Orthopedics-Online

Hammer toe surgery

introduction

The hammer toe is a permanent, claw-like flexion of a toe that occurs primarily in the first toe joint near the metatarsus. Hammer toes are the most common deformity on the foot and affect many people. The extent of the disease has a significant influence on the symptoms, the treatment options and the level of suffering of those affected. In the early stages of the hammer toe, conservative therapy with the help of barefoot walking, special orthopedic insoles or physiotherapy can achieve promising results.

indication

Conservative therapy can effectively counteract an incipient flexion of the toe joints and, in the early stages, stop the hammer toes from advancing and even correct the position of the toes. If a therapeutic success with conservative treatment is not possible, various surgical interventions can be used.

The individual indication for surgical treatment must be determined jointly by the doctor and the patient, taking into account the prospects of success, the situation in life, the level of suffering and the symptoms. Lengthy conservative therapies are not advisable, especially for young, sporty patients and those affected with severe symptoms. In addition to the pain caused by the hammer toe, the decisive symptoms also include calluses, problems with shoes and in everyday life, as well as aesthetic complaints.

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These surgical methods exist

There are primarily two surgical methods available for correcting hammer toes. The surgical procedure can generally only be carried out if there are no hazards, for example problems with anesthesia or severe circulatory disorders in the leg.

Read more on the topic: Risks of anesthesia and circulatory disorders in the legs

The most important differentiator for choosing a surgical method is a contracture of the tendons in the hammer toe. If the examination shows that the malposition is tight and cannot be straightened manually, the Hohmann operation is recommended. Flexible misalignments, on the other hand, should be addressed with the Weil operation.

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Athletes (joggers, soccer players, etc.) are particularly often affected by diseases of the foot. In some cases, the cause of the foot discomfort cannot be identified at first.
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OP according to Hohmann

The Hohmann operation is the major procedure and is only carried out when a so-called fixed hammer toe is present. Over time, the permanent flexion of the toe joints can shorten the tendons. The soft tissues of the toes can also shorten and contractures.

A simple repositioning of the tendons is no longer possible in these cases, so that in the Hohmann operation the head of the metatarsophalangeal joint must also be removed from the bone. The contracted tendon is then stretched and, if necessary, detached from the bone. Such an intervention is called a "Osteotomy“, A bone remodeling that is only used when all conservative and gentle surgical procedures do not help and the hammer toe is completely irreversible.

OP after Weil

The operation according to Weil represents the gentler variant in the treatment of hammer toes. It is only possible with the so-called "flexible" hammer toe. One speaks of this when the hammer toe can be easily returned to its original position. So there are no fixed contractures of the tendons and soft tissue.

In the Weil operation, too, the toe bones are severed, which, however, are only pushed forward in order to change the position of the toe. The metatarsophalangeal joint is retained. Here, too, the tendon is then lengthened. The displacement of the bones is fixed with small screws that can remain in the body.

OP with wire

The introduction of a wire to fix the hammer toe is a common variant of the Hohmann operation. In the case of particularly tight contractures, the toe must be supported with a wire for a few weeks. The wire serves as an internal splint so that the toe does not fall back into its original position after the operation.

For this purpose, the wire can be inserted along the toe intraoperatively and remains there for about 2-4 weeks until the surgical hematomas and swellings have subsided and the bone has had time for primary healing. During this period of time, the toe is difficult to move and should first be wallpapered, splinted from the outside and immobilized. Physiotherapy can only be started after the wire has been removed.

How is the wire removed?

The wires can be inserted at different points for splinting the toe. They can only run through the soft tissues, which makes removal very easy. More rarely, they are also fixed in the bone, which is associated with perforation of the bone and joint and difficult removal.

After the period of 2-4 weeks determined by the surgeon, the wires can be pulled without anesthesia. As a rule, this is a very short and painless process, so that an anesthetic would not bring any benefits.

An important indication for removing the wire immediately is possible redness, overheating and sensitive pain at the point where the wire emerges. This can be local inflammation. In rare cases, removal can be made more difficult by wandering the wires. The wire can be moved and anchored through the healing processes in the bones and soft tissues, so that in rare cases it is not possible to simply remove it without anesthesia.

What complications can there be?

Every surgical procedure is associated with risks and complications. Surgical intervention should always only be planned after carefully considering other treatment options. With toe surgery, the risk of complications is also related to the surgeon's experience.

A typical risk of the operation is infection in the operation area, in a joint of the foot or at the exit point of the wire. Inadvertent injuries to bones, nerves, tendons, muscles and other tissues in the operating room are also always possible during a surgical procedure.

Read more on the topic: Postoperative Complications - What Are There? or fever after an operation

After the operation, problems such as thrombosis can be expected due to prolonged immobilization. It can also happen that the operation does not achieve the desired effect and that the toe has secondary symptoms.

Read more on the topic: Postoperative thrombosis prophylaxis

The anesthesia can also lead to unpleasant symptoms such as allergic reactions or intolerance to the anesthetics. The operation can never guarantee freedom from symptoms. For this reason, the operational risks must never be disregarded and conservative treatments must be in the foreground.

Read more on the topic: Side effects of general anesthesia

Can you do this on an outpatient basis?

The operation of the hammer toe is a comparatively small operation. Outpatient treatment is also possible. Before the operation, an appointment must be made for a preliminary examination, discussion of the procedure and information about the anesthesia. The precautions and fasting times discussed in advance must then be observed for the day of the operation.

Read more on the topic: Anesthesia - procedure, risks and areas of application

The outpatient operation is usually carried out in the morning or in the morning. The operation takes about an hour. The patient still has to stay in the clinic until the anesthesia has completely subsided and the patient feels comfortable. This can take different lengths of time, depending on the type of anesthesia selected. Possible appointments for aftercare and for pulling the wires can follow.

Read more on the topic: Aftermath of general anesthesia

What kind of anesthesia do you need?

The type of anesthesia is chosen jointly by the anesthetist and the patient. There are generally two types of anesthesia available for hammer toe surgery.

In many cases, general anesthesia is performed, which among other things causes sedation and pain relief.

Alternatively, so-called "spinal anesthesia" can be used. The spinal cord is numbed with a syringe in the back. With this variant, the patient is awake and responsive, but only cannot feel his legs. The choice of anesthesia must be made dependent on the comorbidities and the age of the patient, but above all on personal wishes.

Duration of the operation

The duration of the operation can vary widely and depends largely on the measures and techniques required. A simple diversion of the extensor tendon can sometimes take less than 30 minutes. The Hohmann operation also requires bone cuts and often the insertion of a wire, which can take a long time. An operation can always lead to delays due to the individual anatomy or unforeseen circumstances, which can prolong the operation.

Length of sick leave

The length of the sick leave depends on the occupation and the personal condition after the operation. On average, the sick leave for about 2 weeks after the operation. Office work can be resumed at an early stage despite the relief of the foot. Jobs that involve frequent standing and running can often only be carried out again after 4 weeks, when the foot is allowed to be loaded. For some physical activities, gradual reintegration may be necessary in order to be able to slowly get used to stress again.

Duration until you can do sports again

Depending on the surgical method and the surgeon's instructions, a discharge of 2-4 weeks must be observed after the operation. Subsequently and after the removal of the wires, the mobility must first be slowly restored with physiotherapeutic measures. For this purpose, daily exercises are carried out with physiotherapeutic training plans to gain strength and degrees of movement.

Complete natural freedom of movement in the toe can be achieved around 12 weeks after the operation. With a splint of the toe or a special shoe, light sports can be carried out again early on. Unrestricted exercise is only possible after about 4-6 months.

What are the alternatives to surgery?

Surgical therapy is the last method of choice for an advanced hammer toe. Various diagnostic procedures must have preceded it. Any attempt at conservative therapy should precede the operation, because advanced clinical pictures can often still be treated conservatively. In the case of severe tendon contractures, conservative treatment is difficult and lengthy. Hammer toe surgery is often an aesthetic operation. If there is also pain, it can alternatively be treated with adequate pain therapy.

costs

The cost of the operation can vary widely. This depends on the scope and complexity of the operation, the choice of anesthesia and the type of insurance. Whether the operation is performed on an outpatient or inpatient basis also influences the cost of the operation. These can amount to between 1500 € and 3000 €, taking into account all accompanying circumstances.

Does the health insurance pay for that?

Both statutory and private health insurance companies usually cover the costs of the operation. There must be a clear indication and no possibility of successful conservative therapy.