Arthritis of the Great Toe (Hallux Rigidus)
Arthritis of the great toe or hallux rigidus is a common condition that results in a painful and sometimes deformed great toe.
Arthritis is a loss of joint cartilage, which is smooth and slippery. Without it, the bones grind together and the joint becomes stiff and painful. Eventually there may be formation of bony spurs (osteophytes) around the joint.
This arthritis can be caused by a number of problems:
- Long standing bunions
- Rheumatoid or other inflammatory diseases
The most common form is osteoarthritis and is usually caused by age and general wear and tear.
The arthritis causes pain and stiffness in the region of the great toe. This may also lead to problems elsewhere in the forefoot as the weight is unconsciously transferred away from the painful great toe.
Early on, strenuous activity brings on the pain, but as the arthritis progresses even walking or wearing certain shoes will become painful.
As the arthritis becomes more severe, spurs of bone (osteophytes) develop around the joint. These often rub on shoes and cause pain and inflammation.
TREATMENT OF GREAT TOE ARTHRITIS
It is possible to treat this condition without surgery, although it is less effective than other foot problems. Most patients do extremely well with surgery.
Non operative Treatment
Using larger shoes to accommodate spurs and an insole to cushion painful areas can help. Stiffening the sole of the shoe to reduce motion through the painful joint is sometimes effective as are anti-inflammatory medications or tablets.
The aim of surgery is to relieve pain and improve the function of the forefoot. The type of surgery depends on the severity of the arthritis.
There are two different procedures I routinely perform for great toe arthritis:
- Dorsal Cheilectomy and Moberg Osteotomy (clean up of joint)
- Fusion of the joint (arthrodesis)
Dorsal Cheilectomy and Moberg Osteotomy for mild arthritis of great toe (hallux rigidus)
Early on in this condition the arthritis tends to affect the top half of the joint. Therefore if the worst part of the arthritis is removed (shaded area, Figure 1) which is called a cheilectomy, then pain will be reduced or eliminated. In addition to this if a wedge of bone is resected from the base of the great toe (shaded area, Figure 2), it helps to further decompress the joint and allow more upwards motion of the toe.
The disadvantage is that it does not cure the problem and the arthritis will eventually progress to involve the rest of the joint.
Most patients will have a significant improvement for many years before this occurs.
This procedure can be done using a minimally invasive technique, which has a faster and less painful recovery.
Great toe fusion for moderate to severe arthritis of the great toe
Once the arthritis is more advanced, it is not possible to preserve the joint. There are now only two options: replacement (not recommended) or fusion (permanent stiffening) of the joint.
Fusion or arthrodesis remains the gold standard procedure for hallux rigidus. It permanently stiffens the joint and completely relieves pain in the vast majority of patients. It is very well tolerated and does not cause significant limitations as you might expect.
The operation removes the last remaining cartilage and the joint is then held together with screws and a plate until it heals like a fracture.
The only limitations are:
- Difficulty with high speed running and,
- Shoes are limited to a maximum of a one inch heel.
Walking and most sports are unaffected.
Procedure for Surgery
I routinely perform all of these surgeries as a day case under a general anaesthetic. Once asleep, local anaesthetic is injected to make the foot numb for around twelve hours. It is possible to remain in hospital overnight if desired.
You can usually return home within hours of surgery. You will be given painkillers and antibiotics to go home with. It is important to keep the foot elevated as much as possible over the first two weeks to allow the wound to heal.
You are able to bear weight immediately in the postoperative shoe.
It is important not to underestimate the time taken to recover from foot surgery.
As the foot is the most dependant part of the body, swelling is always a problem. Swelling causes pain and delays recovery.
It is important to allow two weeks off work as a minimum for clerical duties and at least six weeks for any form of work that requires long periods of standing or walking.
It is necessary to wear a special postoperative shoe day and night for the first four to six weeks.
Most patients take at least six weeks to fit their foot into a regular shoe. In some, swelling can persist up to six months.
Complications of Surgery
You should be aware that all surgery has a risk of complications and this surgery is no different.
The chance of one of these happening is very small and is reduced by doing the surgery with modern techniques.
There are medical complications such as heart attack, stroke, drug reaction, blood clots in the legs or lungs and even death in very rare circumstances.
Surgical complications include:
Infection: antibiotics are given before and after surgery to reduce the chance of infection, but cannot eliminate it.
Nerve injury: can result from the small sensory nerves being caught up in scar tissue and may leave an area of numbness over the toe or occasionally an area of sensitivity.
Bone healing: may be delayed or fail in rare cases and require another surgery.
Poor position of the joint: in about one in thirty patients after fusion surgery, the position of the toe is not quite right. This may require a repeat surgery to move the toe up or down, or even sideways.
Progression of arthritis: if a joint preserving procedure has been done (Cheilectomy/Moberg), then the arthritis may progress over time and require a fusion.
Wound healing: problems are rare and tend to happen in diabetics and smokers. If you do smoke you should stop smoking for at least four weeks around the operation.
Surgery is very effective in the vast majority of patients with at least nine out of ten being happy with the result.
However it is possible, although very unlikely, to be made worse by surgery if a complication develops that cannot be easily fixed.
A more detailed discussion of your individual case will be made at the consultation.