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Hallux Limitus – Arthritis of the big toe joint

Arthritis of the big toe joint is condition where the cartilage of the big toe joint becomes eroded, leading to limitation of motion and eventually rigidity.  Medically this is termed hallux limitus (for limited arthritis) and Hallux rigidus (for severe arthritis). The big toe joint becomes painful, enlarged and inflamed.

Patients with arthritis of the big toe joint have varying degrees of symptoms depending on the extent of the arthritis.  In general, patients have a painful big toe joint that hurts with activity (such as walking and running). The pain may be deep and sharp to superficial and achy.  Movement of the big toe joint can result in a grinding sensation (medically called crepitus). The top of the joint can become enlarged, and this is often referred to as dorsal bunion.  Irritation from shoe gear can cause redness and swelling. Motion of the joint becomes limited as time progresses, leading to very limited ability to flex the toe.

The two most common causes of arthritis of the big toe joint are biomechanical and traumatic arthritis.  Inflammatory arthritis (ie rheumatoid) can occur but tends to be widespread through the body. Gouty arthritis is more common cause of arthritis in the big toe joint.

Traumatic arthritis occurs after the joint is injured, leading to further degeneration.  Fractures that involve the joint have a high incidence of future arthritis. Injury to the cartilage can also spark the degeneration process.  Sprain and strains have been known to also lead to joint degeneration. Biomechanical arthritis occurs from structural problems within the foot that lead to premature ‘wear and tear’ on the joint.  Shoe gear can also play a role in arthritis development. Arthritis usually develops slowly over time, with periodic flare ups until a critical point is reached resulting in ongoing pain and disNon-operative Treatments For Big Toe Joint Arthritis

Non-surgical methods for neuroma are aimed at decreasing and/or eliminating symptoms (pain).comfort.

Diagnosis

Common reasons patients seek treatment are: pain, interferes with walking or activities, difficulty fitting shoes, grinding sensation, swelling, and/or notice a change in appearance of the foot and/or toe(s).

General Grading system

Although each patient brings their own unique set of symptoms, activity level and goals for the future, a good prognostic grading system for Hallux Limitus helps categorize level of severity and can help in deciding which treatment would best suit each patient.

GradeFindings
1Mild pain at extremes range of motion
2Moderate pain throughout range of motion, increasingly more constant
3Significant stiffness, pain at extreme range of motion, no pain at mid range
4Significant stiffness, pain at extreme and at mid range of motion

 

Treatment

Depending on your overall health, symptoms and severity of the arthritis, the condition may be treated conservatively and/or with surgery.

Non-operative Treatments For Big Toe Joint Arthritis

Prescribe an oral anti-inflammatory medication

  • Anti-inflammatory medication is useful to significantly reduce pain and inflammation.

  Prescribe physical therapy

  • A physical therapist may perform ultrasound and other techniques to reduce inflammation.  You will also be instructed how to stretch your foot and leg properly. Keeping the joint mobile may preserve function.

Prescribe protective pads

  • Padding and/or cushioning of when bone spurs are present on the top of the foot is an effective method of preventing mechanical irritation with shoes.  Pads with cutouts say off-weight specific areas of concern.

  Prescribe custom foot orthotics

  • A custom foot orthotic is a doctor prescribed arch support that is made directly from a casting (mold) of your feet, and theoretically should provide superior support compared to shoe insert that you would purchase from a pharmacy.   In the case of the big toe joint arthritis a stiff forefoot extension may be helpful in reducing symptoms by preventing motion.

Give cortisone injection

  • A intra-articular cortisone injection is a powerful anti-inflammatory medication that is used to rapidly reduce the pain associated with an arthritic joint.  The pain relief that you may experience from the injection(s) is often temporary.

Big Toe Joint Arthritis Surgery

Surgery for arthritis of the big toe joint is separated into two types of procedures – those that spare the joint (joint sparing procedures) or those that remove the joint (joint destructive procedures).

A sparing procedure allows for continued motion with the joint surgically modified or cleaned up of the arthritis and bone spurs to alleviate pain and increase motion.  A destructive procedure involves removing the joint and performing a fusion (locking the bone in place) or a joint replacement (allowing for motion, but with an artificial joint).

Taking into account symptoms, activity level,  and extent of the arthritis, we can discuss which surgical option would better help you reach your goals.

For grade 1 and 2 , Cheilectomy, or removing of the spurs and clean out of the joint has been shown to have very good to excellent results.  For grade 3, literature is less definitive on whether patients do better with cheilectomy, an implant or a fusion of the joint. For Grade 4, best results in pain relief and function are achieved with a fusion.

Joint Sparing Procedures

Bone Spur Removal (cheilectomy):  This procedure involves removing the arthritic bone spurs and removing any arthritic bone that gets dislodged into the joint.  Cheilectomy is ideal for mild arthritis of the big toe joint. However, depending on the patient’s goals, we may commonly perform this procedure for severe arthritis, to avoid fusion or replacement.

Bone Shortening Procedure (Osteotomy):   One method of treating arthritis of the big toe joint is to decompress the big toe joint by shortening the metatarsal bone (the bone that attaches to the toe).  The purpose of this is ‘make room’ for the joint to function. This is best for considered for patients who have moderate arthritis with a long bone.

The Cartiva Implant

Cartiva is an FDA approved synthetic cylindrical shaped cartilage replacement implant that replaces the arthritic portion of the big toe joint.  The implant itself is a organic-polymer with a high water content similar to healthy cartilage – making it deal for replacement of the arthritic portion of the big toe joint.  The surgery involves removing arthritic bone spurs and drilling a small 1-cm hole into the metatarsal bone of the arthritic joint then inserting the Cartiva implant. The Cartiva implant sits slightly proud of the surrounding joint surface, acting as spacer to limit pressure on the joint.

The Cartiva implant is durable and does not degrade over time.   Its ideal for moderate to severe arthritis. A major benefit of the Cartiva implant is that it does not require significant removal of bone (unlike other joint replacement procedures) so should revision be needed in the future, the repair is less complicated.

Joint Destruction Procedures

Fusion of Big Toe Joint:   A fusion of the big toe joint involves surgically removing the arthritis cartilage of the joint, and mending the bones together in a functional position for the foot.  This surgery is excellent in removing the pain, but the downside is permanent loss of motion as the big toe is locked in one place. Most people, by the time they consider fusion, the toe doesn’t move much, so they are comfortable with that trade-off.  Men seem to be more willing for fusion procedures. Women, who wear heels, on the other hand, require some motion of the big toe joint to physically conform into the heels. As such, fusion procedures may not be ideal for women who continue to wear high heels.  Either way, fusion is indicated for severe or end stage arthritis.

Joint Replacement: Joint replacements are indeed an option for the big toe joint.  Advances in recent years have made replacement more functional. Other joints, such as hip and knee, have excellent functional track records, where as joint replacement of the big toe joint is limited. This is because the big toe joint is small (compared to other joint) and demands the pressure of the entire body during a propulsive gait – as such the joint replacements wear out quickly.  Nonetheless, there are options for partial replacement, total replacement, and even metallic resurfacing of the joint.

Big Toe Joint Arthritis Surgery Recovery

Recovery after big toe joint arthritis surgery  varies depending on the method chosen to fix the problem.  Most often patients are allowed to walk in the foot. Minor procedures (such as bone spur removal and Cartiva), patients are walking in a regular shoe in 1-2 weeks.  When bone cuts are performed, patients have more restrictions and may be walking in a surgical shoe for 6 weeks or so. When fusion is necessary, non weight bearing for several weeks may be necessary to ensure the fusion “takes” and helps avoid further complications down the line.

What Anesthesia Is Needed For Big Toe Arthritis Surgery

Big Toe Arthritis surgery is performed as outpatient surgery (this means you go home the same day). It may be performed in a hospital, ambulatory surgery center and even in the doctors office (so long as the facility is set up for surgery).

The surgery can be performed under a local, regional, spinal or general anesthetic. Local and regional blocks, with monitored anesthesia care are most commonly performed. This means that the foot will be numbed with an anesthetic while an anesthesiologist provides sedation to relax you.

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