Surgery should only be considered when non-surgical treatment has failed or (as in active severe infection) is inappropriate. It should not be offered simply because the patient does not like the look of their toes, or as an alternative to shoes that fit, even if unappealing to the patient's views on fashion.
"Make the shoe fit the foot, not the foot fit the shoe"
Surgery aims to:
- correct deformity to reduce pressure on shoes
- stabilise the MTP joint to prevent deformity progression
- correct the factors that lead to metatarsalgia
- correct other foot problems which are causing the patient discomfort, such as hallux valgus
- minimise risk of adverse events
Based on the patient's complaints and the findings as summarised in the Blackburn classification of deformity and Thompson classification of instability, we use the following guide to procedure selection. Nevertheless, a certain amount of judgement and experience are required to personalise surgery to the needs and underlying pathology of individual patients.
Type 1 hammer/clawtoe - flexible PIP and MTP deformity - flexor-extensor transfer
Type 2 hammer/clawtoe - fixed PIP, flexible MTP deformity - PIP excision arthroplasty +/- MTP soft tissue release
Type 3 hammer/clawtoe - fixed PIP and MTP deformity - PIP excision arthroplasty + MTP soft tissue release OR Stainsby procedure
Reducible MTP instability - flexor-extensor transfer OR plantar plate repair +/- hammertoe correction
Irreducible MTP dislocation - open reduction +/- Weil osteotomy +/- hammertoe correction OR Stainsby procedure (depending on joint quality) OR amputation
Mallet toe - DIP fusion + FDL release OR terminalisation
Congenital varus toe - DIP fusion + FDL release OR terminalisation