Definition
Painful restriction of dorsiflexion of the great toe
- secondary to degenerative changes in MTPJ
- initially pain and synovitis
- osteophytes don't form medially or on plantar aspect
Epidemiology
Two peaks
1. Adolescence F > M
2. Middle Age M > F
Aetiology
Often Idiopathic
Trauma
- OCD
- hyperextension injuries
Anatomical
- pronated foot
- abnormally long 1st MT
- pes planus
- DF 1st ray
Inflammatory
- gout
- CPPD
- inflammatory arthropathy
History
Pain on walking
- especially slopes & rough ground
- pain may become continuous
Numbness
- compression of dorsomedial cutaneous nerve
Examination
Shoe shows excessive lateral wear
- toe off on lateral border
- patient avoids dorsiflexion
Look
- hallux is usually straight
- MTPJ is enlarged
Feel
- synovial thickening
- palpable dorsomedial osteophyte & bunion
- altered sensation dorsal toe / due to tethering of dorsomedial nerve by osteophytes
ROM
- DF restricted & painful N = 90°
- PF often reduced and painful N = 30°
X-ray
Changes of osteoarthritis
- dorsomedial osteophyte
- joint space narrowing
Management
Non Operative
Options
Education & Reassurance
Orthotics
- initially stiff soled shoes
- rockerbottom sole
- high toe box
NSAID
HCLA
Operative
1. Moberg Osteotomy
Indication
- young patient with mild OA & > 30° PF
Technique
- dorsal closing wedge osteotomy of P1
- converts PF range into functional DF
2. Cheilectomy
Mann 1988 JBJS
Concept
- removal of dorsal osteophytes
- increase painless DF range (average 20°)
Indication
- for adults with minimal degenerative changes
- normal joint space in plantar half MTPJ
Disadvantage
- recurrence of pain
Technique
- dorsal incision over MTPJ
- joint incised either side EHL
- synovectomy
- remove ~ 1/3 of dorsal MT head
- remove osteophytes from base of P1
- need DF of ~ 90°
- stiff shoe till ROS
- then flexible sole and ROM exercise
3. Arthrodesis
Indication
- adults with significant degenerative changes
Disadvantage
- lateral transfer metatarsalgia
- IPJ OA
- malposition
- limitation of footwear type
- non-union
Technique
- dorsomedial approach
- protect dorsal cutaneous nerve
- mobilise EHL laterally and open capsule
- divide collaterals
- free P1 of soft tissue attachments
- 15° valgus
- 15° DF relative to plantar surface / 20 - 25° relative to metatarsal shaft
- dorsal plate / crossed screws
Results
- 30% develop asymptomatic OA IPJ
4. Interpositional Arthroplasty
Indication
- severe OA & moderate demand
- minimal bone resection
Technique
- imbricate dorsal & volar capsule into joint space
5. Swanson Arthroplasty
Indication
- adults with low demands
Disadvantage
- breakage
- silicon synovitis
- very difficult to salvage
6. Keller's Procedure
Indication
- for elderly with low demands
Disadvantages
- lose windlass mechanism
- transfer metatarsalgia
- cosmetically poor
- drifts into both DF & valgus / Cock Up deformity