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ARTHROPLASTY FOR HAMMERTOE CORRECTION
A corn on the top of the toe is usually a result of an enlarged bone at what is known as the head of the proximal phalanx. This is the longest of the three toe bones found in the smaller toes. (The big toe only has two bones).
Because the toe is bent at the level of the enlarged bone, it rubs against the top of the shoe and the end result is the formation of a corn.
Trimming corns away or changing the style shoe you wear may eliminate the corn, but if that does not work, then surgery should be considered.
In this procedure two incisions are made around the corn and the whole corn is removed. This is done because if you were to leave the corn, generally the tissue underneath the corn is fibrotic and would continue to be a source of discomfort, even with the removal of the underlying bone.
Once the wedge of skin is removed, the enlarged head of the proximal phalanx is identified and removed usually with a bone saw.
Because a piece of bone has been removed, the toe can now sit straight. The incision is closed and the toe lies flat. If you are wondering what happens to the space left from the removal of bone, it fills in with scar tissue and the toe will not end up "floppy". It should be noted, however, that if too much bone is removed, then the toe will flop around and even though the corn is gone, the end result is not considered satisfactory.
FLEXOR SET TENOTOMY FOR MALLET TOE
A mallet toe is basically a hammertoe that occurs at the distal (end) joint of the toe. See the first diagram below. A flexor set tenotomy is performed in cases where the mallet toe is a flexible deformity, meaning the end of the toe can be manually straightened (as opposed to a rigid mallet toe, where you cannot manually straighten the end of the toe).
In this procedure, the flexor tendon, or the tendon on the bottom of the toe is contracted (tight) and is thus causing the end of the toe to bend downward.
By incising (cutting) the tendon, it releases the tension on the end of the toe and the end bone straightens out. The toe is dressed in a splinted type dressing to keep the toe straight while it is going through the healing process.
MALLET TOE SURGERY
A mallet toe deformity is basically a hammertoe deformity occurring at the most distal (end) joint on the toe. The end of the toe becomes bent downward in a rigid fashion and cannot be bent upwards (straightened). The head of the middle phalanx (middle bone in toe) becomes more pronounced and enlarged over time primarily from shoe irritation. The end result is a painful corn over the bone and in many cases an accompanying bursitis.
In many instances the corn may become infected depending on a number of factors including degree of deformity, type of shoe worn, patients age and quality of circulation coming in to the toe.
In the more rigid deformity, first the corn is removed with two semi-elliptical incisions made around it. This is done for two reasons. One is to remove the corn, because over time the skin under the corn will become scarred and may continue to hurt even after surgery. Secondly, by removing a wedge of skin, when the skin is closed, the suturing actually bends the end of the toe back upwards in a straightened position.
The underlying enlarged head of the middle phalanx is then removed and the toe is closed. This procedure should result in a straightened toe.
This procedure may be performed under straight local anesthesia if necessary.
COMPLICATIONS OF HAMMERTOE SURGERY
Although hammertoe surgery is generally a safe, reasonably simple procedure, problems may arise. Some of the potential complications include the following:
Flail toe- In this situation, too much bone is removed usually from the head of the proximal phalanx resulting in a toe that is "floppy" meaning it flops around and has lost the rigidity normally seen in a toe. This can be of particular concern in fifth toe arthoplasties, where simple things like trying to put on a pair of socks becomes an issue because the toe bends backward since there is not enough bone to hold it in place.
Trying to wear flip flops or other open toe shoes can be a problem since the fifth toe will end up hanging over the side of the sole.
Swollen toes- Swelling immediately after surgery is to be expected, but for some people the swelling can become permanent. This seems to be particularly true for the second toe. I have often thought it is due to an obstruction in the lymphatic system which prevents drainage of fluid from the toe. In my patients, in all hammertoe surgery, I routinely keep the toe(s) wrapped in a compression dressing for weeks after surgery. With the addition of humidity in the summer, wrapping under compression can extend for two months or more.
Transfer of pain to adjacent toes- As I said earlier, when correcting a hammertoe, the surgeon has to take into account the adjacent toes. For example, if the painful toe is already shorter then the toes next to it, arthroplasties will further shorten the toe, possibly increasing pressure on the adjacent toe with the possibility of creating issues with that toe.
Toe stiffness- When a hammertoe is purposely fused at the level of the joint, there will be no motion within the toe. For most people that is not an issue. The only time it can be a problem is when the fused toe, because it is too straight, actually is longer than the adjacent toes. What usually happens in these cases is that a corn will eventually form at the end of fused toe because the stiff toe jams into the end of the shoe.
In almost all arthroplasties the toe will never bend at the level where the surgery was performed. This is a joint destructive procedure. Most of the soft tissue release procedures will allow for eventual bending of the toe, but most toes that have soft tissue procedures are of the flexible hammertoe deformity.
Surgical failure- Where not only is the toe not straight but perhaps even worse off then before surgery. For perspective purposes, surgical failure is a possibility in any surgery regardless of location. If the toe ends up being worse off, the only option here is to fuse the toe to the adjacent toe, a procedure most people do not want.
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