Hammertoe Surgery: Why and How Hammertoes Are Corrected

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Published: 06th December 2010
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Hammertoes are perhaps the most common foot deformity one can develop over a lifetime. In this condition, the toes (except the big toe) will slowly begin to contract upward, at one or both joints in the toe. This can lead to painful corns, and to pain with simple shoe use. It can also lead to pain in the ball of the foot. This article will discuss how surgery is used to correct this deformity.

Hammertoes develop mainly due to genetic variations of one's foot structure. This condition is seen with those who have flat feet, and those who have high arches. The most common cause of hammertoes has much to do with imbalance of muscles flexing and extending the toes, with the muscles flexing the toes ultimately winning. This is seen in flat and flattening feet. High arches create hammertoes slightly differently, with the extending muscles dominating the process. Other causes of hammertoes could include muscle or tendon injury, as well as neuromuscular disease like cerebral palsy. There are several other toe contractions that resemble hammertoes, but are slightly different. These include claw toes and mallet toes. For the purposes of this article, treatment is generally similar, and won't be specifically discussed below.

As the toes contract, the joints become prominent on top which will be irritated by shoes, and two hammertoes placed side by side can irritate each other from their contact. The result of this irritation is a corn, also known as a hyperkeratosis. As the body's armor defense mechanism, the development of hyperkeratosis is a normal process. However, when these become thick enough, pain can ensue with pressure from the shoe above or the adjacent toe to the side. In some people, skin wounds can develop underneath the corn as the underlying skin dies from the pressure. Another way hammertoes affect the foot is through the pressure they exert on the long bone that comes before the toe begins. There are five metatarsal bones in the foot, and each connect to the base of a toe at the ball of the foot. As the toe contracts upward, the base of the toe can push down on the end of the metatarsal, driving it downward towards the ground. In turn, this can lead to a painful callus (same tissue as a corn) under the ball of the foot, and can also lead to instability of the joint itself.

Surgery is the only real answer to correcting hammertoes. Non-surgical measures are used to decrease pressure to the skin by employing padding, deep shoes, and corn/callus care to de-thicken skin. The toe temporarily feels better, but the deformity remains. Surgery actually returns the toe to a normal, generally straight position so that the shoe stays away from the skin, and the toes do not rub on each other through their combined bone prominence. Generally all hammertoe surgery is outpatient, same-day surgery, and is performed relatively quickly, as most cases are done in less than an hour (assuming all four lesser toes of one foot are operated on). The procedures can vary depending on the underlying cause of the deformity, and some toes may need several separate procedures. For the most part, recovery is generally quick for foot surgery, with resumption of regular shoe use taking place in a month or less. The only exception is when toes have to be fused, and this will be covered below. Most patients can still walk normally during most of the recovery period, with the assistance of a hard-soled surgical sandal. Complications are usually minimal and infrequent, although infection, numbness, and long term swelling of the toe rank as the most common complications when they do occur.

The traditional technique to correct a hammertoe involves making an incision on the top of the toe and reaching the bones underneath. There are three bones in each lesser toe, and the surgeon directs his/her attention to the bone that is most prominently positioned on top. The tip of this bone is removed at the joint, which allows the toe to flatten down again. The surgeon then goes through a series of sequential tests to release or lengthen specific ligaments, tendons and soft tissue that act on the bones if the contracture is not fully relaxed when the bone is removed. If the base of the toe is contributing to the continued toe contracture, the incision is lengthened down to that area and more joint tissue is released. If the metatarsal is too long and the toe won't settle back into position, a shortening procedure may be performed on the long bone to release pressure on the base of the toe and allow it to become straight again. Once the toe is straight, an external metal wire is used to hold the position for several weeks while the toe heals.

There are sometimes other procedures that must be performed to ensure the toe stays in a proper position long after healing. This can include fusing one of the toe joints if it is very rigid, or if the contracture is due to a progressively present neuromuscular disease that will re-contract the toe later on if it is not made more rigid. Another extra procedure involves transferring one of the tendons that flex the toe over to the top of the toe, where the tendon will now push the toe downward instead of curling and moving it upward. The little toe may require a different approach altogether, as it is often curled to the side as well as contracted. In this case, a special incision is used to rotate the toe back to a proper position, or the little toe is partially fused to the toe next to it to keep the rotation from occurring again.

As discussed above, hammertoe surgery healing takes place over the course of a month or so. Pain following surgery is usually moderate, and well controlled by pain medication or anti-inflammatory medication. The skin heals within two weeks, although toe swelling can take several months to go down. Most people see long-lasting correction, although a small number can have a partial return of the contracture if the forces acting on the toe are too strong. This can be prevented by using a prescription orthotic shoe insert following surgery to control the foot structure and the forces that cause toe deformity over the long term.

One final note on hammertoes involves the motivation for surgery in the first place. There are those who elect to have hammertoe surgery strictly for cosmetic reasons. A word of caution needs to be given for those who seek such treatment. Hammertoe surgery is performed to improve functioning of the toe, and to reduce pain. The toe typically heals in a cosmetically pleasing position, but it is difficult for a toe to stay in an arrow-straight position that is expected by one seeking cosmetic correction. The toe can slightly vary in position, even with the most accurate and detailed correction attempt based on all the forces that influence the toes. For those seeking surgery for pain, this is barely noticeable. For those seeking only a visual change based on inaccurate assumptions of how a toe is 'supposed' to look like, the ultimate result can be disappointing. For that reason, this author does not recommend nor perform hammertoe surgery based strictly on cosmetic concerns.


Dr. Kilberg provides compassionate and complete foot and ankle care to adults and children in the Indianapolis area. He is board certified by the American Board of Podiatric Surgery, and is a member of the American Podiatric Medical Association. He enjoys providing comprehensive foot health information to the online community to help the public better understand their feet. Visit this Indianapolis foot doctor online for more information.

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