Conclusion

Painful toe deformities prevent patients from being able to wear shoes comfortably and perform their normal activities.

There may be additional methods of treatment for this common foot problem. Your podiatrist will discuss these with you. Complete cooperation between you and your doctor is essential for a satisfactory result.

Postoperative Care

After surgery, you will receive instructions from your podiatrist regarding the care of your dressing, your level of activity and weight-bearing. As with all foot surgery, rest and elevation can help reduce pain and swelling. Be sure to ask your podiatrist any questions you have before or after surgery.

Osteotomy

A cut is made through the bone to allow it to be realigned. Wire or pin fixation could be required.

Bone Spur Removal

An incision is made and an instrument is used to file or excise the bone spur and remove the source or increased pressure.

Derotation/Realignment procedure for overlapping toe

A wedge of skin and a segment of bone are removed to realign the overlapping toe.

Arthroplasty with Implantation

Following excision of a joint, a plastic implant is placed inside to act as a functional spacer.

Arthroplasty with Tendon Relocation

A joint space is created and the toe is realigned by relocating the flexor tendon, which pulls the toe down.

Arthroplasty with fixation

This procedure involves joint removal and the use of a wire (pin) to stabilize or fuse an deformed toe.

Arthroplasty

This very popular procecdure involves removal of cartilage and bone in remodeling a deformed joint. it allows for relief of the painful area.

Tenotomy and Capsulotomy

The terms tenotomy and capsulotomy refer to the cutting of tendons and joint capsules. More specifically in relation to hammertoe deformities, the tight tendons and joint capsules located on the top and bottom of the buckled or contracted toe joint are released.

Once these tight, soft-tissue structures are cut and relaxed, the toe can resume its normal flattened posture.

Digital/ Toe Surgical options

These procedures help to straighten the toes by cutting the bone, tendon, joints, and/or ligaments.

Treatment

Conservative treatment can consist of one or more of the following.

1. 
   
   Trimming, digital splinting and/or padding of the corn.


2. 
   
   Orthotics or inserts in shoe to correct improper walking.


3. 
   
   Injections to relieve pain and inflammation.


4. 
   
   Larger or extra depth shoes to accommodate toe deformities.
   

If these conservative methods are unsuccessful in treating your deformity, then corrective toe surgery should be considered. Your podiatrist will conduct a thorough medical history and examination to determine your options. Lab tests, advanced imaging studies and X-rays will be scheduled if necessary.

The surgical correction or your toe deformity may be performed in the office, outpatient surgical procedures. Each case requires individual evaluation to determine the best surgical approach.

Corns

The body's response to excessive amounts of pressure against the skin manifests itself by forming thick, hardened skin or corns. Corns are most often the result of an enlarged bone or bone spur pinching the skin against a shoe. A corn can be indicative of a pressure point between the toes.

Soft corns refer to corns that exist between the toes. They are the result of two bones rubbing against each other, pinching the skin. Sometimes more than one soft corn will form.

Overlapping Toe

An overlapping toe is one that is malpositioned from birth or acquired over time. It often produces some abnormality in tendon, ligaments or skin, many times producing painful corns. All of the toe deformities, enlargement of bone tissue or bone spurs. Shoes further aggravate these conditions and can cause additional pain, inflammation and corns.

Mallet Toe

A mallet toe is similar to a hammer toe, except the deformity occurs closer to the end of the toe.

Hammertoes

A hammertoe is a flexible or rigid contraction usually affecting the second, third, fourth, or fifth toes. Most often a biomechanical abnormality results in the larger muscles of the foot and leg overpowering the smaller intrinsic muscles of the foot. muscles imbalance leads to a bending or "buckling" of the toe joints. These buckled or contracted positions create any number of problems within and on top of the toe deformity. One or more small joints become prominent on top of the malpositioned toe. Tendon, ligaments and joint capsules in that area have a greater chance of tightening and inability to wear shoes comfortably. If left untreated, these conditions can progress to ulcers or infections.

A flexible hammertoe refers to a reducible hammertoe in contrast to the rigid hammertoe where the deformity it fixed or not easily straightened. There are many causes of hammertoe. Some are congenital, hereditary or acquired. An inherited condition may mean an inherited muscle imbalance around the toe or a parent with a abnormally long toe. An acquired hammertoe refers to those with diabetic neuropathy can be more susceptible to hammertoes.

Digital/Toes Deformities

A deformed toe is one of the more common conditions known to afflict the foot, whether it be a hammertoe, mallet toe, or overlapping toe.

Concluding Thoughts

Skin loss, ulceration and breakdown is a limb-threatening, and at times life-threatening, problem. It is essential that you become proactive and a daily observer of your lower extremity to prevent ulceration. In the event you develop an ulcer, you need to partner with your podiatrist, and other members of the team used to coordinate your medical care, in resolving your ulcer condition.

What can I do to prevent ulcers?

• 
  
  If you previously had an ulcer that is now healed or have been identified as as individual who is a risk for an ulcer, the single most important step is daily inspection of your feet. Observe them for any sign of sudden redness, irritation and /or open areas.


• If you have vision loss, engage a family member or friend to help with your inspection. It is critical for you to notify your doctor or podiatrist when these manifestations present themselves.


• When you have an established disease, maintaining its effects becomes a priority.


• If you are diabetic be sure your blood sugar is under control and seek preventative foot examinations and appropriate treatment from your podiatrist.


• If you are a smoker, do all that you can to quit, as this is a factor in wound healing and in the development of poor circulation.
  

I have an Ulcer, How will it be treated?

The very first step in treating an ulcer is having a thorough history and physical exam by your podiatrist. It is necessary to determine what type of ulcer you have and what are the underlying diseases that are causing the problem. Once the type of ulcer has been determined treatment can begin. Often it is necessary to perform lab work X-rays, bone scans, MRIs and circulation tests in order to stage the severity of the ulcer. This testing very often helps to direct a treatment plan.

The cornerstone of treatment in most cases includes good local wound care and trying to address the fundamental cause. Your treatment may consist of:

1. 
   
   Consultation with other professional in vascular surgery, orthotics, endocrinology and primary care;


2. 
   
   Debridement or removal of devitalized tissue within and around the ulcer;


3. 
   
   Oral antibiotics or hospitalization for intravenous antibiotic when severe infection in present;


4. Rest, off-loading the foot to decrease pressure on the ulcer site. This could employ cast braces or splints; 4a. In case of a venous ulcer, compression or Una boot therapy might be used.


5. Use of growth factors directly on the wound;


6. Surgical intervention to remove abnormal or diseased bony prominences and skin grafting or use of skin substitutes to cover the area;


7. Once healing has occurred, the goal is prevention of re-ulceration. This could be achieved with custom molded shoes, braces, inserts.

Very often, treatment is a long, difficult, and sometimes a discouraging process. Realize that it most likely will constitute a team approach to manage the other prevailing medical problems you have that gave way to the development of the ulcer.

It is important for you to follow your podiatrist's directions in your ulcer treatment plan. You are the most important factor in resolving this problem. So be an active participant in your treatment, ask questions and be sure you understand what is being done.

What are the risk factors for ulcerations?

There are a number of co-morbidities that can set one up for ulcer formation. Risk factors include diabetes, peripheral vascular disease, stroke, smoking, loss of sensation, muscle dyfunction form neuropathy (i.e.,damage peripheral nerves), vision loss from diabetic retinopathy and bony deformities of the foot.

What are the causes of Ulcers?

There are a number of causes, but for the most part ulcers can be categorized into three part
ulcers can be categorized into three major causes.

1. Ulceration due to loss of sensation (neurotropic)

2. Ulceration due to poor circulation entering the foot (arterial) or exiting the foot and leg (venous)
3. Ulceration due to pressure (bed sores)

Ulcers can be the result of any combination of these three major causes. A variety of diseases, such a diabetes, arteriosclerosis, venous disease, leprosy, alcoholism, rheumatoid arthritis, gout, syphilis and strokes, can also cause ulcerations of the foot and leg.

Along with the above causes, presser and injury to the skin can be precipitating factors in ulcer formation. The combination of pressure on an abnormal bony prominence and ill-fitting shoes can result in skin breakdown or ulceration. The problem then becomes the ulcer, opening the door for bacteria to enter the body and trigger infection. In conjunction with poor circulation or diabetes, this skin loss or open area could develop into a limb-threatening infection.

Ulcers of the Foot and Lower extremity

What is an ulcer and why should I be concerned?

An ulceration of the skin is a disorder that results in the breakdown of skin layers. This could involve the various layers of the skin, subsequent soft tissue, muscle and bone. The skin is the largest organ system of the body that protects us from the outside. Therefore, ulcer formation is a serious problem adversely affecting the skin's protective resilience and possibly causing acute infection, tissue death, limb loss and even loss of life.

Treatment

Early on, peripheral vascular disease sometimes can be treated with just a few daily life-style changes. These changes can frequently reduce the symptoms and improve circulation. If you smoke, do all that you can to quit. If you are obes, a regular exercise program(before exercising consult your family doctor) and diet changes will facilitate the circulatory system to function more effciently.

Peripheral Vascular Disease can be treated in a variety of ways:

• Medication: In some cases, medication will be prescribed to help improve blood flow and relieve symptoms. Such drugs a Trental and Pletal could be prescribed to aid circulation. Calcium-channel blockers, a medication that helps relax blood vessel walls, can also be used.
• Minimally invasive procedures:If medications fail, your doctor may recommend minimally invasive procedures such as angioplasty ( a small balloon used to compress the plaque), stent placement( tiny tube inserted into the artery and kept there to keep it open), lasers, atherectomy and thrombolytic therapy(use of a drug injected by catheter in the artery to help dissolve the clot). These various therapies try to treat the plaque accumulation/clot in the arteries by either removing it, compressing it or dissolving it.
• Surgery:If the plaque is large or severe enough to restrict blood flow, then surgery may become necessary. At times, balloon angioplasty is necessary to open a blockage. A common surgical procedure for acute blockage is a bypass graft. Here the surgeon attempts to redirect the circulation around the blockage.

Vascular disease in the lower extremity has a wide range of effect from mild and short-term to severe and long-term. However, it is often treatable and extremely preventable. Remember to prohibit from smoking, exercise regularly and maintain a healthy diet.

Vascular Testing

ANKLE/BRACHIAL INDEX (ABI): A simple non-invasive test that measures the ratio of blood pressure in your ankle to that in your arms.

ARTERIAL/VENOUS DOPPLER TESTS: A non-invasive test using sound waves to provide an image inside your blood vessels.

EXERCISE/TREADMILL TEST: Measures the demand for oxygen in your tissues during exercise/walking.

ANGIOGRAM:Test using special dye injected into your arteries under local anesthesia, after which X-rays are taken showing any blockages or narrowing of the arteries.

MAGNETIC RESONANCE ANGIOGRAPHY (MRA): This test uses magnetic fields instead of an X-ray to take pictures of the arteries and veins. You will be asked to drink a liquid that has a special dye in it, or the dye will be injected into a vein.

Symptoms

Symptoms in the lower extremity and feet will depend on the amount of oxygen deprivation. Some indications or signs of peripheral vascular disease may include:

1. claudication or cramping in hips, caves, thighs;
2. buttocks pain;
3. burning, numbness and/or tingling in the legs, feet or toes;
4. change in skin color;
5. infections that do not heal

Other changes can be swelling in one or both legs that increases with the time of day, often with a feeling of heaviness; color variations in the hands, feet and legs along with changes in skin temperature; a deep red or purple color in the feet and legs when they have been dangling for a period of time.

Risk Factors

Studies have shown that certain factors increase your risk for peripheral vascular disease:

• Diabetes



• Smoking



• Obesity



• Lack of exercise



• High Blood pressure



• Increased cholesterol



• Stress



• Family history of vascular disease



• Prolonged bed rest



• Congestive heart failure



• Venous insufficiency



• Stroke
  

Types Of PVD

Atherosclerosis: Thickening and hardening of the arteries. Usually involving the large or medium-sized arteries. The arteries narrow and eventually become blocked. This is also known as Peripheral Arterial Disease (PAD).

Microvascular disease: It affects the smaller arteries and is most commonly associated with Diabetes Mellitus. A side effect is a lack of sensation or feeling (neuropathy) to the skin, which in turn develops into ulcerations.

Venous disease: This sluggish return of blood flow exiting the legs is due to defective valves in the veins. Defective valves produce sluggish blood and possibly deep vein thrombus (clot) formation, which in turn can travel to the lungs causing difficulty in breathing and even death. Superficial veins can develop phlebitis.

Vascular Disease

What is Peripheral Vascular Disease?

Peripheral Vascular Disease (PVD) is any number of disease processes that can affect the vascular tree in the extremitties. It can be artrial, venous or lymphatic in nature.

Arterial PVD by example is a bulid up of plaque in the arties that exist in the legs. When this occurs, blood flow is slowd and some structures of your body, such as your skin, muscle and soft tissue, do not get enough oxygen-rich blood.

Conclusion

There may be additional methods of treatment for this common foot problem. Sometimes vitamins, skin creams or topical liquids are utilized. Your doctor will discuss these with you. Complete cooperation between you and your doctor is essential for a satisfactory result.

Anesthesia/Postoperative Care

Anesthesia

Before the surgical procedures are done, with the exception of the chemical removal, the patient receives an injection of a local anesthetic near the wart.

Postoperative Care

As with all surgical procedures your podiatrist will advise you in detail about post-procedure care, local care to the wart and follow-up visits as required. If there are any problems you are experiencing, consult your podiatrist with any questions or concerns.

Traditional Surgery

In this method,two small semi-elliptical incisions are made surrounding the wart. The skin and wart are then removed. The edges of the skin are then brought together with an appropriate number of skin stitches. If this method is used you will most likely need crutches for two or three weeks to allow the incision to heal without weight-bearing, which otherwise contributes to a greater chance of thick and/or painful scarring.

Cryosurgery

Intense cold has been effective in the treatment of warts. Liquid nitrogen and carbon dioxide are most commonly used to freeze the wart and destroy the lesion. A blister can develop following treatment, but this is removed in approximately 10-14 days.

Laser Surgery

A special high frequency laser can be used to destroy warts. This beam of light destroys cell by vaporizing the moisture within them. Generally the growth is removed first with a hand currette instrument or laser. Postoperatively, bleeding, pain or scarring are less likely. This procedure is performed with the use of a local anesthetic. Ambulation is often permitted immediately after surgery.

Surgical Curettage

Curette

Surgical Galvanism

Surgical galvanism, or electrolysis, is the use of a galvanic low voltage current for the destruction of tissue. This procedure is intended to remove the growth without bleeding and normally leaves no pitting or scarring.