Mallet Toe Treatment & Management
- Author: Christopher Brown, MBBS, FRCSC, FRACS, FAOrthA; Chief Editor: Jason H Calhoun, MD, FACS more...
Nonoperative treatment focuses on relieving the pressure under the tip of the toe. This can be accomplished with extra-depth toe-box footwear. Soft orthoses or toe protectors are useful.
Surgery can be performed under local or regional block, and in appropriate patients, it can be performed on an outpatient or day-surgery basis.
Surgical therapy includes the following options :
Flexor tenotomy, possibly including plantar capsular release and pinning
Condylectomy and fusion of the middle to distal phalanx
Partial or complete amputation of the distal phalanx (occasionally indicated)
A flexible mallet toe is best treated with a flexor tenotomy. A fixed deformity requires a condylectomy. An ulcerated or infected toe would do best with a terminal Syme amputation.
Tenotomy is performed by making a small lateral or medial incision over the distal end of the middle phalanx. The author prefers to visualize the tendon sheath directly by retracting the skin with double skin hooks or a Ragnell. The sheath is incised longitudinally, and the tendon is hooked with a small arthroscopic probe. The tendon then can be divided under direct vision.
If some residual contracture is present, the plantar capsule can be stripped of the phalanx with a Freer dissector. A 1.1 Kirschner wire (K-wire) can be used to immobilize the joint in the neutral position. One skin stitch or Steri-Strip is used to close.
Distal interphalangeal (DIP) joint fusion is carried out by excising a small ellipse over the dorsal aspect of the joint, including the extensor. The bone ends are excised, and pinning is carried out. The skin and extensor are closed in one layer.
Amputation is usually performed as a terminal Syme procedure. The nail bed and the terminal half of the phalanx are excised.
Postoperatively, routine dressings are applied. The patient can mobilize weightbearing in a postoperative shoe. Elevating the limb for the first 5-7 days reduces postoperative swelling. Sutures are removed at 10-14 days. Pins are usually removed at 4 weeks.
Recurrence is possible, especially if associated joint lesions at the metatarsophalangeal (MTP) joint (eg, hyperextension) are not appreciated. Failure to divide the flexor completely can also cause recurrence. Flail toe, if excessive resection has occurred, is occasionally a problem with shoes or stockings, but it is seldom painful.
Neurovascular problems, including numbness, neuromata, and dysvascularity, can also occur. Prolonged swelling is often noted, and patients should be warned beforehand that this may occur. Residual nail deformity is also common. Hyperextension deformity of the DIP joint and flexion deformity of the proximal interphalangeal (PIP) joint can also occur.
Outcome and Prognosis
Most series found excellent results in 85-97% of cases. In some series, tenotomy seemed to increase satisfaction rates. Bony union of the DIP joint where resection was carried out had higher satisfaction rates than fibrous union did.
Future and Controversies
Treatment of mallet toe deformity is relatively straightforward. Some controversy exists over the need for flexor tenotomy when DIP joint fusion is attempted and the question of whether this leads to a higher incidence of hyperextension deformity and PIP joint flexion at the adjacent PIP joint.
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