What are the management options for a patient with hammer toe, considering underlying conditions such as diabetes?

Management of Hammer Toe

Start with conservative management in all patients, but proceed directly to digital flexor tenotomy when conservative treatment fails in diabetic patients with hammertoes and pre-ulcerative signs or distal toe ulcers. 1

Conservative Management (First-Line for All Patients)

Footwear Modifications

• Prescribe extra-depth shoes with wide toe-box and soft uppers to accommodate the deformity and reduce pressure on bony prominences. 2
• The shoe should be 1-2 cm longer than the foot, with internal width equal to the foot width at the metatarsophalangeal joints, and sufficient height for toes. 1
• Fit must be evaluated with patient standing, preferably at end of day. 1

Orthotic Devices

• Consider custom-made insoles or toe orthoses when foot deformity or pre-ulcerative signs are present. 1, 2
• Toe silicone devices and semi-rigid orthotic devices can redistribute pressure and reduce mechanical stress. 3, 4

Professional Foot Care

• Provide regular professional treatment for callus removal, nail care, and pre-ulcerative lesions every 1-3 months for high-risk diabetic patients. 2, 4
• Callus and nail pathology should be treated by trained foot care specialists, never by patients themselves using chemical agents or plasters. 1

Patient Education

• Instruct patients to inspect feet daily, wear properly fitting footwear both indoors and outdoors, avoid barefoot walking, and use emollients for dry skin (but not between toes). 1
• Cut toenails straight across and notify healthcare provider immediately if blisters, cuts, or sores develop. 1

Surgical Management (When Conservative Treatment Fails)

Digital Flexor Tenotomy (First-Line Surgical Option)

This is the preferred surgical intervention for diabetic patients with flexible hammertoes and pre-ulcerative signs or distal toe ulcers. 2

• Healing rates of 92-100% achieved in mean 21-40 days with low complication rates. 2
• Can be performed as outpatient procedure without subsequent immobilization. 2
• Recurrence rates of 0-20% over 11-36 months follow-up, though one recent study showed 22.7% recurrence at mean 149.7 months. 2, 5
• In the original cohort, 0% ulcer occurrence rate in 58 patients over 11-31 months. 2

Proximal Interphalangeal Joint Arthrodesis (For Rigid Deformities)

• Reserved for painful rigid hammertoe deformities that fail conservative care. 6, 7
• Provides osseous fusion rates of 83-98% with patient satisfaction rates of 83-100%. 7
• Pain relief achieved in up to 92% of patients. 7
• Fixation options include Kirschner wire, screws, bioabsorbable pins, or intramedullary implants. 7, 8

Arthroplasty

• Alternative to arthrodesis that allows retained motion, but this motion may lead to recurrent deformity and pain over time. 6, 7

Special Considerations for Diabetic Patients

Risk Stratification

• Hammertoes in diabetic patients with neuropathy or peripheral artery disease are considered pre-ulcerative lesions requiring immediate intervention. 2, 4
• Assess for loss of protective sensation using 10g Semmes-Weinstein monofilament. 1
• Check pedal pulses; if absent, measure ankle-brachial index (normal >0.9). 1

Integrated Care Approach

• Provide integrated foot care every 1-3 months including professional foot treatment, therapeutic footwear, and education. 1, 2
• This comprehensive approach prevents ulcer development in diabetic patients with neuropathy or peripheral artery disease. 2

Surgical Risks

• Post-operative infection risk is 9.5% in diabetic neuropathy patients, requiring careful patient selection. 2
• High mortality rate in this population (55.3% died during mean 149.7 month follow-up in one cohort), emphasizing importance of prevention. 5

Common Pitfalls to Avoid

• Do not delay surgical intervention in diabetic patients with pre-ulcerative signs once conservative treatment has failed—this population has 93.3% risk of developing ulcers and 53.3% risk of amputation during long-term follow-up. 5
• Avoid excessive osseous resection during arthrodesis, which leads to cosmetically undesirable short toe. 7
• Do not use nerve decompression procedures for ulcer prevention—these are not recommended over standard care. 1
• In severe deformities, prefer Kirschner wire fixation over permanent implants, as excessive neurovascular stretching can compromise the toe and wire can be easily removed at bedside if needed. 7