Management of Toe Deformities

General

Abnormally shaped toes can rub against adjacent digits or be irritated by your footwear.  The affected toe is usually prominent with the joint assuming a bent position.  Symptoms include soreness between the toes, over the prominent joint or at the tip of the digit.  Hard skin or corns may form and there can be associated damage to the toenail.

 

Diagnosis

This is a clinical diagnosis made by the examining the foot, X-rays are not normally required.  

Treatment options

Conservative care

• Wider/deeper fitting shoes
• Palliative treatment to remove the hard skin
• Padding, splints or toe props
• Simple insoles

Surgical Management

This involves straightening the toe.  This can be achieved by either removing half of the joint (arthroplasty) or the whole joint and fusing the two bones in a straight position (arthrodesis).  

 

                       

The Xray on the left shows hammer toe deformities( 2nd to the 5th digit).  The X-ray on the right shows the toes being straightened by arthrodesis of the 2nd, 3rd and 4th with an arthroplasty of the 5th.

 The choice between an arthrodesis or an arthroplasty is largely determined by; whether the underlying cause has been resolved (a bunion pressing on the second toe) and which digit or joint is affected.  It is rare to fuse the fourth or fifth toes or a mallet toe deformity. 

 

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 will also 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 foot via several injections around your ankle.  This will make your foot numb although you would still be able to move it.  The alternative is an injection each side of the toe(s) causing just the digit to go numb. 

The operation

Your toe will be straightened by one of two methods:

• Arthroplasty
• Arthrodesis
• In both cases a soft tissue release and tendon lengthening might be required, to ensure a good position. 

 

The incision is made on the top or side of your toe.  Professor Tagoe will use stitches to close the skin, these may need to be removed 10 days after the operation or in some cases they dissolve.

Discharge

Before you leave the hospital you will be given a post operative shoe, in most cases you do not need crutches.  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). 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, from your pharmacy or on line. Professor Tagoe will see you for a dressing change 3-4 days post surgery, at which point most patients can then return to walking to tolerance around the house. 

After 10 days the dressings and stitches will be removed, and you are advised to return to a trainer.  At this stage you can wash your foot and gradually increase your activities.  Once out of the post operative shoe you can drive your car as and when you feel safe.

Physiotherapy

This is not generally required.

Outcome

This type of surgery aims to straighten the toe, allowing 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 don’t 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.

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. Professor Tagoe 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 410448
Email: marina@thetagoeclinic.co.uk