The Top Eleven Pearls For Hammertoe Surgery

By Michael D. Dujela, DPM, James L. Chianese, DPM, James R. Holfinger, DPM, and Richard J. Zirm, DPM

Digital contractures are among the most common deformities we see in podiatric practice. McGlamry described three etiologies for hammertoes: flexor stabilization, flexor substitution and extensor substitution.1 While each entity may exist independently, it is more likely you will see co-existing etiologies, particularly when you’re dealing with more complex deformities.
Most hammertoes in early stages primarily involve sagittal contractures. However, as the deformity progresses, transverse plane components may be unmasked. You may recognize transverse plane deformities early on as a subtle predislocation syndrome.2 Emphasizing aggressive treatment may help prevent frank dislocation.
When it comes to treating hammertoe deformities, therapy has ranged from simple orthodigital splinting devices to “reconstructive disarticulation.”3 Primary surgical treatments commonly involve arthroplasty or arthrodesis, although soft tissue repairs (ranging from simple flexor tenotomy to complex flexor tendon transfer) have also been advocated.
With this in mind, let’s take a closer look at a few surgical pearls and tips that have improved outcomes in treating digital deformities at our institution.

Is A Middle Phalangectomy Better Than The Proximal Interphalangeal Joint Arthoplasty For Fifth Digits?
The standard fifth digit arthroplasty is one of the most commonly performed podiatric procedures. The approach involves removing the head of the proximal phalanx at the surgical neck. Resecting the phalangeal head exposes cancellous bone, which continues to bleed for a period of time. Without meticulous dissection and hemostasis, blood may collect in the newly formed “dead space,” serving as a nidus for infection and promoting low-grade chronic inflammation.
Regardless of the osseous work you perform, the surgical intervention tends to result in interruption of venous and lymphatic channels, which creates a chronic “sausage digit.”
In select patients who have a small to medium-sized middle phalanx (particularly those without symphalangism), we have routinely performed middle phalangectomy to avoid bleeding cancellous bone exposure. When a prominent phalangeal condyle remains, we perform a condylectomy, although this negates some of the benefits inherent to performing just the phalangectomy.
Typically, we do a linear incision or two semi-elliptical converging incisions. Include a de-rotational component if it is required for neutral frontal plane positioning. There are a few caveats, though. When there is a large phalanx, take care to avoid middle phalangectomy, as this may sufficiently decrease the internal cubic content of the joint, resulting in a useless, floppy digit, similar to an aggressive arthroplasty. Additionally, you’ll find dissection becomes more difficult and often more traumatic when removing a large specimen through the standard converging semi-elliptical approach.
However, with appropriate procedure selection, middle phalangectomy often results in less swelling and greater stability, allowing earlier return to activity and normal shoe gear. You also may employ this procedure in the remaining lesser digits with diligence.

Consider Distal Interphalangeal Joint Arthroplasty For Iatrogenic Mallet Digit Deformities
PIPJ arthrodesis results in global shortening of the digit. According to Boberg, this has little or no effect on the long extensor, only the flexors.4 Arthrodesis of the PIPJ converts the long and short flexors to plantar stabilizers of the MPJ. Occasionally, there is a lack of conversion of deforming force from IPJ to MPJ stabilizer. Rather, lengthening the extensor digitorum longus, as commonly performed in a standard sequential reduction, may assist in flexors overpowering the extensors at the most adjacent joint to their insertion. The end result is the iatrogenic mallet toe. Flexor tenotomy and DIPJ arthrodesis have been described to treat this condition.
We have found that performing a simple DIPJ arthroplasty with judicious bone removal reduces the recurrences commonly associated with other procedures. This procedure avoids possible tendon regeneration (you would see with the tenotomy) or the rigidity associated with DIPJ arthrodesis.
Typically, we employ two transverse semi-elliptical converging incisions overlying the DIPJ, removing the resultant skin segment to assist in joint dorsiflexion. Take care to avoid the nail matrix damage associated with an excessive distal approach. The greatest degree of sagittal correction afforded by residual skin excision is with incision placement directly overlying the DIPJ. You can achieve further dorsal stability via end-to-end repair of the EDL and dorsal capsular repair with the DIPJ in minimal hyperextension. K-wire fixation is not required.

Repairing Medial Collateral Ligaments In Fifth Digit Arthroplasty Restores Transverse Plane Stability
Nothing is more troubling to you and your patient than the useless floppy fifth digit that arises following a poorly executed arthroplasty. While podiatrists generally tend to focus on sagittal deviation or the “cocked-up” digit, often the digit has a tendency to become caught in a stocking or deviated in the transverse plane. This is almost exclusively an abductory problem, since adduction is prohibited by close apposition of the fourth digit. Abductory deformation is possible due to transection of the medial collateral ligaments.
As a general rule, we repair the medial collateral ligaments with an over-and-over retention suture of 4.0 absorbable suture. Be sure to hold the digit in a neutral position in the transverse plane and frontal planes while repairing the ligaments. Slight plantarflexion at the joint while suturing provides minimal sagittal stability to the distal segment.

Insights On Using The Proximal Interphalangeal Joint Arthrodesis For Lesser Digits
In order to select an appropriate digital surgical procedure, you should consider the patient’s age, function, apex and flexibility of the deformity, and outcome expectations.
In our opinion, arthroplasty of the proximal interphalangeal joint for second digits generally should be relegated to the geriatric, low functional demand patient population. For young or active patients, performing arthrodesis provides a stable lever arm, allowing the flexor and extensor musculature to act in unison, assisting in metatarsophalangeal joint stabilization.
Arthroplasty results in increased flexibility, which over a period of time, may allow deformity to recur. You’ll find the third digit often does well when you perform an arthrodesis. Depending on shoe gear, flexibility, apex of deformity and digital length, the fourth digit can also sometimes be fused. We never consider arthrodesis for the fifth digit primarily because of shoe fit.

Don’t Overlook A MTPJ Contracture
Often after performing a cursory sequential reduction, a digit will remain dorsiflexed at the MTPJ level. It is a common error to disregard this contracture, believing that extensor tendon lengthening and splinting the digit in a rectus position will eliminate the deformity. Many physicians are willing to trade a “cocked-up” digit to avoid a larger incision, greater dissection, potential scar contracture and, in some instances, increased postoperative pain.
It is important to assess residual contracture after each step of the sequence via the Kellikian push-up test. If the contracture remains, do not hesitate to perform a MTPJ capsulotomy, release plantar capsulodesis with a McGlamry Elevator and consider K-wire fixation across the metatarsophalangeal joint.
When crossing the joint, to ameliorate bending forces which can cause implant failure, we routinely build up the insole of the surgical shoe with 1/2-inch felt padding from the heel to the web spaces plantarly. The distal end of the felt pad is not skived. We maintain this until the fixation is retrograded across the MTPJ.
Above all, do not remove the fixation device prematurely. Generally, you should stabilize the joint for a minimum of three to four weeks to prevent recurrence. When combined with arthrodesis, the fixation is retrograded across the metatarsophalangeal joint in the office setting.
Obtain a radiographic measurement to determine the length of the K-wire from the base of the proximal phalanx to the proximal tip located in the metatarsal. Using pliers in a gentle twisting fashion, slowly retrograde the wire by the pre-determined length until it is entirely within the proximal phalangeal base. Digital anesthesia is not required.
Place the joint through a range of motion to feel for impingement. Bend the wire and cut it at the distal digit. Remove the felt padding from the surgical shoe at this time. Retain the K-wire for an additional two weeks to allow for full consolidation of the PIPJ arthrodesis. At this time, you can remove the fixation. Be aware you may also need to stabilize the digits in the sagittal plane with a postoperative splint (Darco or Budin).

Improve Efficiency In Digital Surgery By Performing Procedures Sequentially
When correcting multiple hammertoes in a single surgical setting, it is common to approach each digit as an individual case. Ultimately, while this approach may seem rational, failing to streamline repetitive motions wastes a great deal of time.
Eliminating simple repetition and wasted movement can dramatically decrease the total time dedicated to each task. For example, irrigating surgical wounds one digit at a time involves refilling the bulb syringe, picking up the basin and reaching for the suction four times. Wasted effort causes increased fatigue, operative time and greater propensity for surgical infection.
We recommend the theme in multiple digit cases be “Pick each instrument up once and work with it until its purpose has been exhausted for the entire case.”
For example, when performing forefoot reconstruction of the second through fifth digits, make all skin incisions in sequence. Carry out deep dissection for each digit and perform tendon work for all digits, following with joint preparation. Irrigate, close and dress wounds sequentially. Doing these things at our institution has revealed a 40 percent decrease in operation time.

Consider Flexor Tenotomy As An Adjunct For Longstanding Clawtoes
When you’re treating longstanding clawtoe deformities, a proximal interphalangeal joint arthrodesis or arthroplasty alone may be insufficient to allow reduction of the distal component of the deformity.
After osseous resection, it is important to ascertain flexibility at the distal interphalangeal joint. In most instances, this results in sufficient soft tissue relaxation. Performing digital stabilization with K-wire generally will allow long-term sagittal correction.
However, in some instances, semi-rigid or rigidly plantarflexed distal interphalangeal joints fail to reduce, essentially becoming iatrogenic mallet digits. In non-reducible cases, we will perform a flexor tenotomy from either a plantar or medial approach, using a 67 blade prior to placing the fixation in order to allow repositioning. Minimal digital purchase may be sacrificed.
Although bandage splintage of the digit may be sufficient to retain position during the healing process, you may prefer K-wire fixation in a retrograde fashion for three to four weeks when performing osseous correction. Long-term orthodigital support may reduce the likelihood of recurrence.

Consider A Lateral Retention Suture For A Transverse Plane MTPJ Deformity
Transverse plane digital deformities are among the most difficult forefoot deformities to correct. The second digit is most commonly affected, with adduction at the metatarsophalangeal joint. Your goal is trying to achieve a rectus digit, which involves plicating attenuated lateral capsule, performing a capsulotomy of the contracted dorsal and medial capsule, as well as repositioning the flexor apparatus relative to the neutral MTPJ axis.
Correction has ranged from soft tissue rebalancing to repositioning osteotomies.1, 5-11 For a typical dorsal MTPJ contracture with adduction, we have had success combining a lateral retention suture in the joint capsule with complete sequential release and arthrodesis as described by Chambers.3
The technique involves standard release of the soft tissues, allowing the toe to be repositioned without resistance. A 2.0 non-absorbable braided suture is used to plicate the plantar lateral capsule with an over-and-over technique. Hold the digit in a corrected position while securing the suture. Generally, we follow this by completing a proximal interphalangeal joint arthrodesis. Should the retention suture be insufficient, continue the K-wire across the MTPJ for four weeks.

Be Aware Of Two Body Planes When Making Cuts
Perhaps attention to body planes is not as crucial for arthroplasty procedures. However, when performing arthrodesis, making precise bone cuts is crucial for apposition of prepared joints. Being aware of the position of the saw blade in the sagittal and transverse planes is essential. Frontal plane positioning, in essence, is not considered when preparing joints in digits but it becomes important in fixation position.
Hansen describes a process called triangulation, whereby the surgeon focuses on one plane and the assistant at a tangential angle corrects the surgeon’s position for an additional plane.12 This process is important to avoid dorsiflexion, plantarflexion or transverse plane deviation of arthrodesis position.

Consider Reaming With Incremental Burrs In Peg-in-Hole Arthrodesis
The peg-in-hole proximal interphalangeal arthrodesis is an alternative to the more conventional end-to-end arthrodesis. Increased bone-to-bone contact provides added osseous stability, which allows for earlier removal of fixation. This procedure is ideal for excessively long digits, due to the inherent shortening achieved.
Certain techniques performed at our institution are valuable for decreasing procedure time while increasing the likelihood for successful union. When preparing the base of the middle phalanx, we begin reaming with a small ball burr and gradually increase the diameter of the burrs, rather than “free handing” the hole with a single burr. You need not remove the remaining cartilage surrounding the reamed portion of the base of the middle phalanx, as it is not part of the fusion interface. Providing the middle phalanx is well-seated on the proximal phalangeal peg with appropriate fixation, you’ll find that the union rate will approach 100 percent.

Be Aware Of Load Tension Transfer Phenomenon
Digital arthroplasty is generally regarded as a relatively benign procedure. However, when planning any surgical procedure involving the release of soft tissue structures surrounding a contracted lesser digit, pay attention to the load tension transfer phenomenon.
This refers to the increase in tension placed on adjacent non-operative digits by either the long flexor or long extensor muscles. Each of these muscles arises from a single origin and then splits, sending tendon slips to each of the four lesser digits. When any one of the four tendon slips is released or lengthened forces are transferred to the adjacent digits.4,14 This can lead to accelerated formation of deformity in these digits.
We do not advocate performing prophylactic surgery on rectus, asymptomatic digits. However, you should be cognizant of the possibility of propagating adjacent deformities. You can minimize this issue by avoiding over-lengthening of extensor tendons during z-plasty, employing judicious use of tenotomy, and by being conservative yet appropriate with bone resection.14

In Conclusion
When correcting digital deformities, it is essential to assess and address each segment of the contracture. You should consider the etiology before selecting the procedure. Multiple procedures exist for correcting hammertoes. This is particularly the case when you’re correcting transverse plane deformities. Appropriate use of a sequential approach via the arthroplasty or arthrodesis yields excellent results. Adjunct procedures such as flexor tendon transfer can add the finishing touch, adding longevity to a correction. And as we discussed above, subtle techniques that can impart efficiency and a degree of finesse will improve you achieve satisfactory treatment outcomes.

Dr. Holfinger is Director of Podiatric Surgical Residency Training at the Southwest General Health Center within the University Hospital Health System in Middleburg Heights, Ohio. Dr. Zirm is on the faculty of the Podiatry Institute in Tucker, Ga., and he is the Associate Director of Podiatric Residency Training at the Southwest General Health Center within the University Hospital Health System in Middleburg Heights, Ohio.
Dr. Dujela is a second-year resident and Dr. Chianese is a first-year resident at the Southwest General Health Center within the University Hospital Health System in Middleburg Heights, Ohio.



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2. Yu GV, Judge M: Predislocation Syndrome of the Lesser Metatarsophalaneal Joint: A Distinct Clinical Entity. In Camasta CA, Vickers NS, Carter SR, (eds.) Reconstructive Surgery of the Foot and Leg, Update 95 Podiatry Institute Publishing, Tucker, GA, pp. 109-11, 1995.

3. Chambers GL: Correction of the Transverse Lesser MTPJ Deformity. The Proceedings of the annual Meeting of the Podiatry Institute, Update 2001. The Podiatry Institute, Inc. Tucker, GA, pp. 11-21, 2001.

4. Boberg JS: Surgical Decision Making in Hammer Toe Deformity. Reconstructive Surgery of the Foot and Leg, Update 1997. Podiatry Institute Publishing, Tucker GA, pp. 3-6, 1997.

5. Deland JT, Sobel M, Arnoczky SP, Thompson FM: Collateral Ligament Reconstruction of the Unstable Metatarsophalangeal Joint: an in vivo Study. Foot Ankle Int. 13:391-95, 1992.

6. Phillips AJ: Chronic Lesser Metatarsophalangeal Dislocations. In Camasta CA, Vickers NS, Ruch JA, (eds.) Reconstructive Surgery of the Foot and Leg, Update 1994, Podiatry Institute Publishing, Tucker, GA, pp. 81-90, 1994.

7. Ruch JA: Use of the EDB Tendon for Muscle-Tendon Balance of the Lesser MPJ. In Camasta CA, Vickers NS, Carter SR, (eds.) Reconstructive Surgery of the Foot and Leg, Update 1995. Podiatry Institute Publishing, Tucker, GA pp. 114-118, 1995.

8. Schuberth JM, Jensen R: Flexor Digitorum Longus Transfer for Second Metatarsophalangeal Joint Dislocation/Subluxation. In Vickers NS, et al. (eds.) Reconstructive Surgery of the Foot and Leg, Update 1997. Podiatry Institute Publishing, Tucker, GA, pp. 11-14, 1997.

9. Schwartz N: New Procedure for Stabilization of Lesser Metatarsophalangeal Joints: A Preliminary Study. J Foot and Ankle Surg. 36(3): 236-39, 1997.

10. Miller SJ: Transverse Plane Metatarsophalangeal Joint Deformity: Another Etiology and Solution. In Vickers NS et al. (eds.) Reconstructive Surgery of The Foot and Leg, Update 1998. Podiatry Institute Publishing, Tucker, GA, pp. 124-28. 1998.

11. Goecker RM: Decompression and Transpositional Osteotomy of a Metatarsal Head for Transverse MTPJ Deformity. The Proceedings of the Annual Meeting of the Podiatry Institute, Update 2001. The Podiatry Institute, Inc. Tucker, GA, pp. 22-25. 2001.

12. Hansen ST, Jr.: Functional Reconstruction of The Foot and Ankle, Lippincott Williams & Wilkins 2000. pp. 5-6.

13. Wilhelmi BJ, et. al.: Do not use Epinephrine in Digital Blocks: Myth or Truth? Plastic Reconstructive Surgery 2001 Feb;107(2):393-7.

14. McGlamary ED, Jimenez AL, Green DR: Deformities of the Intermediate Digits and the Metatarsophalangeal Joint. McGlamary’s Comprehensive Textbook of Foot and Ankle Surgery, 3rd Ed, Vol. 1 Williams and Wilkins, Baltimore, p. 276.

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