MPJ


HALLUX LIMITUS
(Progressive Loss of Motion to the Big Toe Joint
Due to Loss of Cartilage)
By:  Robert H. Sheinberg, D.P.M., D.A.B.F.A.S., F.A.C.F.A.S.

CAUSES:

  • Trauma.
  • Hyperextension injuries (turf toe).
  • Abnormal bone structure (long or elevated first metatarsal).
  • Mild bunion deformities with a crooked big toe.

SIGNS AND SYMPTOMS:

  • Progressive loss of motion to the big toe joint.
  • Swelling on the top of the joint.
  • Tenderness to the big toe joint to touch.
  • Stiffness to the big toe joint with attempted movement.
  • Painful with activity.
  • Difficulty wearing any shoe with a heel.

X-RAYS:

  • Usually, reveal bone spurs on the top of the joint.  Over time bone spurs progress throughout the joint and there is a progressive loss of joint space.

TREATMENT:

  • Evaluation to identify the primary cause.
  • Anti-inflammatories to reduce swelling.
  • Change in shoes (stiff sole, low heel).
  • Orthotic to unload the joint and transfer pressure to the central foot.
  • Mild arthritis – Removal of abnormal cartilage and bone to allow improved joint motion.
  • Moderate arthritis – Removal of abnormal bone and cartilage and reconstructing the joint to allow more mobility.
  • Advanced arthritis – May necessitate an implant to the big toe joint or a fusion of the joint to eliminate pain and allow activity.  In the senior patient with advanced changes the joint can be removed, which will eliminate the pain and allow mobility. 

Stage 1 Hallux Limitus

The spurring is circled and the red area is what will be removed during a Cheilectomy

Stage 2 Hallus Limitus

There is narrowing of the joint space and spurring around the joint. A Decompression Osteotomy is performed.

Stage 3 Hallux Limitus

Joint Space is almost completely gone. A Hemi-Implant is placed in the 1st MPJ

Alternatively, a total implant is used to replace the 1st MPJ.

Stage 4 Hallux Limitus

Patient had end-stage arthitis with no motion left at the joint and a constant pain with walking and standing. A permanent 1st mpj fusion is performed with crossing screws.

  

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First Metatarsal Phalangeal Joint (MPJ) Osteoarthritis

Below is pic of preop and post op first metatarsal osteotomy to decompress arthitic big toe joint

Set of Pre and post op X-rays of arthritis of big toe joint treated with hemi-implant

Pre and Postop Hemi Implant for 1st MPJ Arthitis

Below is an example of a patient with severe arthritis of the first MPJ with complete breakdown of the joint structure with alteration in bone shape and dislocation of the joint. Also note the overlapping dislocation of the second and third toes.

 

The following is an x-ray of the same patient after surgical repair of the joint with fusion surgery involving two Steinmann pins that will hold the great toe in place until fusion occurs. There are also screws placed at the heads of the second and third metatarsal heads with Kirschner wires from correction of dislocated second and third toes. The screws hold in place the cut bones of the ends of the metatarsals that allow increased joint space and slack enough to relocate the toes.

Pictured below is the patient who is 5 months post fusion surgery (arthrodesis) of the First MPJ with complete healing.

Intraop pictures during hemi-implant for hallux limitus

 

OCD of 1st Metatarsal Head

1st MPJ Arthritis before and after 1st MPJ fusion

Picture of a 50 year old man that had pain with activity in his big toe joint.  He had prior surgery with different surgeon. 

Xrays show deformity of big toe (hallux interpahalangeus) which causes increased stress on the outside of the big toe joint.  There is spurring at the dorsal and lateral aspect of the 1st metatarsal head.

These are intraoperative pics after surgery.

An osteotomy was performed of the big toe to realign the toe and decrease stress in the joint. A staple was placed to close the cut in the big toe bone.

These are lateral views where cheilectomy can be seen. There is over 90 degrees of extension of the big toe joint seen on the lower left picture.

Pic showing arthritis and spurring of the big toe joint prior to implant

Pics after implant

Intraop Pics of Cheilectomy and Hemi Implant

Pics of 1st Metatarsal Decompression Osteotomy

Intraoperative Picture of cartilage damage of the 1st metatarsal head during bunion surgery before and after removal of the bad cartilage and subchondral drilling (Below)

 

 

More Pics of Osteochondral Defect of 1st Metatarsal head Below.

After Cleaning up the bone spurs around the head, we perform subchondral drilling with a 1.1 mm drill bit. The size of the defect can be seen on the last 2 pics.

Below, Intraoperative Pics of 1st Metatarsal Osteotomy with cheilectomy and Subchondral drilling of OCD. The 2 titanium screw heads can be seen at the top of the bone.

Intraop Picture of spurring and arthritic overhang of the big toe joint.  The instrument is pointing at the spur

Intraop pic of cartliage damage inside big toe joint that was cleaned up and then drilled to stimualte cartilage regrowth (below)

  

Below is a pic of 2nd MPJ arthitis

Although the other joints are deviated, they have good spacing and are not arthitic