Flexible Hammertoe Deformity

This surgery is used to treat flexible hammertoe deformity. A hammertoe deformity is one in which the toe is bent and looks like a hammer. A flexible deformity is one in which the toe can be manipulated into a straight position. This deformity can cause shoe problems, corns, and pain with walking.

This procedure also can be used to treat conditions in which the toe deviates or crosses over the remaining toes. Prior to considering surgery, a course of non-surgical treatment should be attempted, including shoe modification, splinting and toe sleeves.

The goals of the surgery are to improve the alignment of the toe and reduce pain, eliminate any prominences that can lead to corn formation, and improve shoe accommodation.

Patients with a history of poor circulation and loss of feeling in the feet and toes are at higher risk of wound healing problems, infection, and compromise of the blood flow to the toe.

Treatment

This surgery is performed as an outpatient procedure, meaning the patient can go home the same day. The patient may be under general anesthesia or awake with numbing medication injected into the foot. A tourniquet is applied to your foot to minimize blood loss.

Your foot and ankle orthopedic surgeon makes an incision on the bottom of the involved toe. There are two tendons to each toe that help to flex or bend the toe. One of the tendons is transferred to the top of the toe. It is then attached to the tendon that extends or straightens the toe through an incision on the top of the toe. A pin may be inserted into the toe to help maintain alignment for a number of weeks after the procedure.

Recovery

Patients typically are allowed to walk after the procedure in a post-operative shoe. If other procedures are done simultaneously, this may restrict your ability to weight bear for a period of time after surgery. Sutures generally are removed two weeks after surgery. The toe sometimes is taped to help maintain alignment for several weeks. Patients can be allowed to return to regular shoes approximately four to six weeks after surgery. Swelling can be expected within the toe, possibly for many months after surgery.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Complications from this procedure include stiffness of the toe and potential recurrence of the deformity.

FAQs

When can I return to work?

Return to work is variable and depends on the nature of your occupation. In general, return to a sedentary job can occur over a few days to two weeks. More physically demanding occupations will require a longer recovery.

When will I be allowed to drive?

If the surgery involves the non-driving foot, you can drive within a few days of surgery. If it involves the driving foot, it may be several weeks before you can drive. It is important to discuss this with your physician prior to undergoing surgery.

Flexor Hallucis Longus (FHL)

A flexor hallucis longus (FHL) tendon transfer to the proximal phalanx is used to treat clawing of the toe.

Small muscles in the foot help to stabilize the toes. When those muscles are weakened by disease, an imbalance occurs that leads to clawing. The clawing puts abnormal pressure on the ball of the foot that can cause an ulcer to form. In addition, clawing may lead to pressure on top of the toe from shoes. Clawing is associated with a variety of underlying disorders, including Charcot-Marie-Tooth disease, diabetic neuropathy, traumatic brain injury, polio, and stroke.

The primary goal of an FHL tendon transfer is to decrease the abnormal pressures on the big toe. This will prevent ulcer formation, or in the case of an existing ulcer, promote healing. An FHL tendon transfer often is done at the same time as other foot procedures.

Diagnosis

Indications for the FHL transfer are clawing of the toe with pain and/or ulcer formation that cannot be improved with shoe modification.

This procedure should not be done when there is uncontrolled infection of the soft tissue or bone of the toe. Also, surgery is not recommended if you have poor circulation that would prevent proper healing.

Treatment

Once the patient is under anesthesia, the foot and ankle orthopedic surgeon makes an incision along the inside of the toe. The surgeon takes care to protect the nearby nerve and artery. The tendon is released from its attachment and a stitch is placed into the end of it. A hole is drilled in the bone at the base of the toe close to the metatarsophalangeal (MTP) joint. The tendon is passed through the hole from the bottom of the toe up to the top of the toe, and a stitch is used to tie the tendon securely back to itself.

Although releasing the tendon can allow the toe to straighten, release of the contracted joint capsule often is necessary as well. In many cases, the FHL tendon transfer is used in combination with other procedures to correct other foot deformities.

Recovery

Typically, the foot is splinted for 10-14 days while the incision heals. At that point, stitches are removed and a walking boot is worn for four weeks. During that time weight bearing in the boot may be allowed. If there are other procedures performed at the same time, weight bearing may be delayed and a cast may be necessary. Swelling can persist for several months.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

Complications specific to the tendon transfer include loss of fixation of the transfer and/or recurrence of the deformity. Stiffness at the big toe MTP joint also can be a problem.

FAQs

I have an ulcer on my big toe. Can I still have surgery?

While not ideal, some ulcers may not be a barrier to surgery, especially since an FHL tendon transfer usually helps with ulcer healing.

Flexor Hallucis Longus

The flexor hallucis longus (FHL) is the primary flexor muscle of the big toe. It originates at the back of the leg, transitions into a long tendon as it enters the foot and attaches on the bottom of the big toe.

The peroneus brevis (PB) muscle starts in the leg and continues along the outside of the ankle. It then takes a sharp turn and ends on the outside of the foot. The peroneus brevis works with the peroneus longus (PL) to turn the ankle and foot outward.

The FHL to PB tendon transfer is a surgery to improve the function of the foot. The FHL is passed behind the ankle to the outside of the foot to either assist or replace the damaged PB tendon.

The goal of this surgery is to restore the power of the ankle and foot to turn outward, which is required for cutting and turning movement.

Diagnosis

Repeat ankle sprains can lead to peroneal tendon tears. If left untreated, the tendon may be irreparable, requiring a tendon transfer. Nerve disorders with poor muscle function (often seen in the cavus foot) also may require a tendon transfer.

Patients with active infection should not have this surgery. Vascular disease, poorly controlled diabetes, or heavy smoking also can be reasons to not have this surgery.

Treatment

An incision is made over the course of the PB around the outside of the ankle. The PB is examined carefully and any degenerative portion is removed. A second incision is made on the inside of the foot and the FHL is identified and pulled from the inside of the foot to the outside of the foot where the PB inserts. The FHL can be directly attached with a screw or suture to the bone where the PB inserts. After the tendon transfer, the wound is closed with sutures.

Recovery

Recovery varies from patient to patient. Six to eight weeks of rest may be needed and is dependent on associated procedures. This is followed by physical therapy and gradual return to activity. Return to full function may take up to a year.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. With this procedure there also is the risk of continued PB problems, persistent weakness and scarring.

FAQs

What happens to my big toe if you are transferring the FHL?

Full toe function will not be lost because there is another tendon that attaches to the great toe to help flex it. Following transfer, it is expected that the patient will lose some strength of the great toe. Despite this, patients are satisfied with their toe function.

What outcome can I expect from this procedure?

Isolated tendon transfer has shown good results. However, outcomes are difficult to predict as the procedure is often performed with other procedures, such as correction of a cavus foot.

First MTP Joint Interposition Arthroplasty

The first MTP, also called the first metatarsophalangeal joint, is the big toe joint. A first MTP joint interposition arthroplasty is a surgical procedure to treat arthritis of the big toe. The treatment can stop pain at the base of the big toe by preventing the surfaces of the bones from rubbing together. It also can preserve some motion in the big toe.

Symptoms

The main symptoms of arthritis are pain and loss of motion at the joint between the big toe and the foot. Your foot and ankle orthopedic surgeon will examine you and take X-rays to determine the extent of your arthritis. If it is severe, this procedure may be an option.

Patients with infection or blood vessel disease should not be considered for this surgery. Young age and poor skin around the joint or large deformities are sometimes barriers to surgery. Diabetics should consult their doctor before this surgery.

Treatment

An incision is made over the first MTP joint and carried down to the joint. The joint surfaces along with a small amount of bone are removed.

A newer technique uses a synthetic cartilage implant plug made out of polyvinyl alcohol as a spacer, without covering the surface area of the joint. This procedure requires less bone removal and is easier to convert to fusion if it fails. It also has shown to be as effective as fusion in relieving pain, while preserving motion of the joint. This is a newer procedure; however, current studies have demonstrated good results that appear likely to hold up over time. Many foot and ankle orthopedic surgeons find this procedure helpful but at present it is not universally accepted.

Recovery

After surgery, a gauze dressing and a wrap such as elastic bandages are placed over the toe and foot. The joint should be immobilized followed by early motion to prevent stiffness. Physical therapy may be used to improve motion and strength. Patients should keep their foot elevated as much as possible to reduce swelling. There may be a brief period of time where you should not weight bear but in general you will get back to limited walking within a few weeks of your surgery. Stitches generally are removed after 10 to 15 days, depending on the condition of the skin. Patients are encouraged to wear a hard-soled shoe.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots.

One of the most frequent complications of first MTP joint interposition arthroplasty is failure to relieve pain or preserve motion. Another complication is rejection of the tissue placed in the gap, which may require further surgery. Other complications can include pain at the base of the second toe, delayed wound healing, recurrent deformity, bony overgrowth, disintegration of bone around the graft, implant displacement, instability of the joint and injury to the nerves of the big toe.

FAQs

When can I return to work?

It depends on the physical requirements of your work and your individual pain tolerance. When you can tolerate pain without pain medication and you can walk without assistive devices you can return to a sedentary occupation (desk work, etc.). For more physically strenuous occupations, it could take as much as 12 weeks to safely return to work. You and your orthopedic foot and ankle surgeon can decide when it is right for you to return to work.

Can I play sports after first MTP joint interposition arthroplasty?

Strenuous physical activity such as running, jumping and rock climbing is thought to lead to early failure of the procedure. Light activity, such as walking and cycling, can be performed after the initial healing without significant risk of early failure. Again, this is a matter to be discussed with your orthopedic foot and ankle surgeon.

Will first MTP joint interposition arthroplasty improve my range of motion?

It is unlikely that you will regain more motion than you had prior to surgery.

First Metatarsophalangeal Joint

The first MTP, also called the first metatarsophalangeal joint, is the big toe joint. A first MTP joint fusion is a surgical procedure to treat arthritis of the big toe. This condition can cause pain and swelling and lead to difficulty walking, running, and wearing shoes. Arthritis develops when the cartilage on each bone wears away and the two bones that make up the big toe joint rub against one another.

In a first MTP joint fusion, the bones are joined (fused) together permanently so they cannot rub against each other and cause pain.

Diagnosis

The need for surgery depends on how bad the arthritis is and how much pain you are experiencing. Surgery is recommended for those with pain and stiffness in the big toe joint. Some patients are unable to wear certain shoes (dress shoes, high heels and boots) and can’t participate in activities due to pain. If the condition exists in both feet, the more painful foot is operated on first.

A foot and ankle orthopedic surgeon can determine the severity of the condition. Before deciding on surgery, patients should try non-surgical treatment such as changes in activity and footwear or steroid injections. Patients also can try wearing a shoe with a rounded bottom or using carbon shoe inserts that limit joint motion.

You should avoid surgery if you have an active infection or severe narrowing of the arteries. You must be able to manage a recovery period that can last six months or more.

Treatment

In this procedure, the damaged cartilage is removed and the two bones are fixed together with screws and/or plates to enable them to grow together.

This is routinely performed as an outpatient procedure. Most patients go home the same day of the surgery unless they need to be monitored in the hospital overnight.

Specific Technique

An incision is made on top of the big toe. Any cartilage is cleared away to allow the two bones to heal together. Your foot and ankle orthopedic surgeon may use a combination of tools to shape each bone for a perfect fit.

Once prepared, the two bones are positioned and a metal plate is placed to hold both bones together. An additional screw is set across the joint for extra stability and compression, which aids in healing. In some cases, two screws can be placed across the joint without using a plate. After the hardware is placed, the incision is closed with sutures and the foot is placed in a dressing or splint.

Recovery

After surgery, you will likely be examined at two weeks, six weeks, three months and six months intervals. X-rays may be taken at each visit to evaluate the bone healing and the position of the big toe. Weight bearing status will be determined by your surgeon. After a first MTP fusion, you should not wear shoes that put extra stress on the joint.

Risks and Complications

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Common complications specific to MTP fusion include poor or delayed bone healing, infection, and stiffness in neighboring joints. The metal plate used during surgery can sometimes cause irritation. In this case it can be removed after the bone has healed. Finally, scarring within the joint can limit neighboring tendons.

FAQs

If I have a first MTP fusion, will I have a limp when I walk?

Most people with a first MTP fusion do not have a limp after it is fully healed.