Lesser Toe Deformities Research Articles

Lesser Toe Deformities

Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma, genetics, inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various appliances. Surgical management is reserved for patients who fail nonsurgical treatment. Options include soft-tissue correction (eg, tendon transfer) as well as bony procedures (eg, joint resection, fusion, metatarsal shortening), or a combination of techniques.

Gait, balance and plantar pressures in older people with toe deformities

Older people with toe deformities have been identified as having an increased risk of falling. Little is known, however, about the biomechanical changes that might contribute to this increased risk. Therefore, the purpose of this study was to determine whether older people with hallux valgus and lesser toe deformities displayed different gait, balance and plantar pressure characteristics compared to individuals without toe deformities. The presence of hallux valgus and lesser toe deformities were assessed for 312 community-dwelling older men and women. Spatiotemporal gait parameters were measured using the GAITrite® system, postural sway was assessed on two surfaces using a sway-meter and dynamic plantar pressure distribution was measured using an Emed-AT4 pressure plate. The results indicated that, although there were no effects of toe deformities on spatiotemporal gait characteristics or postural sway, older people with hallux valgus (n=36) and lesser toe deformities (n=71) were found to display altered forefoot plantar pressure patterns. These findings suggest that toe deformities alter weight distribution under the foot when walking, but that the relationship between toe deformities and falls may be mediated by factors other than changes in spatiotemporal gait parameters or impaired postural sway.

Rezidive nach Korrektur von Hammer- und Krallenzehen

Symptomatic lesser toe deformities should be corrected if conservative therapy is exhausted or no longer seems appropriate. Prevention of recurrence starts with the correct indication for the appropriate surgical procedure. The occasional difficult question of the cause of the deformity is crucial in this context. A correct surgical technique and appropriate after-care reduces the risk of recurrence. Due to tensed bony and soft-tissue conditions, revision surgery of the forefoot is challenging. If a revision becomes necessary, the cause of recurrence must be re-examined. This paper explains the appropriate indications and surgical techniques for correction of lesser toe deformities. Subsequently, specific postoperative complications and their management are discussed in detail.

Resection Arthroplasty of the Lesser Metatarsophalangeal Joint for Correction of the Severe Complex Hammertoe

The optimal management of a complex hammertoe deformity, with fixed contractures, remains a clinical and surgical challenge. Numerous surgical techniques have been described for correction of this lesser toe deformity, predominately achieving correction through alteration of both the proximal interphalangeal joint and the metatarsophalangeal joint of the affected toe. The technique presented here uses the metatarsophalangeal joint for treatment of this sagittal plane deformity, accomplished through a metatarsophalangeal joint resection arthroplasty combined with soft tissue interposition. And when reserved for the digit that is not amenable to (or has already failed) standard hammertoe surgical intervention its degree of correction can be quite powerful. This procedure is consistent and durable in nature, and converts a malaligned functionless painful toe into an aligned, painless, and passively flexible digit.

Soft tissue thickness under the metatarsal heads is reduced in older people with toe deformities

The purpose of this study was to determine whether thickness of the plantar soft tissue (ST) under the metatarsal heads (MTH) differed between older individuals with and without toe deformities. Non-weightbearing total ST and fat pad (FP) thickness at the heel, 1st metatarsal head (1MTH) and 5th metatarsal head (5MTH) were measured using ultrasound in 312 men and women aged over 60 years. Each participant had their feet assessed for the presence of hallux valgus or lesser toe deformities. Total ST and FP thicknesses in those with hallux valgus (n=36) or lesser toe deformities (n=72) were compared to gender-, age- and BMI-matched controls using independent t-tests. Individuals with hallux valgus had significantly reduced total ST thickness under 1MTH compared to controls (7.4 ± 1.6 mm vs. 8.5 ± 1.5 mm; p = 0.002). Similarly, individuals with lesser toe deformities displayed significantly reduced total ST thickness under 5MTH compared to controls (5.1 ± 1.0 mm vs. 5.5 ± 1.3 mm; p = 0.01). As FP thickness did not differ between cases and controls, we speculate that the musculotendinous complex is compromised, and may result in reduced toe function in those with toe deformities.

Prospective review of medium term outcomes following interpositional arthroplasty for hammer toe deformity correction

Hammer toe is a common lesser toe deformity that is usually found to affect the second toe. A number of procedures have been applied in its surgical management with varying results but there is still no consensus on the best technique. We prospectively reviewed a consecutive series of patients treated with interpositional arthroplasty, early mobilisation and with a minimal follow up of 6 months. We measured outcome using the Manchester Oxford foot and ankle questionnaire and a global impression of change score. There was a high level of satisfaction with the resulting pain relief and the type of footwear worn thereafter. We had no complications in terms of infection or chronic pain. There were no early recurrences within our follow up period. Overall we demonstrate good to excellent results with this surgical tactic allowing pain relief, early mobilisation and a low risk of infection.

Foot shape of older people: implications for shoe design

Foot problems and deformities, which are highly prevalent in older people, may affect foot anthropometrics and result in older people having difficulty finding shoes that fit. This study aimed to characterise the dimensions and shape of the feet of older people and to determine whether foot anthropometrics were influenced by gender and/or the presence of foot problems in older people. Foot anthropometrics and foot problems were assessed in 312 community-dwelling older men and women. Men had significantly higher normalised first and fifth toe heights and a greater fifth toe angle, whereas women had a significantly longer normalised medial ball length and greater first toe and heel bone angles (p < 0.05). Older people who had moderate-to-severe hallux valgus, lesser toe deformities, swollen or flat feet exhibited different foot anthropometrics to those without foot problems. Consequently, footwear for older people should be designed to cater for the altered morphology of older feet.

Radiographic Analysis of Proximal Interphalangeal Joint Arthrodesis With an Intramedullary Fusion Device for Lesser Toe Deformities

Lesser toe deformities are frequent and bothersome conditions. Many options exist for the treatment of hammertoes and clawtoes. The purpose of this study was to review our experience with the use of an intramedullary fusion device. An IRB approved retrospective review was performed to identify 38 toes in 27 patients treated with the StayFuse (Nexa Orthopaedics) device with a mean followup of 31 months. The indications for surgery were primary deformity in 12 toes and recurrent deformities in 26 toes. Union occurred in 23 of 38 (60.5%). The union rate was nine of 12 for primary procedures and 53.8% (14/26) for revisions. Coronal PIP alignment demonstrated no change in 33 of 38 cases (86.8%) and changed in five of 38 (13.2%). Sagittal PIP alignment demonstrated no change in 36 of 38 cases (94.7%), and changed in 2/38 (5.3%). Including nonunion, the overall complication rate was 55.3% (21/38) (15 nonunions; three hardware failures (two (bent) not requiring intervention and one (broke) leading to a rotational deformity requiring revision), one intraoperative fracture (without sequelae), one requiring MP surgery, and one requiring a larger implant. The index surgery for all three of the patients that required a second surgery was for a recurrent deformity. All three patients requiring a second surgery occurred in the nonunion group. The StayFuse intramedullary fusion device was efficacious in maintaining PIP alignment in the treatment of lesser toe deformities with a relatively low reoperation rate at mid-term followup.

Subcapital Oblique Osteotomy for Correction of Bunionette Deformity

The subcapital oblique osteotomy, or Weil osteotomy, is commonly used for other lesser toe deformities but has been infrequently described as a technique for correcting the bunionette deformity due to a large metatarsal head or mild increase in 4-5 intermetatarsal angle. Combined with distal soft tissue realignment, this technique is effective and has the advantage of allowing for elevation of the metatarsal head when increased plantar pressure presents as part of the pathology.

Reseksjon i proksimale falang ved hammertå

Hammertoe is one of several toe deformities caused by an imbalance between tendons which flex and extend the toes. The condition is most common among women and may be caused by systemic disease, but is most often idiopathic. The standard method of operation is resection of the distal part of the proximal phalanx. We here report an evaluation of our results after operation of hammertoe at a Norwegian hospital. After reviewing medical records for patients operated for hammertoe (at St. Olav Hospital in a 6-year-period [1999-2004]), we requested the patients to assess the intervention in a mailed questionnaire. Those who still had complaints were asked to come for a clinical check-up. 141 patients were operated for hammertoe in the period; 131 completed the questionnaire. The mean follow-up time was 5 years (range 3-8). 86% of those operated were women and the mean age at the time of operation was 65 years. 25% of the operated patients described that they had been dissatisfied with the results of the primary operation. 41% of those who had been dissatisfied had hyperextension in the metatarsophalangeal (MTP)-joint in addition to flexion in the middle joint. A dissatisfaction rate of 25% is too high. An additional diagnosis of hyperextension of the MTP-joint requires MTP soft tissue release, which differs from the standard operation of hammertoe. We suggest that a better preoperative differentiation between the lesser toe deformities can increase satisfaction with the treatment.

ISB Clinical Biomechanics Award 2009: Toe weakness and deformity increase the risk of falls in older people

Background Hallux valgus and lesser toe deformities are highly prevalent foot problems in older people. One factor contributing to the development of these toe deformities is reduced toe flexor strength. As adequate toe flexor strength is also crucial in maintaining balance, it was hypothesised that poor toe flexor strength and toe deformities would increase the risk of falls in community-dwelling older people. Method The feet of 312 men and women aged 60–90 years were assessed for the presence of lesser toe deformities and hallux valgus. Hallux and lesser toe flexor strength were assessed using an emed AT-4 pressure platform and novel test protocol. Participants were then followed prospectively to determine their falls incidence over 12 months. Findings During the 12 month follow-up, 107 (35%) participants experienced a fall. Compared to non-fallers, fallers displayed significantly less strength of the hallux (11.6 (SD 6.9) versus 14.8 (SD 7.8)% BW, P < 0.01) and lesser toes (8.7 (SD 4.7) versus 10.8 (SD 4.5)% BW, P < 0.01), and were more likely to have hallux valgus (relative risk [RR] = 2.36; 95% CI = 1.03–5.45; P < 0.01) and lesser toe deformity (RR = 1.32; 95% CI = 1.04–1.69; P < 0.01). Interpretation Reduced toe flexor strength and the presence of toe deformities increase the risk of falling in older people. To reduce this risk, interventions designed to increase strength of the toe flexor muscles combined with treatment of those older individuals with toe deformities may be beneficial.

Definitions of Hammer Toe and Claw Toe

Lesser toe surgery is among the most conducted interventions in general orthopedic practice. However, the definitions of hammer toe and claw toe are not uniform. The objective of this literature study is to propose clear definitions for these deformities to establish unambiguous communication. A literature search was performed in the PubMed database (May 2006). Of 81 eligible articles, 42 that stated a clear definition of hammer toe or claw toe were selected. In all 35 articles in which hammer toe was clearly defined, flexion in the proximal interphalangeal joint was part of the definition. Seventeen articles (49%) defined hammer toe as a combination of metatarsophalangeal extension and proximal interphalangeal flexion. Thirteen articles showed flexion of the proximal interphalangeal joint as the single criterion. Twenty-three articles with a clear definition of claw toe were selected. Twenty-one articles (91%) showed metatarsophalangeal extension as part of the claw toe deformity. Twelve articles (52%) regarded metatarsophalangeal extension and flexion of the proximal interphalangeal and distal interphalangeal joints as the essential characteristics. Seven articles described a claw toe as metatarsophalangeal extension with flexion in the proximal interphalangeal joint. There are variations in the definitions of lesser toe deformities in the literature. We propose that extension of the metatarsophalangeal joint is the discriminating factor and essential characteristic for claw toe. Claw toe and hammer toe should be characterized by flexion in the proximal interphalangeal joint, which is the single criterion for a hammer toe. The flexibility of these joints could be a basic factor in discriminating between these deformities. The development of these deformities should be regarded as a continuum in the same pathophysiologic process.

Der subligamentäre Transfer der Extensor-digitorum-brevis-Sehne zur Behandlung der medialen Achsenabweichung der Kleinzehen

Realignment of medially deviated lesser toes II-IV via subligamentous transfer of the extensor digitorum brevis tendon to treat painful toe disorders. Flexible medial malalignment of the lesser toes II-IV attributed to transverse instability of the metatarsophalangeal joint. Contract lesser toe deformities. Medial malalignment due to an osseous pathology or instability of the proximal interphalangeal joint. Neuropathy. Infection. Regional anesthesia. Patient in supine position. Dorsal S-shaped skin incision at the metatarsophalangeal joint. Medial split of the extensor hood. Dorsomedial capsular release. Distal tenotomy of the extensor digitorum brevis tendon. Transfer of the tendon slip beneath the intermetatarsal ligament to the lateral aspect of the proximal phalanx. After manual realignment of the toe periosteal or intraosseous fixation of the tendon. Bulky dressing with well-aligned toes. Anti-inflammatory drugs. Walking (full weight bearing) with a forefoot relief orthosis for 4 weeks. Toe splint and/or bandage for 12 weeks. Active exercises (toe flexion, standing on tiptoes, aquajogging) can be started after 4 weeks. Comfortable shoeware after 4 weeks. 23 of 32 patients with flexible medial malalignment of the lesser toes II and/or III were followed up after a mean of 19 months. Medial malalignment could be reduced markedly (preoperatively 28 degrees, postoperatively 6 degrees). Four patients treated with the tendon transfer alone developed a recurrent deformity with dorsal subluxation at the metatarsophalangeal joint level. These patients revealed a concomitant hallux valgus deformity of >30 degrees. Six patients with an additional metatarsal shortening presented with floating toes. Although all patients were able to stand on tiptoes, the active range of toe motion was decreased. Radiologically, joint congruency was improved. 18 patients revealed a congruent joint, and five patients presented with a medial subluxation of the proximal phalanx.

Clinical audit of foot problems in patients with rheumatoid arthritis treated at Counties Manukau District Health Board, Auckland, New Zealand

BackgroundAt diagnosis, 16% of rheumatoid arthritis (RA) patients may have foot joint involvement, increasing to 90% as disease duration increases. This can lead to joint instability, difficulties in walking and limitation in functional ability that restricts activities of daily living. The podiatrist plays an important role in the multidisciplinary team approach to the management of foot problems. The aim of this study was to undertake a clinical audit of foot problems in patients with RA treated at Counties Manukau District Health Board.MethodsPatients with RA were identified through rheumatological clinics run within CMDHB. 100 patients were eligible for inclusion. Specific foot outcome tools were used to evaluate pain, disability and function. Observation on foot lesions were noted and previous history of foot assessment, footwear/insoles and foot surgery were evaluated.ResultsThe median age of the cohort was 60 (IQR: 51–64) years old with median disease duration of 15 (IQR: 7.3–25) years. Over 85% presented with foot lesions that included corns and callus over the forefoot region and lesser toe deformities. Moderate to high disability was noted. High levels of forefoot structural damage were observed. 76% had not seen a podiatrist and 77% reported no previous formal foot assessment. 40% had been seen at the orthotic centre for specialised footwear and insoles. 27% of RA patients reported previous foot surgery. A large proportion of patients wore inappropriate footwear.ConclusionThis clinical audit suggests that the majority of RA patients suffer from foot problems. Future recommendations include the provision of a podiatrist within the current CMDHB multidisciplinary rheumatology team to ensure better services for RA patients with foot problems.

Results of Distal Metatarsal Osteotomy Using Absorbable Pin Fixation

Metatarsalgia with plantar hyperkeratosis can be a difficult problem to treat. Many different techniques have been reported with the Weil osteotomy very popular currently. Despite good results complications include metatarsophalangeal stiffness, hyperextension of the toe, prehensile deficit and a reduction in strength. We evaluated our results with a distal diaphyseal osteotomy. From 1999 to 2005, we performed 66 distal midshaft subtraction osteotomies in 62 patients suffering from metatarsal overload without metatarsophalangeal subluxation. Fixation was obtained with an absorbable pin. Some patients underwent simultaneous corrective surgery for hallux valgus, hallux rigidus or lesser toe deformities. There was an average of 18 months followup. The mean preoperative Maryland score was 52; the mean postoperative score was 86. Seventy-two percent of the patients were very satisfied and 28% felt their condition improved with only occasional pain (VAS 2 to 4). The only complications reported was a loss of correction due to breakage of the pins in three patients (two sustained trauma and the third began walking prematurely without a postoperative shoe). The good clinical results obtained and the low incidence of complications have encouraged us to use this technique to treat symptomatic metatarsal overload. Surgical accuracy, adherence to the postoperative regimen and, where necessary, adequate correction of the first ray were important factors for success.

Opinions on Lesser Toe Deformities Among Dutch Orthopaedic Departments

Wide variations in definitions of lesser toe deformities exist. In addition, a general consensus regarding treatment of lesser toe deformities is lacking. The objective of this study was to evaluate of the definitions, current concepts, and treatment protocols for lesser toe deformities among orthopaedic departments in The Netherlands. A questionnaire with statements regarding lesser toe deformities was sent to all 101 Dutch departments of orthopaedic surgery. In total 76 (75%) completed forms were analyzed. A wide variation regarding definitions, concepts, and treatment strategies of lesser toe deformities was reported among the Dutch orthopaedic departments. Only half of all responding departments had a protocol or consensus in the treatment. The definitions of lesser toe deformities used in Dutch orthopaedic departments do not coincide. This might explain the variations in indications and the various performed interventions for different deformities. The differences of opinion among the Dutch orthopaedic departments may have important clinical consequences because an indication for surgery depends on the correct diagnosis. To correctly interpret and improve treatment results, a consensus on this topic should be introduced.

Prevalence and type of foot surgery performed in Australia: A clinical review

The aim of this study was to investigate the type and prevalence of foot surgery being conducted by fellows of the Australian College of Podiatric Surgeons. Methods A clinical audit of 786 patient files was undertaken, all of whom had been operated on by 10 podiatric surgeons during a 12-month period. A coding framework was used whereby all files audited had each foot condition classified according to the International Classification of Diseases. Results A total of 1575 diagnosed conditions, which subsequently underwent surgical treatment were identified in 785 case files. The most common conditions identified in this study were: lesser toe deformities (46.1%), hallux abducto valgus (20.8%), intermetatarsal neuroma (Morton's) (7.8%), hallux rigidus/limitus (6.6%) and onychocryptosis (6.7%). It would appear that, on a state for state basis, the amount of foot surgery conducted by podiatric surgeons across Australia is relatively uniform. In terms of the type and prevalence of conditions surgically treated by podiatrists internationally, these rates bear striking similarity to the results reported in the United Kingdom and the United States. Conclusion The data suggests podiatric surgeons operate ostensibly on healthy female patients in their fifth and sixth decade of life. Almost half of the patients operated upon underwent multiple procedures, with variability in the type and frequency of procedures most likely being attributable to individual surgeon preference.

Arthroscopy and Endoscopy of the Foot and Ankle: Indications for New Techniques

The scope of arthroscopy and endoscopy of the foot and ankle is expanding. New techniques are emerging to deal with diverse ankle pathology. Some of the conditions that can be dealt with arthroscopically are as follows: hallux valgus deformity, lesser toe deformity, first metatarsophalangeal instability, cock-up deformity of the big toe, peroneal tendon instability, lateral ankle and subtalar instability, hindfoot deformity or arthrosis, first metatarsocuneiform hypermobility, Lisfranc joint arthrosis, various stages of posterior tibial tendon insufficiency, foot and ankle arthrofibrosis, late complications after calcaneal fracture, acute and chronic Achilles tendon rupture, insertional Achilles tendinopathy, entrapment of the first branch of the lateral plantar nerve, Freiberg’s infarction, flexor digitorum longus tenosynovitis, flexor hallucis longus pathology, calcaneonavicular coalition or “too-long” anterior process of the calcaneus, and ganglions. With sound knowledge regarding the indications, merits, and potential risks of new techniques, they will be powerful tools in foot and ankle surgery.

Plantar pressures are higher under callused regions of the foot in older people

Mechanically induced hyperkeratotic lesions (corns and calluses) are among the most common foot problems in older people. However, their aetiology is not well understood. To compare the magnitude of pressures generated under the foot when walking in older people with and without plantar calluses. Peak plantar pressure measurements were obtained from 292 participants (99 men and 193 women) aged 62-96 years (mean +/- SD 77.6 +/- 6.9) recruited from a retirement village and a university health sciences clinic. Comparisons were then made between callused and noncallused regions of the foot. In total, 151 participants (52%) had at least one plantar callus. Those with plantar calluses were more likely to be female, have moderate to severe hallux valgus, and at least one lesser toe deformity. Regional peak plantar pressures were significantly higher in people with calluses under the second metatarsophalangeal joint (2.34 +/- 0.46 vs. 2.12 +/- 0.51 kg/cm(2), P = 0.001), the third to fifth metatarsophalangeal joints (1.71 +/- 0.46 vs. 1.50 +/- 0.51 kg/cm(2), P = 0.009) and the hallux (1.40 +/- 0.34 vs. 1.23 +/- 0.47 kg/cm(2), P = 0.007) compared with people without calluses under these sites. Plantar pressures are significantly higher under callused regions of the foot in older people. Raised pressure may play a role in the development of plantar calluses by accelerating the turnover rate of keratinocytes in the epidermis. Future studies should focus on evaluating the efficacy of pressure-relieving interventions in the prevention and treatment of keratotic disorders in older people.

Transfer of the Flexor Digitorum Longus for the Correction of Lesser-Toe Deformities

This study reviewed the results, complications, and patient satisfaction rates of a modified technique of flexor-to-extensor tendon transfer for correction of lesser-toe deformities. Records of 38 patients (79 toes; 46 feet) were identified and reviewed retrospectively. The mean duration of clinical followup was 33 (range 6 to 121) months. The average age of patients was 65 (range 27 to 82) years; 32 were women (84%) and six were men. In 89% of the toes (70 toes; 34 patients; 42 feet) patients were satisfied with the procedure and would have it again. The technique described for flexor-to-extensor transfer for correction of lesser-toe deformities resulted in few complications, no "floating" toes and high patient satisfaction.