Hammertoe Surgery: PIP Arthroplasty vs. Fusion vs. Tendon Transfer — What’s Right for You?

Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

Understanding Hammertoe Deformity

Hammertoe is an abnormal flexion contracture of the proximal interphalangeal (PIP) joint of the lesser toes (2nd through 5th) that causes the middle portion of the toe to bend upward while the tip points downward. This deformity results from muscle imbalance between the intrinsic and extrinsic toe muscles, often driven by biomechanical factors, ill-fitting shoes, or neurological conditions.

Hammertoes progress through three stages: flexible (the toe can be manually straightened), semi-rigid (partial correction possible), and rigid (the toe is fixed in the bent position). The stage of deformity determines which surgical approach is most appropriate and influences expected outcomes.

The deformity creates problems in two locations: the dorsal PIP joint prominence rubs against the shoe upper causing painful corns, and the tip of the toe is driven into the ground causing end-bearing calluses. Severe hammertoes can also subluxate (partially dislocate) at the metatarsophalangeal joint, creating forefoot instability.

PIP Arthroplasty: Joint Resection

PIP arthroplasty involves removing a small section of bone from the head of the proximal phalanx, creating space within the PIP joint that allows the toe to straighten. This procedure eliminates the bony prominence that causes dorsal corn formation and releases the contracted joint capsule that maintains the bent position.

The procedure is performed through a small dorsal incision over the PIP joint. After bone resection, the toe is held in corrected position with a temporary K-wire (thin metal pin) that extends through the tip of the toe for 3-4 weeks while soft tissues heal in the straightened position.

Advantages of arthroplasty include shorter surgical time, preserved toe flexibility at the resection site, and reliable elimination of the dorsal corn. The procedure is well-suited for elderly patients, patients with peripheral vascular disease, and those who prioritize flexibility over absolute structural rigidity.

The potential disadvantage is that some degree of deformity recurrence is possible because the arthroplasty site heals with fibrous tissue rather than bone fusion. Recurrence rates of 10-15% over 10 years are reported, though most recurrences are mild and well-tolerated.

PIP Fusion: Permanent Correction

PIP fusion (arthrodesis) removes the cartilage surfaces of the PIP joint and fuses the proximal and middle phalanges into a single straight bone segment. This provides permanent structural correction that cannot recur because the joint is eliminated entirely through bony union.

Modern PIP fusion techniques use internal fixation devices — either intramedullary implants or compression screws — that hold the bone surfaces together without the need for an external K-wire protruding from the toe tip. This advances provides better cosmesis, reduced infection risk, and improved patient comfort during recovery.

PIP fusion is preferred for younger active patients, rigid hammertoe deformities, and revision cases where previous arthroplasty has failed. The permanent correction provides the structural stability needed for athletic activity and ensures long-term deformity control.

The trade-off is that the PIP joint is permanently rigid after fusion. However, the PIP joint contributes minimally to normal gait mechanics, and most patients do not notice functional limitation from PIP fusion. Shoe fitting and toe comfort improve significantly despite the loss of this joint’s motion.

Tendon Transfer: Addressing Root Cause

Flexor-to-extensor tendon transfer addresses the underlying muscle imbalance that causes hammertoe deformity by rerouting the flexor digitorum longus tendon from the bottom of the toe to the top, converting it from a deforming force into a corrective force. This rebalances the muscle forces acting across the toe joints.

Tendon transfer is indicated for flexible hammertoes where the deformity can be fully corrected manually. By addressing the dynamic muscle imbalance rather than just the bony deformity, tendon transfer provides physiologic correction without removing bone or fusing joints, preserving normal toe anatomy.

The procedure is often combined with MTP joint release or capsulotomy when the hammertoe is associated with metatarsophalangeal joint subluxation. This combined approach addresses both the toe deformity and the underlying forefoot instability that contributes to deformity development.

Recovery from tendon transfer involves 4-6 weeks of buddy taping the corrected toe to an adjacent toe, followed by progressive activity. The transferred tendon requires 6-8 weeks to heal securely in its new position, during which excessive toe flexion is avoided.

Choosing the Right Procedure

The decision between arthroplasty, fusion, and tendon transfer depends on deformity rigidity, patient age and activity level, associated MTP joint pathology, and individual treatment goals. Dr. Biernacki evaluates each factor during the preoperative consultation to recommend the optimal approach.

Flexible hammertoes in younger patients are often best treated with tendon transfer alone or combined with minimal bony work. This approach preserves joint anatomy while correcting the muscle imbalance that will continue to drive deformity if left unaddressed.

Rigid hammertoes require bony procedures — either arthroplasty or fusion — because the contracted soft tissues and fixed joint position cannot be corrected with tendon work alone. The choice between arthroplasty and fusion depends on patient age, bone quality, and the need for permanent structural correction.

Multiple hammertoe correction is common, and different toes on the same foot may receive different procedures based on their individual deformity characteristics. This customized approach optimizes outcomes for each toe rather than applying a one-size-fits-all technique.

Recovery and Expected Outcomes

Hammertoe surgery recovery follows a predictable timeline regardless of technique. The first 2 weeks focus on incision healing, swelling management, and protected weight-bearing in a surgical shoe. Most patients can walk immediately after surgery with the support of a rigid postoperative shoe.

Swelling is the most persistent postoperative symptom, typically lasting 3-6 months. While functional recovery occurs at 6-8 weeks, the toes may remain mildly swollen for several months. Elevation, ice, and compression manage swelling effectively during this period.

Return to regular footwear occurs at 4-8 weeks depending on the specific procedure. Athletic shoes are typically the first regular shoes to fit comfortably, with dress shoes following as residual swelling resolves. Custom toe spacers or silicone sleeves protect the corrected toes during the transition.

Patient satisfaction rates exceed 90% for hammertoe surgery when appropriate patient selection and surgical technique are combined. The elimination of painful corns, improved shoe fitting, and restored toe alignment consistently exceed patients’ expectations.

The Most Common Mistake We See

The most common mistake patients make regarding hammertoe surgery is waiting until the deformity becomes rigid and severe before seeking correction. Flexible hammertoes can be corrected with simpler procedures (tendon transfer) that preserve joint function, while rigid deformities require more extensive bony surgery. Early evaluation when the toe can still be straightened manually provides the best opportunity for joint-preserving correction.

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In-Office Treatment at Balance Foot & Ankle

Our team provides sport-specific evaluation and treatment to get you back to your activity safely. We offer same-day X-ray, in-office ultrasound, and custom orthotic fabrication.

Same-day appointments available. Call (810) 206-1402 or book online.

Frequently Asked Questions

Is hammertoe surgery painful?

Hammertoe surgery is performed under local anesthesia (toe block) that provides numbness for 4-8 hours. Most patients report moderate discomfort for 3-5 days managed with prescribed medication. Pain decreases significantly after the first week, and many patients report less pain from surgery than from the chronic corn that prompted the procedure.

How long is recovery from hammertoe surgery?

Most patients walk in a surgical shoe immediately after surgery. Regular shoes fit at 4-8 weeks. Full activity resumes at 8-12 weeks. Residual swelling may persist 3-6 months but does not limit function. Return to work depends on job demands — desk work at 3-5 days, physical work at 4-6 weeks.

Will the hammertoe come back after surgery?

Recurrence rates depend on the procedure: PIP fusion has the lowest recurrence (less than 5%), arthroplasty approximately 10-15% over 10 years, and tendon transfer 5-10% when performed for appropriate indications. Proper footwear and orthotics after surgery reduce recurrence risk.

Can all my hammertoes be fixed at once?

Yes. Multiple hammertoes are commonly corrected during a single surgery session. Each toe may receive a different procedure based on its individual deformity pattern. Correcting all toes simultaneously means one recovery period rather than multiple separate recoveries.

The Bottom Line

Hammertoe surgery provides lasting correction of painful toe deformities through techniques tailored to each patient’s specific condition. Board-certified podiatric surgeons at Balance Foot & Ankle offer all three primary approaches — arthroplasty, fusion, and tendon transfer — and select the optimal procedure for your individual needs.

Sources

1. Journal of Foot and Ankle Surgery, ‘Comparative Outcomes of PIP Arthroplasty vs Arthrodesis for Hammertoe,’ 2025
2. Foot and Ankle International, ‘Flexor-to-Extensor Tendon Transfer for Flexible Hammertoe,’ 2024
3. Clinics in Podiatric Medicine and Surgery, ‘Internal Fixation Options for PIP Arthrodesis,’ 2024
4. Foot and Ankle Specialist, ‘Patient Satisfaction After Hammertoe Correction,’ 2025

Advanced Hammertoe Surgery Options

Not all hammertoe surgeries are the same. Dr. Tom Biernacki selects the optimal technique — arthroplasty, fusion, or tendon transfer — based on your deformity severity, flexibility, and activity goals for the best outcome.

Learn About Hammertoe Treatment → | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Coughlin MJ, et al. “Operative repair of the fixed hammertoe deformity.” Foot Ankle Int. 2000;21(2):94-104.
2. Lehman DE, Smith RW. “Treatment of symptomatic hammertoe with a proximal interphalangeal joint arthrodesis.” Foot Ankle Int. 1995;16(9):535-541.
3. 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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