Welcome to my latest article covering hammer toes 

Hammer toes can form a complex problem for the clinician. My aim in this article is to make you aware about data as in facts and the truth and about the complexity of toe surgery. My July Footlocker article covered hammer toes from the patient’s standpoint. This article is recommended to be read with communication and information for your patient.

 


Who is it aimed at?

The general podiatrist in every day practice dealing with the adult-mature foot.

When all conservative care has been concluded and surgery is needed to fix toe deformities, be mindful that lesser toe surgery is perhaps the toughest to get right. I completed a patient article on hammer toes but steered away from too much surgery as the subject demands its’ own platform.  Surgery for hallux valgus is actually easier than managing small toe surgery. In this article I hope to make this distinction clearer. The data used is open and accessible to all. Do note that Diabetics are included in the data shown below.


How often should fact sheets be updated?

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There are no strict criteria for when fact sheets should be updated. If facts and evidence have changed then the sheets should be re-written. It is good practice to check sheets and show when a sheet has been updated even if little change is expected. The agency NICE often leave their data for more than 5 years. A review is always worth considering to see if your material content can be improved. This might suggest improving the layout, adding new references where these are used, or incorporating new images. We should aim to check that our fact sheets are factually correct and that they are presented well. The date when first published should be shown as part of good practice. Any fact sheet that still serves a valid purpose should not be discarded.

 


Data and facts

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Members of the College of Podiatry have free access to a database called PASCOM-10. But the public also have access to the annual reports collated by the working party . Even BoFAS do not use their website to publish open data so this is a truly wonderful resource for everyone. The data for hammer toes is attributed to 296 centres and over 1000 clinicians. Both sets of data are not a reliable snapshot of the number of clinicians because many will work at more than one centre. The location of clinical data refers broadly to the NHS and not the private sector. 

The 2019 PASCOM-10 report is the latest. Broadly there are 2 procedures for hammer toes; removing bone (arthroplasty) or fusing bone-joints at the ipj (arthrodesis); the number of recorded single or multiple procedures are derived from an overall cohort of 13,294 surgeries. This amounts to just under a quarter of surgeries (23%) are likely to involve some type of toe surgery.

I decided to check on the risks and problems with hammer toe surgery as the database offers us an opportunity to filter down to individual procedures. You can do this if you are a registered user for your own clinic but cannot access national data. I have therefore produced 2019 data


Analysis

Surgical problems are referred to as sequellae. The designers of the system decided not to use the term complications largely because some problems are not uncommon. Many can also be managed easily. In 2010 a traffic light risk system was set up and although this is available on all reports, the professional body has not openly endorsed this to date. Data for arthroplasty and arthrodesis (being mixed) included 1517 episodes for 2019. 1164 had no problems (75%) leaving us with a value of around 25% episodes with some type of undesirable post surgical effect. The data is not always easy to read and you have to know the difference between sequellae which is the number of allocated sub-optimal post operative categories versus the number of episodes or treatments. Both values are given.

The Big Five

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Of the top five problems encountered after hammer toe surgery, patients were recorded as having less than 3% incidence. Such problems that rank at the top include the following.  Failure (2.9%) of the procedure, Infection (2.9%), Pain at three months after surgery (2.1%), wound healing delay (1.6%) and fixation removal (1.7%).

 

Factual data

Fixation removal is the type of surgical problem usually applied to the arthrodesis technique. Modern surgery often uses metal or plastic style devices to hold the toe in compression. Failure can mean a wide range of characteristics from poor positioning to failed fusion. Or in the case of the illustrated example shows a break through this metallic fixator. 

(Author) Fracture of fixation device for arthrodesis) 2017

Clinician held view

Clinical assessment or clinician outcome score: To find out in general terms how we have performed we would ask the patient their opinion. In ‘our’ view the clinical outcome measure is based on our achievement met completely. This was recorded as 64% (955). When it came to ‘partly met’ the figure dropped to 6.1% (91). Those patients where their ‘expectations were not met’ from the clinician’s point of view included 8 patients (0.5%). As with any data collection some was not recorded and 62 cases were lost to follow up. We find 25% (377) of data was not recorded.  Two could not be assessed at the time of recording at discharge. 1496 patients were recorded as part of clinician analysis. However if we now look at the patients (1501) who were then surveyed within the same cohort, data was collected for patient satisfaction outcome (PSQ-10).

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Patient held view (PSQ-10)

Ten questions were used to follow up each patient at six months. The questionnaire used is called the patient satisfaction questionnaire ten (PSQ-10) The last 2 questions cover how the patient felt that the original problem was dealt with and their expectations. If expectations are met these form powerful reflections based on the patients opinion; 92.9% of patient felt that their original problem was better or much better. In terms of expectations, those that felt their outcome had been met was recorded at 88.3%. It was determined in the early days of the audit project (1993) that the clinical assessment score should equate to patient perception of outcome (or success). In this case the patient’s perception is better than the clinicians which forms an acceptable outcome. It is the patient’s view point that matters. 

CLINICIAN OUTCOME  (64%) = PATIENT PERCEPTION (88%)

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We can draw from the current results that podiatrists DO deliver a high success rate for hammer toe surgery and yet there are risks. Given the evidence it would appear for the most part these problem have a low frequency and are managed effectively. Patients cannot expect all surgery to be either guaranteed in terms of success. Therefore it is still important for anyone undergoing surgery to understand the risk and likelihood of failure from surgery. Even allowing for some inaccuracy behind data collection, the size of data collected by the College of Podiatry is respectable enough to hold validity. 


The Truth about complexity

Single toe joint surgery at the distal interphalangeal joint (ipj) has a high success rate.

The ellipsoid style joint moves in one direction (sagittal plane). When correcting a turned out abducted toe at the same joint correction is required in two planes (sagittal and transverse)

Where multiple ipj deformities are managed together, the risks increase. Multiple surgery creates more exposure, more wounds and more swelling. Up until this point where surgery concerns the IPJs alone, lesser toe surgery enjoys success. But what if the deformity exists at the metatarsophlanvgeal joint (MTPJ)? 

MTP Joint deformity

Hammer toes with an origin around the MTPJ are entirely different. The MTP joint has a greater propensity for deformity, dislocation and damage because it has more movement. Not only does it have more movement, but the toe can dislocate. Disease attacks the joint and includes the arthritides from gout to psoriatic arthritis, rheumatoid arthritis and soft tissue damage to osteochondroses. Plantar plate damage is renowned and a common cause of instability. The joint will allow both transverse plane and sagittal plane movement, but frontal plane movement is unusual. 

The anatomy of the lesser MTP joint is very complex not least because it functions as part of the anterior windlass mechanism and uses annular ligaments. These rings of ligament provide anchorage for tendon pulleys. Added to the longer tendons and their divisions and insertions, the lubricales and interossei muscles are inherently weak. New techniques have been developed over old. The Girdlestone procedure took the flexor tendons and moved these to the top of the toe so when the flexor tendon was designed to pull the toe down through the extensors. The redirected tendons would ideally improve the biomechanics of the digit. This is an example of a 20th century procedure which is still in vogue and works for flexible toes. More recent techniques allow for repair of the ruptured joint given that equipment today is better refined. Small opening incisional techniques are increasing in their popularity. 

The more pathology, the greater deformity and co-existing problems increases operation time. In turn this escalates post surgical problems and inevitably creates lower reliability. More factors need to be considered for multiple toes and multiple joint correction. For the podiatrist attempting to protect and align flexible hammer toes are one matter, but a fixed deformity at the MTPJ is another.

Explaining the rational for any decisions to patients about their management is important. The consent process must start with the non surgeon. For any foot surgeon, he or she must rely on the non-surgical interventionist before recommending surgical management. Those hidden features must be understand if we are to offer the best advice and management to our patients. 


David Tollafield is a former consultant podiatric surgeon, clinical tutor and examiner for the College of Podiatry. He has written seven books and a number of papers as well as lecturer widely on the subject of foot health and podiatry. In 2018 he retired from clinical contact practice to concentrate on writing and public speaking.


Thanks for reading this article on ‘hammer toes and what the clinician should know’ written by David R Tollafield

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August 2020