Lesser toe problems

Last evidence check March 2011

Principal authors: Jim Barrie and Patrick Whatmough

The Stainsby procedure is a salvage technique for the fixed subluxed or dislocated lesser toe with a fixed hammer or claw deformity (type 3 toe). The classical indication is the rheumatoid forefoot with multiple deformed toes, but it can also be used in non-rheumatoid deformities. Briggs and Stainsby (2001) found the results to be better after multiple toe surgery than single toe surgery.

The key part of the operation is the release and reposition of the plantar plate under the metatarsal head, which automatically draws the plantar fat pad back to the correct position. Most of the proximal phalanx is resected, which makes the toe shorter but allows easy correction and stabilisation. Patients do not normally have active control of the toe and the toe looks short, but the procedure is effective in improving pain.

Although the procedure was originally described by Stainsby and Briggs in a presentation in 1990, no results were published until 2001. Briggs and Stainsby then reported the outcome of single-toe surgery in 52 patients and multiple-toe surgery (mainly for rheumatoid disease) in 29 patients. Mean follow-up was 3.3 years for single toe surgery and 5 years for multiple toes. Using a simple outcome scale, 61% of single-toe patients were symptom free, 22% had few symptoms and no functional limitations, 13% had significant residual symptoms and 4% were no better. 81% of multiple-toe patients were symptom-free, 12% had few symptoms, 7% had significant residual symptoms but none were unimproved. The case-mix was probably different in the two groups; most of the multiple-toe patients had rheumatoid disease. There was recurrent deformity in 12/69 single toes and 2/142 multiple toes.

Mangaleshkar et al (2001) described results in 71 toes, mostly rheumatoid. The mean AOFAS score was 72. Nearly half their non-rheumatoid patients were concerned by the appearance of the toe.

Hossain et al (2003) described results in 88 toes in 32 non-rheumatoid patients at a median follow-up of 3 years. The median AOFAS forefoot score was 80, subjective pain and function scores were relatively higher. 10% of patients were dissatisfied with the appearance of the toe; 14% had some malalignment. 34% of patients had problems with wound healing or infection, possibly due to using a different incision to the original description by Stainsby and Briggs.

The Stainsby procedure is very useful in severe toe deformities but patients need to be counselled carefully about the post-op appearance.