Download Hammer Toe Surgery - Worcestershire Acute Hospitals NHS Trust

Department of Trauma and Orthopaedics
Surgical procedure information leaflet
Diagnosis: Forefoot pain (metatasalgia) and/or Hammer toe (claw toe)
It has been recommended that you have forefoot surgery.
This leaflet explains some of the benefits, risks and alternatives to the operation. We want you
to have all the information you need to make the right decision. Please ask your surgical team
about anything you do not fully understand or want to be explained in more detail.
We recommend that you read this leaflet carefully. You and your doctor (or other appropriate
health professional) will also need to record that you agree to have the procedure by signing a
consent form, which your health professional will give you.
About forefoot surgery
This type of surgery would include an operation to your toes or soft tissue of the forefoot.
Lesser toe procedures
 PIPJ (proximal interphalangeal joint) fusion
This is to correct ‘claw toe’ and involves straightening and
fusing the middle joint of your toe. This will be held in
place by a wire which will be removed in clinic after
approximately four to six weeks.
You will have a bandage and will have to walk on your
heel for approximately four to six weeks.

Distal Phalanges
Proximal Phalanges
1st Metatarsal
1st, 2nd 3rd Cuneiform
Medial, Intermediate,
Lateral
DIPJ (distal interphalangeal joint) fusion
This is to correct ‘hammer toe’ and involves straightening
and fusing the end joint of your toe. This will be held in
place by a wire which will be removed in clinic after
approximately four to six weeks.
We may also need to cut the tendons to straighten your toes.
You will have a bandage and will have to walk on your heel for approximately four to six
weeks.

Stainsby procedure
This procedure involves removing the joint altogether and reattaching the tendon. This will
be held in place by a wire which will be removed in clinic after approximately four to six
weeks.
After stainsby procedure you may be in plaster for four to six weeks and will be able walk
on your heel during this time.

Weils osteotomies
Weils osteotomy is used to treat rheumatoid arthritis and prominent metatarsal heads. It
involves cutting and repositioning of the metatarsal heads, which will be held into place with
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a screw.
After Weils osteotomy you will be in plaster for six weeks and may walk on your heel during
this time. After this time you may walk normally but may require an orthotic insert in your
shoe.

Shaving of the metatarsal heads
This procedure is done to treat rheumatoid arthritis and prominent metatarsal heads. It
involves shaving (cutting) the bone of the metatarsal heads.
After this procedure you will have a bandage for approximately two weeks and you may
walk on your heel during this time. After this time you may walk normally but may require
an orthotic insert in your shoe.
After your surgery you should elevate your foot above your bottom as much as you can for
approximately two weeks. This helps reduce pain and swelling.
Benefits of the procedure
The aim of your forefoot surgery is to reduce pain and correct deformity.
Serious or frequent risks
Everything we do in life has risks. Forefoot surgery has some risks associated with it. The
general risks of surgery include problems with:
o
The wound (for example, infection);
o
Breathing (for example, a chest infection);
o
The heart (for example, abnormal rhythm or, occasionally, a heart attack); and
o
Blood clots (for example, in the legs or occasionally in the lung).
Those specifically related to forefoot surgery include problems with:
o
Damage to the small nerves or blood vessels in the foot (neuro vascular damage
resulting in numbness or delayed healing).
o
Failure of procedure (resulting in further surgery).
o
Non-union of bone (only applies to fusion).
o
Complications during surgery resulting in loss of toe.
o
Weight transfer to the second toe (a corn under the second toe).
o
Floppy lesser toes
o
Malunion – poor position of toes after surgery.
o
Slightly high riding toes.
Sometimes, more surgery is needed to put right these types of complications.
Most people will not experience any serious complications from their surgery. The risks
increase for elderly people, those who are overweight, smoke and people who already
have heart, chest or other medical conditions such as diabetes, kidney failure. As with all
surgery, there is a very small risk that you may die.
You will be cared for by a skilled team of doctors, nurses and other health-care workers who
are involved in this type of surgery every day. If problems arise, we will be able to assess
them and deal with them appropriately.
Other procedures that are available
The options with non-operative management of Hammer toe include:
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 Modify foot wear (allowing more toe room)
 Orthotics (placing pads over the calluses to relieve the pressure)
Your pre-surgery assessment visit
We will ask you to go to a pre-admission clinic where you will be seen by members of the
medical and nursing teams of the surgical unit. The aim of this visit is to record your current
symptoms and past medical history, including any medication you are taking.
It is important to let us know in the pre-admission clinic if you are taking any of the following as
these may have to be discontinued before surgery:
 Anticoagulant drugs (for example, warfarin, aspirin or clopidogrel).
 Non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen and diclofenac.
 Contraceptive pill.
Please bring to your pre-operative assessment visit a list of the medications you are taking or
have recently taken, including medicines prescribed by your family doctor and those bought
“over the counter” without prescription, and also any herbal medications. Keeping an up-todate list of medications with you is highly recommended.
You may have a full examination and the following tests may be done:
 x-rays of your foot and chest if required;
 ECG, a tracing of your heart beat;
 blood tests;
 urinalysis (urine test); and
 MRSA (Methicillin Resistant Straphylococcus Aureus) swabs, this is a test for bacteria that
can be carried in your nose, throat and groin. It is harmless in these areas, but if it reaches
an open wound, it can be very serious. It is relatively uncommon but if you will be given a
treatment pack and instructions. Your operation will be postponed until it is cleared. A
patient information leaflet is available on MRSA. Please ask about this at your preoperative appointment.
The members of the surgical team will check that you agree to have the planned surgery. If
you have been given a consent form please bring it with you, alternatively you will be given a
consent form in clinic. Make sure that you have read and understood this information before
your clinic visit. If you have not understood any part of the information, you will be able to ask
any questions you may have about your planned surgery.
Important:
If you have any kind of infection or skin wound (such as a cut, graze, leg ulcer or broken skin)
please inform the medical team of this at your pre-surgery assessment or early health screen.
Being admitted to the ward
You will usually be admitted on the day of your surgery so you and we can prepare for the
surgery. We will welcome you to the ward and check your details. We will fasten an armband
containing your hospital information to your wrist.
Your anaesthetic
We will carry out your surgery under a general anaesthetic. This means that you will be
asleep during your operation and you will feel nothing.
Before you come into hospital
There are some things you can do to prepare yourself for your operation and reduce the
chance of difficulties with the anaesthetic.

If you smoke, consider giving up for at least six weeks before the operation. Smoking
reduces the amount of oxygen in your blood and increases the risks of breathing
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


problems during and after an operation.
If you are overweight, many of the risks of anaesthesia are increased. Reducing your
weight will help.
If you have loose or broken teeth or crowns that are not secure, you may want to visit your
dentist for treatment. The anaesthetist will usually want to put a tube in your throat to help
you breathe. If your teeth are not secure, they may be damaged.
If you have long-standing medical problems, such as diabetes, hypertension (high blood
pressure), asthma or epilepsy, you should consider asking your GP to give you a check-up.
Your pre-surgery visit by the anaesthetist
 After you go into hospital, the anaesthetist will come to see you and ask you questions
about:
o Your general health and fitness;
o Any serious illnesses you have had;
o Any problems with previous anaesthetics;
o Medicines you are taking;
o Allergies you have;
o Chest pain;
o Shortness of breath;
o Heartburn;
o Problems with moving your neck or opening your mouth; and
o Any loose teeth, caps, crowns or bridges.

Your anaesthetist will discuss with you the different methods of anaesthesia they can use.
After talking about the benefits, risks and your preferences, you can then decide together
what is best for you.

Also, before your operation a member of the theatre nursing staff may visit you. He or she
will be able to answer any questions you may have about what to expect when you go to
theatre.
On the day of your operation
Nothing to eat and drink (nil by mouth)
It is important that you follow the instructions we give you about eating and drinking. We will
ask you not to eat or drink anything (including chewing gum or sucking sweets) for six hours
before your operation. This is because any food or liquid in your stomach could come up into
the back of your throat and go into your lungs while you are being anaesthetised. You may
take a few sips of plain water up to two hours before your operation so you can take any
medication tablets.
Your normal medicines
Continue to take your normal medicines up to and including the day of your surgery. If we do
not want you to take your normal medication, your surgeon or anaesthetist will explain what
you should do. It is important to let us know, before you are admitted, if you are taking
anticoagulant drugs (for example, warfarin, aspirin or clopidogrel).
We will need to know if you do not feel well and have a cough, a cold or any other illness when
you are due to come into hospital for your operation. Depending on your illness and how
urgent your surgery is, we may need to delay your operation as it may be better for you to
recover from this illness before your surgery.
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Your anaesthetic
When it is time for your operation, a member of staff will take you from the ward to the
operating theatre. They will take you into the anaesthetic room and the anaesthetist will make
you ready for your anaesthetic.
To monitor you during your operation, your anaesthetist will attach you to a machine to watch
your heart, your blood pressure and the oxygen level in your blood. General anaesthesia
usually starts with an injection of medicine into a vein. A fine tube (venflon) will be placed in a
vein in your arm or hand and the medicines will be injected through the tube. Sometimes you
will be asked to breathe a mixture of gases and oxygen through a mask to give the same
effect.
Once you are anaesthetised, the anaesthetist will place a tube down your airway and use a
machine to ‘breathe’ for you. You will be unconscious for the whole of the operation and we
will continuously monitor you. Your anaesthetist will give you painkilling drugs and fluids
during your operation. At the end of the operation, the anaesthetist will stop giving you the
anaesthetic drugs. Once you are waking up normally, they will take you to the recovery room.
Pain relief after surgery
Pain relief is important as it stops suffering and helps you recover more quickly.
We may give you tablets or injections to make sure you have enough pain relief. Once you
are comfortable and have recovered safely from your anaesthetic, we will take you back to the
ward. The ward staff will continue to monitor you and assess your pain relief. They will ask
you to describe any pain you have using the following scale.
0
=
No pain
1
=
Mild pain
2
=
Moderate pain
3
=
Severe pain
A local block may also be used. This is an injection of some local anaesthetic near the
nerves that supply the lower half of your body. This will numb the part of your body being
operated on and give good pain relief during and after your operation.
It is important that you report any pain you have as soon as you experience it.
What are the risks of anaesthetic?
Your anaesthetist will care for all aspects of your health and safety over the period of your
operation and immediately afterwards. Risks depend on your overall health, the nature of your
operation and how serious it is. Anaesthesia is safer than it has ever been. If you are
normally fit and well, your risk of dying from any cause while under anaesthetic is less than
one in 250,000. This is 25 times less likely than dying in a car accident. Side effects of having
an anaesthetic include drowsiness, nausea (feeling sick), muscle pain, sore throat and
headache. We will discuss with you the risks of your anaesthetic.
After your surgery
 Once the medical team are happy with your progress, we will usually take you from the
recovery room to the general ward. You will need to rest until the effects of the anaesthetic
have passed. You may have a drip in your arm to keep you well hydrated.
 Your anaesthetist will arrange for you to have painkillers for the first few days after the
operation, as we mentioned earlier.
 We will encourage you to get out of bed and move around as soon as possible, as this
helps prevent chest infections and blood clots. Usually, the physiotherapy or nursing team
will help you with this.
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Leaving hospital
Length of stay
How long you will be in hospital varies from patient to patient and depends on how quickly you
recover from the operation and the anaesthetic. Most patients having this type of surgery will
be in hospital for day case surgery, but occasionally an overnight stay might be required.
Medication when you leave hospital
Before you leave hospital, the pharmacy will give you any extra medication that you need to
take when you are at home.
Rehabilitation
How long it takes you to recover from your surgery varies from person to person. It can take
up to six months. You should consider who is going to look after you during the early part of
this time. You may have family or close friends nearby who are able to support you or care for
you in your home during the early part of your recovery period.
The First 5 Days Following Your Operation
Following your operation to your foot you will be able to stand and take weight on your heel
only, but you must rest with your feet up as much as possible. You should try to restrict your
walking to just going to the bathroom or toilet. After five days you can increase your walking
but you should elevate your foot if swelling increases.
At About 14 Days Following Your Operation
At about 14 days after your operation you will be seen, in the outpatients department for
follow-up the stitches will be removed (or trimmed if absorbable). Depending on the operation
you have had, the plaster may be renewed or plaster may be left off. If there are no wires and
the wounds have healed, you may return to normal footwear. However, this may be a problem
due to swelling.
At About 4-6 Weeks Following Your Operation
If you are not in plaster: At about 4 weeks after the operation swelling should reduce further
and you should be able to start wearing more normal footwear. Any wires may be removed
and you may return to work around this time (depending on your work and the type of footwear
you wear at work). For a job where you are on your feet all day, return to work in less than 4
weeks would be an unrealistic expectation.
If in plaster: The plaster should be removed at this stage and any wires removed. You will
then usually be allowed to mobilise as you wish. You can start to wear more normal footwear
although this is often not possible due to swelling for about another 2-3 weeks. Usual return to
work is about 8 weeks – depending on your type of job.
Other factors such as the severity of the deformity, tissue quality, smoking, circulation and
general health can also make a difference to wound healing and recovery rate. Although the
foot should now be comfortable and returning to normal, there will still be noticeable swelling
particularly towards the end of the day. This is normal and to be expected. Physiotherapy is
not automatically organised and will be arranged as needed. Depending on the surgery you
have had a follow-up appointment may be made for 3 months after surgery.
Running and contact sports should be avoided for up to 12 weeks depending on the type of
surgery
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After 6 Months
The residual swelling should now be slight if not completely resolved. You should now be
starting to get the full benefit of the surgery. You should be able to wear most shoes. The
swelling may however continue until about a year following surgery. Sometimes the forefoot
remains permanently slightly swollen. We do not recommend buying new shoes until about 6
months after surgery due to the swelling.
Stitches / Wound
You will have your dressing (with or without plaster) on for about two weeks. A small amount
of oozing is to be expected.
We will take out stitches that seal the wound after about 14 days at your outpatients
appointment.
Personal hygiene
Your wound dressing (and plaster if you have one) need to be kept dry. If showering or
bathing, we recommend that you cover your foot with a plastic bag, which you will be given
details of in the plaster room.
Diet
You do not usually need to follow a special diet. If you need to change what you eat, we will
give you advice before you go home.
Exercise
When you can exercise depends on your individual operation. You consultant will discuss this
with you.
Sex
You can continue your usual sexual activity as soon as you feel comfortable.
Driving
You should not drive until you feel confident that you could perform an emergency stop without
discomfort – probably at least six weeks after your operation. It is your responsibility to check
with your insurance company.
Work
How long you will need to be away from work varies depending on:
o
how serious the surgery is;
o
how quickly you recover;
o
whether or not your work is physical; and
o
whether you need any extra treatment after surgery.
Most people will not be fully back to work for eight weeks. Please ask us if you need a medical
sick note for the time you are in hospital and for the first three to four weeks after you leave.
You should contact your family GP or Primary Care Centre if:

Your wound continues to bleed.

Your wound becomes increasingly painful or you get reduced sensation or pins and
needles, which is not relieved by elevation.

You become unwell (including a high temperature) following your operation or notice
any foul smell from beneath the plaster.
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Outpatient appointment
Before you leave hospital we may give you a follow-up appointment to come to the outpatient
department, or we will send it to you in the post.
Contact details
If you have any specific concerns that you feel have not been answered and need explaining,
please contact the following.
Worcestershire Royal Hospital
 Hazel Unit Nursing Staff (phone 01905 760266)
Alexandra Hospital
 Ward 16 Staff (phone 01527 512104)
Kidderminster Treatment Centre
 Ward 1 Nursing Staff (phone 01562 512356)
Other information
The following internet websites contain information that you may find useful.
 www.patient.co.uk
Information fact sheets on health and disease
 www.rcoa.ac.uk
Information leaflets by the Royal College of Anaesthetists about 'Having an anaesthetic'
 www.nhsdirect.nhs.uk
On-line health encyclopaedia
 www.worcsacute.nhs.uk
Worcestershire Acute Hospitals NHS Trust
Patient Services Department
It is important that you speak to the department you have been referred to (see the contacts
section) if you have any questions (for example, about medication) before your investigation or
procedure.
If you have any concerns about your treatment, you can contact the Patient Services
Department on 0300 123 1733. The Patient Services staff will be happy to discuss your
concerns and give any help or advice.
If you have a complaint and you want it to be investigated, you should write direct to the Chief
Executive at Worcestershire Acute Hospitals NHS Trust, Charles Hastings Way, Worcester
WR5 1DD or contact the Patient Services Department for advice.
Please contact Patient Services on 0300 123 1733 if you would like this leaflet in
another language or format (such as Braille or easy read).
Bengali
Urdu
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Portuguese
Polish
Chinese
Comments
We would value your opinion on this leaflet, based on your experience of having this
procedure done. Please put any comments in the box below and return them to the Clinical
Governance Department, Finance Department, Worcestershire Royal Hospital, Charles
Hastings Way, Worcester, WR5 1DD.
Name of leaflet:________________________________________ Date:______________
Comments:
Thank you for your help.
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