New Cartiva Technique to Increase Joint Motion
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.
Below is pre operative and post operative x-rays demonstrating severe arthritis of the great to joint (1st MPJ) in a femal patient. Surgery in this case was performed utilizing two Steinman pins for fixation. (From left to right) Pre-op, immediate post operative, and 3 months post operative.
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.
Osteochondral Injury of the 1st Met Head Below
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.
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.
Intraop pic of cartliage damage inside big toe joint that was cleaned up and then drilled to stimualte cartilage regrowth (below)
Intraop Pic before and after subchondral drilling for OCD 1st met head
Intraop Pics of OCD 1st Met Head with Currete and Subchondral Drilling of Defect
Limitation in the range of motion of the hallux secondary to long-term arthritis results in injury to the cartilage that appears irregular as seen in the image below.
After debridement (removal) of the damaged cartilage from the area, one can see that there was more damage to the area than meets the eye. What is left is a large defect in the cartilage and the subchondral bone plate is exposed. This can be very painful with impact during activity with the adjacent bone in the involved joint.
The subchondral bone plate is drilled with holes in order to create active bleeding to the area so that the cartilage will heal itself and replace the hyalin cartilage with fibrocartilage which is the cartilage version of scar tissue to cover the area. The new scar cartilage is not as effective as the original cartilage but does function well enough to improve the patient's condition.
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 pic of Hemi-implant of big toe joint due to arthritis
Intraop Picture of spurring and arthritic overhang of the big toe joint. The instrument is pointing at the spur.
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
Abnormal anatomical position in addition to increased activity throughout a
period of time or in same cases an injury will lead to irregular shaping of
the bones around the big toe joint from abnormal wear and tear. This will
cause arthritis type pain with stiffness and swelling.
With abnormal wearing of the joint, spurring of the top of the joint occurs from jamming causing decreased motion of the big toe in an upwards direction.
Post-operative x-ray of a joint that was repaired with a hemi (partial) joint replacement to alleviate limiting arthritis which also involves reshaping of the bones to eliminate spurring.
This is a before and after of a patient who had a bunion performed by a different surgeon and developed arthritis of the big toe joint. We removed the joint and replaced it with a total 1st MPJ implant.
Preop
Post
Intraop pictures during hemi-implant for hallux limitus
1st MPJ Arthritis before and after 1st MPJ fusion