Hammertime!!

Hammertoes can be very painful and cause a lot of unnecessary problem when walking and in shoes. Hammertoes are when the ball of the foot joint or the metatarsal phalangeal joint become hyperextended. The next joint, which is the large bump you see on the top of the toe, the proximal interphalangeal joint become hyperflexed, leaving the joint at the end of the toe, the distal interphalangeal joint to become hyperextended as well. This happens typically due to genetic predisposition but wearing ill-fitting shoes can exacerbate the problem. What causes this is an imbalance between the tendons on top of the toe and tendons on bottom. These tendons play tug-o-war with each other and at times one of the tendons begins to win the battle. This creates the imbalance at the joint and subsequently the hammertoe develops. Sometimes patients, especially diabetics, develop ulcers or sores on the top of the toe or at the end of the toe. The problem here is that there isn’t much soft tissue covering the top or end of the toe and once an ulcer develops there becomes a very high chance that a bone infection may follow. Hammertoes and ulcers are a large contributor to toe amputations in diabetics.

What can be done?

Fixing a hammertoe is typically a very easy procedure. A lot depends on whether your hammertoe is flexible (meaning can you straighten the toe out) or rigid (meaning you can’t). It also depends on if you have sores or not. However, if you do have a sore, it is always best to have it checked out by a podiatrist before an infection occurs. Finally, depending on which toe has the hammertoe may determine the procedure your podiatrist chooses.

In my opinion there are four types of procedures that can be done for hammertoes.

#1 – Minimally Invasive Surgery
Minimally invasive surgery for hammertoes is my favorite, it involves less pain, less trauma to the tissues and a faster recovery vs. regular surgery. If your toe is rigid we typically use small stab incisions to cut the tendons on top and the bottom of the toe. We cut them in a very specific area to avoid retraction of the tendons. Over time these tendons can “heal” together so that no toe motion is lost. Next, we make a small stab incision over the middle bone of the toe (middle phalanx) and a small cut in the bone is made along the top of the bone. We also make 2 small bone cuts to allow the toe to return to normal position.

Together the bone cuts and the tendon releases, restore some of the natural forces and pulls on the toe as well as removes the hammertoe problem. This procedure can be done on any of the small toes.

If the toe is flexible, we typically only do the bone cuts noted above.

The other great thing about minimally invasive is it can be performed in office. This significantly reduces the costs associated with surgery as we cut out the hospital and anesthesia costs.

#2 Arthroplasty
This is one of the traditional surgeries used to fix hammertoes, more commonly used on the smallest two toes but can be used on any small toe. Here an incision is made over the top of the toe and the joint or knuckle that is sitting up high is identified. The top tendon here is cut to access the joint. Next, using a saw the end of the proximal phalanx is removed. This allows the toe to drop to a more natural position. The tendon is then repaired and the incision closed. The only fallback to this method is if the deforming forces in the tendons return so does the hammertoe.

#3 Arthrodesis
This procedure is better for rigid toes, following the same procedure as the arthroplasty, we simply use an implant (like a rod) that inserts into the proximal phalanx and middle phalanx. This holds the joint straight and when the joint fuses over time the hammertoe will not return due to the internal rod holding it still. The drawback here is a very stiff toe.
#4 Amputation

This is more of a last resort, but depending on your age and severity of the hammertoe, sometimes amputation of the toe is the easiest. It allows you to recover faster as there are no bone cuts. The toe is amputated at the ball of the foot joint. You simply have to wait for the incision to heal and you’re good to go.

Recovery

Recovery for all four procedures is very similar, we place you in a post-op shoe to protect the surgical site for 4-6 weeks. Once the site is healed, you are back in regular shoes and for the most part ready to resume non-high impact daily activities.

If you have hammertoes and they are causing you problems. Give us a call at (503) 668-5210 or visit our webpage at www.elitefaor.com.