What does the operation for bunions and claw and/or hammer toes consist of?

Bunionette surgery

It is a progressive and complex deformity affecting the forefoot. The most obvious signs are deviation of the big toe and bony protrusion at the level of the first toe joint.

A large percentage of the population has toe deformities, especially bunions and claw and/or hammer toes. This explains why they are the main reason for podiatrists’ consultations.

Normally the bunion deformity causes the deviation of the first toe over the other toes, causing them to deform. At other times, claw toes or bunions may develop independently.

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The type of footwear, the structure of the foot, previous traumas or injuries as well as inflammatory diseases can cause the development of these toe deformities.

In order to understand the deformities in the fingers it is necessary to explain that with the exception of the big toe which is composed of two bones or phalanges, the rest of the fingers or little toes are formed by three phalanges, proximal, middle and distal.

The joints between bones form joints and finally, the fingers move thanks to the extensor and flexor tendons of the fingers.

The affected joints become progressively deformed to the point of stiffness and dislocation of the joint.

Fingers without deformity are in a neutral position, however when they are subjected to continuous pressure or when there is an anatomical alteration or neurological deficit, an imbalance between the tendon, ligament and muscle structures is produced, causing a deformity.

The bunion or hallux valgus produces the deviation of the big toe towards the second toe causing pressure and deformity in this one.

Finger deformities are called claw, hammer or gooseneck depending on which joint is affected.

Claw toe occurs when there is a dorsal flexion of the phalanx over the metatarsophalangeal joint (union of the metatarsal with the proximal phalanx) and a flexion of the proximal and distal interphalangeal joints.

Hammertoe occurs when there is abnormal flexion of the medial interphalangeal joint.

Finally, mallet toe occurs when the toe is in a neutral position, except for the distal interphalangeal joint which is in flexion.

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What are claw and/or hammertoes?

The affected joints become progressively deformed to the point of stiffness and dislocation of the joint.

Fingers without deformity are in a neutral position, however when they are subjected to continuous pressure or when there is an anatomical alteration or neurological deficit, an imbalance between the tendon, ligament and muscle structures is produced, causing a deformity.

The bunion or hallux valgus produces the deviation of the big toe towards the second toe causing pressure and deformity in this one.

Finger deformities are called claw, hammer or gooseneck depending on which joint is affected.

Claw toe occurs when there is a dorsal flexion of the phalanx over the metatarsophalangeal joint (union of the metatarsal with the proximal phalanx) and a flexion of the proximal and distal interphalangeal joints.

Hammertoe occurs when there is abnormal flexion of the medial interphalangeal joint.

Finally, mallet toe occurs when the toe is in a neutral position, except for the distal interphalangeal joint which is in flexion.

Claw and/or hammer toes

Toe deformities usually go unnoticed in the early stages when the deformity is mild and flexible, i.e. the toes adapt to the shoe without pain.

These deformities worsen with time, becoming stiff and eventually dislocating. At this stage, claw toes produce pain due to deformity and metatarsalgia (pain in the distal plantar part of the foot).

The stages of claw and/or hammertoes are defined by the degree of stiffness and deformity they acquire over time:

  • Claw toes and/or flexible hammertoes: there is deformity of the toe but it is completely corrected when the foot is placed on the ground or manual pressure is applied.
  • Semirigid claw toe and/or hammer toe deformity: there is toe deformity but it is not completely corrected when the foot is placed on the ground or manual pressure is applied.
  • Rigid claw and/or hammer toes: when the toe presents a severe and rigid deformity that is also painful with the usual footwear.

The foot specialist or podiatrist, by means of a physical examination of the foot will be able to make a diagnosis with precision of the type of deformity of the toes that the patient presents. Normally, flexible claw toes or in early stages, when pressure is applied to the plantar aspect of the foot, the toe is observed to stretch and the deformity disappears.

However, when the deformity does not disappear, we are dealing with rigid claw and/or hammertoes with advanced deformity. In these cases, the only definitive treatment is surgery or minimally invasive foot surgery.

It is important to remember that bunions have a direct impact on toe deformities. For this reason, the bunion should be corrected as soon as possible to avoid toe deformities that require more complex and painful surgical treatments.

Why do claw and/or hammertoes occur?

Claw and/or hammertoes are caused by an anatomical alteration or neurological deficit that causes an imbalance in the muscular and tendon structures causing the deformity of the finger. This deformity worsens over time and is usually related to several factors:

  • Bunions produce an instability and deformity of the big toe that indirectly affects the other toes over time, causing claw and/or hammer toe deformity.
  • Type of hunted. High-heeled, narrow-toed shoes cause toes to bunch up in a very tight space.
  • Previous trauma and injuries. Previous foot injuries or surgeries that have altered or injured the joints of the foot may produce claw and/or hammer toe deformities.
  • Hereditary alterations of the muscular structures of the fingers can cause instability and subsequent deformity of the fingers.

There are also several risk factors for the development of claw and/or hammertoes:

  • Age. The risk of developing claw and/or hammertoes increases with age.
  • Sex. Women are more likely to develop claw and/or hammertoes than men.
  • Finger length. The Greek foot with a second toe that is longer than the first toe is more at risk of developing claw and/or hammer toe.
  • Inflammatory diseases or even diabetes are more likely to develop foot joint deformities.

What is the relationship between bunions and claw and/or hammertoes?

The bunion or hallux valgus can be diagnosed initially with the naked eye, it is observed as a deformity or protrusion in the medial part of the foot, more or less at the level of the big toe. The deviation of the big toe that causes bunions must be treated as soon as possible, otherwise the toe will not only become subluxated but will also cause deformities in the other toes.

The deviation of the big toe produces excessive and continuous pressure on the second toe causing an imbalance of the intrinsic and extrinsic musculature of the toe that eventually deforms into a claw and/or hammertoe.

The best treatment for claw toes is preventive, for this reason when a patient has a bunionette or hallux valgus deformity, he/she should see a foot specialist or podiatrist to correct this deformity as soon as possible. to solve bunions and reduce the likelihood of claw and/or hammertoe deformity.

However, when the patient already has a claw and/or hammer toe deformity, he/she should see a foot specialist or podiatrist for an evaluation. In initial stages, custom orthopedic insoles and silicone orthoses may be sufficient, and in more severe cases, minimally invasive surgery for claw toe correction may be the best option.

Bunion surgery to prevent claw and/or hammertoes

Bunions can be mild, moderate and severe. In the latter, the bony protrusion is usually accompanied by a deviation of the big toe that often affects the second toe and even deforms it.

In these cases, it is very important to perform surgery to correct the bunions and thus avoid the deformity of claw and/or hammertoes.

Minimally invasive or percutaneous bunionette surgery may be an option to correct bunions definitively and prevent the development of claw and/or hammertoes.

Depending on the degree of bunion deformity, two minimally invasive techniques can be used to correct bunions

Surgery for mild bunions or hallux valgus without fracture (without osteotomy):

Minimally invasive or percutaneous surgery allows simple resection of the bony deformity of the bunion, which involves a 7-day postoperative period with little discomfort and full mobility.

It is performed under local anesthesia and does not require any type of screw or pin. This surgery must be performed by foot specialists with great experience with these techniques and with special apparatus and instrumentation.

Surgery of bunions or moderate-severe hallux valgus with fracture (with osteotomy):

En more advanced cases of bunions where there is significant deviation of the big toe that may or may not affect the second toe, resection of the bony protrusion of the bunion and correction of the corresponding angles should be performed. In cases where there is also claw and/or hammer toe deformity, its correction should be performed in the same surgical act.

It is possible to perform all these procedures with minimally invasive or percutaneous technique without the use of screws or pins, both for bunion correction and for claw and/or hammertoes.

The postoperative period for this surgery is usually 40 days, during which the patient is walking from the first day with the help of a special post-surgical shoe for these techniques.

A specialist or podiatrist should be consulted to perform a complete study of the foot, which usually requires a physical examination of the foot and lower limbs, digital radiographs, computerized study of the footprint and finally, a vascular ultrasound of the lower limbs.

The specialist should explain clearly and precisely the best surgical option depending not only on the degree of deformity but also on the patient’s age and associated diseases. Finally, once the patient has understood the procedure, he/she will be able to make a decision about the surgery.

Corrective surgery for claw and/or hammer toes

There are several surgical techniques for the correction of claw and/or hammertoes depending on the degree of deformity.

Minimally invasive or percutaneous surgery is usually the best option as long as it is performed by highly experienced surgeons. In certain cases, open techniques may be necessary to obtain better results. In general, it can be done:

  • Arthroplasty: consists of removing the part of the bone that causes the deformity, maintaining a certain degree of mobility and achieving a shortening of the finger.
  • Arthrodesis: consists of correcting the deviation of the finger by fixing the joint in the neutral position.
  • Digital plastic surgery or “
    Cinderella feet
    In some occasions it may be necessary to shorten a toe by a few millimeters to obtain a proportional foot that fits in the usual footwear.
  • These procedures can also be combined with other techniques to achieve better alignment of the toes and eliminate the metatarsalgia that often occurs in patients with claw and/or hammertoes.

It is important to see a foot specialist or podiatrist for a complete study in order to offer a personalized treatment to each patient.

Postoperative period after surgery for bunions and claw and/or hammer toes.

Recovery time for bunion and claw and/or hammer toe surgery with minimally invasive or percutaneous surgery is 40 days when fracture (osteotomy) is performed, and 7-14 days when fracture is not required.

During the entire post-operative period, patients are walking with the aid of a special shoe, with little discomfort and minimal swelling, thanks to these techniques that cause minimal tissue damage and therefore allow a faster and more comfortable recovery than with other techniques.

Patients should be given an information sheet on post-operative care for bunion and claw and/or hammer toe surgery as well as all the information necessary for a quick and comfortable recovery.

If you or someone you know has bunions or toe deformities, don’t wait any longer because time will only aggravate the problem.

It is advisable to see a foot specialist or podiatrist for an initial assessment and, if necessary, corrective surgery for bunions and claw toes with a minimally invasive or percutaneous technique.

Remember that the feet are the fundamental pillar of our body, since they support

Your lifetime weight.

Bibliography

(Bauer et al., 2010)

BAUER, T., BIAU, D., LORTAT-JACOB, A. and HARDY, P., 2010. Percutaneous hallux valgus correction using the Reverdin-Isham osteotomy. Orthopaedics & Traumatology: surgery & research, 96(4), pp. 407-416.

(Bauer et al., 2009)

BAUER, T., DE LAVIGNE, C., BIAU, D., DE PRADO, M., ISHAM, S. and LAFFENÉTRE, O., 2009. Percutaneous hallux valgus surgery: a prospective multicenter study of 189 cases. Orthopedic Clinics of North America, 40(4), pp. 505-514.

(Brigan et al., 2009)

BROGAN, K., LINDISFARNE, E., AKEHURST, H., FAROOK, U., SHRIER, W. and PALMER, S., 2016. Minimally Invasive and Open Distal Chevron Osteotomy for Mild to Moderate Hallux Valgus. Foot & ankle international, 37(11), pp. 1197-1204.