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(Arthritis of the Great toe)
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. The classification system helps guide the orthopaedic surgeon with appropriate treatment procedure selection.
Cheilectomy (clean-out and spur removal)
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 may help to regain 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 or hard-soled shoe is often used to protect the foot for about 3-6 weeks after surgery.
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.
Occasionally, some patients may be candidates for a resurfacing of the joint. During this procedure a layer of tissue or buffer is used to 'resurface the metatarsal head' This is less common and the outcomes are less predictable. However, there are some circumstances in which this may be the attempted pain relief solution that a patient chooses. Reasons that a resurfacing may be beneficial include pain relief and preservation of motion. Some patients may choose this as a temporary solution, while knowing that they will eventually require another surgery to fuse the joint. Reasons that it may not the best choice for most patients include less predictable pain relief and lack of longevity of the resurfacing compared to more customary procedures.
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 the joint will decrease any remaining motion, fusion also substantially eliminates the pain. In fact, prior to fusion, many patients will find that they already have little to no motion at the joint secondary to the arthritis. In a recent study of patients treated with a fusion for hallux rigidus, the majority of patients actually walked better after the fusion. 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 if the patient so chooses. 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 cheilectomy or fusion 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 6 weeks without putting full pressure on your toes (such at standing on tip-toes). A postoperative boot will help protect the foot. Transitioning back into a regular shoe usually occurs around 6 weeks after surgery. Activities such as jogging usually take at least 10-12 weeks before they can be done comfortably. 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 to avoid swelling in the immediate postoperative period.
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