screw and absorbable pin

So your toe is bent to the point where your shoes rub on the top of your to causing pain.  The skin is always red and sore.  The bending has gotten worse over the past year and at times you have pain in the ball of your foot.  What if I told you I could fix the bend in your toe so that the pain goes away?  Take it one step further, I can fix the bend in your toe so that the pain goes away, but there will be a pin sticking out the end of your toe for 4-6 weeks.  For a lot of people that’s a deal breaker.  They want the toe fixed, are willing to deal with the pain and recovery of hammertoe surgery, but don’t want to see that pin sticking out the end of their toe.

This is a big problem and as your surgeon I have to address your concerns.  I recognized this early in my training and began using absorbable pins that did not stick out of the toe while I was a resident.  Smaller screws became available that could be used in toes and more recently special little devices made of space-age material were introduced just for toe surgery.

I’ve already talked about the difference in hammertoe surgery between the 2nd and 3rd toes as compared to the 4th and 5th.  Here I’m talking about the 2nd and 3rd toes only.  When I fix the bend in your toe I need to make a stiff, straight toe.  I remove the crooked joint and force the bone to heal together straight.  That’s why I need to use a pin, screw, or special little device to get the bones to heal together, or in other words fuse.  The only question to ask for this part of your surgery is how strong is your bone?  That changes my options.  Stronger bone means I can use just about anything, but weaker bone limits my options.

Why do some people still have hammertoe surgery with the pin sticking out of the end of the their toe?  The most common reason is weak bone.  Some things that have been around a long time are still used today because they work in almost every case.  Even if your bone is weak a pin can be used to hold it straight until healed.  The other reason is the joint at the base of our toe where your foot begins.  Many people have toes so badly bent that the joint in the ball of their foot is also bent.  More recent advances have shown that breaking the bone in the ball of your foot to straighten this joint is better than the older method of cutting tendons and ligaments.  When we used to cut the tendons and ligaments in this area the best way to hold the toe straight was using a long wire.  Now we use screws to hold the bone in the ball of your foot without having to use a pin across that joint.

smart toe

New techniques and new technology are sometimes slow to catch on.  Hammertoe surgery without the pin sticking out of your toe is not new.  As I said in the beginning, I started doing this when I was in residency.  I’ve been training residents for about ten years and even the very first resident I taught learned how to fix a hammertoe without a pin sticking out the end of the toe.  When I discuss toe surgery with you I will talk about the options and what I think is best for you.  I want to hear your opinion and make sure I’m addressing your goals.  It is very important that we are on the same page when it comes to fixing your toe.

Hammertoe toe surgery might be in your future.  If you are scared about having a pin sticking out the end of your toe come and talk to me.  More often than not I can straighten your toe without having to leave a pin sticking out the end.

With that said, recovering from hammertoe surgery is usually not that hard.  You should do a few thins to make sure that your healing experience is the most pleasant possible.  Before your surgery is the most important time.  The more you can do for yourself before surgery, the happier you will be after.  Simple things like preparing meals before hand, practicing walking in your special shoe or boot, and planning for time spent resting your foot.

What room in your home worries me most?

Believe it or not it’s your kitchen.  Those kitchen cabinets have that little ledge at the bottom.  Be careful not to hit your toes against this edge.  The shoe or boot you will be wearing is higher than regular shoes and has grabbed hold of more than one of my patients’ bandages.  That’s a good reason to prepare meals before your surgery, but the real reason is you are recovering from surgery.  You shouldn’t have to cook for yourself.  Give yourself at least a little few meals off to rest and stay off your foot.

Since we’re talking about hammertoe surgery most of you will be allowed to walk, but in a special shoe or boot.  You might not think this is going to be hard, but if you’re weak this can be a challenge.  I can send you to physical therapy before the surgery to be sure you can handle the shoe or boot.  This way you and I know exactly what to expect after surgery.  I can even prescribe a strengthening program for you through physical therapy if you need.

Easier Hammertoe Recovery

Other things that can make your recovery from hammertoe surgery easier include getting your house set.  Firsts of all, do you have stairs?  If walking on flat floors is hard in the shoe or boot, stairs might be impossible.  You might want to sleep downstairs the first few days.  You will need to clear a path to the bathroom.  Think about removing area rugs that can slip and slide out from under foot.  Small tables and chairs can have legs that stick out, which could bump your toe.  Think about the ways you can set up your house to help you recover.  My staff has many more ideas that they will be glad to share with you.

Before surgery we developed a plan to help you heal as fast as possible.  After your surgery you need to stick to the plan.  The game plan we designed together before surgery will be given to you in writing.  Obviously there will be a special shoe or boot and pain medication that you should have before you get to the hospital.  That leaves swelling and pain to discuss.  A toe is small and there is not much room for swelling.  The more your foot is down, the more it will swell.  Since there is so little space in the toe this swelling can hurt.  Both of us want your surgery to be as free of pain as possible.  You will need to rest with your foot up.  That means lie flat on the couch or bed and put your feet on pillows.  Make sure your knees are bent a little so this is more comfortable.  Ice can go behind your knee or at the inside of your ankle to prevent swelling.  The ice should be on 20 minutes and then off for 40 minutes.  This can be repeated as often as needed, but usually no less than 3 times per day for the first 3 days.

I like to prepare before surgery as much as possible.  I tell my residents to review a surgery in their mind 5 times before they even step into the operating room.  If your surgeon prepares before surgery shouldn’t you?  I hope this information shows you how Desert Foot Surgeons helps you heal after hammertoe surgery.  Remember, feet are like snowflakes, no 2 are alike.  Choosing your foot surgeon is very important.  Your surgeon needs to have the training and artistic talent to fix your toe.  Equally as important is your ability to communicate with your surgeon.  Ask questions and prepare before your surgery.  You’ll be glad you did.

Let’s start with your 4th and 5th toes.  Unfortunately shoes press the hardest on your 4th and 5th toes.  Because of this constant pressure I can’t make these toes stiff or you would never wear shoes again without pain.  In fact, your 4th and 5th toes are fixed by removing the crooked joint and leaving the toe flexible.  Removing the joint will fix the bend, but does nothing to fix the twisting so I have to use a carefully planned skin incision to un-twist your toe and bring the nail back on top.  The bandages will help to hold your toe in this position since there are no screws or pins, so it is very important that you do not remove your bandages.  To prevent the tendons from pulling on your toe you must wear a special shoe or boot.  You will be allowed to walk after the surgery as long as you wear this shoe or boot, but remember that the more time you spend walking around on your foot after surgery the worse the swelling and pain will be.  Stitches are removed after 10 days and you will wear a loose fitting tennis shoe before you return to tighter shoes.  I expect swelling to last 3-6 weeks, but a lot of that depends on your body.

Your 2nd and 3rd toes are more complicated to fix than the 4th and 5th because they buckle for a different reason.  Because of this difference I have to treat these toes using another approach.  Your 2nd and 3rd toes must be made stiff so that the muscles won’t cause the toe to buckle again after it has been fixed by surgery.  That means that after the surgery your 2nd and 3rd toes will not bend at the toe joint.  You will have a screw or pin in your toe to hold the bones straight.  The screw or pin can be removed in the office at a later date if needed.  No doubt you have heard stories about people having pins sticking out of their toes after hammertoe surgery.  I use newer technology when I can so that you won’t have anything sticking out of your toe.  It is still important that you not change the first set of bandages after surgery.  In straightening your 2nd and 3rd toes I am removing the crooked joint and making the bone ends heal together.  You will be able to walk using special cast boot, but again the amount you walk determines how much swelling and pain you get.  The bone takes about 1 month to heal.  Tennis shoes are easier to wear at first and as swelling and pain subside you can progress to the shoes you want, within reason.

That’s the scoop on the most common hammertoe surgeries.  I’ve told you how fixing your 4th and 5th toes are different from your 2nd and 3rd.  You have an idea of what to expect after surgery.  I have not told you about the more complex toe problems, but will in future posts.  For now remember what I always say, “feet are like snowflakes, no two are alike”.  The surgical approach from one foot to another has to be different, that’s the art of surgery and is one of the main things separating me from other foot surgeons you might meet.

The big toe can develop a lump or bump on the inside of the foot. This prominence initially becomes painful in shoes from pressure, but if left untreated arthritis will set in. The lump on the inside of the foot at the base of the great toe is called a bunion. Often mistakenly referred to as a growth of bone, the cause of a bunion is really the result of an unstable joint. The loss of stability in the big toe joint causes the bone behind the big toe to drift inward leading to the lump or bump. The more the bone drifts, the more your big toe falls toward the second toe.

How the joint becomes unstable is related to the way your foot hits the ground when you walk. A detailed examination of your feet while standing and walking is needed to determine why your foot is unstable. If caught early custom molded foot orthoses can restore stability to the joint and prevent further damage.

If painful, damage to the joint has already occurred. Custom molded foot orthoses will restore stability to the joint, which can improve pain, but usually therapy involving anti-inflammatory medication is needed as well. When pain does not respond to stabilizing the foot, surgery is needed. The goal of surgery is to provide stability to the joint from within preventing further damage. This is accomplished by moving the bone that has shifted back into line with the big toe. The more the bone needs to be shifted, the longer the recovery. So getting treatment early is always recommended.

Dr. Stephen Geller, DPM , AZ Podiatrist

The treatment differs based on the stiffness of the bent toe. Smaller toes such as the 4th or 5th that can be straightened by hand often can be treated by simple tendon release. This is the easiest hammertoe surgery to recovery from often requiring a single stitch. If more than one toe is done at a time the recovery can be slightly longer.

If the bend in the toe cannot be straightened by hand, removal of the rigid joint is performed. At Geller Podiatry we employ a detailed step-wise approach to straighten all parts of the toe. The more deformed the toe, the more steps will be used from simply fusing the toe joint straight to breaking the metatarsal head and repositioning the entire toe. Tight skin has to be lengthened using plastic surgery techniques so that the toe can stay straight and the scar is more cosmetic. In general these procedures require protection from walking using a cast boot. X-rays are used to follow the toe healing process and you will be returned to shoes when your doctor sees evidence of bone healing.

More Info

Hammertoes develop when the toes buckle under the pressure of walking on an unstable foot. When your foot pronates too much, the muscles work harder to support your arch. If your foot remains unstable the toes bend as muscles fight to prevent the arch collapsing while you walk. Left untreated the toes will stay curled leading to corns, calluses, and pain.

Early treatment is important. At Desert Foot Surgeons we perform a detailed examination including video gait analysis to identify the reason for the unstable arch. If you do not correct the true cause of the problem it will only return. Foot orthotics are used to stabilize the arch and prevent hammertoes in the early stages. Once the toes stay bent treatment involves changing the shoes that push on the painful toe or surgically straightening the toe.

Dr. Stephen Geller, AZ Podiatrist