Anatomy of the forefoot
The foot is very complex in structure. A stable unit is created by 26 bones together with more than 100 ligaments and 20 muscles. Numerous nerves register pressure and movement patterns and as a sensitive organ ensure safe standing and walking, in conjunction with well-trained muscles.
Impairments can result from:
- thickening or deformity of the ball of the big toe (hallux valgus or bunion)
- inflammation of the lubricating sac (synovial bursa) at the ball of the big toe
- stiffening of the big toe joint (hallux rigidus)
- hammer or claw toes
- problems associated with splay foot, including calluses
Shoes that are too narrow and, more importantly, too small make existing problems worse and probably caused them in the first place.
Hallux valgus
A splay foot encouraged by pressure points in tight shoes causes the big toe joint to move outwards. This further worsened by inflammatory episodes of the ball of the foot. In the initial stages, all that is needed is to cut a notch into the capsule, with tightening on the inside and loosening on the outside (pure soft tissue procedure, e.g. following the McBride method). If need be, part of the enlarged metatarsal head is resected on the inside.
If the big toe is severely misaligned, corrective surgery has to be performed on the bone itself. A number of different procedures are available to this end. The Keller-Brandes procedure of a straightforward resection of the metatarsophalangeal joint of the big toe - once the standard procedure and still in use - should these days only be used in exceptional cases, because there are tried and tested methods of preserving the metatarsophalangeal joint. Examples of these include procedures according to Chevron or Kramer for moderately severe cases or according to Scarf in severe cases.
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| Radiologically severe splay foot with hallux valgus |
Radiologically complete correction after Scarf and Akin osteotomy | |
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| Severe hallux valgus with splay foot | Complete correction of the deformity after Scarf osteotomy |
After your operation
The following are general guidelines: Elevate. Rest until wound is completely healed (10-14 days). Cool forefoot several times a day with a dry ice-pack (for about 15 minutes). As soon as pain and swelling permit, increase your mobility. Immobilization is generally not required! Aftercare generally occurs without a plaster cast. Weight can be placed on the foot by wearing a special post-operative shoe with forefoot support.
Medication
Anti-inflammatory and analgesic tablets (diclofenac or paracetamol) prevent inflammation and control pain.
Recommended dosage: 3 x 1 tablet per day for 7-14 days
Anti-thrombotic injections (e.g. Fragmin) to prevent thromboses are to be administered for at least as long as you use crutches to ease the load on your foot.
Aftercare
Stitches are generally removed after about 12- 14 days. Active and passive mobilization is started immediately after the operation, by placing some weight on the foot, with a gradual transition to full weight while wearing a special post-operative shoe with forefoot support, move to full weight with the shoe after about 2 weeks. After a period of 4-5 weeks and a radiological alignment check, this is followed by the transition to full weight-bearing with a physiotherapeutic exercise regime. Swelling can occur up to four months after surgery and may require lymph drainage, which is a type of massage to reduce swelling.
Hammer and claw toes
Hammer toe
Uneven muscle tension results in the distortion of one or several of the small toes. Pressure points develop at the raised middle joint as well as at the tip of the toe and underneath the metatarsal head. In the beginning, when the misalignment can still be corrected, it often suffices to lengthen the tendon and to cut a notch into the capsule.
In a contracted misalignment, part of the middle joint is removed to form a replacement joint.
Modern surgical techniques preserve the metatarsophalangeal joint (Weil or Helal osteotomies).
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| Typical hammer toe with corn on the middle joint |
Weil osteotomy with shortening and raising of the metatarsal head |
Aftercare follows the same principles as that of hallux valgus (see above).