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Amputation of a crossover 2nd toe in the presence of hallux valgus
The Foot 13 (2003) 196–198
Amputation of a crossover 2nd toe in the presence of hallux valgus R.O. Sundaram∗ , H.P.J. Walsh Department of Orthopaedics, University Hospital Aintree, Lower Lane, Liverpool L9 7AL, UK Received 3 February 2003; received in revised form 5 May 2003; accepted 19 May 2003
Abstract Background: There are many surgical procedures for the correction of hallux valgus and crossover 2nd toe deformity. Amputation of a crossover 2nd toe is often performed as a salvage procedure if the primary 2nd toe corrective procedure fails. Aims: To assess the outcomes of amputating a crossover 2nd toe in the presence of hallux valgus in elderly patients above 70 years old; as a primary procedure. Materials and methods: Seven patients (8 ft) underwent amputation of their crossover 2nd toe. A disease specific questionnaire using a Visual Analogue Scale (VAS) was implemented measuring pain, deformity, discomfort, and walking distance. Results: The mean age of the patients was 82 years old, range 74–89 years old. Amputation of the 2nd toe significantly reduces pain, discomfort and the appearance of deformity, there was no difference in the patient’s walking distance after surgery. Conclusion: We recommend this type of surgery as a primary procedure in elderly patients above 70 years old, if the first ray is not causing symptoms. © 2003 Elsevier Ltd. All rights reserved. Keywords: Amputation; 2nd toe; Elderly; Primary procedure
1. Introduction Crossover 2nd toe is common and troublesome foot condition often associated with hallux valgus. Quite often the hallux valgus is asymptomatic or minimally symptomatic but causes problems with the 2nd toe. There are approximately 130 different types of surgery for correction of hallux valgus; several surgical procedures have been described for the correction of 2nd toe crossover deformity [1,2]. Corrective surgery of the great and 2nd toes requires 6–12 weeks of recovery and rehabilitation. Many elderly people above 70 years old can find the recovery period quite debilitating. Amputation of a crossover 2nd toe in the presence of asymptomatic hallux valgus, although not corrective surgery; can alleviate the symptoms of the 2nd toe. This type of surgery has advantages; especially in the elderly patients [3]. The operation is a day case procedure, it can be performed under local anaesthetic; patients are mobilized immediately and the recovery period is very short. We aim to review outcomes of elderly patients above 70 years old ∗ Corresponding author. Present address: Department of Orthopaedics, Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral CH49 5PE, UK. Tel.: +44-151-678-5111x6339; fax: +44-125-339-1330. E-mail address: [email protected] (R.O. Sundaram).
0958-2592/$ – see front matter © 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0958-2592(03)00044-0
whom had undergone amputation of their crossover 2nd toe in the presence of hallux valgus.
2. Materials and methods Seven patients (8 ft) underwent amputation of the 2nd toe in the presence of hallux valgus between January 1999 and December 2001. One patient underwent bilateral amputation of the 2nd toes. All patients presented with a history of hallux valgus, though their primary complaint was pain of their crossover 2nd toe over the great toe. Patients selected for surgery were to: (1) be above 70 years old; (2) have hallux valgus which was asymptomatic or minimally symptomatic; (3) have a crossover 2nd toe over the great toe; (4) have significant pain on wearing standard or modified footwear; (5) have failure of conservative management of the symptomatic crossover 2nd toe; and (6) not want hallux valgus or 2nd toe correction surgery. All patients were given the option for the procedure to be performed under general or local anaesthetic. All the amputations were performed as a day case procedure by the second author. A standard racquet shaped incision was used to perform the amputation, the 2nd toe was amputated at the metatarso-phalangeal joint. All patients were seen at 2 and 6 weeks post surgery
R.O. Sundaram, H.P.J. Walsh / The Foot 13 (2003) 196–198
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and were subsequently discharged. Evaluation of the outcome of surgery was performed at a mean 18 months (range 10–44 months) post surgery using a disease specific Visual Analogue Scale (VAS) to determine pre-operative and post-operative symptoms. Patients were recalled to the outpatient clinic for assessment and to complete the VAS. Patients were assessed for pain, deformity, discomfort, and walking distance using a linear VAS. The VAS range was from 0 to 10, where 10 indicated the worst symptoms.
3. Results Seven patients were recruited in the study; six patients were female. The age range was 74–89 years, mean 82 years old. Four patients underwent amputation of the 2nd toe on the right foot; two patients on the left foot. One patient underwent bilateral amputation of the 2nd toes. Five patients had the procedure performed under a local anaesthetic; two patients underwent a general anaesthetic as they declined to have the procedure under a local anaesthetic. Four patients attended the outpatient clinic to complete the VAS, three patients were unable to attend the outpatients due to social circumstances and were asked to complete the VAS at home and return by post. The mean VAS for pain, deformity, discomfort, and walking distance before and after surgery are: [before/after] pain = [7.06/1.06]P<0.001 , deformity = [7.31/2.69]P<0.01 , discomfort = [7.81/1.31]P<0.001 and walking distance = [6.81/6.13]P<0.2 (paired t-test). There were no immediate or early post-operative complications. Patients were clinically assessed or asked to comment on any changes they noticed in their feet following surgery. Two patients noticed increasing valgus deformity of their great toe after 1 year but did not think this was symptomatic and did not want further corrective surgery. There were no other changes in the patients’ feet that were noted. All patients were extremely satisfied with the end result and would have this procedure performed again (Figs. 1 and 2).
Fig. 1. Crossover 2nd toe with hallux valgus.
Fig. 2. Post amputation of crossover 2nd toe.
4. Discussion Crossover of the 2nd toe is a common phenomenon, this may occur in patients with hallux valgus. The cause of this crossover is multi-factorial involving an imbalance between the intrinsic muscles and ligaments of the 2nd toe and extrinsic muscles [1]. The pathophysiology of crossover of the 2nd toe is poorly understood. Cadaveric evidence now shows that medial displacement of the flexor tendons and plantar plate are thought to play a role in the pathophysiology of the crossover 2nd toe in the presence of hallux valgus [4]. Several studies have shown that correction of crossover 2nd toe have resulted in good functional and cosmetic outcomes [1,2,5]. These favorable results have occurred in patients aged below 70 years old. Complications of corrective 2nd toe surgery include infection, persistent pain, long period of morbidity and recurrence of deformity. In particular, elderly patients may have poor peripheral circulation which needs to be carefully assessed prior corrective 2nd toe surgery. Failure of corrective 2nd toe surgery may lead to eventual amputation as a salvage procedure. There is little evidence in the literature regarding outcome measurements for crossover 2nd toe corrective surgery in the population aged above 70 years old. Hallux valgus and 2nd toe corrective surgery may be a major undertaking in the elderly above 70 years old, due to poor tolerance, poor mobility and difficult social circumstances. Amputation of a crossover 2nd toe is a well known procedure; again there is little evidence in the literature regarding patient outcomes in the elderly. All patients in our series were above 70 years old, range 74–89 years old, mean 82 years old. In this study, we show that amputation of the crossover 2nd toe in the presence of asymptomatic or minimally symptomatic hallux valgus significantly reduces the pain, deformity and discomfort of the foot. There was no difference in the mean walking distance as a result of the surgery. This study is limited in that only a small number of patients were recruited as we described six indications in order to perform the amputation surgery. Many patients in our
198
R.O. Sundaram, H.P.J. Walsh / The Foot 13 (2003) 196–198
orthopaedic practice who presented with great and 2nd toe problems did not fit all of the above criteria for amputation surgery. In a similar study by Anwar and Sundar [3], they reported 25 patients over a 10-year period who under went amputation of the second toe as a primary procedure. This study together with that of Anwar et al. show that a carefully selected few patients should undergo this procedure. To assess the outcomes of this study, we used VAS scores. Patient’s pre-operative scores were obtained at the follow-up clinic. Retrospective pre-operative VAS scores were obtainable as all patients could clearly remember the severity of their symptoms prior surgery. All the patients’ pre-operative VAS scores for pain, deformity and discomfort were significantly higher than their post-operative VAS scores. All the patients in this study were extremely happy with their end result; they would all have the same surgery performed again.
5. Conclusion Our study shows that the amputation of the 2nd toe in the presence of asymptomatic or minimally symptomatic hallux valgus in the elderly population above 70 years of age significantly reduces pain, deformity and discomfort. There
is no improvement in the achievable walking distance after surgery. Although this type of surgery is a common procedure; this is only the second study in the English medical literature which has been performed showing the outcome of the surgery. Our findings confirm the findings of Anwar and Sundar [3] that amputation of a crossover 2nd toe may be of benefit in the elderly population. Surgeons should be aware that amputation of a crossover 2nd toe may be of benefit to the elderly patient as a primary procedure than a secondary salvage procedure.
References [1] Coughlin MJ. Crossover second toe deformity. Foot Ankle 1987;8:29– 39. [2] Bogy LT, Vranes R, Goforth WP, Caporusso JM. Correction of overlapping second toe deformity: long term results including a 7 year follow up. J Foot Surg 1992;31:319–23. [3] Anwar M, Sundar MS. Results of second toe amputation: for overriding second toe with asymptomatic hallux valgus and as salvage procedure following failed hammer-toe surgery. Foot Ankle Surg 2002;8:85–8. [4] Deland JT, Sung I. The medial crossover toe: a cadaveric dissection. Foot Ankle Int 2000;21:375–8. [5] Graziano TA. Correction of crossover second toe deformity. Clin Podiatric Med Surg 1996;13:269–78.
Amputation of a crossover 2nd toe in the presence of hallux valgus R.O. Sundaram∗ , H.P.J. Walsh Department of Orthopaedics, University Hospital Aintree, Lower Lane, Liverpool L9 7AL, UK Received 3 February 2003; received in revised form 5 May 2003; accepted 19 May 2003
Abstract Background: There are many surgical procedures for the correction of hallux valgus and crossover 2nd toe deformity. Amputation of a crossover 2nd toe is often performed as a salvage procedure if the primary 2nd toe corrective procedure fails. Aims: To assess the outcomes of amputating a crossover 2nd toe in the presence of hallux valgus in elderly patients above 70 years old; as a primary procedure. Materials and methods: Seven patients (8 ft) underwent amputation of their crossover 2nd toe. A disease specific questionnaire using a Visual Analogue Scale (VAS) was implemented measuring pain, deformity, discomfort, and walking distance. Results: The mean age of the patients was 82 years old, range 74–89 years old. Amputation of the 2nd toe significantly reduces pain, discomfort and the appearance of deformity, there was no difference in the patient’s walking distance after surgery. Conclusion: We recommend this type of surgery as a primary procedure in elderly patients above 70 years old, if the first ray is not causing symptoms. © 2003 Elsevier Ltd. All rights reserved. Keywords: Amputation; 2nd toe; Elderly; Primary procedure
1. Introduction Crossover 2nd toe is common and troublesome foot condition often associated with hallux valgus. Quite often the hallux valgus is asymptomatic or minimally symptomatic but causes problems with the 2nd toe. There are approximately 130 different types of surgery for correction of hallux valgus; several surgical procedures have been described for the correction of 2nd toe crossover deformity [1,2]. Corrective surgery of the great and 2nd toes requires 6–12 weeks of recovery and rehabilitation. Many elderly people above 70 years old can find the recovery period quite debilitating. Amputation of a crossover 2nd toe in the presence of asymptomatic hallux valgus, although not corrective surgery; can alleviate the symptoms of the 2nd toe. This type of surgery has advantages; especially in the elderly patients [3]. The operation is a day case procedure, it can be performed under local anaesthetic; patients are mobilized immediately and the recovery period is very short. We aim to review outcomes of elderly patients above 70 years old ∗ Corresponding author. Present address: Department of Orthopaedics, Arrowe Park Hospital, Arrowe Park Road, Upton, Wirral CH49 5PE, UK. Tel.: +44-151-678-5111x6339; fax: +44-125-339-1330. E-mail address: [email protected] (R.O. Sundaram).
0958-2592/$ – see front matter © 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0958-2592(03)00044-0
whom had undergone amputation of their crossover 2nd toe in the presence of hallux valgus.
2. Materials and methods Seven patients (8 ft) underwent amputation of the 2nd toe in the presence of hallux valgus between January 1999 and December 2001. One patient underwent bilateral amputation of the 2nd toes. All patients presented with a history of hallux valgus, though their primary complaint was pain of their crossover 2nd toe over the great toe. Patients selected for surgery were to: (1) be above 70 years old; (2) have hallux valgus which was asymptomatic or minimally symptomatic; (3) have a crossover 2nd toe over the great toe; (4) have significant pain on wearing standard or modified footwear; (5) have failure of conservative management of the symptomatic crossover 2nd toe; and (6) not want hallux valgus or 2nd toe correction surgery. All patients were given the option for the procedure to be performed under general or local anaesthetic. All the amputations were performed as a day case procedure by the second author. A standard racquet shaped incision was used to perform the amputation, the 2nd toe was amputated at the metatarso-phalangeal joint. All patients were seen at 2 and 6 weeks post surgery
R.O. Sundaram, H.P.J. Walsh / The Foot 13 (2003) 196–198
197
and were subsequently discharged. Evaluation of the outcome of surgery was performed at a mean 18 months (range 10–44 months) post surgery using a disease specific Visual Analogue Scale (VAS) to determine pre-operative and post-operative symptoms. Patients were recalled to the outpatient clinic for assessment and to complete the VAS. Patients were assessed for pain, deformity, discomfort, and walking distance using a linear VAS. The VAS range was from 0 to 10, where 10 indicated the worst symptoms.
3. Results Seven patients were recruited in the study; six patients were female. The age range was 74–89 years, mean 82 years old. Four patients underwent amputation of the 2nd toe on the right foot; two patients on the left foot. One patient underwent bilateral amputation of the 2nd toes. Five patients had the procedure performed under a local anaesthetic; two patients underwent a general anaesthetic as they declined to have the procedure under a local anaesthetic. Four patients attended the outpatient clinic to complete the VAS, three patients were unable to attend the outpatients due to social circumstances and were asked to complete the VAS at home and return by post. The mean VAS for pain, deformity, discomfort, and walking distance before and after surgery are: [before/after] pain = [7.06/1.06]P<0.001 , deformity = [7.31/2.69]P<0.01 , discomfort = [7.81/1.31]P<0.001 and walking distance = [6.81/6.13]P<0.2 (paired t-test). There were no immediate or early post-operative complications. Patients were clinically assessed or asked to comment on any changes they noticed in their feet following surgery. Two patients noticed increasing valgus deformity of their great toe after 1 year but did not think this was symptomatic and did not want further corrective surgery. There were no other changes in the patients’ feet that were noted. All patients were extremely satisfied with the end result and would have this procedure performed again (Figs. 1 and 2).
Fig. 1. Crossover 2nd toe with hallux valgus.
Fig. 2. Post amputation of crossover 2nd toe.
4. Discussion Crossover of the 2nd toe is a common phenomenon, this may occur in patients with hallux valgus. The cause of this crossover is multi-factorial involving an imbalance between the intrinsic muscles and ligaments of the 2nd toe and extrinsic muscles [1]. The pathophysiology of crossover of the 2nd toe is poorly understood. Cadaveric evidence now shows that medial displacement of the flexor tendons and plantar plate are thought to play a role in the pathophysiology of the crossover 2nd toe in the presence of hallux valgus [4]. Several studies have shown that correction of crossover 2nd toe have resulted in good functional and cosmetic outcomes [1,2,5]. These favorable results have occurred in patients aged below 70 years old. Complications of corrective 2nd toe surgery include infection, persistent pain, long period of morbidity and recurrence of deformity. In particular, elderly patients may have poor peripheral circulation which needs to be carefully assessed prior corrective 2nd toe surgery. Failure of corrective 2nd toe surgery may lead to eventual amputation as a salvage procedure. There is little evidence in the literature regarding outcome measurements for crossover 2nd toe corrective surgery in the population aged above 70 years old. Hallux valgus and 2nd toe corrective surgery may be a major undertaking in the elderly above 70 years old, due to poor tolerance, poor mobility and difficult social circumstances. Amputation of a crossover 2nd toe is a well known procedure; again there is little evidence in the literature regarding patient outcomes in the elderly. All patients in our series were above 70 years old, range 74–89 years old, mean 82 years old. In this study, we show that amputation of the crossover 2nd toe in the presence of asymptomatic or minimally symptomatic hallux valgus significantly reduces the pain, deformity and discomfort of the foot. There was no difference in the mean walking distance as a result of the surgery. This study is limited in that only a small number of patients were recruited as we described six indications in order to perform the amputation surgery. Many patients in our
198
R.O. Sundaram, H.P.J. Walsh / The Foot 13 (2003) 196–198
orthopaedic practice who presented with great and 2nd toe problems did not fit all of the above criteria for amputation surgery. In a similar study by Anwar and Sundar [3], they reported 25 patients over a 10-year period who under went amputation of the second toe as a primary procedure. This study together with that of Anwar et al. show that a carefully selected few patients should undergo this procedure. To assess the outcomes of this study, we used VAS scores. Patient’s pre-operative scores were obtained at the follow-up clinic. Retrospective pre-operative VAS scores were obtainable as all patients could clearly remember the severity of their symptoms prior surgery. All the patients’ pre-operative VAS scores for pain, deformity and discomfort were significantly higher than their post-operative VAS scores. All the patients in this study were extremely happy with their end result; they would all have the same surgery performed again.
5. Conclusion Our study shows that the amputation of the 2nd toe in the presence of asymptomatic or minimally symptomatic hallux valgus in the elderly population above 70 years of age significantly reduces pain, deformity and discomfort. There
is no improvement in the achievable walking distance after surgery. Although this type of surgery is a common procedure; this is only the second study in the English medical literature which has been performed showing the outcome of the surgery. Our findings confirm the findings of Anwar and Sundar [3] that amputation of a crossover 2nd toe may be of benefit in the elderly population. Surgeons should be aware that amputation of a crossover 2nd toe may be of benefit to the elderly patient as a primary procedure than a secondary salvage procedure.
References [1] Coughlin MJ. Crossover second toe deformity. Foot Ankle 1987;8:29– 39. [2] Bogy LT, Vranes R, Goforth WP, Caporusso JM. Correction of overlapping second toe deformity: long term results including a 7 year follow up. J Foot Surg 1992;31:319–23. [3] Anwar M, Sundar MS. Results of second toe amputation: for overriding second toe with asymptomatic hallux valgus and as salvage procedure following failed hammer-toe surgery. Foot Ankle Surg 2002;8:85–8. [4] Deland JT, Sung I. The medial crossover toe: a cadaveric dissection. Foot Ankle Int 2000;21:375–8. [5] Graziano TA. Correction of crossover second toe deformity. Clin Podiatric Med Surg 1996;13:269–78.