Hallux Rigidus - Big Toe Arthritis Treatment

How can it be treated?

If you have no pain, discomfort or other symptoms then you do not need any treatment. If you are having symptoms such as pain, swelling, stiffness or rubbing then there are several treatment options.

Non-surgical Treatment

This is more likely to work when the arthritis is being treated in its earlier stages-

Pain killers and activity modifications- simple pain killers may help and your GP will be able to advise on other pain killers that may be suitable for you. Avoiding those activities that cause the pain may also help if you are willing to change your lifestyle and can find pain free activities that keep you active.
Shoe wear modifications - avoiding shoes with a heel if these cause pain and opting for a flat, wide soft shoe that accommodates the foot may help. Some people find a stiff sole that limits movement or even a rocker soled shoe which has a stiff, curved sole that helps counter the loss of motion in the big toe very useful. These tend to be more helpful in less active patients with early arthritis.
In-shoe orthotics - the aim is to limit motion across the joint and they come in a variety of materials, shapes and sizes. They can be particularly useful if your overall foot shape is abnormal (flat footed or a very high arch) and in those that are less active.
Injections- a steroid injection into the joint was a very common treatment in the past. It is falling out of favor as it often only effective for very early arthritis and there is a small chance of introducing infection into the joint. It is still useful in certain circumstances and particularly in older, medically unwell, patients who may be too frail for surgery.

Surgical Treatment

When the treatments above fail to control pain or to allow a return to being active then surgery may be indicated. There is no single best operation and the exact type of procedure that will provide the most benefit varies depending on the person affected. The correct operation depends, to a significant extent, on the type and severity of the arthritis, the overall alignment of the foot and big toe (for example if there is also a bunion), what activities and sports are undertaken and the type of shoes that want to be worn after surgery.

Cheilectomy
In this procedure the bony bump that has formed over the top of the joint is removed. The joint is inspected, debrided (tidied up) as necessary, cartilage regenerating procedures may also be undertaken and any tight structures are then released. This procedure is performed through a small incision over the top of the toe. It is very helpful in milder forms of arthritis where it helps to get rid of pain and increase mobility.
Arthroscopy
In early arthritis and in cases of localized cartilage injury (osteochondral defect) secondary to trauma it is now possible to undergo arthroscopic or keyhole surgery. Two or three very small incisions are placed around the joint allowing a special camera and micro-surgical instruments to be passed into the joint for treatment.
Cartiva® Big Toe Joint Replacement
This is an exciting new treatment being used to help those suffering from more severe arthritis of the big toe that previously would have needed a fusion. The results to date are very promising although the long term outcomes have not been clearly determined. The main advantage of this technique is that it is a joint preserving surgery that is suitable in even more severely arthritic joints that previously would have required a fusion. Joint motion is therefore preserved which makes it easier to perform certain activities and to get into a shoe with a heel. The toe needs to be normally aligned and it is not clear if it can be used if there is also a bunion which needs addressing.
Osteotomy / surgical realignment
It is also possible to treat arthritis of the big toe by realigning the joint surgically with a surgical cut of the bones (osteotomy) - much like one might do for the surgical correction of a bunion. It is occasionally possible to use these techniques in cases of even moderately severe arthritis. Osteotomies are generally combined with a cheilectomy so that any bony prominences are removed and the joint is debrided at the same sitting. The advantage of this type of surgery is that motion is preserved and the natural joint is kept. The surgical cuts can be made in the bones on either side of the joint. When the osteotomy is made in the smaller bone of the joint- the proximal phalanx- it is known as a Moberg osteotomy. In a Moberg osteotomy a ‘V ‘shaped wedge is removed from the bone which is then held with a metal implant to allow it to heal in the correct position. This procedure changes position of the toe so that the motion which is already there is in a more functional or useful position. Alternatively the cut can be in the larger bone of the joint- the metatarsal. These procedure are generally aimed at shortening the bone very slightly such that the joint is decompressed and the arthritis becomes less painful. The bone is also generally moved downwards (plantarly) particularly in cases where it was previously abnormally high or elevated such as in hallux elevatus.
Standard Big Toe Joint Replacements
It is possible to treat arthritis of this joint with a full joint replacement much like those of the hip or knee. These help to get rid of pain and unlike traditional treatment with a fusion motion is preserved which is useful for certain activities and shoes with a heel. Unfortunately to date the joint replacements for the big toe do not have the excellent long term outcomes that are found with joint replacements elsewhere such as the hip or knee. Because of this the indications for this technique remain limited and the long term results are not always good. The alignment of the toe must be normal i.e. no associated bunion. Given enough time and use many of these big toe joint replacements loosen and further surgery is often needed. Generally this is a conversion to a fusion. The type of fusion required after a worn out joint replacement tends to be different to a standard fusion of the big toe and it may be necessary to use a bone graft to help it heal.
Fusion (Arthrodesis)
This is the tried and tested treatment for the more severe forms of arthritis and it is considered to be the surgical ‘gold standard’ treatment. The aim is to get rid of the pain by surgically joining the bones of the joint together permanently, at the same time bony prominences are also removed. In this procedure an incision is made over the top of the toe and, the remaining joint cartilage is removed along with the underlying unhealthy hard bone. This reveals the healthy softer bone underneath which has better healing potential. The bone surfaces of the toe joint are then held in the correct position with a small plate and screws. These bones then heal together much as broken bones join back together. This is a very effective way of eliminating pain and is successful over 90% of the time. The main disadvantage is that all movement is lost in the joint. The small joint (interphalangeal joint) of the toe is left undisturbed so there is still movement in the toe itself. However, the toe is stiff and it will not be possible to get into a high heeled after this procedure. That being said a fusion is fixed in such a position to allow activity and it is possible to get back to sport after- including jogging and running. It is also generally possible to use a small heel after a fusion. While it is not the norm there are people that get back to being very active after a big toe fusion- including doing triathlons and marathons. For more vigorous activities some people find a shoe with a curved or rocker sole, which compensates for the movement lost in the fusion, very helpful.

When can I return to work after surgery?

Arthroscopy

This will depend on the type of work you do

Sedentary jobs: Return to work after 1 week if able to maintain foot elevated at level of waist, otherwise 2 weeks off.
Standing/walking jobs: Return after 2 – 4 weeks, but may be sooner depending on comfort and swelling.
Manual/labouring jobs: 4+ weeks, but may be sooner depending on comfort and swelling. Longer if undergoing cartilage regeneration techniques for an osteochondral defect.

Osteotomy & Fusion

This will depend on the type of work you do

Sedentary jobs: Return to work after 1 week if able to maintain foot elevated at level of waist, otherwise 2 weeks off.
Standing/walking jobs: Return after 6 – 8 weeks, but may be sooner depending on comfort and swelling.
Manual/labouring jobs: 8+ weeks, but may be sooner depending on comfort and swelling.

Cartiva Joint Replacement

Sedentary jobs: Return to work after 1 week if able to maintain foot elevated at level of waist, otherwise 2 weeks off.
Standing/walking jobs: Return after 2 – 4 weeks, but may be sooner depending on comfort and swelling.
Manual/labouring jobs: 4+ weeks, but may be sooner depending on comfort and swelling.

Standard Joint Replacements

This will depend on the type of work you do

Sedentary jobs: Return to work after 1 week if able to maintain foot elevated at level of waist, otherwise 2 weeks off.
Standing/walking jobs: Return after 4-6 weeks, but may be sooner depending on comfort and swelling.
Manual/labouring jobs: This type of procedure is generally not indicated in very active people including labourer’s due to the high risk of failure from implant wear.

When can I drive after surgery?

The DVLA state that it is the responsibility of the driver to ensure they are fit and able to stay in control of their vehicle. A good guide is if you can stamp down hard with the foot comfortably and are able to perform an emergency stop then you may be ready to drive. For left sided surgery in an automatic car i.e. no clutch is required, driving is probably safe 1 week after surgery. For right sided surgery or a manual car, driving is probably safe at 2 to 4 weeks after cheilectomy or joint replacement surgery and after 6 weeks for osteotomy and fusion surgery- i.e. once in a normal shoe. If you are unsure please ask Mr. Al-Nammari. It remains your responsibility to drive safely and you should check with your vehicle insurer to confirm you are covered.

These operations are all fairly small procedures. They can be undertaken as day cases under local anaesthetic block making the leg numb for six to twelve hours. You will be seen by an Anaesthetist and can be awake, sedated or have a general anaesthetic during surgery. It is possible to walk straight away after the operation with a special shoe. There is no need for a cast or prolonged immobility with modern surgical techniques.

Mr. Al-Nammari undertakes the majority of his private operating at The Nuffield Hospital in Ipswich. Using the latest techniques in local anaesthetic blocks means that most people having surgery are comfortable enough to get home on the day of surgery should they so wish. For those who need to or just feel more comfortable spending the night in hospital after surgery this is of course possible. The choice of anaesthetic is based upon your own preferences and the opinion of the Consultant Anaesthetist who you will meet before any surgery. Many people prefer to be asleep during surgery and have the local anaesthetic block performed while asleep to control any post-operative pain.