Lesser Toe Deformity Correction

Indication. Symptomatic lesser toe deformity — a hammer, claw or mallet toe producing a painful dorsal corn, a callosity, or skin breakdown — that has failed a minimum of 3 months of conservative care (toe-box modification, silicone splints, padding and physiotherapy). Absolute indications

• Rigid lesser toe deformity causing painful corns, callosities or ulceration refractory to conservative measures
• Rigid PIPJ flexion deformity (hammer or claw toe) causing a painful dorsal prominence or interphalangeal corn
• Rigid DIPJ flexion deformity (mallet toe) causing a distal tip corn or nail deformity refractory to conservative care Relative indications
• Flexible deformity causing functional impairment or shoewear difficulty where splinting has failed
• Flexible claw toe with plantar MTP synovitis or MTP instability (positive drawer test)
• Lesser toe deformity in the context of hallux valgus requiring correction (the adjacent toe deformity resolves with hallux correction in roughly 30 percent, so assess pre-operatively)
• Ulceration or skin breakdown in the neuropathic foot where the deformity is the underlying cause Contraindications
• Active infection in the operative field, or toe ischaemia
• Severe peripheral arterial disease (ankle-brachial index less than 0.5 or absent toe pressures) — vascular workup and reconstruction first
• Unrealistic patient expectations (the toe will be straight but may not look completely normal)
• An inadequate trial of conservative management (less than 3 months for a flexible deformity)
• Underlying progressive neurological disease not yet managed — address the cause first The decision that drives everything: flexible or rigid? The whole surgical plan turns on this single assessment. Perform the Kelikian push-up test — apply axial compression under the metatarsal head to recreate normal ground reaction force and assess passive correctability at the MTP, PIPJ and DIPJ individually.

Consent specifically for toe numbness or a painful digital neuroma, recurrence (up to 30 percent at 5 years), a floating toe, pin-track infection, non-union, and the fact that the toe will be straight but may not look completely normal. Setup. Supine with the foot at the end of the table, a thigh tourniquet (250-300 mmHg) or ankle tourniquet (150-175 mmHg) inflated after exsanguination, and general anaesthesia, spinal, or an ankle block (a combined popliteal/saphenous block gives excellent analgesia). Mark all deformities and incision sites before inflating the tourniquet, keep the ankle off the end of the table to check toe alignment intra-operatively, and have fluoroscopy available. Limit tourniquet time to 90 minutes at the ankle and 120 minutes at the thigh.

The goal is a straight, plantigrade toe that contacts the ground and is free of painful corns. Three procedures cover almost every lesser toe deformity: PIPJ arthrodesis for the rigid hammer or claw toe, the Girdlestone-Taylor flexor-to-extensor transfer for the flexible claw toe, and DIPJ arthrodesis for the mallet toe. Each is laid out below with its exposure as the first step — the exposure is where the danger structures live, so it is where the operation is won or lost.

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Rehabilitation | Phase | Timing | Shoe and immobilisation | Milestones and activity | |-------|--------|-------------------------|-------------------------| | Immediate | 0-2 weeks | Stiff-soled post-operative shoe, weight-bearing as tolerated from day 1 | Elevation 48-72 hours; daily pin-site care; sutures out at 12-14 days | | K-wire out | 4-6 weeks | Wire removed in clinic under local anaesthetic; buddy-strap 2 weeks | Transition to a wide-toe-box, firm-soled shoe | | Recovery | 6-12 weeks | Wide-toe-box shoe; avoid heels, narrow toe-box and flip-flops | Intrinsic strengthening, scar massage; radiographic fusion at 6-8 weeks | | Return to sport | 3 months | Normal footwear | Running and impact sports permitted | Most patients return to sedentary work at 2-3 weeks, regular footwear and light sport at 6-8 weeks, and running or impact sport at 3 months. Radiographic union for PIPJ and DIPJ arthrodesis is typically apparent at 6-8 weeks, with clinical union at 8-12 weeks and remodelling over 6 months. For the Girdlestone-Taylor transfer, transfer healing is complete at 6-8 weeks and final toe position stabilises by 3-4 months. Complications

Floating toe — prevention is better than cure. The floating toe is almost always caused by over-tension of the extensor mechanism or an over-tight Girdlestone-Taylor transfer. Intra-operatively, assess toe alignment with the ankle at neutral — the corrected toe should rest flat. If a floating toe is recognised immediately post-operatively, early revision (before fibrosis) offers the best results. Managing recurrence. Recurrence is the commonest reason for revision surgery, and the critical question is whether the initial procedure was appropriate: a Girdlestone-Taylor transfer for a rigid deformity will reliably recur, and a PIPJ arthrodesis for a flexible claw toe will not address the MTP. A careful pre-operative flexible-versus-rigid assessment eliminates this avoidable cause. For progressive neurological disease (Charcot-Marie-Tooth, diabetic neuropathy), counsel patients that deformity may progress despite technically successful surgery, and that staged procedures may be required. Warning signs requiring urgent review: increasing pain, warmth or redness around the K-wire site (pin infection); a pale, cold or mottled toe (ischaemia — immediate review); a wire backing out or bending at the exit site (migration); or a sudden worsening of deformity after initial correction (implant failure or non-union).

Surgical anatomy. A few structures govern the whole operation. The PIPJ is a hinge joint: the bicondylar head of the proximal phalanx articulates with the biconcave base of the middle phalanx, with a thick plantar plate (the primary restraint to hyperextension), proper and accessory collateral ligaments, and a thin dorsal capsule continuous with the extensor mechanism. On the flexor side, FDL runs in the fibro-osseous sheath, inserts into the distal phalanx and is the primary DIPJ flexor; FDB divides into two slips that wrap around FDL at Camper's chiasm to insert into the middle phalanx. In a PIPJ arthrodesis the FDB does not need to be divided; in a Girdlestone-Taylor transfer only FDL is split and transferred. On the extensor side, EDL runs dorsally into the extensor expansion, whose central slip inserts into the middle phalanx and whose lateral bands continue to the distal phalanx. The MTP joint is a condyloid joint stabilised chiefly by its plantar plate and the interossei, whose failure produces the intrinsic minus (claw) posture; the deep transverse metatarsal ligament connects the plantar plates across the metatarsal heads. The digital arteries and nerves (proper plantar digital nerves from the medial and plantar nerves) run along the plantar-medial and plantar-lateral surfaces just beneath the skin — the structures most at risk in any plantar dissection or plantar K-wire.

Key evidence. PIPJ arthrodesis is the standard operation for the rigid hammer or claw toe; the Girdlestone-Taylor flexor-to-extensor transfer is the standard dynamic procedure for the flexible claw toe; and percutaneous K-wire fixation remains comparable to far more expensive intramedullary implants for PIPJ fusion. Reported osseous union rates for K-wire PIPJ arthrodesis cluster around 70-75 percent radiographically, and a clinically stable fibrous union is often asymptomatic — so do not overstate fusion as exceeding 90 percent. Myerson and Shereff's cadaveric work showed that adequate correction frequently requires more extensive soft-tissue release than bone resection alone, which is why routine collateral and capsular release is performed at the PIPJ (and at the MTP when it is hyperextended).