Flexible Hammertoe Surgery: Proximal Interphalangeal Joint Arthroplasty for Hammertoe Correction

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What Is Flexible Hammertoe Surgery?

A flexible hammertoe is a toe deformity where the middle joint (proximal interphalangeal or PIP joint) bends downward but can still be manually straightened. Unlike rigid hammertoes — where the joint is fixed — flexible hammertoes have preserved passive range of motion. Surgery for flexible hammertoes is highly effective and involves a procedure called proximal interphalangeal joint arthroplasty.

At Balance Foot & Ankle, our surgical team performs hammertoe corrections as outpatient procedures with high patient satisfaction rates. Most patients are walking the same day of surgery and return to regular footwear within four to six weeks.

Who Needs Flexible Hammertoe Surgery?

Conservative treatment — wider shoes, padding, splinting, and metatarsal supports — is always attempted first. Surgery becomes appropriate when the deformity causes persistent pain, creates skin breakdown or ulceration from shoe pressure, interferes with wearing footwear, causes adjacent toe problems, or significantly affects quality of life despite conservative measures.

The best surgical candidates are non-smokers with good peripheral circulation and realistic expectations about recovery. We evaluate circulation using ankle-brachial index measurements and clinical examination before scheduling surgery.

Surgical Technique: PIP Joint Arthroplasty

Proximal interphalangeal joint arthroplasty is the most common procedure for flexible hammertoe correction. The surgery is performed under local anesthesia with sedation in an outpatient surgical facility.

Step-by-Step Surgical Process

A small longitudinal or elliptical incision is made over the top of the PIP joint. The extensor tendon is identified and either released or lengthened to reduce the deforming force pulling the toe upward. The joint is then exposed by releasing the collateral ligaments on each side. A small amount of bone is removed from the head of the proximal phalanx — this creates a space that allows the toe to be repositioned in a straight alignment.

The toe is held in the corrected position temporarily with a smooth Kirschner wire (K-wire) or an internal implant. K-wires protrude from the tip of the toe and are removed in the office at four to six weeks without anesthesia. Newer absorbable or permanent internal implants are available as alternatives for patients who prefer not to have protruding wires.

The incision is closed with absorbable sutures, and the toe is dressed in a corrective position with gauze and medical tape. A surgical shoe that protects the forefoot while allowing heel weight bearing is provided before the patient leaves the facility.

Additional Procedures Performed at the Same Time

Hammertoe correction is often combined with additional procedures addressing the underlying cause of the deformity. A flexor tendon tenotomy releases the flexor tendon on the bottom of the toe, preventing recurrence from the flexor overpowering the extensor. A metatarsal osteotomy may be performed if the long metatarsal is contributing to forefoot overload and hammertoe formation. Bunion correction (bunionectomy) is frequently performed at the same session when a medially deviated first ray is displacing the second toe.

Recovery After Flexible Hammertoe Surgery

First Two Weeks

Patients are weight bearing immediately in the surgical shoe, though elevation and ice are recommended for the first 72 hours to minimize swelling. Driving is restricted on the operative foot until the surgical shoe is discontinued. Dressing changes are performed by the patient every two to three days using materials provided at discharge.

Weeks Two to Six

Swelling gradually decreases but the toe will remain noticeably swollen for two to four months. If a K-wire is present, it is removed at the four to six week visit. Transition to a wide athletic shoe or surgical sandal typically begins at three to four weeks. Light activity such as walking for exercise can resume once the incision is fully healed.

Three to Six Months

Most patients return to all regular footwear by two to three months. Final surgical results — including full swelling resolution and scar maturation — are assessed at the six-month follow-up. Return to athletic activity including running and court sports typically occurs at three months.

Outcomes and Expectations

Patient satisfaction after flexible hammertoe surgery is high, with most studies reporting good to excellent outcomes in over 85 percent of cases. The toe is permanently straightened and footwear fitting improves significantly. Some residual stiffness at the PIP joint is expected and normal — the joint is intentionally made less mobile as part of the procedure.

Recurrence can occur, particularly if the underlying cause (such as an uncorrected bunion or long metatarsal) is not addressed simultaneously. Our surgeons perform comprehensive preoperative planning to identify all contributing factors and correct them in a single operative session when possible.

Risks and Complications

As with all surgery, risks include infection, wound healing complications, deep vein thrombosis, nerve injury, and anesthetic reactions. Hammertoe-specific risks include recurrence of deformity, transfer lesion (pain shifting to an adjacent metatarsal), floating toe (a toe that does not contact the ground), and vascular compromise. These complications are uncommon when surgery is performed by an experienced foot and ankle surgeon with appropriate patient selection.

Frequently Asked Questions

How long does recovery take after flexible hammertoe surgery?

Patients wear a post-op surgical shoe for 4-6 weeks with protected weight-bearing. Return to regular shoes occurs around 6-8 weeks, with full recovery by 3 months.

Is hammertoe surgery painful?

Most patients experience mild to moderate pain controlled with oral medication for 3-5 days. Ankle or regional blocks during surgery provide 12-24 hours of initial pain relief.

What is the difference between flexible and rigid hammertoe surgery?

Flexible hammertoes are corrected with tendon releases and PIP arthroplasty. Rigid deformities require more extensive bone work, PIP fusion, and longer recovery periods.

Your Board-Certified Podiatrists

Dr. Tom Biernacki, DPM

Board-Certified · FACFAS

Dr. Carl Jay, DPM

Board-Certified Podiatrist

Dr. Daria Gutkin, DPM

Podiatrist

Dr. Tom Biernacki, DPM

Dr. Tom Biernacki, DPM is a double board-certified podiatrist and foot & ankle surgeon at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has reached over one million views.