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?


User Contributions:

Loretta Battistella
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Mar 30, 2006 @ 6:18 pm
I am due to have toe surgery in a couple of weeks. I have to have two toes shortened as my third toe is extremely painful and tends to lean t the right causing pain and also pain in the ball of the foot. I had my fourth toe operated on 30 odd years ago and it seems that too much bone was removed and that toe has shrunk. The specialist informed me that he may have to fuse toe two and three, does that mean I will not be able to walk properly. I'm very concerned.
geoff sleight
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May 10, 2006 @ 11:23 pm
IAM DUE TO HAVE OPERATION IN THREE WEEKS THE SURGOEON IS DR NICOLE LEEKS I HAVE BOTH FEET TO BE DONE ALL MY TOES EXCEPT THE BIG TOES I UNDERSTAND I WILL BE OFF WORK FOR UP TO 7 WEEKS I HAVE CLAWED TOES THEY DO GIVE ME PROBLEMS IAM 58 YEARS OLD CAN YOU TELL ME HOW LONG CAN I EXPECT OFF WORK TILL I CAN WHERE A SAFETY BOOT AS I WORK AT A MINE IN WEST AUSTRALIA HAVE BEAN TOLD THEY WILL BE STRAIGHTEND WHERE PINS WILL BE INSERTED 7 DAYS IN HOSPITAL WEEK IN BED WILL MY FEET BE ELEVATED IN HOSPITAL HOW DO I GO TO TOILET ????
Valerie Kemp
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Mar 27, 2008 @ 12:12 pm
Could one say that hammer toes can develop (apart from badly fitting shoes) as a person gets older. In otherwords can it be an age-related condition.
Maria
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Apr 21, 2008 @ 9:09 am
It is been 2 weeks I had my bunion and hammer toes surgery. My foot is responding very well and I am very happy with my doctor. I am 34 years old and I decided to fix this problem now, because it gets worst as person gets older. My doctor put screws in my toes wich will be removed in 3 months. It is a lot of time of recovery but it worths it.
Marcelo Pinheiro
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Apr 25, 2008 @ 5:05 am
Yes I do have a big hammer toe on my right foot and lately I have been in pain. I am male 36 years old and I don't have health insurance by any chance is there a clinic or a hospital where they can do it for free or charity in NYC area? THanks Marcelo my email housepainternyc@yahoo.com
Betty
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May 21, 2008 @ 6:18 pm
To Loretta Battistella:
I have had the fourth and fifth toe treated for hammer toe repair and also had the fourth metatarsal bone moved back towards my ankle and let me tell you. This was in August of 2007 and it is now May 2008 and I am still in pain. I was diagnosed for hammer toes and the bone being moved. It was suppose to ease the pain from the pressure of the bone pushing up towards my bottom of my foot. I went to see a Orthopaedic Specialist and he claims that I have Morton's Nueroma which is causing all the burning I am having in the bottom of my foot. I orginally went in August for clicking and popping in my fourth toe and the metatarsal bone causing a callus on the bottom of my foot that hurt. I didn't have to have the bone moved. There is a procedure to fix that without moving the bone. It is a malignent tumor that develops and casues the pain. As far as the Neuroma, That is a enlarged neve that can be cut out. It causes burning, clicking, popping and numbing sensation in the toes and feet. I am telling you to investigate and find out everything you can and most of all don't go to a foot doctor. They are not qualified to do the job. I had a tendon cut to release the pressure as the toe was starting to curl under.
Now the toe is inflamed and sore and I believe it is due to the Neuroma. I made a mistake by going to the foot doctor. Go to a Orthopaedic Specialist MD
A foot doctor is not a MD. They are only a foot doctor. Education is the difference. BELIEVE ME!
GOOD LUCK,
Betty
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May 21, 2008 @ 6:18 pm
MARCELO,
You can go to a hospital in your area and they will do a finacial screening to see if you qualify for the surgery to get it done for free or within reason depending on your income. I have tried. I would not give them all the information they are asking for. Like: how may cars you have, checking account number, life insurance policy, savings account number etc. They don't need to know everything about you. They will want to see I think your last 2 or 3 check stubs. I have been there, I know. I have been through alot with my foot now going on 10 months. I have tried every avenue there is and still trying. I am also without insurance and if it won't so high I could afford it.
Good Luck, Betty
trudi ludlow
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Feb 23, 2009 @ 8:08 am
My son's big toe does not straighten and is at a 90 degree angle. He has a big lump on the top of it. If this was on the side of his toe I would think it was a bunion. I have read many articles on claw toe, but they all say that this affects all the toes apart from the big toe. Can you give me an idea what this condition could be please. He does have a high arch. He gets a lot of cramp. He is 14 and plays Rugby
UEHC
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Jul 22, 2009 @ 6:06 am
My fourth and fifth toes are kind of curved and I developed corns and pain on the upper knuckles--so hard to find shoes. A podiatrist cut off the little bony parts and it looked like I would have normal looking feet. He told me I'd be wearing high heels in a month or two. Well, next week is the one-year anniversary. I haven't worn closed shoes except for cloth tennis shoes (4 times)in all this time. Good thing I live in Arizona. I wrap them every day to keep down the swelling. I've gained 13 pounds from not being able to move. Now I can't even ear one-inch heels without throwing out my back. I'm 46 and feel 76. This was one of the top-three worst decisions of my entire life. Don't do it unless you have no choice whatsoever.
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Sep 16, 2010 @ 6:18 pm
hi, i am Mohamed from Egypt , i want to get information about how you can helb me about my leg , i have in my left foot 2 of my middle toes are sticking together and are big more and more than their normal size.
i can send you a photo of my leg and all documents you need to know if you can isolate them and make beautification surgery for them to be like normal or something like that ,because doctors in Egypt said to you must sacrifice of one of this fingers in the surgery , said to me you must sacrifice of one of this fingers in the surgery to make the beautification surgery.

please send me to be in contact with you , thank
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Oct 9, 2010 @ 8:20 pm
Hello, i am a 23 year old female.
I am trying to decide weather or not to have surgery done on my toes. The 3 middle toes on both my feet are hammer toes, It's hereditary. Some days they are quite painful and it hurts to walk. Anyone who has had this surgery done would you recommend it for someone my age?
I am worried what the long term effects could be down the road?
If anyone could give me some feedback on this to help me make my final decision on what to have done i would really appreciate it.
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Oct 31, 2010 @ 5:17 pm
hello, i am 13 years old and i think i have mallet toe on my third toes (both feet). i am going to the doctors in 2 weeks and am very nervous. I have never had surgery of any type but i keep getting blisters everytime i walk for about an hour. I've always found it hard to find shoes that are comfy but i have never related it to this, i thought it may be because i dance and have to wear tight jazz shoes but to be honest its any shoes. Im very shy of getting my feet out in public aswell and try to straighten them out when people can see them.
I was just wondering if anyone else has had mallet toe fixed and could give me some details as no one has posted anything about this deformality. thanks .
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Nov 10, 2010 @ 12:00 am
I need a name of a doctor in Colombus OH is there any list of doctors?
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Feb 11, 2011 @ 1:13 pm
I have had 3 surgery for pain in my middle toe. The lst was an orthopaedic doctor to remove a Nueroma. It wouldn't heal and he wasn't concerned so I went to a foot doctor who reopened, removed (he said) additional Nueroma missed during first surgery. As it healed the middle toe pulled up and over to toward the big toe and the pain was worse. Went to another foot doctore who reopened again (he said) he loosened the tendon so the toe would relax. It still will not bend down correctly at the joint attached to the foot. I didnt' have any problems with this to start with until the firt doctor (orthopaedic) went in. Now the pain is horrible even when I am not walking on it. My last doctor keep saying it is a nerve and has given me 2 injections to kill the nerve and each time it gets worse. The pain is now running under the ball and down the center of my foot. Anybody got any ideas as to the cause and does anyone know a really really really good doctor in Florida. Thanks.
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Mar 7, 2011 @ 2:14 pm
I have 2 hammer toes that need to be repaired,how can they be fixed without surgery.Also can they be repaired in rhode island.
Estela
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Jan 9, 2012 @ 3:15 pm
I have the four toe is't smallet in my right feet I need a surgery in my toe i want to to be normal last month i operated my bunion in my right feet but they can't operate my toe this the reason I want you to operated and fixed my toe I love to put sandals
monnie richmond
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Feb 25, 2012 @ 6:06 am
Does Dow Corning or other manufactures make implants for removal of cartilage of toe in Huffman Proucder?
TINA
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Jul 28, 2012 @ 10:10 am
MY HUSBAND HAD TOE SURGERY 04-24-2011. THE SURGERY WENT BAD AND HE CAN NOT WALK BUT 15 MINS THEN HIS FOOT GETS BIG AND RED AND A RED LINE RUN'S UP HIS WHOLE LEG . HE'S NOW BACK IN THE HOSPITAL 07-28-2012. HE HAS TO HAVE I.V IN AGINE FOR INFECTION. THIS INFECTION KEEPS COMEING BACK STIL 15 MONTHS LATER,NOW THE DOCTER SAYS HE NEEDS TO REMOVE 1 TOE AND THE INFECTION WILL BE GONE GOOD. I WISH HE NEVER HAD THIS SURGERY.

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