Three Common Toe Deformities and How They Are Related
Toe deformities are among the most common disorders in foot and ankle orthopedics. Toes contain some of the smallest bone structures found in the body but the pain they can generate is anything but small. Bunions, hallux valgus and hammer toes are three of the most common toe deformities. How are they interrelated and how are these conditions treated?
Hammer toe is a bending of one or both joints in any one of the four small toes caused by a muscle or tendon imbalance. It may occur due to previous trauma, such as a broken toe, or it may be hereditary. Hallux valgus, is a condition that affects the joint at the base of the big toe (the word “hallux” refers to the big toe and “valgus” refers to the deformity that moves the toe out of line and toward the lesser toes). The bump that grows on the side of the first metatarsophalangeal (MTP) joint is referred to as a bunion. Bunions, however, are more than just bumps on the big toe. Even though “bunion” is often used as the common term for hallux valgus, bunions are actually a separate, progressive disorder in which the big toe leans toward the second toe which throws the bones out of alignment, producing the bump.
According to the PearlDiver Patient Record Database, these toe deformities are differentiated into 10 different sectors shown below. (The PearlDiver database consists of over 136 million orthopedic patient records of patients up to 65 years of age collected by United Healthcare). Over four million patients experience toe deformities every year and the number is rising.
Table 1 shows the toe deformities and their annual number of occurrences in the PearlDiver database. Hallux valgus is the number one deformity followed closely by hammer toe. Bunion is a distant third.
Table 1: Deformities of Toes Diagnoses (2004-2007)
Source: PearlDiver Patient Record Database 2004-2007
To help explain the data, Dr. Steven L. Haddad, Associate Professor of Clinical Orthopedic Surgery at Northwestern University, is one physician who certainly knows toes. Dr. Haddad is the lead surgeon of a design team creating a new total ankle replacement in conjunction with Wright Medical Technologies, Inc. He has given over 200 national and international lectures on foot and ankle surgery and is currently practicing at Illinois Bone and Joint Institute, Glenview, Illinois.
OTW: Hallux valgus is often termed bunion, but these two conditions have separate diagnostic codes. What is the difference?
Dr. Haddad: Hallux valgus is a deformity of the great toe—it drifts towards the lesser toes. That may or may not occur with a bunion which is an isolated bump on the medial border of the foot at the first metatarsal head. Bunion is the Latin word for turnip, as it appears as a red prominence on the inside of the foot. You can have hallux valgus without a bunion and a bunion without hallux valgus.
Even though these conditions have separate diagnostic codes, they still appear to be interrelated. Table 2 illustrates the number of patients who were diagnosed with other toe deformities after the primary diagnoses. Out of the 112,591 patients diagnosed with bunions, 18,179 were later diagnosed with hammer toe and 43,971 patients were later diagnosed with hallux valgus. A similar analysis appears for hallux valgus and hammer toe in the table below.
Table 2: Patients Follow-Up Deformities AFTER (2004-2007)
Source: PearlDiver Patient Record Database 2004-2007
OTW: A good number of the patients who have had one of these deformities go on to be diagnosed with one or both of the other two as well. What do you see and is this common?
Dr. Haddad: I agree that you often see all three together, but that is not always the case. They are separate deformities. A hammer toe may occur when the great toe pushes on the second toe (from hallux valgus). Over time, this chronic pressure may cause the second toe to contract at the proximal interphalangeal joint, creating a hammer toe. A hammer toe may also occur due to the lack of push-off power from the great toe suffering from hallux valgus. The lesser toes may absorb that stress, creating increased pressure across the joints and a subsequent hammer toe.
Surgeons and doctors use numerous procedures to correct these deformities. Appropriate shoes and foot pads are generally recommended. The following table shows the number of corrective treatments performed for each diagnoses. Metatarsal osteotomy (a surgical operation of dividing the metatarsal bone or cutting out a piece of the metatarsal bone) is generally performed for bunion and hallux valgus while a corrective procedure like interphalangeal fusion is performed for hammer toe. These deformities are treated primarily in an outpatient setting. Less than 1% of patients are treated as inpatients.
Table 3: Procedures Following These Toe Deformities (2004-2007)
Source: PearlDiver Patient Record Database 2004-2007
From PearlDiver data, one can estimate that, nationally, over one million surgical procedures are performed annually for toe deformities. Almost 99% of the patients are treated in a physician’s office while fewer than 10,000 procedures are performed in an inpatient setting.
OTW: What are the most common procedures related to these deformities and what surgical corrections have been the most successful in correcting them? Do these deformities come back again?
Dr. Haddad: There are over one hundred procedures described to correct bunions. The most common procedures are distal osteotomies (i.e., Chevron osteotomy) for smaller bunion deformities, and proximal procedures (i.e., crescentic osteotomies, opening wedge osteotomies) for greater deformity. For an unstable first metatarsocuneiform joint due to gross ligament laxity, fusion of the first MTC joint is performed (a Lapidus procedure). Most bunion procedures work to correct the deformity. The key is in selecting the appropriate procedure based on the magnitude of the deformity and the pathophysiology of the bunion for that individual patient. Hammer toe deformities are corrected in a more standard fashion: resecting the proximal interphalangeal joint and pinning it straight with a removable pin. If there is a contracture about the metatarsophalangeal joint, then lengthening the lesser toe extensor tendons and cutting the dorsal capsule are performed simultaneously.
OTW: Nationally, we are looking at over three million patients experiencing toe deformities while just over one million are surgically corrected. Do you think these deformities have been overlooked and not much has been written about them?
Dr. Haddad: No, I don’t think this deformity has been overlooked. It is simply the case that many patients with lesser toe or great toe deformities do not require surgery for they are not symptomatic. The only reason to operate on a person with these deformities is pain or difficulty with shoe wear.
OTW: Are there controversies related to treatments for these deformities? What about innovation and new techniques for better treatment? Are the current treatments being well received?
Dr. Haddad: There are plenty of controversies. For bunion deformities there are those who think the first MTC joint is always lax and needs to be fused. Others think that it is never hyper mobile and that proximal procedures work as well as fusions. There has been much testing in this area to determine if bunions are created by lax joints, primarily the first MTC joint. Hammer toes are not terribly controversial but if the second toe has synovitis at the MTP joint, and the joint dislocates or crosses over the great toe, there is controversy on how to reduce and stabilize that joint. Most favor tendon transfers to hold the second toe in position. Some favor cutting the bone of the second metatarsal head and shortening it to decompress the joint. There is no good answer as to which works better, though it seems that tendon transfers make the toe stiffer, and osteotomies cause the toe to be elevated and not touch the ground. The StayFuse by Tornier is one such product that is used as a new method for correcting hammer toes. The OrthoHelix plates and the Wright Medical plates are also new technologies for securing bunion osteotomies.
OTW: Which companies and products do you use and who is the largest distributor of toe deformities products?
Dr. Haddad: Mostly screw products. Some are beginning to use plates. Synthes makes cannulated screws that many surgeons use. Wright Medical also makes very good plates for bunion corrections. Tornier makes a component to stabilize lesser toe PIP joints called the StayFuse. It works well to hold the toe straight, and avoids pin fixation. OrthoHelix has some innovative plates as well.
How much does it cost to treat these conditions? Table 4 below shows the surgical correction treatments for the three main toe deformities. Except for the injection procedure, represented by CPT-20550, every other surgical procedure cost is in the range of $1,200 to $2,700. Inpatient charges are a different story. Fewer than 1,000 patients in the PearlDiver database were treated as inpatients over the four years of this data. The average charges for these patients were between $20,000 and $25,000 and they had hospital stays ranging from a day and a half to two days.
Table 4: Average Charges for Toe Deformities
Source: PearlDiver Patient Record Database 2004-2007
Temporary relief from toe deformities can be obtained by wearing proper shoes or shoe pads but surgical correction is often necessary and has been well received by both surgeons and patients. It is common for patients to get diagnosed with second toe deformities, as illustrated by PearlDiver data and Dr. Haddad’s personal experience, so patients with toe deformities should keep a careful watch on their feet after initial treatments. With more than one million surgical corrections performed annually, companies such as Wright Medical, Tornier, and Synthes have established themselves as pioneers within the toe deformity market. As they continue research on better devices and treatments, little toes will hopefully become less of a big pain.