Girdlestone-Taylor Flexor-to-Extensor Transfer (Claw Toe)

Indication. A symptomatic flexible (passively correctable) claw toe that has failed conservative care (accommodative footwear, toe strapping, insoles) and causes a functional disability — pain, callosity over the dorsal PIP or under the metatarsal head, shoe-fitting difficulty, or skin breakdown. The deformity must reduce under anaesthetic. Why the toe claws (the principle the operation reverses). A clawed lesser toe is the visible result of an intrinsic-minus imbalance. The lumbricals and interossei normally act through the extensor (dorsal) expansion to flex the MTP and extend the interphalangeal joints. When they are weak, paralysed or overpowered, the EDL is unopposed at the MTP and hyperextends (and may dorsally sublux) the joint, while the FDL is unopposed distally and flexes the PIP and DIP. The result is the classic claw posture of MTP hyperextension with PIP and DIP flexion. The Girdlestone-Taylor transfer directly reverses this by converting the FDL — the deforming flexor of the IP joints — into an intrinsic-substitute that flexes the MTP and helps extend the IP joints through the expansion. Indications and contraindications - Absolute indications. Flexible claw toe with functional disability, or symptomatic clawing in an intrinsic-minus foot (idiopathic, neuromuscular, post-compartment-syndrome, inflammatory arthropathy) that reduces under anaesthetic.

• Relative indications. Flexible claw toes within a cavus or Charcot-Marie-Tooth reconstruction (combined with the appropriate bony and soft-tissue procedures); a flexible claw second toe associated with hallux valgus, addressed at the same time as the first ray; recurrent clawing after an isolated soft-tissue release where residual flexibility remains.
• Absolute contraindications. A fixed (rigid) PIP deformity that does not passively correct (transfer alone will fail — use PIP arthrodesis or resection arthroplasty); active forefoot or toe sepsis or critical digital ischaemia; a non-reducible dislocated MTP that cannot be reduced even with extensive soft-tissue release (may need metatarsal shortening, a Weil osteotomy, or MTP resection).
• Relative contraindications. Peripheral vascular disease or significant neuropathy compromising healing and tendon viability; untreated severe cavus or first-ray-driven deformity (correcting the toes without the driver invites rapid recurrence); a limited dorsal skin envelope that cannot accommodate the extensor lengthening and capsular work. The central planning decision — flexible or fixed? The choice between a dynamic flexor-to-extensor transfer and a static PIP procedure rests on whether the deformity is passively correctable. The two are complementary rather than competing, and many reconstructions combine elements of both.

Role of associated procedures. The transfer almost always sits within a broader reconstruction: - EDL Z-lengthening and dorsal MTP capsular release — essential whenever the MTP is hyperextended or dorsally subluxed; the transfer maintains what the release creates.

• Plantar-plate / plantar capsular release — needed for a subluxed or dislocated MTP that will not reduce with dorsal release alone.
• Weil osteotomy — shortens and/or elevates a metatarsal when metatarsalgia, overload or a long metatarsal coexists; often combined with the transfer for the second toe.
• Hallux valgus correction — addressed first when clawing of the second toe is secondary to hallux crowding.
• Cavus correction (Dwyer calcaneal osteotomy, first-ray plantarflexion correction, tendon transfers) — the primary procedure in a Charcot-Marie-Tooth foot, with the lesser-toe work as a secondary stage. Consent specifically for the expected prolonged swelling (often many months), stiffness of the toe, the possibility of recurrence or of a floating toe, the temporary K-wire and its pin-site care, and the small risk of digital nerve injury or vascular compromise. Set the expectation that the toe will be stiffer than a normal toe. Setup. Supine with a bump beneath the ipsilateral calf so the foot rests in a neutral plantigrade position and the forefoot sits at a comfortable working angle. Whole-leg prep and drape to allow a thigh tourniquet and access for concomitant procedures. General or regional (popliteal/sciatic) anaesthesia, often with an ankle block for post-operative analgesia; WALANT is rarely used here because of the precise multi-level tendon work and the need for a bloodless field. A thigh tourniquet is preferred over a calf tourniquet to leave the ankle and calf free of pressure and to give a truly bloodless field for fine dissection.

The goal is to convert the deforming FDL into an intrinsic-substitute through two working exposures used in combination: a medial (or lateral) mid-axial toe incision to harvest and split the FDL, and a short dorsal incision over the MTP to lengthen the extensor, release the capsule, balance the joint, and dock the transfer. The split slips are passed dorsally around the proximal phalanx, deep to the digital neurovascular bundles, and sutured to the extensor expansion with the toe held corrected and protected by an axial K-wire.

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Implants and fixation. No formal hardware is buried — the fixation is a temporary K-wire removed in clinic, keeping the operation low-profile and revisable. | Item | Typical choice | Purpose | |------|----------------|---------| | Tendon suture | 3-0 or 4-0 non-absorbable braided polyester or polypropylene | Securing the FDL slips to each other and to the extensor expansion | | K-wire | 1.1 mm to 1.6 mm smooth wire | Axial fixation across the PIP and MTP for four to six weeks | | Skin suture | 4-0 or 5-0 nylon or absorbable | Skin closure of the fine toe incisions | | Dressing | Bulky compressive forefoot dressing plus backslab/cast as needed | Oedema control and protection |

Rehabilitation | Phase | Timing | Protection | Therapy | |-------|--------|------------|---------| | 1 | 0–2 weeks | Bulky compressive forefoot dressing, backslab/cast if multiple toes or bony work; strict elevation | Finger and ankle motion only; heel-weight-bearing in a stiff-soled post-operative shoe | | 2 | 2–6 weeks | Removable protection in a post-operative shoe; K-wire remains in situ | Wound check, suture removal, pin-site inspection at two weeks; gentle compression once healed | | 3 | 4–6 weeks | K-wire removed in clinic once the transfer consolidates | Gradual active and gentle passive toe range exercises under physiotherapy | | 4 | 6–12 weeks | Wide, deep, stiff-soled shoe, then normal footwear as swelling allows | Intrinsic strengthening; protected against resisted motion early on | Return to function. Desk work within two to three weeks; standing or manual work from six to eight weeks once the wire is out and swelling is controlled; driving once in a normal shoe on the operative foot and off all opiate analgesia; low-impact activity from eight weeks and higher-impact sport typically from ten to twelve weeks, accepting the toe will remain somewhat stiffer and prone to swelling after exertion. Rehabilitation principles. Swelling is the long pole — counsel the patient honestly that the toe may remain swollen for three to six months and that this is expected, not a complication. Stiffness is the trade-off of a straightened toe. Light buddy-taping to the adjacent toe is a useful adjunct during the transition back to normal footwear and after wire removal, gently maintaining alignment while soft tissues settle — but it never substitutes for correct intra-operative tensioning or MTP balancing. Complications

Epidemiology. Lesser-toe deformities are very common and become more prevalent with age and in women, driven by ill-fitting footwear, neuromuscular imbalance and inflammatory arthropathy. Flexible claw toes in a young patient with a cavus foot are the hallmark presentation that should trigger a Charcot-Marie-Tooth work-up. The deformity is frequently bilateral and part of a global foot imbalance rather than an isolated toe problem. Pathoanatomy. A clawed lesser toe results from an intrinsic-minus imbalance. The lumbricals and interossei normally act through the extensor (dorsal) expansion to flex the MTP and extend the IP joints; when they fail, the EDL is unopposed at the MTP and hyperextends (and may dorsally sublux or dislocate) the joint, while the FDL is unopposed distally and flexes the PIP and DIP. Over time the plantar plate and plantar capsule at the MTP attenuate dorsally, allowing progressive dorsal subluxation. The net result is the classic claw posture of MTP hyperextension with PIP and DIP flexion, which the Girdlestone-Taylor transfer directly reverses by converting the FDL into an intrinsic-substitute. The lesser-toe deformities distinguished. The Girdlestone-Taylor transfer is a claw-toe operation; distinguishing the three deformities is a perennial viva point.

Relevant surgical anatomy. The flexor digitorum longus (FDL) inserts onto the base of the distal phalanx of the lesser toes and flexes the DIP, PIP and (assisting) the MTP; it is the deforming force harvested and rerouted. The flexor digitorum brevis (FDB) splits to insert on the sides of the middle phalanx, deep to the FDL at the chiasma of Camper, and is left intact. The extensor digitorum longus (EDL) and extensor digitorum brevis (EDB) form the extensor expansion over the dorsum of the toe; the EDL is the tendon lengthened at surgery and the expansion is the anchor for the transfer. The lumbricals and interossei insert into the expansion and normally flex the MTP and extend the IP joints — the function the transfer restores. The paired digital nerves and arteries run along the medial and lateral borders of each toe, immediately plantar to the mid-axial line and just superficial to the slip-passage plane, and are the structures at greatest risk. Key evidence. The operation rests on Taylor's 1951 description of transferring the long toe flexors into the extensor mechanism for claw toes, which established the principle of converting the deforming flexor into an intrinsic-substitute that flexes the MTP and rebalances the toe. Myerson and Shereff (1989) defined the pathological anatomy of claw and hammer toes, demonstrating attenuation of the plantar plate and MTP capsule with dorsal subluxation in chronic deformity, which underpins the modern practice of combining MTP soft-tissue balancing with the tendon transfer rather than operating on the toe alone. Coughlin (1984) provided the definitive clinical classification of mallet, hammer and claw toe deformities and defined the flexor-to-extensor transfer as the operation of choice for flexible claw toes in the intrinsic-minus foot. Kuwada (1988) reinforced matching the procedure to the flexibility of the deformity and the status of the MTP joint. Guyton and Mann (2000) established that lesser-toe correction in the Charcot-Marie-Tooth foot must follow or accompany correction of the hindfoot and first ray or it recurs, framing the transfer within a global cavus reconstruction.