RISK FACTORS FOR SUBOPTIMAL OUTCOMES IN HAMMERTOE SURGERY JACOB RANDICH BS

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

I and my co-authors have nothing to disclose

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%

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

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

METHODS Retrospective cohort study; Included consecutive patients between 1/1/2011 12/31/2013 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

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

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

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

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

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)

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

Favorable Outcome Suboptimal Outcome Hazard Ratio Patient Variable (n=243 toes) RESULTS Favorable Outcome (n=68 toes) Rheumatoid arthritis 26.7 26.5 (95% CI) 1.07 (0.62-1.84) 0.808 Patient Variable (n=243 toes) (n=68 toes) P value Flexion deformity PIPJ Preoperative deformity (in degrees)* 49.7 ± 19.7 50.7 ± 21.01.00 (0.99-1.01) Total sagittal plane deformity, 2 nd 84.9 ± 27.9 84.7 ± 33.0 0.897 1.00 (0.98-1.02) 0.996 Extension deformity MTPJ Flexion 35.2 deformity ± 11.0 PIPJ 49.7 ± 19.7 1.00 (0.98-1.02) 34.0 50.7 ± 21.0 ± 13.1 0.996 0.99 (0.97-1.03) 0.735 Extension deformity MTPJ 35.2 ± 11.0 34.0 ± 13.1 0.99 (0.97-1.03) 0.735 Flexion deformity PIPJ Extension deformity MTPJ 1.01 (0.99-1.02) Total sagittal plane deformity, 3 rd /4 th 37.2 ± 25.6 40.7 ± 23.5 0.306 22.2 ± 19.6 25.9 ± 20.31.01 (0.99-1.03) Flexion deformity PIPJ 22.2 ± 19.6 25.9 ± 20.3 0.215 1.00 (0.97-1.04) Extension 15.0 deformity ± 10.4 MTPJ 15.0 ± 10.4 14.8 ± 7.9± 7.9 0.853 1.01 (0.99-1.03) 1.00 (0.97-1.04) 0.215 0.853 Total transverse plane deviation, 2 nd 16.4 ± 11.7 21.5 ± 16.9 1.02 (1.00-1.04) 0.060 MTPJ transverse deviation PIPJ transverse deviation 1.03 (0.99-1.07) MTPJ transverse deviation 8.0 ± 6.2 10.9 ± 9.1 0.107 1.03 (0.99-1.06) PIPJ transverse 8.0 ± deviation 6.2 8.3 ± 8.3 10.9 10.6 ± 9.8 ± 9.1 0.110 Total transverse plane deviation, 3 rd /4 th 1.02 (1.00-1.04) 8.3 ± 8.3 29.1 ± 19.4 10.6 41.1 ± 20.2 ± 9.8 0.007 1.03 (0.99-1.07) MTPJ transverse deviation 10.6 ± 8.4 13.5 ± 8.8 0.099 1.03 (0.99-1.07) 1.03 (0.99-1.06) 0.107 0.110 PIPJ transverse deviation 18.5 ± 14.5 27.7 ± 15.7 1.03 (1.01-1.05) 0.007 Suboptimal Outcome Hazard Ratio (95% CI) P value Age (yrs.) 61.3 ± 11.8 63.1 ± 6.5 1.01 (0.99-1.04) 0.266 Female gender 81.9 88.2 1.19 (0.56-2.49) 0.647 BMI (kg/m 2 ) 26.7 ± 5.5 28.9 ± 6.5 1.05 (1.01-1.09) 0.020 Comorbidity Seronegative arthritis 2.1 0.0 n/a 0.985 Diabetes mellitus Operative toe = 2 nd (vs. 3 rd or 4 th ) Revision surgery MTP joint dislocated Age (yrs.) 61.3 ± 11.8 63.1 ± 6.5 1.01 (0.99-1.04) 0.266 Female gender 4.9 81.9 88.2 10.3 1.19 (0.56-2.49) 0.647 BMI (kg/m 2 ) 26.7 ± 5.5 28.9 ± 6.5 1.05 (1.01-1.09) 0.020 Comorbidity 50.6 57.3 Rheumatoid arthritis 26.7 26.5 1.07 (0.62-1.84) 0.808 Seronegative arthritis 7.0 2.1 0.0 19.1 n/a 0.985 Diabetes mellitus 4.9 10.3 2.38 (1.08-5.22) 0.030 18.9 25.0 1.49 (0.92-2.41) Operative toe = 2 nd (vs. 3 rd or 4 th ) 50.6 57.3 0.107 2.38 (1.08-5.22) 1.49 (0.92-2.41) 1.70 (0.92-3.13) 1.46 (0.84-2.53) 0.030 0.107 0.089 0.176 Preoperative deformity (in degrees) Revision surgery 7.0 19.1 1.70 (0.92-3.13) 0.089 Total sagittal plane deformity, 2 nd MTP joint dislocated 84.9 ± 27.9 18.9 1.46 (0.84-2.53) 25.0 84.7 ± 33.0 0.176 1.00 (0.99-1.01) 0.897 Total sagittal plane deformity, 3 rd /4 th 37.2 ± 25.6 40.7 ± 23.5 1.01 (0.99-1.02) 0.306 Total transverse plane deviation, 2 nd 16.4 ± 11.7 21.5 ± 16.9 1.02 (1.00-1.04) 0.060 Total transverse plane deviation, 3 rd /4 th 29.1 ± 19.4 41.1 ± 20.2 1.02 (1.00-1.04) 0.007 MTPJ transverse deviation 10.6 ± 8.4 13.5 ± 8.8 1.03 (0.99-1.07) 0.099 PIPJ transverse deviation 18.5 ± 14.5 27.7 ± 15.7 1.03 (1.01-1.05) 0.007

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 (0.55-1.48) 0.683 Resection arthroplasty, K-wire 19 (7.8) 2 (2.9) 0.36 (0.09-1.48) 0.157 Interpositional implant arthroplasty 16 (6.6) 3 (4.4) 0.57 (0.18-1.83) 0.348 Arthrodesis, buried K-wire 55 (22.6) 18 (26.5) 1.19 (0.69-2.04) 0.526 Arthrodesis, commercial implant 38 (15.6) 8 (11.8) 1.36 (0.64-2.86) 0.418 Proximal phalangeal osteotomy 22 (9.0) 10 (14.7) 1.92 (0.97-3.79) 0.059 Other technique 7 (2.9) 6 (8.82) 2.09 (0.90-4.84) 0.085 MTP joint reduction Extensor tenotomy 111 (45.7) 32 (47.1) 1.00 (0.62-1.61) 1.000 Dorsal capsulotomy 142 (58.4) 43 (63.2) 1.13 (0.68-1.85) 0.632 Flexor tenotomy 16 (6.6) 9 (13.2) 1.57 (0.77-3.16) 0.212 Flexor tendon transfer 8 (3.3) 5 (7.3) 1.97 (0.79-4.88) 0.147 Weil metatarsal osteotomy 44 (18.1) 17 (25.0) 1.38 (0.79-2.38) 0.253 Weil osteotomy + plantar plate repair* 23 (9.5) 9 (13.2) 1.30 (0.64-2.62) 0.466 Partial metatarsal head excision 10 (4.1) 2 (2.9) 0.61 (0.15-2.49) 0.491 Concomitant 1 st ray procedure 115 (47.3) 21 (30.8) 0.61 (0.36-1.01) 0.056 Scarf bunionectomy 87 (35.8) 16 (23.5) 0.69 (0.39-1.21) 0.193 Akin osteotomy 75 (30.8) 12 (17.6) 0.54 (0.29-1.01) 0.056 Scarf & Akin procedures 68 (27.9) 11 (16.2) 0.58 (0.30-1.12) 0.103 1 st MTP joint arthroplasty 18 (7.4) 3 (4.4) 0.83 (0.26-2.65) 0.757

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 (0.30-0.87) 0.0130 Total transverse deviation angle 1.03 (1.02-1.04) <0.0001 Operative toe = 2nd (vs. 3rd or 4th) 2.23 (1.31-3.81) 0.0033 PIP joint reduction = 'other' technique PIP joint reduction = phalangeal osteotomy 2.62 (1.09-6.26) 0.0306 2.77 (1.36-5.64) 0.0049

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<0.0001 Survival Time (in days)

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 (0.19-0.81) 0.0105 Total transverse deviation angle 1.03 (1.01-1.05) 0.0035 Flexor tenotomy 3.90 (1.43-10.6) 0.0079 Diabetes mellitus 4.14 (1.54-11.1) 0.0047

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 (1.01-1.06) 0.0027 PIP joint reduction = 3.69 (1.33-10.3) 0.0122 phalangeal osteotomy Dislocated MTP joint 5.19 (1.52-17.7) 0.0087

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)

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

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