Hammertoe Correction - Conservative and Surgical Approach

Introduction:

Hammertoe is a surgical corrective procedure to rectify hammertoe. Hammertoe is characterized by hammertoe appearance due to abnormal bends in one or more of the smaller toes, especially the second, third, and fourth toes. If conservative treatment like using appropriate footwear, application of orthotic devices, and toe-stretching exercises have failed, then surgical correction is recommended. If the flexibility of the toe is intact, corrective measures aim to redirect a tendon within the toe to straighten the joint. If the toe is rigid and fixed in a straight position, the surgeon may perform ligament and tendon cuts and remove a bone section. Post this, the toe alignment is made by using pins. The surgical correction aims to restore structural abnormality by straightening the toes and reducing pain and discomfort.

What Is a Hammertoe?

Hammertoe is a deformity occurring in the second, third, or fourth toes. A hammer like appearance is created due to a bend in the middle joint. During the initial days, there can be flexibility in the toes, but if they are not treated at an early stage, surgery may be required. The main cause of this condition is an imbalance in tendons, muscles, and ligaments that helps in the maintenance of proper toe alignment. It can be due to wearing improper footwear that does not fit well, high heel footwear, and narrow-toe boxes that exert high pressure on the toes. Hammertoe can cause swelling, redness of the toes, and inability to straighten the toes.

There can be difficulty in walking and corn and callus formation as the disease progresses. Footwear that are tapering towards the toe will exert pressure on the smaller toes, causing them to be bent. The bending results in friction between toes and shoe, which ultimately causes the formation of corns and calluses, which will worsen the existing condition. High heels push the foot downward, which will press the toes against the shoe and intensifies the pressure and toe curvature. As the disease worsens, two muscles become incapable of toe straightening. Other medical conditions causing the disease include structural abnormalities, nerve damage, arthritis, etc.

How Is a Hammertoe Managed?

Hammertoe can be corrected using surgical as well as non-surgical techniques. The surgeon will choose the appropriate technique for the correction of hammertoe based on the characteristics and severity of the abnormality. The surgical technique can involve the release or lengthening of the tight ligaments or tendons, excision of a small segment, realignment of the toe joint, and stabilizing the toe using implants, pins, or wires.

Nonsurgical Treatment: Hammertoe can be corrected by non-surgical techniques like:

1. Footwear Modifications: As hammertoe usually develops because of ill-fitting shoes, the doctor will recommend changes in footwear as the first line of management of hammertoe. Choosing a sandal or shoe that provides adequate toe space will help manage symptoms of hammertoe in the early stages. Also, it is important to avoid pin-pointed shoes, heels, and small footwear.

2. Orthotic Devices: Orthotic devices can be purchased in drug stores. Shoe inserts that will provide extra cushion and foot support. Sometimes the doctor may prescribe customized orthotic shoes. These will alter heel position and provide symptomatic relief from hammer toe.

3. Splinting or Stripping: This is done to realign the bent toe with the use of splints or small straps.

4. Corn and Callus Management: The physician might trim callus and corns formed around the affected joints in the feet. Specially designed pads are prescribed by the physicians that are employed to protect the corns and calluses from further irritation.

5. Cortisone Injections: Direct injection of cortisone on the inflamed tissues around the affected joints can help the inflammation and pain caused by hammertoe.

6. Medications: Anti-inflammatory medications like NSAIDs are prescribed, which include Ibuprofen, Aspirin, and Naproxen for the management of pain and inflammation.

Surgical Management: If the non-surgical methods are ineffective or if the condition is severe and cannot be treated by conservative approaches, surgery is usually recommended to treat hammertoe. There are two common types of surgery:

1. Arthroplasty: This procedure involves the removal of small sections of bone on both sides of the middle joint in the toe. This can uncurl and straighten the joint.

2. Arthrodesis: This is done in cases where hammertoe causes significant impairment leading to rigidity and stiffness of the affected toe. In this procedure, a fusion of a small joint in the toe is carried out to restore it to its normal position. Typically, a small pin is used to hold the joint in place while the toe heals. Though this surgery corrects the hammertoe, it limits the ability to bend the toe again.

3. Tendon Lengthening: If the toe joint is flexible, lengthening the tendons that cause joint imbalance is done, which can help manage hammertoe.

4. Tendon Transfer: The tendons from the bottom are transferred to the top of the toe, which aid in pulling the joint to a straight position.

What to Expect After Surgical Correction of Hammertoe?

There can be some swelling and redness at the surgical site for four to six weeks. Recovery from surgical correction takes a few weeks, although swelling may last up to a year. The doctor may prescribe a special shoe to help balance and walk easier while the toe heals. It is crucial to keep weight off the feet and use crutches or walk with the support of a walker during recovery. The operated foot should be kept elevated for a few weeks after the procedure to prevent swelling and pressure on the toe to encourage healing. Driving is also not advised during the recovery period. Exercise can help faster healing and speedy recovery.

What Are the Risks Associated With Hammertoe Correction?

Like every surgery, hammertoe correction surgery has a few risks, like the toe being unstable as a result of surgical manipulation of ligaments, tendons, and bones and recurrence of hammertoe which may require additional surgery. In the case of surgeries involving fusion, there is a risk of bone not healing properly.

Conclusion:

Hammertoe can be best prevented by the use of properly fitted shoes and avoiding high heels or improper footwear. Surgery involving the repositioning of the toe can help in providing balance and improve symptoms of hammertoe. Surgical management of the hammer toe has provided relief in 80 to 90 % of cases. About less than 5 % of patients complain of recurrence of this condition and need a second surgery.