Emerging Concepts In Hammertoe Surgery

William Fishco, DPM, FACFAS

Although podiatrists commonly perform hammertoe surgery, the procedure can be fraught with complications. Accordingly, this author shares pearls on internal fixation, soft tissue management and metatarsal surgery, and offers pertinent principles on ensuring postoperative success.

   Hammertoe surgery has always been considered one of the “easier” surgeries when it comes to foot surgery as a whole. For those of us who can think back to when we first started in residency, it was hammertoe surgery procedures in which we initially got our chance to hold a scalpel and perform surgery. This is ironic as hammertoe surgery, in reality, can be the most difficult foot surgery when it comes to achieving predictably good results. We can all think of incidences in which we were humbled by “simple hammertoe surgery.”

   Some of the more challenging aspects of hammertoe surgery include management of prolonged swelling, stiff toes, “pencil straight” toes, recurrence of deformity and lack of toe purchase to the ground just to name a few. Needless to say, the profession is still looking for a way to get predictable, reproducible, good results in the long term.

   Since the hammertoe deformity is very complicated, there is no one answer that can address all types of hammertoes. In podiatry school, we learned about biomechanical etiologies of hammertoes such as flexor and extensor substitution. We also learned an algorithm for surgical treatment based on the etiology. I personally do not put much faith in that as hammertoe deformities are complex and sometimes can be multifactorial in etiology.

   To that end, when it comes to hammertoe surgery, I believe one has to fix the deformity of the bone and balance the soft tissues. That is it in a nutshell. However, this is easier said than done.

   Generally speaking, the term hammertoe describes a wide variety of toe deformities although other more descriptive terms include claw toe, mallet toe, crossover toe and clinodactyly. All hammertoes are not created equal. I have found that the second and fifth toes are the most difficult to treat with consistent good results.

   The fourth toe seems to swell the most after surgery, which can be aggravating for both physicians and patients. Transverse plane deformity of the toe can be present along with the more common saggital plane contractures. The fourth and fifth toes may have adductovarus deformity as well and can sometimes deform after surgery if one does not address the influence of the long flexor tendon.

   So why are hammertoes so difficult to treat surgically? Well, it is all about the soft tissues as opposed to the bone. If we put two ends of bone together and stabilize them, the bone will heal that way. However, if there are deforming forces on the toe from soft tissues (including tendons, capsule and ligaments) that affect the bones, then the toe is going to deform over time. We have all seen internal hardware break in a toe due to persistent forces on the toe. In addition, after the amputation of a great toe, the lesser toes will often adduct and claw due to tendinous imbalance. These examples are a testament of how deforming these soft tissue forces can be.

What You Should Know About Internal Fixation And Decompression Techniques

   The most notable recent changes in hammertoe surgery involve internal fixation techniques and decompression techniques by shortening the metatarsal segment.

   For the past 30 years or more, Kirschner wires have been the method of choice for fixation of toes. It is technically simple to “pin the toe” and, if necessary, the K-wire can cross the metatarsophalangeal joint (MPJ) to stabilize that joint as well.


Good article, thank you.

Dear Dr. Fishco:

Great article and discussion re: hammertoe surgery. Thank you for your insight and information. I am a physical therapist in a sports medicine clinic (we see lots of podiatric patients of all ages, also diabetic feet), and have a DPM on staff. Also, I am a podiatric surgical consultant. Appreciate your words of wisdom...

Thanks again,

Linda Meneken,PT

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