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Keyhole Surgery for Lesser Toe Problems

Minimally Invasive Lesser Toe Surgery

Mr Redfern first introduced these techniques in the UK in 2009 (with a French colleague) and has since developed new keyhole techniques and approaches which he continues to teach worldwide.

Mr Redfern and his techniques for treating lesser toes have been the focus of an article in the Daily Mail

Mr Redfern and his techniques for treating lesser toes have been the focus of an article in the Daily Mail

It is now possible to offer minimally invasive surgery to treat almost all deformities of the lesser toes. Many of the corrections possible with minimally invasive surgery are simply not possible with traditional open surgery.
— Mr Redfern - internally recognised expert in minimally invasive surgery

Mr Redfern and a handful of surgeons worldwide have continued to develop new keyhole techniques for various lesser toe deformities which have revolutionised what can be offered and achieved with modern surgery. He has published his techniques in the international medical literature and continues to teach and lecture worldwide.

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Hammer Toes

This is perhaps the commonest type of toe problem that Mr Redfern sees in his practice. It often affects the second toe as seen here. It is usually but not always, due to a bunion (hallux valgus) upsetting the mechanics of the forefoot. The hammer deformity occurs due to overload of the joint at the base of the toe which damages the restraining ligaments.

The Revolution Of Minimally Invasive Surgery

Minimally invasive surgery has revolutionised the treatment available to patients with lesser toes deformities.

Background: Surgery to the lesser toes is usually carried out for painful deformities that have not been successfully treated with other methods such as toe moulds, toe socks or shoe modification. Traditional open surgery to correct lesser toes deformities generally involves making incisions to cut, lengthen or transfer tendons and/or fuse or excise the joints of the toes. Large wires are often used to hold the toes straight and the toes tend to be very stiff after surgery.

Minimally Invasive Surgery: This is a very different approach because the surgery can be undertaken through tiny incisions using very fine instruments including a 3mm knife and specialised 2mm drills (burrs).

Mr Redfern performing keyhole forefoot surgery under image guidance.

Mr Redfern performing keyhole forefoot surgery under image guidance.

Key to toe terminology: This diagram explains the nomenclature used in describing the different parts of the lesser toes.

Minimally invasive correction involves surgery to the soft tissues and/or bones and joints.

An example of Mr Redfern’s keyhole surgery to treat lesser toe problems .Here is an example of a patient who complained of painful deformed 2nd and 3rd toes which were causing great difficulty with footwear. Mr Redfern undertook minimally invasive surgery to correct the toes without the need for wires or other implants and without fusing the joints rigid. Such deformities are in fact very difficult to adequately correct with traditional open surgery.

Surgery to the soft tissues may involve releasing/lengthening tendons and releasing tight joints.

Surgery to the bones involves making tiny cuts (osteotomies) to re-align them using specialised tiny drills (burrs). Sometimes it is necessary to operate on the small joints of the toes (proximal and distal interphalangeal joints) which can be fused to correct the deformity in some circumstances. 

It is generally possible to carry out all the necessary elements of surgery using keyhole surgery (minimally invasive surgery).

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Minimally invasive surgery

This diagram shows how a tiny burr is used to cut a slot in the bone(s) of the toe and the toe then re-aligned by bending the remaining hinge of bone. This can be repeated in different bones of the same to correct the alignment in all 3 planes without resorting to permanently stiffening (fusing) the joints.

Much of the time there is no need for wires in the toes to hold them in position and simple taping or strapping is sufficient. If wires are required then Mr Redfern uses very fine wires which are bent over the tip of the toe so that they are hardly visible and can be easily covered and protected.

 

An example of Mr Redfern’s surgery. This severe deformity of the 2nd toe was corrected using minimally invasive surgery in combination with surgery to correct an arthritic bunion.

An example of Mr Redfern’s surgery. This severe deformity of the 2nd toe was corrected using minimally invasive surgery in combination with surgery to correct an arthritic bunion.

General points:

Minimally Invasive Lesser Toe Surgery

  • Minimally invasive surgery is generally associated with very little pain after surgery

  • You will normally be able to weight-bear on the foot immediately in a stiff soled post-operative shoe

  • Due to the tiny incisions, multiple toes can be corrected in one operation with keyhole surgery

  • Strict elevation is very important initially after the surgery in order to avoid swelling

  • You will be instructed on any taping or strapping of the toe(s) necessary in the post-operative period

  • Because the toe swells after surgery, footwear is often still limited at the 6 weeks following the operation.

  • The swelling generally takes approximately  4-6 months to fully disappear (and sometimes up 12 months). 



Post-operative Course: 

Minimally Invasive Lesser Toe Surgery

Day 1 

  • Foot wrapped in bandage and surgical shoe

  • Start walking in surgical shoe only

  • Elevate, take pain medication as instructed by Mr Redfern

  • Expect numbness in foot 12-24 hours due to the local anaesthetic

  • Blood drainage through bandage may occur but should not cause concern  - Do not change bandage 

  • After one week you may drive with caution in surgical shoe ONLY IF surgery to left foot only and automatic vehicle (otherwise return to driving at 6-8 weeks post surgery)

7-14 Days (as advised by Mr Redfern)

  • Follow-up in the outpatients for wound review & removal stitches

  • Dressing changed 

  • Elevation still required some of the day, sufficient to minimise swelling and assist healing

  • Shower when incision dry (unless wires in toe in which case foot to be kept dry)

6 weeks 

  • Follow-up in the outpatients 

  • Removal of wire if present - this not generally painful (no anaesthetic required)

  • A regular shoe may be worn as comfort and swelling allows  



Main Risks of Surgery:

Swelling – Initially the toe(s) and foot will be swollen and needs elevating.  The swelling will disperse over the following weeks and months but may be apparent for up to 6-12 months.

Infection – This is an important risk with any surgery.  Smoking increases the risk substantially.  You will be given intravenous antibiotics to help prevention.  However, the best way to reduce your chances of acquiring an infection is to keep the foot elevated over the first 7-14 days.  If there is an infection, it may resolve with a course of antibiotics. Mr Redfern has a very low rate of infection with his minimally invasive techniques (1%)

Wound problems – Sometimes the portals/wounds can be slower to heal and this does not usually cause a problem but needs to be closely observed for any infection occurring.

Scar sensitivity – Scar sensitivity is a generally a risk of traditional open surgery and is very uncommon with keyhole surgery (1%). If present, sensitivity usually subsides without treatment although there some simple treatments available to help it settle.

Nerve Injury – It is quite common to notice some altered sensation / numbness in the toes after surgery (~10%), whether traditional open or keyhole surgery. If there is some altered sensation then this may return over several months following the surgery but not always fully.

CRPS – (<1% in Mr Redfern’s practice). This stands for complex regional pain syndrome. It occurs very rarely in a severe form and is not properly understood. It is thought to be inflammation of the nerves in the foot and it can also follow an injury. We do not know why it occurs. It causes swelling, sensitivity of the skin, stiffness and pain. It is treatable but in its more severe form can takes many months to recover.

Delayed and non union– This is when the bones fail to join and bone has not grown across the cut bone and instead it heals with scar tissue.  If this is painful then further surgery may be needed although this is a very small risk with this type of surgery (1%).

Malposition – ideally the toe is fused in a position that allows optimum function and gives the best appearance. We will try to fuse the joint in the best position, using a flat surface to simulate the normal standing posture of the foot.  However, as you are asleep and lying down, it is not always possible to achieve this best position.  The toe can also sometimes deviate after surgery whilst healing is occurring. Generally it is unusual to require any further treatment but occasionally further surgery may be necessary.

Deep Vein Thrombosis (DVT) – This is a clot in the deep veins of the leg and the risk of this occurring following forefoot surgery is very low (generally< 1%). Mr Redfern does not use a tourniquet for his minimally invasive toe corrections and hence the risk of DVT is extremely low (<1:1000 in his practice). The fact that you are mobile after surgery and able to take weight through the foot of the operated foot also very much helps to minimise this small risk.

Stiffness – The lesser toes are very sensitive to surgery and stiffness can occur due to scar tissue that forms. Early movement of the toe(s) will be encouraged by Mr Redfern wherever possible in order to reduce the risk of stiffness. Most of the movement usually returns but some stiffness may remain permanently.

Continuing symptoms – Most people (~90%) are very happy with the results of their surgery but you can appreciate that if some of the above problems occur then this may affect the end result. Occassionally (5%) the deformity may recur although not usually to the same degree. If there is a recurrence then you don’t necessarily require any further surgery – this will depend upon your symptoms.



Sick Leave

In general, 1-2 weeks off work is required for sedentary employment, 6 weeks for work involving standing or walking and manual labour work.  An appropriate sick certificate can be provided where required.

Driving

You may return to driving after outpatient review at 2 weeks post surgery ONLY IF left leg surgery only and automatic vehicle – otherwise unable to drive until 4-6 weeks after surgery (as advised by Mr Redfern).

These notes are intended as a guide and some of the details may vary according to your individual surgery or because of special instructions from your surgeon.