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

Mechanism of Disease - Why the Toe Claws

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 joint and extend the interphalangeal joints. When these intrinsic muscles are weak, paralysed or mechanically overpowered:

• The extensor digitorum longus (EDL), unopposed at the MTP, hyperextends the metatarsophalangeal joint and may dorsally sublux or dislocate it.
• The flexor digitorum longus (FDL), unopposed distally, flexes the PIP and DIP joints.
• The plantar plate and plantar capsule at the MTP attenuate dorsally, allowing progressive dorsal subluxation.

The net result is the classic claw posture: 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 extensor expansion.

Surgical Indications

Absolute Indications

• Flexible (passively correctable) claw toe with a functional disability - pain, callosity over the dorsal PIP or under the metatarsal head, shoe-fitting difficulty, or skin breakdown
• Symptomatic clawing in an intrinsic-plus-minus / intrinsic-minus foot (idiopathic, neuromuscular, post-compartment-syndrome, inflammatory arthropathy) where the deformity reduces under anaesthetic

Relative Indications

• Flexible claw toes as part of a cavus or Charcot-Marie-Tooth foot reconstruction, combined with the appropriate bony and soft-tissue procedures
• Flexible claw second toe associated with hallux valgus, addressed at the same time as the first-ray correction
• Recurrent clawing after isolated soft-tissue release where residual flexibility remains

Contraindications

Absolute:

• Fixed (rigid) PIP deformity that does not passively correct - the transfer alone will fail; PIP arthrodesis or resection arthroplasty is the primary procedure
• Active forefoot or toe sepsis or critical digital ischaemia
• A non-correctable dislocated MTP that cannot be reduced even with extensive soft-tissue release (may require metatarsal shortening / Weil osteotomy or MTP resection)

Relative:

• Peripheral vascular disease or significant neuropathy that compromises healing and the viability of the transferred tendon and toe
• Untreated severe cavus or first-ray driven deformity - correcting the toes without addressing the driver invites rapid recurrence
• Limited skin envelope on the dorsum of the toe that cannot accommodate the extensor lengthening and capsular work

Decision: Transfer vs PIP Fusion

The choice between a dynamic flexor-to-extensor transfer and a static PIP procedure is the central planning decision, and it rests on whether the deformity is flexible or fixed.

A flexible deformity with intrinsic-minus aetiology is the ideal indication for the transfer, whereas a fixed deformity is better served by PIP fusion - the two are complementary rather than competing, and many reconstructive cases combine elements of both.

Role of Associated Procedures

• 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

Relevant Surgical Anatomy

The Long Flexors and Extensors of the Lesser Toes

• Flexor digitorum longus (FDL): inserts onto the base of the distal phalanx of the lesser toes (lateral four). It flexes the DIP, PIP and (assisting) the MTP, and is the deforming force that flexes the IP joints in a claw toe. It is the tendon harvested and rerouted in the Girdlestone-Taylor transfer.
• Flexor digitorum brevis (FDB): splits to insert on the sides of the middle phalanx, deep to FDL at the chiasma of Camper. It is usually left intact.
• Extensor digitorum longus (EDL) and extensor digitorum brevis (EDB): form the extensor expansion over the dorsum of the toe. EDL unopposedly hyperextends the MTP in intrinsic-minus disease and is the tendon lengthened at surgery.

The Extensor (Dorsal) Expansion

The lumbricals and interossei insert into the extensor expansion. Through this expansion the intrinsics flex the MTP and extend the IP joints. Loss of intrinsic function collapses this balance and produces the claw posture. The Girdlestone-Taylor transfer restores this mechanism by anchoring the rerouted FDL to the expansion, so the transfer reproduces the missing intrinsic pull.

Digital Neurovascular Bundles

• 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 plane in which the FDL slips are passed dorsally around the proximal phalanx.
• They are the structures at greatest risk during slip passage and the reason capillary refill is monitored throughout.

The Plantar Plate and MTP Capsule

• The plantar plate at the MTP attenuates dorsally in chronic clawing, permitting dorsal subluxation and dislocation. Releasing (and where possible reefing) this structure is part of balancing the MTP.

Surgical Approach

The Girdlestone-Taylor transfer uses two working exposures, used in combination:

1. Medial (or Lateral) Mid-Axial Toe Incision

A longitudinal mid-axial incision is made along the chosen side of the toe (typically medial for the second toe, the side that allows the most natural routing), extending from just distal to the MTP crease to the level of the DIP. The mid-axial line lies dorsal to the neurovascular bundle, which is protected plantarward. Through this incision:

• The FDL is identified at its insertion on the base of the distal phalanx and detached.
• The tendon is split longitudinally into two slips.
• A curved clamp is passed from plantar to dorsal around each side of the proximal phalanx (deep to the neurovascular bundles) to deliver each slip dorsally.

2. Dorsal Approach to the MTP and Extensor Mechanism

A short dorsal incision over the MTP (in line with the EDL tendon) is used to:

• Perform EDL Z-lengthening when the MTP is hyperextended.
• Release the dorsal MTP capsule and, if needed, the plantar plate.
• Receive and suture the two FDL slips onto the extensor expansion.
• Allow insertion of the axial K-wire and MTP reduction.

Positioning and Preparation

Patient position: Supine, with a bump beneath the ipsilateral calf to allow the foot to rest in a neutral plantigrade position and to bring the forefoot into a comfortable working angle. The whole leg is prepared and draped to allow a thigh tourniquet and, where needed, access for concomitant procedures.

Anaesthesia: General or regional (popliteal/sciatic) anaesthesia is typical; the procedure is fine under a combination with an ankle block for post-operative analgesia. WALANT-type awake local is rarely used here because of the multi-level, precise tendon work and the need for tourniquet control.

Tourniquet: 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; inflate to the standard pressure for the patient after exsanguination.

Consent: Specifically counsel the patient on 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.

Step-by-Step Technique

Step 1: Confirm Flexibility and Plan

Before incising, re-examine the toe under anaesthetic and confirm the deformity passively corrects. Mark the medial mid-axial line and the dorsal MTP incision. Plan any concomitant procedures (EDL lengthening, MTP release, Weil osteotomy, hallux correction, contralateral cavus surgery).

Step 2: Medial Mid-Axial Incision and FDL Harvest

Make the longitudinal mid-axial incision along the toe. Gently dissect to expose the FDL tendon at its insertion on the base of the distal phalanx. Detach the FDL at this insertion and deliver it proximally. Confirm you have the FDL and not the FDB (the FDB splits around FDL at the chiasma and inserts on the middle phalanx - leave it intact).

Step 3: Split the FDL into Two Slips

Split the harvested FDL longitudinally into two equal halves, carrying the split proximally to the level of the MTP so that each slip has enough length and independent mobility to be routed around each side of the proximal phalanx.

Step 4: Route the Slips Dorsally Around the Proximal Phalanx

Using a curved clamp or tendon passer, create a tunnel on each side of the proximal phalanx, passing from the plantar (mid-axial) wound to the dorsal wound. Keep the dissection tight to the bone of the phalanx so the digital neurovascular bundles ride safely superficial. Grasp each FDL slip and deliver it dorsally, so the two slips now lie on either side of the proximal phalanx, emerging dorsally over the extensor mechanism.

Step 5: Balance the MTP (Concomitant Soft-Tissue Release)

Through the dorsal incision, perform an EDL Z-lengthening if the MTP is hyperextended, and a dorsal MTP capsulotomy. If the MTP is subluxed or dislocated, add a plantar-plate / plantar capsular release until the joint reduces. This balancing is what allows the transfer to hold the MTP down; performing the transfer without it is the commonest cause of recurrence.

Step 6: Tension and Suture the Transfer

With the toe held in the corrected position - MTP in slight flexion, PIP neutral - bring the two FDL slips together dorsally over the extensor expansion and suture them to each other and to the EDL/EDB tendon using a non-absorbable suture (for example 3-0 or 4-0 braided polyester or polypropylene). The transfer should hold the toe flat against its neighbour without bowstringing it into hyperextension. The principle is to tension slightly on the loose side: it is far easier to deal with minor residual laxity than with an over-tight, floating toe.

Step 7: Rigid Fixation with an Axial K-Wire

Reduce the toe fully and drive a smooth K-wire (commonly a 1.1 mm to 1.6 mm wire) retrograde from the tip of the toe (just plantar to the nail), across the PIP and the MTP, into the metatarsal head to hold the toe straight and the MTP reduced while the transfer heals. The wire is bent and cut at the skin and protected with a cap. Fixation is typically maintained for four to six weeks.

Step 8: Wound Closure and Dressing

Close the skin with fine sutures (absorbable or non-absorbable per preference). Apply a bulky, well-padded compressive forefoot dressing; many surgeons add a forefoot bandage or a below-knee backslab/CAST for protection, particularly when multiple toes or concomitant bony procedures have been performed. Recheck capillary refill before leaving theatre.

Implants and Fixation

No formal implants or hardware are buried; the fixation is a temporary K-wire that is removed in clinic, which keeps the operation low-profile and revisable.

Post-operative Protocol

Early Phase (Day 0 to Week 2)

• Dressing and protection: A bulky compressive forefoot dressing is maintained, supplemented by a backslab or cast when multiple toes or concomitant bony work have been performed. The dressing is inspected but kept supportive at the first review.
• Elevation: Strict elevation of the foot above the heart for the first 48 to 72 hours is the single most effective measure against the otherwise prolonged swelling.
• Weight-bearing: Heel-weight-bearing in a stiff-soled post-operative shoe is generally permitted to protect the forefoot; the exact regimen depends on concomitant procedures.
• Analgesia: Paracetamol and an NSAID; stronger analgesia for the first 24 to 48 hours.
• Pin-site care: Keep the K-wire protected with a cap; the patient is taught not to disturb the wire and to watch for discharge or loosening.

Intermediate Phase (Week 2 to Week 6)

• Review at two weeks: wound check, dressing change, suture removal if non-absorbable sutures were used, and pin-site inspection.
• Continued protection: The toe remains protected in the post-operative shoe; the K-wire stays in situ.
• Swelling management: Continue elevation and begin gentle compression (a toe sock or Coban) once wounds are healed.
• Capillary refill and neurology: Recheck digital perfusion and sensation at each visit.

Wire Removal and Mobilisation (Week 4 to 6)

• The axial K-wire is removed in clinic at four to six weeks, once the transfer has begun to consolidate and the MTP is stable.
• After wire removal, gradual active and gentle passive range-of-motion exercises of the toe are begun under physiotherapy guidance.
• The transfer is deliberately protected against resisted motion for the first few weeks after wire removal to avoid attenuation.

Return to Function

• Shoes: Transition from the post-operative shoe into a wide, deep, stiff-soed shoe, then into normal footwear as swelling allows.
• Driving: Once in a normal shoe on the operative foot and off all opiate analgesia.
• Return to work: Desk work within two to three weeks; standing or manual work from six to eight weeks once the wire is out and swelling controlled.
• Sport and impact: Low-impact activity from eight weeks; higher-impact sport once comfortable, typically from ten to twelve weeks, with the expectation that 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: a successfully transferred toe is straighter and more comfortable but is rarely as mobile as a native toe; manage expectations.
• MTP and intrinsic rehabilitation: once healed, gentle intrinsic strengthening and MTP mobility work help maintain the balance the transfer has restored.
• Surveillance for recurrence or floating toe: review the toe at three months to confirm it rests flat and loads in gait; an over-corrected floating toe or a recurrent claw is addressed before it becomes fixed.

Toe Strapping and Buddy-Taping

• 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.
• Strapping does not substitute for correct intra-operative tensioning or MTP balancing, but it can protect the correction during the vulnerable early mobilisation phase.