What are the indications for a toe tenotomy and how is the procedure performed, including anesthesia, incision technique, postoperative care, and potential complications?

Toe Tenotomy: Indications and Procedure

Primary Indication

Digital flexor tenotomy should be used in diabetic patients with neuropathic plantar or apex ulcers on digits 2-5 secondary to flexible toe deformities (hammertoes, claw toes, mallet toes) to promote and sustain ulcer healing 1. This is a strong recommendation with moderate-quality evidence for treatment of existing ulcers 1.

Indications

Treatment Indications (Strong Evidence)

• Active neuropathic ulcers on the apex or plantar tip of toes 2-5 with flexible digital deformities 1
• Ulcers that have failed to heal with non-surgical offloading interventions 1

Prevention Indications (Conditional Evidence)

• Non-rigid hammertoes with nail changes, excess callus, or pre-ulcerative lesions on the apex or distal toe 2
• Pre-ulcerative lesions that fail to respond to conservative treatment (padding, orthoses, footwear modifications) 2
• Only consider after exhausting non-surgical options 2

Patient Selection Criteria

The procedure is appropriate for:

• Diabetic patients with peripheral neuropathy (loss of protective sensation) 3, 4
• Adequate vascular supply (palpable pulses, good capillary refill) 4, 5
• Can be performed even with neuroischemic ulcers if perfusion is adequate 4
• Osteomyelitis of the terminal phalange is NOT a contraindication, though healing time increases from 3 weeks to 8 weeks 5

Procedure Technique

Anesthesia

• Local anesthesia only - no general anesthesia required 2, 6
• Performed as outpatient procedure 2, 3
• Optional IV sedation or VR distraction available but not necessary 7

Surgical Approach

Two described techniques:

1. Percutaneous plantar approach (most common):

   • Small transverse plantar stab incision just proximal to the web space level 4
   • Performed under sterile technique 3
   • Uses 18-gauge needle or fine scalpel blade 3
   • Cut both superficial and deep flexor tendons 4

2. Percutaneous dorsal approach:

   • 16- or 18-gauge needles 6
   • Various needle techniques described 6

Procedure Duration

• 1 to 30 minutes depending on technique and number of toes 6
• Simple, rapid procedure 2

Additional Maneuvers

• If rigid flexor contracture at proximal interphalangeal joint persists: perform osteoclasis (manual fracture) to correct remaining deformity 5

Postoperative Care

Immediate Post-Procedure

• No immobilization required 2
• Patient can bear weight immediately 2
• Elastic taping of toes may be used 8

Follow-up Schedule

• Weekly reviews until incision and ulcer heal 3
• Then follow-up at 3 and 6 months 3

Expected Healing Times

• Surgical incision: All heal uneventfully 4
• Ulcer healing without osteomyelitis: Mean 10.2 days (range 7-21 days) 3, 4
• Ulcer healing with osteomyelitis: Mean 8 weeks (range up to 224 days) 4, 5
• Healing rate: 86.7-100% of ulcers heal 3, 4, 9

Activity Restrictions

• Return to normal activities within 3-7 days 7
• Must continue wearing appropriate therapeutic footwear 1
• Combine with offloading device during healing phase 1

Complications and Risks

Infection Rate

• Very low: 2.8% per episode of care 3
• No infections reported in surgical incisions in multiple series 4, 5

Transfer Lesions

• Moderate risk: 14.5% develop transfer lesions to adjacent digits 3
• Mean time to development: 95.5 days (±98 days) 3
• Transfer pressure to adjacent metatarsophalangeal joints possible 2
• Critical pitfall: Monitor for transfer lesions during follow-up

Long-term Outcomes

• Recurrence of deformity: 22.7% at 12+ years follow-up 10
• Recurrent ulceration: 3 patients in one series, but overall low rate 4
• No toe amputations directly related to procedure 4
• High patient satisfaction (mean 4.45/5) 7

Contraindications to Consider

• Poor arterial supply increases risk of non-healing surgical incision 2
• However, adequate perfusion (palpable pulses) allows safe performance even in neuroischemic patients 4

Key Clinical Pearls

When to Perform

• First-line for active toe ulcers with flexible deformities 1
• After non-surgical treatment failure for prevention 2
• Do not delay if ulcer present - promotes rapid healing 3, 4

Cost-Effectiveness

• Procedure cost at least 50% less when performed in podiatry clinic versus operating room (£554 vs £1100+) 9
• Prevents ongoing costs of repetitive conservative treatments 2

Provider Considerations

• Can be safely performed by trained podiatrists with outcomes equivalent to orthopedic surgeons 9
• Requires appropriate training in sterile technique and tendon anatomy 3

Critical Warning

Despite excellent short-term outcomes, this population remains at extremely high risk: 93.3% develop new ulcers elsewhere, 53.3% require amputation, and 55% mortality at 12 years 10. Tenotomy addresses only the local mechanical problem - comprehensive diabetic foot care with regular monitoring, appropriate footwear, and vascular assessment remains essential 1, 2.