RISK FACTORS FOR SUBOPTIMAL OUTCOMES IN HAMMERTOE SURGERY JACOB RANDICH BS

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1 RISK FACTORS FOR SUBOPTIMAL OUTCOMES IN HAMMERTOE SURGERY JACOB RANDICH BS RACHEL ALBRIGHT DPM, MOIZ HASSAN MS, ROBERT O KEEFE DPM, ERIN E. KLEIN DPM, MS, LOWELL WEIL JR. DPM, MBA, LOWELL WEIL SR. DPM, ADAM FLEISCHER DPM, MPH WEIL FOOT & ANKLE INSTITUTE DES PLAINES, IL USA

2 I and my co-authors have nothing to disclose

3 HAMMERTOE SURGERY.NOT A PERFECT SCIENCE Hammertoes are estimated to affect 1/3 of the general population ELLINGTON ET AL; REVISION RATE OF 7.9% Revision rates are higher than what we would expect SUNG ET AL; REVISION RATE OF 10-38% BAIG ET AL; REVISION RATES 50%

4 KRAMER ET AL. FAI 2015 Largest study to examine risk factors for recurrence (n=876, toes = 2698) Follow up = 20.8 mos. Limitations: Single surgeon/technique No multivariable analysis

5 PURPOSE To identify patient and surgeon factors associated with suboptimal outcomes after hammertoe surgery. We examined multiple techniques for reducing the PIP joint deformity and ran a multivariable analysis to determine which are most important. Suboptimal Outcome = Need for Revision Surgery or Symptomatic Recurrence

6 METHODS Retrospective cohort study; Included consecutive patients between 1/1/ /31/2013 undergoing hammertoe corrective surgery for toes 2, 3, and/or 4 All methods of hammertoe correction were included Non-elective surgery, mallet toes and 5 th toes were excluded

7 METHODS Predictor Variables Patient Specific Age Gender Body Mass Index Operative Toe (2, 3, or 4) Co-morbidities (DM2, RA, HTN, arthritis) Degree of Deformity (TRVS and Sagittal) Dislocated MTP joint (y/n) Revision Surgery (y/n) Provider Specific Technique for Correcting PIP joint Technique for Correcting MTP joint Concomitant 1 st Ray Surgery (y/n, and type) PIP Joint

8 METHODS PIP joints assigned to one of the following groups (mutually exclusive):

9 METHODS Predictor Variables Patient Specific Age Gender Body Mass Index Operative Toe (2, 3, or 4) Co-morbidities (DM2, RA, HTN, arthritis) Degree of Deformity (TRVS and Sagittal) Dislocated MTP joint (y/n) Revision Surgery (y/n) Provider Specific Technique for Correcting PIP joint Technique for Correcting MTP joint Concomitant 1 st Ray Surgery (y/n, and type) MTP Joint PIP Joint

10 METHODS Techniques used for reducing the deformity at the MTP joint included: 1. Extensor tenotomy 2. Dorsal capsulotomy 3. Flexor tenotomy (primarily for PIP joint reduction) 4. Flexor tendon transfer 5. Weil metatarsal osteotomy 6. Plantar plate repair 7. Metatarsal head partial excision MTP Joint

11 METHODS Predictor Variables Patient Specific Age Gender Body Mass Index Operative Toe (2, 3, or 4) Co-morbidities (DM2, RA, HTN, arthritis) Degree of Deformity (TRVS and Sagittal) Dislocated MTP joint (y/n) Revision Surgery (y/n) Provider Specific Technique for Correcting PIP joint Technique for Correcting MTP joint Concomitant 1 st Ray Surgery (y/n, and type)

12 Magnitude of Deformity: X-rays examined preoperatively to determine magnitude of deformity METHODS

13 METHODS Statistical Analysis: Cox proportional hazards regression models were used to examine associations between predictor variables and suboptimal outcomes. Hazards ratios (HRs) and 95% confidence intervals (CIs) were generated for variables retained in the final models. Three MV models were developed: 1) all toes (n=311) 2) 2 nd toes only (n=162) 3) 3 rd & 4 th toes (n=149)

14 RESULTS 152 patients (311 toes), mean age: 61.7 ± 10.8 yrs (range: 16 to 87 yrs) Mean follow up of 24.7 ± 17.4 mos Mean time to failure (n=68 toes) = 16.8 ± 13.3 mos (range 1 to 49 mos) Nine surgeons included, 3 accounted for > 3/4ths of toes (83%, 259/311) Surgeon was not associated with hammertoe outcomes (p>0.05 for all) Suboptimal outcomes: 68 toes (67 revisions, 1 symptomatic but no sx) Reason for revision: 20 buried hardware complications (dislodged) 45 painful recurrence/malalignment 1 symptomatic non-union 1 vascular compromise/amp

15 Favorable Outcome Suboptimal Outcome Hazard Ratio Patient Variable (n=243 toes) RESULTS Favorable Outcome (n=68 toes) Rheumatoid arthritis (95% CI) 1.07 ( ) Patient Variable (n=243 toes) (n=68 toes) P value Flexion deformity PIPJ Preoperative deformity (in degrees)* 49.7 ± ± ( ) Total sagittal plane deformity, 2 nd 84.9 ± ± ( ) Extension deformity MTPJ Flexion 35.2 deformity ± 11.0 PIPJ 49.7 ± ( ) ± 21.0 ± ( ) Extension deformity MTPJ 35.2 ± ± ( ) Flexion deformity PIPJ Extension deformity MTPJ 1.01 ( ) Total sagittal plane deformity, 3 rd /4 th 37.2 ± ± ± ± ( ) Flexion deformity PIPJ 22.2 ± ± ( ) Extension 15.0 deformity ± 10.4 MTPJ 15.0 ± ± 7.9± ( ) 1.00 ( ) Total transverse plane deviation, 2 nd 16.4 ± ± ( ) MTPJ transverse deviation PIPJ transverse deviation 1.03 ( ) MTPJ transverse deviation 8.0 ± ± ( ) PIPJ transverse 8.0 ± deviation ± ± 9.8 ± Total transverse plane deviation, 3 rd /4 th 1.02 ( ) 8.3 ± ± ± 20.2 ± ( ) MTPJ transverse deviation 10.6 ± ± ( ) 1.03 ( ) PIPJ transverse deviation 18.5 ± ± ( ) Suboptimal Outcome Hazard Ratio (95% CI) P value Age (yrs.) 61.3 ± ± ( ) Female gender ( ) BMI (kg/m 2 ) 26.7 ± ± ( ) Comorbidity Seronegative arthritis n/a Diabetes mellitus Operative toe = 2 nd (vs. 3 rd or 4 th ) Revision surgery MTP joint dislocated Age (yrs.) 61.3 ± ± ( ) Female gender ( ) BMI (kg/m 2 ) 26.7 ± ± ( ) Comorbidity Rheumatoid arthritis ( ) Seronegative arthritis n/a Diabetes mellitus ( ) ( ) Operative toe = 2 nd (vs. 3 rd or 4 th ) ( ) 1.49 ( ) 1.70 ( ) 1.46 ( ) Preoperative deformity (in degrees) Revision surgery ( ) Total sagittal plane deformity, 2 nd MTP joint dislocated 84.9 ± ( ) ± ( ) Total sagittal plane deformity, 3 rd /4 th 37.2 ± ± ( ) Total transverse plane deviation, 2 nd 16.4 ± ± ( ) Total transverse plane deviation, 3 rd /4 th 29.1 ± ± ( ) MTPJ transverse deviation 10.6 ± ± ( ) PIPJ transverse deviation 18.5 ± ± ( ) 0.007

16 Provider/Technical Variable Favorable Outcome (n=243 toes) Suboptimal Outcome (n=68 toes) Hazard Ratio (95% CI) P value PIP joint reduction Resection arthroplasty, no fixation 83 (34.2) 25 (36.8) 0.90 ( ) Resection arthroplasty, K-wire 19 (7.8) 2 (2.9) 0.36 ( ) Interpositional implant arthroplasty 16 (6.6) 3 (4.4) 0.57 ( ) Arthrodesis, buried K-wire 55 (22.6) 18 (26.5) 1.19 ( ) Arthrodesis, commercial implant 38 (15.6) 8 (11.8) 1.36 ( ) Proximal phalangeal osteotomy 22 (9.0) 10 (14.7) 1.92 ( ) Other technique 7 (2.9) 6 (8.82) 2.09 ( ) MTP joint reduction Extensor tenotomy 111 (45.7) 32 (47.1) 1.00 ( ) Dorsal capsulotomy 142 (58.4) 43 (63.2) 1.13 ( ) Flexor tenotomy 16 (6.6) 9 (13.2) 1.57 ( ) Flexor tendon transfer 8 (3.3) 5 (7.3) 1.97 ( ) Weil metatarsal osteotomy 44 (18.1) 17 (25.0) 1.38 ( ) Weil osteotomy + plantar plate repair* 23 (9.5) 9 (13.2) 1.30 ( ) Partial metatarsal head excision 10 (4.1) 2 (2.9) 0.61 ( ) Concomitant 1 st ray procedure 115 (47.3) 21 (30.8) 0.61 ( ) Scarf bunionectomy 87 (35.8) 16 (23.5) 0.69 ( ) Akin osteotomy 75 (30.8) 12 (17.6) 0.54 ( ) Scarf & Akin procedures 68 (27.9) 11 (16.2) 0.58 ( ) st MTP joint arthroplasty 18 (7.4) 3 (4.4) 0.83 ( ) 0.757

17 FINAL COX REGRESSION MODEL FOR PREDICTING A SUBOPTIMAL OUTCOME AFTER HAMMERTOE SURGERY (ALL TOES, N=311) Risk Factor Hazard Ratio (95% CI) P value Concomitant 1 st ray procedure 0.51 ( ) Total transverse deviation angle 1.03 ( ) < Operative toe = 2nd (vs. 3rd or 4th) 2.23 ( ) PIP joint reduction = 'other' technique PIP joint reduction = phalangeal osteotomy 2.62 ( ) ( )

18 COX ADJUSTED SURVIVAL CURVES SHOWING TIME TO REVISION AND/OR SYMPTOMATIC RECURRENCE AFTER HAMMERTOE SURGERY IN THE SECOND TOE (RED LINE) VERSES TOES 3 OR 4 (BLUE LINE) 3 rd /4 th toes 2.5 yrs 2 nd toes Chi-square = 25.32, p< Survival Time (in days)

19 FINAL COX REGRESSION MODEL FOR PREDICTING A SUBOPTIMAL OUTCOME AFTER HAMMERTOE SURGERY (ALL TOES, N=311) Risk Factor Hazard Ratio (95% CI) P value Concomitant 1 st ray procedure 0.51 ( ) Total transverse deviation angle 1.03 ( ) < Operative toe = 2nd (vs. 3rd or 4th) 2.23 ( ) PIP joint reduction = 'other' technique PIP joint reduction = phalangeal osteotomy 2.62 ( ) ( )

20 FINAL COX REGRESSION MODEL FOR PREDICTING A SUBOPTIMAL OUTCOME AFTER 2 ND HAMMERTOE SURGERY (N=162 TOES) Risk Factor Hazard Ratio (95% CI) P value Concomitant 1 st ray procedure 0.39 ( ) Total transverse deviation angle 1.03 ( ) Flexor tenotomy 3.90 ( ) Diabetes mellitus 4.14 ( )

21 FINAL COX REGRESSION MODEL FOR PREDICTING A SUBOPTIMAL OUTCOME AFTER 3 RD /4 TH HAMMERTOE SURGERY (N=149 TOES). Risk Factor Hazard Ratio (95% CI) P value PIP joint transverse plane deviation angle 1.04 ( ) PIP joint reduction = 3.69 ( ) phalangeal osteotomy Dislocated MTP joint 5.19 ( )

22 LIMITATIONS Selection bias: Only those with 6 months of follow up were included Retrospective design: Relying on pre-existing records Small sample size: Few data points for some of our techniques Generalizablity: Full spectrum of techniques was not represented (e.g., arthrodesis with percutaneous k wire)

23 CONCLUSIONS Non-modifiable Risks Greater TRVS deviation of toe 2 nd toes Modifiable Risks Correct hallux valgus Avoid less common procedures for PIP joint reduction phalangeal shortening osteotomies middle phalangectomy syndactylization

24 Thank You! JACOB RANDICH BS WILLIAM M SCHOLL COLLEGE OF PODIATRIC MEDICINE