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Hallux Limitus Management

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.

 

 

The X-ray of the left foot shows mild arthritic changes to the big toe joint  with a reduced joint space .

 

 

End stage arthritis with obliteration of the right big toe joint space and gross enlargment.
   

 

 

Treatment options

Conservative care

• Footwear with a stiff rocker sole e.g light weight hiking shoe or MBT trainer.  This reduces the movement across the joint within the foot and is an effective way of managing the pain associated with this condition.
• Orthoses / insoles
• Anti inflammatories and analgesics
• Therapeutic injections

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 removing the bony outgrowths that form around the joint.  In mild cases this can reduce symptoms and increase the range of motion at the joint.  The recovery is relatively short for this procedure.

Decompressive Metatarsal Osteotomy

If the first metatarsal appears long, this can have a detrimental effect on the function of the big toe joint.  The operation involves shortening the metatarsal bone to within normal limits, as well as removing the bony outgrowths from around the joint.  Once the bone has been shortened by the desired amount, screws are used to maintain the position whilst the healing process takes place.

Sesamoidectomy

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

 

 

There are two small bones under the ball of the big toe called sesamoids.  These form part of the joint with the first metatarsal head gliding over them as the big toe joint moves.  In Hallux limitus these two bones can become enlarged and the surrounding cartilage lost. As a consequence the sesamoids adhere to the metatarsal head, restricting movement with resultant pain.    Removing these bones as well as the bony outgrowths around the top of the joint can re-establish movement and reduce symptoms.

 

A CT scan of the big toe joint looking from the side.  On top is a large outgrowth of bone (osteophyte).  Under the joint the sesamoid is enlarged and fused to the metatarsal head.

Joint destructive procedures

Joint replacement

This operation is recommended for those with moderate to severe degenerative joint disease. The silicone joint implant has an average life expectancy of 10-15 years.  They have been used widely with success in the UK and the 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 hinge in the remaining space. The implant keeps the two bone surfaces apart and therefore reduces pain, whilst allowing some motion.  Because of the lifespan of the implant, this procedure is normally reserved for patients aged 60+.  In the event that the implant wears out and the symptoms return, the implant can be replaced.  This is not easy to do and the new joint doesn’t always work.

 

Joint fusion (Arthrodesis)

This operation is recommended when there are severe degenerative changes at the big toe joint. In most cases the amount of movement at the joint is severely restricted due to the bony outgrowths around the joint.  The remaining motion is often very painful. The joint is fused in a position which allows you to roll off the big toe.  In order to fuse the joint, the bones will need to be held in place with screws and possibly a plate. Following the surgery you can return back to sports and normal shoes, although the heel height will be limited.

 

Day surgery

You are admitted to the hospital on the day of your operation.  Professor Tagoe will confirm your consent form and mark the surgical site.  Dr Nathwani (anaesthetist) will visit you to discuss your anaesthesia.

Anaesthesia

Most patients elect to have their operation carried out under local anaesthetic with sedation, under the care of Dr Nathwani Consultant Anaesthetist.

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 patients remember nothing of the experience at all.

Local Anaesthesia

Professor Tagoe will anaesthetise your leg via an injection in the back of your knee (Popliteal block).  This will be carried out 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 and has the advantage of providing long lasting pain relief and numbness. 

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 aa Aircast partially weight bearing until the first dressing change in 3-4 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 48hrs (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 pharmacy. Professor Tagoe will see you for a dressing change 3-4 days post surgery, most patients can then return to walking to tolerance around the house.  You will be seen by the nurses 10 days following the surgery when the dressing will be removed and the suture tags cut.  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.

Physiotherapy

This is instigated 10 days post surgery. The physiotherapist will demonstrate range of motion exercises and help improve your walking.

Protocol for the decompressive metatarsal osteotomy

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 can buy a purpose made waterproof cover to keep the leg dry, from your local pharmacy. Professor Tagoe will see you for a dressing change 3-4 days post surgery, most patients can then return to walking to tolerance around the house.  You will be seen by the nurses 10 days 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 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 2 bones 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.

Physiotherapy

This is instigated 10 days post surgery. The physiotherapist will demonstrate range of motion exercises and help improve your walking.

Protocol for the joint fusion

You must rest with the leg elevated for the first 48hrs partially weight bearing in an Aircast Walker. It is important that you keep the foot clean and dry and don’t walk on the operated foot unless the Aircast is on.  Professor Tagoe will see you 3-4 days post surgery when the wound will be checked and the foot x-rayed. The Aircast can be removed for foot and ankle exercises and sleeping. 

The nurse will see you 10 days post surgery  to inspect the wound and cut the suture tags.  From this point on you should be able to get the foot wet in the bath.  At six weeks you will be seen by Professor Tagoe when the foot will be X-rayed.  If sufficient healing has occurred you will be advised to return to a trainer.   From this point, a gradual increase of low impact activities is possible. No hopping, skipping or jumping for the next 6 weeks, as it takes this length of time for the bones to fully unite. Once out of the cast you can drive your car 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

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 operations*
• Haematoma – a painful accumulation of blood within the operation site. No recorded incidents.
• Thick and or sensitive scar – no audit data is available.
• Screws and plates were removed from 118 patients during a twelve month period.  This is often planned but can occur as a result of irritation.  
• 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*
• Infection of bone occurred in 3 out of 916 patients.
• Delayed healing of soft tissue or bone.  No audit data is available.
• Circulatory impairment with tissue loss occurred in 3 out of 9000 patients over a 10 year period.
• Loss of sensation can occur although this is usually transient but can take up to a year to resolve.
• 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 specialists in this condition and doesn’t always resolve.  This is a rare complication with no audit data available.
• Reoccurrence of the deformity or failure of the operation: incidence is 1 in every 500 operations.*
• Development of secondary problems including overloading of joints adjacent to the ones operated on occurs in 1 in every 700 operations.*

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. 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 Professor Tagoe 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 exercises and in certain cases physiotherapy 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 individuals, education, training and experience, in accordance with the ethics of the profession and applicable law.  

Podiatric Surgical Training
3 year:	Degree in Podiatry
2 year:	General Podiatric Practice
2 year:	Diploma in the theory of podiatric surgery
2 Year	Surgical training programme (Podiatric Surgical Trainee)
	Final fellowship examinations
3 year:	Specialist training (Podiatric Registrar)
Accreditation with the Faculty of Podiatric Surgery Consultant Podiatric Surgeon

Secretaries:

Marina Nichols:
08700 410 448
Email: marina@thetagoeclinic.co.uk