Often times, patients present to our office with an enlarged bone on top of their big toe joint causing pain and limitation of motion. This is a “dorsal bunion” and is different than the typical bunion that protrudes from the medial side of the foot. This “bunion bump” on top of the big toe causes jamming of the joint leading to stiffness and pain. Typically, this problem develops from one’s genetic foot structure and over time causes the first metatarsal/ big toe joint to become elevated. This leads to excessive rubbing of the big toe against the first metatarsal head with resultant wear and tear of the cartilage. As the body tries to heal this injury, hypertrophic or excessive bone is formed on top of the joint. Unfortunately, this bump often rubs against one’s shoe causing pain. And, as a consequence of the limited motion, the foot must rotate to the outside (supinate) at the push-off phase of walking or running, which causes detrimental damage and pain to other joints in the foot and body above. Depending on the severity of pain, conservative treatments including wearing specially designed orthotics, or wearing a Rockerbottom soled shoe which are included within many of the newly designed athletic shoes. There are different stages of hallux rigidus and for those with more severe pain, a corticosteroid injection and/or homeopathic injection under fluoroscopic guidance may be performed in our office. Weightbearing X-rays, MRI, and/or CT scan help to determine the severity of the arthritic changes. It is not uncommon for x-rays to show broken pieces of bone or distortion of the joint in longstanding cases.
For those patients with moderate hallux rigidus with enlargement of bone on top of the joint, our office excels in performing these procedures by using a European side incision approach instead of a dorsal (top) incision. This helps to reduce potential scar tissue over the joint allowing for improved range of motion. Our athletic patient population has been able to return to exercise walking, running, and jumping activities rather quickly without problems.
For those who have painful advanced hallux rigidus, our office rarely fuses the big toe joint. It is our philosophy that fusion causes one to walk in an abnormal manner (just like the hallux rigidus problem) causing compensatory problems to occur in other foot and leg joints. Having performed hundreds of toe joint replacement surgeries, it is imperative that one starts progressive walking within a few days of surgery. This helps to prevent scar tissue and preserve joint range of motion.
There are many manufacturers of big toe joint implants. We have specifically shied away from hemi-implants and prefer to use the full length Silastic type flexible implant with grommets. These implants require minimal joint resection, and act as a spacer to prevent boneon-bone or bone-on-joint compression thereby allowing for pain free anatomical motion. Patients with the total joint implant have returned to exercise activities. It is often stated that implants may last 15 to 20 years. In our experience, it is rare that the total joint implant has had to be removed but if there is a problem, a new implant may always be swapped out an older one. Likewise, we have removed many of the hemi-implants and cartilage implants, which have failed to provide adequate range of motion and have swapped them out for a new total joint Silastic hinged type implant. Should you have any concerns for hallux rigidus type pains and if coming from outside of New York metropolitan area, please contact our office to help arrange for travel arrangements.
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Written by Richard T. Braver, DPM, FACFAS