Lesser-toe deformity

Indication

Lesser-toe deformities (hammer toe, claw toe, mallet toe) are typically addressed surgically when conservative care fails to relieve pain, shoe conflict, or functional limitation. The main decision point for surgeons is whether to fuse the proximal interphalangeal joint (PIPJ) or preserve motion with resection arthroplasty, and — if fusion is chosen — whether to fix it with a K-wire or an intramedullary implant.

The techniques

• K-wire fixation – percutaneous or open insertion of a smooth Kirschner wire across the PIPJ to maintain alignment until fusion; wire typically removed at 4–6 weeks.
• Intramedullary implant – a permanent or bioabsorbable device (e.g., Smart Toe, Nextra, TenFUSE, Ossiofiber) placed entirely within the phalanges to compress and stabilise the PIPJ for fusion.
• Resection arthroplasty – excision of the proximal phalanx base (or both articular surfaces) without fixation, relying on fibrous union to maintain a shortened, flexible toe.
• PIPJ arthrodesis (fusion) – joint preparation with or without fixation (K-wire or implant) to achieve bony union in a corrected position.

What the evidence says

Two RCTs comparing PIPJ arthrodesis with resection arthroplasty found no significant differences in pain, AOFAS scores, or patient satisfaction at 6 months [1] and 1 year [2], despite a significantly higher radiographic union rate with arthrodesis (P=.001) [1]. A 2020 systematic review of five studies (one RCT, four comparative) reported that intramedullary implants achieved higher union rates than K-wires, but clinical outcomes — pain, satisfaction, function, complication rates — were equivalent [3]. A 2025 systematic review of 12 implants in 1,118 toes confirmed wide fusion-rate variation (22.2 %–96 %) and noted that while three implants (Smart Toe, TenFUSE, Nextra) showed statistically better union than K-wire (p<0.05), functional and patient-reported outcomes remained equivocal; all studies carried high or critical risk of bias [4]. A 2025 RCT comparing minimally invasive versus open correction (both using K-wires) found more wound complications with open surgery (p=0.029) but similar K-wire issue rates and equivalent clinical/radiological correction [5]. A 2024 systematic review highlighted the paucity of post-surgical kinematic data across all techniques [6].

What members see

Members who have switched from K-wires to intramedullary implants: have you observed a tangible reduction in pin-track infections or revision rates that matches the union-rate data [PMID 32223520; PMID 40132246]? For those performing both arthrodesis and resection arthroplasty, do your 6–12 month pain and satisfaction scores mirror the RCT findings of no clinical difference [PMID 35021029; PMID 26843544]? How often do you encounter floating or malrotated toes after resection arthroplasty versus non-union after attempted fusion?

Cost and access

The supplied sources do not report cost figures. Factors that drive cost differences include implant purchase price (typically higher than K-wires), potential elimination of a second procedure for wire removal, theatre time for implant insertion versus wire placement, and any additional imaging (CT/MRI) needed to assess union with radiolucent implants.

Open questions

• Does the higher radiographic union rate with intramedullary implants translate into lower long-term revision rates compared with K-wires?
• Are there specific patient subgroups (e.g., rheumatoid arthritis, diabetes, severe osteopenia) in which one technique consistently outperforms the others?
• What is the true incidence of implant-related complications (subsidence, breakage, MRI artefact, need for removal) beyond the short follow-up in current studies?
• Does minimally invasive correction change the risk-benefit calculus for K-wire versus implant fixation?
• How do patient-reported outcome measures correlate with objective gait or pressure-plate data after each procedure?

References

6 of 6 papers retrieved for this room are cited above. The search was limited to systematic reviews, meta-analyses and randomised trials in humans, English, 2016 onwards. Query and full result set: research/raw/lesser-toe-deformity.json.

1. 1Comparison of Lesser Toe Proximal Interphalangeal Joint Arthrodesis Versus Resection Arthroplasty: A Randomized Controlled Study. Orthopedics 2022 · PMID 35021029 Randomized Controlled Trial
2. 2Lesser Toe PIP Joint Resection Versus PIP Joint Fusion: A Randomized Clinical Trial. Foot Ankle Int 2016 · PMID 26843544 Randomized Controlled Trial
3. 3Ideal implant choice for proximal interphalangeal joint arthrodesis in hammer toe/claw toe deformity correction: A systematic review. J Orthop Surg (Hong Kong) 2020 · PMID 32223520 Systematic Review
4. 4Implants for proximal interphalangeal joint arthrodesis of the lesser toes: Where are we? A systematic review. Foot (Edinb) 2025 · PMID 40132246 Systematic Review
5. 5Correction of lesser toe deformities: minimally invasive versus open surgery-a prospective randomised study. Arch Orthop Trauma Surg 2025 · PMID 41284098 Randomized Controlled Trial
6. 6A systematic review of the claw toe deformity: What is known and what is needed apart from surgical procedures. Int Wound J 2024 · PMID 39379064 Systematic Review

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