The most common and probably also the simplest way to correct a hallux limitus deformity is to "just" remove the bone spur on the top of the foot that is causing limitation of motion of the big toe joint and accompanying pain.
The bone spur on top of the foot may be growing either from the head of the first metatarsal or from the base of proximal phalanx (toe), or from both bones. In many instances the bone spur, if large enough will have fractured and the fractured piece of bone must be removed as well.
Anyone who corrects these problems will tell you that in the vast majority of the cases, the bone spur on top of the foot is just the "tip of the iceberg" meaning that the destruction to the big toe joint is usually a lot worse once it can be visualized.
Once the bone spur is removed and the rest of the area inspected for other spurring, the area is closed. This is an outpatient procedure and the patient generally leaves the hospital with nothing more than a dressing and surgical shoe.
The current thinking is to get the patient walking as soon as possible in order to get motion back in the great toe joint. To this end, I see my patients a couple of days after surgery, change the dressing, and insist that they walk around the house without their surgical shoe, in order to force the toe to start to bend. The problem with surgical shoes is that even though they protect the foot, they do not allow for any motion. Failure to start early movement in the surgical site will lead to adhesions (scarring) and very little motion once healed.
In this procedure the base of the proximal phalanx (one of the bones making up the big toe) is remodeled in such a fashion to create a "peg and hole" fixation. As the remodeled bone is forced into the larger portion of bone it creates a space in the joint which in theory should allow for better motion and a diminishment of pain.
This procedure has lost some of the enthusiasm that it originally enjoyed. The problem with this procedure is that it is technically difficult to perform in the sense that it is difficult to create a wedge of bone that fits snugly when the two ends of bone are pressed together thus increasing the possibility of a non-healing fracture.
The other problem is that even though the final produce looks good on x-ray, in most cases the space that is created in the joint will eventually close down and you will end up with degenerated bone rubbing on degenerated bone which may be painful.
Although usually not a problem, the great toe will be slightly shorter.
In this procedure the patient is experiencing pain in the big toe joint because the first metatarsal is dorsiflexed (elevated) relative to the big toe. Thus the big toe is not able to bend upwards as it jams into the elevated metatarsal.
A V type cut is made into the metatarsal shaft looking from the side of the metatarsal bone with the apex (point) directed towards the big toe. A second cut is then made on the top portion of the V and the resulting wedge of bone is removed.
The head of the metatarsal is then pressed back into the shaft and fixated with a k-wire or perhaps bone screws. Since the wedge of bone has been removed, it has the effect of plantarflexing the head, so that once healed, the head of the metatarsal is even with the big toe and now the toe should be able to bend upwards.
There are inherent risks with this procedure. The first is that since a wedge of bone has been removed sometimes when the head is re-positioned on the shaft, there may be a space and this can result in a non-healing of the fracture (osteotomy).
Another problem is that if the head is plantarflexed too much, it will cause the big toe to automatically bend upwards and remain that way. This can then be an issue when trying to wear shoes as it will cause irritation on the toe.
This is an out-patient procedure. Even though the osteotomy site is fixated with hardware, I feel the patient should also be in a walking boot in order to enhance the healing of the broken bone and minimize complications.
continue.... surgical procedures for hallux limitus
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