12 Surgical Treatment of Hammer Toe, Claw Toe, and Mallet Toe Deformity

Surgical Treatment of Hammer
Toe, Claw Toe, and Mallet
Toe Deformity
Angela Simon
Hammer toe and claw toe deformity is often addressed
surgically. Depending on the stage of the deformity
and on the dynamic and static factors, the surgical
treatment should be performed via sequential procedures. The decision of how many surgical procedures
will be required is done preoperatively as well as in the
surgical theatre during the progression of surgically
stabilizing and balancing the ray (digit and metatarsal). The definition of the deformities of lesser toes in
the literature varies. In this chapter I define the digital
deformities1 according to Table 12.1 (Fig. 12.1).
More important for planning the surgical treatment
is the knowledge of biomechanical basics in order to
treat the anatomical structure. Knowledge of how to
balance the tendon pathology avoids the recurrence of
the deformity.
Biomechanical Basics
The hinge joints have the sagittal range of motion in
dorsiflexion and plantarflexion. To maintain balance,
tendons normally have a combination of forces. It is
important to know that only the intrinsic muscles,
lumbricales and interossei, have a direct influence on
plantarflexing the metatarsalphalangeal joint (MTPJ)
A. Simon
Klinik für Orthopädie 2, Fußzentrum Malchin,
Dietrich-Bonhoeffer-Klinikum, Basedower Strasse 33,
17139 Malchin, Germany
e-mail: [email protected]
of the lesser toes. They blend distally into the extensor
hood of the proximal phalanx (Fig. 12.2).2,3 They stay
plantarly of the MTPJ axis. “The lumbricales tendons
cause plantarflexion at the Metatarsophalangeal joint
and dorsiflexion of the Interphalangeal joints by a
sling mechanism.”2
In comparison, the tendon of the flexor digitorum longus inserts more distal at the middle phalanx. Their influence of plantarflexing the MTPJ is not direct. They
plantarflex the proximal interphalangeal joint (PIPJ) and
cannot neutralize the deforming forces (Fig. 12.3a).4
Imbalance of the tendons, depending on different
causes, develops almost always, with the exception of
special neuropathic disorders,5 weakness of the intrinsic muscles. The result is the permanent dorsiflexion
of the proximal phalanx in the MTPJ and the plantarflexion in the PIPJ (Fig. 12.3b). “the flexion moment
of the interossei at the MTPJ is decreased markedly
because of their normal proximity to the insert center
of rotation of the MTP joint on the metatarsal head”.6
The flexible deformity advances to a rigid and painful
situation with callosity at the tip of the deformity
(dorsal PIPJ) because of the pressure from the shoe
dorsally and from the ground plantar.
The severe deformity shows a permanent dorsal
luxation of the proximal phalanx.
“The base of the proximal phalanx is displaced onto
the dorsum of the metatarsale neck along with the
Table 12.1 Determining hammer toe, claw toe, and mallet toe
Hammer toe
Claw toe
Mallet toe
Straight (extended)
A. Saxena (ed.), International Advances in Foot and Ankle Surgery,
DOI: 10.1007/978-0-85729-609-2_12, © Springer-Verlag London Limited 2012
A. Simon
Fig. 12.2 Intrinsic muscles2
Extensor digitorum brevis
Extensor digitorum longus
Flexor digitorum longus
Plantar plate
Flexor digitorum
Long extensor
Short extensor
Plantar plate
Long flexor
Short flexor
Fig. 12.3 (a) Normal basic bony, tendinous, and capsular
anatomic features in the lesser toes.3 (b) Typical deformity of the
lesser toes.4
b Displaced fascial slips
Dorsally dislocated
MP joint
Streched plantar
fascial slips
encircle MT neck
Fig. 12.1 (a) Hammer toe. (b) Claw toe. (c) Mallet toe (third toe)
Fig. 12.4 Plunger effect3
Increased ‘plunger’ effect of
dorsally displaced plantar plate
when plantar fascia tightens
Surgical Treatment of Hammer Toe, Claw Toe, and Mallet Toe Deformity
Fig. 12.5 Push-up test for a flexible hammertoe deformity (a) which reduces with plantar pressure (b)7
remnants of the plantar plate and the transverse intermetatarsale ligament”.4 The pathologic direction of
tendon forces intensifies the deformity. Stainsby calls it
a “plunger effect”: “The plantar plate is tethered to the
contiguous deep transverse metatarsal ligament. Because
of the dorsally displaced slips of the deeper layer of
plantar plate, the MT head becomes depressed by a
plunger mechanism”3 (Fig. 12.4).
The mallet toe deformity results in a flexible or
rigid contraction of the distal phalanx and is the result
of a hyperactivity or contracture of the flexor digitorum longus tendon. It creates compression on the
flexed tip of the toe, including the nail. A callosity
and even ulcer may develop in this region.
Clinical Examination
Painful callosity at the tip of the PIPJ or below the metatarsal head is often the reason for patients’ first consultation to the foot surgeon. The inspection of the axis of hip,
knee, and ankle joint and the examination of muscle function is necessary to integrate or distinguish the deformity
of the toes. Rotation disorders of the leg can be compensated by hyperfunction of the extrinsic muscles (extensor
digitorum longus or flexor digitorum longus) and neutralize while correcting the axis of the leg if the deformity
still is flexible. “Neuropathic disorders (e.g., hereditary
motor–sensory neuropathy) show an imbalance preponderating the power of the extensor digitorum longus
tendons, while the intrinsic Muscles – responsible to platarflex the MPTJ – are weakened.”5 After the examination, including the gait and standing bare-foot, the
palpation of the foot is important to feel indurations, flexibility of every joint, tension of tendons, and painful spots.
The push up test 7 (Fig. 12.5), a passive test to examine
the flexibility of the MTPJ and PIPJs, is very important in
deciding if a surgical release of these joints is necessary.
Examination of the distal interphalangeal joint and
testing the flexibility of the flexed position of the distal
phalanx should be performed actively and passively.
It is useful to observe the loaded foot to determine if
A. Simon
Fig. 12.6 X-ray or
hammertoe 2nd and clawtoe
3rd digits AP (a) and lateral
view (b)
the deformity is flexible. Additionally, passive testing
should be performed by direct palpation of the joint,
and also with a flexed MTPJ. In this position the flexor
digitorum longus tendon is relaxed and a flexible
deformity would disappear.
The active range of motion and also the isometric
tests of the muscles are necessary to get the information
about the dynamic balance between dorsiflexing and
plantarflexing function at every joint of the lesser toes.
Radiological Information
It proves useful to perform the x-ray of the whole foot in
weight-bearing dorsoplantar view and exact lateral view
(Fig. 12.6). In cases where the metatarsalgia is dominant, an axial view of the metatarsal heads (“sprinter/
plantar axial view”) is good additional information.
Surgical Treatment
If the clinical examination has revealed that the deformity is no longer flexible, there is no chance to correct
the axis and the dynamic imbalance with taping,
insoles, orthoses, or stretching. The indication for a
surgical treatment is the rigid and painful deformity.
“Unattractive deformity that is painless is not an
indication for surgical correction.”6
The goals of the lesser toe surgery:
s Correcting the axis of the toe
s Stabilizing the dynamic balance between dorsi-and
s Preserving vessels and nerves to maintain a good
integrity, especially lymphatic drainage
12.5.1 Performance of the Surgical
Correction of the digital deformity is the goal. The push
up test is a useful and important help during the
1. Skin incision is longitudinal dorsal from distal of
the PIPJ, V-shaped above the MTPJ (Fig. 12.7) to
avoid a hyperdorsiflexion because of a rigid skin
scar afterward.
2. Isolate the tendons of the extensor digit, longus and
brevis, cutting the distal insertion of the brevis
tendon, which is always located lateral of the
extensor digitorum longus (EDL), inserting at the
extensor hood.
3. In most cases, where the proximal phalanx does not
present a total subluxation in the MTPJ, split the
tendon of the EDL longitudinally (Fig.12.8a) for a
later Z-plasty lengthening (Fig.12.8b). Attention: In
case of a severe luxation I suggest the Stainsby
Surgical Treatment of Hammer Toe, Claw Toe, and Mallet Toe Deformity
Fig. 12.7 Skin incision
procedure with a transposition of the tendon. If
deciding to perform the Stainsby procedure, at this
step of the surgery procedure the EDL tendon is cut
proximally without splitting (described later in this
4. Open the PIPJ, resect the collateral ligaments
(Fig.12.9a), and resect the condyles (Fig. 12.9b, c)
of the distal proximal phalanx to produce a little
hollow in the surface.
5. Remove the cartilage of the base of the middle
phalanx (Fig. 12.10a), creating a little roof. With
these formations, like a positive and negative
(Fig.12.10b), it is possible to avoid a rotating
6. First push up test: Does the ray, the MTPJ included,
stay in a right, straight position? (Fig.12.5).
7. A – Yes? Then the procedure will be finished with
the temporary transarticular fixation of the ray,
including the PIP fusion:
s A double tip K-wire (1.4 mm diameter) drilling backward (Fig. 12.11a) from the middle phalanx out of
the top of the toe, then holding the ray in the straight
position drilling forward (Fig. 12.11b) the proximal
end of the pin through the proximal phalanx into
the distal metatarsal. The distal end of the K-wire is
bent as a loop or covered with a plastic cap.
s The two halves of the tendon of the ext. digitorum longus are sutured in a moderate tension as
a lengthening Z-plasty (Fig. 12.12).
B – No! If the ray does not stay rectus, the remaining deformity in the MTPJ (rigid dorsiflexion) has to
be corrected:
Fig. 12.8 (a) Isolating and splitting the ext. digit. lg. tendon
and (b) longitudinal splitting
s Open the capsule of the MTPJ (Fig. 12.13);
the dorsal capsule should be resected and the
contracted collateral ligaments are incised. Be
careful not to cut the vessels and nerves.
8. Second push up test: Does the ray, the MTPJ
included, stay in a right, straight position?
9. A – Yes? Finish the procedure as shown in 7–A.
B – No! Free the MTPJ plantarly; either
adhesive capsule to the plantar plate or a ruptured
A. Simon
Fig. 12.9 (a) Opening the PIPJ. (b) Resecting the collateral ligaments and resection of the condyles. (c) Removal of the
resected condyles
plantar plate is the reason for this remaining
s With a special instrument, the McGlamry elevator, carefully release this rigid tissue (Fig. 12.14a);
the instrument is very sharp and the formation
or the shape of the metatarsal head having a
big convex structure plantarside must be known.
Otherwise the cartilage or bone will be damaged.
Surgical Treatment of Hammer Toe, Claw Toe, and Mallet Toe Deformity
Fig. 12.10 (a) Removing cartilage of the base of the middle phalanx. (b) Formation of the surfaces as positive and negative
Fig. 12.11 Fixation with a K-wire. (a) Retrograde and (b) anterograde
s If the plantar plate is ruptured, the current opinion
in the literature is to repair the defect. Otherwise
the head of the metatarsal can be dislocated again
as the forces of the tendons are not in correct
balance and the plunger effect will recur.
s The plantar plate can be sutured from the dorsal
approach, but the gap of the joint is narrow. An
assistant is needed to distract the ray. With a little
needle using a 2-0 suture (nonabsorbable) it might
be possible to close the defect. Otherwise closure
can be performed with a separate approach from
plantarly: “The surgical approach for repair of
an unstable second MTPJ is through a plantar
incision in the first intermetatarsal space.”8
A. Simon
Fig. 12.12 Lengthening suture of the ext. digit. lg. tendon
Fig. 12.14 (a) The McGlamry elevator. (b) Fixation with a
K-wire anterograde
Fig. 12.13 Opening the capsule of the MTPJ
– Carefully approach through the plantar soft
tissue, preserving the vessels and nerves
between the metatarsal heads at both sides.
Open the sheet of the flexor tendons and
separate the tendons to reach the plantar plate
and visualize the rupture. “With the flexor
tendons retracted, a well-defined defect in
the midsubstance of the plantar plate is
– Now you have a direct view of the cartilage of
the metatarsal head. Suture with 2.0 nonabsorbable (Fig. 12.15).
10. Third push up test: Does the toe, the MTPJ
included, stay in a right, straight position?
Surgical Treatment of Hammer Toe, Claw Toe, and Mallet Toe Deformity
Fig. 12.15 Repair of the plantar plate from the plantar approach.
Courtesy of Richard Bouché, DPM
11. A – Yes? Then finish the procedure as in step
Figure 12.16 shows the preoperative situation.
Keep the K-wire for 5 weeks. The removal is not
painful; normally local anesthesia is not needed. Take
care that the toe is fixed while extracting the K-wire
with a forceps, otherwise the fusion of the PIP joint
can burst.
B – No! Then there are usually three kinds of disorders. The decision of surgical treatment depends on the
etiology of the disorder.
I. Rheumatoid arthritis (Fig. 12.17). I suggest
the Stainsby procedure after steps 1–10 (without step 7A). Shorten the base of the proximal
phalanx and interpose the tendon of the EDL
from dorsal, through the gap of the MTPJ to
plantar and fix it on the plantar plate or to the
flexor tendons (if the plantar plate is damaged)
(Fig. 12.18).
Surgical technique of the Stainsby procedure –
step by step:
(a) Skin incision is made longitudinal dorsal with
a v-shape above the MTPJ proximal to the
distal metatarsal area (Fig. 12.17e).
(b) Prepare the EDL tendons, cut the ext. digit.
brevis tendon at the distal insertion, and cut
the EDL tendon as proximal as possible
(Fig. 12.19). Mobilize the EDL tendon until
Fig. 12.16 (a) claw toe II and hallux valgus. (b) Same patient
after sequential surgical procedure
it is the distal insertion. Save the free portion
in moistened gauze.
(c) After performing the steps for the PIP fusion,
usually necessary (steps 9–11, above), the base
of the proximal phalanx is resected (Fig. 12.20).
Now the gap at the MTPJ is larger.
(d) With a mosquito-clamp the plantar plate is
mobilized dorsally. If the plantar plate is damaged, mobilize (pull) the flexor tendons through
this gap dorsally. The EDL tendon is interposed into the gap and fixed with a suture
(vicryl 3–0) to the plantar plate or flexor tendon in a moderate, soft tension (Fig. 12.21).
(e) Now continue with step 7A for finishing the
surgical procedure (Fig. 12.22).
(f) Sometimes it is necessary to perform a subcapital closing wedge osteotomy of the metatarsal bone for elevating and shortening the
metatarsal. (See step 11B-II, below).
A. Simon
Fig. 12.17 (a) Rheumatory deformity of the lesser toes. (b) Lesser toe deformity; frontal view. (c) X-ray dp, rheumatory deformity
of lesser toes. (d) X-ray lateral view, luxated lesser toes at rheumatory arthritis. (e) Skin incision, Stainsby procedure
The result of the Stainsby procedure is an
interposition arthroplasty of the MTPJ with
dynamic stabilization. The advantage in rheumatoid arthritis is to preserve the metatarsal head.
Sometimes it is necessary to correct all lesser
toes (Fig. 12.23).
II. Propulsion- or Transfer-metatarsalgia. The
metatarsal bone, regarding the alignment of the
length of all metatarsals, is too long (in case of a
painful propulsion) or plantarized (in case of a
painful weight-bearing while standing). A subcapital dorsal wedge osteotomy will elevate and
Surgical Treatment of Hammer Toe, Claw Toe, and Mallet Toe Deformity
Fig. 12.18 Cutting the ext. digit. lg. tendon as proximal as
Fig. 12.19 Resection of the base of the proximal phalanx
shorten the metatarsus. In some severe claw toe
deformities it is necessary to shorten the metatarsal bone, otherwise the reposition of the subluxed ray is not possible, though the steps before
have released and relaxed the deformity. In these
cases, where the soft tissue is not able to tolerate
a distraction for a straight position of the ray, the
shortening osteotomy is successful. If the goal of
the osteotomy is to elevate the metatarsal head,
the direction of the bone cut should be in a correct position being sure to elevate and not plantarize the metatarsal head. If the osteotomy is
too steep to the weight-bearing surface, the subcapital oblique cut from dorsal distal to proximal
plantar cannot elevate the head. Shifting the
metatarsal head proximal may plantarize the
metatarsal head. It is difficult to bring the saw
blade to a transverse position such that angulating the cut proximally will elevate the head. The
complication of an oblique cut is plantarizing
the head. With this failure more painful pressure
is produced to the head than before surgery. This
can lead to a floppy toe. Because of the difficulty
with this osteotomy, it is easier and more secure
to perform a second cut, less oblique, called a
closing wedge osteotomy (Fig. 12.24). Fixation
is performed with a cannulated screw (2.0 mm),
from proximal dorsal to distal plantar, self-drilling and self-cutting (Fig.12.25). More complicated is a twist off screw, which could break off
in the bone or disconnect, before reaching the
final insertion.
III. Flexor tendon contracture. The imbalance
between flexor and extensor tendons and the
weakness of the lumbricales and Interossei produce this deformity. With the transfer of the
flexor digit, longus tendon a balance can be
restored to avoid the pathologic dorsalflexion
of the proximal phalanx. With a little transversal plantar incision below the distal interphalangeal joint the tendon is identified with a
moskito clamp and cut. In the gap of the opened
metatarsophalangeal joint the tendon can be
harvested between the tendons of the flexor
digit, brevis, laying in the middle. Pulling the
distal cut flexor digit, longus tendon dorsally,
the tendon is split longitudinally and both sides
are bent from plantar to dorsal around the
Fig. 12.20 (a) Suture of the
ext. digit. lg. tendon. (b)
Interposition of the ext. digit.
lg. tendon plantarside
A. Simon
Fig. 12.21 (a) Pin fixation
after tendon interposition. (b)
Interposition of the ext. digit.
lg. tendon
Surgical Treatment of Hammer Toe, Claw Toe, and Mallet Toe Deformity
position. A small bandage, keeping the distal phalanx
in the straight position is useful for 2 weeks.
The flexor tenotomy procedure is very useful in diabetic patients to avoid ulcerations of the tip of the toe.
Local anesthesia is not needed for neuropathic diabetic
Partial weight-bearing is allowed in a special shoe with
a hard insole for 5 weeks, to protect the position of the
pins (K-wires). K-wire removal is done after 5 weeks.
Local anesthesia normally is not needed. Physiotherapy
is performed after removal of the pins, taking care that
the PIP-fusion should not be moved or bent. Only the
MTPJ needs some exercises in dorsi- and plantarflexion.
For the passive movement the toe must be stabilized at
the proximal phalanx and not at the middle phalanx
because of the PIP-fusion. Rigid Deformity
To correct the rigid flexion contracture of the DIPJ, it
is necessary to perform a fusion in a rectus position.
The dorsal skin incision should be curved like a
hockey stick, protecting the region of the nail and
preserving the vessels and nerves. The extensor digitorum longus tendon is transversely incised. The
DIPJ is exposed by further resecting the collateral
ligaments, removing cartilage of both bones, just with
minimal transversal resection with a small saw blade.
Cancellous bone should be exposed. Next the view
to the gap on the plantar capsule is possible. The
capsule should be opened and the flexor tendon is
Fusion with a double-ended K-wire is performed
as with PIPJ hammertoe surgery. Forward (antegrade) drilling of the k-wire is performed from the
distal phalanx through the tip of the toe and then
backward (retrograde), through the middle and proximal phalanx, holding the toe in a rectus position.
Penetrating the MTPJ should be avoided (unless
MTPJ deformity needs to be stabilized). The tendon
of the extensor digitorum longus is sutured. The skin
can be closed with resorbable or nonresorbable material. The K-wire is removed after 4 weeks.
12.5.3 Mallet Toe Deformity: Performance
of the Surgical Procedure
Fig. 12.22 Schematic of the Stainsby procedure
diaphysis of the proximal phalanx, preserving
vessels and nerves. “The ends are sutured dorsally to eachother and to the extensor tendon in
a mild tension, while the MP-Joint is fixed in
20° plantarflexion and the ankle joint in neutral
position”9 (Fig. 12.26). This surgical procedure
is completed as in step 7A (above).
12.5.2 Postoperative Care Flexible Deformity
The treatment usually involves a simple flexor tenotomy. Flexor digitorum longus tenotomy is a minimally invasive, percutaneous technique:
Using a large gauge needle (16 or greater), insert
plantarly at the joint line of the DIPJ exactly in the middle of the toe. This location avoids injuring the vessels
and nerves medially and laterally. Palpating the tendon
with the tip of the needle, move or carefully advance
the needle 3mm to the left and right, like a windshield,
holding the distal phalanx in the most extended position as possible. The sharp tip of the needle will cut the
tendon. The result is the relaxed distal phalanx in rectus
Author’s Experience
12.6.1 Skin Incision
The v-shape above the MTPJ might avoid a contracting skin scar, which may cause recurrence of the dorsiflexion deformity of the proximal phalanx (floppy toe,
nonpurchasing toe).
12.6.2 PIP-Fusion
The typical, well-known Hohmann/Post procedure
(proximal phalangeal head resection) did not
consider removal of the cartilage at the base of the
A. Simon
Fig. 12.23 (a) Stainsby procedure performed at the right foot (see patient like in figure 12:17a, b, c, d). (b) Stainsby, same patient
frontal view (right foot). (c) X-ray after removing K-wires
Surgical Treatment of Hammer Toe, Claw Toe, and Mallet Toe Deformity
Fig. 12.24 (a) First oblique cut in subcapital region. Second cut less oblique (b). Wedge removed (c). Reduction of osteotomy with
McGlamry elevator (d)
middle phalanx. This is an important reason why the
correction of the deformity could not succeed. The
fusion of the PIPJ, which is stabilizing the toe in a
straight position needs the same condition for a fusion
as with any other fusion of two bones.
To avoid a painful nonunion it seems to be more
secure to remove the cartilage of the base of the middle
phalanx (Fig. 12.10). Additionally cartilage removal
can prevent a rotational failure and a nonunion if the
surfaces of the connecting bones have a three-dimensional formation, like a saddle roof at the middle phalanx and a v-shaped gutter at the proximal phalanx
(“cup” and “cone”) (Fig. 12.27). In my opinion the
peg-and-hole arthrodesis2 is quite difficult to perform
because the K-wire may damage the peg; it can also
fracture at osteoporotic bone.
Finally after the temporary longitudinal fixation of
the toe with the K-wire, be sure that the surfaces of the
PIP area fits together like press fit, without any gap.
On the contrary, the gap of the MTPJ should be fixed
in distraction to support the release of the capsule
(Fig. 12.14b).
12.6.3 MTPJ Release
The recurrence of the deformity in hyperdorsiflexion of
the MTPJ may happen if the MTPJ has not been
released and the permanent dorsiflexion of the phalanx
will continue. Every fiber of the capsule and collateral
ligaments must be opened if there is a contracture
of these structures. The push up test is essential. To
release the plantar plate, the McGlamry elevator is very
useful because of the formation of this instrument, but
take care that the cartilage is not damaged with its sharp
tip. Remember that the head has a large flare plantarly.
A. Simon
Fig. 12.26 Schematic of lateral view of extensor lengthening
(1) and flexor transfer (2) with Girdlestone technique9
Fig. 12.25 (a) Fixation with 2.0 cannulated screw. (b) X-ray of
the closing wedge metatarsal osteotomy, II–V. ray
12.6.4 Fixation of the Ray (MTPJ Through
Pay attention that, at the end of the procedure, the correct straight position of the toe does not produce too
much distraction for the soft tissue. Otherwise the neurovascular structures may be stretched too much and
may lose their function. In the worst case the toe will
become necrotic. If the normal skin color and temperature does not recur after 2 h and the toe stays pale and
Fig. 12.27 X-ray: bone formation for a secure PIPJ fusion
cold, try to infiltrate the toe with a nitroglycerin; the
arteries should vasodilate.
If the toe maintains the hypoxia (Fig. 12.28a, b)
after two nitroglycerin infusions, remove the K-wire
to reduce the distraction. Now it is important to
hold the toe straight with a bandage or soft tape, but
likely the PIP fusion will not heal in a rectus position. Nevertheless it is better than producing the
worst complication: a necrotic toe which has to be
Surgical Treatment of Hammer Toe, Claw Toe, and Mallet Toe Deformity
plate is about 1 cm long. Rolling this end in the joint
gap around the K-wire after drilling the K-wire, which
is transarticular fixing the ray, supports to maintain the
gap as an additional interposition.
12.6.6 Metatarsal Osteotomy
It is useful to locate the joint line of all MTPJs with a
needle. Mark it intraoperatively, into the joint gap, in
the sagittal plane. If more than one ray shall be corrected, it is important to maintain the physiological
alignment of the length of the metatarsal bones
which helps to avoid the recurrence of a propulsion
Fig. 12.28 (a) Situation pre-op: normal perfusion; (b) post-op:
hypoxia of the second toe
12.6.5 Stainsby Procedure
The proximal free end of the extensor digit, longus.
tendon after interposing it and suturing it to the plantar
1. Simon A. Korrektur der Hammer-und Krallenzehenfehlstellungen: Ambulant Operieren. 2007;14:24-29.
2. Mc Glamry ED. Lesser ray deformities. In: Mc Glamry ED,
Banks AS, Downey MS, eds. Comprehensive Textbook of
Foot and Ankle Surgery, vol. 1. 3rd ed. Baltimore: Lippincott
Williams & Wilkins; 2001:253-304.
3. Stainsby GD. Pathologic 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 Engl. 1997;79(1):58-68.
4. Hansen ST. Tendon transfers and muscle-balancing techniques. In: Hansen ST, ed. Functional Reconstruction of the
Foot and Ankle. Philadelphia: Lippincott Williams &
Wilkins; 2000:455-458.
5. Döderlein L. Pathomechanik des Ballenhohlfußes. In:
Döderlein L, Wenz W, Schneider U, eds. Der Hohlfuß.
Berlin: Springer; 2000.
6. Kitaoka HB. Realignment of lesser toe deformities. In:
Kitaoka HB, ed. The Foot and Ankle. 2nd ed. Philadelphia:
Lippincott Williams & Wilkins; 2002:147-170.
7. Niezold D, Ferdini M. Klinische untersuchung. In: Wirth CJ,
ed. Orthopädie und Orthopädiche Chirurgie. Fuß. Stuttgart:
Thieme; 2002:9-19.
8. Chang TJ. Lesser digital surgery: arthroplasty, arthrodesis
and flexor tendon transfer. In: Chang TJ, ed. Master
Techniques in Podiatric Surgery: The Foot and Ankle.
Philadelphia: Lippincott Williams & Wilkins; 2005:35-48.
9. Walsh HPJ. Kleinzehendeformitäten: transfer der beugesehne
und weichteilrelease des metatarsophalangealgelenkes. In:
Wülker N, Stephans M, Cracchiolo A III, eds. Operationsatlas
Fuß und Sprunggelenk. Stuttgart: Enke; 1998:85-92.