1st Metatarso-phalangeal (MTP) joint osteoarthritis

Big toe arthritis

What is it

Wear and tear at the joint of the midfoot and the great (big) toe cause loss of cartilage and the smooth movement of the joint. As the smooth joint surface is lost this becomes painful and movement restricted.

Non-surgical options

  • Advice regarding shoeware such as changing to a well fitting pair of "off the shelf" rocker-bottom shoes, which can decrease the need for the painful joint to bend during walking, and thus decrease the pain and inflammation.
  • A very stiff soled walking boot (such as one that can take crampons) will achieve the same goal.
  • Weight -loss if overweight is very important, as being lighter means less pressure through the painful joint, and therefore less pain. 
  • Standard pain killers can help as well, and this may be something to talk to your GP about.

If these methods of symptom control do not work then an injection of local anaesthetic and steroid into the joint may be helpful. If so I would perform this in theatre to reduce the risk of infection.

Surgical options

Cheilectomy 

If the pain you get is mainly over the top of your big toe joint, and worse on bending your toe up, you may benefit from the removal of the excess bone that the body has made in response to the arthritis. This is done through a cut over the top of the toe or through a very small cut at the side of the toe (minimally invasive surgery) and helps to increase the range of movement, stops pressure from the excess bone against your shoe, and decreases the trapping of the joint lining between the excess bone. This operation is only good for certain levels and types of 1st MTP arthritis. 

Cartivia 1st MTP implant

There are many cases of big toe arthritis which are too severe for cheilectomy. Of these some are suitable for a motion preserving implant - the Cartivia.  The patient information leaflet can be downloaded here. Mr Machin will discuss your suitability for this at your appointment.

1st MTP Fusion 

With a fusion the damaged and worn out joint surfaces are removed using special tools that allow the two bones to be pulled very close. These two bones are then held with a plate and should fuse together to become one. The operation is usually performed through an incision over the top of the joint. The plate and screws are usually left in and cause no problems.

Risks of surgery specific to this procedure

Cheilectomy

Continued pain and stiffness, may require a fusion in the future.

Fusion

There is a small chance of the bones not fusing together and this is called "non-union". Smoking and diabetes increase this risk. If this happens you may need further operations to deal with the problem. Occasionally the plate and screws can become prominent and need removing through the same incision at a second operation.

What to expect after surgery

  • This will be done as a day case procedure under a general anaesthetic.
  • A local anaesthetic block is used around the ankle to decrease post-operative discomfort.
  • The patient is discharged home from hospital on the day of the operation with painkillers to use as necessary.
  • The patient must keep their foot up above the level of the groin for 23 hours every day for two weeks. This minimises swelling, decreases discomfort and reduces the risk of wound complications and infection.
  • The patient is able to weight bear in a special shoe from day one to move around the house.

Expected recovery milestones

  • At two weeks you will be seen for a wound check; if the wound is healed you will be able to do more walking around but will be quite uncomfortable until six weeks post-operatively when you will be seen again.
  • At the six week appointment an x-ray will be taken to check on the healing of the bone.
  • Between six weeks and three months you should expect to return to work and normal activities. I would expect to discharge you from further follow-up after three months.
  • Between three months and one year there will still be some swelling and minor discomfort.