Mallet Toe Treatment & Management

Updated: Jun 05, 2020
  • Author: Christopher Brown, MBBS, FRCSC, FRACS, FAOrthA; Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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Treatment

Approach Considerations

The usual indication for surgery is the presence of a painful deformity for which reasonable attempts at nonoperative treatment, including shoe-wear modification, have failed. [14] Occasionally, cosmesis may be raised as a presenting complaint.

Contraindications for surgery include the following:

  • Vascular compromise
  • Active infection
  • Lack of symptoms
  • Significant psychiatric disorders

The literature does not support the position that patients with lesser-toe deformities who have rheumatoid arthritis need be treated differently from patients with similar deformities who do not have rheumatoid arthritis; however, little has been published on outcomes in this patient population. [15, 16] Noncompliance or inability to comply with nonoperative treatment should be considered a relative contraindication.

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Medical Therapy

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.

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Surgical Therapy

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 [17] :

  • 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 (rarely indicated)

A flexible mallet toe is best treated with a flexor tenotomy. A fixed deformity requires skeletal work, whether via condylectomy, resection arthroplasty, or arthrodesis at the distal interphalangeal (DIP) joint. An ulcerated or infected toe would do best with a terminal amputation. [12]

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. [18] One skin stitch or Steri-Strip is used to close.

DIP joint arthrodesis 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. [19]

Some controversy exists regarding the need for flexor tenotomy when DIP joint arthrodesis is attempted and the question of whether this leads to a higher incidence of hyperextension deformity and proximal interphalangeal (PIP) joint flexion at the adjacent PIP joint.

Amputation is rarely necessary; when indicated, it is usually performed as a terminal Syme procedure. [20, 21] The nail bed and the terminal half of the phalanx are excised.

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Postoperative Care

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.

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Complications

Recurrence is possible, especially if the deformity is more than an isolated mallet toe. Failure to divide the flexor completely can also cause recurrence. Flail toe is occasionally a problem with shoe or stocking wear if excessive resection has occurred, but it is seldom painful.

Neurovascular problems (eg, 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 PIP joint can also occur.

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