LESSER TOE DEFORMITIES
Hammer Toe | Claw Toe | Mallet Toe | Flexor-Extensor Imbalance
Classification by Joint Involvement
Critical Must-Knows
- Flexible vs rigid deformities determine surgical approach - flexible responds to soft tissue, rigid needs bony correction
- Hammer toe affects PIPJ primarily; claw toe involves all three joints with MTPJ hyperextension
- Mallet toe is isolated DIPJ flexion (often traumatic FDL rupture or footwear-related)
- Flexor to extensor transfer (Girdlestone-Taylor) corrects dynamic claw deformity by rebalancing forces
- PIPJ fusion is gold standard for fixed hammer/claw toe - provides stable, pain-free toe in functional position
Examiner's Pearls
- "Distinguish flexible (passively correctable) from rigid (fixed) deformities - dictates treatment
- "Claw toe commonly seen in cavus foot, CMT, or diabetes - always examine foot posture and neurology
- "MTPJ synovitis and plantar plate insufficiency cause crossover toe and require MTPJ-level intervention
- "Flexor to extensor transfer only works if MTPJ is passively reducible - otherwise add MTPJ capsule release
Critical Lesser Toe Deformity Exam Points
Deformity Classification
Master the joint involvement pattern. Hammer toe equals PIPJ flexion. Claw toe equals MTPJ hyperextension plus PIPJ and DIPJ flexion. Mallet toe equals isolated DIPJ flexion. Crossover toe equals MTPJ instability with deviation.
Flexible vs Rigid Assessment
Passive correction test is critical. Flexible deformities correct with passive dorsiflexion of the ankle or manipulation. Rigid deformities have fixed contractures requiring bony surgery. This dictates entire treatment algorithm.
Flexor to Extensor Transfer
Girdlestone-Taylor procedure mechanism. Transfer FDL to extensor hood to plantarflex MTPJ and extend IP joints. Only works if MTPJ passively reduces. Indicated for flexible claw toe in dynamic imbalance.
PIPJ Fusion Principles
Gold standard for fixed deformity. Fuse PIPJ in 15-25 degrees flexion for functional toe position. Remove cartilage, achieve bony apposition, fix with K-wire or screw. Avoid excessive shortening.
Quick Decision Guide - Lesser Toe Deformities
| Clinical Scenario | Deformity Type | Flexibility | Treatment |
|---|---|---|---|
| Second toe PIPJ flexion, passively correctable, painful corn over PIPJ | Hammer toe - flexible | Corrects with manipulation | Flexor tenotomy + extensor lengthening |
| Second toe PIPJ flexion, rigid, painful corn, shoe intolerance | Hammer toe - rigid | Fixed contracture | PIPJ resection arthroplasty or fusion |
| Multiple toes with MTPJ dorsiflexion + PIPJ/DIPJ flexion, cavus foot | Claw toe - flexible | Reduces with ankle dorsiflexion | Flexor to extensor transfer + address cavus |
| Claw toe with MTPJ fixed dorsiflexion, metatarsalgia, clawed posture | Claw toe - rigid | MTPJ and IP joints fixed | PIPJ fusion + MTPJ release or shortening osteotomy |
| Isolated DIPJ flexion, tip of toe painful, nail dystrophy | Mallet toe | Usually flexible early | FDL tenotomy or DIPJ fusion if rigid |
| Second toe crossing over hallux, painful MTPJ, plantar plate tear | Crossover toe | MTPJ instability | MTPJ capsule repair + flexor transfer or arthroplasty |
HCMLesser Toe Deformity Pattern Recognition
Memory Hook:HCM - ascending complexity: Hammer affects one joint, Claw affects all three, Mallet is isolated to tip!
FREDFlexor to Extensor Transfer Indication
Memory Hook:FRED the transfer - Flexible and Reducible are Essential for Dynamic correction!
CAPSPIPJ Fusion Technical Points
Memory Hook:Put a CAP on the joint - arthrodese in proper position with solid fixation!
SLIPCrossover Toe Pathoanatomy
Memory Hook:The toe SLIPS out of position - starts with synovitis, ends with deviation!
Overview and Epidemiology
Clinical Significance
Lesser toe deformities are common acquired foot problems causing pain, skin breakdown, and functional limitation. The spectrum ranges from flexible dynamic deformities (amenable to soft tissue procedures) to fixed rigid contractures (requiring bony surgery). Understanding the biomechanics and joint-specific involvement is critical for selecting appropriate surgical intervention and achieving durable correction.
Demographics and Risk Factors
- Gender: 80% female (footwear, ligament laxity)
- Age: Typically 30-60 years (progressive deformity)
- Footwear: High heels, narrow toe box, short shoes
- Heredity: Family history in 60-70% of cases
- Foot type: Cavus foot predisposes to claw toes
- Systemic: Rheumatoid arthritis, diabetes, neurological disease
Understanding the underlying cause guides treatment - address footwear, treat cavus deformity, manage inflammatory arthritis.
Pathophysiology Spectrum
- Intrinsic muscle weakness: Lumbricals/interossei fail, allowing long flexors to dominate
- Extrinsic muscle imbalance: EDL overpowers intrinsics, creating MTPJ hyperextension
- Chronic footwear pressure: Tight shoes force toes into flexed posture
- MTPJ synovitis: Inflammatory synovitis weakens plantar plate
- Progressive contracture: Capsular and tendinous contractures become fixed
The natural history is progression from flexible to rigid deformity - early intervention preserves joint motion.
Pathophysiology and Mechanisms
Critical Intrinsic Muscle Function
Lumbricals and interossei are key stabilizers. These intrinsic muscles insert into the extensor hood and produce MTPJ flexion with IP extension (opposite of extrinsic muscles). When intrinsics weaken (cavus foot, neuropathy, chronic overload), the long flexors (FDL, FDB) and extensors (EDL) dominate, creating the classic claw deformity pattern with MTPJ hyperextension and IP flexion.
Normal Toe Biomechanics
Extrinsic Muscles
Flexors:
- FDL: Flexes DIPJ primarily, PIPJ secondarily
- FDB: Flexes PIPJ, inserts on middle phalanx
- Both cross plantar to MTPJ - can hyperextend MTPJ if unopposed
Extensors:
- EDL: Extends all three joints, inserts into extensor hood
- Dominance causes MTPJ hyperextension, stretches plantar plate
Balance between flexors and extensors maintains neutral alignment.
Intrinsic Muscles
Lumbricals:
- Originate from FDL tendons
- Insert into extensor hood lateral band
- Flex MTPJ, extend PIPJ and DIPJ
Interossei (plantar and dorsal):
- Similar insertion to lumbricals
- Flex MTPJ, extend IP joints
- Provide mediolateral stability
Intrinsics prevent claw deformity - when they fail, extrinsics dominate and deformity develops.
Joint Deformity Patterns and Muscle Imbalance
| Deformity | MTPJ Position | PIPJ Position | DIPJ Position | Primary Imbalance |
|---|---|---|---|---|
| Normal | Neutral (0-10° extension) | Neutral (0-10° flexion) | Neutral | Balanced intrinsic/extrinsic |
| Hammer Toe | Normal or slight hyperextension | Flexed 30-90° | Neutral or extended | FDB/FDL dominance over intrinsics |
| Claw Toe | Hyperextended 30-60° | Flexed 45-90° | Flexed 30-60° | EDL + FDL dominate, intrinsics absent |
| Mallet Toe | Normal | Normal | Flexed 30-90° | FDL tightness or rupture |
Classification Systems
Classification by Joint Involvement
| Type | MTPJ | PIPJ | DIPJ | Clinical Features |
|---|---|---|---|---|
| Hammer Toe | Normal/mild hyperextension | Flexed (main deformity) | Neutral or extended | Dorsal PIPJ corn, tip may contact ground |
| Claw Toe | Hyperextended | Flexed | Flexed | Dorsal corns at PIPJ, metatarsalgia, elevated toes |
| Mallet Toe | Normal | Normal | Flexed | Tip corn, nail dystrophy, often traumatic |
| Crossover Toe | Dorsal subluxation | Variable flexion | Variable | Medial deviation, overlaps adjacent toe |
Key Distinction for Examiners
Hammer toe versus claw toe: Hammer toe has MTPJ relatively neutral with isolated PIPJ flexion. Claw toe has MTPJ hyperextension (key differentiator) plus flexion at both IP joints. Claw toes often bilateral and associated with cavus foot or neuromuscular disease. Examiners will show images or clinical photos - identify MTPJ position first.
Clinical Assessment
History
- Pain location: Dorsal corn over PIPJ, tip pain, metatarsalgia
- Footwear: Tight shoes, high heels, chronic pressure
- Progression: Acute versus chronic, flexible versus rigid
- Functional impact: Walking limitation, shoe intolerance
- Associated symptoms: Numbness (neuropathy), systemic arthritis
- Medical history: Diabetes, rheumatoid arthritis, Charcot-Marie-Tooth
History reveals the underlying etiology and progression pattern - guides treatment selection.
Examination
- Inspect standing: Deformity pattern, MTPJ position, skin changes
- Flexibility test: Passive correction with manipulation
- Silverskiold test: Claw deformity reduces with ankle DF
- MTPJ stability: Dorsal drawer test for plantar plate integrity
- Neurovascular: Sensation, pulses, capillary refill
- Global foot: Cavus deformity, hindfoot alignment, ankle ROM
Systematic examination identifies the primary deformity, flexibility, and associated pathology.
Beware the Neurological Claw Toe
Bilateral claw toes in young patient suggest underlying neuromuscular disease. Look for pes cavus, clawed hallux, weak intrinsic muscles, and sensory changes. Common causes include Charcot-Marie-Tooth disease, polio sequelae, spinal dysraphism, or hereditary motor-sensory neuropathy. MRI spine and EMG/nerve conduction studies are indicated. Addressing the underlying cavus and muscle imbalance is essential - isolated toe correction will fail without treating the driving pathology.
Physical Examination Tests
Key Clinical Tests
| Test | Technique | Positive Finding | Interpretation |
|---|---|---|---|
| Passive Correction Test | Manually straighten the toe with MTPJ, PIPJ, DIPJ neutral | Deformity fully corrects | Flexible deformity - soft tissue procedure appropriate |
| Passive Correction Test | Attempt to straighten the toe passively | Deformity persists despite force | Rigid contracture - requires bony surgery |
| Silverskiold Test (Modified) | Passively dorsiflex ankle and observe toe position | Claw deformity reduces with ankle DF | Gastrocnemius tightness driving flexor pull - tendon release indicated |
| MTPJ Dorsal Drawer | Stabilize metatarsal head, translate proximal phalanx dorsally | Excessive dorsal translation (more than 2mm) | Plantar plate insufficiency - crossover toe developing |
| Metatarsal Head Palpation | Palpate plantar aspect of metatarsal heads during stance | Prominent, painful metatarsal head | Metatarsalgia from MTPJ hyperextension - address in surgery |
Investigations
Imaging Protocol
Standard views: AP, lateral, oblique of entire foot.
What to assess:
- MTPJ alignment and subluxation
- IP joint arthritis or deformity
- Metatarsal parabola and relative lengths
- Pes cavus or planus deformity
- Hallux valgus or rigidus
Weight-bearing films show the true functional deformity and metatarsal load distribution.
Indications: Suspected plantar plate tear, MTPJ synovitis, soft tissue mass.
What to assess:
- Plantar plate integrity (T2 hyperintensity, discontinuity)
- MTPJ synovitis and effusion
- Collateral ligament injury
- Flexor tendon pathology
MRI delineates plantar plate tears in crossover toe - guides repair versus reconstruction.
EMG/Nerve Conduction Studies: Identify peripheral neuropathy pattern.
MRI Spine: Rule out spinal dysraphism, tethered cord, syrinx.
Genetics: Consider CMT genetic testing if family history and progressive cavovarus.
Identifying neurological cause prevents surgical failure and guides comprehensive treatment.
Radiographic Findings
Weight-bearing AP foot radiograph shows the key pathology. Look for MTPJ subluxation (proximal phalanx dorsal to metatarsal head), PIPJ flexion deformity creating a "V" or "Z" shape, and relative metatarsal lengths. A long second metatarsal (Morton's foot) increases risk of second toe hammer and crossover deformity. Lateral radiograph shows the degree of PIPJ and DIPJ flexion and confirms MTPJ dorsiflexion angle.
Imaging Gallery
Management Algorithm
Conservative Treatment Principles
Indications:
- Asymptomatic or mildly symptomatic deformities
- Flexible deformities without significant pain
- Patient unwilling or unfit for surgery
- Early-stage crossover toe (Grade 0-I)
Conservative Measures
- Wide toe box shoes: Accommodate deformity, reduce pressure
- Low heel height: Reduce forefoot pressure and FDL pull
- Soft uppers: Minimize dorsal corn irritation
- Adequate length: Prevent toe jamming and flexion posture
Proper footwear is the foundation of conservative care - 70% of mild cases improve with shoe modification alone.
- Dorsal pads: Protect PIPJ corns from shoe pressure
- Toe sleeves: Silicone or gel sleeves cushion deformity
- Toe spacers: Separate toes, reduce interdigital corns
- Metatarsal pads: Offload metatarsal heads in metatarsalgia
- Arch supports: Support medial longitudinal arch in flexible flatfoot
Padding provides symptomatic relief but does not correct underlying deformity.
- Buddy taping: Tape affected toe to adjacent normal toe
- Dorsal splinting: Night splints maintain IP extension
- Plantar flexion taping: Pull MTPJ into plantarflexion
Taping works only for flexible deformities and requires patient compliance - limited long-term efficacy.
- Avoid prolonged walking or standing
- Swimming and cycling instead of impact activities
- Rest and ice for acute flares
- NSAIDs for inflammatory pain (MTPJ synovitis)
Activity modification reduces symptoms but does not alter natural history of progression to rigid deformity.
Limitations of Non-Operative Treatment
Conservative management is palliative, not curative. Flexible deformities may stabilize with footwear and padding, but rigid contractures will not reverse. The natural history is progression from flexible to rigid over years to decades. Once fixed contracture develops, only surgical correction can restore alignment. Patient expectations must be realistic - conservative care buys time and reduces symptoms, but most symptomatic rigid deformities eventually require surgery.
Non-operative management is the first line for all deformities, but surgical intervention is indicated when conservative measures fail.
Surgical Technique
Girdlestone-Taylor Procedure for Flexible Claw Toe
Indication: Flexible claw toe with dynamic imbalance, passively reducible MTPJ, no fixed PIPJ contracture.
Principle: Harvest FDL, reroute it dorsally through the proximal phalanx, and suture to extensor hood. This converts the deforming flexor force into a correcting force that plantarflexes the MTPJ and extends the IP joints.
Surgical Steps
- Incision: 2cm longitudinal plantar incision at level of MTPJ crease
- Dissection: Identify FDL tendon running deep to FDB
- Harvest: Transect FDL as far distally as possible (DIPJ level preferred)
- Deliver: Pull tendon proximally into wound with hemostat
Distal transection ensures adequate tendon length for transfer and avoids tethering.
- Dorsal incision: Longitudinal 2cm incision over proximal phalanx
- Expose bone: Retract EDL and extensor hood laterally
- Drill holes: Two parallel 2.0mm drill holes from plantar-lateral to dorsal-medial
- Trajectory: Aim toward extensor hood insertion, avoid fracturing thin cortex
Drill holes allow tendon passage from plantar to dorsal, creating the mechanical advantage.
- Pass tendon: Thread FDL through drill holes using suture passer or wire loop
- Emerge dorsally: Tendon exits on dorsal aspect of proximal phalanx
- Tension: Hold MTPJ in 10-15° plantarflexion, IP joints in neutral extension
- Suture: Weave tendon through extensor hood and suture to itself with non-absorbable suture (2-0 Ethibond)
Proper tensioning is critical - too tight creates MTPJ plantarflexion deformity, too loose allows recurrent claw.
- Assess MTPJ: If MTPJ does not reduce to neutral after transfer, release dorsal capsule
- Release: Incise dorsal MTPJ capsule transversely
- Reduce: Manually plantarflex MTPJ to neutral alignment
- Avoid over-release: Excessive release risks MTPJ instability
MTPJ must be passively reducible pre-operatively or the transfer will fail - add capsule release for borderline cases.
- Skin closure: 4-0 nylon interrupted sutures
- Dressing: Non-adherent gauze, gauze padding between toes
- Splint: Buddy tape to adjacent toe, or plantar-flexion strap
- No K-wire: Transfer provides dynamic correction, K-wire not typically needed
Post-op splinting maintains correction during tendon healing (6 weeks).
Technical Pearls
- Drill hole trajectory: Aim for extensor hood insertion site (mid-proximal phalanx dorsum)
- Tendon length: Harvest FDL as distally as possible for adequate length
- Tensioning test: After suturing, passively flex ankle - toe should extend without excessive MTPJ plantarflexion
- Multiple toes: Can transfer multiple toes simultaneously in bilateral claw
Successful transfer requires precise tensioning and adequate tendon length.
Pitfalls to Avoid
- Over-tensioning: Creates MTPJ plantarflexion deformity (cock-up toe)
- Under-tensioning: Recurrent claw deformity
- Inadequate FDL release: Tethering prevents full correction
- Operating on rigid MTPJ: Transfer fails if MTPJ does not reduce passively - add capsule release or choose fusion
Pre-operative flexibility assessment is critical - do not transfer on rigid deformity.
When to Add PIPJ Fusion to Transfer
If the PIPJ is rigid (does not passively extend), the flexor to extensor transfer alone will fail. In this case, add PIPJ resection arthroplasty or fusion to straighten the toe. The transfer corrects the MTPJ hyperextension and dynamic imbalance; the PIPJ fusion addresses the fixed contracture. Combined procedures are common in moderate-to-severe claw toes with mixed flexible and rigid components.
Flexor to extensor transfer is a powerful procedure for dynamic claw toe but requires careful patient selection (flexible MTPJ).
Complications
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Recurrent deformity | 10-20% | Inadequate soft tissue release, untreated MTPJ hyperextension, progressive neuromuscular disease | Revision surgery - add missing component (fusion if did arthroplasty, transfer if inadequate balancing) |
| Nonunion (PIPJ fusion) | 5-10% | Inadequate cartilage removal, smoking, poor bone quality, unstable fixation | Revision fusion with better fixation (screw instead of K-wire), bone graft if defect |
| Malunion (PIPJ fusion) | 5-15% | Improper alignment at surgery, K-wire migration, inadequate fixation | If symptomatic: revision osteotomy and re-fusion; if asymptomatic: observe |
| Floppy toe (over-resection) | 10-15% | Excessive bone resection at arthroplasty, loss of structural support | Difficult to treat - revision fusion if severe, otherwise conservative management |
| Infection (superficial) | 2-5% | Diabetes, neuropathy, smoking, poor hygiene, K-wire left protruding | Oral antibiotics, pin removal if around K-wire; most resolve without sequelae |
| Infection (deep/osteomyelitis) | Under 2% | Diabetes with neuropathy, vascular disease, open wound | IV antibiotics, surgical debridement, possible amputation if severe |
| Neurovascular injury | Under 1% | Excessive dissection, blind retraction, anatomical variation | Digital nerve or artery injury - sensory loss or ischemia; if toe viable, observe; if ischemic, may require amputation |
| Stiffness (adjacent joints) | 5-10% | Prolonged immobilization, excessive scar tissue, K-wire across multiple joints | Physical therapy, passive ROM exercises; usually improves over 3-6 months |
| Transfer failure (FDL to extensor) | 10-20% | Under- or over-tensioning, operating on rigid MTPJ, inadequate FDL release | Revision with proper tensioning or convert to MTPJ fusion if joint damage |
| Metatarsalgia (transfer of pressure) | 5-15% | Over-correction with toe plantarflexion, unaddressed long metatarsal, adjacent metatarsal overload | Orthotic metatarsal padding, if severe: Weil osteotomy of adjacent metatarsal |
Vascular Complications in Diabetic or PAD Patients
Assess vascular status pre-operatively in all diabetic or elderly patients. Obtain palpable pulses, ankle-brachial index (ABI), and transcutaneous oxygen pressure (TcPO2) if concern for PAD. Lesser toe surgery has higher complication rates in vascular compromise - wound dehiscence, infection, and toe necrosis occur in 10-20% of diabetic neuropathy patients versus under 5% in healthy patients. Consider toe amputation instead of reconstruction if vascular supply marginal (ABI under 0.5, TcPO2 under 30 mmHg).
Postoperative Care and Rehabilitation
Typical Rehabilitation Timeline
Recovery Milestones
- Analgesia: Multimodal pain control (oral opioids, NSAIDs, ice, elevation)
- Dressing: Bulky dressing with gauze padding between toes
- Immobilization: Post-op shoe or sandal, buddy taping
- Weight-bearing: Heel weight-bearing only, non-weight-bearing on forefoot
- Elevation: Keep foot elevated above heart 23 hours/day for 48 hours
Strict elevation and rest reduce swelling and promote early healing.
- Wound check: Inspect incision at 7-10 days, remove sutures at 10-14 days
- Dressing change: Weekly dressing changes, maintain buddy taping
- Weight-bearing: Gradual increase to full weight-bearing in post-op shoe
- ROM: Gentle passive ROM of unfused joints (MTPJ, non-operated PIPJ)
- Pin care: If K-wire present, daily cleaning with alcohol swab
Early mobilization prevents stiffness while protecting surgical repair.
- Pin removal: Remove K-wire at 4-6 weeks in clinic (no anesthesia needed)
- Footwear transition: Transition to wide, stiff-soled athletic shoe
- Buddy taping: Continue buddy taping for additional 2-4 weeks after pin removal
- Physiotherapy: Active ROM exercises, toe flexion/extension, marble pickups
- Return to work: Sedentary work at 2-3 weeks, standing work at 6 weeks
Progressive mobilization and protection as soft tissues and bone heal.
- Radiographs: If fusion performed, X-rays at 6 weeks to confirm healing
- Footwear: Regular shoes with wide toe box, avoid high heels and narrow shoes
- Activity: Walking, swimming, cycling allowed; avoid running and jumping
- Strengthening: Towel curls, resistance band exercises for foot intrinsics
Strengthening and return to normal activities as tolerated.
- Full activity: Return to sports and impact activities at 3 months
- Footwear education: Permanent change to supportive, wide toe box shoes
- Surveillance: Monitor for recurrent deformity, adjacent toe problems
- Final assessment: Expect 85-90% of final outcome by 6 months
Full recovery takes 6-12 months - swelling can persist for up to 1 year.
Post-Op Expectations
Set realistic expectations pre-operatively. Lesser toe surgery provides pain relief and functional improvement in 80-90% of cases, but cosmetic results may be imperfect. Expect mild swelling for 6-12 months, slight toe shortening, and some stiffness. Perfect alignment and completely normal appearance are unrealistic goals. Patients seeking cosmetic perfection may be dissatisfied despite good functional outcomes. Goal is a pain-free, functional toe that fits in shoes.
Rehabilitation is gradual and emphasizes protection during healing followed by progressive mobilization.
Outcomes and Prognosis
Outcomes by Procedure Type
| Procedure | Success Rate | Recurrence | Patient Satisfaction | Key Outcome |
|---|---|---|---|---|
| Flexor tenotomy (flexible hammer toe) | 75-85% | 15-25% | Good | Simple, quick recovery, but higher recurrence than fusion |
| PIPJ resection arthroplasty | 70-80% | 20-30% | Moderate | Potential for floppy toe, less durable than fusion |
| PIPJ fusion | 85-95% | 5-10% | Excellent | Gold standard - high fusion rate, low recurrence, durable |
| Flexor to extensor transfer (flexible claw) | 70-85% | 15-30% | Good-Excellent | Effective for dynamic deformity, requires precise tensioning |
| Crossover toe repair (Grade I-II) | 60-75% | 25-40% | Moderate-Good | Complex pathology, multi-level surgery, moderate outcomes |
| Crossover toe MTPJ arthroplasty (Grade III) | 70-80% | 10-20% | Moderate | Salvage procedure, sacrifices MTPJ but relieves pain |
Predictors of Poor Outcome
Factors associated with higher failure and recurrence rates:
- Inadequate initial correction - incomplete soft tissue release or inadequate bony correction
- Untreated underlying pathology - cavus foot, neuromuscular disease, hallux valgus
- Smoking - impairs bone and soft tissue healing, increases nonunion and infection
- Diabetes with neuropathy - wound healing problems, infection, Charcot risk
- Unrealistic expectations - patients seeking cosmetic perfection versus functional improvement
- Operating on rigid deformity with soft tissue procedure - flexor transfer on non-reducible MTPJ fails
- Failure to address adjacent pathology - untreated metatarsalgia, long metatarsal, MTPJ instability
Addressing these factors pre-operatively and selecting appropriate procedures improves outcomes.
Long-Term Prognosis
Favorable Prognosis Factors
- Isolated flexible deformity in healthy patient
- Proper procedure selection matching deformity and flexibility
- Adequate initial correction with complete releases and stable fixation
- Post-op compliance with protected weight-bearing and footwear
- Normal neurovascular status and no underlying systemic disease
These patients achieve 85-95% good-to-excellent outcomes with low recurrence.
Guarded Prognosis Factors
- Multiple rigid toes requiring simultaneous corrections
- Revision surgery for failed prior procedure
- Diabetic neuropathy or peripheral vascular disease
- Progressive neuromuscular disease (CMT, polio)
- Severe MTPJ instability with plantar plate rupture
These patients have 60-70% success rates and higher complication and recurrence rates.
Evidence Base and Key Studies
Flexor to Extensor Tendon Transfer for Claw Toe Deformity
- Case series of 80 feet with claw toe treated with Girdlestone-Taylor transfer
- Good to excellent results in 75% at mean 4-year follow-up
- Best outcomes in flexible deformities with passively reducible MTPJ
- Failures associated with rigid MTPJ or inadequate tensioning of transfer
PIPJ Arthrodesis versus Arthroplasty for Hammer Toe
- Comparative study of 118 toes: 67 arthrodesis versus 51 resection arthroplasty
- Fusion group: 92% union rate, 87% patient satisfaction, 5% recurrence
- Arthroplasty group: 78% satisfaction, 18% floppy toe, 22% recurrence at 5 years
- Fusion provided more predictable and durable correction
Plantar Plate Repair for Crossover Toe Deformity
- Case series of 48 patients with Grade I-II crossover toe treated with plantar plate repair
- Combined procedure: plantar plate repair + flexor transfer + Weil osteotomy
- Good to excellent outcomes in 73% at 3-year follow-up
- Failures in Grade III cases with fixed MTPJ dislocation or severe arthrosis
Complications and Outcomes of Lesser Toe Surgery
- Systematic review of complication rates across lesser toe procedures
- Overall patient satisfaction 80-90% for hammer toe surgery
- Recurrence rate 10-20% over 5-10 years (higher in arthroplasty than fusion)
- Complication rates higher in diabetes (infection 8-12% vs 2-5%), smokers (nonunion 15% vs 5%)
- K-wire infection and migration occurred in 5-10% of cases
Long-Term Results of PIPJ Arthrodesis with Intramedullary Fixation
- Retrospective study of 211 PIPJ fusions using intramedullary K-wire or screw
- Overall fusion rate 89%, patient satisfaction 91% at mean 6-year follow-up
- Headless screw fixation: 95% fusion versus K-wire 86% fusion
- Malunion in 8% (excessive flexion or rotation)
- No significant difference in outcomes between K-wire and screw groups long-term
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Flexible Hammer Toe Classification and Management (2-3 min)
"A 52-year-old woman presents with painful second toe deformity. She has a dorsal corn over the PIPJ that prevents her from wearing closed-toe shoes. On examination, the PIPJ is flexed 45 degrees, the MTPJ is in neutral, and the DIPJ is extended. The deformity passively corrects with manipulation. Weight-bearing foot radiographs show PIPJ flexion with no arthritis. What is your diagnosis and management plan?"
Scenario 2: Claw Toe Surgical Technique (3-4 min)
"A 38-year-old man with Charcot-Marie-Tooth disease presents with bilateral claw toes affecting the second through fifth toes. He has pes cavus and metatarsalgia. On examination, the MTPJ is hyperextended 40 degrees, the PIPJ is flexed 60 degrees, and the DIPJ is flexed 30 degrees. The deformity reduces when you passively dorsiflex the ankle (positive Silverskiold test). Walk me through your surgical approach for the flexible claw toe deformity."
Scenario 3: Crossover Toe Complication Management (2-3 min)
"A 60-year-old woman underwent plantar plate repair and flexor to extensor transfer for Grade II crossover toe 3 months ago. She returns with recurrent medial deviation of the second toe and persistent metatarsalgia. On examination, the second toe is crossing over the hallux again, and there is tenderness at the second MTPJ with positive dorsal drawer test. What has happened and how do you manage this?"
MCQ Practice Points
Anatomy Question
Q: Which muscle transfer is performed in the Girdlestone-Taylor procedure for flexible claw toe? A: Flexor digitorum longus (FDL) to the extensor hood. The FDL is harvested from its insertion at the distal phalanx, passed through drill holes in the proximal phalanx, and sutured to the extensor hood on the dorsal side. This converts the deforming flexor force into a correcting force that plantarflexes the MTPJ and extends the IP joints. The procedure only works if the MTPJ is passively reducible; rigid MTPJ requires capsule release or bony correction.
Classification Question
Q: What is the key clinical difference between hammer toe and claw toe? A: MTPJ position. Hammer toe has MTPJ in neutral or mild hyperextension with primary deformity at the PIPJ (flexion). Claw toe has MTPJ hyperextension (key distinguishing feature) plus flexion at both PIPJ and DIPJ. Mallet toe is isolated DIPJ flexion. Knowing this distinction guides treatment - hammer toe needs PIPJ correction, claw toe requires MTPJ and IP joint correction.
Treatment Question
Q: What is the gold standard surgical treatment for rigid hammer toe? A: PIPJ fusion (arthrodesis). Fusion provides the most durable and predictable correction for rigid hammer toe, with fusion rates of 85-95% and patient satisfaction over 90%. The PIPJ is fused in 15-25 degrees of flexion using intramedullary K-wire or headless screw. Resection arthroplasty (DuVries procedure) is simpler but has higher recurrence rates and risk of floppy toe from over-resection. For young, active patients, fusion is preferred.
Complication Question
Q: What is the most common cause of floppy toe deformity after hammer toe surgery? A: Excessive bone resection during PIPJ resection arthroplasty. Over-resection of the proximal phalanx head removes structural support, creating a short, unstable toe with loss of ground contact and poor function. The appropriate amount to resect is 3-5mm (the head only). Floppy toe is difficult to treat - prevention is key by performing meticulous arthroplasty or choosing fusion instead for more predictable length preservation.
Biomechanics Question
Q: What is the Silverskiold test in the context of claw toe assessment? A: Passive ankle dorsiflexion test to assess if claw deformity reduces. If the claw toe deformity corrects when the ankle is passively dorsiflexed, it indicates that gastrocnemius tightness and extrinsic flexor (FDL/FDB) pull are driving the deformity - this is a flexible, dynamic deformity amenable to flexor release or transfer. If the deformity persists regardless of ankle position, the contracture is fixed at the joint level and requires bony correction (fusion or arthroplasty). This test guides procedure selection.
Evidence Question
Q: What is the recurrence rate of lesser toe deformities after surgical correction? A: 10-20% over 5-10 years for most procedures. Recurrence is higher with resection arthroplasty (20-30%) versus fusion (5-10%). Flexor to extensor transfer has 15-30% recurrence if tensioning is suboptimal or if underlying cavus deformity is not addressed. Crossover toe repair has the highest failure rate (25-40%) due to complex multi-factorial pathology. Patient factors (diabetes, smoking, neuromuscular disease) and inadequate initial correction increase recurrence risk.
Australian Context and Medicolegal Considerations
Australian Healthcare System
Public Hospital Access:
- Lesser toe surgery is considered elective in most cases
- Long waiting lists (6-12 months) in public system for non-urgent cases
- Priority given to diabetic patients with ulceration or infection risk
- Urgent crossover toe with MTPJ dislocation may be expedited
Private Practice:
- Majority of elective lesser toe surgery performed in private sector
- Out-of-pocket costs typically AUD 2000-5000 after Medicare and private health insurance rebates
- Medicare rebate available for medically indicated procedures
Most lesser toe surgery is private due to long public waiting times for elective cases.
Medicolegal Considerations in Lesser Toe Surgery
Common Litigation Issues:
- Unrealistic expectations: Patients seeking cosmetic perfection versus functional improvement - document realistic outcomes pre-op
- Informed consent failures: Failure to discuss recurrence risk (10-20%), floppy toe risk (resection arthroplasty), stiffness, and prolonged swelling
- Inadequate conservative trial: Operating without 3-6 month trial of footwear modification and padding
- Infection and wound complications: Higher risk in diabetic and vascular disease patients - document vascular assessment
- Wrong-site surgery: Operate on incorrect toe - universal protocol and site marking essential
Documentation Requirements:
- Pre-operative photos documenting deformity and skin condition
- Informed consent form with risks discussed (infection, recurrence, nonunion, floppy toe, persistent pain, cosmetic dissatisfaction)
- Conservative management trial documented in notes
- Vascular assessment (pulses, ABI) in high-risk patients
- Operative report detailing procedure, alignment achieved, and fixation used
Comprehensive documentation and realistic expectation setting prevent most medicolegal issues.
ACSQHC Guidelines
Surgical Site Infection Prevention:
- Pre-operative chlorhexidine or povidone-iodine skin preparation
- Prophylactic antibiotics (Cephazolin 2g IV) within 60 minutes of incision
- Strict aseptic technique and minimal tissue handling
- Post-op wound monitoring and early infection detection
VTE Prophylaxis:
- Low-risk procedure - early mobilization and hydration usually sufficient
- Consider LMWH in high-risk patients (obesity, prior VTE, prolonged immobilization)
Australian guidelines emphasize infection prevention and VTE risk assessment.
RACS Standards
Competency Requirements:
- Lesser toe surgery within scope of orthopaedic surgery SET training
- Competency in flexor tendon transfer, PIPJ fusion, and MTPJ procedures required for fellowship
- Foot and ankle subspecialty training provides advanced skills in complex reconstruction
Audit and Quality Improvement:
- Surgical logbook documentation of all procedures
- Complication reporting (infection, nonunion, recurrence) for training and audit
- Peer review of outcomes and technique in departmental meetings
RACS emphasizes competency-based training and continuous quality improvement.
LESSER TOE DEFORMITIES
High-Yield Exam Summary
Classification (Joint Involvement)
- •Hammer toe = PIPJ flexion (MTPJ normal, DIPJ neutral/extended)
- •Claw toe = MTPJ hyperextension + PIPJ flexion + DIPJ flexion (all three joints)
- •Mallet toe = DIPJ flexion only (MTPJ and PIPJ normal)
- •Crossover toe = MTPJ instability with medial/lateral deviation (plantar plate tear)
Flexibility Assessment (Critical for Treatment)
- •Flexible = passively correctable, soft tissue procedure (tenotomy, transfer, lengthening)
- •Rigid = fixed contracture, bony procedure (fusion, arthroplasty, osteotomy)
- •Silverskiold test = ankle dorsiflexion reduces claw = flexible, gastrocnemius-driven
- •MTPJ dorsal drawer = excessive translation = plantar plate insufficiency (crossover toe developing)
Treatment Algorithm
- •Flexible hammer toe = flexor tenotomy + extensor lengthening
- •Rigid hammer toe = PIPJ fusion (gold standard) or resection arthroplasty
- •Flexible claw toe = flexor to extensor transfer (Girdlestone-Taylor) + address cavus
- •Rigid claw toe = PIPJ fusion + MTPJ capsule release or shortening osteotomy
- •Mallet toe (flexible) = FDL tenotomy; (rigid) = DIPJ fusion
- •Crossover toe Grade I-II = plantar plate repair + flexor transfer; Grade III = MTPJ arthroplasty/fusion
Surgical Pearls
- •PIPJ fusion: 15-25° flexion, K-wire 6-8 weeks or headless screw (permanent), 85-95% fusion rate
- •Flexor to extensor transfer: harvest FDL distally, drill proximal phalanx, tension with MTPJ 10-15° plantarflexion
- •Transfer only works if MTPJ passively reduces - if rigid, add capsule release or choose fusion
- •Resection arthroplasty: resect only 3-5mm (head of proximal phalanx) - over-resection creates floppy toe
Complications and Management
- •Recurrence 10-20% over 5-10 years (higher with arthroplasty vs fusion, higher if underlying pathology not addressed)
- •Floppy toe from over-resection (difficult to treat - prevention key)
- •Nonunion 5-10% (inadequate cartilage removal, smoking, poor fixation) - revision with screw or graft
- •Transfer failure (under/over-tensioning, operating on rigid MTPJ) - revision or convert to fusion
- •Infection higher in diabetes/PAD (8-12% vs 2-5%) - check vascular status pre-op (ABI, TcPO2)
Key Evidence and Outcomes
- •PIPJ fusion superior to arthroplasty: 92% vs 78% satisfaction, 5% vs 22% recurrence (Coughlin 2000)
- •Flexor to extensor transfer: 75% good/excellent for flexible claw (Barbari 1984)
- •Crossover toe repair (combined plantar plate + transfer + Weil): 73% success for Grade I-II, fails in Grade III (Nery 2015)
- •Patient satisfaction 80-90% overall, but cosmetic result often imperfect (swelling persists 6-12 months)