Jessica Sciulli, DPM, Podiatrist and co-director of the Wound Care Center, explains hammertoes and bunions and when is the best time to take care of them.
Tell me a little bit about hammertoe for our viewers who may have heard of it and aren’t really familiar.
JESSICA SCIULLI: The hammertoe can affect typically the second, third, and the fourth toe. It’s a contraction of the joint which can be distal or can be the middle part of the joint. Typically with that, the toe starts to contract. The two things that can make hammertoe worse is genetics, which obviously the patient can’t control. The other is shoe gear. Some people have hammertoes that are really contracted that it doesn’t cause them pain. Typically, the issue becomes when it starts rubbing on a type of shoe gear, and then they start develop pre ulcerative lesions. That can actually affect the skin and then the rubbing is really what contributes to the pain.
When you say contraction, can you describe for our viewers what it might start to look like?
JESSICA SCIULLI: The toe itself typically has a little bit of a natural arc to it, and this will start to contract like this. When it’s contracted like that, usually the middle and the distal part of the joint start to curl up. It can be contributed from the tendons that pull the toe up, which may be overpowering the ones that pull the toe down. And that’s typically how it starts to form.
You said it’s often genetic. If you look at your dad’s toes or your mom’s toes, does that give you a pretty good idea if you have a risk?
JESSICA SCIULLI: Yes, a lot of times with that usually I tell most of my patients because when they’re asking for conservative measures you really can’t control the genetics part of it. It’s typically also with a lot of women that wear really tight shoes. That can actually make the deformity worse over time. But the genetics is usually a good indicator when people say my mom or my dad’s feet was pretty bad and they had issues with it. That usually contributes to that as well.
If you have that predisposition, that genetic factor, what can you do to prevent it from worsening?
JESSICA SCIULLI: I tell most of my patients wired or shoe gear. Wearing tennis shoes that have a wide toe box, wearing work shoes that actually give you enough space because that way it’s not contributing to the rubbing. It’s also not causing your toes to become contracting when you’re in the shoe. That’s really the only conservative measure that you can really do to prevent it from getting worse. Typically, I tell most of my patients once it starts causing you pain and you’ve tried those wider shoes and really alleviated those factors that caused the rubbing is when we talk about surgical options.
Are men more prone? Are women more prone? Or does it hit equally?
JESSICA SCIULLI: There’s an equal distribution to that. I mean, I would say that I operate on more women than I do men for this problem just because of the shoes that they usually wear. But equally distributed between men and women.
You had said that once it gets to a point where those second, third and fourth toes are contracted and sometimes it’s rubbing. What are some of the other risks? What are some of the other factors if you have hammertoe? It’s not just the discomfort of having the toe contracted.
JESSICA SCIULLI: The biggest thing is also causing the bunion to get worse because a lot of times when the toe becomes contracted and you’re in the shoe it starts pushing. A lot of times actually the bunion is what contributes to the hammertoes getting worse. Over time as it gets worse and the deformity gets more severe, the surgical options become more severe as far as what needs to be done to correct it. I tell most of my patients you want to kind of get ahead of the game if it’s really becoming a problem that you know surgically you want to have fixed because then really the surgical procedures that I’m going to choose to do a little bit less complication and a little bit less recovery time.
If you’re going to do it, do it early rather than wait till it’s a problem?
JESSICA SCIULLI: Yes.
Can you describe the surgery? What are you actually doing?
JESSICA SCIULLI: Whenever you’re doing the hammertoe surgery, you actually make an incision over the toe overlying the joint. You release the tendon that’s contracting the toe up and then you also perform what’s called an arthroplasty where you take that knuckle of the bone out. I use a saw to really take that knuckle out, and typically with that you pin it. You can use an observable pin. Sometimes, you use a pin that actually, like, stays in the toe. You can also do what’s called an arthroplasty where you don’t use any hardware but typically with that patients are more prone to the toe becoming floating. I’d say a majority of the time when I do the procedure I use any type of absorbent pin internally where the patient doesn’t feel it and there’s nothing sticking out of the toe post-operatively. And it gives it a little bit of a natural feel and people do pretty well.
When you say you’re taking that joint or that knuckle out, what does that do?
JESSICA SCIULLI: Down the road? Basically, what you’re doing is you’re releasing that contraction of the tendon. When you take that part of the bone out, the toe itself will sit flat. The only thing you run into as far as potential complications is if you overcorrect it and you’re over aggressive, you can actually shorten the toe. But I typically don’t have that problem because you’re only taking a very small piece of the bone now which is probably about a half a centimeter.
How about function? Do people have a difference in function after the surgery?
JESSICA SCIULLI: Typically, people go through the post-operative recovery and that’s part of the biggest thing with foot and ankle surgery is the swelling. You also are going to be walking on an area that you’ve had surgery. I tell most of my patients it’s not like having elbow or hand surgery because you start putting weight on an area pretty quickly. But once the healing process has taken place and the swelling starts to normalize people do really well, and they go back to normal function. I mean, I have a lot of athletes that come and see me a lot of nurses a lot of doctors that are on their feet. People do really well, and they return to function, but it is a recovery process because you are having surgery on the foot.
Is there a physical therapy?
JESSICA SCIULLI: With a lot of my patients, if I do more than one procedure, I usually prescribe the physical therapy to help with just a little bit of pain control swelling crossfire with massage, return to normal function, gait control and things like that.
About how long? What’s the downtime?
JESSICA SCIULLI: Typically, if you’re just doing the hammertoe after you have the surgery, the stitches stay in for about two and a half weeks. They’re able to wait with a surgical shoe after the procedure. Now if they have a bunion, it’s a little bit of a longer recovery time. After that once the stitches are out, I usually keep them in the surgical shoe for another two weeks to just help with the swelling and help their foot reacclimate to normal, and then slowly transition into normal shoes.
You’ve mentioned that if you’re having problems or if you’re thinking about having the procedure early is better. How do you know when it’s time?
JESSICA SCIULLI: I usually tell my patients that come and see me you’ll know when it’s time. Typically, they always return when they know that it needs to be done because you’re dealing with an elective procedure. As a surgeon, I mean, I love to operate, but you never want to force people into having surgery, especially an elective procedure. I usually tell them when it starts to bother you, and it’s affecting and hindering your life on a daily basis is usually when I recommend having something done.
Can you tell me a little bit about Sue?
JESSICA SCIULLI: Sue came to see me initially in the wound care center because she had a wound that was lingering and had been treated for about like two years that she couldn’t get to close. And I initially started treating her for the wound, and we got the wound to heal. On her follow up visit after the wound was closed, she had mentioned to me about looking at her foot because she had a bad bunion and hammertoe. I initially looked at it and I told her, she’s a nurse so she’s on her feet all the time and I had explained to her the recovery time and I kind of told her the same thing, which is you’ll know when it’s time. But her foot was pretty deformed. She probably could have had it done that day, but she had a really severe bunion, really contracted hammer toes, could hardly get into a shoe had a lot of pain with ambulation, a lot of pain with work as well. When she came to see me for the initial consult, we had gone through everything and then I had fixed the hammertoe and I had fixed her bunions and of course she went through the post-operative period. Especially when you’re doing surgery on a lot of areas, the foot naturally had a lot of swelling. Once all that healed and the stitches healed and the swelling calmed down, her foot looks great and she’s pretty much back to normal. I feel like I’ve given her some sense of her life back to be able to do things and to be able to be at work and to be able to function and not be limited really from her foot.
Is there anything I didn’t ask you that you would want people – want to make sure that people know?
JESSICA SCIULLI: I think that people always assume foot surgery is barbaric in a sense. I hear all of these horror stories from patients that come and see me. You know, that they’ve had friends that have had surgery and it’s been really bad. I think the biggest thing with having any type of elective foot surgery is just really knowing the post-operative period. It’s not a barbaric type of surgery. It’s more of the recovery time and the expectations and knowing again that you’re putting your weight on an area that we operate on. But I usually would advise people when you don’t want to wait too long, and it’s not something that I think people should shy away from if they’re having problems.
And we’re going to look at the before and after pictures. If you could describe it for me, how is it – I know your surgeon and you see a lot of these but to you what’s the difference?
JESSICA SCIULLI: To me, it’s extremely rewarding. When I look at her foot initially and then I look at her pictures after it gives me a really sense of pride. I love what I do and I like helping people. It was a very challenging case. Her foot was a very challenging case just because of the deformity and the severity and trying to get it back to normal and look somewhat normal. When I look at her foot, I really see a drastic change. It really gives me a lot of sense of reward knowing that that I’ve impacted someone like this.
What made it so challenging?
JESSICA SCIULLI: The deformity because she had a really bad bunion which was pressing on the hammer toe. It wasn’t just really correcting the hammertoes. When it’s contracted to the extent that hers is contracted, her soft tissue has been in that position for a long time. It was really getting the bunion fixed, but then also getting the rest of her toes to sit down in a normal anatomic position when it’s been contracted for a long time.
Do you remember if she said how long?
JESSICA SCIULLI: I think that she’s had that almost her whole life.
And right foot, left foot and the bunion was on the inside of the toe then right?
JESSICA SCIULLI: Yes, the bunions on the great toe and then her hammer toes were the two three and four which were sitting up.
How long have you done this?
JESSICA SCIULLI: Six years. Six and a half. Feels like forever.
You started in general surgery?
JESSICA SCIULLI: I went to John Carroll bio major and then I went to podiatry school, and then my residency was specialized in all foot and ankle surgery. After I finished residency, I moved back to Pittsburgh and started my own practice.
END OF INTERVIEW
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