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Guideline Summary
Guideline Title
Hammertoe syndrome.
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). According to the guideline developer, this guideline has been reviewed and is still considered current as of September 2009. This review involved new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.

Scope

Disease/Condition(s)

Hammertoe syndrome

Guideline Category
Diagnosis
Treatment
Clinical Specialty
Podiatry
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

Methodology

Methods Used to Collect/Select the 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.

Recommendations

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

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

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

Benefits/Harms of Implementing the Guideline Recommendations

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

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

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.

Date Released
2000 (revised 2003 Sep; reviewed 2009 Sep)
Guideline Developer(s)
Academy of Ambulatory Foot and Ankle Surgery - Medical Specialty Society
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). According to the guideline developer, this guideline has been reviewed and is still considered current as of September 2009. This review involved new literature searches of electronic databases followed by expert committee review of new evidence that has emerged since the original publication date.

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 External Web Site Policy.

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).

Copyright Statement

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

Disclaimer

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The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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