• Academy of Ambulatory Foot and Ankle Surgery. Hammertoe syndrome. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2003. 8 p. [31 references]

This is the current release of the guideline.

This guideline updates a previous version: Academy of Ambulatory Foot and Ankle Surgery. Hammertoe syndrome. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2000. 23 p.

The guideline is reviewed and updated twice a year as needed (in May and October).

Hammertoe syndrome

Diagnosis
Treatment

Podiatry

Podiatrists

To provide recommendations for the diagnosis and treatment of hammertoe syndrome

Patients with hammertoe syndrome

Diagnosis

1. History, including an evaluation of the chief complaint, nature, location, duration, onset, course, anything that improves or exacerbates, any previous treatment, and past medical history (allergies/medications, medical history, surgical history, family history, social history)
2. Physical examination, including peripheral vascular, neurological, orthopedic (palpation, range of motion, biomechanical/gait analysis) dermatologic exams
3. Diagnostic procedures, including radiological examination, laboratory tests, additional tests (i.e., nerve conduction studies, electromyography, noninvasive vascular testing)

Treatment

1. Nonsurgical treatment, such as debridement, padding, shoe modification, oral anti-inflammatory medication (NSAIDs), anti-inflammatory injectables, orthotics, orthodigital devices
2. Surgical treatments, such as:
   • Tendon lengthening/tenotomy
   • Capsulotomy
   • Arthroplasty
   • Osteotomy or ostectomy
   • Exostosectomy
   • Arthrodesis
   • Diaphysectomy
   • Phalangectomy
   • Skin-plasty
3. Postoperative management, including x-rays, follow-up visits, weight bearing or immobilization, and orthotics

Not stated

Searches of Electronic Databases

The guideline development process began with a thorough MEDLINE search as well as a "call for papers" from the membership of the Academy of Ambulatory Foot and Ankle Surgery at large.

Not stated

Not stated

Not applicable

Review

Not applicable

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Drafts of the guidelines were reviewed in detail by each member of the Board of Trustees.

1. Diagnosis
   1. History: This may include any of the following:
      1. An evaluation of the chief complaint (including the nature, location, duration, onset, course, anything that improves or exacerbates, and any previous treatment)
      2. The past medical history (including allergies/medications, medical history, surgical history, family history, and social history)
   2. Physical examination: The following may be important parts of the appropriate examination:
      1. Peripheral vascular
      2. Neurological
      3. Orthopedic (involvement may be ascertained by examining the foot in either the weight bearing or non-weight bearing positions)
         1. Palpation
         2. Range of motion
         3. Biomechanical/gait analysis
      4. Dermatologic (presence of lesions or hyperkeratoses)
2. Diagnostic Procedures
   1. Radiological examination: X-rays must be taken. They may be used to evaluate the type of deformity as well as other factors. X-rays may be weight bearing, partial weight bearing, or non-weight bearing.
   2. Laboratory tests: Not required in the nonsurgical patient, unless underlying factors exist (i.e., infection or inflammatory disease)
   3. Additional tests (nerve conduction studies, electromyography (EMG), noninvasive vascular testing). These studies may be utilized in isolated situations when deemed necessary.
3. Nonsurgical Treatment
   1. The primary reasons for nonsurgical treatment are:
      1. Due to the patient's health status, surgery is contraindicated
      2. The patient does not want surgery
   2. Types of nonsurgical treatment
      1. Debridement
      2. Padding
      3. Shoe modifications
      4. Oral anti-inflammatory medication (NSAIDs)
      5. Anti-inflammatory injectables
      6. Orthotics
      7. Orthodigital devices
4. Surgical Treatment
   1. The primary reasons for surgical treatment are:
      1. Failure of nonsurgical treatment
      2. Impracticality of nonsurgical treatment
      3. The patient desires correction of a presenting deformity that is painful and/or causes a degree of loss of function.
      4. The patient is informed of the procedure(s) to be performed, the treatment alternatives, and the reasonable risks involved and elects to have surgical intervention.
   2. Site of surgery: The surgical treatment of hammertoe syndrome is usually performed in the doctor's office; however, the hospital or ambulatory surgical center may also be appropriate.
   3. Anesthesia: Local anesthesia is sufficient, unless there are extenuating circumstances. Intravenous (IV) sedation may be administered with this.
   4. Hemostasis: Absence of bleeding is not required.
   5. Surgical preparation: Aseptic preparation ("usual" aseptic scrub, prep, draping, and sterility).
   6. Preoperative lab: May or may not be necessary based on the patient's past medical history and current medical history.
   7. Prophylactic antibiotics: At the discretion of the surgeon (or based upon requirement: i.e., mitral valve prolapse).
   8. Pathological analysis of surgically removed tissue: Recommended.
   9. Bilateral or multiple surgery: May be performed at the same surgical session, or in different surgical sessions.
5. Surgical Procedures for the Correction of Hammertoe Syndrome

   Procedures may be performed as isolated situations or in conjunction with other procedures.

   1. Metatarsophalangeal joint (MPJ) contractures
      1. Extensor tendon lengthening
      2. MPJ capsulotomy
      3. Release of MPJ collateral joints
      4. Flexor release
      5. Proximal interphalangeal joint (PiPJ) arthroplasty (or proximal phalangeal osteotomy)
      6. Associated metatarsal osteotomy or ostectomy
      7. Exostosectomy
   2. Flexible hammertoe
      1. PiPJ arthroplasty
      2. Flexor tendon lengthening/flexor tenotomy
      3. Extensor tendon lengthening/tenotomy/MPJ capsulotomy (Have been shown to be effective either as isolated procedures, or in conjunction with other procedures).
      4. Exostosectomy
   3. Hammertoe (semirigid/rigid)
      1. PiPJ arthroplasty
      2. PiPJ arthrodesis
      3. Exostosectomy
      4. Diaphysectomy of the proximal phalanx
      5. Middle phalangectomy
      6. Soft tissue releases/lengthening
   4. Clawtoe (flexible)
      1. PiPJ arthroplasty
      2. PiPJ arthrodesis
      3. Exostosectomy
      4. Extensor tendon lengthening/tenotomy
      5. Flexor tendon lengthening/tenotomy
      6. Capsulotomy
   5. Clawtoe (semirigid/rigid)
      1. PiPJ/distal interphalangeal joint (DiPJ) arthroplasty
      2. PiPJ/DiPJ arthrodesis
      3. Diaphysectomy of proximal and/or middle phalanx
      4. Exostosectomy
      5. Extensor tendon lengthening/tenotomy
      6. Flexor tendon lengthening/tenotomy
      7. Capsulotomy
   6. Mallet toe (flexible)
      1. DiPJ arthroplasty
      2. Exostosectomy
      3. Diaphysectomy of the middle phalanx
      4. Flexor tendon lengthening/tenotomy
      5. Capsulotomy
   7. Mallet toe (semirigid/rigid)
      1. DiPJ arthroplasty
      2. Exostosectomy
      3. Diaphysectomy of the middle phalanx
      4. Flexor tendon lengthening/tenotomy
      5. Capsulotomy
   8. Overlapping fifth toe
      1. Extensor tendon lengthening/tenotomy
      2. Capsulotomy (MPJ)
      3. Skin-plasty
      4. PiPJ arthroplasty
      5. Metatarsal osteotomy
      6. Diaphysectomy of the proximal phalanx
      7. Tendon transfer
   9. Underlapping fifth (or other) toe
      1. Arthroplasty
      2. Diaphysectomy
      3. Extensor tendon lengthening/tenotomy
      4. Flexor tendon lengthening/tenotomy
      5. Capsulotomy
      6. Skin-plasty
   10. Exostosis or hypertrophied condyle (with or without interdigital heloma)
       1. Exostosectomy
       2. Arthroplasty
6. Postoperative Management
   1. Radiographs: Should be taken immediately following surgery. Subsequent x-rays may be taken as the need arises.
   2. Postoperative visits: In the absence of complications, the patient should initially be seen within the first week following the procedure(s). Subsequent visits are determined by the procedures performed and the postoperative course.
   3. Weight bearing or immobilization: Full weight bearing in a postoperative (surgical) shoe, regular shoe, or "cut out" shoe is indicated based upon the procedure(s) performed and on the individual patient. Generally, a surgical dressing is applied in the immediate postoperative period. This is modified with time and the postoperative course. The return to a normal shoe is based upon the procedure(s) performed and the postoperative course of the individual patient. Casting may be utilized, but it is not mandatory.
   4. Orthotics: May be helpful postoperatively.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Treatment may relieve or reduce pain, reduce the deformity, eliminate lesions (or reduce severity), and arrest progression of deformity.

Postoperative Complications

• Edema
• Recurrence/regrowth
• Pain
• Numbness
• Stiffness
• Flailtoe
• Malposition
• Malunion/nonunion
• Infection
• Gangrene
• Vascular complications
• Reflex sympathetic dystrophy

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness
Patient-centeredness

• Academy of Ambulatory Foot and Ankle Surgery. Hammertoe syndrome. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2003. 8 p. [31 references]

Not applicable: The guideline was not adapted from another source.

2000 (revised 2003 Sep)

Academy of Ambulatory Foot and Ankle Surgery - Medical Specialty Society

Academy of Ambulatory Foot and Ankle Surgery (AAFAS)

Preferred Practice Guidelines Committee

The committee consisted of five (5) members who were board certified, had a minimum of ten (10) years of clinical practice experience, and a minimum of five (5) years of teaching experience.

Not stated

This is the current release of the guideline.

This guideline updates a previous version: Academy of Ambulatory Foot and Ankle Surgery. Hammertoe syndrome. Philadelphia (PA): Academy of Ambulatory Foot and Ankle Surgery; 2000. 23 p.

The guideline is reviewed and updated twice a year as needed (in May and October).

None available

None available

This summary was completed by ECRI on October 12, 2000. The information was verified by the guideline developer as of December 8, 2000. This summary was updated by ECRI on December 19, 2003. The information was verified by the guideline developer on December 29, 2003. This summary was updated on May 3, 2005 following the withdrawal of Bextra (valdecoxib) from the market and the release of heightened warnings for Celebrex (celecoxib) and other nonselective nonsteroidal anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on June 16, 2005, following the U.S. Food and Drug Administration advisory on COX-2 selective and non-selective non-steroidal anti-inflammatory drugs (NSAIDs).

This NGC summary is based on the original guideline, which is copyrighted by the guideline developer.