There are different operations to correct severe deformities of the small (lesser) toes, usually hammer, claw, mallet or curly toes. These include:

Modified “Oxford” procedure

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 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.

Modified “Stainsby” procedure

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 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.

Toe fusion

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

Tendon transfer or tenotomy

A tendon transfer or tenotomy will be performed if the toe is completely mobile and the deformity can be corrected. This will usually only be performed in younger patients. 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. A simple tenotomy involves a cut on the bottom of the toe and lengthening of the tendons by cutting them in two. The skin is then stitched up and splinted with steristrips.

When would these procedures be necessary?

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. 

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 2-6 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 to allow swelling to go down. This will be discussed with you in clinic when you are offered surgery.

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

The operation can be done under general anaesthetic (asleep). Alternatively, an injection 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, in that case, you may have to go to sleep if the operation is to be performed. 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 asleep to reduce the pain after the operation even if you go to sleep 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

Recovery and rehab after your procedure

The dressings on your foot will be removed approximately 2 weeks after surgery in a nurse-led clinic. If a pin has been put in the toe, this will stay in for another 4 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 3 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

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. It will be impossible to wear an ordinary shoe because of the dressings, so you will be provided with a special shoe.

Go back 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 2 months off work. How long you are away from work will depend on where your job fits between these two extremes.

Drive

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.

Play sport

After your pins or paper 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.

What are the risks?

Excess and prolonged Pain - Chronic Regional Pain Syndrome (CRPS)

The main symptom of complex regional pain syndrome (CRPS) is pain, which can sometimes be severe, continuous and debilitating.

Recurrence of the deformity

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.

Nerves and blood vessels

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.

Swelling

Most people’s toes will be fairly swollen after the operation and sometimes some swelling persists indefinitely. There is usually some bruising.

Bleeding

The wounds and pinhole usually heal quickly, but occasionally these can bleed, become infected or need antibiotics. There are general risks with any operation that include blood clots (Deep Vein Thrombosis & Pulmonary Embolism), anaesthetic complications and tourniquet complications.

How you can reduce your risks

Most patients find that simple measures can make a big difference to the outcome of surgery. The evidence from studies and our experience supports this:

• Take simple Vitamin C and vitamin D tablets for healing
• Stop smoking, smoking slows down healing and is linked to increased complications
• Keep fit and a healthy weight, many foot problems are improved by losing weight.