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Surgical Correction/Arthritis in the Big Toe Joint

Written By: Brian De Yoe, D.P.M Editor, PodiatryNetwork.com

Description

Hallux limitus is a reduction in the ability to dorsiflex or move the big toe upward. This inability to move the big toe normally affects the way a person walks and runs. Eventually pain will develop in the joint behind the great toe. This joint is called the first metatarsophalangeal joint. This pain is due to an irritation of the joint capsule and/or destructive changes to the joint surfaces. As destructive changes to the joint surfaces become more severe, the toe gradually loses the ability to move upwards. This condition affects people of all ages and gender equally. There are numerous causes of hallux limitus. These causes include: arthritis both traumatic (ie: caused by injury) and systemic (ie: rheumatoid arthritis), an elongated first metatarsal (the long bone that is directly behind the big toe), an elevated first metatarsal, a first metatarsal bone that has too much motion, and a bunion deformity. All of the above conditions can have profound effects on the motion of the big toe joint. Identifying the cause will determine the various treatment options available to the patient.

Diagnoses

Diagnosis of hallux limitus is made by both physical and x-ray examination. Physical examination will reveal pain and limitation in the motion of the big toe. Pain is particularly severe with dorsiflexion or upward movement of the big toe. There is commonly mild swelling and bony prominences associated with the first metatarsophalangeal joint behind the big toe.

X-ray examination of the foot will reveal the true severity of the patients condition. It will allow the physician to evaluate the joint for bone spurs, decrease in joint space, flattening of joint surfaces, and loose bodies in the joint. X-rays can also reveal the causes of hallux limitus such as an elongated or elevated first metatarsal.

Surgical Treatment

Surgical intervention is utilized when conservative therapy fails or the amount of deformity is too great. The goal of surgery is to obtain a more functional and less painful joint. Mild deformities are usually treated by removing bone spurs and prominences that develop around the first metatarsophalangeal joint. This helps to increase the amount of function and motion of the great toe. Occasionally, cuts in the bones called osteotomies, are made adjacent to the joint to correct for structural abnormalities. Osteotomies are held in place by screws, pins, or wires while the bone heals. By correcting for structural deformity the function of the great toe is increased as well as reducing the possibility for reoccurrence.

Moderate to severe deformities require a more aggressive surgical approach. Moderate deformities are almost always treated with not only removing spurs that inhibit motion but also with osteotomies to realign the joint. Osteotomies are utilized to prevent progression to a more severe deformity. However it is often difficult to determine in advance if adequate bony correction can be accomplished in order to prevent progression of the condition. Following the surgery the patient should wear a functional foot orthotic. These devices will correct much of the underlying functional cause of the deformity. When errosive changes in the joint result in absence of a large portion of the joint surface it may be necessary to perform a joint destructive procedure. These severe deformities require either a joint replacement or fusion procedure. The appropriate procedure depends on the patient's activity level and age.

Recovery Time

Your surgeon will usually require you to be off work for a minimum of one week. This is necessary to help control pain and post-operative swelling. Your return to work is dependent on the type of surgery that was performed and the demands of the job. Most patients are able to walk in a post-operative shoe or cast boot. Some surgeries however require the use of crutches and avoidance of placing pressure on the operative foot. At the end of one week most patients can return to work if they have a sedentary job. For patients that have an active job requiring a large amount of standing and walking, a longer recovery is necessary. Return to normal shoes and activities are dependent on the type of procedure and should be discussed with your surgeon. Following recovery from the surgery most surgeons will prescribe a functional foot orthotic. These devices are useful in reducing the reoccurrence of the condition and continued deterioration of the joint.

Potential Complications

Complications are rare, however they can occur in all surgeries. The most likely complications include: infection, delay or failure of the bone to heal, continued joint stiffness and pain, and prolonged swelling. Many complications can be avoided by taking prescriptions as directed and strictly following your surgeon's post-operative instructions.

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