Features July 2019 Issue

Surgery for Hammertoes

When surgery is needed for hammertoes, new approaches make it even more successful.

The abnormal bending of the toes known as hammertoes is a common foot deformity, especially for women. The end of the toe bends down and the middle joint sticks up. Hammertoes mainly cause difficulty fitting into shoes and corns and calluses from pressure and rubbing. "These can generally be managed by accommodating for the deformity," says Georgeanne Botek, DPM, Head of Podiatry in the Department of Orthopaedic Surgery at Cleveland Clinic.

But if hammertoes become stiff, painful and limit activity, surgery may be warranted. And there are advancements in the procedure that make it more effective over the long term.

Hammertoes result from an imbalance between muscles, tendons and ligaments. In many cases, heredity is to blame. There are other causes as well, including ill-fitted shoes (see box on page 7).

Nonsurgical Treatment First

When you have hammertoes, you can develop corns on the top of the foot, on the top of the toe or on the side of the toe. Calluses can form underneath the foot.

Careful choice of shoes can help prevent corns and calluses. Dr. Botek advises wearing shoes with a wide and deep toe box. Some people find shoes made with mesh or sandals more comfortable.

"A more dynamic approach is to do toe exercises to strengthen the small muscles to maintain flexibility," says Dr. Botek. This may prevent the hammertoe from becoming a rigid deformity, which is more likely to cause pain. "If we can keep toes flexible, they are less painful," says Dr. Botek.

In addition to exercises, there are devices you can wear to stretch toes. Splints, such as Yoga Toes®, can be worn for extended periods while you are sleeping or sitting for long periods.

Other types of splints hold the toe in a neutral position and can be worn inside shoes. "It doesn't correct the deformity, but it helps while you wear it," says Dr. Botek.

Surgery

hammerToe

© Wavebreakmedia | Getty Images

An imbalance in muscles, tendons and ligaments can cause the joint in the middle of a toe to stick up—a hammertoe.

"The number one indication for surgery is pain," says Dr. Botek. Hammertoes that are flexible and don't cause pain are considered mild to moderate. Surgery is done for severe deformities that are fixed and immobile and causing pain.

"I don't usually advise surgery just to fit into shoes," says Dr. Botek. There are exceptions. "There may come a time when you can't fit into shoes that you need to wear," she says.

The most common surgical procedure for hammertoes is proximal interphalangeal (PIP) joint fusion. The toe is straightened and stabilized by permanently fusing the two bones together.

The traditional way to do this is by cutting the ends of the bones in the joint and joining them together. A wire (called a K-wire) is inserted to hold them in place for three to six weeks while they naturally fuse together. At that point, the wire is removed.

"The K-wire is a stainless steel pin that sticks out the front of your toe-kind of like a shish kebab," says Dr. Botek. "We put a little ball at the end so it doesn't catch, and we cover the foot with a soft dressing, but most patients don't like those."

New Approach

With a newer approach, rods and screws are permanently implanted in the toe. These do not stick out, and they are not removed. "An advantage is it will hold the toe stable in a reliable position, even if you stub your toe or otherwise injure your foot later on," says Dr. Botek.

Both surgical procedures are done in an outpatient setting under light sedation. You'll wear a postsurgical shoe that offloads weight for four to six weeks. "It can take eight to 12 weeks before you are able to wear most of your shoes," says Dr. Botek.

The surgery is successful 80 to 90 percent of the time, and the rate of complications is very low. There may be some mild discomfort.

"The most common complaint is stiffness and swelling of the toe, which can last for a few months," says Dr. Botek. The fixation device loosens or becomes painful in about 1 to 3 percent of people.

A deformity reoccurs in about 5 to 10 percent of people who have surgery. It's not always in the same joint or even the same toe. Hammertoe surgery is usually done in the middle joint of the toe. There's another joint underneath the toenail that may develop a deformity. Or, the next toe over could become destabilized and prone to develop a hammertoe.

More Than One Toe

It's common to have multiple hammertoes as well as a bunion. With a bunion, the big toe bends toward the second toe. Over time, the pressure this puts on the second toe can cause a hammertoe.

A bunion and multiple hammertoes often will be addressed in one surgery. "We can operate on more than one toe at a time, but we usually address only one foot at a time," says Dr. Botek.

If more than one toe is operated on, the procedures may vary. You may have a PIP joint fusion for a hammertoe and a different procedure for a bunion. You may also have a procedure to rebalance the ligaments and tendons around the base of the toe or a procedure to cut and shorten the bones.

Other Options

Less invasive surgical procedures are being developed for hammertoes. Cutting the bone using minimally invasive approaches is gaining some momentum. And addressing the soft tissue rather than cutting the bone is also being done by some foot and ankle surgeons.

One procedure, called tenotomy, involves cutting the tendon. "We're not cutting the bone, we're releasing tendons," says Dr. Botek.

"The jury is still out in terms of the long-term effects," says Dr. Botek. Currently, soft tissue procedures are done for more flexible and mild deformities, or for people with medical conditions that make undergoing surgery risky.

Causes of Hammertoes

painfulShoes

© alphabetMN | Getty Images

You can inherit a predisposition to develop hammertoes. Other causes include:

Shoes that are too snug or short. This can have a buckling effect on toes. Muscles and tendons tighten and become shorter.

Brachymetatarsia. With this condition, one or more metatarsal (toe) bones are abnormally short.

Bunion. This can put pressure on the second toe, causing it to bend.

Plantar plate tears. The plantar plate is a ligament on the ball of the foot. This can wear out over time, especially in people who spend a lot of time on the ball of their feet (such as women who wear high heels or people who work on ladders). A tear can cause a hammertoe to develop suddenly.

Diabetes. Nerves can malfunction, especially in the feet. This can lead to weakness in small muscles. Tendons can overpower them, causing hammertoes.

Rheumatoid arthritis. This form of arthritis often affects the feet. Damage to joints in the toes can lead to hammertoes.

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