Great toe arthritis

What is hallux rigidus?

Hallux rigidus is a term for arthritis affecting the metatarsophalangeal joint (MTPJ) of the big toe. Arthritis occurs when the smooth cartilage surface of the joint wears away. This causes the formation of bony spurs, pain and stiffness.

The cause is usually unknown and occurs more frequently as you get older. It can be associated with trauma, gout or other inflammatory arthritic conditions.

What are the symptoms?

The symptoms of big toe arthritis are dependent on the stage. In the early stages spurs form and may cause lumps which can rub in enclosed footwear. These can cause pain when the toe is in certain positions. As the condition progresses toe pain and stiffness increases, which can affect walking and recreational activities. To try and avoid walking on the toe, patients walk on the outside of your foot and cause further foot pain.

What is the non-operative treatment?

General treatment

  • Activity modification
  • Weight loss which reduces the load through the joint
  • Pain relief such as Paracetamol or
  • Anti-inflammatories taken before activity rather than after

Specific treatment for hallux rigidus

  • Shoe modification- by having shoes enlarged to accommodate bony lumps
  • Stiff orthotics – a thin carbon fibre plate to restrict the painful motion of the great toe MTPJ to allow ease of walking.

What are the operative options?

The type of operation is determined by the severity of the arthritis and whether maintenance of motion is desired.

Moderate arthritis

  • Steroid injection and manipulation
  • Joint debridement +/- osteotomy

Severe arthritis

  • MTP joint fusion

In cases where preservation of motion is desired

  • Cartiva
  • Hemicap ( half joint replacement)

What does the surgery involve?

Joint debridement
This is performed to remove spurs, inflammation and to improve MTPJ movement. This is performed by minimally invasive surgery and is combined with an arthroscopy. An osteotomy of the base of the big toe may be required to increase the joint movement. Debridement is 80% successful in the long term.
Dependent on the severity of arthritis up to 20% of patients may need further surgery in the future if there is progression of the arthritis.

MTP fusion
This takes a painful stiff joint and makes it a painless stiff joint by removing the joint and holding the bones together with screws or a plate.

This is the most reliable operation with 90-95% success.


Cartiva

A new synthetic cartilage implant aimed at recreating joint motion and reducing pain.
Long term results are not known.

Metatarsal head replacement

A procedure to replace the metatarsal head with a metal implant in an attempt to preserve motion.
Long term results are not known.
The risk of maintaining motion includes joint stiffness and incomplete resolution of pain.
There can be loosening or failure of the implant and arthritis can progress.
These problems require a fusion of the joint.

What does the rehabilitation involve?

Joint debridement

  • Day procedure
  • For 2 weeks elevate your feet as much as possible to minimize swelling
  • You are able to fully weightbear immediately in a stiff soled shoe. This shoe is to be worn for 2-4 weeks.
  • Formal physio to begin at 2 weeks.
  • By 4-6 weeks you can begin wearing wide or open shoes and should be comfortable walking around your house.
  • By 3 months you should be back to recreational walking.
  • Swelling can take 6-9 months to resolve and tight shoes may be difficult for this period.

MTP Fusion

  • 1 night in hospital
  • For 2 weeks you should elevate your feet as much as possible to minimize swelling
  • You are able to begin weightbearing immediately in a stiff soled shoe. This shoe is to be worn for 6 weeks. There is no plaster required.
  • By 6 weeks you should be comfortable walking around your house usually in wide or open shoes.
  • By 3 months you should be back to recreational walking usually in normal shoes
  • Swelling can take 6-9 months to resolve and tight shoes may be difficult for this period.

Surgery to both feet

Recovery time for surgery on both toes is increased by approximately 50%

How long will I be off work?

This is dependent upon your occupation

  • Seated job 3-4 weeks
  • Standing job 6-8 weeks
  • Heavy lifting job 8-12 weeks

When can I drive?

  • Manual car – no driving for 6 weeks
  • Automatic car
    • Left foot no driving for 2 weeks
    • Right foot no driving for 6 weeks

What are the risks of the procedure?

General risks of surgery

  • Infection and wound healing problems
  • Nerve injury and scar sensitivity
  • Blood clots to the leg
  • Anaesthetic problems
  • Incomplete resolution of symptoms

Specific risks for joint debridement surgery

  • Joint stiffness
  • Incomplete symptom resolution
  • Progression of arthritis – 20%

Specific risks for MTP fusion surgery

  • 5% risk of joint not fusing
  • Malposition of the toe
  • Adjacent joint arthritis
  • Unable to run or wear high heels
This information is an overview of the management of big toe arthritis and is not all inclusive.

If you have any questions please contact Mr Curry’s rooms on (03) 99286560