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Hallux Rigidus

Arthritis is a condition in which the cartilage or lining surface of a joint wears away. This condition can be hereditary or related to trauma or injury. This loss of cartilage causes inflammation in the joint with resultant pain. As the cartilage wears away, the body forms spurs on the top part of the joint. A bone spur or osteophyte is a bony growth/extra bone that forms on the edge of a joint. It forms as the body tries to repair itself by building extra bone. This spurring or extra bone can lead to stiffness of a joint.

Hallux Rigidus is arthritis of the 1st toe joint. This has also been called a dorsal bunion. The arthritis involves the large joint of the big toe called the MTP joint (between the 1st metatarsal and the proximal phalanx). The 1st MTP joint is an important joint during walking. It can bend up to 90 degrees. The 1st MTP joint can develop arthritis at a young age (patients in their 30's or 40's). The cause of the arthritis is thought to be secondary to a prior injury or hereditary. Patients often have pain and irritation from shoe wear (secondary to the shoe rubbing on the bone spurs). The joint becomes stiff and swollen.

Many patients can be treated with wider/extra depth shoes. Other patients feel better in a stiffer shoe. In a stiff shoe, such as a clog, the stiff 1st MTP joint does not have to bend as much when walking. A further non-operative treatment option is the use of orthotics. In particular an orthotic with a carbon fiber insole can be helpful in order to decrease motion in the 1st toe joint. Other options include use of NSAIDs (such as Advil or Ibuprofen) and possible cortisone injections.

If there are increasing symptoms/limitations, a patient will require surgery. There are four surgical options for Hallux Rigidus including: cheilectomy, interpositional arthroplasty, replacement and fusion.

1st MTP Cheilectomy

This procedure involves removing the painful and prominent bone spurs on the top of the toe joint. This is done to allow increased motion through the MTP joint, decrease shoe wear irritation from the bony prominence, and eliminate some early arthritis on the upper surface of the joint. Typically, the top 1/3 of the MTP joint has arthritic changes. The bone spurs and arthritic areas need to be removed in order to allow increased motion and improvement in symptoms. This procedure is effective only for patients who have arthritis involving the top part (dorsal aspect) of the joint. It is not indicated in patients with extensive arthritis involving the entire joint (ie: more severe or end/late-stage Hallux Rigidus).

Recovery from a cheilectomy is typically relatively rapid. Patients are allowed to weight bear as tolerated in a stiff-soled shoe following surgery. There is no need for crutches. The sutures are removed at approximately ten days s/p surgery. Patients are allowed to return to a sneaker by three weeks s/p surgery. Typically 2-3 visits of physical therapy are used for instruction in a home exercise/motion program. Return to sports is approximately six weeks s/p surgery. However, residual pain and swelling can be expected to limit some activities for at least a few more months post-operatively.

Potential complications of the surgery include infection, wound healing problems and irritation of the nerve that provide sensation to the toe. Patients are instructed in cleaning their foot the night before surgery and IV antibiotics are given during surgery to decrease the chance of infection. Patients who smoke are encouraged to stop smoking before/after surgery to allow full, rapid wound healing.

One other potential complication of a cheilectomy would be continued 1st toe pain. The cheilectomy removes the bone spurs, however it does not reverse the arthritis in the joint. If the arthritis is significant some patients have continued pain and may need a different procedure. . This need for a further procedure can occur relatively quickly if there was more wear and tear arthritis in the great toe joint than expected.

Interpositional Arthroplasty

This procedure involves removal of bone spurs, as in a cheilectomy, followed by a placement of tissue to resurface/form a new gliding surface for the joint. At times further resection of bone (than that for a cheilecotmy) is required. This procedure has typically been done for patients with more significant arthritis that do not want to consider a fusion of the joint. After the bone spurs are removed a portion of the lining of the joint or capsule can be placed between the two bones of the 1st MTP joint. Sometimes a genetically engineered substance (such as treated human skin cells i.e. Graft Jacket from Wright Medical) is used. This substance can be used a spacer or cushion between the two bones or can be draped over the end of the bones to allow the two bones to glide against each other. This gliding surface is not as good as normal cartilage, but can allow a mobile pain-free joint.

Recovery from an interpositional arthroplasty is similar (however usually prolonged) to a cheilectomy. Risks of surgery are similar to the risks after cheilectomy surgery.

The long term results of this procedure can be variable. Many patients do well for many years while others have continued difficulties and require a fusion procedure.

Joint Replacement

This procedure involves replacement of one side or both sides of the 1st MTP joint with metal or other substance. This would be similar to joint replacement of a hip. The initial replacements were made of silicone and there have been other replacements made of metal that have been manufactured. Most Orthopaedists do not routinely use these devices as the results of these implants in the Orthopaedic literature have not been reliable. In particular, many of these reports describe loosening of the implants with resorption/destruction of the bone causing pain, deformity of the toe and need for further surgery. Most patients who require further surgery undergo a fusion of the joint. At times this can be a difficult surgery secondary to lose of bone requiring use of bone graft.

Fusion

A fusion consists of making the 1st toe joint stiff by removing the remaining cartilage of the joint and allowing the two bones to heal together. This procedure is done by preparing the joint surfaces and then placing screws or using a plate to compress the two bones together. The two bones heal together in a similar process to bones healing in a fracture. A fusion (also known as an arthrodesis) is very reliable in decreasing pain at the expense of decreased motion. Having a fused joint sounds very limiting, however patients can be very active including walking and many sports. It is possible to play tennis and some patients can also run. There are some limitations with shoe wear such as limited use of high heel shoes for woman. The majority of patients are happy with the results of a fusion.

A fusion can be necessary if other procedure for Hallux Rigidus fail. In particular, continued pain after a cheilectomy often requires a fusion. Failure of a joint replacement is typically managed with a fusion although this can be a difficult procedure requiring use of bone graft (often from the pelvis area or iliac crest) to account for bone destruction from the failed replacement procedure.

Recovery from a fusion typically includes use of a hard soled shoe although casting/walking boots are used at times. Typically weight bearing is allowed after 3 weeks although some patients are not allowed to place full weight until later. Most patients can progress to a sneaker by 4-6 weeks s/p surgery.

Risks of surgery include similar risks to a cheilectomy in terms of infection, wound healing difficulties or nerve irritation. Some patients are bothered by the metal used for the fusion. If a plate is used it is often prominent and needs to be removed after the fusion is healed. The other specific risk of a fusion procedure would be a non-union. A non-union means that the two bones do not fuse or heal together. This occurs in approximately 10% of cases. It can be related to smoking. If a non-union occurs and there is continued pain, a revision fusion using bone graft may be necessary.