Management of dislocated toe deformities
This is an abnormally positioned toe that can rub on, 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 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 Miss Feeney will discuss with you.
- Wider/deeper fitting shoes
- Chiropody treatment
- Padding, splints or toe props
- Simple insoles
- Steroid injection into the painful joint.
Surgical ManagementThis will vary depending on
- Whether the toe can be moved into the corrected position manually without pain by the clinician. 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.
Ideally the aim is to reposition the toe without compromising the major joints, allowing full function. However, this is not always achievable.
If the joint is manually reducible with minimal pain on mobilisation then reconstructive procedures are advocated otherwise a more aggressive approach is indicated.
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 joint (arthrodesis). An arthrodesis has two small wires buried in the bone to keep it straight. These wires should not bother you but can be removed after 6 weeks if they do.
To repair the plantar plate an incision would be placed on the sole of your foot over the joint. The ligament is repaired and the tendon shortened to reduce the risk of the toe moving out of alignment again. In order to reduce the risk of a painful planter scar, a below knee, non weight bearing cast is applied for 3 weeks.
This procedure is selected when the toe sits in a subluxed position, but it 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 to pulling it down into a straight position. This procedure will require you being in a cast for 4 weeks, followed by a return to a trainer for a further 3-4 weeks.
Closing wedge osteotomy
This procedure is selected when the toe deviates towards the next toe. A section of bone is removed from the toe in such a way that the toe can be straightened. Small wires 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. This will require a period of 2 weeks in dressing then returning to a trainer for a further 4 weeks.
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.
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 and resolve the 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.
This will require a period of 2 weeks in a post operative shoe an then a return to your own comfortable shoe.
Amputation of the toe:
This procedure is most commonly selected when the great toe has deviated in towards the lesser digits (bunion). This can cause the second toe to dislocated and cross over the great toe. Here 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 this procedure offers a quick return to normal shoes and function. The risk is that the big toe could drift over further. Post operatively you would be in a post operative shoe for 2 weeks and then a return to your regular footwear.
You are admitted to the hospital on the day of your operation. You will be shown to the ward and asked to change into a gown. Miss Feeney will confirm your consent form and mark the surgical site(s).
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.
Most patients elect to have their operation carried out under local anaesthetic with sedation.
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 most patients remember nothing of the experience at all.
Miss Feeney will anaesthetise your leg via an injection in the back of your knee (Popliteal block). This will be carried out on the ward with adequate time given to allow the local anaesthetic to take effect.
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.
Your toe will be realigned by one of the following methods:
- Arthrodesis and plantar plate repair
- Basal arthroplasty with syndactylisation of the digits
- Tendon transfer
- Closing wedge osteotomy
Miss Feeney will discuss with you, your options pre-operatively and fill out your consent form.
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. You will be seen for a dressing change along with the cast if appropriate 3-6 days post surgery. Patients not in a cast will return to walking to tolerance around the house.
For reconstructive procedures (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. If a wire has been placed through the toe, this will be removed at the six week mark. You can then gradually return back to your normal footwear and activities. A full recovery often takes 6 months.
Patients undergoing a closing wedge osteotomy will be in the post operative shoe for 10-14 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. The team will advise you whether this is required. Destructive surgery (amputation, syndactylisation) the dressing is removed after 10-14 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.
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 especially at night can be very helpful, ask the team for further information. In some instances physiotherapy is requested.
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.
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 pins may become loose or 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.