Hammertoe correction is a therapeutic foot surgery procedure used to correct the most common deformity (malposition) of the toe joints, the hammertoe. Hammertoe, also known as digitus malleus, is characterized by permanent claw-like flexion (bending) of a toe. This clinical presentation results from nonphysiologic extension (stretching) of the metatarsophalangeal joints (MTP; middle toe joint/basal joints between the metatarsals and metatarsophalangeals) with concomitant hyperflexion (excessive flexion) of the proximal interphalangeal joints (PIP; anterior toe end joint/joints between the phalanges of the toes) and hyperextension (excessive extension) of the distal interphalangeal joints (DIP; posterior toe end joint). Hammertoe most commonly occurs on the second toe. A distinction is made between a fixed and a flexible hammer toe. The classification is based on the degree of mobility of the affected toe. Furthermore, it should be noted that not only one toe can be affected, but also the other toes. Since the extent of hammertoe can vary, in addition to the rough division into a flexible and fixed hammertoe are also divided into different degrees of severity. In the presence of a hammer toe, a distinction must therefore be made as to whether the toe deformity is strongly contracted (permanently shortened) or can be easily redressed (the physiological starting position can be achieved). Furthermore, it should be noted that the hammer toe is usually acquired and does not exist from birth. The consequence of this deformity is, on the one hand, an altered load and balance of the affected foot, so that further lighter deformities can arise from this. On the other hand, the presence of the deformity can also cause redness or a clavus (or clavus; synonyms: hen’s eye, crow’s eye, light thorn). Moreover, the presence of a hammer toe can lead to pain, so that surgical intervention often becomes unavoidable. However, before it can be decided whether the present hammer toe should be treated conservatively (without surgical intervention) or surgically, a detailed examination of the patient must take place. Here, it is necessary to examine the affected patient both sitting and standing in order to be able to directly determine, when manipulating the joints, whether the hammer toe is fixed or flexible and to what extent the expression changes under different conditions. The classification of hammertoe is important due to the fact that the selection of treatment options is directly dependent on the mobility of the toe joints. Furthermore, it is indispensable to perform an X-ray examination, as this is the only way to confirm the diagnosis. No surgical intervention should be performed without radiographic examination.
Indications (areas of application)
- In the case of a present hammer toe with accompanying pain – due to the pain, the affected patient adopts a slow walk to reduce pain, which, however, results in other compartments of the musculoskeletal system being subjected to non-physiological stress or overload, respectively, so that other deformities may develop in addition to the hammer toe.
- In the case of an existing hammer toe with increased risk of falling – due to the progressive strengthening of the hammer toe with increasing age, especially older patients are often at risk of falling, so that surgery could reduce the risk of this.
Contraindications
- Skin infections in the surgical area
- Thrombosis patients
Before surgery
- Because surgical treatment of hammertoe is performed under either general or spinal anesthesia, the patient should remain fasting the evening before the procedure, although exceptions may be made in individual cases.
- In many cases, medications that inhibit blood clotting, such as acetylsalicylic acid (ASA), must be discontinued prior to surgery.
- Furthermore, prior to surgery, X-ray diagnostics must be used to determine which conservative or surgical procedure is suitable as a therapeutic measure and thus recommended.
The procedures
Conservative therapy for hammer toe:
- In the majority of cases, conservative therapy is not indicated for a present hammer toe.Failure to perform surgical intervention should only be considered if the deformity is a mild hammertoe that is judged to be completely flexible on examination.
- To curb the progression of the defect, the patient should switch to open-toed footwear or a so-called orthosis that shifts the affected joints plantar (toward the sole of the foot).
- An additional positive effect can be achieved through the use of physical therapy. With the help of stretching exercises and massage of the toe joints, if necessary, can increase the likelihood of slowing down or even inhibiting (blocking) the progression (advancement) of symptoms.
- Bandages, rein dressings, and night splints are also thought to reduce overall patient suffering. However, even with consistent conservative treatments, it is not possible to achieve permanent correction. Surgical intervention is essential for this goal. Even in the early stages of deformity, physical measures can not permanently reduce the deterioration of the disease.
Surgical treatment options for hammertoe:
The primary goal of surgical intervention is the permanent correction of the toe deformity, as well as the removal of the stiffness and the ongoing reduction or elimination of pain caused by the existing hammer toe. In order to achieve this, there is the possibility to perform a relief of the passive tendon tension, which is based on the shortening of the bone distance. Depending on the indicated therapy, there are various surgical techniques and therapeutic options, the selection of which can be correctly performed by the treating physician only if an informative diagnosis is available. Before the correction of the deformity can take place, the patient must be anesthetized. The surgical procedure can be performed under general anesthesia or after spinal anesthesia. If the deformity at hand is still a flexible hammer toe that can still be straightened by hand, the shortened tendon and capsule of the toe joint should be cut. Subsequently, the surgically cut tendon is lengthened and relocated to the place of origin, so that this procedure is a joint-preserving operation. It is also possible to correct the existing deformity by a joint-preserving tendon redirection operation, so that subsequently the joint is not manipulated. However, if a fixed hammer toe is present, the deformed toes also cannot be passively guided into an extension position by reducing the adjacent tissue (no “straightening” is possible). Regaining flexibility in the affected toe is possible through a more extensive procedure in which passive tendon tension is relevantly reduced by shortening the bony distance.
The surgical procedures
- Hohmann surgery – this surgical method is a resection arthroplasty in which the head of the metatarsophalangeal joint is removed through a small incision. Following this step, the shortened flexor tendon is lengthened by manual correction. In most cases, resection (removal) of the upwardly protruding head of the affected bone is performed so that the existing restrictions can be eliminated. However, there may also be a need for partial removal of the capsule of the metatarsophalangeal joint. In general, the application (administration) of a local anesthetic (local anesthesia) is completely sufficient for performing this procedure. In order to stabilize the operated area after the surgery, a bandage or wire is used for about two weeks. Furthermore, after the operation, the patient should be encouraged to use additional orthotics to improve posture and stability. Normally, prolonged unloading or resting of the foot is not necessary, and may even be contraindicated (not advisable). Already after two weeks, a physiological load is possible.
- Operation according to Weil – this surgical method represents an osteotomy procedure in which a correction of the present deformity can be made by a joint-preserving displacement of the metatarsal bones. In parallel, the surgeon performs extensor tendon lengthening and capsular release. Furthermore, stabilization of the joints is achieved by additional mini-screws.After the treatment is completed, it is not necessary to remove the implanted screws. The procedure is of particular importance in the treatment of the first toe. In contrast to the operation according to Hohmann, the procedure according to Weil is used relatively rarely.
- Flexor tendon redirection – in this procedure, an overall adequate position correction is achieved by means of joint-preserving tendon redirection surgery, so that the flexibility of the affected toe can be significantly improved. Furthermore, the direction of tendon pull is changed during this procedure so that the physiological condition is achieved. Moreover, no further conservative therapy measures are necessary for stabilization parallel to the operation. The choice of this procedure should always be made on an individual basis and after assessment of x-rays. The suitability for a surgical procedure depends, among other things, on the age of the patient and the nature of the complaints.
After surgery
- Pain – as anesthesia (numbing) progressively wears off after surgery, pain may increase significantly as the procedure progresses, so taking an analgesic (pain-relieving medication), preferably a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen, is indicated. The substance to be taken and the dosage are selected by the attending physician.
- Immobilize the affected foot – to reduce swelling and improve healing, the operated leg or foot should be spared. However, all usable joints should be moved to avoid further consequential damage.
Possible complications
- Bone or joint infections – surgical procedures on the skeletal system are always associated with a risk of infection.
- Nerve lesions – due to the surgical area, there is a possibility that an adjacent nerve may be affected by the surgical intervention.
- Anesthesia – the procedure is performed under general anesthesia or after performing spinal anesthesia, resulting in different risks. General anesthesia can cause nausea (nausea) and vomiting, dental damage, and possibly cardiac arrhythmias, among others. Circulatory instability is also a feared complication of general anesthesia. Nevertheless, general anesthesia is considered a procedure with few complications. Spinal anesthesia is also relatively low in complications, but complications can occur with this method as well. Injury to tissue, such as nerve fibers, could lead to a long-lasting impairment of quality of life.
