Hallux Limitus Management(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 by the 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.
Treatment options
Conservative care
- Footwear with a stiff rocker sole e.g light weight hiking shoe or MBT trainer
- Orthoses / insoles
- Anti inflammatory tablets and analgesics
- Steroid injection
Surgical Management
The surgical management for hallux limitus will vary depending on the severity of the arthritis, local anatomy, the effect on your lifestyle, your age as well as expectations. The surgical options can be divided into joint preservation procedures. These aim to maximise the life of your joint as well as reducing symptoms. Such procedures should be considered as a stop gap, with the possibility of further surgery in the future. Joint destructive procedures which include a joint fusion or joint replacement are reserved for those with severe arthritis as seen on X-ray.
Reconstructive procedures
Cheilectomy
This involves cutting away the irregular excess bony prominences that have formed around the joint. The recovery is relatively short for this procedure and can be used for mild to severe joint disease depending on precise symptoms.
Decompressive Metatarsal Osteotomy
This operation involves shortening the metatarsal bone by a small amount. To do this the bone is cut at an angle and slid back or a small section of bone is removed. In either case fixation is used to maintain the bony position and alignment whilst it heals again.
Recovery entails being in a post op shoe for approximately 2 weeks, replaced with a good lace/trainer shoe for a further 6 weeks. During this period you should not undergo any high impact activities e.g running, jumping.
Sesamoidectomy
There are two small bones under the ball of the big toe called sesamoids. Removing these bones can help increase the range of movement and reduce the pain experienced by freeing up the joint. At the same time any irregular margins of the joint are removed. This procedure preserves the joint, hopefully giving you a longer period of pain free movement. Given the condition is degenerative a further procedure may be required in the future.
Recovery is 1-2 weeks in a post op shoe with regular range of motion exercises undertaken from day 3-4. You should be able to return to normal activities from 2-3 weeks post operatively.
Joint destructive procedures
Joint replacement
This operation is recommended for those with moderate to severe degenerative joint disease. The silicone joint implant has a anticipated life expectancy of 10-15 years. They have been used widely in the UK and US over the past 20 years. The procedure involves making an incision along the top of the big toe joint, removing both sides of the joint and placing a silicone hinged joint in the remaining space.
Recovery is 2 weeks in a postoperative shoe after which you can transfer into a good lace shoe/trainer. You will need to undertake regular range of motion exercises for 3 months following surgery to maintain good movement in the artificial joint.
Joint fusion (Arthrodesis)
This operation is recommended primarily for men who have severe degenerative changes at the big toe joint. It involves cutting away both surfaces of the joint, angling the big toe upwards slightly to allow for walking and fixing it in this position with screws/plates. The two cut bone surfaces will then naturally fuse together as what normally occurs when bone is fractured. Recovery requires a non-weight bearing below knee postoperative cast for 6 weeks. The fixation screws/plate/wire will not require removing unless it bothered you at a later date.
Day surgery
You are admitted to the hospital on the day of your operation. You will be shown to the ward / room and asked to change into a gown. The surgical site(s) will be marked by Miss Feeney and your consent confirmed.
Anaesthesia
Most patients elect to have their operation carried out under local anaesthetic with sedation.
Sedation
There are different depths of anaesthesia from sedation through to a general anaesthetic. Sedation provides reduced consciousness with most of your reflexes left intact and spontaneous breathing. This means that your airway is secure and there is no need to place a tube into your throat. As well as sedation a local anaesthetic block at the level of the ankle is performed to render the surgical area anaesthetised. This allows us to keep the amount of drugs used to a minimum. The sedation wears off within a few minutes of the end of the operation, without the accompanying drowsiness and nausea, which is sometimes associated with general anaesthesia. The operation is pain free and most patients remember nothing of the experience at all.
Local Anaesthesia
We will anaesthetise your leg via an injection in the back of your knee (Popliteal block). This will be carried out by Miss Feeney on the ward with adequate time given to allow the local anaesthetic to take effect.
As the anatomy behind the knee varies a little from person to person, we use a nerve stimulator to locate the nerves. This sends a small electric current down the needle which stimulates the nerve. This means that the muscles controlled by the nerve begin to contract and relax causing the foot to ‘flick’. Whilst this is a strange sensation it is not uncomfortable and helps us to deliver the anaesthetic with precision.
Local anaesthetic at the level of the knee not only blocks sensation but also movement of your foot. This is temporary lasting for 24 to 36 hours
Discharge
Before you leave the hospital you will be given a post operative shoe and crutches. In the case of the joint fusion you will be in a cast non-weight bearing until the first dressing change in 4 days. Post operative painkillers will be dispensed by the nurses. You should arrange to go home via car or taxi with an escort. You are advised to have someone with you for the first twenty four hours in case you feel unwell.
Recovery
Protocol for sesamoidectomy, cheilectomy and joint replacements
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 can buy a purpose made waterproof cover to keep the leg dry, from a chemist. You will be seen for a dressing change 3-6 days post surgery, most patients can then return to walking to tolerance around the house. You will be seen by the team 2 weeks following the surgery when the dressing will be removed and the suture tags cut. Range of motion exercises for the joint will be started and you can return to a trainer. From this point on you can wash your foot. 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
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 can buy a purpose made waterproof cover to keep the leg dry, from your local chemist. You will be seen for a dressing change 3-6 days post surgery. Most patients can then return to walking to tolerance around the house. You will be seen by one of the team 2 weeks following the surgery when the dressing will be removed and the suture tags cut. Range of motion exercises for the joint will be started and you can return to a trainer. From this point you can wash your foot. A gradual increase of low impact activities is possible. No hopping, skipping or jumping for the first 8 weeks as it takes this length of time for the bone to heal. Once out of the post operative shoe you can drive your car as and when you feel safe.
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
You must rest with the leg elevated for the first 48hrs (essential hopping only). It is important that you keep the cast dry and don’t walk on the operated foot. You will be seen 3-4 days post surgery when the wound will be checked and the foot x-rayed. A further cast will be applied
Physiotherapy
This is not generally required but you are advised to massage the area locally once all dressings/casts are removed, this can help to reduces scar tissue.
Outcome
The big toe should be significantly straighter than the pre-operative position and the painful symptoms reduced.
Possible complications
Approximately 900 patients annually undergo foot surgery within the Department of Podiatric Surgery at West Middlesex University Hospital with most patients having an uneventful recovery. However, complications can still occur, outlined below are the common problems or those with poor outcomes. In cases where we don’t have accurate audit we have used published results from the podiatric literature, these are accompanied by an *.
- 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. No recorded incidents.
- Thick and or sensitive scar - no audit data is available.
- 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 No audit data is available.
- 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. Deep vein thrombosis incidence is 1 in every 900 cases.
- 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 with no audit data available.
Specific complications following an osteotomy or joint fusion
- Non-union of bones (the 2 bone surfaces do not heal and this complication is higher with the joint fusion procedure)
- Delayed union (slow healing) or non-union
- Fracture
- Joint stiffness (osteotomy, sesamoidectomy or cheilectomy)
- Rejection of implant (rare)
- Reoccurrence of symptoms.
- Fixation irritation
- Transfer pain
- A lumpy scar tissue, this normally resolves with post-operative massage or physiotherapy
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. If there is a question mark against your health then further investigations and
when required the advice of other surgical and medical specialities will be sought. The surgeon 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.