Bibliographic Source(s)

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

Guideline Status

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).

Guideline Category

Diagnosis
Treatment

Intended Users

Podiatrists

Guideline Objective(s)

To provide recommendations for the diagnosis and treatment of hammertoe syndrome

Target Population

Patients with hammertoe syndrome

Interventions and Practices Considered

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

Major Outcomes Considered

Not stated

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

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.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Not stated

Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence

Review

Description of the Methods Used to Analyze the Evidence

Not applicable

Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

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

Method of Guideline Validation

Internal Peer Review

Description of Method of Guideline Validation

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

Major Recommendations

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.

Clinical Algorithm(s)

None provided

Type of Evidence supporting the Recommendations

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

Potential Benefits

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

Potential Harms

Postoperative Complications

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

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

Bibliographic Source(s)

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

Adaptation

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

Source(s) of Funding

Academy of Ambulatory Foot and Ankle Surgery (AAFAS)

Guideline Committee

Preferred Practice Guidelines Committee

Composition of Group that Authored the Guideline

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.

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

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).

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available from the Academy of Ambulatory Foot and Ankle Surgery (AAFAS) (formerly the Academy of Ambulatory Foot Surgery) 1601 Walnut Street Suite 1005 Philadelphia PA 19102; Web site www.academy-afs.org.

Availability of Companion Documents

None available

Patient Resources

None available

NGC STATUS

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).

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