In elderly patients with severe or recurrent deformities of the second toe or fixed dislocation, an amputation through the MTP joint gives good pain relief with acceptable cosmesis (Anwar and Sundar 2002, Gallentine and De Orio 2005). Removal of the toe allows the great toe to fall into valgus, but these two series did not find this a clinically significant problem.
If disarticulating a fixed, dislocated second MTP joint, the plantar plate will often be found adherent to the top of the MT head. This should be released and reduced, or the plunger effect can continue even in the absence of the toe.
Terminalisation of the 2nd and 3rd toes. At this stage the 4th and 5th toes were asymptomatic, but two years later the patient requested they be terminalised also.
Both mallet and varus toe corrections may recur, in which case the best salvage is to terminalise the toe through the DIP joint, turning the tip pad up to close. This is sometimes known as the "terminal Syme's procedure", by analogy with the Syme's amputation at the ankle. The only report of the results of this procedure found that 95% were very happy with the cosmetic and functional result. Indeed, we find that patients (usually in older age groups) sometimes suggest terminalisation as primary treatment. This is particularly appropriate if there is a very tender callus at the tip of the toe, or the toe has been deformed so long that it is severely mis-shapen.