First MTP/MPJ procedures (Big Toe)

The first MTP, also called the first metatarsophalangeal joint, is the big toe joint. Arthritis in the big toe can cause a number of problems. The need for surgery depends on how bad the arthritis is and how much pain you are experiencing. Surgery is recommended for those with pain and stiffness in the big toe joint. Some patients are unable to wear certain shoes (dress shoes, high heels and boots) and can’t participate in activities due to pain. If the condition exists in both feet, the more painful foot is operated on first.

Conditions

Hallux Rigidus is arthritis in the big toe. Arthritis develops when the cartilage on each bone wears away and the two bones that make up the big toe joint rub against one another. Bones spurs, which block the toe’s motion, may develop due to arthritis. This progressive disorder renders the toe stiff and unable to move. This condition can cause pain and swelling and lead to difficulty walking, running, and wearing shoes.

Surgery

All surgeries come with possible complications, including the risks associated with anesthesia, infection, damage to nerves and blood vessels, and bleeding or blood clots. Before deciding on surgery, patients should try non-surgical treatment such as changes in activity and footwear or steroid injections. Patients also can try wearing a shoe with a rounded bottom or using carbon shoe inserts that limit joint motion.
You should avoid surgery if you have an active infection or severe narrowing of the arteries. You must be able to manage a recovery period that can last six months or more.

Depending on the severity, there are a range of surgical treatments that can be used:

• First MTP Cheilectomy:
  This surgical procedure removes bone spurs on the top surface of the big toe joint. An incision is made over the top of the first MTP joint.
  Care is taken to avoid the tendon that extends the big toe. Any bone spurs on the top of the metatarsal and phalanx bones are removed and the joint is cleaned out. Any free-floating debris in the joint is removed. If there is inflamed joint tissue or debris, these are removed as well. The cartilage on the joint surfaces is inspected.

  With a cheilectomy, there is a risk of numbness along the big toe, a painful scar or an incision that does not heal properly. Arthritis is a progressive problem, and you may have continued pain after the surgery. While most patients do well with a cheilectomy for more than 10 years, some may need additional surgery, such as a fusion. This can occur in 20 to 30 percent of patients with big toe arthritis.

• First MTP Joint Fusion:
  In this surgical procedure the bones are joined (fused) together permanently so they cannot rub against each other and cause pain.
  An incision is made on top of the big toe. Any cartilage is cleared away to allow the two bones to heal together. Your foot and ankle orthopaedic surgeon may use a combination of tools to shape each bone for a perfect fit. Once prepared, the two bones are positioned and a metal plate is placed to hold both bones together. An additional screw is set across the joint for extra stability and compression, which aids in healing. In some cases, two screws can be placed across the joint without using a plate. After the hardware is placed, the incision is closed with sutures and the foot is placed in a dressing or splint.

  Common complications specific to MTP fusion include poor or delayed bone healing, infection, and stiffness in neighboring joints. The metal plate used during surgery can sometimes cause irritation. In this case it can be removed after the bone has healed. Finally, scarring within the joint can limit neighboring tendons.

• First MTP Joint Interposition Arthroplasty:
  This treatment prevents the surfaces of the bones from rubbing together while preserving some motion in the big toe.
  An incision is made over the first MTP joint and carried down to the joint. The joint surfaces along with a small amount of bone are removed. The remaining space can be treated in two different ways.
  In one method, a sheet of tissue is placed over the bone and stitched into place to resurface the joint. This material can come from another part of your body, a donor or a graft made from animal or synthetic materials.
  A newer technique uses a synthetic cartilage implant plug made out of polyvinyl alcohol as a spacer, without covering the surface area of the joint. This procedure requires less bone removal and is easier to convert to fusion if it fails. It also has shown to be as effective as fusion in relieving pain, while preserving motion of the joint.

  One of the most frequent complications of first MTP joint interposition arthroplasty is failure to relieve pain or preserve motion. Another complication is rejection of the tissue placed in the gap, which may require further surgery. Other complications can include pain at the base of the second toe, delayed wound healing, recurrent deformity, bony overgrowth, disintegration of bone around the graft, implant displacement, instability of the joint and injury to the nerves of the big toe.

• First MTP Joint Replacement:
  The bone on either side of the joint is partially removed and replaced with metal, plastic, or a combination of both.
  An incision is made over the first MTP joint and carried down to the joint. The joint surfaces along with a small amount of bone and any bone spurs are removed. The foot and ankle orthopaedic surgeon makes a small channel in the bone to place the implant. The joint capsule and skin are closed with stitches.
  Any deformity should be corrected during the surgery, as the implant will fail if it is not well-aligned. There are many different types and brands of implants. The best one will be determined by you and your foot and ankle orthopaedic surgeon.

  Joint Replacement complications include failure of the implant and need for further surgery. These can be associated with death of the bone due to interruption of the blood supply, transfer pain to the second toe, recurrent deformity, bony overgrowth, disintegration of bone around the implant, implant displacement, instability of the joint, and injury to the nerves of the big toe.

• First MTP Joint Resection Arthroplasty:
  An incision is made over the first MTP joint and carried down to the joint. The joint capsule is opened to expose the diseased joint. The joint surfaces along with a small amount of bone are removed from the arthritic joint, which creates a space for tissues to be placed around the area and sewn together to stabilize the space. Finally, the joint capsule and skin are closed with stitches. The space created may eventually fill with scar tissue.

  With Resection Arthroplasty, patients may suffer from a “floppy” big toe that lacks power and function. This “floppiness” may bother patients during even minor activities such as dancing. Other complications include delayed wound healing, recurrent deformity, bony overgrowth, disintegration of bone, instability of the joint, and injury to the nerves of the big toe.