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.
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.
around the joint and an absence of the joint space)
Treatment options
Conservative Care
The success of conservative care is based on wearing stiff soled shoes 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
Hoka Walking shoe
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.
b) Joint destructive procedures 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.
- 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.
- 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.
Osteotomy of the proximal phalanx (big toe)
A wedge of bone is removed from the proximal phalanx (bone at the base of the big toe) and gap closed and held with a screw or wire. The procedure elevates the big toe allowing the individual to rock of the toe, this can help reduce pain when walking.
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 30 years. National Institute of Clinical Excellence (NICE) have reviewed the use of these implants and considered them 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. They are not indicated in patients who have an active lifestyle or the under the age of 65 years.
- Arthroplasty
This procedure reduces the function of the big toe and can lead to weight transferring to the smaller foot joints. It has the advantage of providing some motion at the joint although the toe post-surgery is significantly shorter. This procedure is generally reserved for patients who have low levels of activity and require a short recovery time. Half of the arthritic joint (shaded area) is removed by resecting the base of the proximal phalanx. The operation should reduce the joint pain but can leave the big toe shorter and not as stable on the ground.
- 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.
| Operation | Cheilectomy exostectomy sesamoidectomy joint replacement Arthroplasty |
Osteotomy | fusion |
| Follow-up appointments
3-4 days |
– Dressings removed and return to post op shoe – start range of motion exercises on the big toe joint |
– Dressings change – X-ray – return to post op shoe – start range of motion exercises on the big toe joint |
– Dressings change – X-ray – return to post op Aircast Walker |
| 10-14 days | – Dressings removed and suture tags cut – You can bathe your foot – Return to trainers – Gentle walking, cycling, X-trainer |
– Dressings removed and suture tags cut – You can bathe your foot – Remain in the Aircast walker |
|
| 6 weeks | – Unrestricted exercise |
– X-ray – Normal activities – Exercise to tolerance – No high impact activities eg running – Continue with range of motion exercises |
– X-ray – Return to trainers – Gentle exercise walking, X-trainer, cycling or swimming |
| 12 weeks | – X-ray If no concerns the return to all activities |
Possible complications
Approximately 700 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 operations*
- Haematoma – a painful accumulation of blood within the operation site.
- Thick and or sensitive scar.
- Adverse reaction to the post-operative pain killers. 1 in every 50 patients report that the codeine preparations can make them feel sick. *
- Infection of soft tissue. The incidence is 1 in every 83 operations*
- Delayed healing of soft tissue.
- Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10-year period.
- Deep vein thrombosis which can result in a clot in the lung is potentially a life-threatening condition. Within the published literature, deep vein thrombosis requiring treatment 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 incident. This normally requires management by specialist in this condition and doesn’t always resolve. This is a rare complication.
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
- Fixation irritation
- Further surgery
- 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 post-operative instructions which include resting and elevating the operated leg. Keeping the wound clean and dry until advised otherwise is essential. Please ask the nurse or Podiatric surgeon if you are not sure what to do.
- Having a healthy diet is important. This provides the nutrition required for healing.
- Smoking is associated with a 20% increased risk of delayed or non-healing of bones.
- Alcohol can interact with the drugs that we will prescribe and in excess can impair wound healing.
- Post-operative mobilisation will be advised. This helps improve the flexibility, strength and stability of your foot
Podiatric surgeons evaluate, diagnose, prevent and treat diseases, disorders and conditions affecting the foot and all associated structures. This is carried out in keeping with the individual’s education, training and experience, in accordance with the ethics of the profession and applicable law.
Podiatric surgeons are not medical doctors.
Podiatric Surgical Training
3 year: Degree in Podiatry (BSc)
2 year: Masters in the theory of podiatric surgery (MSc)
2 year: Surgical training programme
(Podiatric Surgical Trainee)
Final fellowship examinations
(Podiatric Surgeon)
3 year: Specialist training (Podiatric Registrar)
Accreditation with the Faculty of Podiatric Surgery
Consultant Podiatric Surgeon