In this episode of PodMD, experienced orthopaedic surgeon Dr Daniel Goldbloom will be discussing the topic of great toe arthritis, including what great toe arthritis is, the required imaging, the expectations for surgery, the role of podiatry in this condition and more.
- Transcript
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*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Dr Daniel Goldbloom
Dr Daniel Goldbloom is an Australian trained orthopaedic surgeon with a subspecialty interest & expertise in all aspects of foot and ankle surgery.
Dr Goldbloom is the Director of Malvern MSK, which he established in Melbourne. In addition to inner Melbourne, his practice also concentrates around Bayside, Casey and the Mornington Peninsula.
Today, we’ll be discussing the topic of Great Toe Arthritis.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.Daniel, thanks for talking with us on PodMD today.
Daniel : Thank you for having me.
Question 1
The topic of today’s discussion is Great Toe Arthritis. Can you describe for our listeners what the condition is?Daniel: Great toe arthritis is otherwise known as helix rigidus, and it’s arthritis of the first metatarsophalangeal joint of the foot. It’s a fairly common condition. It’s present up to about 10% of those in the younger years, say 20s and 30s and between 10 and 40% of patients over 50, depending on which study you read. It’s mostly associated with family history, but there is definitely association with previous trauma and also an association with systemic conditions such as gout or rheumatoid arthritis.
Question 2
How would a patient with Toe Arthritis typically present?Daniel: They would typically present with pain at the great toe. In the earlier stages, the patient might only notice pain when they go into the dorsiflexed position while weight bearing. So for example, just before you’re about to toe off. In the later stages the whole range of motion of the joint can be quite irritable and at a very advanced stage, the range of motion becomes very limited, but the toe still remains painful.
The other major feature of helix rigidus or great toe arthritis is the bump on the top of the toe. At the at the first metatarsophalangeal joint and this can have an effect on the type of footwear that the patient can be able to wear. This is due to an osteophyte, which is one of the classic features of great toe arthritis.
Question 3
If a GP or podiatrist suspects Great Toe Arthritis, what imaging should be requested to help plan further management.Daniel: I would recommend plain weight bearing X-ray of the foot in an AP and a lateral plane. That’s usually all that’s required to manage this sort of condition. You’ll be able to see that dorsal bump and you’ll also be able to see the classic signs of arthritis throughout the joint if they’re present, such as that subchondral sclerosis and the loss of joint space.
The reason that the films need to be weight bearing relates to assessment of their overall alignment in the functional position. And also in planning for any surgery. When I’m explaining to, for example, when I’m explaining to patients about what arthritis looks like on an X-ray, I’ll often show them the comparison between the second metatarsophalangeal joint and the first.
Question 4
What are the treatment options?Daniel: So in terms of surgical options, we would divide those who just need the bump treated versus those that have the arthritis right through the joint. Removing the bump has a very good track record in resolving dorsal impingement type symptoms and allows the patient to get back into regular footwear, and it’s a relatively quick operation with a fairly easy recovery.
In addition, it may also be reasonable to augment that procedure with a small redirection osteotomy of the adjacent proximal phalanx to further improve that dorsiflexion range of the joint and this does not add much to the burden of recovery. However, in cases where the irritability and the pain is right through the range of motion, then that joint can no longer be salvaged, and in those cases the most reliable thing to do is to simply fuse that first MTP joint.
This usually results in a painless great toe and a return to almost all levels of function, such as running and tennis, for example. The middle ground in terms of surgical techniques is an interposition arthroplasty, where a spacer is placed between the phalanx and the metatarsal to prevent the two bones grating against each other. But still allows for a range of motion to occur.
Question 5
Have there been any developments in surgical treatment in the last few years?Daniel: Years. Yes, there have been developments on 2 fronts in recent times. Firstly, minimally invasive techniques have become more refined for first MTP arthritis. The removal of the dorsal bump, or the redirection of osteotomy and indeed, the first MTP fusion can now be performed through very small incisions. And we think it results in less stripping of the blood supply that’s required for healing, and of course the patients prefer a smaller scar.
Secondly, in cases where the interposition procedure is deemed appropriate. There’s a relatively new implant called cartiva that is designed for this purpose. It’s made of a Poly vinyl alcohol and has been likened to a fruit tube or a contact lens. The midterm results for cartiva are reasonable, but there have been noted complications such as chronic synovitis in the joint and subsidence of the implant. This just means that patient selection and informed consent are very important preoperative considerations for this procedure.
Question 6
What can the gp inform the patient about expectations of surgery for this condition?Daniel: In all surgical techniques related to 1st MTP, arthritis, the post OP recovery will require strict elevation for a week or two to reduce the swelling. The GP can tell the patients that they’ll still be allowed to wait there from day one. They can expect to use a stiff soled sandal for between 2 to 8 weeks, depending on which procedure is performed. It’s also very important to explain to the patient the limitations of the first MTP fusion. It will result in permanent loss of movement at that joint and patients need to understand that this would permanently preclude positions of extreme dorsiflexion, such as during certain yoga or pilates type of exercises. And it also precludes the wearing of stilettos.
Question 7
What is the role of podiatry in this condition?Daniel: Well, it’s always good medicine to avoid the risks of surgery if they’re not necessary. And so Podiatry might be a great first line option for first MTP arthritis. And their role will be but will be based around adjusting footwear to reduce the load through the joint and create more room for the bump.
Question 8
When should a GP refer?Daniel: Ongoing pain or difficulty with footwear. Including situations where Podiatry input has not been successful and that this pain is affecting the patient’s quality of life and ability to do their normal activities of daily living.
Concluding Question
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on Great Toe Arthritis.Daniel: Number one, that great tool arthritis is common and can be quite debilitating. Two, always obtain weight bearing AP and lateral X-rays of the foot as the important most important investigation and three, that surgery for this condition is by and large very successful.
Thanks for your time and the insights you’ve provided.
Daniel: Thank you
