755472

research-article2018
FAIXXX10.1177/1071100718755472Foot & Ankle InternationalMueller et al

Article
Foot & Ankle International®

Complication Rates and Short-Term

1­–8
© The Author(s) 2018
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Outcomes After Operative Hammertoe sagepub.com/journalsPermissions.nav
DOI: 10.1177/1071100718755472
https://doi.org/10.1177/1071100718755472

Correction in Older Patients journals.sagepub.com/home/fai

Claire Mackenzie Mueller, BA1 , Stephanie Ann Boden, BA1,

Allison Lee Boden, BA1, Samuel David Maidman, BA1, Anya Cutler, BA, MS2,
Danielle Mignemi, MS, ATC3, and Jason Bariteau, MD1

Abstract
Background: Hammertoe deformities are the most common lesser toe deformity. To date, no studies have looked
at outcomes of operative management in the geriatric population, which may be at greater risk for complications or
functional compromise because of comorbidities.
Methods: Data on 58 patients undergoing operative correction of hammertoe deformities were prospectively collected.
Clinical outcomes were assessed using preoperative and postoperative visual analogue scale (VAS) and Short Form Health
Survey (SF-36) scores with a minimum of 6-month follow-up. Patients were divided into 2 groups on the basis of age at
the time of surgery: younger than 65 and 65 and older. Complication rates and mean VAS and SF-36 improvement were
compared. Forty-seven patients met inclusion criteria (7 men, 40 women), with 26 patients (37 toes) in the younger cohort
and 21 patients (39 toes) in the older cohort.
Results: Overall, patients demonstrated significant improvement from baseline to 6 and 12 months postoperatively in
VAS (P < .001 and P < .001) and SF-36 (P < .001 and P < .001) scores. Mean improvement in VAS and SF-36 scores was not
significantly different between the groups at 6 and 12 months postoperatively. Complications occurred in 13.5% and 10.3%
of patients in the younger and older cohorts, respectively.
Conclusions: Outcomes of operative correction of hammertoe deformities in older patients were similar to outcomes
in younger patients after greater than 6 months of follow-up. Overall improvement in VAS and SF-36 was statistically
significant for both cohorts. There was no associated increase in complications for older patients.
Level of Evidence: Level, III comparative series.

Keywords: hammertoe deformity, older patients, geriatrics, outcome studies, forefoot disorders

Hammertoe deformities are the most common lesser toe
deformities and can cause significant pain and dysfunction.10
A recent study found that lesser toe surgery makes up 48%
of all forefoot operations.16 Hammertoe deformities often
affect multiple toes, with nearly 40% of patients having 3 or
more toes involved.3 The natural history of the deformity
involves the joint transitioning from being flexible to rigid,
arthritic, and fixed.10
Nonoperative treatment for pain associated with a ham-
mertoe deformity includes improving footwear, using pads
over calluses to prevent abrasions, and daily stretching of
the joints.1 Operative correction is indicated when conser-
vative intervention fails. A number of different operative
interventions have been used for the management of painful
hammertoe deformities, including flexor-to-extensor trans-
fer, interphalangeal joint arthroplasty, arthrodesis, and plan-
tar plate repair. In the literature, tendon releases and
transfers are commonly used for flexible and mobile ham-
mertoe deformities.
Although various methods exist for operative treat-
ment of painful hammertoe deformities, few reports have
analyzed clinical outcomes following operative manage-
ment. Additionally, although old age has been shown to
play a significant role in the development of a hammertoe
deformity,10 no studies have looked specifically at opera-
tive outcomes of hammertoe correction in the geriatric
patient population. This warrants further investigation, as
geriatric patients are generally at increased risk for opera-
tive complications relative to their younger counterparts.
This is due in part to their existing comorbidities and
1
Emory University School of Medicine, Atlanta, GA, USA
2
Rollins School of Public Health, Atlanta, GA, USA
3
Emory Orthopaedics and Spine Center, Atlanta, GA, USA
Corresponding Author:
Jason Bariteau, MD, Emory Orthopaedics and Spine Center, 59
Executive Park South, Suite 2000, Atlanta, GA 30329, USA.
Email: jason.bariteau@emory.edu
2 Foot & Ankle International 00(0)
age-associated changes.16 Additionally, these patients are
often limited in mobility, which may further compromise
the path to recovery from operative correction of ham-
mertoe deformities.
The aim of this study was to examine differences in out-
comes of pain, improvement of physical and mental quality
of life, and complication rates in younger compared with
older patients who underwent operative correction of ham-
mertoe deformities. We hypothesized that patients 65 years
and older would have worse outcomes as measured by
visual analogue scale (VAS) and Short Form Health Survey
(SF-36) scores and have a higher complication rate com-
pared with patients younger than 65 years of age.
Methods
This study is a retrospective observational study of prospec-
tively collected data. We identified all patients who under-
went operative correction of hammertoe deformities between
August 1, 2014, and December 1, 2016. Individuals who
indicated a willingness to participate were given information
about the purpose of the study and the risks and benefits of
participation. Patients were informed that participation in
the study was strictly voluntary.
We identified 69 patients who underwent operative cor-
rection of hammertoe deformities and met inclusion crite-
ria. Of those identified, 58 patients (76 toes) were enrolled
in the study over a 2.5-year period. Forty-seven patients (7
men, 40 women) had at least 6 months of follow-up data
(81% follow-up rate) and were included in our analysis.
These patients had a mean age of 60.9 years. The 11 patients
(19% attrition rate) without 6 months of follow-up were cat-
egorized as “lost to follow-up” and were not included in our
analysis. Of the patients included in analysis, 12 (25.5%)
did not have complete data and were called retrospectively
to complete data collection. The mean change in scores did
not differ significantly between the patients who completed
data collection at the time of follow-up and those who were
called to complete surveys retrospectively.
After splitting patients into 2 groups on the basis of age
at the time of surgery, there were 26 patients in the younger
cohort (37 toes) and 21 patients in the older cohort (39
toes), with mean ages of 52.7 years (range, 25–64 years)
and 71.0 years (range, 65–82), respectively. The mean fol-
low-up length was 8.5 months in the younger group and
10.3 months in the older group. Smoking status, diabetes,
rheumatoid arthritis, body mass index, and use of blood
thinners were recorded for each patient. With the numbers
available, there was no significant difference in the pres-
ence of these covariates between the 2 age groups (P =
.470, P = .413, P = .826, P = .182, and P = .291, respec-
tively), and there was no significant difference in the num-
ber of hammertoes addressed per surgery between the
cohorts (P = .088) (Table 1). There were significantly more
flexor-to-extensor transfer procedures completed among
patients aged less than 65 years (P = .03). There was no
significant difference in the number of other adjunct proce-
dures completed at the time of surgery between the 2
groups (Table 1).
A single senior surgeon performed all operations.
Operative technique for each toe involved a proximal inter-
phalangeal (PIP) arthroplasty and flexor tenotomy. If the
toe demonstrated persistent extension contracture at the
metatarsophalangeal joint, the patient underwent extensor
lengthening. If continued extension was noted following
lengthening, a capulsotomy of the metatarsophalangeal
joint was performed. If a plantar plate tear was present, or if
the toe could not be adequately reduced with a capsulotomy,
a Weil osteotomy was performed. Finally, ligamentous
reconstruction and flexor transfer was performed for any
continued angular toe deformity: the long flexor tendon was
brought up and transferred to the extensor hood on the side
of the continued deformity. As an example, for a varus toe,
the flexor tendon was brought up the medial side of P1 and
transferred to the extensor hood. All PIP joints were stabi-
lized with two 0.062 Kirschner wires. Weil osteotomies
were fixed with 1 or 2 twist-off screws. Following surgery,
all patients were full weightbearing on their heel in a post-
operative shoe or boot. Sutures were removed after 2 weeks.
At 5 to 6 weeks, the Kirschner wires were removed, and
patients were advanced to full weightbearing. Patients were
then transitioned to normal shoes as tolerated.
Subjective assessments of pain and function were
obtained at regular intervals using a 10-point VAS and the
SF-36. The SF-36 survey was used to compute a physical
component score (PCS) and mental component score
(MCS). VAS and SF-36 scores were obtained preopera-
tively to establish baseline scores and were also obtained at
6 and 12 months postoperatively at the patients’ follow-up
appointments. Patients who were enrolled but did not have
complete data were called retrospectively to complete the
surveys. Patients who did not have at least 6 months of fol-
low-up data were excluded from the analysis and were con-
sidered lost to follow-up.
Prior to data analysis, patients were divided into 2 groups
on the basis of age at the time of surgery: those younger
than 65 years and those 65 years and older. The improve-
ments in mean VAS and SF-36 scores for the younger
patients and older patients were determined. A retrospective
chart review was conducted on all patients, and all opera-
tive and postoperative complications were noted.
Statistical Analysis
Student t tests were used to assess whether there were sig-
nificant changes between baseline VAS score, PCS, and
MCS and 6 and 12 months postoperatively across all
patients. Patients were then split into 2 age groups: those
Mueller et al 3

Table 1.  Descriptive Characteristics of Study Population by Age.a

Variable Age < 65 y Age ≥ 65 y P

Participants (toes) 26 (37) 21 (39)  
Age, mean (range), y 52.7 (25–64) 70.9 (65–82)  
Follow-up length, mean, mo 8.5 10.3  
Comorbidities  
  Ever smoker 4 (15.4) 5 (10.6) 0.470
  Diabetes or prediabetes 3 (6.4) 1 (2.1) 0.413
  Rheumatoid arthritis 3 (6.4) 2 (4.3) 0.826
  BMI, mean (95% CI), kg/m2 29.7 (27.1–32.3) 27.9 (25.3–30.5) 0.182
  On blood thinners 7 (15.6) 8 (17.8) 0.291
Number of hammertoes addressed 1.4 (1–4) 1.9 (1–4) 0.088
per patient, mean (range)
Adjunct procedures  
  PIP arthroplasty 24 (92.3) 15 (71.4) 0.12
  Flexor-to-extensor transfer 18 (69.2) 8 (38.1) 0.03
  Extensor transfer 7 (26.9) 6 (28.6) 0.90
  Extensor lengthening 14 (53.8) 9 (42.9) 0.45
  Flexor transfer 1 (3.8) 0 (0.0) 1.00
  Flexor tenotomy 10 (38.5) 11 (52.4) 0.34
  Weil osteotomy 12 (46.2) 6 (28.6) 0.22
  Plantar plate repair 7 (26.9) 3 (14.3) 0.29
  MTP joint capsulotomy 19 (73.1) 12 (57.1) 0.25
  Lateral collateral ligament 4 (15.4) 4 (19.0) 1.00
reconstruction
 Bunionectomy 4 (15.4) 2 (9.5) 0.68
  Calcaneal bone graft 1 (3.8) 2 (9.5) 0.57
  Corn debridement 0 (0.0) 1 (4.8) 0.45

Abbreviations: BMI, body mass index; CI, confidence interval; MTP, metatarsophalangeal; PIP, proximal interphalangeal.
a
Data are expressed as number (percentage) except as indicated.

younger than 65 years and those 65 years or older at the
time of surgery. Fisher exact tests were used to determine if
the age groups differed in the number of subjects with a
variety of different comorbidities. Differences in the
change in scores from baseline to 6 or 12 months postop-
eratively between age groups were assessed using one-way
analysis of variance. Multiple linear regression models
were run to determine if an association existed between the
change in score and age group after controlling for smok-
ing, diabetes, blood thinners, rheumatoid arthritis, and
body mass index. The above statistical tests were per-
formed using SAS version 9.4 (SAS Institute, Cary, NC).
Two-tailed P values ≥ .05 were considered to indicate sta-
tistical significance.
Repeated-measures analyses were also used to analyze
the VAS and the physical and mental components of the
SF-36 using a means model via SAS MIXED PROC, pro-
viding separate estimates of the means by age group (<65 or
≥65 years) and months of follow-up (baseline and 6 and 12
months after surgery). A compound-symmetric variance-
covariance form in repeated measurements was assumed
for each outcome, and robust estimates of the standard
errors of parameters were used to perform statistical tests
and construct 95% confidence intervals.5 Predictors
included in each model were age group, follow-up interval,
and the interaction between age group and follow-up inter-
val. All specific statistical tests were done within the frame-
work of the mixed-effects linear model, using t tests to
compare differences between the model-based means. The
results were summarized with adjusted means and 95%
confidence intervals by age group and follow-up interval.
Statistical tests were 2 sided and unadjusted for multiple
comparisons. P values ≤ .05 were considered to indicate
statistical significance.
Results
Overall, VAS scores significantly improved at both 6 and 12
months postoperatively (P < .001 and P < .001, respec-
tively) (Table 2, Figure 1). PCSs also significantly improved
from baseline to 6 months postoperatively (P < .0126) and
from baseline to 12 months postoperatively (P < .001)
(Table 2, Figure 2). For MCSs, change was significant only
12 months postoperatively (P < .001).
4 Foot & Ankle International 00(0)

Table 2.  Mean VAS and SF-36 Scores.a

Variable All Patients (n = 47) Pb Age < 65 y (n = 26) Age ≥ 65 y (n = 21) Pc

VAS Score  
 Preoperative 4.4 (3.6 to 5.2) 4.7 (3.6 to 5.7) 4.1 (3.0 to 5.2) .462
  6 mo 2.1 (1.5 to 2.7) <.001 2.3 (1.5 to 3.0) 1.9 (1.0 to 2.9) .605
  12 mo 1.1 (0.6 to 1.6) <.001 0.86 (0.11 to 1.6) 1.3 (0.10 to 2.4) .575
  Δ Baseline to 6 mo −2.3 (–3.1 to −1.5) −2.4 (–3.7 to −1.1) −2.2 (–3.3 to −1.0) .766
  Δ Baseline to 12 mo −3.5 (–4.3 to −2.6) −3.9 (–5.9 to −1.9) −3.4 (–4.9 to −1.9) .637
SF-36 physical component score  
 Preoperative 60.8 (55.0 to 66.7) 62.6 (54.5 to 70.7) 58.7 (50.1 to 67.2) .520
  6 mo 71.6 (65.7 to 77.4) .0126 74.7 (67.3 to 82.1) 67.7 (58.3 to 77.0) .251
  12 mo 76.6 (70.1 to 83.0) <.001 83.3 (76.2 to 90.4) 70.8 (61.4 to 80.3) .0515
  Δ Baseline to 6 mo 12.0 (5.71 to 18.4) 14.5 (4.7 to 24.3) 9.0 (0.2 to 17.8) .397
  Δ Baseline to 12 mo 10.1 (4.81 to 15.4) 11.7 (1.8 to 21.4) 11.3 (3.6 to 19.1) .954
SF-36 mental component score  
 Preoperative 81.0 (75.7 to 86.2) 77.7 (70.0 to 85.4) 84.9 (78.2 to 91.4) .153
  6 mo 71.6 (65.7 to 77.4) .367 82.5 (76.2 to 88.9) 86.0 (80.0 to 92.1) .438
  12 mo 90.1 (86.0 to 94.1) <.001 89.1 (81.4 to 96.7) 90.9 (86.7 to 95.0) .679
  Δ Baseline to 6 mo 5.02 (–0.84 to 10.9) 8.2 (−1.0 to 17.5) 1.2 (–6.7 to 9.0) .249
  Δ Baseline to 12 mo 5.04 (–0.59 to 10.7) 5.4 (–5.1 to 15.9) 5.4 (−1.9 to 12.6) .994

Abbreviations: SF-36, Short Form Health Survey; VAS, visual analogue scale.
a
Data are expressed as mean (95% confidence interval).
b
P value correlates with P value between preoperative score and specific time point for all patients.
c
P value correlates with P value between means of patients <65 and ≥65 years of age.

Figure 1.  Mean visual analogue scale scores at baseline and 6 and 12 months postoperatively.

Although VAS and SF-36 scores showed improvement for
both age groups independently, with the numbers available,
there was no significant difference in scores between the 2
groups at 6 and 12 months postoperatively (Table 2, Figures
1 and 2). To account for variance in scores, we calculated
delta values that reflected improvement in scores from base-
line (preoperatively) to the determined postoperative time
points. The mean changes in VAS scores from baseline to 6
months and from baseline to 12 months postoperatively were
not significantly different between the 2 groups, with P val-
ues of .766 and .637, respectively (Table 2, Figure 1). The
mean improvements in SF-36 PCS preoperatively to 6
months postoperatively (P = .397) and preoperatively to 12
months postoperatively (P = .945) were not significantly dif-
ferent between the 2 groups (Table 2, Figure 2). Additionally,
preoperative scores at 6 and 12 months postoperatively for
Mueller et al 5

Figure 2.  Mean SF-36 physical component scores (PCSs) and mental component scores (MCSs) at baseline and 6 and 12 months
postoperatively.

the SF-36 MCS were not significantly different between Table 3.  Complication Rates per Hammertoe Correction.
the 2 groups, with P values of .249 and .994, respectively
(Table 2, Figure 2). Variable Age < 65 y Age ≥ 65 y P
Multiple linear regression models showed no significant Overall complication rate 13.5% (5/37) 10.3% (4/39) .665
association between age group and delta score after con- Complications reported  
trolling for a variety of comorbidities, indicating no sig-   Valgus malalignment 2.7% (1/37) 0.0% (0/39)  
nificant difference in improvement of pain or function  DVT/PE 5.4% (2/37) 0.0% (0/39)  
between age groups (Table 1). Additionally, none of the   Pain/hardware removal 0.0% (0/37) 2.6% (1/39)  
covariates tested showed a significant association with  Other 0.0% (0/37) 5.1% (2/39)  
VAS score, PCS, or MCS.  Recurrence 0.0% (0/37) 2.6% (1/39)  
When using the repeated-measures statistical model, with  Revision 5.4% (2/37) 0.0% (0/39)  
main effects for age group, time, and the interaction between
Abbreviations: DVT, deep vein thrombosis; PE, pulmonary embolism.
age group and time, we found similar results. VAS scores in
the 2 age groups changed in similar ways during the year of
follow-up when testing for interaction between time and age cases of recurrence in the younger group. Other complica-
group (P = .33). Both SF-36 PCS and MCS in the 2 age tions in the younger group included valgus malalignment (1
groups also changed in similar ways during the year of fol- of 37 toes), deep vein thrombosis or pulmonary embolism
low-up (P = .34 and P = .44, respectively). Mean VAS and (3 of 37 toes), and revision surgery (5 of 39 toes). Other
SF-36 physical and mental components in the 2 age groups complications in the older cohort included pain/hardware
were similar when testing the time-averaged differences removal (2 of 39 toes), and other/nonspecified (2 of 39
between the 2 groups (P = .78, P = .16, and P = .76, respec- toes). No patients in either age group developed floating
tively). Again, the overall improvement during the year of toes postoperatively. There was no significant difference in
follow-up in VAS scores and SF-36 physical component was complication rates between age groups (P = .665).
significant (P < .001 and P < .001, respectively).
Overall complication rates were 13.5% (5 of 37) and
Discussion
10.3% (4 of 39) for the younger and older cohorts, respec-
tively (P = .665) (Table 3). In our follow-up period, there Between 2000 and 2011, repair of hammertoe deformity was
was 1 case of recurrence of the hammertoe deformity the most common foot and ankle surgery in the Medicare
requiring revision surgery in the older group (2.6%) and no population, with 114,993 procedures costing $1.04 billion.2
6 Foot & Ankle International 00(0)
The estimated economic burden of foot and ankle surgery in
the Medicare population was $11 billion in 2011, an increase
of 38.2% from 2000. Indirect productivity costs were
responsible for 89% of the $11 billion total, suggesting that
function, pain, and complications are extremely important
outcomes in the geriatric population. Additionally, by 2050,
the population of adults aged 65 and older is projected to be
83.7 million, double the 43.1 million in 2012.15 As an
increasing share of the population older than 65 remains in
the work force, correcting deformities that affect functional-
ity in older Americans is even more important.2
As the population continues to age, it is important to
examine operative outcomes in this unique group of
patients. However, a large gap exists in the literature regard-
ing operative outcomes of hammertoe deformity in the geri-
atric population, which is clinically relevant, as old age has
been shown to be a major contributing factor in the devel-
opment of a hammertoe deformity.10 In this study we exam-
ined differences in outcomes of pain, improvement of
physical and mental quality of life, and complication rates
in younger patients compared with older patients who
underwent operative correction of hammertoe deformities.
A number of different operative interventions have been
suggested and tried in the management of painful hammer-
toe deformities, both simple and complex; however, no
single approach has been accepted as the gold standard.1,3,10
The best operative plan often takes into account multiple
variables, including age, activity level, patient expectations,
and precise etiology of the hammertoe deformity.9 In our
study, all hammertoes were treated with PIP arthroplasty,
extensor lengthening, and flexor tenotomy with possible
transfer. Additional operative techniques were tailored to
each patient’s deformity according to surgeon preference.
Although a number of different operative techniques
were used, all procedures were completed by the same sur-
geon. There was a statistical difference in the frequency of
flexor-to-extensor transfers between the 2 groups, but there
was no statistical difference between age groups of any of
the other adjunct procedures (Table 1). This may indicate
that more angular deformity was seen in younger patients.
However, prior studies have demonstrated that there is no
significant difference in VAS scores and postoperatively
measured angular deformity among patients undergoing
various operative techniques for hammertoe correction,
with joint resection arthroplasty, PIP arthrodesis without
osteotomy, and interpositional implant arthroplasty.19
We found that when all patients were combined, both
VAS score and PCS significantly improved at the 6- and
12-month time points postoperatively, while MCS improved
at 12 months. Additionally, with the numbers available,
there was no significant difference found in improvement of
pain or functioning at either postoperative time period
between the 2 age groups, including when analyzing the
data using a repeated-measures statistical model. These
results suggest that hammertoe surgery improves pain and
physical functioning both 6 and 12 months after surgery,
and emotional quality of life at 12 months, for all patients
regardless of age. The mean improvement in VAS scores
after 6 and 12 months for both age groups was greater than
1.2 points, which has been cited as the minimal clinically
important difference.6,8,11 These improvements in VAS
scores demonstrate that operative management is associated
with clinically significant reduction of pain in both younger
and older patients. Thresholds of 2.5, 3, or 5 points on the
PCS and MCS have been cited as minimal clinical improve-
ments in studies of rheumatoid arthritis.12,20 The improve-
ment of SF-36 scores in our study was markedly higher than
the minimum threshold for clinical improvement. This sug-
gests that operative management of hammertoe deformities
is also associated with clinically significant improvements
in physical and emotional quality of life, regardless of age.
After controlling for comorbid conditions using multiple
regression analysis, there was still no significant difference
in improvement of pain or function between age groups.
Complication rates for operative hammertoe correction
vary widely in the literature, and none are stratified on the
basis of age. Catena et al3 reported a complication rate of
5% (2 of 42), all of which were superficial infections.
O’Kane and Kilmartin14 had complication rates of 60% (15
of 25) for complex hammertoe corrections and 21.3% (16
of 75) for simple hammertoe corrections; 3 toes had super-
ficial wound infections, 18 toes were floating toes, and 4
toes were still slightly hammered following surgery. In our
follow-up period, there was only 1 case of recurrence of the
hammertoe deformity, which occurred in a patient in the
older age group. No patients in either group developed a
floating toe postoperatively. Complication rates per ham-
mertoe were 13.5% (5 of 37) and 10.25% (4 of 39) for the
younger and older cohorts, respectively, which compared
favorably with rates reported in the literature.
In general, geriatric patients are at increased risk for
postoperative complications relative to their younger coun-
terparts. This is due in part to existing comorbidities and
age-associated changes in older individuals.17 Despite this
general trend, we found no difference in operative compli-
cation rates or hammertoe recurrences between those 65
and older and those younger than 65.
Because of the relatively small sample sizes in each
group and the results demonstrating no statistical difference
in mean VAS or SF-36 scores between age groups, we con-
ducted a post hoc power analysis. Our analysis revealed that
with our sample sizes, the study was adequately powered to
detect a mean difference of 0.9 points in the VAS, 11 points
in the SF-36 physical component, and 12 points in the
SF-36 MCS between age groups. As we were powered to
detect a difference of 0.9 points on the VAS scale, which is
below the aforementioned minimal clinically important dif-
ference, if any difference in VAS scores existed between
Mueller et al 7
groups, it was smaller than the minimal clinically important
difference and therefore likely to be clinically insignificant.
For the SF-36 MCS and PCS, the study was powered to
detect differences of 11 and 12 points, respectively. The
reported differences between age groups in the present
study were 7.4 points for the PCS and 1.6 points for the
MCS. Because the study was not powered to detect differ-
ences that were as small as those observed, it is possible that
there may be a statistically significant difference in these
domains. However, because the observed differences were
clinically small, it is unlikely that there would be a clini-
cally significant difference between age groups.
Although we did not control for the adjunctive operative
procedures, the frequencies of the adjunctive procedures
were not significantly different between groups for all but
flexor-to-extensor transfer (Table 1). As discussed above,
prior studies have shown that postoperatively measured
angular deformity does not significantly affect VAS
scores.19 As none of the other procedures were significantly
different, this minimizes the potential for the adjunctive
procedures to have had an impact on VAS scores, SF-36
scores, or complication rates between the 2 age groups.
Additionally, we did not collect data at time intervals prior
to 6 months postoperatively. Therefore, we could not detect
if there was a difference in time to recovery between the 2
age groups prior to 6 months.
There is the possibility for recall bias associated with
patients who were called to complete the questionnaires ret-
rospectively. However, studies have shown that patients can
reliably recall functional status up to 2 years after orthope-
dic surgery and can recall pain up to 3 months after total hip
arthroplasty.7,18 In our study, mean scores did not differ sig-
nificantly between those who were called and those who
completed the surveys at the time of their appointments, so
we do not believe this greatly affected the results.
Eleven patients (8 younger than 65 years, 3 patients 65
years or older) who were at least 6 months postoperatively
from their hammertoe correction surgery did not have 6
months of follow-up data and were therefore categorized as
lost to follow-up and not included in our analysis. Although
Choi et al4 demonstrated no significant difference in patient-
reported outcomes among total joint arthroplasty patients
who actively follow-up in office and those who are non-
compliant with follow-up office visits, bias would still be a
possibility.
The strengths of this study include the high response rate
to the questionnaires, with at least 6 months of data col-
lected on 47 of 58 patients (81.0% response rate). Our study
population is similar to other populations examined in pre-
vious studies about hammertoe correction operations with
regard to gender and age,3,10,14 suggesting that our patients
are likely a representative sample of patients who undergo
hammertoe corrective surgery in general. Another strength
of the study is that we used validated questionnaires to
determine the subjective assessment of pain and function
(the VAS and SF-36 survey),13 and obtained both preopera-
tive and postoperative responses. Additionally, all opera-
tions were performed by a single surgeon, which helped
minimize any intraoperative variation in operative tech-
nique. In the future, we hope to replicate these results in a
larger study. Although it is outside the scope of the present
study, future studies should analyze radiographic images of
the hammertoe deformities preoperatively and postopera-
tively to determine if there would be a difference in severity
of hammertoe deformity, and to compare postoperative
radiographic outcomes between groups.
In conclusion, outcomes of operative correction of ham-
mertoe deformities in patients 65 and older were similar to
outcomes in patients under the age of 65 after a minimum of
6 months of follow-up. The overall improvement in VAS
score and PCS were statistically significant for both cohorts,
with no significant difference after controlling for a number
of comorbidities. Additionally, the complication rates were
similar for both age groups. The results of our study demon-
strate that operative management for hammertoe deformi-
ties was associated with clinical improvement in pain and
functioning for older and younger patients with a variety of
comorbidities. Therefore, operative management can be
considered in patients in whom conservative management
has failed, regardless of age.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
ICMJE forms for all authors are available online.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Claire Mackenzie Mueller https://orcid.org/0000-0002-9415-1744
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