Can a doctor really do a hammer toe surgery using nothing but a needle? Well, that is what we’re talking about today on the Doc On The Run Podcast.
Today’s question comes from a runner who asked me a very interesting question. This was during a surgical second opinion where we were doing a webcam call going through all of her imaging, pictures of her feet, talking about her situation, trying to figure out whether or not she really needed surgery, if it was going to help her and if it would actually help her get back to running.
She seemed to be really confused because the doctor had recommended, number one, performing surgery in the doctor’s office and not an operating room. She thought that was weird. Sounds kind of weird when you put it that way and she was also describing that she was going to have surgery that would be performed using only a needle and not a knife or a scalpel.
So, let’s talk about this procedure and whether or not it’s actually reasonable. Well, I will tell you straight off the bat, it is reasonable. It’s a thing called a percutaneous flexor tenotomy. Okay, what does that mean? That means through, per, as in through, and cutaneous. So cutaneous, it is skin, right? So, through the skin. Flexor means to pull down and tenotomy means to cut into two pieces. So, if you have a tendon and you cut it, that is a tenotomy.
Let’s talk about how this works with a hammer toe. Well, it’s not a hammer toe that they’re talking about if they’re talking about doing this. They’re talking about a mallet toe. A mallet toe is where you have a contracture at one specific joint in the toe. It’s not the one where the metatarsal bone attaches to the proximal phalanx bone. That is different and it’s not where you have the proximal interphalangeal joint. Where you have the trouble is at this joint between these two bones. The distal phalanx and the intermediate phalanx.
The metatarsal and the proximal phalanx are in the right place, but the contracture is here. So, the toe is actually tilted downward, and you start getting a painful sore or a callus on the end of the toe typically when you have this condition. The reason you’re getting it is that you have a couple of different tendons. You have a short flexor tendon that goes down and attaches to the base of the proximal phalanx here. There’s nothing wrong with that one. It’s doing its job because this bone is still flat. It’s not contracted. But you have a second one.
You have one tendon here and then you have a second long flexor. So in red, that is the short flexor and doctors call it short flexor. If you look it up, it’s called something different. It is called the flexor digitorum brevis. Again, short flexor is easier. You also have, if you have a short one, you have a long one. So, you have a long one. That one, this red one starts within your foot. The long one actually starts up in your leg, deep to the calf muscle, comes down and goes all the way out and attaches right here to the base of that bone.
What you’re trying to do is get that thing to stop pulling the toe down because it’s way too tight. So, what we do is we take a needle. I’ll try to put a picture of this in the show notes, but we actually take a needle, and we take an 18-gauge needle. It’s a big needle. And so, the needle is not just a pointy thing. It is pointed, but it’s beveled. And if you look at it from this, sort of from the side, this is a hole. And so, you have a bevel, right? So, if you look at it from exactly from the side, it’s shaped like that.
It’s a shaft and then it’s cut off. So, if you take a tube and you skive it off that way, then when you look at it from 90 degrees, what you see is this. So, this is the entrance to the tube and that edge right there is very, very, very sharp. We take this big needle, and we go right through the skin. And if you look at the toe from underneath, if this is your toe and that is the bone there and the interphalangeal joint and the proximal phalanx, and then the metatarsal bone in your foot, what we’re doing is you’ve got the blue tendon here attaching right there.
It literally goes through the skin with the needle, and we take the bevel of the needle, and we use it like a knife and right there we cut it and we release the tendon. So, the toe’s crooked. We go through the skin, and we pull up on the toe. When we do it, it goes and the toe straightens out. It’s kind of like magic. All you’re doing is releasing that with a needle through the skin. So, it is not necessary to use a scalpel to do that. With a needle hole, you don’t even really need stitches.
In fact, for years I volunteered at a homeless clinic where I took care of homeless people’s feet at no charge whatsoever on my own time. And I did this procedure on some people who were homeless that had these very painful sores underneath the end of the toe. I was doing them on homeless people that I knew might have drug and alcohol problem or something and maybe not even show up again. But I would not cut them open and put in stitches if I thought they might wander off and never come back. But this is a very low risk procedure.
If the doctor recommended this to you, the only thing I would say is that you want to make sure that you remind them that your intent is to run, not just make the toe straight. You’ve got to make sure that they understand that because that some kind can change the discussion with your doctor.
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