Claw toe surgery in Nice and Cap d'Ail

What are toe claws (hammertoe) ?

Toe claws are when the lateral toes become deformed in flexion or extension. Much like, hallux valgus or quintus varus (bunionette), there are common causes that favor toe claws. These deformations can be painful because they modify the ground support. In the shoe, the deformed toe can rub and become painful, causing the appearance of corns on the foot or calluses.

At the level of a toe, there are 3 joints that can enter into the formation of a claw: the metatarsophalangeal (MP), the proximal interphalangeal (IPP) and the distal interphalangeal (IPD).

• The proximal claw is the most common form of toe claw characterized by a deformation of the PPI: the proximal part deforms upwards and the distal part downwards. The junction of these 2 deformations which can rub and come into conflict with the shoe to form a horn.
• The distal claw or hammer toe touches the IPD joint and corresponds to the flexion of the distal part of the toe only.
• When the 2 mechanisms are associated, we speak of mixed or total claw.

Where does it come from and what are the aggravating factors?

Muscles insert themselves into the bones of the toes through their end: the tendons. There are extensor tendons and flexor tendons. The toe claw reflects an imbalance of force between these tendons which deforms the toe by the play of the bony levers. This deformation is perpetuated over time.

The most common cause for a hammertoe deformity is hallux valgus. Hallux valgus is a deviation of the big toe towards the 2nd toe. He will push the latter and overload it mechanically: the 2nd toe deforms into a claw. Over time, the claw gets worse, which can lead to dislocation of the joint. It is best to see a toe specialist before this stage. In advanced hallux valgus, it is common to observe an overlap of the toes (supraductus or infraductus toe).

The causes may be related to an abnormality specific to the affected toe, such as excess skeletal length. There are contributing factors such as shoes that are too small or with a narrow toe, shoes with heels that constrict the toes and manhandle them. In addition to improper fit, certain shapes of the foot predispose to the development of hammertoe. For example, if the lateral toes are longer than the big toe (Greek foot), they will tend to claw more easily.

Contributing factors of claw toe:

• Flat or hollow foot shape
• Certain chronic inflammatory diseases (inflammatory polyarthritis)
• History of trauma
• Congenital pathology
• Certain sports such as skiing or dancing
• Hallux valgus or other problems on the big toe
• Narrow or high-heeled shoes
• 2nd toe too long (Greek foot)

What are the symptoms ?

The main reasons for consultation are pain, discomfort when putting on shoes or the presence of corns and partridge eye on the toes. The deformation of the toe will cause a conflict with the shoe and friction. The skin under these pressures defends itself and thickens causing horns in the form of corns above the toe, calluses at the tips of the toes, or "partridge's eye" between the toes. This keratotic skin quickly becomes painful as it thickens, requiring a pedicure to thin it out. Do not wait before making an appointment with a hammer toe or claw surgeon.

What is the evolution?

The deformity of the claw toes spontaneously progresses towards aggravation with increased pain and difficulty in putting on the shoes. The development of a toe claw goes through several stages:

• During the formation of the claw, the toe retracts on itself but it remains reducible and in contact with the ground. At this stage, we speak of flexible and reducible claw.
• Secondly, the claw becomes more pronounced with the worsening of the tendon retractions, the toe begins to rise, increasing the friction with the shoe above, and loses its support on the ground. The deformation becomes less and less reducible: we speak of a fixed or irreducible claw.
• Thirdly, the deformity progresses, tendon retraction continues, and the toe goes up so much that it ends up spontaneously coming out of its joint, achieving a subluxation or dislocation of the MP joint. At this stage, the toe is no longer touching the ground and the pressure is only on the metatarsals: we can see pain in the forefoot or plantar pain (metatarsalgia) and plantar hyperkeratosis.

In severe claws of the foot, complications may appear such as wounds or ulcers (diabetic foot +++) or joint (arthritis) or bone (osteitis) infections. Prompt consultation with a toe surgeon is essential to initiate medical treatment and avoid the operation.

What treatment for the claw toe can we offer?

The claw toe intervention will only be offered if non-surgical treatment is unsuccessful:

• The care of the pedicure is sufficient to relieve the painful areas when the deformities are minor. The pedicure-podiatrist will remove the thick superficial horn, without removing in depth because we must not forget that this horn is a means of defense of the skin against the mechanical stresses of friction and overload. Removing too much horn will reveal thin and fragile skin, which will no longer have the ability to defend itself, and which will be even more painful. The intervention of the podiatrist relieves the pain well, however,this is only temporary because the horn will reform.
• Adaptation of the footwear to these deformed toes: flexible and spacious shoes should be preferred
• Perform massages of the sole of the foot with stretching of the toes and their tendons.
• Making orthoplasty (soft splint) for correction claw toe to be done at the podiatrist or for protection (pharmacy). The podiatrist often makes silicone molds adapted to your foot shape. In pharmacies, you will find standard toe splints or digitubes.
• Physiotherapy: it fights against contributing factors such as the contracture of the gastrocnemius muscles and helps to keep the flexibility of the toes.
• If the medical treatment is no longer effective, that is to say that all the above measures are no longer sufficient to avoid the pain and the formation of horns, then a claw toe surgery should be considered. A consultation with your toe claw surgeon will allow you to make the diagnosis, offer medical treatment or even surgical treatment if necessary.

How do you prevent toe claws and hammer toes?

As mentioned above, toe claws should be treated as early as possible. If you have a conflict with your shoes or a beginner's claw, that is to say a deformation without pain or conflict in the shoe, it is possible to prevent the aggravation by simple preventive measures:

• Avoid overweight
• Favor flat shoes and avoid wearing high heels
• Prefer shoes with a wide forefoot that does not tighten the toes
• Have a pair of made-to-measure soles made (to be changed every year)
• Do physiotherapy to stretch the tendons and work on flexibility

What is the purpose of the claw toe procedure?

Learn all about hammer toe surgery, the operation and its prices.

The goal of the intervention on the claw toe is to straighten it long term, that is to say to put it back flat and to recover support on the ground (pulp contact). We do not perform isolated resections of corns, hyperkeratosis, horns or calluses (significant risk of failure) because the aim of the surgery is to treat the cause and not the consequence of the claw. The main goal of hammer toe surgery is to have a painless, shoe-able foot. The presence of corns (plantar hyperkeratosis) disappears within a few weeks with the modification of the mechanical constraints and testifies to an effective intervention. Each label is unique and only a specialized consultation can inform you about the actions to be carried out. To know exactly the nature of the treatment to be performed, the surgeon will first have to specify certain elements in consultation. The choice of technique and the assessment of the procedures to be performed is left to the surgeon depending on the severity of the condition and the complexity of the intervention. The tracks from a few millimeters to a few centimeters depend on the technique used.

However, we can remember that the intervention of the hammertoe combines gestures :

• On the soft parts : tendon lengthening or tendon section (tenotomies)
• On the joints : release of joint retractions (arthrolysis)
• On the bones : osteotomies, arthrodeses or arthroplasties of the phalanges and metatarsals

To achieve this result, different surgical techniques are possible, such as percutaneous claw toe surgery, minimally invasive surgery or more traditional techniques called « open ». Percutaneous (micro-incisions) and minimally invasive surgery largely in dits place in surgical treatment. The surgical procedures performed are the same as in conventional surgery but the incisions made are smaller. These modern surgical techniques reduce postoperative pain and allow faster rehabilitation in everyday life.

How is the claw toe surgery performed ?

The operation is usually performed on an outpatient basis, reducing the length of hospital stay to one day. However, for various reasons, it is possible to provide for 1 night of hospitalization.

You will need to perform the mandatory pre-anesthetic consultation with the anesthesiologist. During this consultation, the anesthesiologist will explain the possible modes of anesthesia to you according to your associated pathologies and the planned surgical procedure. If necessary, he will adapt your treatment before and after the procedure and may prescribe anticoagulants, painkillers, anti-inflammatory drugs or others.

Several types of anesthesia are possible : you may benefit from local or regional anesthesia meaning that only your leg will be desensitized : this is the most common. General anesthesia is also a solution if you prefer to sleep.

• Before the toe claw operation : you will be placed on a bed and then taken to the pre-anesthesia room. Local anesthesia will be performed before entering the operating room.
• Installation in the operating room : you will be installed in the supine position (on your back)
• The tourniquet : Throughout the operation, a tourniquet is usually placed at the ankle to prevent bleeding.
• The incision : The incision measures a few millimeters with the percutaneous technique (minimally invasive or micro-invasive surgery). The surgeon works with specific instruments through the skin and with a preoperative x-ray machine. The surgeon performs a section of the retracted structures then the osteotomies. The technique called « open » requires an incision of a few centimeters, this technique is useful in severe deformities : the scar is made on the top of the toe or on the side.
• The surgical procedure : the objective of the surgical procedure is to realign the toes and to relax the retracted parts. We perform bone or soft tissue procedures such as tendon lengthening or sections of tendons (tenotomy) and bone procedures such as fractures (osteotomy), arthroplastic resections or arthrodeses (surgical fusion of a joint).
• Operative time : the duration of the surgical procedure is relatively short, generally 30 to 60 minutes. The intervention may be longer in the event of associated procedures or operating difficulties.
• The material : In some cases, the osteotomies performed are not fixed and do not require any fixing material. In other cases, it is common to use hardware such as screws or specific implants.
• At the end of the operation : the surgeon uses a dressing that must be kept for 21 days.
• It is important to note that the surgeon may face an unforeseen or unusual situation requiring different acts than those initially planned. In this case, the surgeon will explain the difficulties encountered and the actions taken as soon as you wake up or return to your room.

What are the postoperative consequences ?

WALKING

As soon as you leave the operating room, walking is authorized in most cases on condition that you wear the special shoe that was prescribed for you in consultation. This shoe is worn for 2 to 6 weeks. After this time, you can put on regular shoes if the pain permits. You should strive to walk with your whole foot and not just the inner edge. Crutches can be useful for the first few days to make walking easier.

THE BANDAGE

Care of dressings may be necessary. In this case, a prescription will be given to you by the secretary. In the other cases, the surgeon makes a dressing of the foot in the operating room which you will have to keep for 21 days. This dressing is an integral part of the surgical treatment and should be kept until the next consultation appointment. It can only be removed or changed by the surgeon, even if it is stained with blood. If you are worried about the dressing, contact the secretary and we will receive you for consultation as soon as possible. We will do the bandage again to make sure there is no problem. The first dressing will be repaired by us during your postoperative appointment 21 days after the operation.

SWELLING

Swelling is not a complication and is a common occurrence after such an operation. To speed up its absorption, it is recommended to regularly ice the foot and put the foot up as soon as you feel the swelling. It takes about 2 months for the swelling to deflate to 80% and 6 to 9 months for the foot to deflate completely.

CARE AT HOME

Unless your surgeon advises otherwise, no dressing is necessary.

MEDICINAL TREATMENTS

Depending on your history, your existing medical conditions and your mobility, the anesthesiologist may prescribe anticoagulant therapy by injection (subcutaneously) or systemically (per os). This treatment helps prevent the onset of phlebitis, i.e. the formation of a clot in the veins.

It is strongly recommended to take the painkillers prescribed systematically during the 2 days following the surgery.

PHYSIOTHERAPY

Physiotherapy is not systematic ; its usefulness will be assessed by the surgeon during your first postoperative consultation. In order to accelerate functional recovery and the elimination of swelling, self-rehabilitation is essential. If necessary, physiotherapy sessions will be prescribed to you during your first postoperative appointment.

DRIVING AND STOPPING WORK

Driving is prohibited for 3 weeks (unless you have had surgery on your left foot and you have an automatic car). The average time off work is 30 to 60 days depending on your professional activity.

SPORTS ACTIVITIES

The resumption of swimming and cycling is allowed from the 1st month and the resumption of other activities from the 2^nd postoperative month.

POST-OPERATIVE FOLLOW-UP

Two post-operative appointments are necessary : ​​on the 21st day and then 60 days after the operation.

IN CASE OF QUESTIONS

For any additional questions or in the event of a problem, you can contact his secretary (email secretariat@chirurgie-pied-sport.com).

The purpose of the claw toe operation is to realign the toes and regain contact with the ground removing the bump and the conflict with the shoe. In most cases, the surgical procedure is an outpatient hospitalization and support is authorized immediately.

What are the complications of the surgery ?

The following list of complications are not exhaustive, but the most frequent complications are mentioned.

Any surgery exposes you to complications that are both common and specific to the type of intervention performed. This risk varies from one individual to another depending on their age, existing medical conditions (hypertension, diabetes, poor skin condition, etc.) as well as depending on their lifestyle (tobacco, alcohol, practice of a sports activity).

Some complications can be prevented by simple measures such as :

• compliance with postoperative instructions.
• stopping smoking.

Common Complications

• hematoma is an infrequent complication, favored by certain drug treatments (anticoagulants). Some risky drugs can be stopped and taken over by the anesthesiologist. The hematoma rarely requires surgical revision, it most often resolves with ice and rest.
• The healing problems are exceptional thanks to the use of percutaneous and minimally invasive techniques. Their occurrence is increased by tobacco and poor skin condition.
• Swelling is not a complication but a reaction of the body to the aggression of surgery. In order to lessen its importance, it is useful to do your self-rehabilitation by moving your toes, to remain at rest for 15 days and to elevate your foot as much as possible when you are at rest. If you are standing, you have to walk with the special shoe (avoid standing still).
• Thrombophlebitis is the formation of a clot in a vein, most often in the leg or foot. Its prevention is walking and possibly, depending on the anesthetic prescriptions, the administration of an anticoagulant treatment by the subcutaneous route or even systemically.
• Algodystrophy or « complex regional pain syndrome » is an overreaction of the body to the aggression of surgery. The symptoms are : redness, stiffness, edema and pain. The evolution is always towards healing without sequelae but the evolution is long (up to 18 months). Certain simple measures minimize this risk : the pain must not be allowed to set in and the prescribed painkillers should be taken systematically during the 48 hours postoperatively. Infection can occur despite precautions (preoperative shower, surgical aseptic preparation). It should be considered in case of fever, scar breakdown, purulent discharge or significant redness. It requires surgical advice.

Specific complications

• Insufficient correction is the persistence of the little hammertoe
• Pseudarthrosis is the failure of fractures to heal. This complication is rare thanks to percutaneous surgery. Lack of bone healing is often asymptomatic. Revision surgery will only be considered in the event of discomfort or pain.
• Bone necrosis is the death of bone due to damage to its vascularization.
• Recurrence of the deformity is the reappearance of the deformity after surgery.
• Appearance of other toe claws : each toe is independent and can undergo at its own pace and in time the effects of the musculo-tendon retraction of its own tendons. They are likely to continue their deformation process, and may one day also request their own intervention.
• Secondary displacement is the displacement of fractures or screws during the period of bone healing. Protecting the support with the postoperative shoe reduces this risk. It most often occurs as a result of trauma or sudden landing on the operated foot.