What are the surgical indications for toe (digit) deformities or conditions?

From the Guidelines

Surgical indication for toe conditions, particularly in individuals with diabetes, is strongly recommended for non-rigid hammertoes with nail changes, excess callus, or pre-ulcerative lesions on the apex or distal part of the toe, with digital flexor tendon tenotomy being a valuable procedure to prevent foot ulceration 1.

Key Considerations

• The decision to proceed with surgery should be made after a thorough evaluation of non-surgical treatment options by an appropriately trained healthcare professional.
• Digital flexor tenotomy has been shown to reduce the risk of ulcer development in people with diabetes with excess callus on the tip of their toes or thickened nails, with moderate desirable effects and small undesirable effects 1.
• The procedure is easily performed in an outpatient setting, with no need for subsequent immobilization, and is not likely to negatively affect foot function.
• Adverse effects of the surgery may include transfer lesions or transfer pressure, and should be discussed with the patient, particularly in individuals with poor arterial supply to the foot 1.

Surgical Approach

• Digital flexor tenotomy is a relatively straightforward procedure that can be performed in an outpatient clinic, with negligible to small additional resources required 1.
• The procedure may be cost-effective based on the balance of effects in favor of digital flexor tenotomy and the small initial costs.
• Equity is likely increased due to the negligible to small additional costs, minimal extra surgical skill required, and worldwide availability of the procedure 1.

Recovery and Outcomes

• Recovery from digital flexor tenotomy typically involves a period of limited weight-bearing, elevation, and gradual return to activities over 6-12 weeks.
• The goal of surgery is to restore function, relieve pain, and improve quality of life by addressing the underlying anatomical problem, with a strong recommendation in favor of digital flexor tenotomy as a first-line treatment for neuropathic plantar or apex ulcers on digits 2-5 secondary to a flexible toe deformity 1.

From the Research

Surgical Indications for Toe

• Surgical indications for toe conditions include:
  • Severe cases of hammertoes that have not responded to non-surgical treatment, where tendon transfers, joint arthrodesis, or arthroplasty may be considered 2
  • Bunions that are painful and have not responded to non-operative treatment, where referral to an orthopaedic surgeon is recommended 3
  • Lesser toe deformities, such as bunionette correction, where percutaneous procedures may be indicated 4
  • Severe idiopathic toe walking that has not responded to conservative treatment, where surgical intervention such as plantar flexor lengthenings may be beneficial 5
• The decision to operate on toe conditions depends on various factors, including:
  • Severity of symptoms and impact on patient function
  • Response to non-surgical treatment
  • Presence of underlying medical conditions
  • Patient's overall health and suitability for surgery
• It is essential to carefully evaluate the indications and contraindications for surgery, as well as the potential risks and benefits, to ensure the best possible outcomes for patients with toe conditions 4, 3, 2, 6

Considerations for Surgical Intervention

• Smoking is a relative contraindication to surgery, and cessation is recommended 3
• Cosmesis alone is not an indication for operative management 3
• Patient-related variables, such as age and underlying medical conditions, should be considered when evaluating the suitability of surgical intervention 6
• A comprehensive understanding of toe anatomy, pathophysiology, and treatment options is crucial for the effective management of toe conditions 2