Claw Toe Treatment & Management

Medical treatment for claw toes depends on the underlying cause. Therefore, anti-inflammatory drugs, glucose-lowering agents, and antibiotics all may be appropriate. However, these treatments are not believed to reverse the claw toe position.

Conservative treatment

After medical treatment is initiated, consider conservative therapy, including avoidance of wearing high-heeled, narrow-toed shoes, which increase dorsal ground reactive forces on the toe and crowd the toes against each other, producing impingement. Shoes with a wide toe box, soft upper shoe, and stiff sole to absorb dorsally directed forces against the plantar plate are appropriate. Some high-quality athletic shoes fulfill these criteria. A metatarsal bar can be added to the shoe to avoid metatarsal pressure, but patients more easily accept metatarsal pads. Cushioning sleeves or stocking caps with silicon linings can relieve pressure points at the PIP joint and tip of the toe. A longitudinal pad beneath the toes can prevent point pressure at the tip of the toes.^{[16, 17]} See images of pads and silicone caps below.

Because the MTP joint is always dorsiflexed by definition, some correction of its position is necessary to restore a more neutral angle at the MTP joint. This consists of Z lengthening of the extensor tendon, dorsal MTP capsulotomy, and collateral ligament release (see images below). If deviation is present in the frontal or coronal plane in addition to claw toe, the loose collateral ligament side can be imbricated instead of released.^{[10, 18, 19, 20] [21, 22]}

At the PIP joint (if it is completely flexible), an FDL transfer to extensor tendon can bring the toe into alignment. This is accomplished by making a longitudinal cut across the plantar MTP proximal skin crease, retracting the skin with 1 or 2 small Meyerding retractors if necessary, splitting the tendon sheath, isolating the FDL tendon between the FDL brevis tendons, passing a small curved hemostat beneath the long flexor to establish tension in the tendon, and then cutting the tendon distally through a small stab incision in the skin just proximal to its attachment.

The 2 distal raphes are held with 2 hemostats, and blunt separation is accomplished by cutting the distal connecting raphe of the FDL tendon into 2 parts with tenotomy scissors. Through the dorsal incision used to address the Z tendon lengthening, curved hemostats are directed circumferentially around the proximal phalanx. The tip of the FDL tendon raphe is grasped on the medial side and brought from the plantar wound dorsally. A similar technique is used to grab the lateral raphe and bring it dorsally. The tendons are attached to themselves and to the repaired extensor Z-lengthened tendon with 2-0 absorbable suture (see images below). Absorbable suture prevents the formation of a permanent knot bump on the dorsal aspect of the toe. The final image below is a 4-minute video showing the tendon transfer.

If the PIP is fixed in flexion or cannot be brought back easily to a neutral position, remove the distal portion of the proximal phalanx along with the articular cartilage of the middle phalanx. If only a PIP resection is required (an FDL transfer is not needed), a shorter longitudinal incision can be made dorsally over the MTP joint and proximal phalanx for the Z lengthening, dorsal capsulotomy, and collateral ligament release surgery. A transverse incision can then be made at the PIP joint for correction of the fixed deformity.

If an FDL transfer is necessary along with a PIP resection, this may be accomplished with extension of the dorsal longitudinal MTP incision over the PIP joint. Once through the skin, a continuation of the Z lengthening of the tendon may be accomplished across the PIP joint. The distal portion of the proximal phalanx is isolated by cutting the collateral ligaments and exposing the bone. The distal portion of the proximal phalanx is cut with a small, sharp, bone-cutting device (eg, saw), just proximal to the flare of the condyles.

The articular cartilage is then removed from the proximal portion of the middle phalanx. A 0.54-mm doubly pointed Kirschner wire (K-wire) is driven into the distal-cut bony surface of the middle phalanx, taking care to keep the guidewire in the center of the bone to avoid eccentric positioning. The K-wire is brought out of the tip of the toe while the DIP joint is held in neutral position. The K-wire is then grasped distally and drilled back through the proximal phalanx across the metatarsal head, holding the interphalangeal joints in neutral position with slight flexion at the MTP joints (see images below).^{[23, 24]}

The resected PIP joint is now inspected to avoid eccentricity and bone prominence. If this is found, the prominence is resected or the guidewire is replaced. This guidewire (being somewhat larger than the previously recommended 0.54-mm K-wires) is less likely to break, does not become unstable (which would cause infection), and can be left in place for 4 weeks to increase the chance of fusion and/or fibrosis of the PIP joint.

If the PIP joint is not resected, stabilization of soft tissue at the MTP joint is important to promote ultimate healing in the corrected position. Therefore, a K-wire can be driven from the articular cartilage of the proximal phalanx out of the tip of the toe and back antegrade through the metatarsal head. This can also be attempted retrograde from the tip of the toe, with the toe in a slightly plantar-flexed position at the MTP joint and neutral at the PIP and DIP joints. This is more difficult. However, even if the pin only engages the capsular tissue of the MTP joint, this is often enough to keep the joint relatively stable. The pin is removed after 2 weeks, because the goal is joint stability, not arthrodesis. The joint may be taped for an additional 4 weeks if further immobilization is necessary.

Almost always, the DIP joint is flexible in a claw toe and is relieved with a flexor-to-extensor transfer. However, should a fixed DIP joint be found, especially if it is part of the problem (ie, pressure on the nail or the tip of the toe), resection of the distal portion of the proximal phalanx and articular portion of the distal phalanx can be performed in a similar fashion to that used on the PIP joint. A pinning technique similar to that described above also may be used.

Sometimes, such chronic dorsal dislocation of the proximal phalanx is present on the metatarsal head that reduction of the proximal phalanx is not possible or, if attempted, leaves an extreme tightness across the MTP joint, resulting in vascular compromise. In this instance, an osteotomy, from the proximal dorsal articular surface of the metatarsal head in a direction plantar proximal along a plane parallel to the sole of the foot, allows metatarsal head retraction and reduction of the tension in the neurovascular bundle. The dorsal lip of the metatarsal shaft can be removed, and the head is fixed to the remaining shaft with a screw or continuation of the lesser toe pin into the dorsal metatarsal head and then into the center portion of the shaft. This technique is preferable to metatarsal head resection, which can result in a transfer lesion to another metatarsal head.

Forefoot surgery is typically performed in an outpatient setting. A fresh dressing is applied the next day, and stitches are removed after 2 weeks. Arthrodesis pins are removed after 4 weeks, and the other types of pins are removed after 2 weeks. Patients may shower with pins protruding from the toes.

The image below is an algorithm to help determine the appropriate surgical procedure and postoperative treatment.

The most common complication is pain from recurrent deformity in the sagittal or frontal plane due to inadequate correction of the deformity, failure to obtain an arthrodesis or stable fibrosis, or premature or patient-prompted pin removal. Other complications include pain from failure of the wound to heal, infection, numbness, dysesthesias, vascular compromise with blistering or eschar formation, and loss of the toe. If pallor of the toe is still present 30 minutes following surgery, the toe is manipulated into a more dorsiflexed position with the pin in place. If the toe does not become pink within 15 minutes, the pin is removed.

The experiences of other authors indicate that complete correction of the toe is necessary to achieve the best result. Of course, this presumes careful attention to detail and a toe with normal vascularity. Taylor^{[18, 19]} and Pyper,^[25] via transfer of both the long and short flexor to the extensor hood without bony resection, achieved only 72% and 51% good results, respectively. Pyper also noted that with soft-tissue procedures alone, the deformity recurred and results were somewhat unpredictable. Therefore, Frank and Johnson^[26] and McCluskey et al^[27] recommend PIP resection along with soft tissue procedures to realign the toe.

Barbari and Brevig^[28] reviewed 31 patients who had surgery on multiple toes. These authors concluded that the best cosmetic results were achieved in younger patients, and they noted that active or passive motion in the interphalangeal joints was present in 60% of these cases. Of course, restriction in range of motion is an intended outcome of the procedure. Patients must be aware that in most instances, they will sacrifice prehensile action of the toe for less pain, will have better shoe-wearing capabilities, and, ideally, will have an improved cosmetic result. Specific disease entities seem to fare similarly; Cyphers and Feiwell^[29] reported 60% good results in patients with myelomeningocele.

A future prospective study that separates claw toes from hammer toes, fixed from flexible, severe from mild, and bony correction (ie, PIP and metatarsal neck osteotomies) from soft-tissue procedures alone is necessary. The addition of an extensor tendon transfer beneath the intermetatarsal ligament with reattachment to the proximal phalanx may help improve continued deformity at the time of surgery or recurrent postoperative dorsiflexion deformity.

When to perform each of the procedures on a claw toe and the extent of the surgical procedure on a single toe remain controversial. Other controversies are a bolster suture above the PIP joint in lieu of a pin, the size of the toe fixation pin, the duration it needs to remain in place, and whether or not it needs to cross the MTP joint.