0636 Hammertoe Repair - Aetna

http://www.aetna.com/cpb/medical/data/600_699/0636.html

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Hammertoe Repair

Clinical Policy Bulletins Medical Clinical Policy Bulletins

Policy History Last Revi

ew

09/11/2019

Effective: 08/16/200

Next Review:

06/26/2020

Review History

Definitions

Additional Information

Number: 0636

Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.

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 the

following criteria are met:

I. Radiographic* confirmation of hammer toe deformity; and

II. Documentation of skeletal maturity; and

III. Documentation of persistent pain and difficulty walking following at least 3

months of conservative treatment under the direction of a healthcare

professional which includes, but may not be limited to:

A. Corticosteroid injections

B. Debridement of associated hyperkeratotic lesions (corns, calluses)

C. Foot orthotics (shoe inserts, footgear modifications, corrective splinting)

(may be contractually excluded)

D. Oral analgesics and/or nonsteroidal anti-inflammatory drugs (NSAIDs)

E. Orthotics (shoes with a wide and deep toe box) (may be contractually

excluded)

F. Protective padding; and

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G. Taping or adhesive devices; and

IV. Member has 1 or more of the following indications for hammertoe repair:

A. Adventitious bursitis on the dorsal surface of the hammertoe; or

B. Ankylosis of the distal interphalangeal (DIP) joint or proximal

interphalangeal (PIP) joint; or

C. Inter-digital neuroma caused by the deformity; or

D. Lateral metatarsophalangeal (MTP) capsular tear caused by the

deformity; or

E. Painful nail conditions secondary to persistent trauma; or

F. Presence of co-existing or causative conditions (e.g., tendon contracture)

that need repair; or

G. Subluxation or dislocation of the MTP joint; or

H. Synovitis/capsulitis of the MTP joint; or

I. Ulceration of the apices.

Aetna considers repeat hammer toe surgical treatment medically

necessary following failure of a previous surgical procedure.

*Radiographic confirmation must include interpretation and report of

anterior/posterior and lateral views of the affected foot.

Aetna considers hammertoe repair experimental and investigational when criteria

are not met.

Aetna considers fixation implants (e.g., the Acumed Hammertoe Fusion Set, the

BME Hammerlock Implant, the CannuLink Intramedullary Fusion Device, the

CrossTie Intraosseous Fixation System, the Futura Flexible Digital Implant, the

Futura LMP Lesser Phalangeal Joint Implant, the HammerFix IP Fusion System,

the Integra Hammertoe Implant, the OsteoMed Interflex IPG System, the Pro-Toe

Hammertoe Implant, the Smart Toe, the StayFuse Fusion Device, the ToeGrip

Device, the Two-Step Hammer Toe Implant, the Weil-Carver Hammertoe Implant,

and the Wright Cann Phalinx System) experimental and investigational for

hammertoe repair because of a lack of evidence of effectiveness and safety in the

peer-reviewed published medical literature.

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See also CPB 0629 - Bunionectomy (0629.html), and

CPB 0708 - Metatarsal Phalangeal Joint Replacement (../700_799/0708.html).

Background

Deformities of the lesser (two through five) toes are generally known as hammer

toe, claw toe and mallet toe. Hammer toe refers to an abnormal flexion posture at

the proximal interphalangeal (PIP) joint of one or more of the lesser four toes. The

most commonly affected toe is the second, although multiple toes can be involved.

If the flexion contracture is severe and of long duration, associated hyperextension

of the metatarsophalangeal (MTP) joint and extension of the distal interphalangeal

(DIP) joint may occur. Hammer toes are classified as either flexible (passively

correctable) or rigid (not passively correctable to the neutral position). In claw toe,

there is dorsiflexion of the proximal phalanx on the MTP joint and plantar flexion of

the PIP and DIP joints. Mallet toes demonstrate a flexion contracture of the DIP

joint only. As all of these are similar in their etiology and treatment, this policy

pertains to all three deformities.

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

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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

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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. Surgical procedures utilized for the correction of hammer toe

include, but may not be limited to, amputation for severe deformity, arthrodesis,

arthroplasty, flexor to extensor tendon transfer, partial or total phalangectomy or

tenotomy. Kirschner wires may be used as fixation devices for arthrodesis and

arthroplasty. 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.

Fixation Implants

Implants have been developed to stabilize the PIP joint, purportedly to promote

fusion. Such implants are not universally accepted and are exceedingly difficult to

remove should the surgery fail. Their removal could lead to substantial bone loss,

making subsequent revision procedures challenging.

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

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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.

Scott et al (2013) noted that hammertoe digital deformity correction is a very

controversial topic among foot and ankle surgeons. Current treatment options are

often guided by the patient's discomfort as well as the reducibility of the affected

digit. Kirschner wires (K-wires) have long been considered the gold standard for

hammertoe digital repair. Although K-wires are simplistic to use as fixation, they

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carry inherit risks such as pin tract infections, migration, and breakage. This has

led to multiple intramedullary hammertoe devices including the PROTOE

intramedullary device.

In a case-series study, Catena et al (2014) prospectively evaluated clinical and

radiographic outcomes of hammertoe operative correction utilizing an internal

implant (intramedullary implant) and assessed its ability to maintain post-operative

alignment. A total of 29 patients (53 toes) with a painful rigid hammertoe deformity

were prospectively enrolled and operatively treated with resection arthroplasty of

the PIP joint and fixation with an implant. Five patients were lost to follow-up, and

24 patients (42 toes) returned at an average of 12 months for final clinical and

radiographic evaluation. All patients were evaluated pre- and post-operatively by

American Orthopaedic Foot and Ankle Society (AOFAS) and visual analog pain

scale (VAS) scores. On physical examination, the location and magnitude of the

deformity, callosities, and digit circumference were recorded. Radiological

parameters evaluated were digital alignment, successful union, implant position,

and bone reaction. All patients reported satisfaction at final follow-up, with an

average improvement of AOFAS score from 52 (range of 24 to 87 points) to 71

(range of 42 to 95 points) points. The mean VAS pain score improved from 5

points (range of 2 to 10) pre-operatively to 1 point (range of 0 to 5) post-

operatively. Of patients, 87 % reported an ability to return to their pre-operative

activities without limitations. Regarding digital alignment, there were no recurrent

deformities or transverse plane deformities; 1 toe presented with a minor digital

rotational deformity at final follow-up. Post-operative radiographs indicated 100 %

of proximal inter-phalangeal (PIP) joints with good alignment, and 81 %

demonstrated bony union. The authors concluded that this study suggested that

utilization of an internal implant for hammertoe correction was safe and provided

acceptable alignment, pain reduction, and improved function at final follow-up. This

case-series study provided level IV evidence; its findings need to be validated by

well-designed studies.

Basile et al (2015) stated that hammertoe is one of the most common foot

deformities. Arthrodesis or arthroplasty of the proximal interphalangeal joint using

temporary Kirschner wire fixation is the most widespread method of surgical

stabilization. However, this type of fixation is associated with some potential

complications that can be obviated if percutaneous fixation is avoided. These

researchers prospectively collected clinical and radiographic outcomes of operative

correction of hammertoe deformity using a permanently implanted 1-piece

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intramedullary device. A total of 29 patients with 60 painful, rigid hammertoes were

prospectively enrolled, clinically and radiographically examined, operatively treated,

then followed and re-examined. The outcomes were measured in terms of the

AOFAS lesser toe and VAS. After greater than or equal to 18 months of follow-up,

the incidence of fusion with satisfactory radiographic alignment was 85 % (51 of 60

toes). One toe (1.67 %) developed early post-operative implant failure because of

dislocation of the device, there were no cases of infection, and the mean AOFAS

lesser toe score was 87.4 ± 1.3 and the mean VAS was 1.78 ± 0.94. Twenty-five

patients (86.21 %) stated that they had no symptoms in the involved toes after

surgery, and 4 (13.8 %) experienced occasional pain, 2 (6.9 %) of whom reported

limitations of recreational activities and 2 (6.9 %) reported persistent swelling

without activity limitations. The authors noted that all the patients stated that they

would undergo the surgery again if they had the same pre-operative condition.

Well-designed studies with larger sample size and longer follow-up are needed to

validate these findings.

Obrador and associates (2018) analyzed functional outcomes in patients who had

undergone PIP joint fusion using 2 types of intramedullary implant, the Smart Toe

and the TenFuse, and compared them with the outcomes in patients treated with

standard K-wire fixation. A retrospective review of operative hammertoe correction

by a single surgeon was performed in 96 patients followed for more than 12

months. Functional outcome was assessed using the Foot Function Index (FFI),

the Short Form 36 (SF-36), and the 10-point VAS validated questionnaires.

Complications and fusion rates were also evaluated. Several patients in the study

underwent corrections in different toes; thus, a total of 186 toes were included in

the study. From these, 65 toes (34.9 %) were treated with K-wire fixation, 94 (50.5

%) with Smart Toe titanium implant, and 27 (14.5 %) with TenFuse allograft

implant. No statistically significant differences in functional outcome and incidence

of complications were observed among the 3 fixation groups, although the 2

intramedullary implants were associated with greater fusion rates and patient

satisfaction. Breakage of the Smart Toe implant was significantly higher than that

of the other fixations, with 10.6 % of implants breaking within the 1st year post-

operatively; SF-36 and VAS scores decreased 12 months after surgery for the 3

types of fixation, with no statistically significant differences observed. The authors

concluded that the use of Smart Toe and TenFuse implants provided operative

outcomes comparable to those obtained using a K-wire fixation and slightly better

patient satisfaction. They stated that these findings suggested that utilization of

these implants for hammertoe correction was a reasonable choice that provided

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good alignment, pain reduction, and improved function at final follow-up. However,

they are more expensive than K-wires. These investigators stated that for this

reason, in-depth cost-benefit studies are needed to justify their use as a standard

treatment.

Albright and colleagues (2018) stated that hammertoe deformities are one of the

most common foot deformities, affecting up to 1/3 of the general population. Fusion

of the joint can be achieved with various devices, with the current focus on

percutaneous K-wire fixation or commercial intramedullary implant devices. These

investigators examined if surgical intervention with percutaneous K-wire fixation

versus commercial intramedullary implant is more cost effective for PIP joint

arthrodesis in hammertoe surgery. A formal cost-effectiveness analysis using a

decision analytic tree model was conducted to investigate the healthcare costs and

outcomes associated with either K-wire or commercial intramedullary implant

fixation. The outcomes assessed included long-term costs, quality-adjusted life-

years (QALYs), and incremental cost per QALY gained. Costs were evaluated from

the healthcare system perspective and were expressed in U.S. dollars at a 2017

price base. These researchers found that commercial implants were minimally

more effective than K-wires but carried significantly higher costs. The total cost for

treatment with percutaneous K-wire fixation was $5,041 with an effectiveness of

0.82 QALY compared with a commercial implant cost of $6,059 with an

effectiveness of 0.83 QALY. The incremental cost-effectiveness ratio of

commercial implants was $146,667. With an incremental cost-effectiveness ratio of

greater than $50,000, commercial implants failed to justify their proposed benefits

to out-weigh their cost compared to percutaneous K-wire fixation. The authors

concluded that percutaneous K-wire fixation would be preferred for arthrodesis of

the PIP joint for hammertoes from a healthcare system perspective.

CannuLink Intramedullary Fusion Device

In a retrospective, comparative study, Richman and colleagues (2017) compared

the outcomes of hammertoe correction performed with K-wire fixation versus a

novel intramedullary fusion device (CannuLink). A retrospective review of

hammertoe correction by a single surgeon was performed from June 2011 to

December 2013. A total of 60 patients (95 toes) underwent K-wire fixation and 39

patients (54 toes) underwent fusion with the CannuLink implant. Average age was

61.7 years and 61.4 years, respectively. Average length of follow-up was 12.9 and

12.3 months, respectively. Patients were evaluated for medical co-morbidities,

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smoking status, inflammatory arthritis, peripheral vascular disease, peripheral

neuropathy, pre- and post-operative VAS, bony union percentage, revision rate,

complications (hardware and surgery-related), and persistent symptoms at last

follow-up. There was no significant difference in demographics or co-morbidities

between the 2 groups (p > 0.05). In the K-wire group, 16 patients (18 toes)

remained symptomatic at last follow-up (27 %); 9 toes (9.5 %) had recurrent

deformity, 3 toes (3 %) developed a late infection because of the recurrent

deformity, and 1 toe (1 %) developed partial numbness; 1 patient suffered a calf

deep vein thrombosis (DVT) and peroneal nerve neuritis, 1 patient developed foot-

drop, and 3 patients continued to complain of pain; 5 toes required revision surgery

(5.3 %). In the intramedullary group, 3 (7.7 %) patients remained symptomatic and

all were associated with a complication; 1 patient developed chronic regional pain

syndrome (CRPS) in the foot, a calf DVT, and a nonfatal pulmonary embolus. A

2nd patient developed a painless recurrent deformity. A 3rd patient had wound

dehiscence. Nobody had hardware failure or required a 2nd operation. The

authors concluded that the CannuLink intramedullary device for hammertoe

correction resulted in fewer complications, only 1 recurrent deformity, and no re-

operations compared with K-wire fixation. Level of Evidence = III. This was

relatively small study (n = 39 for the CannuLink group) and the follow-up was short-

term (12.3 months).

CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":

CPT codes covered if selection criteria are met:

28285 Correction, hammertoe (e.g., interphalangeal fusion, partial or total

phalangectomy)

28286 Correction, cock-up fifth toe, with plastic skin closure (e.g., Ruiz- Mora

type procedure)

CPT codes not covered for indications listed in the CPB:

CrossTie Intraosseous Fixation System - no specific code:

Other CPT codes related to the CPB:

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Code Code Description

73620 - 73630 Radiologic examination, foot

HCPCS codes not covered for indications listed in the CPB:

CannuLink intramedullary fusion device - no specific code:

L8641 Metatarsal joint implant

Other HCPCS codes related to the CPB:

J0702 Injection, betamethasone acetate 3 mg and betamethasone sodium

phosphate 3 mg

J0833 Injection, cosyntropin, not otherwise specified, 0.25 mg

J0834 Injection, cosyntropin (Cortrosyn), 0.25 mg

J1020 Injection, methylprednisolone acetate, 20 mg



J1094 Injection, dexamethasone acetate, 1 mg

J1100 Injection, dexamethasone sodium phosphate, 1 mg

J1700 Injection, hydrocortisone acetate, up to 25 mg

J1710 Injection, hydrocortisone sodium phosphate, up to 50 mg

J1720 Injection, hydrocortisone sodium succinate, up to 100 mg

J2650 Injection, prednisolone acetate, up to 1 ml

J2920 Injection, methylprednisolone sodium succinate, up to 40 mg

J2930 Injection, methylprednisolone sodium succinate, up to 125 mg

J3300 Injection, triamcinolone acetonide, preservative free, 1 mg

J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg

J3302 Injection, triamcinolone diacetate, per 5 mg

J3303 Injection, triamcinolone hexacetonide, per 5 mg

L3000 - L3030 Foot, insert/plate, removable

ICD-10 codes covered if selection criteria are met:

E64.3 Sequelae of rickets [hammertoe, claw toe, mallet toe]

G57.60 - G57.63 Lesion of plantar nerve [interdigital neuroma]

L97.501 -

L97.529

Non-pressure chronic ulcer of other part of foot [of apices]

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M20.5x1 -

M20.62

M12.279

M20.42

M24.576

M24.671 -

M24.676

M65.879

M67.00 -

M67.02

M77.52

M77.9

Q66.7

Q74.2

S92.529x

S92.129x

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.

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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.

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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.

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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.

Copyright © 2001-2019 Aetna Inc.

http://www.aetna.com/cpb/medical/data/600_699/0636.html 09/25/2019


AETNA BETTER HEALTH® OF PENNSYLVANIA

Amendment to Aetna Clinical Policy Bulletin Number: 0636 Hammertoe

Repair

There are no amendments for Medicaid.

www.aetnabetterhealth.com/pennsylvania revised 09/09/2019

http://www.aetnabetterhealth.com/pennsylvania

Documents

0636 Hammertoe Repair - Aetna