Arthritis is the thinning of the cartilage within a joint, where two bones meet. The ends of the bone have a particular shape to allow for a specific movement of that joint, and the ends are covered in cartilage to allow for smooth gliding of that joint. The cartilage can experience wear and thinning for a variety of causes, leading to three main categories of arthritis: osteoarthritis, inflammatory arthritis, and post-traumatic arthritis. Arthritis can also be caused in rarer circumstances by infection, nerve damage, crystalline deposition, and other causes.
The most common form of arthritis in the foot and ankle affects the great toe MTP joint, known as Hallux Rigidus. The great toe provides significant push-off strength both during walking and during athletic activity. A significant amount of stress goes through the great toe; about fifty percent of the body’s weight is borne through this portion of the foot. Inflammatory arthritis, post-traumatic arthritis, gout, and osteoarthritis are common in this joint and lead to destruction of the cartilage. Many people first notice stiffening of the joint; they are no longer able to bend the toe upwards as far as they used to. There may be pain with push-off or standing on tiptoe. It may be difficult for women to wear high-heeled shoes. Patients often notice a bone spur on the top of the joint that may rub on the shoes. A deeper, aching pain at night or when barefoot signifies more severe cartilage damage within the joint.
Nonsurgical options include a stiffening device in the shoe such as a carbon fiber insert, or use of stiff-soled shoes, that minimize the motion of the great toe. A shoe with a roomy toe box and soft upper will accommodate the bone spur. Anti-inflammatories, ice (if no numbness), and rest from aggravating activities will also help.
Surgical options include a variety of choices, depending on the symptoms and severity.
For patients who mostly have pain due to stiffness and a dorsal bone spur, a cheilectomy may be a good option, which is the removal of the bone spurs on either side of the joint. The joint is opened and evaluated for loose pieces of bone and cartilage that can be removed. This does not reverse the wear of the joint, which is the root of the problem. However, joint range of motion is maintained or improved. It should be understood that in patients with more severe arthritis, this will not improve a deep-seated pain due to cartilage wear.
Traditionally, more severe arthritis has required an arthrodesis or fusion surgery, which removes the cartilage from each joint surface and permanently fixes the joint into place. Push-off strength is lost, but the pain of arthritis is completely removed. Because the position of the great toe is fixed, either a flat shoe up to about a 1½ inch heel can be worn. The more distal joint in the great toe often compensates with extra motion over time. This option is less than ideal for a patient who wishes to wear higher heels or perform yoga without modifications. However, it is a robust surgery and a very good option for many.
Recent technology in the field has allowed for a hydrogel implant called Cartiva to be inserted in certain cases of Hallux Rigidus. Early data is promising for effective pain relief with maintenance of joint range of motion, and is an option for certain cases of hallux rigidus. If you are a candidate for Cartiva, we can supply you with more specific information.
Total or partial joint replacements of the metatarsophalangeal joint of the great toe thus far do not have the longevity to make them a viable alternative. The need for revision surgery is common, but significant bone is removed in the first surgery yielding less than satisfactory results of the fusion afterward. This surgery is not recommended.
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