Arthritis, Joint Disease and Common Digital Deformities

Corns, Calluses and Pain May Indicate Joint Problems

Many disorders can affect the joints of the toes, causing pain and preventing the foot from functioning as it should. People of all ages can have toe problems, from infants born with deformities, to older adults with acquired deformities.

The major culprit of toe deformities in adults is tendon imbalance. When the natural function of the foot is disrupted (through a variety of causes), the tendons may stretch or tighten to compensate. Thus, people with abnormally long toes, flat feet or high arches have a greater tendency to develop toe deformities.

Arthritis that slowly destroys the joint surface is another major cause of discomfort and deformity. Toe deformities also can be aggravated by restrictive or ill-fitting footwear worn for a prolonged amount of time. Or, problems with toe position may occur if a fractured toe heals in a poor position.

Common Deformities The most common digital deformities are hammertoes, claw toes, mallet toes, bone spurs, overlapping and under lapping toes, and curled toes.

These deformities may or may not be painful. Corns and calluses - a buildup of skin on the affected joint, often associated with bursitis (inflammation of small pouches, called bursae, which lie above the joint between the tendon and skin) - are perhaps the most noticeable and bothersome symptoms. If deformities are left untreated, the toe's mobility may become limited, and more serious problems, such as skin ulceration and infection, may develop. Any one of the toes can overlap or under lap, pushing on adjacent toes and causing irritation.

Treatments for Toe Deformities

Any toe problems that cause pain or discomfort while walking should be given prompt attention by a podiatric surgeon. Ignoring the symptoms can aggravate the condition, and over time may lead to an infection, a breakdown of tissue or ulceration. For people with poor circulation or an underlying medical problem, loss of the toe is possible. Treatments will vary depending upon the severity of the condition.

Conservative Treatments

For people who have minor discomfort, less advanced conditions or are unable to undergo surgery, the symptoms may be treated conservatively (without surgery). This usually involves:

• Trimming or padding corns and calluses.
• Wearing supportive orthotics (insoles) in shoes. This helps relieve pressure on toe deformities and allows the toes and major joints of the foot to function more appropriately.
• Splints or small straps to realign the toe.
• Wearing shoes with a wider toe box.

In certain cases, anti-inflammatory medications may be injected to relieve pain and inflammation. Medications have proven to be successful in relieving the discomfort associated with bursitis. Unfortunately, conservative treatments provide only temporary relief of symptoms - they do not correct the deformity.

Surgical Treatments

When the deformity is painful or permanent, surgical correction is recommended to relieve pain, correct the problem and provide a stable, functional toe. Some of the most common surgical procedures are described below.

Depending on health status, surgery may be conducted on an outpatient basis at the surgeon's office. The procedures are usually comfortably performed under local anesthesia or with intravenous sedatives administered by trained anesthesia personnel.

Tenoplasty and/or capsulotomy refer, respectively, to the release or lengthening of tightened tendons and ligaments that have caused the joints to contract. In some flexible hammertoe cases, the toe straightens out after these soft tissue structures are lengthened or cut and relaxed. Surgery relieves pain and improves the toe's mobility.

Tendon transfer, another treatment for a flexible hammertoe deformity, involves the repositioning of a tendon to straighten the toe.

Bone arthroplasty procedures, some bone and cartilage are removed to correct the deformity. A small portion of bone is removed at the joint, eliminating pressure on the toe, relieving pain and straightening the digit. The tendons and ligaments surrounding the joint also may be reconstructed. Multiple digits can be operated on simultaneously in certain cases.

De-rotation arthroplasty is a variation of arthroplasty used to realign the toe. A small wedge of skin is removed and the toe is properly positioned. The surgeon also may remove a small amount of bone, and will repair the toe's tendons and ligaments.

Athrodesis (Fusions) of the toe is most often used to correct toe fractures or, like implant arthroplasty, to increase the stability of the toe after arthroplasty. After the bone ends are removed, they are positioned together and compressed so that the bones unite.

Fusions may be stabilized with a stainless steel pin as the bone heals. Care must be taken to avoid any impact that would damage or break the pin after surgery. Pins typically remain in place for approximately five to eight weeks.

JOINT REPLACEMENTS WITHIN THE FOOT

Implants and Foot Surgery

The choice to use an implant is made carefully, only after the podiatric surgeon has decided that another type of surgery would not provide as many benefits. Implants made from silicone rubber, polyethylene (a form of plastic), or titanium (see Implant Types and Materials) is quite safe.

Implants for Pain Relief and Support

The narrow space separating the two bones of the joint permits movement. An implant's primary purpose is to maintain this joint space and support the toe. Because the implant replaces damaged or diseased bone and the bone's cartilage, it keeps the toe at an appropriate length. Without an implant, the toe may appear shorter.

The implant helps eliminate pain, and provides stability to the previously weakened joint. A secondary purpose of an implant is to permit the toe to bend and function more freely. As the joint heals, new tissue forms around the implant, making the joint stable and the reconstruction more durable.

Implant Reconstruction

The podiatric surgeon will expose the damaged joint and carefully remove any inflamed tissue. A small portion of damaged bone also will be removed, and the bone ends smoothed.

The next step is enlargement of the natural canals within the bones. The sterilized implant (double-or single-stem) is then inserted and is supported by the bones. Finally, the tendons, ligaments and joint capsule are reconstructed around the implant.

Antibiotics may be administered both before and after surgery.

Activity Restrictions

The podiatric surgeon may restrict any activity for at least 24 hours. Depending on which joint was fused, a cast and crutches may be necessary for as long as six weeks.

Implant Types and Materials Most implants used in the foot are made from silicone rubber, a synthetic compound that is both flexible and strong. When a less flexible implant is needed, podiatric surgeons choose implants made from metals such as titanium, a durable, lightweight material. Some implants combine a metal with a plastic such as polyethylene.

This is what's known as a Silastic joint implant, which is designed to, replaced rigid joints within the toes. It is held in place with grommets. These joint replacements give good range of motion to joints, which have virtually fused together.

This is the second type of joint implant, which is available. It is made from Titanium which is well known for it's durability. At YPS we can offer both types of joint implant. You can discuss any aspects of toe joint replacement with our Podiatric Surgeon

Answers to Questions About Implant Reconstructions

How Long Will the Implant Last?

Although every individual is different, most implant recipients can expect the benefits of surgery to last for at least 10 to 20 years. Several thousand people have had these implants for more than 15 years, and remain pain-free and without complications.

Implants are designed specifically for durability and the ability to withstand the pressures of joint movement. No implant, however, is indestructible. With use, especially in young or active people, it is possible that the implant will wear down. Other surgery may become necessary. Your podiatric surgeon can advise you about other patients' experiences with implant durability.