Lesser Toe Surgery

Patient Information Leaflet

Lesser Toe Surgery (small toe surgery)

Introduction

This is the information about the proposed surgery on your foot. You have been seen by a foot and ankle team and they are considering lesser toe surgery on your foot. This leaflet aims to give you additional information about your condition and the treatment. It is designed to give you some general details about the recovery from surgery if necessary and the common risks and complications. Please ask your surgeon if you have any further questions.

If anything changes before the operation, please let your surgeon or their secretary know (e.g., skin problems, infections, injuries).

What is lesser toe surgery?

There are different operations to correct severe deformities of the small toes, usually known as “hammer” or “claw” toes. These include:

1. Modified “Oxford” procedure
2. Modified “Stainsby” procedure
3. Toe fusion
4. Tendon transfer

Why would they be done?

If the deformity is painful, causes the toe to rub in the shoe or causes pressure in the ball of the foot and cannot comfortably fit 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.

An “Oxford” procedure will be performed if the toe is fixed in position and it is painful on the top or tip of the toe.

A “Stainsby” procedure will 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 will be performed if the toe is completely mobile and the deformity can be corrected. This will usually only be performed in younger patients.

What does each operation involve?

These operations will involve the use of a tourniquet (tight band) to stop the blood flow to the limb

1. Modified Oxford procedure

A straight cut is made at the base of the toe. The tendon on the top is lengthened and the joint at the base of the toe is freed up. A small incision is made across the first joint in the toe and a small piece of bone removed from it. The joints and tendons are stitched up and the toe splinted with paper stitches that hold it in the corrected position.

2. Modified Stainsby procedure

A cut is made at the base of the toe. The joint at the base of the toe is freed up, some bone is removed from this joint and the tight ligaments are freed to allow the joint to be corrected. The top and bottom tendons are stitched together and the toe is usually stabilised with a pin in the tip of the toe. The cut is stitched up and dressings applied.

3. Fusion

A cut is made across the end of the toe and a small piece of bone is removed from each bone in the toe. The toe is then stabilised with a pin or screw in the tip of the toe.

4. Tendon transfer

A cut is made along the top of the toe and the tendon on the top may be lengthened. Two small cuts are made on the bottom of the toe and the bottom tendon released at the end of the toe. The tendon is split in two and passed through into the cut on the top of the toe and stitched to the tendon on the top. The skin is then stitched up and the toe splinted with Steri-Strips.

Can they be done as a day case operation?

If you are medically fit, have someone who can collect you and look after you after the operation and you are comfortable afterwards, the operation can be done on a day case basis. However, if you have other medical problems such as diabetes, asthma or high blood pressure, you may have to attend the preoperative assessment clinic two-six weeks before your surgery. You may need to stay in overnight after your surgery. You must stay overnight to avoid complications if there is no one to collect and look after you. If you are having many toes operated on, especially if both feet are involved, you may need to stay in for a day or two to allow swelling to go down. This will be discussed with you in clinic when you are offered surgery.

Will I have to be put to sleep (general anaesthetic)?

The operation can be done under general anaesthetic (asleep). Alternatively, an injection (local anaesthetic) given in the back, leg or around the ankle can be given to make the foot numb while you remain awake. Local anaesthetic injections do not always work and you may need to have a general anaesthetic. Your anaesthetist will advise you about the best choice of anaesthetic for you.

In addition, local anaesthetic may be injected into your leg or foot while you are having your surgery, this is to reduce the pain after the operation even if you have a general anaesthetic for the surgery. You will also be given painkilling tablets as required.

Will I have a plaster on afterwards?

No plaster is required if you are only having your toes straightened.  Some people also have a bunion corrected or an operation for arthritis of the big toe at the same time. If so, you may have a plaster applied to protect the big toe.

What will happen afterwards?

The dressings on your foot will be removed two weeks after surgery in a nurse-led clinic. If a pin has been put in the toe, this will stay in for another four weeks. For the other operations, the paper stitches will be replaced and need to be kept on for another 4-8 weeks. Keep the pin and wounds dry until any scabs have healed and fallen off. If you have a pin you must keep this dry at all times.

After the pin or paper stitches have been removed, you will be shown how to massage the wound and the toe and how to tape the toe to prevent it tightening up again. Once the pinhole is dry and the scab has fallen off, you can get the toe wet. Usually, you will be seen about three months later to check all is well. You can arrange to return if you are having any problems

How soon can I walk on the foot?

You can walk on the foot immediately after surgery. For the first two 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.  It will be impossible to wear an ordinary shoe because of the dressings, so you will be provided with a special shoe.

When can I return to work?

If your foot is comfortable, and you can keep your foot up and work with your foot in a special shoe, you can go back to work 3-4 weeks after surgery. In a manual job with a lot of dirt or dust around, you may need to take anything up to two months off work. How long you are away from work will depend on where your job fits between these two examples.

When can I return to driving?

Most people prefer not to drive until the dressings are off, they can wear a shoe and are able to fully weight bear. 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. If only your left foot is operated on and you have an automatic car, you can drive within a few weeks of the operation, when your foot is comfortable enough and you can bear weight through it

When can I return to sports?

After your clips or stitches are removed, you can start increasing exercise. Start with walking or cycling, building up to more vigorous exercise as comfort and flexibility permit. Most people can return to their previous level of activity within 3-4 months of surgery.

Surgery Risks

• The most common 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. There is usually some bruising.
• The wounds and pinhole usually heal quickly, but occasionally these can bleed, become infected or need antibiotics.
• There are risks with any operation that include blood clots/deep vein thrombosis (DVT) and pulmonary embolism (PE), anaesthetic complications and tourniquet complications. Generalised pain, swelling and stiffness can occur (chronic regional pain syndrome-CRPS)
• 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.

Wellbeing Advice

Patients that have a healthy diet, regular exercise and refrain from smoking prior to surgery are more likely to experience quicker and better recovery and may also have a more successful outcome with their surgery. If you have any concerns about your general health and well-being (diet, exercise, smoking cessation) you are encouraged to discuss this with your GP, who will be able to provide advice on the options available to you.

Further Information

The figures for complications given in this leaflet have been taken from information produced by the British Orthopaedic Foot Surgery Society using audits from all areas of the UK.

The British Orthopaedic Foot Surgery Society web site is available at: www.bofas.org.uk/PublicArea/PatientAdvice/tabid/ 85/Default.aspx (accessed September 2008)

Mann, Coughlin and Saltzman (2007) Surgery of the Foot and Ankle 8th edition, Elsevier, Philadelphia.

Myerson, S (Ed) (2000) Foot and Ankle Disorders, Saunders, Philadelphia.

NHS Constitution. Information on your rights and responsibilities. Available at www.nhs.uk/aboutnhs/constitution

dgft.midlandsorthopaediccentre@nhs.net

01384 456111 Ext 4638

dgft.vfc.dudley@nhs.net

http://www.midlandsorthopaediccentre.co.uk/

Please visit our YouTube channel to access some of our fracture patient information videos

If you have any questions, or if there is anything you do not understand, please contact the Russells Hall Hospital switchboard number on 01384 456111 and ask for the relevant department who issued this leaflet.

If you have any feedback on this patient information leaflet please email dgft.patient.information@nhs.net

This leaflet can be made available in large print, audio version and in other languages, please call 0800 073 0510.

Originator: Mr K Jain, T&O Department. Date originated: November 2023. Date reviewed: November 2023. Next review due: August 2026. Version: 1. DGH ref.: DGH/PIL/02181