Clayton Hoffman Procedure

What is a Clayton Hoffman procedure?

Clayton Hoffman procedure is a commonly performed salvage surgery for advanced rheumatoid forefoot deformity.

What is Rheumatoid forefoot deformity?

The rheumatoid forefoot pattern of involvement usually includes degeneration and instability at the first metatarsophalangeal (MTP) joint, leading to hallux valgus and bunion deformity.

The Clayton Hoffman procedure entails resection of all the metatarsal heads through two approaches. They are as below.

  • either a plantar approach
  • dorsal approach

Rarely, only two metatarsal joints will be involved, and the procedure can be performed only on the involved joints.

Clayton Hoffman Procedure

In severe RA, the MP joint at the base of the toes may be too arthritic or displaced to be preserved.

In this situation, it may be necessary to perform a standard Clayton-Hoffmann procedure, which involves a resection of all four lesser (rays 2-5) metatarsal heads, along with an associated correction of the claw toes themselves. 

This can be very effective for pain relief of a moderate to severely deformed/arthritic forefoot.

While this lessens the pain, however, it does not address the dysfunction of the foot and it should, therefore, be considered an effective but nonetheless salvage procedure.

With this operation, the toes will no longer be able to articulate, which will limit the patient’s activity.

The toes are much stiffer and straighter, and patients will state they “just float in space there”. 

They can also describe a much decreased push-off strength in this foot, even though the pain is remarkably improved as compared to pre-operatively. 

Despite these limitations, however, almost all of these patients, if bad enough to justify the procedure in the first place, will state they would have the procedure again if such a choice had to be re-made.

This involves creating a stable hallux metatarsophalangeal joint (MTPJ) with an arthrodesis, resection of the lesser metatarsal heads, and correction of the lesser toes with osteoclasis of the proximal interphalangeal joints (PIPJs) or condylectomy of the proximal phalangeal heads.

For patients who have endured longstanding suffering from walking on exposed metatarsal heads, often with gross deformity, the operation is life-changing, and it is rewarding for the surgeon too.

With symptomatic lesser deformities and better management with disease-modifying drugs, joint-preserving procedures can be considered, such as shortening, elevating osteotomies of the lesser metatarsals, and correction of hallux valgus with conventional soft-tissue and bony work.

Research Studies supporting the Clayton Hoffman Procedure

Research Study 1

Here is the Study report of the experience in the use of the Clayton modification of the Hoffman procedure in the Ulcerated Diabetic Neuropathic Foot.

This study is conducted on twelve patients with type 2 diabetes

These patients have varying degrees of insensitivity of the foot presented with problems of forefoot ulceration beneath one or more metatarsal heads.

This was associated with local abscess formation.

Some of these patients had previously been subjected to surgical procedures such as ray resection or single metatarsal head resection for earlier problems

Hence these patients were left with areas of increased pressure especially in the weightbearing surface of the forefoot.

The Infectious Diseases service started the Appropriate antibiotic therapy for each patient.

Blood flow to the extremity was evaluated by pulse volume recordings and measurement of Doppler pressures at various levels down the extremity.

Vascular reconstruction was indicated in two of these patients.

After this reconstruction, circulation was deemed adequate to perform the Clayton procedure.

This procedure was also done on 10 other patients with more adequate circulation.

Although the time of healing was prolonged in some instances, all feet healed and the patients were successfully graduated to full weightbearing with extra depth shoes with soft neoprene rubber insoles.

This procedure should be considered instead of transmetatarsal amputation in some patients with problems of ulceration and abscess formation of the forefoot if circulation is adequate, or can be restored to adequate levels by vascular reconstruction.

Research Study 2

An observational study reported the results at an average of five and a half years following thirty seven consecutive forefoot arthroplasties performed in twenty patients by one surgeon using a technique that is modified Hoffman procedure in the rheumatoid forefoot involving resection of all five metatarsal heads.

This study shown that in patients with rheumatoid arthritis-related metatarsalgia and hallux valgus, excision of all five metatarsal heads can be a safe operation that offers reasonable, albeit infrequently total, alleviation of symptoms.

It is not advised to remove just one or three of the affected metatarsal heads, though.

The Clayton Hoffman technique and the fusion of the first metatarsophalangeal joint are sometimes performed together.

  1. Long-term results of the modified Hoffman procedure in the rheumatoid forefoot. Surgical technique
  2. Clayton, M.L.: Surgery of the forefoot in Rheumatoid Arthritis. Clin. Orthop. 16:136–140, 1960) modification of the Hoffman (Hoffman, P.: An operation for severe grades of contracted or clawed toes. Am. J. Orthop. 9:441–449, 1911


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