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 Common Toe Deformities.

Toe deformities are quite common and there are a variety of types. These include hammertoe, mallet toes, clawed toes and overriding toes. The 2nd toe (next to the big toe) is most commonly affected, not only by hammertoe (bending of the middle joint)  but also by being retracted (pulled up) usually as a result of a tight tendon or rupture of the joint capsule under the ball of the foot (plantar plate rupture). It is very commonly seen in association with a bunion deformity.

These deformities have often developed over time and there are a range of reasons why they occur including gait , posture, injury or other biomechanical problems. They usually cause the patient pain and discomfort as they try to compensate for the position of the toe as well as causing constant rubbing in shoes. Infact our patients tell us  it  can often become virtually impossible to find comfortable shoes.

All these deformities can be corrected by a variety of surgeries and have predictably good results. Surgery will include joint pinning and tendon lengthening procedures to achieve good realignment.

The surgery for all these toe deformities can be carried out either as a day-case surgery under a local anaesthetic with sedation or under a general anaesthetic. Most procedures take around 15 minutes per toe depending upon the severity of the deformity. in simple terms the tried and tested procedures we use involve removing thin pieces of bone often at the joint to straighten and realign the toe  into its normal position, and re-adjusting  tendons. Pins or screws are used to hold the toe into position whilst healing takes place. Sometimes these are removed at a later stage.

 The Procedures we use

Arthrodesis (often combined with tendon and skin lengthening)

This is used when the toe is retracted at the joint where the toe joins the foot, and when the toe is very unstable.The problem toe will be dealt with by removing a thin piece of the joint from each side. The two pieces are then held together with Kirchner wires (bone pins) or bone screw in order to set the toe in a straight position. Usually this can be combined with lengthening the extensor tendon on top of the toe, which often becomes tighter and contracted when the toe is retracted. The skin may also be very tight and often requires a plastic surgical technique, called a z-plasty, to lengthen it so that the toe will remain in its corrected position. Occasionally, the long tendon from under the toe is transferred to the top of the toe, which then reduces the deformity. The toe will be stiffer and straighter and by realigning the toe, should reduce pressure under the ball of the foot. The wires will protrude from the end of the toe and will remain there for 5-6 weeks; and then removed in the outpatient clinic. Swelling is common for 3-6
months following surgery.

Arthroplasty

Used to treat hammertoe and mallet toe deformity as above. The problem toe will be dealt with by removing a small piece of bone from one side of the small toe joint. The repair is then completed by interposing the capsule and tendon into the realigned joint to stabilize the toe. The toe may not be completely straight but will be improved. The toe will remain swollen for around 4months after the operation.

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Potential Risks and Complications

This information is provided so that you can make an informed decision over your treatment; it is not designed to frighten you as it should be remembered that the overwhelming majority of our procedures are very successful and all complications are treatable. Your surgery carries the following unlikely but possible complications:

Infection, (approximately 2% risk). The vast majority of these are softtissue infections, treatable by antibiotic tablets as an outpatient. Bone infections are very uncommon, but would require hospital admittance for treatment.

Severe pain only occurs in around 7% of cases in the first 24 hour period. We use a combination of local anaesthetic techniques and compound analgesics, which is usually very effective. Rarely, patients can develop Complex Regional Pain Syndrome (cause unknown), requiring specialist treatment at a pain clinic.

Swelling is common to all surgery and may take 46 months or longer to reduce.

There is an approximate 7% risk of the arthrodesis not fusing properly. In approximately half of these cases the toe remains stable and comfortable without further treatment. If you smoke, you may increase the risk of nonhealing by up to 20%. The toe should be stiff but a lot straighter.

Pins / Kirchnerwires may need to be removed early if they become infected or are damaged e.g. by accidentally kicking something unforgiving. This may cause the procedure to fail. You will need to keep the toe protected and dry until the pin is removed. An open sandal is recommended.

Recurrence of deformity is much less common with arthrodesis than arthroplasty. Arthroplasty may leave a small amount of movement in the little toe joint operated on and carries less risk of infection than arthrodesis.

The toe may be weak or not touch the ground following surgery, especially if the retraction was severe.

Vein clots can occur with any lower limb surgery, but in our practice they are seen in less than 1 in 200 cases (compared with general orthopaedics where the occurrence is reported as high as 4 out of 10 cases). Vein clots, or Deep Vein Thrombosis (DVT), is more common in elderly patients, diabetics, obese patients and patients where two or more immediate family members have suffered DVT, stroke or heart attack.

Unsightly scarring (hypertrophic or keloid) is more common in AfroCaribbean;
Middle and farEastern skintypes. Scarring can be reduced by starting to use - 2 weeks after surgery - Boots scar reduction pads (£19.99) and also using an emollient cream at 4 weeks onwards, massaged into and across the scar. At 6 weeks following surgery, you may wish to use a hydrocortisone cream to massage vigorously along the scarline twice a day for 2weeks
e.g. HC45 cream.

Recurrence or failure of surgery: there is no absolute guarantee that your surgery will be a success. Usually we talk in terms of percentage improvement. The problem/s that you have means your foot is no longer normal. It is certainly not normal to have surgery and therefore your foot cannot ever be normal again. Your Consultant has performed over 6000 foot and ankle procedures, and it is our hope that these experiences and skills will help to rectify your current foot problems. Occasionally, patients do not do well from surgery, for a variety of reasons, often outside of the control of the surgeon or the patient. Very rarely a patient may be left worse off after surgery; although this is extremely uncommon. In these cases further (revision) surgery may prove necessary.