http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 1 of 16
(https://www.aetna.com/)
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
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 2 of 16
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.
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 3 of 16
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
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 4 of 16
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
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 5 of 16
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
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 6 of 16
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
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 7 of 16
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
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 8 of 16
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
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 9 of 16
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,
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 10 of 16
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:
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 11 of 16
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
J1030 Injection, methylprednisolone acetate, 40 mg
J1040 Injection, methylprednisolone acetate, 80 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]
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 12 of 16
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.
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 13 of 16
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.
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 14 of 16
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.
09/25/2019
http://www.aetna.com/cpb/medical/data/600_699/0636.html
Page 15 of 16
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.
37. Scott RT, Hyer CF, Berlet GC. The PROTOE intramedullary hammertoe
device: An alternative to Kirschner wires. Foot Ankle Spec. 2013;6(3):214-
216.
38. Catena F, Doty JF, Jastifer J, et al. Prospective study of hammertoe correction
with an intramedullary implant. Foot Ankle Int. 2014;35(4):319-325.
39. Kramer WC, Parman M, Marks RM. Hammertoe correction with k-wire fixation.
Foot Ankle Int. 2015;36(5):494-502.
40. Basile A, Albo F, Via AG. Intramedullary fixation system for the treatment of
hammertoe deformity. J Foot Ankle Surg. 2015;54(5):910-916.
41. American College of Foot and Ankle Surgeons (ACFAS) Website. ACFAS
position statement on cosmetic surgery. February 2013.
42. American College of Foot and Ankle Surgeons (ACFAS) Website. Clinical
Practice Guideline. Diagnosis and treatment of forefoot disorders. March/April
2009.
43. National Guideline Clearinghouse (NGC) Website. Work Loss Data Institute.
Ankle & foot (acute & chronic). August 19, 2013.
44. Richman SH, Siqueira MB, McCullough KA, Berkowitz MJ. Correction of
hammertoe deformity with novel intramedullary PIP fusion device versus
K-wire fixation. Foot Ankle Int. 2017;38(2):174-180
45. Obrador C, Losa-Iglesias M, Becerro-de-Bengoa-Vallejo R, Kabbash CA.
Comparative study of intramedullary hammertoe fixation. Foot Ankle Int.
2018;39(4):415-425.
46. Albright RH, Waverly BJ, Klein E, et al. Percutaneous Kirschner wire versus
commercial implant for hammertoe repair: A cost-effectiveness analysis. J
Foot Ankle Surg. 2018;57(2):332-338.
47. Rothermel SD, Aydogan U, Roush EP, Lewis GS. Proximal interphalangeal
arthrodesis of lesser toes utilizing K-wires versus expanding implants:
Comparative biomechanical cadaveric study. Foot Ankle Int. 2019;40
(2):231-236.
09/25/2019
Page 16 of 16
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