You have been directed to this section of the website because you have a dislocated or dislocating toe.
Toes commonly dislocate at the joint in the ball of the foot because of a ligament (plantar plate) injury. Unlike other joints where a dislocation may occur due to a sudden injury, a dislocated toe normally develops over a more gradual period of time. The problem occurs in the joint at the base of the toe from repetitive increased stress and strain. This results in the toe sitting up off the floor. With time, the joint can become damaged. Symptoms include soreness in the ball of the foot, shoe pressure on the top of the toes and difficulty with footwear fitting.
The diagnosis can normally be made following a clinical examination and an x-ray is routinely requested. On occasions, investigations such as ultrasound or MRI may be required. The underlying cause needs to be established as this often plays an important part in the decision of how to treat the problem.
The effectiveness of both conservative and surgical treatments normally relates to how severe the problem is and the length of time the toe has been out of position.
- Footwear- Mr McCallum will give you advice on the most appropriate type of shoe for your condition.
- Padding or strapping/splinting.
- Ice- can be effective in the early stages of the injury.
- Steroid injection into the painful joint. This is not a suitable option on its own. It holds the risk of weakening the position of the toe and making the alignment worse. It is only appropriate when a suitable shoe or protective boot is worn.
The conservative treatment options are not likely to improve the position of the toe but they can be very effective in reducing pain.
The success of surgery over the long term may depend on whether or not the cause of the problem has been addressed. This is not always possible.
The surgical approach may involve a combination of procedures depending on the clinical presentation. The options include:
- Plantar plate repair
- Tendon transfer
- Closing wedge osteotomy
- Basal arthroplasty with syndactylisation
- Amputation of the toe
The above options are explained below and Mr McCallum will advise you which options are suitable in your case.
- Arthrodesis: this involves fusing the joint in the middle of the toe into a straight position by cutting the bent joint and putting a wire through the toe which maintains the position while the bones fuse together. This prevents the toe from bending out of position again.
The diagram below shows the bones being held together with a wire. This is removed 6-weeks after the operation.
- Plantar plate repair: The plantar plate is a strong ligament that supports the joint at the base of the toe and holds it in position. When the plantar plate stretches or tears, the toe normally sits up (as seen in the photograph at the top of this page).
There are two approaches to this procedure and Mr McCallum will decide the better approach for you.
- Plantar incision: an incision is made through the bottom of the foot and it enables good access to the torn ligament.
- Dorsal incision: an incision is made on the top of the foot. It requires the metatarsal to be cut to gain access to the torn ligament. The metatarsal is then screwed back together.
In order to reduce the likelihood of a painful plantar scar, a cast or boot may be used to help keep the weight away from the incision line for up to 4-weeks.
- Tendon transfer: The tendon under the toe is released from where it attaches to the bone and is transferred to the top of the toe. This causes the tendon to pull the toe down into a better position. A wire or screw is then used to secure the tendon in place.
- Closing wedge Osteotomy: This procedure is selected when a toe deviates towards the next toe. A section of bone is removed from the toe in such a way that the toe can be straightened. A wire is used to secure the bones together.
- Basal arthroplasty with syndactylisation: This procedure is selected when the toe is dislocated/crosses over an adjacent toe or if the joint has been damaged. It is normally preferred when the toe has been out of position for a long period of time and it is not possible to manually reduce the position of the toe. It may also be chosen due to its relatively quick and straightforward recovery.
Half of the joint at the base of the toe is removed allowing the toe to be repositioned. This leaves the toe very unstable and so the skin between this toe and the next is removed and the toes are joined together with stitches. The diagram below shows the 4th and 5th toes sewn together and the photograph shows the 2nd and 3rd toes sewn together. This photo was taken 12-weeks following the surgery.
- Amputation of the toe: this is most often performed to provide a solution when complex surgery would otherwise be required but is inappropriate.
The following protocols are guides. Mr McCallum may amend or change the protocol based on how he sees fit after taking into consideration your individual circumstances.
Protocol for arthrodesis, syndactylisation, amputation and closing wedge osteotomy
A protective shoe will be put onto your foot before you leave the hospital. This is removable and can be taken off when resting. Crutches will be provided when necessary.
You should travel home by car and keep your foot elevated on the back seat where possible. When you go home, you must rest with the leg elevated for the first 2-4 days (essential walking only). It is important that you do not interfere with the dressings and that you keep them dry. You can buy a purpose made waterproof device from the chemist if you wish.
Mr McCallum will review you within one week of your operation for a change of dressing and at the 2-week mark, the dressings will be removed and the sutures will be removed. You can now wash your foot as normal and return to a comfortable shoe.
Mr McCallum will review you after a further 4-weeks to assess your progress and if you have had an arthrodesis, the wire in your toe will be removed. After this, you can treat the foot as normal. It can often take 6-months for the toe to completely settle down but this will depend on exactly what you have had performed.
Protocol for tendon transfer/plantar plate repair
After your operation, you will be placed into an Aircast walking boot and you will remain in this for a period of approximately 6-weeks. The Aircast is removable and you should take it off when resting so that you can mobilise your foot and ankle. It must be worn at all times when moving around.
Before you are discharged from the hospital, you will be shown how to use crutches so that you can partially weight bear on the foot whilst wearing the Aircast.
You should travel home by car and keep your foot elevated on the back seat where possible. When you go home, you must rest with the leg elevated for the first 2-4 days (essential walking only). It is important that you do not interfere with the dressings and that you keep them dry. You can buy a purpose made waterproof device from the chemist but if washing, you must exercise caution when putting the foot to the floor in a shower.
Mr McCallum will review you within one week of the surgery for a re-dressing then a further 1-2 weeks later the sutures will be removed. At the 6-week mark it is normally safe for you to return to your own comfortable footwear (a running shoe is ideal) and you can gradually increase your activity levels to tolerance. If you have a wire in your toe, this will be removed at this stage.
On average, it takes 6-9 months for the foot to have fully recovered although this time will obviously depend on the exact procedure you have had performed. It is not unusual to experience stiffness and discomfort for this period of time.
This type of surgery aims to reduce pain, realign or in cases of amputation, remove the toe. This should allow you to wear a greater range of footwear without discomfort. Unfortunately, none of the procedures are capable of restoring the toe to a completely normal state. The intention is to provide a significant improvement.
Possible Complications following surgery:
Outlined below are the possible problems or the rare complications following foot surgery with serious outcomes. In cases where there are no accurate audit results, published results from podiatric literature have been used.
- Prolonged swelling taking more than 6-months to resolve can occur in 1 in 500 operations.
- Haematoma- a painful collection of blood under the skin. This can increase the risk of developing an infection and may require further surgery to resolve.
- Thick or sensitive scar.
- Irritation from internal fixation. Screws and plates are only required whilst the bone is healing (during the first 3-months) after which they provide no further benefit. However, fixation is not generally removed unless it causes a problem. This may occur in up to 10% of cases.
- Adverse reaction to the post-operative painkillers. 1 in 50 patents report that codeine preparations make them feel sick.
- Infection of the soft tissue. 1 in every 83 operations.
- Infection of bone- osteomyelitis. This is a serious complication and in severe cases, can lead to amputation.
- Delayed healing of soft tissue or bone.
- Circulatory impairment with loss of tissue.
- Loss of sensation can occur although this is not normally permanent and can continue to improve over 18-months.
- Deep vein thrombosis (blood clot) can result in the clot travelling to the lung and this can be a life threatening condition. Deep vein thrombosis incidence is 3 in 1000 cases.
- Complex pain syndrome- a condition where the nervous system dealing with pain over reacts. This is a very painful condition that can result with even with minor trauma. It normally requires management by specialists in this condition and does not always resolve. This is a rare condition that occurs in 3 in 2500 cases.
- Recurrence of deformity or failure of the surgery.
Specific risks following dislocated toe surgery:
- Insufficient correction or recurrence of the deformity.
- Prolonged swelling of the toe.
- The toe may be weak or not touch the ground- floating toe.
Additional risks associated with arthrodesis:
- The wire may become loose or require early removal.
- The two bones may not fuse (non-union). This is not always problematic and the toe may remain straight. If painful or if the toe becomes deformed as a result of the non-union, further surgery may be required.
Additional risks associated with a plantar plate repair:
- Painful scar on the sole of the foot.
- Continued elevate of the toe.
- Stiffness of the toe with an inability to bend it up or down.
The risk of developing 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 post-operative regime.
The pre-operative screening helps us determine whether you are fit for surgery or if any extra measures need to be considered to minimise your risk of developing a complication. It is important that you disclose your full medical history. If there is a query regarding your health then further investigations may be required and Mr McCallum will liaise with the appropriate medical specialists. Mr McCallum and the there team will ensure that your operation is carried out safely and effectively.
You can improve your healing process and reduce the risks by:
- Adhering to the post-operative instructions, which include resting and elevating the operated foot. Keeping the wound dry and clean until advised otherwise. Please ask Mr McCallum 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 bone.
- Alcohol can interact with the drugs that are prescribed and can impair wound healing.
- Post-operative mobilisation will be advised, this helps improve flexibility, strength and stability of your foot.