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.

What is hallux valgus and how is it evaluated for surgery?

Hallux valgus is the most common affliction of the normal adult foot. It is a condition where the large toe is deviated laterally with the first metatarsal head deviated medially causing bunion deformity.

The hallux valgus angle is measured by a line drawn through the proximal phalanx of the large toe and through the first metatarsal.

A normal angle is 0 to 15 degrees with moderate (>25 degrees) and severe (>35 degrees) deformities commonly occurring.

The cause of hallux valgus can be attributable to heredity, especially in combination with a short big toe relative to the second toe (Greek foot). Other congenital causes include pes planovalgus (flat feet) and metatarsus primus varus. The intermetatarsal angle between the first and second metatarsals is measured by a line drawn through the first and second metatarsals.

The intermetatarsal angle is normally 0 to 10 degrees, whereas angles >16 degrees are moderate and >21 degrees are severely deformed.

The need for surgical correction is considered if the painful deformity interferes with a patient’s lifestyle or ability to wear shoes and there is a failure of conservative management (wider toe box shoes).

Cosmetic surgery is out of place in hallux valgus. The danger is far too great that a previously symptom-free patient will suffer pain for weeks or even months after the intervention. For surgical treatment to be indicated, the patient must have pain that is not alleviated by a simple change of shoes or by other, conservative treatments. Moreover, the pain must be regular in occurrence and must noticeably impair the function of the affected foot.

The pain does not necessarily have to involve the great toe itself. Patients often initially complain of pain arising from the other digits, which may already have been forced upwards as hammer or claw toes. In such a case it is not enough to correct the deformity of the smaller toes; the hallux valgus must be rectified.

There are over 100 different operations for correction of hallux valgus.

The choice depends on the surgeon’s skill and how the deformity needs correction (i.e., proximal metatarsal wedge osteotomy if intermetatarsal angle too great, etc.). Implant arthroplasty does not provide reliable long-term results compared with arthrodesis (15 degrees valgus, 25 degrees dorsiflexion).

The lesser toes are also involved with synovitis, leading to subluxation and eventual dislocation at the remaining metatarsophalangeal joints.

This results in prominent metatarsal heads on the plantar surface and the development of intractable plantar keratoses.

This progressive deformation commonly involves all the metatarsophalangeal joints to some degree.

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.

Sources

• Long-term results of the modified Hoffman procedure in the rheumatoid forefoot. Surgical technique
• 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