Hammer, claw, and mallet toe surgery

Definition

Hammer, claw, and mallet toe surgery refers to a series of surgical procedures performed to correct deformed toes.

Purpose

There are three main forms of toe abnormalities in the human foot: hammer toes, claw toes, and mallet toes. A hammer toe, also called contracted toe, bone spur, rotated toe, or deformed toe, is a toe curled as the result of a bend in the middle joint. It may be either flexible or rigid, and may affect any of the four smaller toes. The joints in the toe buckle due to tightening of the ligaments and tendons, which points the toe upward at an angle. The patient's shoes then put pressure on the prominent portion of the toe, leading to inflammation, bursitis, corns, and calluses. Mallet toes and claw toes are similar to hammer toes, except that different joints on the toe are affected. The joint at the end of the toe buckles in a mallet toe, while a claw toe involves abnormal positions of all three joints in the toe.

Toe deformities are caused by a variety of factors:

• Genetic. All three toe deformities may be hereditary.
• Poorly fitted shoes. Claw toes are usually the result of wearing shoes that are too short. Many people have second toes that are longer than their big toes; if they wear shoes sized to fit the big toe, the second toe has to bend to fit into the shoe. High-heeled shoes with pointed toes are also a major cause of claw toes.
• Bunions. A bunion is an abnormal prominence of the first joint of the big toe that pushes the toe sideways toward the smaller toes. Hammer toes often develop together with bunion deformities, and they are often treated together.
• Flat feet. This condition is due to poor biomechanics of the foot and may lead to hammer toes.
• Highly arched feet.
• Rheumatoid arthritis.
• Tendon imbalance. When the foot cannot function normally, the tendons may stretch or tighten to compensate and lead to toe deformities.
• Traumatic injuries of the toes.

When the toe deformity is painful or permanent, surgical repair is performed to relieve pain, correct the problem, and provide a stable, functional toe.

Demographics

As of 2002, the incidence of claw and hammer toe deformities ranges from 2–20% of the population in the United States, with the frequency gradually increasing in the older age groups. Claw and hammer toes are most often seen in patients in the seventh and eight decades of life. Women are affected four to five times more often than men. Little is known about the incidence of these deformities among people who usually wear sandals or go barefoot.

Description

Some of the most common surgical procedures used to repair hammer, claw, and mallet toes include:

• Tenoplasty and capsulotomy. These procedures release or lengthen tightened tendons and ligaments that have caused the toe joints to contract. In some patients with flexible hammer toes, the toe straightens out after these soft tissue structures are lengthened or relaxed.
• Tendon transfer. This procedure is used to correct a flexible hammer toe deformity. It involves the repositioning of a tendon to straighten the toe.
• Bone arthroplasty . In this procedure, the surgeon removes some bone and cartilage to correct the toe deformity. A small segment of bone is removed at the joint to eliminate pressure on the toe, relieve pain, and straighten the toe. The tendons and ligaments surrounding the joint may also be reconstructed.
• Derotation arthroplasty. In this technique, the surgeon removes a small wedge of skin and realigns the deformed toe. The surgeon may also remove a small section of bone, and repair tendons and ligaments if necessary.
• Implant arthroplasty. In this procedure, the surgeon inserts a silicone rubber or metal implant specially designed for the toe to replace the gliding surfaces of the joint and act as a joint spacer.

Diagnosis/Preparation

Patients usually consult a doctor about toe deformities because of pain or discomfort in the foot when walking or running. The physician takes several factors into consideration when examining a patient who may require surgery to correct a toe deformity. Some surgical procedures require only small amounts of cutting or tissue removal while others require extensive dissection. The blood supply in the affected toe is an important factor in planning surgery. It determines not only whether the toe will heal fully but also whether the surgeon can perform more than one procedure on the toe. In addition to a visual examination of the patient's foot, the doctor will ask the patient to walk back and forth in the office or hallway in order to evaluate the patient's gait (habitual pattern of walking). This part of the office examination allows the doctor to identify static or dynamic forces that may be causing the toe deformity. Imaging tests are also performed, usually x-ray studies.

If the doctor considers it necessary to rule out systemic disorders, he or she may order the following laboratory tests: a fasting glucose test to evaluate or rule out diabetes, and a sedimentation rate test to evaluate the possibility of an underlying infection in the foot.

Before surgery, the patient receives an appropriate local anesthetic, and the foot is cleansed and draped.

Aftercare

The patient can expect moderate swelling, stiffness and limited mobility in the operated foot following toe surgery, sometimes for as long as eight to 12 weeks. Patients are advised to keep the operated foot elevated above heart level and apply ice packs to reduce swelling during the first few days after surgery. Many patients are able to walk immediately after the operation, although the podiatric surgeon may restrict any such activity for at least 24 hours. Crutches or walkers are not usually needed. There is no cast on the foot, but only a soft gauze dressing. Wearing a splint for the first two to four weeks after surgery is usually recommended. Special surgical shoes are also available to protect the foot and help to redistribute the patient's body weight. If the surgeon has used sutures, they must be kept dry until they are removed, usually seven to 10 days after the operation.

The patient's physician may also suggest exercises to be done at home or at work to strengthen the toe muscles. These exercises may include picking up marbles with the toes and stretching the toe muscles.

Risks

Risks associated with hammer, claw, and mallet toe surgery include:

• swelling of the toes for one to six months following surgery
• recurrence of the deformity
• infection
• persistent pain and discomfort
• nerve injury

Normal results

All corrective toe procedures usually have good outcomes in relieving pain and improving toe mobility. They restore appropriate toe length and anatomy while realigning and stabilizing the joints in the foot.

Morbidity and mortality rates

There are no reported cases of death following corrective surgery on the toes.

Alternatives

Conservative treatments may be tried by patients with minor discomfort or less serious toe deformities. These treatments include:

• trimming or wearing protective padding on corns and calluses
• wearing supportive custom-made plastic or leather shoe inserts (orthotics) to help relieve pressure on toe deformities. Orthotics allow the toes and major joints of the foot to function more efficiently
• using splints or small straps to realign the affected toe
• wearing shoes with a wider toe box
• injecting anti-inflammatory medications to relieve pain and inflammation

See also Arthroplasty .

Resources

BOOKS

Adelaar, R. S., and R. B. Anderson, eds. Disorders of the Great Toe . Rosemont, IL: American Academy of Orthopaedic Surgeons, 1997.

Holmes, G. B. Surgical Approaches to the Foot and Ankle . New York: McGraw-Hill, 1994.

Marcinko, D. E. Medical and Surgical Therapeutics of Foot and Ankle . Baltimore: Williams & Wilkins, 1992.

PERIODICALS

American College of Foot and Ankle Surgeons. "Hammer Toe Syndrome." Journal of Foot and Ankle Surgery 38 (March-April 1999): 166-178.

Coughlin, M. J., J. Dorris, J, and E. Polk. "Operative Repair of the Fixed Hammertoe Deformity." Foot Ankle International 21 (February 2000): 94-104.

Harmonson, J. K., and L. B. Harkless. "Operative Procedures for the Correction of Hammertoe, Claw Toe, and Mallet Toe: A Literature Review." Clinical Podiatric Medical Surgery 13 (April 1996): 211-220.

Hennessy, M. S., and T. S. Saxby. "Traumatic Mallet Toe of the Hallux: A Case Report. A Thirty-Year Follow-Up." Foot Ankle International 22 (December 2001): 977-978.

Miller, S. J. "Hammer Toe Correction by Arthrodesis of the Proximal Interphalangeal Joint Using a Cortical Bone Allograft Pin." Journal of the American Podiatric Medical Association 92 (November-December 2002): 563-569.

"What is a Hammer Toe, and What Causes It?" Mayo Clinic Health Letter 20 (July 2002): 8.

ORGANIZATIONS

American Academy of Orthopaedic Surgeons (AAOS). 6300 North River Road, Rosemont, Illinois 60018-4262. (847) 823-7186. http://www.aaos.org

American College of Foot and Ankle Surgeons (ACFAS). 515 Busse Highway, Park Ridge, IL, 60068. (847) 292-2237 or (800) 421-2237. http://www.cmeonline.com/index.html

American Podiatric Medical Association (APMA). 9312 Old Georgetown Road, Bethesda, MD, 20814. (301) 571-9200 or (800) ASK-APMA. http://www.apma.org .

OTHER

ACFAS. Digital Disorders and Treatments . http://www.acfas.org/brdigdis.html .

Foot Pain and Podiatry Online. Hammertoe Deformity . http://www.footpain.org/hammertoes.html .

OhioHealth. Hammertoe and Mallet Toe . <www.ohiohealth.com/healthreference/reference/E655C4AD-F921-4C63- B76434A5D565643.htm?category=diseases> .

Monique Laberge, Ph.D.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Corrective toe surgery is performed by experienced podiatric surgeons, who are physicians who specialize in foot and ankle surgery. Patients who are otherwise healthy usually have toe surgery on an outpatient basis at the surgeon's office or in an ambulatory surgery center. The procedures are usually performed under local anesthesia or with intravenous sedatives administered by trained staff.

QUESTIONS TO ASK THE DOCTOR

• What can I do to prevent the deformity from recurring after surgery?
• What are the chances that the toe will be completely corrected?
• How long will it take to recover from the surgery?
• What specific techniques do you use?
• How many corrective toe procedures do you perform each year?