Hammertoe Surgery: What We Learn From Difficult Cases

Key Takeaways

1. Hammertoe complications can occur at any stage—preoperative, intraoperative, or postoperative.
Misaligned patient expectations, incomplete deformity assessment (including bunion or MPJ pathology), small intraoperative alignment errors, and unaddressed soft tissue or biomechanical contributors can all derail outcomes. Even minor degrees of residual deformity may significantly impact patient satisfaction.

2. Functional outcomes matter more than radiographic perfection.
A straight toe on X-ray does not guarantee comfort or satisfaction. Surgeons must consider postoperative functionality—shoe wear, activity level, swelling, recurrence risk, and adjacent joint compensation—rather than focusing solely on static alignment.

3. In revision cases, less can be more—and clarity is critical.
Before pursuing additional surgery, allow appropriate time for healing and carefully identify the true source of the problem. Successful revision requires precise problem-solving, honest patient conversations, and avoiding both overcorrection and undertreatment.

Transcript

Hello everybody and welcome to Podiatry Today Podcasts where we bring you the latest in foot and ankle medicine and surgery from leaders in the field. We are continuing our coverage today of the 2026 ACFAS Annual Scientific Conference with our next guest, Dr. Lowell Weil, Jr. He is the executive chairman of Balance Health and a physician with Weil Foot and Ankle Institute, and he is speaking at the ACFAS ASC on Hammer Toes Gone Wrong. So this is something that I think that every foot and ankle surgeon has encountered at one point or another, and although it's a small joint, it can be a big challenge for the majority of us. So I'm looking forward to hearing from you, Dr. Weill, on this topic. And we have a couple questions for you today. When discussing hanmertoes gone wrong, which I love the title by the way, what stage of the perioperative process do you find things most often go off track?

I think it can happen at any stage. Sometimes it happens really immediately. Sometimes it's months or years down the road when it comes to hammer, toes gone wrong and I think just the title hammertoes gone wrong. I didn't choose this title. I was asked to present on it. I think foot and ankle surgeons, whether they're podiatric, orthopedic or whoever else, I think one of the biggest bugaboos that we run into is hammertoes. I think if you talk to some of the most accomplished surgeons in the world, they dislike hammertoes more than some of the more crazy complex stuff because the consistency of outcome is so not there. And if you talk to the everyday surgeon doctor, I think they also, they're not maybe on the podiums as much, but when you really talk to them sitting around at dinner table or just in the exhibit hall of meetings, they're always really fretting over hammertoes because you would think it was such a simple thing.

And I think we all think of it, oh, it's very simple. It's not rear foot reconstruction, it's just a simple hammer toe. But I think there's a level of expectation of our patients that may be higher with four foot reconstruction in the toes, bunions, hammertoes, things like that, that hold us to a much higher level of outcome. So back to your question, which is when does it go awry? I think it can go awry preoperatively with the conversation of expectations and the decision choice of what kind of hammer toe surgery I'm going to do. Am I going to do a fusion, an arthroplasty? If I'm going to do a fusion, what kind of device am I going to fuse two joints or one joint? Am I going to pin the MPJ? Am I not? Is there soft tissue structures that I need to address?

Is there concurrent like a bunion that if I leave uncorrected, is it going to affect recurrence rates? Am I going to try an MIS procedure? Is that a better option? Am I good at MIS? What's the better outcome of the MIS? Am I really doing the patient a favor by doing MIS? So I just threw a whole host of things at you, Jennifer, but those literally should be or probably are in some way, shape or form what every surgeon is thinking about when it comes to the hammer to, so the preoperative decision and then intraoperatively like it is such a small error percentage. If I missed by a couple of degrees, the patient is going to stare at that toe and say, yeah, my toe was really bad before, but now it's leaning a couple of degrees to the right. And you're like, I just changed this horrible deformity into something that you are staring at and it's off just a tiny bit and you're not happy about it.

And I think many foot and ankle surgeons over the course of their career have run into the man, I made a big change in this person, and they are getting caught up in a slight degree or two of inaccuracy or whatever you want to call it. So that's intraoperatively. And then the postoperative, they swell for a long time. A arthroplasty will have a high rate of recurrence rate or deformity occurrence. The fusion, you fuse the PIP, you start to get co contra deformity of the DIP. If you fuse both, you've got this really straight uncomfortable toe and people don't like it. As a surgeon, you look at an x-ray and say, oh, look how straight that is. And you look at the foot sitting static in a treatment chair and you're like, well, the toe is straight. But the functionality isn't making people happy. And I think where we go wrong as a surgeon group is we don't understand the postoperative functionality of what we do. And so yes, we have x-rays and yes, we have the static picture, but how is the patient going to put it in shoes and exercise and do the things that are so important in people's lives And so I think you asked me a simple question, and here I've gone off on a diatribe, but I think they're all really important thoughts and factors when we think about hammer toes.

No, they definitely are. And this may be a little bit more of an open door, but what role do you feel the biomechanical exam plays in avoiding these complications or procedural failures? Are there any particular components of it that are super important for hammer toes?

Yeah, so I kind of have two answers to this question. One is I think sometimes as podiatrists, we over view biomechanics even though I'm a very big biomechanics person and my dad taught me to be into biomechanics, and I've always been big into biomechanics. And I think biomechanics is what differentiates podiatrists from other specialists in the foot and ankle. But I think sometimes we overanalyze the effects of biomechanics. They're all really important, but extensor substitution, flexor substitution, all that's important. But is it super practical? When we get into surgery, what I think is important biomechanically to getting to your specifics of your question, Jennifer, is what are the combined effects that create the hammertoe? Is there a metatarsal problem? Is there a soft tissue contributing factor like plantar plate insufficiency or collateral ligament problems at the MPJ? Is the bunion playing a role in some insufficiency in the first metatarsal phalangeal joint? All of those things play a role. And so those biomechanic understandings are really important as we address hammertoes. And if we just correct a hammertoe in isolation, we may end up looking back six months a year or two later and saying, wow, there are these other issues going on that I sort of didn't address. And now we're now left with maybe a bigger, more challenging problem because we've got the hammertoe in, its whatever stage of problem, but now we've got MPJ problem, first ray problem, things like that.

Absolutely. And although we already noted the challenges of hammer toe surgery in general, revision hammertoe surgery can be even more challenging, I'm sure. Are there any principles that guide your approach to these types of cases? And are there expectations that you feel surgeons should be setting for themselves and their patients
at times?

I think number one, less is more. And I think sometimes we as surgeons think we can solve any problem with more and more surgery. And so I often try to delay revisional surgery just to allow the human body, which is miraculous to do its thing. Now, there are times where it's a obvious problem that you've got to go in and address head on and you can't delay it. That would be foolish. And then when you do, what is the problem? Is it just like there's a little bit of a bump that the patient is problematic with and can you just shave down the bump in a little MIS procedure or do you really have to go back and stabilize the joint more effectively? And so I don't know that there is any one way to skim this particular cat, but I think you've got to really understand what the problem is and address the problem for what it is. Don't do more than you need to and try to avoid doing too little and hiding from the real problem.

Is there anything else you think the audience should know or be looking forward to taking away from your session if they're in attendance?

Yeah, so I think it's super interesting because I am presenting, one thing I love about this particular session, it's not like a super academic session. It's not like you're doing, which I often am doing. I'm not doing a research history of the research and I'm not going through a lot of evidence-based medicine. It's really like an experiential type of lecture. And I literally am presenting on a patient who's been a patient in the last couple of years who has been the worst cascade of hammer toe problems that I've ever addressed. And it's one of those, if it could go wrong, it went wrong over and over and over again. And so I'm sort of at this stage of my career, I used to be the youngest person on the podium, and now I'm sort of moving towards one of the oldest, which I always feel young, but when I get up in the podium and I see all these talented young people around me.

I like sharing the bad experiences because we all, as surgeons go through it. And I think with experience, I can share some things that maybe younger people aren't as confident sharing or haven't walked into as much. So I feel very fortunate that I'm able to share a real bad thing that went for this patient in me, and I was very much front and center as the reason for it. I didn't do anything wrong, but things went wrong. And so I'm happy to be able to share that with the audience. And I think they can take away a lot of really important messages, and not just for hammer toes, but all of surgery of addressing problems head on and having good conversations with your patients and then trying to solve the problem in a collaborative way.

Thank you so much Dr. Weil for joining us today and for sharing your insights with us. We hope that you'll see the rest of our conference coverage from the ACFAS ASC on our website under conference coverage. And if you would like to see this and listen to other episodes of Podiatry Today Podcasts, be sure to go to podiatrytoday.com. SoundCloud, Apple Podcast, Spotify or your favorite podcast platforms. I'm Dr. Jennifer Spector, the Associate Editorial Director for Podiatry Today, and we're so grateful that you all joined us. We hope that we'll have you listen in next time.