Performed by – David Hinsley, Ngwe Phyo, Nick Ward

Osteoarthritis of the great toe (Hallux) metatarsal-phalangeal joint (MTPJ) presents with stiffness of the great toe, some swelling, and pain. Impact activities such as running usually exacerbate the symptoms. It can be caused by previous trauma to the big toe, inflammation within the joint, or may develop without any obvious precipitating cause.

Treatment options include simple analgesia and activity modification, shoe modifications, injections, cheilectomy (removing some of the bony lumps and worn areas of the joint), fusion (making the joint stiff), and joint replacement.

Cheilectomy aims to improve the range of MTP joint dorsiflexion by excising dorsal osteophytes from the head of the metatarsal and base of the proximal phalanx. In removing these abnormal bone growths from the margins of the joint, and the most worn portions of the joint surfaces, the joint is often more comfortable, but not always pain free. The recovery from this operation is quicker than a fusion.

Sutures are removed after 10-14 days and early range of motion exercises are encouraged. Patients may weight bear as tolerated and aim to wear a normal shoe after 6 weeks. As a general rule you will retain approximately half the extra range of dorsiflexion that is achieved at the time of surgery. If the surgery is not as successful as hoped, then a fusion operation can be performed at a later date.

Fusion surgery aims to make the big toe joint permanently stiff, and therefore abolishing all pain from that joint. It is currently the gold standard operation for an arthritic big toe joint. The joint becomes solid so the joints proximal and distal to the fused joint will adapt to allow more movement within them. The toe is fixed in a slightly elevated position to allow normal walking and the use of a small court shoe if required. High heels will not be possible. Patients quickly adapt to the fusion and walk normally, with some patients achieving a high level of function such as recreational running and a return to sporting activities.

The arthritic joint is excised and the two bones are then fixed temporarily with a smooth wire and then fixed using two crossed screws or a plate and screws. The wound is closed using dissolvable sutures. Post operatively the foot should be elevated for 24-48 Hrs. Walking is permitted, but only in the rigid flat post operative shoe, for 6 weeks. Suture ends are trimmed off at 2 weeks.

The foot is X-rayed at 6 weeks and if satisfactory normal shoes can now be worn. A final x-ray at 12 weeks is required before full impact activities (running, dancing etc.) can resume.