Hammer, mallet or claw toes are terms that are used to describe various deformities of the lesser toes where the tip of the toe is bent downwards. This can result in the knuckle of the toe to be raised on the back of the toe. The symptoms arise when the tip of the toe rubs against the floor or the back of the knuckle against the shoe.
Surgical correction can be a very good and simple solution to symptomatic lesser toe deformity if all else has failed.

What are the alternatives to surgery?

The main alternative to surgery is to wear shoes that have wide and tall toe box. There are also various splints on the market that can help a great deal.

What does the surgery involve?

There are various surgical techniques used depending on the particular problem and your surgeon will discuss these with you. Some of these are outlined below.

Extensor tendon lengthening –

the tendon and soft tissue on the back of the foot maybe tight and short elevation your toe. This can be released surgically and the tendon lengthened.

Flexor tenotomy-

sometimes the problem is a tight tendon underneath the toe. This can be released through a small cut on the undersurface of the affected toe.

Inter-phalangeal joint fusion–

this is when the bone in the knuckle of the affected toe joint is excised to allow the toe to be straightened. It is done through a small cut on the back of the affected toe and the joint is then held with a wire or sometimes an implant until it is fused.

Weil’s Osteotomy-

this is a procedure where the main foot bone joining the toe is broken (osteotomy) and shortened. This is needed if you have a dislocated toe or if you have pain in the ball of the foot. A longer incision or cut is required over the foot near the involved toe. The bone is then fixed with a small screw.

What are the main risks of surgery?

Infection

Floppy or short toe – on occasions the toe may be too short and the tendons therefore relatively long. This may result in a toe that feels loose and floppy and you may not have enough control over. In mild instances this will not cause any problems however if it is causing symptoms the. Revisions surgery may be needed.

Elevated toe-

on occasions and especially if a Weil’s osteotomy is performed the toe will have a tendency to rise above the ground. This can often be controlled with stretching exercises but occasionally may need revision surgery to correct.

Malunion or non-union –

when an interphalangeal joint fusion is performed the toe may heal with some angulation or may not heal at all. If the healing is with fibrous tissue or the angulation is mild then nothing further is needed otherwise revisions surgery may be indicated.

Numbness-

it is common for the toe to feel “numb” or “odd”. Completely numb toes are rare but may occur due to injury to the nerves.

Swelling-

your toe will be swollen for sometime after the surgery. This may take 6 months before resolving. On occasions it maybe larger than its neighbouring toes indefinitely. This is of no consequence and tolerated well.

Vascular (blood flow) compromise –

very rarely the blood supply to the toe may be interrupted which may in turn lead to necrosis and loss of the toe. This is extremely rare and happens in less than 1 in 5000 cases. This risks may be higher if the toe is very short, dislocated or severely deformed.

What Happens after surgery?

Weeks 0-2

Following the surgery you will have bulky bandaging on your foot. If pins have been used you may see the end of the wire from the tip of your toe. You will see the physiotherapist who will show you how to use crutches. You are able to bear weight fully using a flat sandal.
You can inspect the toes through the dressing to ensure they are pink and healthy. Also make sure the pin is kept dry and clean.
You should continue will regular elevation of your foot and take your painkillers as prescribed.

Weeks 2-6

You will be seen in the clinic at around 2 weeks post op for a wound inspection. The dressing is changed. If there are no wires or they are small then it may be possible to go into your usual shoes. Do bring these with you to your appointment. You may however be put back in the flat sandal. Continue with elevation and weight bearing in this period.

Week 6 onwards

At your sixth week appointment the K-wore is removed. Normal activities can now resume although the toes may remain swollen for 3-6 months and sometimes longer. Impact active can be slowly introduced over the next 6 weeks.