It’s Really Not a Bunion?

June 28, 2011
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A bunion and HL/HR are two different conditions and although patients often confuse them, it’s important when presenting to a Podiatrist that the conditions are separated from each other, as etiology and treatment different.

Hallux limitus is a restriction or limitation to motion of the great toe joint that results mainly from biomechanical abnormalities of the foot. As the condition, progresses the joint motion becomes so restricted that motion at the great toe joint ceases all together, resulting in a condition called hallux rigidus. After a complete evaluation of the involved foot, your Podiatrist will discuss all treatment options for HL and HR with you, most often suggesting treatment options that are first conservative. We mentioned several of those options last week including orthotics, joint injections and padding of the toe to decrease pressure in the area of concern. When conservative treatments have been attempted and exhausted without resolution of symptoms including pain and discomfort in the great toe joint, surgical options can be explored.

As with any surgical procedure, your Podiatrist will review your x-rays, re-examine your foot and recommend a surgical procedure most appropriate for the status of your HL/HR condition that aims to decrease your current level of pain. In treating HL/HR there are 3 larger categories of surgical procedures that we will briefly discuss; the first two options, in order to decrease your current level of pain, aim to decompress the joint to accomplish this goal. Decompression allows for the creation of a larger space between the two bones that make up the great toe joint therefore, allowing greater motion and less jamming between the two. You and your Podiatrist will discuss the options and determine which is the best option for you.

1. Joint Cleaning: The first procedure attempts to enter the great toe joint and clean up the area between the two involved bones. Any inflammation within the joint is removed, any boney spurs are shaved down and smoothed off and the joint is closed. This procedure is typically reserved for patients in the early stages of HL/HR development and often provides great relief. Removing any spurs and inflammation decompresses the joint, allowing for greater motion. Recovery is generally short, approximately 2-4 weeks, as only soft-tissues need to heal before activity can be resumed.
2. Bone Cutting Procedures: This category encompasses several different types of procedures, but all accomplish decompression of the great toe joint with the result of greater motion and decreased pain by surgically cutting one or both of the bones making up the great toe joint. The procedures aim to lower and slightly shorten the 1st metatarsal to create a larger joint space. Be aware, fixation including pins and screws may be utilized! These types of procedures are typically reserved for patients with more advanced HL and recovery time is typically longer versus joint cleaning procedures (closer to 6-8 weeks), because the surgery is more involved and needs to allow significant time for the bone to heal.
3. Fusion: A fusion procedure of the great toe sounds just as it is; the great toe joint is fused whereby motion at the joint is surgically eliminated with the use of pins and screws to hold the toe in its desired position. As we mentioned last week, if there is no motion, there is no pain! This procedure is reserved for “worst-case” patients and those who have unbearable pain at a young age and is considered a definitive procedure. Recovery is longer than even the bone cutting procedures to ensure that complete fusion has take place before weight bearing can begin.

As with any surgical procedure the risks and benefits should be considered and discussed with your Podiatrist before any decisions are made. Complications with any of the HL/HR procedures described above can include infection, scarring, recurrence of deformity, and transfer pain among others, although the risks of any such complications are minimal. The object of both conservative and surgical treatment options is to decrease pain and increase motion at the great toe joint while keeping you on your feet!

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