patients, 34 were female and 6 were male; 28 right feet and 12 left were treated from January 2008 to December 2010 using subtraction osteotomy of the proximal phalanx neck. All patients were clinically and radiographically evaluated, pre- and postoperatively, with follow-up visits at 4, 6, and 8 weeks postoperatively and again at the final postoperative visit at a mean of 24.4 (minimal 12, maximal 36) months. Patients with
dislocated, irreducible MTPJs were treated using another method and were not included in the present study. No patients were lost to follow-up. In 26 of the 40 patients, correction of the second toe was performed simultaneously with the correction of hallux valgus. The latter was treated with distal osteotomy of the first metatarsal head according to Austin and Leventen (13). For the clinical evaluation, we used the American Orthopaedic Foot and Ankle Society (AOFAS) score, which provides a maximum score of 100 points and includes an evaluation for pain, functional limitations, tolerance to footwear, motility of the interphalangeal joint, joint stability, presence of callosity, and interphalangeal joint alignment (14,15). A subjective rating scale was used for the patients to evaluate their results. The patients were asked to rate their satisfaction with their ability to wear normal shoes and perform their normal daily activities after surgery. The patients rated their result as excellent, good, fair, or poor. A rating of excellent indicated that the patient had no pain, walked without difficulty, and was very satisfied with the result. A rating of good indicated that minimal pain was present and was satisfied with the result. A rating of fair indicated that the patient had moderate residual foot pain and walked with some difficulty. A rating of poor indicated that the patient continued to have foot pain, walked with difficulty, and regretted undergoing the procedure. Data were abstracted from the medical records by 2 coauthors (A.C. and P.C), radiographs were measured by another coauthor (A.C.), and statistical analyses were carried out by 2 coauthors (G.R. and P.C.). We evaluated the following radiographic parameters on 2 standard projections: the interphalangeal angle, correction of the axial and sagittal plane deformities, presence of axial deviation and the quality and timing of the osteotomy consolidation. We considered an interphalangeal angle of 0 in the anteroposterior projection to be normal, and we considered any axial deviations in the horizontal plane to indicate a pathologic outcome. In the lateral projection, regarding the dorsoplantar angulation, we considered an angle of the PIPJ from 0 to 10 to be
p
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Correction of Hammer Toe Deformity of Lateral Toes With Subtraction Osteotomy of the Proximal Phalanx Neck Paolo Ceccarini 1, Alfredo Ceccarini 2, Giuseppe Rinonapoli 3, Auro Caraffa 4 1
Resident, Department of Orthopaedics and Traumatology, S.M. Misericordia Hospital, University of Perugia, Perugia, Italy Orthopaedic Surgeon, Department of Orthopaedics and Traumatology, S.M. Misericordia Hospital, University of Perugia, Perugia, Italy 3 Associate Professor, Department of Orthopaedics and Traumatology, S.M. Misericordia Hospital, University of Perugia, Perugia, Italy 4 Professor in Chief, Department of Orthopaedics and Traumatology, S.M. Misericordia Hospital, University of Perugia, Perugia, Italy 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
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. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: foot surgery forefoot hammertoe lesser toe deformity
Hammer toe (hammertoe) deformity of the lateral toes is characterized by flexion of the proximal interphalangeal joint (PIPJ), associated with the hyperextension of the metatarsophalangeal joint (MTPJ) and the neutral, sometimes hyperextended, position of the distal interphalangeal joint (1) (Fig. 1). The indications for surgery depend on the degree of the deformity and the severity of pain. The goals of surgery are to provide a durable correction of the deformity, restore the balance of flexion and extension musculotendinous forces of the toes, and restoration of the anatomic relationships between the interosseous muscles and the metatarsal bones. The classic surgical techniques included correction of the deformity using proximal interphalangeal arthrodesis, an arthroplasty, or, more recently, percutaneous techniques of osteotomy of the first and second phalanxes (2). Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Paolo Ceccarini, Department of Orthopaedics and Traumatology, S.M. Misericordia Hospital, University of Perugia, Perugia 06125, Italy. E-mail address: [email protected] (P. Ceccarini). 1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2014.11.013
Fig. 1. Hammer toe deformity.
2
P. Ceccarini et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
Fig. 2. (A) With a transverse skin incision, the osteotomy is performed perpendicularly to the axis of the phalanx. (B) Subtraction osteotomy was performed.
The arthroplasty according to Duvries and Lelievre (3) consists of correction of the deformity with excision and removal of the head of the proximal phalanx. This resection has a width that varies according to the degree of the deformity and the width of the toe to be corrected, allowing for correction of the varus and valgus deviations. It is stabilized with a Kirschner wire. The resected bone is replaced by the formation of a more or less solid fibrous ankylosis, sufficient, according to most investigators, to maintain the alignment of the 2 phalanges. The limitations include anatomic changes, with alteration of the normal joint conformation, a possible limited duration of the correction, and imbalance of the musculotendinous forces with the possibility of recurrence and secondary deformities (4). Arthrodesis is characterized by the resection of the 2 articular ends (head of the proximal phalanx and basis of the middle phalanx) and stabilization with a Kirschner wire, which should be maintained for 4 to 6 weeks. The goals are to stabilize the joint and reduce the recurrence rate (5). Arthrodesis is indicated for severe and irreducible hammer toes. Regarding the various types of arthrodesis, the most commonly used has been the end-to-end procedure. The distal portion of the proximal phalanx is resected with a saw, and the articular surface of the middle phalanx is prepared, removing the cartilage with a small rongeur or curet. It is important to have a parallel PIPJ after bone resection to prevent varus–valgus or flexion–extension deformity. The bone resection should reduce the tension of the soft tissues and conserve an appropriate toe length. These arthrodeses tend to be physiologic but can usually require a long immobilization period
(6 weeks) with Kirschner wires. Such immobilization increases the risk of infection and a delay in the use of normal shoes. Thus, some investigators prefer stable internal fixation with screws or absorbable pins (6–8). Furthermore, we undertook a review of a series of patients upon whom we performed this procedure with the aim of determining clinical outcomes following subtraction arthroplasty. Regarding the occurrence of insufficient correction, additional operative times are often necessary at the level of the MTPJ, which consists of the release of the joint, lengthening of the extensor apparatus, and possible fixation of the MTPJ with a Kirschner wire. In a few cases, a percutaneous tenotomy of the long extensor according to McGlamry will be sufficient (5,9). The most common complications include infections and the partial collapse of the arthrodesis at the level of the PIPJ after involuntary removal of the Kirschner wire before the fifth week. Late complications have included nonunion, recurrence of the deformity, malalignment of the toe in the frontal plane at the level of PIPJ (surface not perpendicular to the axis of the phalanges), and rotational defects of the distal part of the toe on the frontal plane (5,10–12). Thus, we decided to perform subtraction osteotomy of the proximal phalanx neck to obtain stable and lasting correction of the deformity, preservation of the joint motion of the PIPJ, and bony union with the characteristics of minimal invasiveness. Furthermore, we reviewed a series of patients who underwent subtraction osteotomy of the proximal phalanx for treatment of hammer toe deformity, with the aim of determining clinical outcomes associated with this intervention.
Fig. 3. Passing the Kirschner wire out the tip of the toe.
Fig. 4. Kirschner wire fixation.
P. Ceccarini et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–6
3
Fig. 5. (A and B) Hammer toe correction with Kirschner wire fixation.
We were interested in finding a technique permitting us the correction of the hammer toe deformity and, at the same time, maintaining the PIPJ articulation and showing the same positive outcomes reported in literature. We hypothesized, therefore, that a shortening osteotomy would result in a stable and enduring correction of the deformity maintaining the joint of the PIPJ with miniinvasive surgery. Our main aim was to evaluate the conservation of the PIPJ and the satisfaction of our patients; our secondary aim was to assess the capacity of correction and the stability of the osteotomy. Therefore we evaluated a series of patients that had undergone this procedure to determine the clinical results obtained with this technique.
Patients and Methods We evaluated a group of 40 patients with a second hammer toe deformity (40 toes). We recruited both from our clinic and a coauthor’s private practice (A.C.). The mean age of the patients was 61.3 (range 18 to 82) years. Of the 40 patients, 34 were female and 6 were male; 28 right feet and 12 left were treated from January 2008 to December 2010 using subtraction osteotomy of the proximal phalanx neck. All patients were clinically and radiographically evaluated, pre- and postoperatively, with follow-up visits at 4, 6, and 8 weeks postoperatively and again at the final postoperative visit at a mean of 24.4 (minimal 12, maximal 36) months. Patients with
dislocated, irreducible MTPJs were treated using another method and were not included in the present study. No patients were lost to follow-up. In 26 of the 40 patients, correction of the second toe was performed simultaneously with the correction of hallux valgus. The latter was treated with distal osteotomy of the first metatarsal head according to Austin and Leventen (13). For the clinical evaluation, we used the American Orthopaedic Foot and Ankle Society (AOFAS) score, which provides a maximum score of 100 points and includes an evaluation for pain, functional limitations, tolerance to footwear, motility of the interphalangeal joint, joint stability, presence of callosity, and interphalangeal joint alignment (14,15). A subjective rating scale was used for the patients to evaluate their results. The patients were asked to rate their satisfaction with their ability to wear normal shoes and perform their normal daily activities after surgery. The patients rated their result as excellent, good, fair, or poor. A rating of excellent indicated that the patient had no pain, walked without difficulty, and was very satisfied with the result. A rating of good indicated that minimal pain was present and was satisfied with the result. A rating of fair indicated that the patient had moderate residual foot pain and walked with some difficulty. A rating of poor indicated that the patient continued to have foot pain, walked with difficulty, and regretted undergoing the procedure. Data were abstracted from the medical records by 2 coauthors (A.C. and P.C), radiographs were measured by another coauthor (A.C.), and statistical analyses were carried out by 2 coauthors (G.R. and P.C.). We evaluated the following radiographic parameters on 2 standard projections: the interphalangeal angle, correction of the axial and sagittal plane deformities, presence of axial deviation and the quality and timing of the osteotomy consolidation. We considered an interphalangeal angle of 0 in the anteroposterior projection to be normal, and we considered any axial deviations in the horizontal plane to indicate a pathologic outcome. In the lateral projection, regarding the dorsoplantar angulation, we considered an angle of the PIPJ from 0 to 10 to be
p
