Overview
Infection of the big toe, often localized to the first metatarsophalangeal joint (MTPJ), represents a significant clinical challenge due to its potential to disrupt gait, cause chronic pain, and necessitate extensive surgical interventions. This condition predominantly affects individuals with predisposing factors such as diabetes, peripheral vascular disease, or a history of trauma or previous surgical procedures like arthroplasty. Early recognition and prompt management are crucial to prevent severe complications and preserve function. In day-to-day practice, accurate diagnosis and timely intervention are essential to avoid irreversible joint damage and improve patient outcomes 47.Pathophysiology
The pathophysiology of big toe infection typically begins with microbial invasion, often facilitated by trauma, surgery, or underlying systemic conditions that compromise local tissue defenses. Common pathogens include Staphylococcus aureus and other gram-positive organisms, sometimes complicated by polymicrobial infections. Once established, infection leads to inflammation and subsequent tissue destruction, including bone involvement (osteomyelitis). This inflammatory cascade can result in joint space narrowing, cartilage degradation, and bone erosion, ultimately compromising joint stability and function. The immune response further exacerbates tissue damage, creating a vicious cycle that necessitates aggressive treatment to halt progression 47.Epidemiology
The incidence of infection in the first MTPJ is relatively rare compared to other joints but carries significant morbidity. It predominantly affects middle-aged to elderly individuals, with a slight male predominance. Risk factors include diabetes mellitus, peripheral neuropathy, and prior surgical interventions such as arthroplasty or arthrodesis. Geographic variations are less documented, but trends suggest an increasing incidence with aging populations and higher rates of diabetes. Limited data suggest that the prevalence may be rising due to improved diagnostic imaging and increased awareness, though robust epidemiological studies are still needed to establish precise figures 45.Clinical Presentation
Patients typically present with localized pain, swelling, and erythema over the affected toe. Systemic symptoms like fever and malaise may indicate a more severe infection. Specific red-flag features include persistent pain unresponsive to initial conservative treatment, purulent drainage, and signs of systemic infection such as elevated white blood cell count. Functional limitations, such as difficulty walking or bearing weight on the affected foot, are common. Less typical presentations might include insidious onset with gradual worsening symptoms, particularly in diabetic patients where neuropathy can mask early signs 47.Diagnosis
Diagnosis of big toe infection involves a comprehensive clinical evaluation followed by targeted investigations. Key diagnostic criteria include:Management
Initial Management
Second-Line Management
Refractory Cases
Complications
Refer to orthopedic specialists for surgical interventions and infectious disease specialists for complex antibiotic management when complications arise 45.
Prognosis & Follow-up
The prognosis varies based on the severity and timeliness of intervention. Early diagnosis and aggressive treatment improve outcomes significantly. Prognostic indicators include:Recommended follow-up intervals include:
Special Populations
Key Recommendations
References
1 Kamiza MM, Halsey TJ. Management of an infected metacarpophalangeal joint replacement with a temporary articulated cement spacer. The Journal of hand surgery, European volume 2025. link 2 Holleyman RJ, Jameson SS, Meek RMD, Khanduja V, Reed MR, Judge A et al.. Association between surgeon and hospital volume and outcome of first-time revision hip arthroplasty for aseptic loosening. The bone & joint journal 2024. link 3 Perry DC, Parsons N, Costa ML. 'Big data' reporting guidelines: how to answer big questions, yet avoid big problems. The bone & joint journal 2014. link 4 Garras DN, Durinka JB, Bercik M, Miller AG, Raikin SM. Conversion arthrodesis for failed first metatarsophalangeal joint hemiarthroplasty. Foot & ankle international 2013. link 5 Mankovecky MR, Prissel MA, Roukis TS. Incidence of nonunion of first metatarsal-phalangeal joint arthrodesis with autogenous iliac crest bone graft after failed Keller-Brandes arthroplasty: a systematic review. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons 2013. link 6 Vellar ID. David Murray Morton: father figure of surgery at St Vincent's Hospital, bush lawyer and thwarted reformer of the medico-legal system. ANZ journal of surgery 2002. link 7 Hetherington VJ, Mercado C, Karloc L, Grillo J. Silicone implant arthroplasty: a retrospective analysis. The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons 1993. link 8 Kitaoka HB, Holiday AD, Chao EY, Cahalan TD. Salvage of failed first metatarsophalangeal joint implant arthroplasty by implant removal and synovectomy: clinical and biomechanical evaluation. Foot & ankle 1992. link