Surgery for lesser toe problems

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 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.

Sometimes the problem is because the main bone to the toe in the foot (the metatarsal bone) is too long or is prominent on the ball of the foot. This may present with a feeling that you are walking on pebbles. The corresponding joint may also become inflamed and arthritic.

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. Shoe inserts and physiotherapy can also help with symptoms if there is pain in the ball of the foot. Injections into the joints or web-spaces can help with symptoms if the pain is felt to be arising from those areas.


How is the surgery performed?

There are various surgical techniques used depending on the problem you are having, 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 may be tight and short and thus elevating your toe. This can be released surgically, and the tendon lengthened.

Flexor tenotomy– sometimes the problem is a tight tendon underneath the toe pulling the tip downwards. This can be released through a small cut on the under surface 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. This means that instead of a bent and stiff toe you will have one that is still stiff but straight.

Weil’s or BRT Osteotomy these are different methods where the main foot bone joining to the toe (metatarsal) is broken (osteotomy) and shortened and/or elevated. 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 risks of surgery?

This information should be read in conjunction with the information on this site on general complications of foot and ankle surgery

Some of the risks specific to lesser toe surgery is detailed below.

This is a risk with any surgery however due to the presence of a wire that is protruding from the skin, care must be taken that the tip of the wire remains clean and dry. If there are any concerns this needs to be raised immediately and my office informed. Infection in the wire can spread rapidly into the bone and at such early removal of the wire may be indicated.

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 then revision surgery may be needed.

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

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.

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.

Your toe or foot will be swollen for some time after the surgery. This may take up to 6 months before fully resolving. On occasions it may be subtly larger than its neighboring toes indefinitely. This is of no consequence and tolerated well.

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.

The bones in the ball of the foot (metatarsals) have a very delicate balance to ensure even loading of weight in the forefoot. Surgery to alter the length or position of these bones can sometimes lead to a change in the biomechanics which may result in overload of a neighboring metatarsal. This is referred to as ‘transfer pain’ or ‘transfer metatarsalgia’. In mild cases a shoe insert can help resolve the symptoms however occasionally revision surgery may be required.


What happens after the surgery?

Please read this information together with that on the rehabilitation following forefoot surgery where you can find some general guidance on the recovery following forefoot surgery. Some specific points regarding lesser toe surgery are detailed below.

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 can bear weight fully using a flat sandal and can start walking straight after the surgery. The crutches are there for support and although some people like using them you can quickly discard them as soon as you feel confident.

the local aneasthetic block will last for several hours and sometimes until the next day, be prepared to take some painkillers when this wears off. pain is usually mild and can be managed easily with elevation and the provided pain medication.

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 must remain particularly vigilant that any pins are not caught up in bed sheets or against socks as this can sometimes pull the pin out inadvertently. Care should also be taken to avoid stubbing the pin against furniture as the can damage the pin and sometimes drive it further into the toe.

You should continue with regular elevation of your foot and take your painkillers as prescribed.

You will be seen in the clinic at around 2 weeks post op for a wound inspection. The dressing is changed.

If the surgery was on your toes alone and if there are no wires or they are small, then it may be possible to go into your usual shoes. A wide fitting, comfortable, and supportive pair such as some trainers would be ideal.  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.

If you have had an osteotomy then you may stay in the post operative sandal for this period to protect the healing of that.

I will arrange an appointment to see you at the end of this to assess your progress. If there is a wire in place this is normally removed six weeks from surgery.


How is the wire removed from my toe and is it painful?

If you have had surgery on the toe itself, you may have had it pinned with a wire. These wires are normally removed in clinic after six weeks. The removal of the wire is a very straight forward procedure and there is no cause for concern. There is very little pain felt, although there may be some bleeding from the tip of the toe but this normally can be dealt with simple dressings.