sara@thetagoeclinic.co.uk    0333 800 4101

Management of Hallux Limitus

(Osteoarthritis in the big toe joint)

 

General

Hallux Limitus is a stiff painful big toe joint often referred to as osteoarthritis.  In a normal joint the surfaces are covered by cartilage, allowing one surface of the joint to glide smoothly over the other. The loss of cartilage results in pain.  As the condition progresses, the body lays down additional bone around the joint margins, which restricts and can obliterate movement.  The cause of osteoarthritis is not clear.  Sometimes it is due to a specific joint injury or fracture.  However in most cases we are not sure.  Many suggestions have been made, which include poor foot function, an abnormally long first metatarsal, as well as problems in the formation of cartilage.

Most people find that the symptoms are made worse by increased activity or wearing shoes with high heels. Hallux Limitus is a progressive degenerative condition that gets worse over time, although the rate of deterioration varies from person to person.

 

Diagnosis

This is made following a clinical examination and X-rays. The severity of the joint disease on X-ray can vary from mild to severe, although this does not necessarily correlate directly with the symptoms experienced.

HP-pic-1

The left foot has a normal big toe joint with a smooth profile and a healthy joint space representing normal articular cartilage. The right foot in contrast shows a joint with mild degenerative disease, with the start of bony outgrowths forming around the joint and narrowing of the joint space.

HP-pic-2

This X-rays demonstrate a big toe joint with extensive arthritis (large bony outgrowths around the joint and an absence of the joint space)

intra

An intra operative view of the big toe joint showing a loss of cartilage on the 1st metatarsal head

Treatment Options

Conservative Care

The success of conservative care is based on wearing stiff soled shoes (hiking shoes/ MBT footwear) when active.  This footwear reduces the movement of the arthritic joint and therefore the symptoms when walking. The following treatments may also help when used with these shoes:

  • Orthoses
  • Anti-inflammatory and analgesics tablets
  • Steroid injections
hiking

Hiking shoe reduces the movement across the ball of the foot and therefore symptoms

Surgical Management

The surgical management for Hallux Limitus will vary depending on the severity of the arthritis. The surgical options can be divided into a) joint preserving procedures, which aim to extend the life of your joint and reduce symptoms.  These procedures should be considered as a stopgap, with further surgery in the future if the joint becomes painful again. Joint destructive procedures b) which include joint fusion or joint implant.  These are reserved for those with severe arthritis and pain.

 

Joint Preserving Procedures

These operations will hopefully decrease your symptoms and increase your movement for a period of time.  If the joint becomes painful in the future, you may require another operation.

  • Cheilectomy

This involves removing the bony prominences and remodeling the joint.  The recovery is relatively short for this procedure and can be used for mild to moderate joint disease.

  • Decompressive metatarsal osteotomy

A long first metatarsal is considered to be a causative factor in hallux limitus.  Shortening the metatarsal can facilitate joint movement; at the same time the bony prominences around the joint will be removed.  The position of the shortened bone is maintained with fixation

HP-pic-5

A long first metatarsal pre-operatively

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The first metatarsal post surgery has been shortened and the excess bone around the joint removed, improving the range of motion

  • Sesamoidectomy

There are two small bones under the ball of the big toe called sesamoids.  When the joint becomes arthritic these bones can become enlarged and unable to glide under the metatarsal resulting in pain and stiffness. Removing these bones can help increase the range of movement and reduce the pain experienced by freeing up the joint.  At the same time the bony prominences around the joint are removed.

HP-pic-7

Two normal sesamoids sitting under the frist metatarsal head with an even joint space and smooth profile.

  • Exostectomy

This procedure is used when the joint is not painful but the bony outgrowth on the top of the joint results in footwear irritation.  The bony growth is removed producing a smooth profile to the joint.

HP-pic-3

A side view of the big toe joint with extensive arthritis and a large bony outgrowth

Joint destructive procedures
  • Joint implant

This operation is recommended for those with moderate to severe degenerative joint disease. The silicone joint implant has a likely life span of 10-15 years.  They have been used widely in the UK and US over the past 20 years and have been reviewed by NICE and considered appropriate in the right circumstances. The procedure involves making an incision along the top of the big toe joint, removing both sides of the joint and placing a silicone hinge in the remaining space..

jHP-pic-9

Pre operative X-ray of an arthritic big toe joint, this was addressed by removing the joint and placing a Silastic joint replacement between the two bones on the above X-rays.

  • Joint fusion (Arthrodesis)

This operation is generally considered to be the gold standard for patients with severe painful arthritis of the big toe joint.  It involves removing both surfaces of the joint and aligning the big toe to allow you to roll through the joint, the absence of movement alleviates the joint pain.  The new position is maintained with screws and plates allowing the two bones to join together.  Following the surgery you can return back to sports and normal shoes, although the heel height will be limited.

HP-pic-10

Post operative X-ray of a big joint fusion with a plate and screws.

Recovery

Protocol for sesamoidectomy, cheilectomy, joint implant and exostectomy:

You must rest with the leg elevated for the first 48 hrs (essential walking only). It is important that you do not interfere with the dressings and keep them dry.  You will be seen for a dressing change 3-4 days post surgery.  Most patients can then return to walking to tolerance around the house. 2 weeks following the surgery the dressing will be removed and the suture tags cut.  In all cases except for an exostectomy, range of motion exercises for the joint will be started. From this point on you can return to comfortable footwear and normal bathing.

A gradual increase in your activities will reduce the likelihood of local scarring.  Once out of the post operative shoe you can drive your car as and when you feel safe.

 

Protocol for the decompressive metatarsal osteotomy:

An Aircast boot will be placed on your leg in theatres.  This is removable and should be taken off at rest and the foot and ankle mobilised.  You must rest with the leg elevated for the first 48hrs (essential walking only).  It is important that you do not interfere with the dressings and keep them dry.  You will be seen for a dressing change 3-4 days post surgery and the foot will be x-rayed.  Most patients can then return to walking to tolerance around the house. 2 weeks following the surgery the dressing will be removed and the suture tags cut.  Range of motion exercises for the joint will be started.  From this point on you can wash your foot.  You will remain in the Aircast for a further 4 weeks fully weight bearing.  A gradual increase of low impact activities is possible. No hopping, skipping or jumping for the first 12 weeks is requested as it takes this length of time for the bone to heal.

It is normally six or seven months before patients have fully recovered. Swelling and an ache around the surgical site are common during this period.

 

 Protocol for the joint fusion:

An Aircast boot will be placed on your leg in theatres.  This is removable and should be taken off at rest and the ankle mobilised.  You must rest with the leg elevated for the first 48hrs (essential walking only).  It is important that you do not interfere with the dressings and keep them dry.  You will be seen for a dressing change 3-4 days post surgery and the foot will be x-rayed.  Most patients can then return to walking to tolerance around the house.  You will be seen 2 weeks following the surgery when the dressing will be removed and the suture tags cut.  From this point on you can wash your foot.  You will remain in the Aircast for a further 4 weeks fully weight bearing.  A gradual increase of low impact activities is possible. No hopping, skipping or jumping for the first 12 weeks as it takes this length of time for the bones to heal.

Possible complications

Approximately 900 patients undergo foot surgery annually within the Department of Podiatric Surgery at West Middlesex University Hospital.  Most patients have an uneventful recovery.

Outlined below are the common problems or those rare complications with serious outcomes. In cases where we don’t have accurate audit we have used published results from the podiatric literature.  These are accompanied by an asterisk *.

  • Prolonged swelling taking more than 6 months to resolve occurs 1 in every 500 *
  • Haematoma – a painful accumulation of blood within the operation
  • Thick and or sensitive scar.
  • Adverse reaction to the post-operative painkillers. 1 in every 50 patients report that the codeine preparations can make them feel *
  • Infection of soft The incidence is 1 in every 83 operations. *
  • Delayed healing of soft
  • Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10-year
  • Deep vein thrombosis, a complication of which would be a clot that dislodges and settles in the This is potentially a life threatening condition. Within the published literature, deep vein thrombosis requiring treatment after surgery is 0.3%. *
  • Chronic pain syndrome: this is where the nervous system dealing with pain over reacts in a prolonged manner often to a minor This normally requires management by specialist in this condition and doesn’t always resolve.  This is a rare complication with no audit data available.

Specific complications following a joint replacement

  • Rejection of the implant

Specific complications following an osteotomy or joint fusion

  • Non-union of bones
  • Delayed union (slow healing)
  • Fracture
  • Joint stiffness
  • Reoccurrence of
  • Fixation irritation
  • Transfer pain

 

The risk of having a complication can be minimised when the patient and all those concerned with the operation and aftercare work together. This starts with the pre- operative screening and continues through to the rehabilitation exercises.

Pre-operative screening of your health allows us to determine whether you are fit for surgery.   It is important that you disclose your full medical history.  If there is a query regarding your health, then further investigations or the advice of other surgical and medical specialties will be sought. Professor Tagoe and the theatre team will ensure that the operation is performed effectively and with the minimum of trauma.

You can improve the healing process and reduce the risks of complications by:

  • Adhering to the postoperative instructions, which include resting and elevating the operated Keeping the wound clean and dry until advised otherwise is essential, please ask if you are not sure what to do.
  • Having a healthy diet is important; this provides the nutrition required for
  • Smoking is associated with 20% increased risk of delayed or non-union of
  • Alcohol can interact with the drugs that we will prescribe and in excess can impair wound
  • Post-operative mobilisation when advised, this helps improve the surgical outcome