Emerging Advances In Treating Great Toe Arthritis

Babak Baravarian, DPM, FACFAS

   Orthotics also offer a great option to treat hallux limitus. I prefer to make a moderately stiff orthotic and carry the plastic piece of the orthotic in the form of a Morton’s extension to the tip of the great toe. I then cover this with a soft material. This limits motion of the great toe and stiffens the sole of the shoe. Injection therapy is limited in the great toe joint but in certain cases, joint lubrication and viscosupplementation is a good short-term, non-surgical option.

A Closer Look At Surgical Options

Surgical treatment has generally consisted of: spur removal or cheilectomy; metatarsal or phalangeal osteotomy for realignment and/or shortening; joint replacement; or fusion. I have found that these options are surgeon and patient dependent.

   In my hands, I find that cheilectomy is an excellent option for early to moderate cases of hallux limitus/rigidus. It is important to remember to be aggressive. In many cases, a cheilectomy may fail due to insufficient bone removal from the dorsum of the great toe phalanx base and metatarsal head. I rarely will perform an osteotomy of the phalanx or ray, and find these procedures to be short-term fixes with the potential for transfer pain to other metatarsals.

   I still find fusion of the first metatarsophalangeal joint (MPJ) the gold standard in pain control. I utilize this procedure extensively in men who have moderate to severe arthritis, do not go on their tiptoes and wear regular men’s shoes. The most difficult cases are young women who wish to avoid fusion procedures and cases of mild to moderate arthritis that may not require a fusion as the ultimate procedure. In such cases, I have begun to use resurfacing procedures as an excellent option.

   Finally, if the level of great toe arthritis is mild but there is hypermobility and an elevated first ray, I utilize a first metatarsocuneiform fusion and cheilectomy combination to clean up the joint and realign the first ray.

Key Insights On Resurfacing Procedures

When it comes to resurfacing procedure options, I divide them into autograft, allograft and metal options. Each has positives and negatives. I have found it necessary to have all three options in my bag of tricks to be able to treat the different cases.

   Autograft cases are those in which I use the patient’s joint capsule for interposition to decrease pain. I free the dorsal capsule from the base of phalanx, tuck it into the great toe joint and suture it to the base capsule after an aggressive cheilectomy. This is a simple procedure but you cannot reline the entire joint or the sesamoid complex with this procedure. I use this for patients with mild to moderate articular damage and no major sesamoid arthritis.

   If the sesamoid complex is mildly to moderately arthritic, one may use allogenic graft material such as animal pericardium to line the entire metatarsal head in order to decrease the grinding that may occur. This is fairly new and lacks long-term studies but we have had excellent outcomes in our short-term studies.

   I prefer to use metallic replacements in lower stress patients who do not require a great deal of impact resistance out of the great toe. I prefer to resurface the side of the joint with the greater level of arthritis. This means using an implant on the base of the phalanx or the metatarsal head but never both. By leaving the patient’s joint integrity partially intact, I believe there are fewer issues with instability and transfer. Furthermore, the implant seems to last longer.

   As to which surface is better to resurface, I do not think it matters much except if there is sesamoid damage. If the sesamoid complex is damaged, a metatarsal head resurfacing is preferable. With both types of implant, a small amount of decompression is possible but one can perform greater decompression of the metatarsal surface than the phalanx base due to the tendinous attachments on the phalanx base.

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