Secrets To Navigating Hammertoe Surgery On The Fifth Toe

This blog is dedicated to the ultimate podiatry oxymoron: a simple hammertoe surgery of the fifth toe.

When it comes to foot surgery, we all got our start working on toes. In school, we all learned the three etiologies of hammertoes: extensor substitution, flexor substitution and flexor stabilization. Based on those theories, we learned a surgical algorithm. Once we got into residency, we learned that nobody really used the "textbook" for making a decision on what to do surgically.

So it came down to “arthroplasty versus arthrodesis.” You quickly learned that some of your attendings were arthroplasty guys and some were fusion guys. When it comes to the fifth toe, we all learned that you never do an arthrodesis (with the rare exception in a neurologic foot). This is where people fall into a trap with the fifth toe.

Let me elaborate. Let us say you have a patient with hammertoe and corn on the fifth toe, and you recommend surgery. What are you going to do? We have already established the fact that you are not going to do an arthrodesis. Therefore, you are going to do an arthroplasty, right? So you go and do an arthroplasty and it works most of the time. What about the times when the surgery does not work? Why does the corn remain or move to a slightly different location?

I think we can all agree that the most difficult hammertoe to correct is the crossover second toe. There is a lot of intra-operative decision making. There is a stepwise approach to correcting the transverse plane deformity after the “hammertoe” is fixed. To that end, I have always believed the fifth toe closely rivals the second toe in complexity and for surgical planning.

Key Preoperative Considerations

So how many times do you book that patient for a hammertoe repair on the fifth toe and you go through the motions, do an arthroplasty and call it a day? I am going to share with you some of the critical checkpoints that I go through when planning a fifth toe surgery.

1. What is the position of the toe/nail when weightbearing and non-weightbearing? Does the toe need to be derotated?

2. Does the toe purchase the ground on weightbearing? If it is floating, then doing an arthroplasty alone will most likely fail to resolve the patient's symptomatology.

3. Consider the location of the corn. Is it located dorsally, dorsolaterally or mostly laterally? A corn located due north on the toe is most likely a digit with only a sagittal plane deformity. A lateral lesion is usually present in a toe with adductovarus deformity.

4. As far as X-ray evaluation goes, is there symphalangism of the middle and distal phalanges? Is the middle phalanx wide and irregularly shaped (spool/spindle shaped), or does it have a prominent lateral condyle? Toes with symphalangism are more rigid and more likely to have distal corns over the middle and distal phalanges.

Certainly, there are probably infinite combinations of possibilities when evaluating each fifth toe. When it comes to bone work, I will consider doing a lateral hemiphalangectomy of the middle and distal phalanges along with the head resection of the proximal phalanx if the corn is mostly lateral and oblong encompassing both the proximal and middle phalanges. If there is a "double" corn, then two bone segments are involved. When there is symphalangism, there is a greater likelihood of a Lister's corn in addition to the run of the mill proximal interphalangeal joint (PIPJ) corn.

A lot of decision making comes into play when considering soft tissues. If the toes are not purchasing the ground, then you will need to consider at the very least an extensor hood recession of the extensor tendon and a dorsal capsulotomy of the metatarsophalangeal joint (MPJ). If you are doing a revision in a patient with a longstanding deformity, you may have to consider skin lengthening techniques.

In the more severe deformity, I will also consider taking a plantar skin wedge resection in the sulcus to keep the toe down. There are times when you may consider using a K-wire in the fifth toe, especially when you are dealing with a floating hammertoe. I prefer not to do a flexor digitorum longus tendon transfer but it is always in the back of my mind for the most severe deformity.

Adductovarus influence on the fifth toe can be very strong. In this case, more often than not, one would perform a derotational skin plasty. I have found that a more aggressive skin wedge design is best.

So the next time you are going to book your simple fifth toe hammertoe surgery, take the time to do a thorough exam. Look at the position of the toe when weightbearing, when the foot is relaxed and the location of the corn. Study the X-rays to get clues as to the “bone(s)” causing the problem.

Figure 1. This fifth toe had multiple "hammertoe surgeries." The patient’s pain was mostly on the nail bed. She also had her nail removed to try to address the problem. Nothing would work short of getting the toe to purchase the ground when weightbearing.
Figure 2. One can use a plantar skin wedge resection in combination of lengthening techniques of the dorsal soft tissue structures for floating toes.
Figure 3. This preoperative illustration shows a fifth toe that is dorsally elevated on weightbearing. Note the adductovarus deformity.
Figure 4. This is the foot of the same patient after surgery, which included an arthroplasty of the PIPJ, deroational skin plasty, EDL lengthening with MTPJ capsulotomy, and a V-Y lengthening skin plasty.
Figure 5. This foot had prior hammertoe surgery. Note that bone has regenerated and the symphalangism of the middle and distal phalanges. These toes tend to be more rigid. A lateral hemiphalangectomy and remodeling of the proximal phalanx are necessary.
Figure 6. Here is a classic example of a spool shaped middle phalanx. The author always considers a lateral hemiphalangectomy with a PIPJ arthroplasty in these patients.
Figure 7. This patient has a smooth bordered middle phalanx, which is less likely to be contributing to a corn.
Figure 8. Here one can see a "double" corn, which is most likely caused by the proximal and middle phalanges.
Figure 9. This patient has an isolated Lister's corn. In some cases, there will be a Lister's corn in addition to a hammertoe with PIPJ corn. In that case, the author will add the "exostectomy" to the hammertoe procedure.


Anonymoussays: November 30, 2010 at 11:35 pm

I agree (almost) completely with all the tips presented in the article. My feeling is that the 5th digit, even in severe cases or revision cases, does not require flexor tendon transfers or even MTPJ work in the most severe cases. In those cases, I like performing a syndactylization. It is much easier to perform, requires less dissection, is usually less painful and has predictable results. Just a thought.

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Anonymoussays: December 1, 2010 at 8:24 am

I do syndactyly on occasion especially in the geriatric patient where cosmesis is not a concern. My advice on syndactyly is that the neighboring toe has to be in good position without deformity or else the "unit" of two toes will be deformed together over time. This is less likely to happen with the 4th and 5th toes versus the 2nd and 3rd. I feel that syndactyly works best for an unstable or floppy toe versus a "deformed" toe that you are trying to stabilize and/or correct. The soft tissue forces affecting the hammertoe have to be neutralized one way or another.

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Anonymoussays: December 9, 2010 at 2:01 pm

With a curled fifth toe and symptomatic inner, medial distal corn, I like to use the approach of a total middle phalangectomy, followed by a distal medial condylectomy, all through a dorsolateral skin wedge incision over the DIPJ. Reapproximate all wound layers as one with non-absorbable skin sutures. Total middle phalangectomies vs head arthroplasy works out nice when appropriate as less bleeding bone diminishes post-op swelling.

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