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Print this PageWhat is it?
Arthritis of the big toe joint, also known as hallux rigidus. Hallux means big toe and rigidus, rigid, ie the big toe joint is stiff and doesn’t move.
What are the Symptoms?
Pain around the big toe joint and stiffness, so the joint moves much less. Swelling also occurs and this is a combination of soft tissue inflammation and new bone formation. This new bone commonly forms on the top of the joint and may cause shoes to rub and also restricts the movement. This causes pain on activities and difficulty in wearing certain shoes, such as tight fitting foot wear or a high heel. At rest, pain is not normally a problem. These symptoms normally form over a period of months or years.
Will It Get Worse?
Progression of the arthritis usually occurs, but over what time period is difficult to predict. This can take years.
What Is The Treatment?
If you have no discomfort or pain, then you do not need to do anything. If you have symptoms, there are a number of non surgical options you should try, before considering surgery:
Modify or change your foot wear – A softer shoe, which accommodates the foot well. A rocker soled shoe which has a curved sole or a shoe with a rigid sole both reduce the need to bend the toe.
Pain killers or anti inflammatories
Steroid injection – Mr Gordon will consider this if you are in the early stages
Surgery – If non surgical options fail to improve symptoms, then surgery can be considered.
What Does Surgery Involve?
This will depend on the severity of the arthritis you have, what activities you would like to undertake and the shoes you wish to wear. The surgical options include Cheilectomy, Joint Replacement and Fusion.
Cheilectomy
The aim of this procedure is to remove the bump on top of the foot and increase the range of motion of the joint and to relieve pain. Mr Gordon performs this using minimally invasive techniques. The excessive bone (osteophytes) on the top of the big toe joint (left hand x ray below), is removed with a saw. The excessive bone has the appearance of a lip (Greek=cheilo). The joint is evaluated and tight structures released, as well as other osteophytes removed. Cartilage stimulating procedures may also be performed.
Joint Replacement
The aim of this procedure is to relieve pain while preserving movement in the joint (unlike a fusion which stiffens the joint completely). This will allow you to wear a heel and therefore may be the preferred option in females wishing to wear certain footwear. Most joint replacements become loose over time, requiring further surgery, often being converted to a fusion. Mr Gordon will discuss this with you when you are trying to decide which operation to have.
Fusion
This is the ‘gold standard’ procedure for big toe arthritis. The aim of this procedure is to relieve pain while stiffening the joint completely, so no movement occurs at the joint. Fusions, once healed, don’t become loose, but the toe joint will never move. Some compensatory movement may occur at adjacent joints. There are no restrictions on your activities once the fusion has healed and walking is relatively normal.
A fused big toe joint using 2 screws
What Are The Risks Of Surgery?
Although most surgery is complication free, there are risks involved. Below lists the most common first.
Swelling–Your foot may remain swollen for up to 1 year after surgery, but will eventually resolve. It is important to elevate your foot as per Mr Gordon’s post operative instructions, to minimise this. You may not be able to get into your normal shoes until 6-8 weeks after surgery and even then, they may need to be loosened. After a cheilectomy, you can get into a normal shoe after 3 days if desired and comfortable enough.
Nerve injury–This may lead to a permanent numb area on the toe which is not painful.
Infection–Despite thorough cleaning before surgery and antibiotics, wound redness and pain may occur, although uncommon. This should be dealt with urgently.
Residual pain–Sometimes some pain remains in the toe despite surgery, this is normally a significant improvement to before surgery
Delayed or non union in fusion surgery–Sometimes the bones take longer than 6 weeks to join together, rarely, they may not join at all and smoking increases this chance
Toe position problems in fusion surgery –Sometimes the joint may not be fused in the ideal position
Prosthesis loosening in joint replacement surgery–Eventually, depending on a number of factors, a joint replacement may loosen and cause persistent pain. If this is significant, a fusion can then be performed
What is the Rehabilitation After Surgery?
Please go to the relevant Post Operative Rehabilitation Guides for Cheilectomy, Joint Replacement and Fusion.
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