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UpgradeClaw toes are flexion deformity of the PIP joints and hyperextension of the MTP joints. Hammertoes are flexion deformity of the PIP joints. Mallet toes are flexion deformity of DIP joints.
The term hammer toe is used when a lesser toe appears bent. When it can be straightened we call it flexible and if not able to then we call it fixed. Usually one or two toes will be affected. These look worse on standing. The causes maybe due to subtle muscular imbalance, longer lengths of the lesser metatarsals especially the second, poorly fitting shoes and gradual deviation of the first toe otherwise called as bunion in lay terms.
Claw toes appear to look the same as hammer toes but it is a term used when all lesser toes are affected and usually have a background neuromuscular cause. These too can be either flexible or fixed. Similar causes as above including poorly fitting shoes, overcrowded toes and the background neurological condition create these deformities and can cause progression.
Common complaints are of pain, redness or corns on top of the bent toe especially after standing and working all day in shoes. Also one can develop an end corn at the tip of the bent toe just below the nail. Sometimes one can have pain at the ball of the foot in relation to the hammer or claw toe.
Treatment is considered when non operative measures have failed and the patient has symptoms of pain, formation of corns, difficulty with shoe wear and progression of deformities of the toes.
Treatment is generally initially by giving advice on using better fitted shoes, wider toe box , softer uppers of the shoes, straps and sometimes internal pads in the insoles. Most of these generally do not work well. If these measures fail then surgical correction of these toes is indicated. The surgical treatment is based on whether these toes are flexible or fixed.
If they are flexible soft tissue procedures generally suffice where the guiders(tendons) are either lengthened, released or transferred to balance the guiders.
If the hammer or claw toe is fixed, then one needs to fuse the first joint called the PIPJ and held with a wire which is cut and bent at the tip of the toe with or without soft tissue procedures.
All these type of operations are done as day cases either by general, spinal or local anaesthesia and the patient can go home the same day. They need to bring their medications and the prescription. It is advisable for the patient to have showered that morning and to wear clean socks.
Th patient will be mobilised with a flat accommodative shoe with a bulky dressing and generally do not need crutches. Some blood staining of the dressings is usually noted. The dressings are usually removed at 3-4 weeks for soft tissue procedures and for bony procedures at 4 weeks and then at 8 weeks when an xraywill be done and the wires removed.
The aims of surgical treatment is to place the toes as straight as possible especially on standing and shoe wear can be tolerated and made comfortable. The toes will still move at the joint above otherwise called as the MTPJ and the one lower called the DIPJ. The patient also will not have the problems of corns and pain associated with them.
Most will recover well by 8 weeks and the swelling will generally settle down, rarely in a few the bone may not heal very well and may take longer and the toes may need to be taped for a few more weeks.
Most patients recover well as the physios in the ward will get them walking and exercising. A pain package is prescribed by the anaesthetist but mostly paracetamol, NSAID’s and Codeine are the commonest medications unless one has allergies. A single dose of antibiotics are given at surgery to prevent any infection. Patient is advised to mobilise as much as possible as this will aid in recovery. No sporting or lower limb leisure activity is advised in the first 3 weeks. The surgeon will let you know the time that you can return to your leisure activities, running treadmill and other sport. Physiotherapy will be arranged only when there are multiple toes being operated.
The surgeon will generally let you know on the same day if the surgery has been successful, but the results will be seen at the first post operative visit. Patient and the surgeon can appreciate the difference from the preoperative appearance of the toes. Xrays of the bony procedure will show the bone healing of the PIPJ fusion generally at 6-8 weeks. Usually the surgeon will see you once post operatively for soft tissue procedures and maybe 2-3 visits for bony procedures.
Any symptoms of being unwell, fever, pain not managed by simple analgesia after the first 2-3 days and night pain should bring to the notice of the surgeon. Post operative appointments are routinely made by the surgeon as and when.
All small chores can be done from day one after surgery. Periods of rest is advised in between. Most patients can manage their day today living even if single and may need the occasional help especially if both feet and multiple toes are operated.
Most can go back to work by 3-4 weeks for soft tissue surgery. For bony operations one may need about 8 weeks. It also depends on one’s profession and the amount of standing one must do. Many desk jobs can go back earlier, and this can be decided by the employer and the type of work. A sick note will be provided at the request of the patient.
Generally diving is possible after 4 weeks. If one has an automatic car and the left foot was operated upon, then one can drive earlier. Manual cars generally will need to wait after the dressings are off and the wires removed. It is advisable for the patient to inform their insurance company prior to driving again.
The surgeon will discuss the type of surgery needed and will inform you of the results and complications that can happen. Most surgical interventions are safe and get a good result 90-92 percent of the time. There are always risks of infection, wound breakdown, poor bone and wound healing, loosening of the wire, recurrence of the deformities, very rarely chronic neuropathic pain and loss of circulation of the toes, the latter being extremely rare. Patient is advised to exercise the ankle and knees to reduce any chances of clots in the calf (DVT) and also to elevate the leg at night times.
One Health waiting times from consultation to treatment are 3 - 7 weeks on average.
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One Health waiting times from consultation to treatment are 3 - 7 weeks on average.
