Hallux Limitus - Foot Surgery London

Osteoarthritis of the Big Toe Joint - Hallux Limitus

You have been directed to this section of the website because you have arthritis of your big toe joint. This will explain what arthritis is and will outline what your options are.

Osteoarthritis is commonly referred to as “wear and tear arthritis” and patients with hallux limtus commonly present with a painful and stiff big toe joint. The correct term for the big toe joint is the 1^st metatarso-phalangeal joint.

In a normal joint, the bones have a covering of cartilage on each end allowing one bone to move smoothly against the other. In osteoarthritis, the cartilage is damaged or lost and this results in one bone grinding against the other causing pain. As the condition progresses, new bone is produced around the edges of the joint. This can restrict movement and also lead to bony outgrowths that rub on shoes. This occasionally is mistaken for a bunion.

The cause of hallux limitus is not clearly understood in the majority of cases. It may result from a specific episode of injury to the joint or big toe but in most cases, a number of factors are likely to play a part. A number of suggestions such as poor foot function, structural abnormalities or problems with cartilage formation have been made. Hallux limitus is a progressive condition that worsens over the course of time. The rate at which it worsens varies from person to person.

Most people find that their symptoms are worsened by increased activity and wearing flexible or high-heeled shoes.

Diagnosis:

This is made following a clinical examination and x-rays. Occasionally, additional imaging modalities may be required. The picture below shows an x-ray of hallux rigidus (the x-ray in the corner is of a normal 1^st metatarso-phalangeal joint). The intra-operative photograph (above) shows an area of the joint surface where the cartilage is missing.

Treatment Options:

Conservative Treatment

Many patients find that they can control their symptoms with the use of non-surgical treatments. The use of the correct type of shoe is fundamental to the conservative management of the condition and Mr McCallum will provide advice on the most appropriate shoe for you. Generally a rigid sole hiking shoe is ideal.

In combination with suitable footwear, the following options may also help:

Insoles (orthoses)
Anti-inflammatory and pain killing medication
Joint injections

Surgical Treatment

The surgical management of hallux limitus will depend on the severity of the arthritis. The options can be divided into:

Joint preserving procedures- aim to extend the life span of the joint and reduce the symptoms. They should be considered ‘holding’ procedures as they generally do not work forever and further surgery in the future is likely if/when the joint becomes painful again. If you have one of these procedures, there is always a risk that the joint will continue to be stiff and painful afterwards. If this is the case, further treatment/surgery may be necessary.
Joint destructive procedures- are generally reserved for severe arthritis or pain and in the majority of cases, further surgery is not necessary in the future.

Joint Preserving Procedures

Cheilectomy

decompressive metatarsal osteotomy, Foot Surgery, London Clinic

This involves cutting away the bony outgrowths from around the joint. The recovery is relatively short and the procedure can be used in cases of mild to moderate joint disease.

Decompressive Metatarsal Osteotomy

This involves shortening the 1^st metatarsal bone. The bone is cut in such a way with a small segment removed (red) so that it can be moved backwards by a number of millimeters. The bone is normally held in its new position with one or more screws while it heals. At the same time, any irregular bony outgrowths can be removed.

Sesamoidectomy

There are two small bones under the big toe joint called sesamoids (x-ray below). They are normally peanut sized bones but in cases of hallux limitus, they often become enlarged and irregular. Then can prevent the joint from remaining flexible. Removing these bones can help free up the joint and increase the range of motion and reduce pain. At the same time, any irregular bony outgrowths can be removed.

Exostectomy

This procedure is used when the joint is not painful but the bony outgrowths result in footwear irritation. The bony growths are removed producing a smooth profile to the joint.

Joint Destructive Procedures

Joint fusion (arthrodesis)

joint fusion, Foot surgery Clinic, London — joint fusion, Foot Clinic, London

This operation is considered the gold standard treatment for severe hallux limitus. It involves removing both surfaces of the joint and joining the two bones together. Metal screws and a plate are normally used to secure the bones in position while they join. This procedure leaves no movement at the big toe joint but provided the bones successfully join, it will take away all of the pain. The procedure will result in a limited heel height of approximately 1-inch.

Joint Implant

This operation is recommended for those with moderate to severe arthritis. It involves removing both surfaces of the joint and placing a silicone ‘hinge’ into the space. This implant has a life span of 10-15 years and when it has expired, it is not always possible to replace it with a new one. The procedure is normally reserved for patients who are over the age of 65 or those who are not particularly active.

Recovery:

The following information relates to the differing recoveries associated with the various procedures outlined above. These are guides and are based upon the average patient. Mr McCallum may change your post-operative regime based upon personal circumstances.

Following any of the above procedures, you should have someone with you for 24hours in case you feel unwell or have any problems.

Cheilectomy/Sesamoidectomy/Exostectomy/Joint Implant

You will given a protective shoe before you leave the hospital. This is removable and can be taken off when resting. Crutches will be provided when necessary.

You should travel home by car and keep your foot elevated on the back seat where possible. When you go home, you must rest with the leg elevated for the first 2-4 days (essential walking only). It is important that you do not interfere with the dressings and that you keep them dry. You can buy a purpose made waterproof device from the chemist if you wish.

You will be reviewed within one week of your operation for a change of dressing and at the 2-week mark, the dressings will be removed and the suture tags will be cut. You will be shown how to perform range of motion exercises (except for cases of exostectomy) and from this point forward, it is safe to get the foot wet and return to your own comfortable footwear. It is safe at this point to gradually return to your normal activity levels.

Decompressive metatarsal osteotomy

After your operation, you will be placed into an Aircast walking boot and you will remain in this for a period of approximately 6-weeks. The Aircast is removable and you should take it off when resting so that you can mobilise your foot and ankle. It must be worn at all times when moving around.

Before you are discharged from the hospital, you will be shown how to use crutches so that you can partially weight bear on the foot whilst wearing the Aircast. It is advisable to use your crutches until Mr McCallum reviews you with a post-operative x-ray.

You will be reviewed within one week of your operation for a change of dressing and at the 2-week mark, the dressings will be removed and the suture tags will be cut. You will be shown how to perform range of motion exercises and from this point forward it is safe to get the foot wet. You will be reviewed again at the 6-week mark to ensure that the bone is healing in a satisfactory manner and it is normally safe to transfer into your own comfortable footwear at this stage and gradually increase your activity levels. After 3-months, the bone should have healed sufficiently for you to resume full activity levels.

On average, it takes approximately 6-9 months for the foot to have fully recovered and it is not unusual to experience swelling, discomfort and stiffness during this time.

Joint fusion

After your operation, you will be placed into an Aircast walking boot and you will remain in this for a period of approximately 6-weeks. The Aircast is removable and you should take it off when resting so that you can mobilise your ankle. It must be worn at all times when moving around.

Before you are discharged from the hospital, you will be shown how to use crutches so that you can partially weight bear on the foot whilst wearing the Aircast.

You should travel home by car or taxi and keep your foot elevated on the back seat where possible. When you go home, you must rest with the leg elevated for the first 2-4 days (essential walking only). It is important that you do not interfere with the dressings and that you keep them dry. You can buy a purpose made waterproof device from the chemist if you wish.

You will be reviewed within one week of your operation for a change of dressing and an x-ray. At the 2-week mark, the dressings will be removed and the suture tags will be cut. From this point forward it is safe to get the foot wet. You will be reviewed again at the 6-week mark when another x-ray will be taken to ensure that the bones are healing in a satisfactory manner. If all is well, you will be allowed to return to your own comfortable footwear (a running shoe is ideal) and gradually increase your activity levels. Occasionally patients have to remain in the Aircast for a further 2-4 weeks. After 3-months, the bones should have healed sufficiently for you to resume full activity levels.

On average, it takes approximately 12-months for the foot to have fully recovered and it is not unusual to experience swelling, discomfort and stiffness during this time.

Possible Complications following surgery:

Outlined below are the possible problems or the rare complications with serious outcomes following foot surgery. In cases where there are no accurate audit results, published results from podiatric literature have been used.

Prolonged swelling taking more than 6-months to resolve can occur in 1 in 500 operations.
Haematoma- a painful collection of blood under the skin. This can increase the risk of developing an infection and may require further surgery to resolve.
Thick or sensitive scar.
Irritation from internal fixation. Screws and plates are only required whilst the bone is healing (during the first 3-months) after which they provide no further benefit. However, fixation is not generally removed unless it causes a problem. This may occur in up to 10% of cases.
Adverse reaction to the post-operative pain killers. 1 in 50 patents report that codeine preparations make them feel sick.
Infection of the soft tissue. 1 in every 83 operations.
Infection of bone- osteomyelitis. This is a serious complication and in severe cases, can lead to amputation.
Delayed healing of soft tissue or bone.
Circulatory impairment with loss of tissue.
Loss of sensation can occur although this is not normally permanent and can continue to improve over 18-months.
Deep vein thrombosis (blood clot) can result in the clot travelling to the lung and this can be a life threatening condition. Deep vein thrombosis incidence is 3 in 1000 cases.
Complex pain syndrome- a condition where the nervous system dealing with pain over reacts. This is a very painful condition that can result after minor trauma. It normally requires management by specialists in this condition and does not always resolve. This is a rare condition that occurs in 3 in 2500 cases.
Recurrence of deformity or failure of the surgery.
Development of secondary problems such as overloading of adjacent joints- transfer metatarsalgia.

Complications specific to cheilectomy and sesamoidectomy:

Ongoing/worsening pain
Stiffness
Further surgery

Complications specific to a joint replacement:

Rejection of implant
Painful irregular bony regrown
Transfer pain to the adjacent joints
Stiffness

Complications specific to osteotomy and fusion:

Fracture
Non-union
Fixation irritation
Transfer pain to adjacent joints

The risk of developing 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 post-operative regime.

The pre-operative screening helps us determine whether you are fit for surgery or if any extra measures need to be considered to minimise your risk of developing a complication. It is important that you disclose your full medical history. If there is a query regarding your health then further investigations may be required and Mr McCallum will liaise with the appropriate medical specialists. Mr McCallum and the there team will ensure that your operation is carried out safely and effectively.

You can improve your healing process and reduce the risks by:

Adhering to the post-operative instructions, which include resting and elevating the operated foot. Keeping the wound dry and clean until advised otherwise. Please ask Mr McCallum 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 bone.
Alcohol can interact with the drugs that are prescribed and can impair wound healing.
Post-operative mobilisation will be advised; this helps improve flexibility, strength and stability of your foot.