Claw, hammer and mallet toes all involve some form of contracture (stiffness and deformity) of the joints of the involved toes. The cause is not always clear. It may result from an associated deformity of the big toe (crowding with a bunion deformity), from a dysfunction of the small muscles of the foot, wearing too small footwear, trauma or hereditary factors.
Often these toes cause no problems. Most toes with contractures, bony prominences and resultant corns (and occasionally ulcers) can be managed without surgery. Appearance is not a reason to operate. Simple orthotics with silicone pads, wearing bigger shoes with more box space and regular podiatry to abrade the calluses, can often manage the problem.
Indications for surgery
- Difficulty with daily activities and wearing shoes due to pain in toes.
- Significant pain and stiffness in the foot while walking.
- Rest and pain relief medication fail to control toe inflammation.
- Toe deformity- deformity of one toe leading to a deformity of another toe or crossover.
- Ongoing symptoms despite shoe modifications.
- Significant pain despite paracetamol and /or anti-inflammatory drugs.
As mentioned cosmetic appearance is not an indication for surgery. It is possible for the toe to become painful after surgery, even if it was not painful prior to surgery.
Peri-operative patient education
At the time of consultation, Dr Lane will give a full explanation the proposed surgery, recovery and risks involved. Educational leaflets supplied by the Australian Orthopaedic Association are also supplied for your information which cover a variety of surgical foot procedures. If there are any other concerns, the staff at Lake Kawana Specialist Centre are happy to take calls and if needed further consultation with Dr Lane is encouraged.
Often a combination of procedures are required (including bunion surgery of big toe to reduce crowding). There are a number of surgical options. Each address different underlying cause for the toe problem and for this reason may be used in various combinations. The aim of surgery is to address the imbalance of the toe joint – either due to soft tissue imbalance (tendon and ligaments) and / or bone-joint mal-alignment.
Extensor tendon lengthening
This is often performed with other surgery. An incision is made at the top of the foot over the tendon at the base of the affected toe. The tendon is lengthened and then sutured in the lengthened position.
Joint release or inter-phalangeal arthrodesis
Several surgical options are available depending on the severity of the contracture of the toe. All involve incision over the top of the toe. For less severe deformities a simple release of tight structures (usually ligament or capsule of contracted joint) and temporary pinning of the toe will straighten the toe preserving some motion at this joint and maintaining toe length. For more severe deformities, fusion of the inter-phalangeal joint of the toe is performed. This allows the toe to be safely straightened without subjecting the toe artery to excessive tension, which may compromise the blood supply to the toe. During this procedure, the actual knuckle joint is excised, opposing bone then pinned with stainless steel wire. This wire protrudes at the end of the toe and is covered with a small ball which remains in position for 6 weeks. At the end of this period the wire is simply removed in Dr Lane’s rooms.
An osteotomy is a cut in the bone to realign bone/joint with a view to correcting the overall toe deformity. Often it is used to help relocate a metatarsophalangeal joint which is either subluxed or dislocated. Usually an extensor tendon lengthening is required as well. Once the joint is realigned, the toe is then plantar flexed (pushed downwards) exposing the metatarsal head. A very fine saw is then used to cut the metatarsal approximately parallel with the sole of the foot. The metatarsal head is then allowed to slide and hence shorten. The osteotomy (bone) is then fixed with a screw. The osteotomy takes 6 weeks to heal and a post-operative surgical shoe is given to wear for 6 weeks to avoid weight bearing on the forefoot.
Anti-inflammatory drugs such as Feldene, Naprosyn, Indocid, Voltaren, Mobic and Celebrex should be stopped 5 days before surgery. These drugs increase the risk of bleeding. Aspirin or other blood thinning drug use prior surgery should be discussed with Dr Lane as this would depend on the patients underlying medical condition. The foot to be operated on should be free of cuts as this would increase the risk of infection following surgery. If you have damaged skin, your surgery will be postponed until healed.
Lesser toe surgery is a day procedure. The reception staff will give clear instructions when to attend the day hospital depending on your surgery time. You are advised to take your foot X-rays or scans, Medicare, DVA or private health care cards. Do not to eat or drink anything 6 hours prior to your surgery.
Once your details are taken at the admission desk:
- You will be admitted by the duty nurse and baseline observations taken.
- Theatre gown given to wear.
- The foot will be inspected by the nursing staff and anti-septic applied to the foot which is then covered with a sterile drape.
- The other leg will have a TED stocking applied to reduce the risk of thrombosis after surgery.
You will be taken from the day Hospital to the theatre complex by the nursing staff and then to the anaesthetic bay which is situated next to the operating room. There you will meet Dr Lane and the anaesthetist.
Foot surgery is usually performed under a general anaesthetic (when the patient is asleep) but can be done under a spinal or local nerve block with twilight sedation.
A single dose of intravenous antibiotics is usually given before surgery begins, to reduce the risk of post-operative infection.
When you are asleep in theatre, a tourniquet is applied above the ankle to give the surgeon a bloodless field to perform surgery. The skin is then prepped with an antiseptic solution and sterile drapes covers patient -leaving a window for the operating site.
The surgery time is dependent on the complexity of the surgery required to correct the problem. It usually takes between ½ (if only lesser toe involved) to 2 hours (if added procedures for toe re-alignments such as bunion surgery).
Once surgery is complete the wound is closed with sutures and local anaesthetic injected to aid pain relief after surgery. Then primapore and sterile dressings applied.
After surgery, you will be taken to the recovery room. Once you are adequately awake, observations normal, able to eat and drink, you will be discharged from hospital. You will require someone to take you home. A script for pain relief medication is given.
The patient will be given a surgical shoe to wear when walking and so usually able to walk immediately after the operation. Foot dressing should be kept dry and intact until review by Dr Lane. For the first few days following surgery, the patient is advised to spend most of the time with the foot elevated to reduce pain and swelling. Sutures are removed in Dr Lane’s rooms 10 to 14 days after surgery at the first post-operative visit.
Most patients can expect lasting improvement with surgery- reduction in pain and improvement in their toe deformity.
General risks associated with Anaesthetic (rare)
- Myocardial infarction (heart attack).
- Short term confusion.
Local complications associated with toe surgery (uncommon)
- Nerve damage (numbness, irritation or tingling).
- Persistent Pain.
- Failure of toes fusion and poor positioning.
- Deep venous thrombosis (rare)
- Recurrence of deformity may require corrective surgery
- Vascular compromise especially when correcting a severe deformity can occur and can result in partial or even complete loss of the toe (rare)
- Swelling and stiffness of toes
Patients with diabetes, pre-existing multiple medical conditions and smokers will have an increased risk of adverse complications.