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The Jones procedure is a straightforward operation for correction of the significantly clawed great toe.
It is most often carried out in the patient with underlying neurological disorder and may well be part of a more comprehensive overall cavus foot correction.
It is highly effective in relieving the painful pressure points resulting from a clawed hallux in the neurological foot but does not produce a normally functioning great toe. Gait abnormalities, hallux flexus and hallux limitus are common post operatively.
An alternative to consider, especially in the more active and less neurologically challenged patient with a flexible deformity, is Hansens’ technique of transferring the flexor hallucis longus to the base of the first proximal phalanx. This technique is also covered at the end of the section.
Presentation is with local dorsal toe or plantar metatarsal head calluses and associated pain. These deformities are almost exclusively in those with underlying neurological condition, for which the aetiology can be wide, though in some cases it can be secondary to an isolated familial trait.
The first metatarsal is plantar-flexed due to the abnormal action of the extrinsic toe muscles (potentially FHL, EHL and peroneus Longus). The Jones operation works by transferring the action of the Extensor Hallucis Longus to become an elevator of the first Metatarsal. For the operation to work in isolation first metatarsal plantar flexion must be passively correctable and not fixed (if fixed a dorsiflexing osteotomy at the 1st metatarsal base will be required).
Often therefore there are additional deformities and results of a cavo-varus foot that need to be dealt with. A full assessment of the presentation of the rest of the foot (and lower limb) needs to be made also. An assessment of the ankle, hindfoot, midfoot and forefoot needs to be made with respect to their alignment relative to each other, correctability and power must be made. There are a wide range of bony and soft tissue/tendon transfer procedures which may be required in addition including wedge tarsectomy, dorsiflexing metatarsal basal osteotomy, calcaneal osteotomy, transfer of tibialis posterior, tibialis anterior , achilles and plantar fascia lengthening.
An alternative to be considered is the Flexor Hallucis Longus transfer to the base of the proximal phalanx as described by Hansen (in Functional reconstruction of the foot & ankle, Lippincott ,Williams & Wilkins) especially in the less neurologically challenged foot and patient.
Conservative management can be attempted using accommodative shoewear and a total contact insole.
General or Regional anaesthetic
Antibiotics & LMW Heparin on induction
Laminar flow theatre if available
Thigh tourniquet (ankle tourniquet gets in the way of positioning the wire driver and drill during fixation)
Patient supine
Pre/post operative Nerve block (popliteal and / or inter-metatarsal )for analgesia
Day-case or overnight stay
LMW Heparin 2 weeks
Weight bear using post operative shoe for 5 weeks
Crutches likely required 1-2 weeks
Change dressings at 1 and 2 weeks Weeks 1-5 are spent in a forefoot plaster slipper with a great toe extension.
Weight bearing allowed with a stiff soled plaster shoe.
Check Xray required at 5 weeks to confirm bony union, and clinical review.
Once out of cast continue dressings whenever in shoe wear for a further month, and daily dorsal to plantar strapping of toe for 4 weeks by patient.
Once out of cast cleanse the foot twice a day, once in a salt water bath and once by bathing/showering
Appropriate shoe-wear fit is vital in the first month or so .
I advise fit-flops, Uggs, wider fits or open sandals. Stiff low heels ( platform or wedge ) are encouraged in women , from when comfortable .
Function after correction of a clawed great toe by a modified Robert Jones transfer.
Breusch SJ, Wenz W, Doderlein L. Journal Bone and Joint Surg 2000.82-B:250-4
81 feet underwent the operation and were reviewed after almost 4 years.
The patient satisfaction rate was almost 90% and correction of deformity successful in 80%. No pain noted in just under 2/3 rds of cases and mild to moderate pain in just over 1/3rd . Approximately 10% suffered non-union at the IP joint (though crossed K-wires were used to fix the fusion ). The MTP joint was normally mobile in 36% only. Gait abnormalities noted in almost 80% (but all patients had an associated hindfoot procedure also).
Alternative to the modified Jones procedure: Outcomes of the Flexor Hallucis Longus tendon transfer for the correction of clawed Hallux.
Kadel NJ, Donaldson-Fletcher ,Hansen T, Sangeorzan B. Foot Ankle Int 2005.26(12):1021-6
The operation entails passing 2/3 of the FHL from plantar to dorsal through a drill hole in the proximal phalanx then suturing back onto itself under appropriate tension.
Follow up of just over 4 years in 19 patients of whom 13 were fully satisfied with the outcome and 6 somewhat satisfied. 15 patients had no shoe-wear restrictions imposed by the toe .
Reference
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