What are the treatment options for hammertoe?

Hammertoe Treatment Options

Digital flexor tenotomy is strongly recommended as the primary surgical intervention for hammertoe deformities, particularly in patients with neuropathic plantar or apex ulcers, with a high healing rate of 97% and significant reduction in plantar pressure. 1

Conservative Treatment Options

Conservative management should be attempted first for flexible hammertoe deformities:

1. Proper footwear modifications:

   • Wear shoes with wide toe boxes to accommodate the deformity 1
   • Use extra-depth shoes to reduce pressure on toes 1
   • Avoid thin-soled slippers, walking barefoot, or wearing only socks 1

2. Orthotic devices:

   • Toe silicone or semi-rigid orthotic devices to reduce excess callus 1
   • Felted foam combined with appropriate footwear for temporary relief when other biomechanical options aren't available 1

3. Professional foot care:

   • Regular callus removal and proper nail care 1
   • Application of topical emollients to dry skin, periungual folds, and nail plate daily 1
   • Therapeutic footwear with demonstrated plantar pressure-relieving effect (30% relief compared to standard footwear) 1

4. Kinesiology Taping:

   • May provide symptomatic relief for patients with flexible hammertoe deformities 2
   • Can improve parameters such as foot length, maximum foot load, and load under the metatarsals 2
   • Good alternative for patients who cannot or do not want surgery 2

Surgical Interventions

When conservative measures fail, surgical options should be considered:

1. Digital flexor tenotomy (first-line surgical option):

   • Strongly recommended for hammertoe deformities, especially in diabetic patients 1
   • High healing rate (97%) and significant reduction in plantar pressure (398 kPa lower) 1
   • Decreased infection risk (RR 0.33) 1
   • Low recurrence rate (0-20%) 1
   • Can be performed in outpatient settings with minimal resources 1

2. Proximal interphalangeal joint (PIPJ) arthrodesis:

   • For rigid hammertoe deformities 3
   • High patient satisfaction rates (83-100%) and fusion rates (83-98%) 3
   • Can be performed with Kirschner wire fixation or internal fixation devices 3

3. Other surgical options for complex cases:

   • PIPJ arthroplasty 4, 5
   • Metatarsal head resection 1
   • Joint arthroplasty 1
   • Achilles tendon lengthening (for diabetic patients with recurrent plantar forefoot ulcers) 1
   • Plantar plate repair (for complex hammertoe deformities) 4

4. Minimally invasive vs. open hammertoe correction:

   • Both techniques show similar outcomes for time to osseous union and return to activity 6
   • Minimally invasive approach had 3.23% recurrence rate vs. 0% for open approach 6
   • Unplanned hardware removal was more common in minimally invasive approach (4.03% vs. 0%) 6

Patient Monitoring and Education

• High-risk patients with toe deformities should be monitored every 1-3 months, especially diabetic patients 1
• Post-procedure monitoring should include assessment for new callus formation and evaluation of toe position and function 1
• Patients should be educated on proper footwear and foot care 1
• Monitoring foot temperature can help identify early signs of inflammation 1

Treatment Algorithm

1. For flexible deformities:

   • Start with conservative measures (proper footwear, orthotic devices, professional foot care)
   • Consider kinesiology taping if available
   • If conservative measures fail, consider digital flexor tenotomy

2. For rigid deformities:

   • Surgical intervention is typically required
   • Digital flexor tenotomy is the first-line surgical option
   • For complex cases, consider PIPJ arthrodesis, arthroplasty, or plantar plate repair based on patient factors

3. For diabetic patients with hammertoe deformities:

   • More aggressive monitoring (every 1-3 months)
   • Therapeutic footwear with pressure-relieving effect
   • Digital flexor tenotomy for neuropathic ulcers
   • Consider Achilles tendon lengthening for recurrent plantar forefoot ulcers

Common Pitfalls and Caveats

• Excessive osseous resection during surgery can lead to cosmetically undesirable short toes 3
• Implants used for arthrodesis may be too large for smaller toes, particularly the fifth toe 3
• In severe deformities, excessive stretching of the neurovascular bundle can lead to toe compromise 3
• Post-surgical patients may experience persistent pain or swelling for several weeks 3
• Longitudinal incisions across joints can lead to scar contracture that elevates the toe 3