Hallux Rigidus

Introduction

Arthritis of the big toe joint causes pain, stiffness and swelling at the point where the toe joins the foot. It is also referred to as hallux rigidus and hallux limitus. The condition may affect one or both feet and can occur in isolation or as part of a more generalised arthritis. The pain can start to affect the toe at almost any age but is more common in middle age onwards.

As the name would suggest, people with hallux rigidus notice the toe getting progressively more stiff and frequently, more painful. There is often a bump on the top of the joint that may cause problems in shoes. Depending on the stage of the problem, the toe may be painful all the time with any movement, or in milder cases, only painful at the extreme of movement. Pain at night is also a common feature as the condition progresses.

Diagnosis

Diagnosis is made through a combination of clinical assessment (involving both history and examination) and x-rays. The surgeon will assess the range of movement of the joint, whether pain is throughout the range of motion or just the extreme and the condition of the adjacent joints. X-rays are useful to confirm the extent and severity of the problem.

Treatment

In the earliest stages of the problem it is important to try and keep the toe mobile. Painkillers, supportive shoes such as trainers and keeping active all help. As the condition progresses, keeping the toe mobile may prove increasingly difficult and painful. When this starts to happen symptoms may be controlled by restricting the range of motion of the joint through using stiff soled shoes or special orthotics such as carbon fibre inserts.

Surgery becomes necessary when these conservative treatments are no longer sufficient to alleviate the symptoms. The exact surgery varies on the stage of the problem but will usually take one of 3 forms:

1. CheilectomyThis is an operation where the lump that forms over the top of the toe, caused by the growth of new bone is removed, along with a portion of the joint itself. The aim of the procedure is to improve the range of movement of the joint and to reduce pain. The operation is successful in 85 – 90% of patients in reducing pain and improving the range of motion. If the arthritis returns, or the operation has not been successful, then conversion to a fusion is possible.
   The recovery from cheilectomy is quicker than the recovery from fusion with return to normal footwear being possible after 2 weeks. Once the dressing has been removed at the 2 week stage it is important to participate in exercises to regain the range of movement and optimise the result.
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2. Cartiva Implant
   Over recent years a new procedure has started to become popular. This is the implantation of the cartiva implant. This remains a fairly new procedure and, as a result, the long term results are not known. However, the 5 year outcomes are published and appear promising. The procedure involves removing a portion of the new bone growth around the arthritic joint and implanting a spacer to replace the lost joint surface with the aim of preserving motion and reducing pain. Whilst results appear promising at this stage, it is important to recognise that the recovery from this procedure is probably the longest out of the 3 options described and the longer-term outcomes are not yet known. Further information can be found here -https://www.cartiva.net
3. Fusion (1st MTPJ Arthrodesis)
   This is often regarded as the “gold standard” treatment for arthritis of the big toe with high rates of patient satisfaction and success. When the majority of the joint is affected, or the toe is exceptionally stiff cheilectomy may no longer be appropriate. In this situation the most reliable procedure is an arthrodesis, or fusion, of the joint. In this procedure the joint is removed, and the bones held together using a combination of metal plates and screws to allow them to heal into 1 bone. This leaves the inter-phalangeal joint (the one 3.behind the nail) free to move, but permanently stiffens the main toe joint. The toe is a little short after the operation but because of the pain being abolished, function is usually much better. However, it is not likely to be possible to wear high heeled shoes.
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   Despite the fact that the toe has no movement, the results are usually very good with many patients being able to return to sporting activity.

What can I expect after the operation?

All of these operations are usually performed as a day-case where you are usually allowed home on the same day as the operation. The foot is bandaged at the end of the operation and this will usually be kept in place for 2 weeks. An element of pain is to be expected after an operation on the foot, but this is usually controlled by simple painkillers.

For the first two weeks after the operation it is important to rest with the foot elevated as much as possible. This primarily helps to reduce the swelling from the operation, helping to reduce the pain you experience but also helps the wound to heal and reduces the risk of infection. Once the dressing has been removed at the 2 week follow up and the wound checked, the recovery will vary depending on the type of surgery you have had:

• Cheilectomy: At 2 weeks following a cheilectomy you will be advised to start to mobilise the toe and work on regaining the range of movement. Whilst normal shoes are possible at this stage, the swelling will usually mean that open toed sandals or adjustable trainers are required. The symptoms from the toe should then gradually settle over the following weeks and months.
• Cartiva: Following the wound check at 2 weeks it is possible to start mobilising the toe and start the process of returning to normal shoes. As with a cheilectomy, the swelling can make this difficult and adjustable footwear / sandals will be very helpful. The recovery from a cheilectomy is frequently longer than both cheilectomy and fusion with patients reporting more discomfort for several months. This is important to expect as it can be concerning but appears to be a normal feature of the procedure.
• Fusion: After the wound is checked at the 2 week review it is important to continue to use the stiff soled post-operative shoe. You will then be seen again at the 6 weeks stage following the operation and an Xray taken before you are allowed to return to normal shoes.

For all of the operations described, full recovery takes several months and it is often at least 3 months before a return to recreational walking and light sporting activity can be considered. Full recovery can take up to a year.

Are there any risks or complications?

Despite the greatest of care, complications are an unavoidable part of surgery. A small proportion of people (<10%) may have problems such as:

1. In fusion surgery. The bones may not heal (occurs in about one in 20 people), and this may require further surgery. Smoking increases the risk of this complication considerably.*
2. Also in fusion surgery, the position in which the toe is set can cause problems. A few people will find that the position in which the toe is set does not suit them individually, and may consider further surgery to adjust this.*
3. Sensitisation of the foot due to damage to the small nerves and blood vessels. This can lead to a condition called “neuropathic pain”
4. Weight transfer to the second toe (a corn under the second toe)
5. Infection is an unavoidable risk for any operation although great lengths are taken to reduce this. Keeping the foot elevated for the first 2 weeks will help reduce this risk.
6. The complications of any surgery such as thrombosis (a blood clot) and anaesthetic problems.

The majority of complications can be treated through simple methods such as medications or physiotherapy. On occasion, further surgery may be required. Even with all of the treatments available, however, on occasion poor results can occur. For this reason, it is strongly advised to avoid surgery for cosmetic reasons or to prevent problems that may, or may not occur in the future.