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Management of dislocated lesser toe deformities

General

This is an abnormally positioned toe that has lost alignment at the joint where it meets the foot.  The poor position means that the toe can rub on the upper of the shoe, or cross over adjacent digits with a loss of its ability to purchase the ground. This initially tends to be due to a soft tissue injury, often a torn ligament.  Initially this is reducible, but with time the joint adapts to this poor position and this can lead to arthritic changes.  Symptoms include soreness from shoe pressure on the toes or joint pain as a result of the soft tissue injury.

        

The second toe is elevated, non weight bearing and bent. The scan on the right shows the anatomy with M3 (3rd metatarsal head), ET (extensor tendon), FT (flexor tendon) and the black arrows marking out the strong plantar plate.

Diagnosis

The diagnosis is made clinically although the degree of joint involvement often requires an X-ray to be taken.  The extent of the deformity both clinically and radiographically will determine the effectiveness of treatment options which Professor Tagoe will discuss with you.

Treatment options

Conservative care

• Wider/deeper fitting shoes with a rigid sole to minimise the movement across the inflammed joints.
• Palliative treatment to remove callous
• Padding, splints or toe props
• Simple insoles
• Steroid injection into the painful joint.

Surgical Management

This will vary depending on:

• Whether the toe can be moved into the corrected position manually without pain.  If this is the case then minimal joint changes have occurred
• Other deformities that may be effecting the toe e.g. hallux valgus (bunion)
• The effect that this complaint has on your lifestyle, as well as your expectations

Surgical options:

If the joint is manually reducible with minimal pain on mobilisation then reconstructive procedures are advocated otherwise a more aggressive approach is indicated.  Ideally the aim is to reposition the toe without compromising the major joints, allowing full function.  However, this is not always achievable.

Reconstructive procedures

• Arthrodesis and plantar plate repair:

This involves straightening the toe and repairing the torn ligaments that have allowed the toe to move out of alignment.  The most significant ligament is the plantar plate that holds the toe down.  To reduce the likelihood of the deformity re-occurring the toe is held straight by fusing the bent toe joint (arthrodesis).

To repair the plantar plate an incision would be placed on the sole of your foot over the joint.  The ligament is repaired and in order to reduce the risk of a painful planter scar, a below knee, non weight bearing cast is applied. 

Tendon Transfer:

This procedure is selected when the toe sits in a subluxed position, but can still be straightened manually. There is normally no pain affecting the metatarsal phalangeal joint.  A tendon from the bottom of the toe is cut and transferred onto the top of the toe, pulling it down into a straight position. This procedure will require you being in a cast.

Closing wedge osteotomy

This procedure is selected when the toe deviates towards the next toe. A section of bone is removed from the digit in such a way that the toe can be straightened.  A small wire or a screw is used to hold the 2 bones together whilst they unite.  These normally remain in place unless they move or cause irritation.

Joint destructive procedures

These operations are employed when the joint can not be realigned manually due to severe joint adaptation, arthritis or reconstructive surgery is not appropriate for the patient.

• Syndactylisation

This procedure is selected when the toe is dislocated/crosses over the next toe or the joint is arthritic. Here half of the joint is removed allowing the toe to be realigned, resolving any arthritic pain.  However, the toe is now unstable and is unlikely to stay in this corrected position without further support.  Consequently the toe is joined to its neighbour by removing the skin between the two and sewing them together.  This provides stability with the two toes moving in unison.

Amputation of the toe:

This procedure is most commonly selected when the patient has a severe bunion with the second toe overlying it. Here reconstructive surgery would require the bunion to be corrected in order for there to be room for the second toe to sit down.  In patients who do not want to undergo bunion surgery and a major reconstructive procedure for the 2nd digit, or are too frail; this procedure offers a quick return to normal shoes and function.  The risk is that the big toe could drift over further.

Day surgery

You are admitted to the hospital on the day of your operation.  Professor Tagoe will confirm your consent form and mark the surgical site(s).  Dr Nathwani (anaesthetist) will see you to discuss your anaesthesia.

Anaesthesia

Most patients elect to have their operation carried out under local anaesthetic with sedation, under the care of Dr Nathwani Consultant Anaesthetist.

There are different depths of anaesthesia from sedation through to a general anaesthetic.  Sedation provides reduced consciousness with most of your reflexes left intact and spontaneous breathing. This means that your airway is secure and there is no need to place a tube into your throat. As well as sedation a local anaesthetic block at the level of the ankle is performed to render the surgical area anaesthetised. This allows us to keep the amount of drugs used to a minimum.  The sedation wears off within a few minutes of the end of the operation, without the accompanying drowsiness and nausea, which is sometimes associated with general anaesthesia. The operation is pain free and patients remember nothing of the experience at all.

Local Anaesthesia

Professor Tagoe will anaesthetise your leg via an injection in the back of your knee (Popliteal block).

As the anatomy behind the knee varies a little from person to person we use a nerve stimulator to locate the nerves. This sends a small electric current down the needle which stimulates the nerve. This means that the muscles controlled by the nerve begin to contract and relax causing the foot to ‘flick’. Whilst this is a strange sensation, it is not uncomfortable and helps us to deliver the anaesthetic with precision.

Local anaesthetic at the level of the knee not only blocks sensation but also movement of your foot.  This is temporary lasting for 24 to 36 hours and has the advantage of providing long lasting pain relief and numbness. 

The operation

Your toe will be realigned by one of the following methods:

• Arthrodesis and plantar plate repair
• Tendon transfer
• Closing wedge osteotomy
• Basal arthroplasty with syndactylisation of the digits
• Amputation

Professor Tagoe will discuss with you, your options pre-operatively and fill out your consent form.

Discharge

Before you leave the hospital you will be given a post operative shoe or placed in a cast depending on your procedure.  You will be given crutches and shown how to use them. Post operative painkillers will be dispensed by the nurses. 

You should arrange to go home via car or taxi with an escort.  You are advised to have someone with you for the first twenty four hours in case you feel unwell.

Recovery

You must rest with the leg elevated for the first 48hrs (essential walking only, or hoping if a cast has been put on your leg). It is important that you do not interfere with the dressings and keep them dry.  You can buy a purpose made waterproof cover to keep the leg dry in the bath or shower, from your chemist. Professor Tagoe will see you for a dressing change 3-4 days post surgery.

Plantar plate repair and tendon transfer: the patient will remain in the cast for 3-4 weeks with a gradual return back to comfortable shoes.  You can then gradually return back to your normal footwear and activities.  A full recovery often takes 6 months.

Closing wedge osteotomy: post operative shoe for 10 days.  Thereafter you should remain in a trainer for an additional 4 weeks whilst the bone begins to heal.  During this time you should refrain from any high impact activities (running jumping etc.)  Taping the two toes together can provide initial support.

Amputation and syndactylisation:  the dressing is removed after 10 days along with the sutures if they are not the dissolving type.  You can then gradually return back to your regular footwear and activities 

Once out of the post operative shoe or cast you can drive your car as and when you feel safe.

Physiotherapy

This is not generally required for destructive procedures.  Reconstructive surgery will require you to actively mobilise the joint in a downward direction.  In addition you need to forcibly contract the toe against the ground.  Splinting in the first instance at night using a Darco Toe Alignment Splint can be very helpful. In some instances physiotherapy is requested

Outcome

This type of surgery aims to reduce pain, realign the toe, or in the case of an amputation, remove it. This will allow you to wear a greater range of footwear without discomfort.

Possible complications

Approximately 900 patients undergo foot surgery annually within the Department of Podiatric Surgery at West Middlesex University Hospital.  Most patients have an uneventful recovery.  Outlined below are the common problems or those rare complications with serious outcomes.  In cases where we do not have accurate audit, we have used published results from the podiatric literature.  These are accompanied by an asterisk *

• Prolonged swelling taking more than 6 months to resolve occurs 1 in every 500 operations*
• Thick and or sensitive scar – no audit data is available.
• Adverse reaction to the post operative pain killers.  1 in every 50 patients report that the codeine preparations can make them feel sick.*
• Infection of soft tissue.  The incidence is 1 in every 83 operations*
• Infection of bone occurred in 3 out of 916 patients.
• Delayed healing of soft tissue or bone.  No audit data is available.
• Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10 year period.
• Loss of sensation can occur although this is usually transient but can take up to a year to resolve.
• Deep vein thrombosis which can result in a clot in the lung is potentially a life threatening condition.  Deep vein thrombosis incidence is 1 in every 900 cases.
• Chronic pain syndrome: this is where the nervous system dealing with pain over reacts in a prolonged manner often to a minor incident.  This normally requires management by specialists in this condition and doesn’t always resolve.  This is a rare complication with no audit data available.

Specific complications following digital surgery:

• Insufficient correction obtained following the surgery or recurrence of deformity.
• Prolonged swelling of the toe
• The toe may be weak or not touch the ground

Additional risks associated with an arthrodesis

• The pin may become loose and require removal
• The two bones may not fuse (non-union). This is not always problematic as the toe may remain straight.  However, if accompanied by pain, or recurrence of deformity, revision surgery may be required.

Additional risks associated with a plantar plate repair or tendon transfer

• Painful scaring on the sole of the foot
• Metatarsal phalangeal joint stiffness

The risk of having a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre-operative screening and continues through to the rehabilitation exercises.

Pre operative screening of your health allows us to determine whether you are fit for surgery.  It is important that you disclose your full medical history.  If there is a query regarding your health, then further investigations or the advice of other surgical and medical specialties will be sought. The surgeon and the theatre team will ensure that the operation is performed effectively and with the minimum of trauma.

You can improve the healing process and reduce the risks of complications by:

• Adhering to the post operative instructions which include resting and elevating the operated leg.  Keeping the wound clean and dry until advised otherwise is essential.  Please ask the nurse or Professor Tagoe if you are not sure what to do.
• Having a healthy diet is important. This provides the nutrition required for healing.
• Smoking is associated with a 20% increased risk of delayed or non healing of bones.
• Alcohol can interact with the drugs that we will prescribe and in excess can impair wound healing.
• Post-operative exercises and in certain cases physiotherapy will be advised.  This helps improve the flexibility, strength and stability of your foot.


Podiatric surgeons evaluate, diagnose, prevent and treat diseases, disorders and conditions affecting the foot and all associated structures.  This is carried out in keeping with the individuals, education, training and experience, in accordance with the ethics of the profession and applicable law.  



Podiatric Surgical Training
3 year:	Degree in Podiatry
2 year:	General Podiatric Practice
2 year:	Diploma in the theory of podiatric surgery
2 Year	Surgical training programme (Podiatric Surgical Trainee)
	Final fellowship examinations
3 year:	Specialist training (Podiatric Registrar)
Accreditation with the Faculty of Podiatric Surgery Consultant Podiatric Surgeon

Secretaries:

Marina Nichols:
08700 410 448
Email: marina@thetagoeclinic.co.uk