Research Article| Volume 57, ISSUE 2, P332-338, March 2018

Percutaneous Kirschner Wire Versus Commercial Implant for Hammertoe Repair: A Cost-Effectiveness Analysis


      Hammertoe deformities are one of the most common foot deformities, affecting up to one third of the general population. Fusion of the joint can be achieved with various devices, with the current focus on percutaneous Kirschner (K)-wire fixation or commercial intramedullary implant devices. The purpose of the present study was to determine whether surgical intervention with percutaneous K-wire fixation versus commercial intramedullary implant is more cost effective for proximal interphalangeal joint arthrodesis in hammertoe surgery. A formal cost-effectiveness analysis using a decision analytic tree model was conducted to investigate the healthcare costs and outcomes associated with either K-wire or commercial intramedullary implant fixation. The outcomes assessed included long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. Costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2017 price base. Our results found that commercial implants were minimally more effective than K-wires but carried significantly higher costs. The total cost for treatment with percutaneous K-wire fixation was $5041 with an effectiveness of 0.82 QALY compared with a commercial implant cost of $6059 with an effectiveness of 0.83 QALY. The incremental cost-effectiveness ratio of commercial implants was $146,667. With an incremental cost-effectiveness ratio of >$50,000, commercial implants failed to justify their proposed benefits to outweigh their cost compared to percutaneous K-wire fixation. In conclusion, percutaneous K-wire fixation would be preferred for arthrodesis of the proximal interphalangeal joint for hammertoes from a healthcare system perspective.

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        • Dunn J.E.
        • Link C.L.
        • Felson D.T.
        • Crincoli M.G.
        • Keysor J.J.
        • McKinlay J.B.
        Prevalence of foot and ankle conditions in a multiethnic community sample of older adults.
        Am J Epidemiol. 2004; 159: 491-498
        • Coughlin M.J.
        • Dorris J.
        • Polk E.
        Operative repair of the fixed hammertoe deformity.
        Foot Ankle Int. 2000; 21: 94-104
        • Marks R.
        Anatomy and pathophysiology of lesser toe deformities.
        Foot Ankle Clin. 1998; 3: 199
        • Kernbach K.J.
        Hammertoe surgery: arthroplasty, arthrodesis or plantar plate repair?.
        Clin Podiatr Med Surg. 2012; 29: 355-366
        • Shirzad K.
        • Kiesau C.D.
        • DeOrio J.K.
        • Parekh S.G.
        Lesser toe deformities.
        J Am Acad Orthop Surg. 2011; 19: 505-514
        • Ellington J.K.
        Hammertoes and clawtoes: proximal interphalangeal joint correction.
        Foot Ankle Clin. 2011; 16: 547-558
        • Kramer W.C.
        • Parman M.
        • Marks R.M.
        Hammertoe correction with K-wire fixation.
        Foot Ankle Int. 2015; 36: 494-502
        • Atinga M.
        • Dodd L.
        • Foote J.
        • Palmer S.
        Prospective review of medium term outcomes following interpositional arthroplasty for hammer toe deformity correction.
        Foot Ankle Surg. 2011; 17: 256-258
        • Dhukaram V.
        • Hossain S.
        • Sampath J.
        • Barrie J.L.
        Correction of hammer toe with an extended release of the metatarsophalangeal joint.
        J Bone Joint Surg Br. 2002; 84: 986-990
        • Myerson M.S.
        • Shereff M.J.
        The pathological anatomy of claw and hammer toes.
        J Bone Joint Surg Am. 1989; 71: 45-49
        • Dodd L.
        • Atinga M.
        • Foote J.
        • Palmer S.
        Outcomes after the Stainsby procedure in the lesser toes: an alternative procedure for the correction of rigid claw toe deformity.
        J Foot Ankle Surg. 2011; 50: 522-524
        • Haddad S.L.
        • Sabbagh R.C.
        • Resch S.
        • Myerson B.
        • Myerson M.S.
        Results of flexor-to-extensor and extensor brevis tendon transfer for correction of the crossover second toe deformity.
        Foot Ankle Int. 1999; 20: 781-788
        • Edwards W.H.
        • Beischer A.D.
        Interphalangeal joint arthrodesis of the lesser toes.
        Foot Ankle Clin. 2002; 7: 43-48
        • Harmonson J.K.
        • Harkless L.B.
        Operative procedures for the correction of hammertoe, claw toe, and mallet toe: a literature review.
        Clin Podiatr Med Surg. 1996; 13: 211-220
        • O'Kane C.
        • Kilmartin T.
        Review of proximal interphalangeal joint excisional arthroplasty for the correction of second hammer toe deformity in 100 cases.
        Foot Ankle Int. 2005; 26: 320-325
        • Unsdorfer G.L.
        • Unsdorfer K.M.
        Proximal phalangeal osteotomy with proximal interphalangeal joint arthrodesis for multiplanar deformities of the second toe: historical perspectives and review of a case series.
        J Foot Ankle Surg. 2011; 50: 687-694
        • Good J.
        • Fiala K.
        Digital surgery: current trends and techniques.
        Clin Podiatr Med Surg. 2010; 27: 583-599
        • Newman R.J.
        • Fitton J.M.
        An evaluation of operative procedures in the treatment of hammer toe.
        Acta Orthop Scand. 1979; 50: 709-712
        • Klammer G.
        • Baumann G.
        • Moor B.K.
        • Farshad M.
        • Espinosa N.
        Early complications and recurrence rates after Kirschner wire transfixion in lesser toe surgery: a prospective randomized study.
        Foot Ankle Int. 2012; 33: 105-112
        • Holinka J.
        • Schuh R.
        • Hofstaetter J.G.
        • Wanivenhaus A.H.
        Temporary Kirschner wire transfixation versus strapping dressing after second MTP joint realignment surgery: a comparative study with ten-year follow-up.
        Foot Ankle Int. 2013; 34: 984-989
        • Jacobs A.
        Are digital implants more cost-effective than K-wires.
        Podiatry Today. 2013;
        • Lamm B.M.
        • Ribeiro C.E.
        • Vlahovic T.C.
        • Fiorilli A.
        • Bauer G.R.
        • Hillstrom H.J.
        Lesser proximal interphalangeal joint arthrodesis: a retrospective analysis of the peg-in-hole and end-to-end procedures.
        J Am Podiatr Med Assoc. 2001; 91: 331-336
        • Halpern F.P.
        • Trepal M.J.
        • Hodge W.
        Contamination and infection rate of percutaneous Kirschner wires in foot surgery.
        J Am Podiatr Med Assoc. 1990; 80: 433-437
        • Reece A.T.
        • Stone M.H.
        • Young A.B.
        Toe fusion using Kirschner wire: a study of the postoperative infection rate and related problems.
        J R Coll Surg Edinb. 1987; 32: 158-159
        • Scholl A.
        • McCarty J.
        • Scholl D.
        • Mar A.
        Smart toe(R) implant versus buried Kirschner wire for proximal interphalangeal joint arthrodesis: a comparative study.
        J Foot Ankle Surg. 2013; 52: 580-583
        • Shaw A.H.
        • Alvarez G.
        The use of digital implants for the correction of hammer toe deformity and their potential complications and management.
        J Foot Surg. 1992; 31: 63-74
        • Jay R.M.
        • Malay D.S.
        • Landsman A.S.
        • Jennato N.
        • Huish J.
        • Younger M.
        Dual-component intramedullary implant versus Kirschner wire for proximal interphalangeal joint fusion: a randomized controlled clinical trial.
        J Foot Ankle Surg. 2016; 55: 697-708
        • Witt B.L.
        • Hyer C.F.
        Treatment of hammertoe deformity using a one-piece intramedullary device: a case series.
        J Foot Ankle Surg. 2012; 51: 450-456
        • Guelfi M.
        • Pantalone A.
        • Daniel J.C.
        • Vanni D.
        • Guelfi M.G.B.
        • Salini V.
        Arthrodesis of proximal inter-phalangeal joint for hammertoe: intramedullary device options.
        J Orthop Traumatol. 2015; 16: 269-273
        • Sun K.
        • Song J.
        • Manheim L.M.
        • Chang R.W.
        • Kwoh K.C.
        • Semanik P.A.
        • Eaton C.B.
        • Dunlop D.D.
        Relationship of meeting physical activity guidelines with quality-adjusted life-years.
        Semin Arthritis Rheum. 2014; 44: 264-270
        • McGuire K.J.
        • Chacko A.T.
        • Bernstein J.
        Cost-effectiveness of teaching hospitals for the operative management of hip fractures.
        Orthopedics. 2011; 34: e598-e601
        • Ellington J.K.
        • Anderson R.B.
        • Davis W.H.
        • Cohen B.E.
        • Jones C.P.
        Radiographic analysis of proximal interphalangeal joint arthrodesis with an intramedullary fusion device for lesser toe deformities.
        Foot Ankle Int. 2010; 31: 372-376
        • Richman S.H.
        • Siqueira M.B.
        • McCullough K.A.
        • Berkowitz M.J.
        Correction of hammertoe deformity with novel intramedullary PIP fusion device versus K-wire fixation.
        Foot Ankle Int. 2017; 38: 174-180
        • Moon J.L.
        • Kihm C.A.
        • Perez D.A.
        • Dowling L.B.
        • Alder D.C.
        Digital arthrodesis: current fixation techniques.
        Clin Podiatr Med Surg. 2011; 28: 769-783
        • Hood C.R.
        • Blacklidge D.K.
        • Hoffman S.M.
        Diverging dual intramedullary Kirschner wire technique for arthrodesis of the proximal interphalangeal joint in hammertoe correction.
        Foot Ankle Spec. 2016; 9: 432-437
        • Canales M.B.
        • Razzante M.C.
        • Ehredt Jr, D.J.
        • Clougherty C.O.
        A simple method of intramedullary fixation for proximal interphalangeal arthrodesis.
        J Foot Ankle Surg. 2014; 53: 817-824
        • Ara R.
        • Brazier J.
        Deriving an algorithm to convert the eight mean SF-36 dimension scores into a mean EQ-5D preference-based score from published studies (where patient level data are not available).
        Value Health. 2008; 11: 1131-1143
        • Bennett P.J.
        • Patterson C.
        • Dunne M.P.
        Health-related quality of life following podiatric surgery.
        J Am Podiatr Med Assoc. 2001; 91: 164-173
        • Groarke P.
        • Galvin R.
        • Kelly J.
        • Stephens M.M.
        Quality of life in individuals with chronic foot conditions: a cross sectional observational study.
        Foot (Edinb). 2012; 22: 66-69
        • Lopez D.L.
        • Callejo Gonzalez L.
        • Losa Iglesias M.E.
        • et al.
        Quality of life impact related to foot health in a sample of older people with hallux valgus.
        Aging Dis. 2016; 7: 45-52
        • Maher A.J.
        • Kilmartin T.E.
        An analysis of EuroQol EQ-5D and Manchester Oxford foot questionnaire scores six months following podiatric surgery.
        J Foot Ankle Res. 2012; 5: 17
        • Neary K.C.
        • Mormino M.A.
        • Wang H.
        Suture button fixation versus syndesmotic screws in supination-external rotation type 4 injuries: a cost-effectiveness analysis.
        Am J Sports Med. 2017; 45: 210-217
        • Henning J.A.
        • Jones C.B.
        • Sietsema D.L.
        • Bohay D.R.
        • Anderson J.G.
        Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study.
        Foot Ankle Int. 2009; 30: 913-922
        • Gold M.
        • Siegel J.
        • Russel L.
        • Weinstein M.
        Cost Effectiveness in Health and Medicine.
        Oxford University Press, New York, NY1996
        • Shepard D.S.
        Cost-effectiveness in health and medicine, by M.R. Gold, J.E Siegel, L.B. Russell, and M.C. Weinstein (eds). New York: Oxford University Press, 1996.
        J Ment Health Policy Econ. 1999; 2: 91-92
        • Gray A.
        • Clarke P.
        • Wolstenholme J.
        • Wordsworth S.
        Applied Methods of Cost-Effectiveness Analysis in Health Care.
        Oxford University Press, Oxford, UK2011