Hallux Limitus and Hallux Limitus Management

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.

Reconstruction 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 sesamoidectory, cheilectomy and joint replacement

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.

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

The Operation

The standard incision is on the inside of the foot over the bunion deformity. The incision is on average 6-8 cm in length. Dissolving sutures are used to close the skin. The operation normally takes about 40 minutes.

The Scarf

This is a transposition osteotomy, although in some cases a small amount of rotation can be achieved. It is normally indicated for mild to moderate deformities. The new position of the first metatarsal is maintained with 2 screws improving its stability. Once the bone has fully healed the screws are no longer required. However, we only remove them if they cause irritation.

Discharge

Before you leave the hospital you will be given a post operative shoe and shown how to partially weight bear on the foot using crutches. 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

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. You will be seen 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 depending on how well you are progressing. The physiotherapist will demonstrate range of motion exercises and help improve your walking.

Lapidus (metatarsal cuneiform fusion)

This involves a fusion of the first metatarsal cuneiform joint allowing the first metatarsal to be rotated back into a straight position. It is normally reserved for severe deformities or for arthritis at the first metatarsal cuneiform joint. Once the corrected position has been obtained it is usually maintained by a plate and four screws. You will be in a post-operative cast for 6 weeks partial weight bearing, although for the first few days you will not be able to put the foot to the ground. If the screws and plate cause irritation then they will be removed once the bones have united.

Discharge

Before you leave the hospital you will be shown how to use crutches. 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

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. You need to order a FP Aircast Walker which you can then partial weight bear on. The Aircast can be removed to allow ankle and foot exercises and whilst sleeping.

You will need to make another appointment to see the nurse and the Physiotherapists at 10 days post surgery. The nurses will check the wound and cut the suture tags. From this point on you should be able to wash the foot. At six weeks you will be reviewed and the foot X-rayed, if healing is occurring in a satisfactory manner then you will be advised to return to a trainer. From this point on 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 2 bones to unite (12 weeks in total). Once out of the post operative cast and fully weight bearing you can drive your car once you feel safe. It is normally a year before patients have fully recovered. The most common complaints are swelling and an ache around the surgical site.

Physiotherapy

This is instigated 10 days post surgery if required.

Outcomes

An audit using a 100 point clinical rating system was used to assess pain, function and alignment, a score of 100 being perfect. The average score before surgery was 47.33. Following the surgery the average outcome was 91.08 within our department. The risk of a non union at the fusion site was 5%.

Specific complications following bunion surgery

  • Non-union of bone following surgery which is higher for the Lapidus at 5%.
  • Delayed union (slow healing)
  • Fracture
  • Joint stiffness
  • Reoccurrence of symptoms or deformity.
  • Fixation irritation
  • Transfer pain

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 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 mobilization will be advised, this helps improve the flexibility, strength and stability of your foot.

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 audit data is available.
  • Thick and or sensitive scar – no audit data is available.
  • Screws and plates were removed from 10% of patients. 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 overreacts 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.*.