Lesser toe surgery: a guide for patients

Toe deformities can cause problems and affect your quality of life in a number of ways; poor fitting footwear, corns or hard skin formation, ulceration and nail thickening.

Toe deformities can be either congenital (you are born with them) or acquired (you develop them). Congenital conditions include curly toes and acquired conditions can occur secondary to the way that your foot functions, for example a foot that rolls out and pronates can develop hammer toes and certain medical conditions, such as rheumatoid arthritis and neurological conditions, can lead to toe deformities.

Digital deformities can be divided into three main types: Hammer, mallet and clawed.

Hammer toe

A hammer toe is where a kink develops in the first joint of the toe causing the end of the toe to touch the ground and the bent joint to rub against the shoes. A hammer second toe is often seen with a bunion deformity.

Mallet toe

A mallet toe is where the joint at the end of the toe is kinked causing the end of the toe to bend downwards and contact the ground. With this type of deformity a corn can develop at the tip.

Claw toe

A claw toe is a more complex deformity and can be secondary to a high arched foot, neuromuscular conditions or inflammatory joint disease, such as rheumatoid arthritis. In a claw toe, the toe is in a fixed position with the base of the toe pointing upwards from the ball of the foot and the next joint being bent downwards, like in a hammer toe. Surgical management of claw toes can be more involved and complex and may require additional surgery at the adjacent joint and bone, known as lesser metatarsal surgery.

What treatment is available?

Treatment can consist of both conservative and surgical options:

Non-surgical treatment

• Alteration of footwear: changing to a wider/deeper fitting shoe can reduce the pressure on the toe.
• Protective padding and silicone toe moulds.

Surgical treatment

There are many different types of operations for digital deformities and some operations would be suitable for one person but may not be another. The two main types of operations are: arthroplasty and arthrodesis.

An arthroplasty involves removing a section of joint to reduce the kink that has developed. The toe is repaired in a realigned position. In the majority of cases, there will be some movement at the arthroplasty site.

An arthrodesis is performed when the toe is very unstable or there is a risk of the deformity re-developing; this can occur in the medical conditions previously mentioned. The joint is removed from the bent joint and the bony surfaces are brought together and held together, often with a wire. The two bony surfaces fuse together, holding the toe in a straight position. The end of the wire sits outside of the toe, it is protected by a dressing and removed around six weeks following the surgery.

Metatarsophalangeal release

• This involves releasing the tendon and the soft tissue structure around the ball of the foot joint. Tension is reduced and the toe assumes a straighter position.

Skin plasties

• This is where the skin needs to be lengthened to allow the toe to sit in a better position.

Flexor to extensor tendon transfer

• This aims to reduce instability of the toe around the ball of the foot joint. The procedure moves the tendon on the bottom of the toe to the top, bringing the toe down and helping to maintain a straight position.

Removal of the base of the toe bone

This procedure is required when there is a non-reducible severe dislocation of the toe at the ball of the foot joint, metatarsophalangeal. The base of the toe bone nearest the knuckle joint is removed. This is commonly known as a Stainsby’s procedure. You quickly recover from the procedure, but it does leave the toe shorter and sometimes floppy. This procedure is often used to treat severe rheumatoid arthritic toes.

Lesser metatarsal osteotomy

A lesser metatarsal osteotomy is required when there is irreducible dislocation of the toe at the metatarsophalangeal joint, which may also be associated with pain of that joint.

Dislocated lesser toes/windswept toes

A toe can also deviate sideways. There are many reasons why this can happen, including disease processes, such as inflammatory arthritis, injury to the joint capsule on the underside or side of the metatarsophalangeal joint or secondary to the position of the metatarsals (the long bones of the forefoot). Correcting these deformities can be difficult and sometimes the results may not be perfect or the deformity comes back.

Correction of these types of deformity can be achieved by rebalancing the soft tissue around the joint, but often a section of bone needs to be removed from the base of the toe to obtain a straighter position. The toe is usually strapped in the corrected position for four weeks. During this time, you will need to remain in the surgical shoe.

Syndactylisation

Syndactylisation is the joining together of the toes. This may be required if the toe is very unstable and needs to be supported by the toe next to it or if there is an interdigital corn that has not responded to previous conservative or surgical care. The toes are joined together by removing the skin between the two and stitching them together.

About day case surgery under local anaesthetic

Surgery is carried out under local anaesthetic as a day case. This means that you are awake during the operation but a screen will prevent you from seeing the operation.

To numb your toe, you will be given some injections around the base of your toe or around your ankle (ankle block).

You can eat and drink on the day of surgery; there is no need for fasting.

The operation may take between 10 minutes to one hour depending on the complexity of the toe deformity but you should be prepared to be at the hospital longer than this to allow for preparation and recovery. Throughout the operation you will have a tight band (called a tourniquet) placed around your ankle to keep the blood away from your foot. This is sometimes uncomfortable but is released immediately after the operation.

You must have a competent adult at home for the first day and night after surgery.

If you decide on surgical management you will be invited back to attend a pre-surgical assessment clinic. A member of the nursing team will take a medical history and if you are on any medication please bring a list of these with you. This is a good opportunity to ask us any questions or concerns you may have about the procedure.

Recovery after your operation

As the operations for toe deformities are so diverse the recovery can vary between procedures. Outlined beneath is the most common recovery pathway. However, this may not be entirely applicable to your current surgeries and if this is the case the podiatric surgeon will discuss this with you.

The first two to three days

• You must rest with your foot elevated to hip level.
• You should restrict your walking to bathroom visits only, and if you have been given crutches you must use them in the way shown. You may be able to bear a little weight on the foot.
• You should take the pain killers that have been prescribed and if you experience pain, it is usually worse for the first two days.
• After three to four days if you are still experiencing pain that is not relieved by the pain killers you should contact the department directly.
• If you have any concerns over your foot you should contact the department directly.
• The Department is closed over the weekend. During out of hours you should contact your GP or attend your local accident and emergency department.

Two weeks after surgery

• Two weeks after the operation you must attend for removal of the dressing and stitches
• You should no longer need a bandage and will be able to wear a normal shoe again. But this shoe does need to be roomy (ideally a trainer) because your foot will be quite swollen. If you do not have any you will need to purchase some prior to the surgery.
• At this stage you can gradually and gently increase your activities. You will still need to rest between your activities.
• You can normally start bathing the foot once again one to two days following stitch removal.

If you have had an arthrodesis or a toe procedure with a wire out of the end of the toe you will need to wear the post operative shoe for six weeks.

Between two and eight weeks after surgery

• During this time the foot gradually returns to normal and you may be able to vary your footwear a little.
• There will still be noticeable swelling especially towards the end of the day and this is quite normal.
• Three to four weeks after the surgery you can look at returning to work (this is not the case for an arthrodesis). Returning to work is dependent on the type of shoes and activities required of your job. At this time you can also look at a return to driving, however you must feel able to perform an emergency stop. (It is worth checking with your insurance company about when you policy covers you to drive).
• Although normal everyday activities will be possible, sporting activities are still restricted at this stage.
• At six weeks following the surgery you can look at returning to high impact activities as long as the toe does not become too painful and swollen

Between eight and 12 weeks after surgery

• The foot should now be comfortable and returning to normal but there may still be some slight swelling.

Six months after surgery

• The residual swelling should now be very slight, although the healing process continues for a year. You should be getting full benefit from the surgery.

Twelve months after the surgery

• All healing is now complete.

Frequent or serious occurring risks

Unfortunately, all operations carry a small risk of complications. In foot surgery complications are uncommon and most resolve without permanent disability or pain. General and specific complications of this procedure include:

• Infection (two in 100)
• Delayed healing of the skin (eight in 100)
• Non compliance of patients (four in 100)
• Bone break associated with non compliance (two in 100)
• Prolonged swelling post operatively (four in 100)
• Thick or sensitive scar formation (four in 100)
• The toe may not be perfectly straight or may not touch the ground
• The toe may become stiff which could affect the heel height of the shoes you wear (one in 100)
• Recurrence of the toe deformity (two in 100)
• Development of secondary pain or tenderness under the toe knuckle joint (three in 200)
• Loosening or movement of the screws or wires used to fix the bones (two in 100)
• Delayed / Non-union of the osteotomy or arthrodesis site.
• Blood clot deep vein thrombosis (DVT).

Please make a note of any questions you might want to ask at your appointment.