Management of Toe Problems

 General

This is an abnormally shaped toe that 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
  • Chiropody treatment
  • 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). An arthrodesis requires fixation with two small internal wires. These wires are buried in the bone and will stay in place unless they trouble you. Although unlikely, they can be removed if they cause a problem.

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. 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, 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.


Anaesthesia

You have the option of having a local or general anaesthestic/sedation. In either case the operation is normally carried out as a day case.


General Anaesthesia/Sedation

Here you would be put to sleep by the anaesthetic team for the duration of your operation, waking up in recovery. Prior to having a general anaesthetic, you would be reviewed by the nurses to ensure that you were fit and well. You will be given all the relevant information on general anaesthesia and the opportunity to ask questions.


Local Anaesthesia

Miss Feeney 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. The podiatric surgeon will use stitches to close the skin, which will need to be removed 10-14 days after the operation. Sometimes a dissolvable suture is used depending on the type of incision made.


Recovery

You must rest with the leg elevated for the first 48 hrs (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 chemist. You will be seen for a dressing change 3-6 days post surgery, most patients can then return to walking to tolerance around the house.

After 10-14 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 internal 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.

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 improves 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 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.