HALLUX RIGIDUS (GREAT TOE ARTHRITIS)
The term hallux rigidus refers to a common arthritic condition of the big toe characterized by pain at the metatarsophalangeal (MTP) joint. The pain caused by this arthritic process may severely impair a person's ability to walk, run, or participate in athletics. The cause of hallux rigidus is incompletely understood, but it may be associated with prior injury, heredity, and abnormal biomechanics of the foot. Patients generally complain of pain, stiffness, and swelling. Radiographs may show bone spurs or a decrease in the cartilage with joint space narrowing. Hallux Rigidus has been classified into different stages based on the magnitude of the disease process. This classification system helps guide the orthopaedic surgeon with appropriate treatment selection. New advances in the the field of orthopaedic foot and ankle surgery are promising and continue to investigate joint preservation techniques for more advanced stages of this disease process in young patients and athletes.
Regardless of the magnitude of the arthritis, there are some very effective conservative modalities that may relieve pain and help you avoid the need for an operation. Shoe-wear modifications, specifically a stiff sole shoe, or insoles to help stabilize the toe may help increase comfort. Anti-inflammatory medications are sometimes helpful to decrease swelling and provide pain relief. Activity modification such as avoiding steep terrain may decrease symptoms.
If patients continue to have pain with conservative therapy then an operation may be beneficial. Early stages of the disease process may respond to bone spur removal (known as cheilectomy) and a joint clean out. The clean-out procedure is generally followed by motion exercises to help avoid stiffness. In fact, removing the bone spur and cleaning out the joint usually regains some of the lost motion. Generally, patients can begin walking on the heel immediately and begin putting weight on the toe about 2-3 weeks after surgery. A postoperative boot is often used to protect the foot for about 6 weeks after surgery.
More advanced stages of the hallux rigidus may necessitate a joint fusion. Fusion of the MTP joint for hallux rigidus has been an effective treatment for decades and continues to be highly successful. Many patients are concerned that a fusion may reduce their motion and may negatively affect their gait. While it is true that fusion of the toe will decrease motion, fusion also substantially, if not completely, eliminates pain. In fact, prior to fusion, many patients will find that they already have no motion at the joint secondary to the arthritis. In a recent study of patients treated with a fusion for hallux rigidus, 50% of patients actually walked better after the fusion, and 40% of patients walked the same. This is a highly effective treatment that has withstood the test of time with a high satisfaction rate.
The fusion operation includes placement of internal implants such as a small plate and/or screws. The internal fixation generally does not cause a problem and can be left in permanently or eventually removed. Following surgery, careful postoperative care is needed in order to keep the foot in proper alignment while healing occurs. Usually patients do not need to spend the night in the hospital after a hallux rigidus surgery. Office visits are necessary to inspect the incisions and to splint the toe in the correct position. Stitches are usually removed at 2-3 weeks. You will likely be able to bear weight on your heel the first week after surgery. Although we will allow you to put weight on your heel, to help insure a good outcome, we request that you would walk flat-footed for about 8 weeks without putting full pressure on your toe. A postoperative boot and toe taping will help protect the foot. Transitioning back into a regular shoe usually occurs around 8-12 weeks after surgery. Activities such as jogging usually take at least 12-16 weeks before they can be done safely. Time off from work depends on the occupation, but prepare to take off at least 1 week because elevation of the foot is very important in the immediate postoperative period.
Recent developments in Hallux Rigidus treatment have led to the popularity of a resurfacing implant. The implant is a polyvinyl alcohol hydrogel called 'cartiva'. It has a rubber consistency like a pencil eraser and, at 10mm, it is little bit larger than an eraser. The benefits of the cartiva implant include pain relief while maintaining motion in a moderately or more severely arthritic joint that would have traditionally been fused. Total joint replacement in the toe has had dismal results with high failure rates and is hard to salvage to a fusion because the substantial bone resection during the implantation process. The cartiva implant requires much less bone to be sacrificed during implantation and thus it is easier to convert to a fusion on down the road if it fails or the arthritis progresses and becomes painfully worse. Many patients may best be served with either a standard 'clean-out' procedure or a 'fusion' procedure, but some may be candidates for a cartiva resurfacing implant, and this can be discussed with an experienced physician. Below are some pictures and a short video on the implant.