Lesser toe deformities

What are lesser toe deformities? 

Lesser toe deformities are caused by changes in normal anatomy that create an  imbalance between the foot’s muscle groups (intrinsic and extrinsic). Causes include  improper shoe wear, trauma, genetics (family history), inflammatory arthritis, and  neuromuscular and metabolic diseases.  

Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover  toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux  valgus of the first MTP joint and instability of the lesser MTP joints, especially the  second toe. Midfoot and hind foot deformities may be present as well.  

Nonsurgical management focuses on relieving pressure and correcting deformity with  various appliances. Surgical management is reserved for patients who fail to improve  with nonsurgical treatment. Surgical options include soft-tissue correction (e.g., tendon  transfer) as well as bony procedures (e.g., joint resection, fusion, metatarsal  shortening), or a combination of techniques. 

Surgical correction 

If the deformity is painful, causes the toe to rub in the shoe or causes pressure in the  ball of the foot and cannot be accommodated in a shoe, surgery would be considered.  Some people prefer to have shoes with extra depth and possibly an insole. Others do  not like such shoes or are not comfortable in them. The choice of operation depends on the type and severity of the deformity.

Common surgical procedures 

∙ Interpositional arthroplasty surgery may be performed if the toe is fixed in  position and it is painful on the top or tip of the toe. 

∙ A Stainsby procedure may be performed if the toe is fixed in position and it causes  pain on the ball of the foot as well as pain on the top of the toe. 

∙ A fusion is usually performed if the toe is deformed at the last joint causing pain at  the end of the toe, but the rest of the toe is pain free. 

∙ A tendon transfer may be performed if the toe is completely mobile and the  deformity can be corrected. This will usually only be performed in younger patients. 

Can surgery be done as a day case operation? 

Yes. If you are medically fit, have someone who can collect you and look after you after  the operation and you are comfortable afterwards. If you have other medical problems  such as diabetes, asthma or high blood pressure, you may have to attend the  preoperative assessment clinic 2-6 weeks before your surgery to ensure you are as fit  as possible before your operation. If you do have other health issues it may be safer for  you to stay in overnight after your surgery.  

You must stay overnight if there is no one to collect and look after you. 

Will I have to go to sleep (general anaesthetic)? 

The operation may be done under general anaesthetic (asleep). Alternatively it may be  possible to have the operation performed under a local anaesthetic (often the case for  single toe surgeries). There may be advantages to choosing a local anaesthetic such  as less drowsiness, quicker recovery time, being able to eat and drink immediately  afterwards and faster discharge from hospital. Your surgeon and anaesthetist will  advise you about the best choice of anaesthetic for you. 

If a general anaesthetic is given, local anaesthetic may also be injected into your leg or  foot while you are asleep to reduce the pain after the operation. You will also be given  pain-killing tablets as required.

Will I have a plaster on afterwards? 

No. Some people also have a bunion corrected or an operation for arthritis of the big  toe at the same time. It is very unlikely that you will have a plaster put on as padding  and a firm bandage will be applied. 

You can go home when comfortable and safe. For the first 2 weeks, you should avoid  walking if possible and only put your weight through the heel. When not walking, rest  with your foot elevated to reduce swelling. 

What will happen afterwards? 

The dressings on your foot will be removed 2 weeks after surgery in clinic. Your wound  will be assessed and sutures removed. If a pin has been put in the toe, this will stay in  for another 2-4 weeks. Keep the pin and wounds dry. If you have a pin you must keep  this dry at all times. Any paper stitches/strapping will be replaced and need to be kept  on for another 4 weeks. 

Usually, you will be seen about 6-8 weeks after surgery to check all is well. Your wires  will be removed at this appointment in the clinic. You will more than likely be  discharged at this appointment. You can arrange to return if you are having any  problems. 

How soon can I … 

Walk on the foot? 

You will be provided with a surgical shoe. For the first 14 days you should avoid  walking if possible, but if you need to walk put all of your weight on the heel. When not  walking, you must rest with your foot elevated as much as possible to reduce swelling.  After this you can be more mobile. 

Go back to work? 

This depends on what you do and how you get to work. If you have a sitting-down job  that you could do with your foot in bandages and you can get to work, you could  probably go back to work 2-3 weeks after surgery. If you have a heavy manual job you  may be off for up to 2 months. If you need to drive to work, this will affect when you can 

go back. Your surgeon or foot and ankle practitioner will advise you about going back  to work. 

Drive? 

Once your bandages have been removed you may be able to start driving again (not if  you have wires in the toe/s). You must be comfortable before trying to drive. Start by  sitting in the car and trying the pedals. Then drive round the block. Drive short  distances before long ones. If you cannot safely make an emergency stop, your  insurance will not cover you in the event of an accident. Ask your surgeon or foot and  ankle practitioner when it is safe for you to drive again. 

Play sport? 

After your dressings have been removed you can start gently exercising your foot and  walking further each day. After discharge, when you are comfortable, you can start  gentle exercise and stretching. Contact, twisting and impact sports can follow as  comfort dictates. Everyone varies as to how quickly they can take up exercise again.  Be guided by your own body’s reactions and the advice of your surgeon. Most people  can get back to most of their previous activities at about 3 months following  uncomplicated lesser toe surgery. 

Risks 

∙ The commonest problem is recurrence of the deformity, usually to a much less  severe degree than before. This occurs in about 1 in 10 people, but only a few of  these will have to have further surgery. 

∙ Most people’s toes will be fairly swollen after the operation and sometimes some  swelling persists indefinitely. 

∙ The wounds and pinhole usually heal quickly, but occasionally these can become  infected and need antibiotics. 

∙ The nerves and blood vessels in a toe are quite small and may be stretched or  damaged in the course of surgery. In severely deformed and stiff toes, all the  vessels and nerves tend to be tethered together close to the joints. As a result,  about 5-10 in 100 toes will be a bit numb or sensitive afterwards.  

∙ Rarely, the blood supply to a toe may be so badly affected that it dies or has to be  amputated. 

∙ Wires can come loose or be accidentally removed. Contact your surgical team if a  wire is removed. Rotating of the wire while in the toe is common and does not  present a risk to your surgical recovery.