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Hammer Toe Correction

  • Editor(s): Todd W Thomsen, MD, Gary S Setnik, MD, FACEP
  • Section Editor(s): Phillip M Harter, MD
  • Contributor(s): Carmie Chan, MD
PRE-PROCEDURE
INDICATIONS
  • Only the symptomatic toe should undergo surgery.
    • An unattractive deformity is not a strong enough indication for surgical correction.
  • Table 1 lists the most commonly recommended procedures that have available evidence as to their efficacy.
  • Conservative treatment of hammer toe usually is disappointing
  • Operative procedures may be divided into Soft tissue procedures and Bone and Joint Procedures
    Soft tissue procedures
    • Without bone shortening or arthrodesis, there many not be permanent correction.
    • Soft tissue procedures are indicated in the following:
      • A skeletally immature foot with symptomatic flexible hammer toe(s).
      • A young adult foot with dynamic flexible deformities of one or more toes (prominent hammering only with weight-bearing) that interfere with shoe wear, the following procedure is indicated.
    Bone and Joint procedures
    • The indicated (and recommended) procedure varies on the stage of deformity:
      • Mild deformity
        • No fixed contracture at the metatarsophalangeal or proximal interphalangeal joints. The deformity increases on weight-bearing.
        • Perform flexor-to-extensor transfer using the flexor digitorum longus
      • Moderate deformity
        • A fixed flexion contracture at the proximal interphalangeal joint, and no extension contracture at the metatarsophalangeal joint.
        • Perform resection of the head and neck of the proximal phalanx and dermodesis
      • Severe deformity
        • A fixed flexion contracture at the proximal interphalangeal joint, with a fixed extension contracture at the metatarsophalangeal joint; no subluxation or dislocation of the metatarsophalangeal joint.
        • Perform resection of the head and neck of the proximal phalanx through a dorsal elliptical skin window (and dermodesis), lengthen the extensor digitorum longus, tenotomize the extensor digitorum brevis, and perform a dorsal capsulotomy at the metatarsophalangeal joint
      • Severe deformity with subluxation or dislocation of the metatarsophalangeal joint
        • A metatarsophalangeal joint arthroplasty, or distal metatarsal osteotomy (Weil) may be needed to decompress the metatarsophalangeal joint.
    CONTRAINDICATIONS

    Cosmetic deformity alone is not sufficient to warrant surgical intervention.
    EQUIPMENT
    • Round-end knife
    • Beaver blade
    ANATOMY
    • The most powerful extension force on the metatarsophalangeal joint is delivered by the extensor digitorum longus tendon
      • This extends the metatarsophalangeal joint through a fibroaponeurotic sling that attaches plantarly to the plantar plate and capsule and suspends the phalanx
      The extensor digitorum longus is able to extend the interphalangeal joints of the toe only when the metatarsophalangeal joint is in a neutral or flexed position.
      • Therefore, if a toe is held in an extended position, such as in a high-heeled shoe, the extensor digitorum longus becomes a deforming force on the metatarsophalangeal joint.
    • Flexion of the metatarsophalangeal joint primarily is a function of the intrinsic muscles.
      • The second toe is unique in that there are two dorsal interossei and no plantar interossei.
    • The lumbrical muscle is located on the medial side of the joint and axis and acts as an unopposed adductor of the toe.
      • With chronic extension deformity it becomes ineffective as a plantar flexor.
    • Static restraints for joint stability include the collateral ligaments and the plantar plate.
    Fixed flexion contracture of proximal interphalangeal joint with flexible metatarsophalangeal and distal interphalangeal joints. From Canale ST, Beaty JH (eds): Campbell’s Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
    Figure 1 :  Fixed flexion contracture of proximal interphalangeal joint with flexible metatarsophalangeal and distal interphalangeal joints. From Canale ST, Beaty JH (eds): Campbell’s Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.

    Anatomy of extrinsic and intrinsic musculature of metatarsophalangeal joint. From Canale ST, Beaty JH (eds): Campbell’s Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
    Figure 2 :  Anatomy of extrinsic and intrinsic musculature of metatarsophalangeal joint. From Canale ST, Beaty JH (eds): Campbell’s Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.

    None avail
    Table 1 :  None avail


    PROCEDURE
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    • Links to medical evidence and related procedures
    <b>A-G</b>, Flexor tendon transfer to dorsum of second toe. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
    Figure 3 :  A-G, Flexor tendon transfer to dorsum of second toe. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.

    <b>A-G</b>, Flexor tendon transfer to dorsum of second toe. From Canale ST, Beaty JH (eds): Campbell’s Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008. From Canale ST, Beaty JH (eds): Campbell’s Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
    Figure 4 :  A-G, Flexor tendon transfer to dorsum of second toe. From Canale ST, Beaty JH (eds): Campbell’s Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008. From Canale ST, Beaty JH (eds): Campbell’s Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.

    Postoperative dressing must be conforming and binding enough to hold toe in exact position; if not, Kirschner wire should be used. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
    Figure 5 :  Postoperative dressing must be conforming and binding enough to hold toe in exact position; if not, Kirschner wire should be used. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.

    Technique for correction of severe hammer toe deformity. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.
    Figure 6 :  Technique for correction of severe hammer toe deformity. From Canale ST, Beaty JH (eds): Campbell's Operative Orthopaedics, 11th ed. Philadelphia, Elsevier, 2008.


    POST-PROCEDURE
    TECHNIQUES
    • Post Procedure: Flexor-to-Extensor Transfer
    • Post Procedure: Correction of Moderate Deformity
    • Post Procedure: Correction of Severe Deformity

    Post Procedure: Flexor-to-Extensor

    POST-PROCEDURE CARE
    • A short leg, well-padded cast extending past the toes is applied in the operating room.
    • Elevate foot for 48 to 72 hours
    • Weight-bearing is allowed as tolerated
    • Crutches are optional
      • If crutches are used, the patient usually is off crutches within a week.
    • The cast is removed at 4 weeks, and wearing a shoe with a deep, wide toe-box and soft-vamp is allowed.
    • Active toe exercises are encouraged at 6 weeks.
    Complications
    • Infection
    • Delayed wound healing
    • Recurrence
      • This is a common complication and may be due to inadequate correction or wearing inappropriate footwear.
    • Metatarsalgia
      • Diffuse pain over the metatarsal heads
      • Thought to be a result of altered gait
    • Neurovascular injury
    Procedure: Flexor-to-Extensor Transfer

    Post Procedure: Correction of moderate deformity

    POST-PROCEDURE CARE
    • Weight bearing to tolerance is allowed after 48 to 72 hours of elevation of the foot.
    • A wooden-soled shoe is worn for 4 weeks.
    • The sutures are removed at 12 to 16 days
    • At 4 weeks, the dressing and taping usually can be discontinued
      • It should be continued another 2 to 4 weeks if the deformity has any tendency to recur.
    COMPLICATIONS
    • Infection
    • Delayed wound healing
    • Recurrence
      • This is a common complication and may be due to inadequate correction or use of inappropriate footwear
    • Metatarsalgia
      • Diffuse pain over the metatarsal heads
      • Thought to be a result of altered gait
    • Neurovascular injury
    Procedure: Correction of Moderate Deformity

    Post Procedure: Correction of Severe Deformity

    POST-PROCEDURE CARE
    • Weight bearing to tolerance is allowed after 48 to 72 hours of elevation of the foot.
    • A wooden-soled shoe is worn for 4 weeks.
    • The sutures are removed at 12 to 16 days
    • At 4 weeks, the dressing and taping usually can be discontinued
      • It should be continued another 2 to 4 weeks if the deformity has any tendency to recur.
    COMPLICATIONS
    • Infection
    • Delayed wound healing
    • Recurrence
      • This is a common complication and may be due to inadequate correction or use of inappropriate footwear
    • Metatarsalgia
      • Diffuse pain over the metatarsal heads
      • Thought to be a result of altered gait
    • Neurovascular injury
    Procedure: Correction of Severe Deformity
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