Common Lesser Toe Problems - Surgical Options
Claw, Hammer and Mallet Toes
Claw, hammer and mallet toes all involve a degree of contracture (stiffness and "deformity") of the joints
of the involved toe. The cause is not always clear. It may result from dysfunction of the small muscles of
the foot, an associated deformity of the big toe (e.g. crowding with a bunion deformity), by forcing the
toes into shoes that are too small, trauma or hereditary factors. The joints involved become prominent and
painful rubbing over the top of the toes occurs with shoe-wear. In many cases these toes cause no problem
at all, however this is not always the case.
Corns are thickened skin caused by friction between bony prominences or bone & the shoe.
Friction between the shoe and a bony prominence causes the skin to thicken and form a corn or a callosity
(occasionally even an ulcer) on the knuckle of the toe or at its tip. The bony prominence is usually caused
by a contracture of one of the toe knuckle joints. Occasionally the affected toe may cross over or under
neighbouring toes, which can cause the problem. An associated contracture of the more proximal
metatarso-phalangeal joint will result in a prominence of the metatarsal head on the sole of the foot with
callosity forming beneath the metatarsal head (ball of the foot).
Sometimes the bony prominences or condyles of the toes simply become prominent rather than the joints
being contracted (bent). They may rub on each other or on the shoe. When rubbed by the shoe the callous
formed is "hard" but when toes rub together the skin often macerates and causes an extremely painful
"soft corn" or ulcer.
Most toes with contractures and corns can be managed without surgery. Appearance is not a reason
to operate
Many people suffer only minor complaints, and not all need aggressive treatment. Furthermore sometimes
a very simple modification of shoes can be of tremendous benefit. Primarily, this means ensuring that
there is enough room in the toe box of the shoe. Further help may be gained by the use of simple pads
(usually silicone sleeves are the best) and the use of simple abrasion of the callosities on a regular basis.
These techniques do not always work and particularly if there is recurrent ulceration then operative
intervention may be required.
Often a combination of procedures is required - similarly deformity of the great toe needs to be
corrected to reduce both crowding & hence allowing a lasting result. There are a number of surgical
options used to correct lesser toe problems. Each addresses a different underlying cause for the toe
problem and for this reason they may be used in various combinations
What follows is simply an overview of a few of the more frequently performed operations. In any case it
is important that if there is a significant deformity of the foot contributing to lesser toe pathology (most
frequently hallux valgus - a bunion causing crowding & increased stress), this needs to be addressed
simultaneously. If a significant underlying cause for deformity remains, a recurrence is likely.
Extensor tendon lengthening
This operation is often performed in association with other surgery and is performed under a local
anaesthetic ankle block. A dorsal (on the top of the foot) forefoot incision is made over the tendon at the
base of the affected toe. The tendon is lengthened and the tendon is sutured in the lengthened position.
Joint release or inter-phalangeal arthrodesis.
Depending on the severity of the contracture of the toe joint several treatment options are available. For
less severe deformities a simple release of tight structures (usually ligaments and capsule of the 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 a fusion of the interphalangeal joints of the toes is performed. In this
procedure the knuckle joint is actually excised. This allows for the toe to be safely straightened without
subjecting the toe arteries to excessive tension, which may compromise the blood supply of the toe.
Either procedure is performed through the dorsum (top) of the toe. A stainless steel wire is used to pin the
toe straight and protrudes from the end of the toe for a period of 4 to 6 weeks. At the end of this time the
wire is simply removed in the clinic.
Weil Osteotomy
This procedure allows for realignment and shortening of a metatarsal bone. Often it is used to help
relocate a metatarso-phalangeal joint, which is either subluxed or dislocated (out of joint). Typically an
extensor tendon lengthening is needed as well. The joint is then opened through the same incision and
often the capsule / ligaments are released. Once realignment is achieved the toe is plantar flexed (pushed
downward) 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 then allowed to slide and hence, shorten. The
osteotomy (bone) is fixed rigidly with a screw, This gives a stable osteotomy and the patient is able to
walk on the foot in a rigid soled post operative shoe immediately after the surgery. The osteotomy takes
approximately 6 weeks to heal and during this time the postoperative shoe must be worn at all times while
walking.
PERI-OPERATIVE PROGRESSION AND POTENTIAL PROBLEMS
Surgery is typically performed under ankle block as a day case procedure.
Lesser toe surgery is routinely performed under a local anaesthetic ankle block. In combination with a
rigid sole post-operative shoe the patient is usually able to walk on the operative foot immediately after
the operation. The first five to ten days should be spent with the foot elevated for most of the time to
decrease swelling and pain. Sutures are generally removed approximately 2 weeks after surgery at the first
postoperative visit. When K-wires are used for temporary fixation their removal is typically straight
forward, and is very similar to removal of sutures as far as the patient is concerned.
Recovery varies, taking longer with more extensive procedures & can take up to one year.
After the immediate postoperative phase walking becomes progressively easier. Recovery very varies
according to the extent of the procedure and from person to person. Usually the postoperative shoe is
required for a period of between four to six weeks after the operation. After this time capacious shoes can
usually be worn for a further four to six weeks. Postoperative ache, stiffness and swelling usually settle
over 3 months although some symptoms persist for six to twelve months. Lesser toe surgery is by no
means "small" surgery. At about one year, approximately one in ten lesser toes requires further surgical
adjustment.
Most patients can expect lasting improvement with surgery but some are made worse.
Although most patients report a successful outcome following lesser toe surgery not all patients are happy
following surgery. Common problems that may be encountered include persistent toe swelling and
stiffness and in some patients, persistent pain. Other potential problems include infection, delayed
wound healing, nerve injury (e.g. numbness, irritation or tingling) and recurrence of deformity.
Occasionally bone healing is delayed, fails or is poorly positioned. Recurrence of deformity may require
revision surgery. Although rare, vascular compromise of the toe can occur especially when correction of
severe deformities is undertaken. This can result in partial or even complete loss of the toe.
However, most patients expereice is that this surgery alleviates pain and allows for easier fitting of
shoewear.
