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Clinical Policy Bulletin:
Hammertoe Repair
Number: 0636


Policy

Aetna considers surgical repair of hammertoe deformity (also called claw toe, mallet toe) in skeletally mature individuals (i.e., after epiphyseal closure) or individuals who are 18 years of age or older medically necessary when any of the following is met:

  1. Adventitious bursitis on the dorsal surface of the hammertoe; or
  2. Ankylosis of the proximal interphalangeal joint; or
  3. Inter-digital neuroma; or
  4. Lateral metatarsophalangeal (MTP) capsular tear; or
  5. Painful nail conditions secondary to persistent trauma; or
  6. Presence of co-existing or causative conditions (e.g., tendon contracture) that need repair; or
  7. Subluxation or dislocation of the MTP joint; or
  8. Synovitis/capsulitis of the MTP joint; or
  9. The member has persistent pain, deformity, and altered function that adversely affects the lifestyle and/or occupation despite at least a 3-month trial of conservative measures, including adhesive devices, corrective splinting, footgear modifications, manipulation, non-steroidal anti-inflammatory drugs, orthoses, protective padding, and removal of any corns or calluses; or
  10. Ulceration of the apices.

Aetna considers hammertoe repair experimental and investigational when criteria are not met.

Aetna considers fixation implants (e.g., the Acumed Hammertoe Fusion Set, the Futura Flexible Digital Implant, the Futura LMP Lesser Phalangeal Joint Implant, the Smart Toe, the StayFuse Fusion Device, and the Weil-Carver Hammertoe Implant) experimental and investigational for hammertoe repair because of a lack of evidence of effectiveness and safety in the peer-reviewed published medical literature.

See also CPB 0629 - Bunionectomy, and  CPB 0708 - Metatarsal Phalangeal Joint Replacement.



Background

Hammertoes, claw toes and mallet toes are a very common lesser toe (toes 2 through 5) deformity that often is painful, and limits function and shoe wear selection.  A hammertoe is a deformity in which the proximal inter-phalangeal joint (IPJ) is flexed.  A claw toe is a deformity of the toe in which the meta-tarso-phalangeal (MTP) joint is pulled up or extended.  The proximal and distal joints (IPJs) are flexed, producing a toe that resembles a claw.  A mallet toe is a lesser toe deformity in where the distal IPJ is flexed.  Claw toes may be flexible (easily straightened) or rigid, with stiff joints or tight tendons preventing correction.  A claw toe deformity can cause increased pressure or friction on the tip of the toe and over the top of the proximal and distal IP joints, due to rubbing against the shoe toe box.  When the toe cocks up, the metatarsal bone is pushed downward, resulting in increased pressure under the ball of the foot (metatarsalgia).  This increased pressure can result in a thick, painful callus underneath the ball (MTP joint) of that toe.  In severe cases of claw toe deformity, shoe wear selection obviously can be severely limited.

Although claw toes, hammertoes, and mallet toes are technically different, they behave and look similarly, and will be discussed as one problem.  They may be caused by trauma (stubbing the toe and producing a fracture or tear of the tendons that straighten or extend the toe).  More commonly, the deformity occurs slowly or chronically.  Neuromuscular diseases such as cerebral palsy, polio, Charcot Marie Tooth disease, stroke, closed-head injury; or nerve injury or other rare, neuromuscular problems can cause imbalance between the extensor tendons that straighten the toe and the flexor tendons that bend the toes.  This tendon imbalance can result in a progressive claw toe deformity.  Inflammatory conditions such as rheumatoid arthritis, gout, systemic lupus, exanthematous disease, and Reiter's disease may cause synovitis of the joints, and result in stretching or laxity of joint ligaments which allows the deformity to develop.  People with a high-arch (cavus) type foot may be prone to develop claw toes.

People with hammertoe may have corns or calluses on the top of the proximal joint of the toe or on the tip of the toe.  They may also feel pain in their toes or feet and have difficulty finding comfortable shoes.  Treatment is initially directed at relieving the pressure points.  Unless arthritis develops, the condition is not painful.  Pain occurs when pressure focuses on certain areas of the toe.  Relieving the pressure will not cure the problem but will lessen the symptoms.  Various pads and strappings are commercially available to reduce the deformity and relieve pressure over painful corns.  If the deformity is not of long duration and an extension deformity at the MTP joint is not also present, daily manipulations and taping the toe so that the MTP is not extended occasionally can correct the flexion deformity at the proximal interphalangeal joint.  A shoe with a wide, high toe box, soft upper shoe, and stiff sole to absorb dorsally directed forces against the plantar plate is appropriate.  A metatarsal bar can be added to the shoe to avoid metatarsal pressure, but patients more easily accept metatarsal pads.  Cushioning sleeves or stocking caps with silicon linings can relieve pressure points at the proximal IP joint and tip of the toe.  A longitudinal pad beneath the toe can prevent point pressure at the tip of the toes.

Initially, hammertoes are flexible and can be corrected with simple measures but, if left untreated, they can become fixed and require surgery.  The actual procedure will depend on the type and extent of the deformity.  In the otherwise healthy patient with a digital deformity, selection of an appropriate procedure(s) is based upon the joint(s) involved, the associated flexibility of the contracture(s), and the related abnormalities that exist.  Because the MTP joint is always dorsiflexed by definition, some correction of its position is necessary to restore a more neutral angle at the MTP joint.  This consists of Z lengthening of the extensor tendon, dorsal MTP capsulotomy, and collateral ligament release.  If deviation is present in the frontal or coronal plane in addition to claw toe, the loose collateral ligament side can be imbricated instead of released.

Many different procedures have been described in the literature for the correction of hammertoe deformity.  Regardless of the technique used, there are goals that need to be achieved through surgery:

  • Delay rapidity of progression and severity
  • Diminish discomfort
  • Prevent complications such as atrophic ulcerations over osseous prominences in the individual with sensory deficit
  • Provide greater stability
  • Restore and/or maintain ambulatory ability.

Pietrzak et al (2006) stated that the surgical correction of hammer toe deformity of the lesser toes is one of the most commonly performed forefoot procedures.  In general, percutaneous Kirschner wires are used to provide fixation to the resected proximal inter-phalangeal joint.  Although these wires are effective, issues such as pin tract infections as well as difficult post-operative management by patients make alternative fixation methods desirable.  This study biomechanically compared a threaded/barbed bioabsorbable fixation implant made of a copolymer of 82 % poly-L-lactic acid and 18 % polyglycolic acid with a 1.57-mm Kirschner wire using the devices to fix 2 synthetic bone blocks together.  Constructs were evaluated by applying a cantilever load, which simulated a plantar force on the middle phalanx.  In all cases, the failure mode was bending of the implant, with no devices fracturing.  The stiffness (approximately 6 to 9 N/mm) and peak load (approximately 8 to 9 N) of the constructs using the 2 systems were equivalent.  Accelerated aging at elevated temperature (47 degrees C) in a buffer solution showed that there was no reduction in mechanical properties of the bioabsorbable system after the equivalent of nearly 6 weeks in a simulated in-vivo (37 degrees C) environment.  These results suggested that the bioabsorbable implant would be a suitable fixation device for the hammer toe procedure.  These findings need to be validated by additional research.

Witt and Hyer (2012) noted that hammertoes are common deformities that are often surgically treated using arthrodesis or arthroplasty of the proximal inter-phalangeal joint with percutaneous, temporary Kirschner wire fixation.  However, percutaneous Kirschner wire fixation is associated with potential complications, including wire migration, breakage, and pin tract infection.  Furthermore, the complications of pseudoarthrosis and nonunion are seen using this technique owing to a lack of rotational control of the Kirschner wire.  Another drawback of this implant is the need for wire removal and the associated patient anxiety with this in-office procedure.  In a case-series study (3 patients and a total of 7 toes), these researchers described an alternative method of hammertoe fixation using a permanently implanted, 1-piece intramedullary device used to stabilize the proximal inter-phalangeal interface.  The potential advantages of this prosthesis include elimination of wire migration and breakage, enhanced control and stability of the digit, elimination of potential pin tract infection, and decreased patient anxiety since hardware removal is not required.  The patients were followed-up for approximately 1 year after the surgery, and no intra-operative or post-operative complications were observed.  The implant maintained proper clinical and radiographic alignment throughout the observation period, without implant failure or breakage.  All patients were satisfied with the cosmetic appearance of their surgically corrected toes and were able to perform all activities of daily living without the use of assistive devices.  Also, their post-operative pain and function were acceptable.  The authors concluded that the implant used in the patients described in the present report appears to be a viable alternative for the treatment of hammertoe.  These preliminary findings need to be validated by well-designed studies.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
28285
28286
HCPCS codes not covered for indications listed in the CPB:
L8641 Metatarsal joint implant
ICD-9 codes covered if selection criteria are met:
268.1 Rickets, late effect [hammertoe, claw toe, mallet toe]
735.4 Other hammer toe (acquired)
735.5 Claw toe (acquired)
754.71 Talipes cavus [claw toe, congenital]
755.66 Other anomalies of toes [hammer toe, congenital]
Other ICD-9 codes related to the CPB:
355.6 Lesion of plantar nerve [interdigital neuroma]
700 Corns and callosities
707.15 Ulcer of other part of foot [of apices]
718.47 Contracture of joint, ankle and foot [MP joint]
718.57 Ankylosis of joint, ankle and foot [ankylosis of proximal interphalangeal joint]
719.27 Villonodular synovitis, ankle and foot [of MP joint]
729.5 Pain in limb
726.79 Other enthesopathy of ankle and tarsus [adventitious bursitis on the dorsal surface]
726.90 Enthesopathy of unspecified site [synovitis/capsulitis]
727.00 Synovitis and tenosynovitis, unspecified [of MP joint]
727.81 Contracture of tendon (sheath)
755.69 Other anomalies of lower limb, including pelvic girdle [subluxation or dislocation MP joint]
838.05 Dislocation of foot, metatarsophalangeal (joint)
845.12 Sprain and strains of metatarsophalangeal (joint) [lateral MP capsular tear]


The above policy is based on the following references:
  1. Coughlin MJ, Dorris J, Polk E. Operative repair of the fixed hammertoe deformity. Foot Ankle. 2000;21:94-104.
  2. Van Wyngarden TM. The painful foot, part I: Common forefoot deformities. Am Fam Physician. 1997;55(5):1866-1876.
  3. Oliver TP, Armstrong DG, Harkless LB, Krych SM. The combined hammer toe-mallet toe deformity with associated double corns: A retrospective review. Clin Podiatr Med Surg. 1996;13(2):263-268.
  4. Harmonson JK, Harkless LB. Operative procedures for the correction of hammertoe, claw toe, and mallet toe: A literature review. Clin Podiatr Med Surg. 1996;13(2):211-218.
  5. Shaw AH, Alvarez G. The use of digital implants for the correction of hammer toe deformity and their potential complications and management. J Foot Surg. 1992;31(1):63-74.
  6. Stainsby GD. Pathological anatomy and dynamic effect of the displaced plantar plate and the importance of the integrity of the plantar plate-deep transverse metatarsal ligament tie-bar. Ann R Coll Surg Eng. 1997;79:58-68.
  7. Mann RA, Mizel MS. Monarticular non-traumatic synovitis of the MTP joint: A new diagnosis? Foot Ankle. 1985;6:18-21.
  8. Thompson FM, Deland JT. Flexor tendon transfer for metatarsophalangeal instability of the second toe. Foot Ankle. 1993;14:385-388.
  9. Fortin PT, Myerson MS. Second metatarsophalangeal joint instability. Foot Ankle Int. 1995;16(5):306-313.
  10. Gazdag A, Cracchiolo A. Surgical treatment of patients with painful instability of the second metatarsophalangeal joint. Foot Ankle Int. 1998;19:137-143.
  11. Rochwerger A, Launay F, Piclet B, et al. Static instability and dislocation of the 2nd metatarsophalangeal joint. Comparative analysis of 2 different therapeutic modalities. Rev Chir Orthop Reparatrice Appar Mot. 1998;84(5):433-439.
  12. Barbari SG, Brevig K. Correction of clawtoes by the Girdlestone-Taylor flexor-extensor transfer procedure. Foot Ankle. 1984;5:67-73.
  13. Parrish TF. Dynamic correction of clawtoes. Orthop Clin North Am. 1973;4:97-102.
  14. Turan I. Deformities of the smaller toes and surgical treatment. J Foot Surg. 1990;29:176-178.
  15. Shaw SJ, Hodgkinson JP, Thompson H. The Lambrinudi operation for the correction of clawtoes. Foot. 1991;1:28-31.
  16. Baig AU, Geary NPJ. Fusion rate and patient satisfaction in proximal interphalangeal joint fusion of the minor toes using Kirschner wire fixation. Foot. 1996;6:120-121.
  17. Alvine F, Garvin KL. Peg and dowel fusion of the proximal interphalangeal joint. Foot Ankle. 1980;1:90-94.
  18. Coughlin MJ. Crossover second toe deformity. Foot and Ankle. 1987;8:29-39.
  19. Lehman DE, Smith RW. Treatment of symptomatic hammertoe with a proximal interphalangeal joint arthrodesis. Foot and Ankle. 1995; 16:535-541.
  20. Myerson MS. Arthroplasty of the second toe. Semin Arthroplasty. 1992;3:31-38.
  21. Newman RJ, Fitton JM. An evaluation of operative procedures in the treatment of hammertoe. Acta Orthop Scand. 1979;50:709-712.
  22. Kuwada GT. A retrospective analysis of modification of the flexor tendon transfer for correction of hammer toe. J Foot Surg. 1988;27(1):57-59.
  23. Berstein DA, Gumm D, Weiss M. Dorsolateral approach for hammer toe correction. J Am Podiatr Med Assoc. 1986;76(8):473-476.
  24. Bartee SL, Midenberg M. A modified arthroplasty procedure for rigid hammertoe. J Foot Surg. 1983;22(1):40-44.
  25. Mladick RA. Correction of hammer toe surgery deformity by Z-plasty and bone graft. Ann Plast Surg. 1980;4(3):224-226.
  26. Coughlin, MJ. Operative repair of the mallet toe deformity. Foot Ankle. 1995;16:109-116.
  27. Nishimoto GS, Attinger CE, Cooper PS. Lengthening the Achilles tendon for the treatment of diabetic plantar forefoot ulceration. Surg Clin North Am. 2003;83(3):707-726.
  28. Academy of Ambulatory Foot and Ankle Surgery. Hammertoe syndrome. Philadelphia, PA: Academy of Ambulatory Foot and Ankle Surgery; 2003.
  29. Gallentine JW, DeOrio JK. Removal of the second toe for severe hammertoe deformity in elderly patients. Foot Ankle Int. 2005;26(5):353-358.
  30. Pietrzak WS, Lessek TP, Perns SV. A bioabsorbable fixation implant for use in proximal interphalangeal joint (hammer toe) arthrodesis: Biomechanical testing in a synthetic bone substrate. J Foot Ankle Surg. 2006;45(5):288-294.
  31. Boyer ML, DeOrio JK. Transfer of the flexor digitorum longus for the correction of lesser-toe deformities. Foot Ankle Int. 2007;28(4):422-430.
  32. Bouché RT, Heit EJ. Combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: Preliminary observations. J Foot Ankle Surg. 2008;47(2):125-137.
  33. Schrier JC, Verheyen CC, Louwerens JW. Definitions of hammer toe and claw toe: An evaluation of the literature. J Am Podiatr Med Assoc. 2009;99(3):194-197.
  34. Shirzad K, Kiesau CD, DeOrio JK, Parekh SG. Lesser toe deformities. J Am Acad Orthop Surg. 2011;19(8):505-514.
  35. Kernbach KJ. Hammertoe surgery: Arthroplasty, arthrodesis or plantar plate repair? Clin Podiatr Med Surg. 2012;29(3):355-366.
  36. Witt BL, Hyer CF. Treatment of hammertoe deformity using a one-piece intramedullary device: A case series. J Foot Ankle Surg. 2012;51(4):450-456.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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