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Big Toe Arthritis - Hallux Rigidus

Hallux rigidus is the wear and tear (osteoarthritis) in the joint at the base of the big toe. It can develop due to overuse (sports, squatting and other similar activities), previous injury (fracture), and as a part of other types of arthritic conditions (rheumatoid, inflammatory, gout).​


What are the symptoms?

Usual symptoms include pain on movements of the big toe, stiffness, swelling, bony bump and difficulty in wearing shoes with heels. 


What treatment options are available for Hallux Rigidus?


Many individuals may not require any form of treatment if the arthritis is mild and not painful. In case of painful joint, flat and well-fitting shoes with wider toe box, rigid sole, laces or adjustable strap are recommended. You may require pain killer medications. 


In early stages, a steroid injection can be helpful to control the pain. If pain worsens despite of using these measures and causes difficulties in activities of daily living with advanced stage of arthritis confirmed on x-rays, then surgery may be needed to address the arthritic joint. 


Surgery for Hallux Rigidus


Surgery will not cure the arthritis. In less severe cases the extra spikes of the bone around the joint can be cleared to improve the pain and function (Cheilectomy). For definitive treatment, the worn out joint can either be fused (more commonly done) or replaced (less common). The aim of surgery is to alleviate the pain, straighten the shape of the big toe and hence improve the function of daily living. Surgery is not done for cosmetic reasons.

The operation is usually performed as a day case procedure. It can be done either under a general or a spinal anaesthetic (the options discussed by the anaesthetic in detail prior to surgery) depending on your medical fitness and mutual preference. Regional local anaesthetic in the nerves of the lower part of the leg is also often used to help in maintaining appropriate pain relief after surgery. 


The operation involves making a cut (incision) over the big toe joint, excision of the worn out joint surfaces and fixing them together in a straight position using small screws or metal plates in case of a fusion procedure and replaced with a silicon implant in case of a silastic replacement. The wound is closed with removable (removed in two weeks after surgery) or absorbable sutures depending on surgeon’s preference. You will have a bulky wool and crepe bandage around the foot and will be provided with a wooden-sole shoe and a pair of crutches to help in mobilising for a period of 6 weeks, through which you are allowed to weight bear as you are able.

Recovery In the first few days, elevation of the foot is recommended (above the level of heart) to help minimising the swelling. You will require oral pain killer medications in the first few days to keep the pain under control. You will be reviewed in clinic or at your GP surgery in 2 weeks after surgery to check the wound and remove the sutures. You will then be reviewed at 6 weeks stage in clinic for obtaining an x-ray of your foot to assess the healing and usually start to use your own shoe wear at this stage. However, in case of fusion you may require some additional time with wooden-sole shoe if the healing is not sufficient at 6 weeks stage. You will be encouraged to mobilise your foot and with gradual return to normal activities and driving depending on your comfort level from there onwards. 


In case of left foot surgery, you can start driving an automatic car once the wound has healed. In case of right foot surgery, most individuals can start driving at around 8 weeks after surgery. Air travel is not recommended within 6 weeks after surgery. Return to an office based job may be possible at around 6 weeks (depending on the need for driving). Manual work is not recommended until up to 12 weeks. 


What is the difference between a fusion and a replacement?


Both procedures are aimed at alleviating the pain from the arthritic joint. The fusion means the joint will be fixed in one position and will lose its movements and replacement means it will maintain its range of movements. Fusion is performed far more commonly and is more suitable for high demand individuals with physical work requirements. Replacement option is not available in every centre and is usually reserved for patients with relatively less physical demands. 


Both procedures achieve excellent results with good pain relief and comfort in wearing the routine shoe wear. In case of fusion, the metal work is not routinely removed unless it causes any issue. In case of replacement, the silicon implant is likely to last for 10 years of longer in more than 90% cases according to the available evidence. 


What complications can occur after surgery?


Potential risks and complications after surgery include infection, wound problems, bleeding, blood clots in the legs or lungs (deep vein thrombosis, pulmonary embolism), delayed healing or non-healing of the bone (fusion), ongoing pain, stiffness in the big toe joint (replacement), numbness around the scar, chronic regional pain syndrome, metalwork problems that may require removal, long-term risk of neighbouring joints becoming worn out requiring further treatment and anaesthetic risks. These potential problems occur in a small percentage of cases but the risk increases with the presence of certain medical conditions and the use of certain long-term medications.

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