Painful Great Toe

2021-08-10T17:38:05+00:00

Understanding Painful Great Toe

Pain in the great toe, otherwise known as the first metatarsophalangeal joint, can be caused by osteoarthritis, rheumatoid arthritis, bone spurs, bunions and posttraumatic injuries.

Hallux limitus and hallux rigidus are terms used to describe the loss of motion in the first metatarsophalangeal joint with hallux rigidus being considered the end stage of hallux limitus. This is a challenging problem that can affect patients of all ages and activity levels. The majority of cases appear to be mechanically induced and are often associated with a long first metatarsal and fallen arch foot types. However, trauma such as a stubbing injury may also result in hallux limitus. Long-standing gout can be a contributing factor as well.

Osteoarthritis (OA), also known as degenerative arthritis, is the most common type of arthritis and usually develops slowly over several years. It occurs when there is a systematic loss of cushioning cartilage in the joints and the bones in the joint rub against one another; this can be very painful and reduce movement drastically in the joint. If the condition is not treated, the bones could overgrow and fuse together on their own causing a complete loss of function.

Rheumatoid Arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. A typical joint in the body is made up of bones that move against each other and are held together by ligaments and a sheath (called a capsule) that surrounds the entire joint. The inner lining of the capsule is called the synovium. In rheumatoid arthritis, the synovium of the joint becomes inflamed and enlarged, eroding the neighboring bones, ligaments, and cartilage. The end result is damaged and painful joint surfaces.

Osteophytes, or bone spurs, are bony projections that form along joints. They are due to arthritis or damage of the joint, and they may limit joint movement and cause pain.

A bunion is an enlargement of bone or tissue around the joint at the base of the big toe. It is a condition caused by abnormal mechanics of the foot or congenital factors, such as flat feet, abnormal bone structure, and neurological conditions. The end of the large toe, or the phalange, points toward the second toe causing the metatarsal to bump, or bow outward.

Learn more about hallux rigidus and the BioPro Hemi. 

Symptoms

Common symptoms of osteoarthritis, rheumatoid arthritis, bone spurs, and/or a bunion are:

  • Pain experienced when walking
  • Joint tenderness
  • Inflammation that may produce a mild warm feeling or occasional redness
  • Significant stiffness of the toe
  • Loss of function

Treatments

Before considering surgery there are always non-operative treatments such as:

  • Shoe modifications
  • Cast immobilization with a reduction in activity
  • Anti-inflammatory drugs
  • Physical therapy
  • Local injections

When non-operative solutions are no longer able to control the pain and disability, surgery becomes a reasonable option. Surgical options include:

Keller Arthroplasty

The base of the phalanx and the attached tendons are severed and approximately 1/3 to 1/2 of the phalange is removed. This decompresses the joint and allows soft tissue to in-grow. Complications may include flail toe, which is where the toe sticks up in the air, and a return of pain as there is still the potential for bone on bone contact.

Cheilectomy

Bone spurs on the top of the metatarsal head that interfere with movement are removed, thus allowing joint motion. Along with the Keller arthroplasty, a cheilectomy is simply the removal of bone without resurfacing the joint. The possibility of having bone on bone or diseased/damaged cartilage post surgery is still a concern.

Arthrodesis (Fusion)

The cartilage surfaces of the joint are removed and a device such as a screw or plate is utilized to prevent motion. The bones eventually grow together which prevents pain; however, a loss of function occurs as the joint will no longer bend. With this loss of motion, your gait, or way of walking, may change, which could affect other joints such as knees, hips, spine, etc. Additionally, shoe wear selection may be limited due to the inability to bend your toe.

Hemi-Joint Arthroplasty

The surface of the metatarsal head is reshaped and the phalange is resurfaced with a new, smooth-surfaced component. This eliminates the possibility of bone on bone contact, thereby reducing pain, while restoring motion and maintaining function of the toe. Great toe joint replacement is usually performed to treat severe arthritis conditions. Most patients with a great toe joint prosthesis are middle-aged and older, but the operation may be performed on younger patients at the discretion of the surgeon. Though motion and function should be restored, achieving the normal movement of a completely healthy joint may not be possible.

How the BioPro Hemi Toe Implant Works

The BioPro Hemi Toe Implant treats the arthritic joint by resurfacing the phalanx (low force, non-weight-bearing joint side) with a smooth, durable metal implant for the metatarsal head to articulate against. Watch the surgical animation below.

Why it Works

Many factors allow the implant to provide improved range of motion, pain-relief and long-term survivorship.1,2,3,4,5,6,7,8,9,10,11,12,13

Improved range of motion

During the surgical procedure, large osteophytes (bony outgrowths) are removed and the joint is smoothed out. This, along with minimal bone resection, allows for decompression of the joint and improved range of motion.

Pain relief

Before surgery, the joint had damaged cartilage or was bone on bone. After surgery, there is a remodeled metatarsal head articulating against a smooth metal spacer allowing for reduced pain and restored motion.

Long-term survivorship

Since the implant is placed on the phalanx, it avoids the weight-bearing forces placed on the metatarsal head. Furthermore, the implants outer edge rests on hard cortical bone, preventing the implant from receding into the soft cancellous bone. The implant is manufactured from a well established biocompatible material with a durable wear surface that is proven to last over 30 years.7

How big is the implant?

The implant is very similar in both thickness and diameter to a US coin. It is 2mm thick and available in diameters from 17mm to 23mm depending on a patient’s anatomy.

Why resurface only the phalanx?

While walking or running the foot goes through a “gait cycle”. The cycle involves six main phases: heel strike, foot flat, mid stance, heel off, midswing, and toe off. Although the big toe joint is not a direct weight-bearing joint, during heel off and toe off, the metatarsal head is subject to 119% of the patient’s bodyweight16. Since the BioPro Hemi is placed on the proximal phalanx it avoids this force and simply glides up (dorsiflexion) the metatarsal head.

Long-term data

A 40 year review of the BioPro First MPJ Hemi Implant was conducted and then published in 1994. The study included 279 patients ranging from 8 months to 33 years postoperative.10

The patients were evaluated through questionnaires that measured pain, joint stiffness, functional disability, and overall satisfaction. They were also clinically examined for range of motion and alignment. In order to achieve “Excellent” results, the patient had to be entirely pain-free in all activities, with no functional limitation of motion and have normal alignment.

The study showed 93.1% excellent, 2.2% good, and 4.7% unsatisfactory. The study was then followed up on in 1998, in which 189 patients were added.7 The follow up on the 468 patients was conducted from 2 months to 38 years postoperative and showed a 97.3% implant survivorship. Read the full study here.

Since then, several studies have been conducted on the BioPro First MPJ Hemi Implant.

BioPro vs Fusion

A recent study was published comparing long-term results (average 8.3 years) of the BioPro implant hemiarthroplasty procedure to arthrodesis (fusion). A total of 78 procedures performed from 2005 to 2011 were reviewed (31 hemiarthroplasty and 47 fusion). The data revealed that hemiarthroplasty provided better functional outcomes with considerably more satisfied patients.13 You can read the full study here.

The following charts highlight some key findings.

What to expect after toe implant surgery

Most patients have a rapid recovery and have considerably less pain than they did before surgery. Partial to full weight-bearing is permitted at the discretion of the surgeon. A standard post-operative shoe may be used for the first 3 weeks. Dressings are changed for 3 weeks, with sutures usually removed at the 2 week period. Passive range of motion, such as movement of the foot upward or downward is permitted by the 2nd or 3rd post-operative week. Physical therapy and return to soft shoes are usually permitted by the 3rd to 4th post-operative week.

Note: dressing changes, return to regular shoes and types of postoperative range of motion therapies may vary based on your surgeon’s recommendations.

Possible complications after surgery include:

Infections – Any infection in your body can spread to your joint replacement. Infections may occur while you are in the hospital or after you go home. Minor infections can be treated with antibiotics, while major infections may require surgery and removal of the prosthesis.

Stiffness – In some cases, the ability to bend the toe does not return to normal after an artificial great toe joint replacement. This can be reduced with aggressive physical therapy.

FAQ's

Yes, most insurance plans cover this procedure. It is important to get a pre-authorization from your insurance company prior to surgery.

There are many surgeons located around the world that currently use the BioPro First MPJ Hemi Implant. If you would like contact information on surgeons near you, fill out the contact form to the right and one of our customer service agents will be happy to give you the information.

The fusion is considered the "Gold Standard" procedure for treating Hallux Rigidus, so many surgeons prefer this procedure. Many surgeons are not aware of the clinical studies supporting our implant. Also, there are many other implants currently on the market for surgeons to choose from, so your surgeon may be using a similar implant.

Implants manufactured from metal, such as cobalt chrome and titanium, have proven to be long-lasting and biocompatible. Some synthetic materials have been shown to break down and cause inflammation.15 Be sure to mention to your doctor if you have a Nickel allergy as cobalt chrome contains nickel and your surgeon will want to use a titanium implant.

References 

1. Timothy Voskuijl, MD, Ron Onstenk, MD. Operative Treatment for Osteoarthritis of the First Metatarsophalangeal Joint: Arthrodesis Versus Hemiarthroplasty. The Journal of Foot & Ankle Surgery xxx (2015) 1–4
2. Karin H. Simons, MD, Pieter van der Woude, MD, Frank W.M. Faber, MD, PhD , Paulien M. van Kampen, PhD , Bregje J.W. Thomassen, PhD. Short-Term Clinical Outcome of Hemiarthroplasty Versus Arthrodesis for End-Stage Hallux Rigidus. The Journal of Foot & Ankle Surgery xxx (2015) 1–4
3. Giza E, Sullivan MR. First Metatarsophalangeal Hemiarthroplasty for Grade III and IV Hallux Rigidus Techniques in Foot and Ankle Surgery 4(1):10-17,2005
4. Clement, N. D., MacDonald, D., Dall, G. F., Ahmed, I., Duckworth, A. D., Shalaby, H. S., & McKinley, J. (2016). Metallic hemiarthroplasty for the treatment of end-stage hallux rigidus. Bone Joint J, 98-B(7), 945-951.
5. Taranow, DO. et al. Contemporary Approaches to Stage II and III Hallux Rigidus: The Role of Metallic Hemiarthroplasty of the Proximal Phalanx. Foot and Ankle Clinics , Volume 10 , Issue 4 , 713 - 728
6. Roukis TS, Townley, MD. BIOPRO resurfacing endoprosthesis versus periarticular osteotomy for hallux rigidus: short-term follow-up and analysis. Journal of Foot & Ankle Surgery 2003;42(6):350-8
7. Juan C. Goez, DPM, Charles O. Townley MD, Warren Taranow, DO. An Update on the Metallic Hemiarthroplasty Resurfacing Prosthesis for the Hallux. Presented at the 56th Annual Meeting and Scientific Seminar of the American College of Foot and Ankle Surgeons. Orlando FL February 1998
8. Charles G. Kissel, DPM, FACFAS, Zeeshan S. Husain, DPM AACFAS, Paul H. Wooley, PhD, Michael Kruger, MS, Mark A. Schumaker, DPM, Michael Sullivan, DPM, and Todd Snoeyink, DPM. A Prospective Investigation of the Biopro® Hemi-Arthroplasty for the First Metatarsophalangeal Joint. The Journal of Foot & Ankle Surgery 47(6):505–509, 2008
9. Taranow, DO , Townley, MD. Metallic proximal phalangeal hemiarthroplasty for hallux rigidus. Operative Techniques in Orthopaedics 1999;9(1):33
10. Townley, MD, Taranow, DO. A metallic hemiarthroplasty resurfacing prosthesis for the hallux metatarsophalangeal joint. Foot & Ankle International 1994;15(11):575-80
11. Christine C. Salonga, DPM, David C. Novicki, DPM, FACFAS , Martin M. Pressman, DPM, FACFAS , D. Scot Malay, DPM, MSCE, FACFAS. A Retrospective Cohort Study of the BioPro Hemiarthroplasty Prosthesis. The Journal of Foot & Ankle Surgery 49 (2010) 331–339
12. Giza, E., Sullivan, M., Ocel, D., Lundeen, G., Mitchell, M., & Frizzell, L. (2010). First metatarsophalangeal hemiarthroplasty for hallux rigidus. International Orthopaedics, 34(8), 1193–1198. https://doi. org/10.1007/s00264-010-1012-x
13. Beekhuizen, Stefan R. et al. Long-Term Results of Hemiarthroplasty Compared With Arthrodesis for Osteoarthritis of the First Metatarsophalangeal Joint. The Journal of Foot and Ankle Surgery , Volume 57 , Issue 3 , 445 - 450
14. Giza E, Sullivan M, Ocel D, Lundeen G, Mitchell M, Frizzell L. First metatarsophalangeal hemiarthroplasty for hallux rigidus. International Orthopaedics. 2010;34(8):1193-1198. doi:10.1007/s00264-010-1012-x.
15. Verhaar J, Vermeulen A, Bulstra S, et al. Bone reaction to silicone metatarsophalangeal joint-1 hemiprosthesis. Clin Orthop Relat Res. 1989;245:228–232
16. Jacob HA. Forces acting in the forefoot during normal gait--an estimate. Clin Biomech (Bristol, Avon). 2001 Nov;16(9):783-92. doi: 10.1016/s0268-0033(01)00070-5. PMID: 11714556.

The information provided is offered for general education purposes only and should not be used for diagnosing orthopedic problems, nor should it be considered a replacement for consultation with a physician. Only your healthcare provider can diagnose you and treat you in the way best suitable for you. While BioPro has endeavored to make sure the information contained in this site is accurate, BioPro can not guarantee the accuracy of such information, and it is provided without warrant or guarantee of any kind. If you have any questions or concerns about your health, please contact your healthcare provider.

Hammertoes

2020-08-20T16:55:54+00:00

Understanding Hammertoes

An abnormal bending of the 2nd, 3rd, 4th, and/or even the 5th joint in between the phalanges is known as a hammertoe. The most common cause is due to a muscle and/or tendon imbalance due to abnormal mechanics of the foot along with congenital factors. There are two types of hammertoes:

  • Flexible hammertoes: movement is still possible at the joint. This is a milder condition and there are several treatments for this condition
  • Rigid hammertoes: the tendons become rigid and the toe can no longer be moved. This usually means surgery is needed.

 

Symptoms

Common symptoms of hammertoes are:

  • Abnormal bending of the toe
  • Pain or irritation
  • Forming of corns and calluses (build up of skin).

 

Treatments

There are always non-operative alternatives for hammertoes such as:

  • Shoe modifications
  • Splinting of the toe
  • Padding or trimming corns and calluses
  • Exercises or therapy
  • Medications

When non-operative solutions are no longer able to control the pain and disability to your satisfaction, surgery becomes a reasonable option. Surgical options include:

Joint Fusion (arthrodesis) – The cartilage surfaces of the joint are removed and a device such as a screw is utilized to prevent motion. The bones eventually grow together which prevents pain; however, a loss of function occurs as the joint will no longer bend.

Phalangeal head resection (arthroplasty) – a portion of the phalanx is removed, releasing tension on the tendons. This may be done in conjunction with or without some type of implant. Advantages include retaining motion, but may be accompanied by a flail toe and loss of stability.

Tendon Transfers – the tendons that are too tight may be cut or transferred to relieve the tension and allow the toe to straighten. While this allows motion to be retained, like the head resection it can lead to a flail toe or loss of stability.

 

Why the BioPro Digital Compression Screw?

The Digital Compression Screw is used to fuse the joint, permanently straightening it. Unlike some other options, it provides compressive forces across the bones, which speed the fusion process. The screw is also buried beneath the skin, allowing the patient to wash their feet with no exposed wires, eliminating the potential for pin track infections. The Digital Compression Screw is also easily removed. Some devices permanently remain within the bone and require very invasive surgeries if removal is necessary.

 

What to expect during and after hammertoe surgery

The goal of the surgeon is to restore normal alignment of the joint and eliminate pain by fusing the joint. A Digital Compression Screw is inserted into the tip of the toe and compresses the bones together, speeding the fusion process. The screw typically stays in for 6-8 weeks while the bones heal, after which it is removed.

Varying degrees of hammertoe deformities with severe contracture and/or displacement on the metatarsal heads may require your surgeon to perform additional procedures in conjunction with the hammertoe repair. These may include metatarsal osteotomies or tendon transfers to maintain toe purchase after fusion.

Most patients have a rapid recovery and have considerably less pain than they did before surgery. Weight-bearing is only allowed while wearing a stiff soled post-operative shoe until the screw is removed.

Bunions

2020-08-20T16:57:38+00:00

Understanding Bunions

Bunions (hallux valgus) are a common foot problem involving the formation of a bump at the base of the big toe joint (first metatarsal joint). Bunions often lead to pain, swelling, and tenderness of the affected area. Sometimes, bunions can form on the outside base of the little toe. These are called a tailor’s bunion or bunionettes.

Bunions are found in people of all ages and genders. However, some people are more likely to get bunions than others, including:

  • Women
  • The elderly
  • People with a family history of bunions

Bunions occur in approximately 30% of women and 13% of men. They are found in 23% of adults ages 18 to 65 and over 35% of adults over the age of 65. Bunions are more likely to develop with advancing age. However, bunions have been reported in children as young as 5 or 6 years of age. Bunions in young children can get worse throughout childhood and adolescence and are highly linked to a family history of the condition. Bunions can be very painful and can get worse if left untreated.

 

Symptoms

The symptoms caused by bunions vary from person to person, and can include:

  • The appearance of a bump on the base of the big toe joint
  • Pain in or around the big toe joint, often described as a dull ache with some shooting pains
  • Reddening and/or inflammation of the bump from pressure and rubbing of the area
  • Pain when moving the big toe joint Formation of blisters and/or calluses in and around the first and second toes
  • Dull or sharp pain in the ball of the foot, especially in the center and spreading outward
  • Pain with walking or when wearing restrictive shoes

Over time, symptoms can worsen and include:

  • A shift of the big toe towards the second toe
  • Sometimes, this can change the position of the other toes and may even cause the toes to lie on top of one another
  • Arthritis of the big toe joint A stress fracture
  • Difficulty walking and finding comfortable shoes

The symptoms associated with bunions can vary from person to person. In fact, the worst bunions do not always cause the most severe symptoms. Furthermore, the wrong shoes and too much activity can causes symptoms to worsen. Once symptoms are felt, they generally get worse and the bunion must be treated.

 

Treatments

Non-Surgical Treatments for Bunions

Non-surgical treatment is a good way to reduce the pain and other symptoms associated with bunions, but these therapies will not cure or eliminate bunions. The success of non-surgical treatments often depends on the severity of the symptoms and how long the bunion has been present. Using non-surgical treatments early is important for preventing the development of more severe complications. If bunions are treated early, they can be managed and more serious interventions, such as surgery, may not be needed.

 

Wearing comfortable and supportive shoes is the first step in helping to relieve pain and other symptoms associated with bunions. Good choices for shoes may include:

  • A stretchable, breathable slip-on or tie type shoe
  • A shoe with good arch support and a wide toe box
  • A shoe that fits well and conforms to the shape of the foot
  • A shoe with a rigid heel counter

Custom orthotics, which are arch supports prescribed by a foot and ankle specialist, are made individually for each patient and can be helpful in relieving symptoms. Each custom orthotic is specifically made from an impression of the patient’s foot. Many modifications can be made depending on how bad the bunion is. Long-term arch support with a reduction in symptoms is the main goal of custom orthotics.

 

Surgical Treatments for Bunions 

Surgical correction for bunions may be recommended by a foot and ankle specialist. There are many effective surgical options available and the type of procedure selected is based on the needs of the patient and the current condition of the bunion. Before undergoing any procedure, it is important to have realistic goals and expectations about the surgery and the rehabilitation process, and to talk about the procedure with a foot and ankle specialist.

 

General goals for surgery:

  • Remove the bump on the big toe joint
  • Straighten the joint as much as possible
  • Provide greater range of motion

 

How does the BioPro Accu-Cut Guides Help?

Bunionectomies, the cutting of the first metatarsal, are traditionally done free hand. The Accu-Cut® Guide is available for a large variety of procedures and guide the blades to ensure the most precise cuts possible. This in turn ensures that the bone surfaces match up as closely as possible, helping speed bone healing time.

 

What to expect during and after bunion surgery?

Bunions can be categorized as simple, moderate or severe which will require different selective procedures, decided on by your surgeon. Surgery is typically not recommended only for improving the look of the foot. For a very minor bunion with bump pain, a foot and ankle specialist may recommend a simple shaving of the painful bump with or without soft tissue removal. However, this is not the way most bunions are corrected.

Bunion surgery commonly involves cutting the first metatarsal and shaving off the bony bump of the big toe joint. This is commonly referred to as a bunionectomy or an osteotomy. Once the metatarsal is cut, it is realigned into its appropriate position and is secured with screws or some other fixation device. The screws usually stay in the foot permanently, but may be removed once the bone fully heals.

Bunion surgery may be completed under local, spinal, or general anesthesia, depending on your surgeons preference.

 

Recovery and Rehabilitation for Bunion Surgery

What to expect after surgery:

  • There will be some pain after surgery
  • Wearing of a specialized postoperative shoe
  • There may be periodic swelling on or near the site of the bunion for 6-12 months
  • Physical therapy may be recommended
  • Long-term use of non-surgical devices, such as orthotics, and therapy is often recommended to prevent bunions from returning

Recovery time depends on the type of surgery that is performed and may vary from patient to patient. For example, recovery after a traditional bunionectomy will typically take longer than recovery after a simple shaving procedure. In most cases, a surgical shoe or walking boot is recommended after surgery. This allows the patient to return to normal activities sooner while still protecting the foot. If a cast is required, crutches, a walker, or a wheelchair may be used to assist in non-weight bearing of the recovering foot.

A physician is able to track bone healing through physical evaluations and by using x-rays. As a general rule, the patient can be more active and return to wearing normal shoes once the bone has fully healed. Even once the bone has healed, the patient may experience mild to moderate swelling and may need ongoing physical therapy and non-surgical treatment.

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