Hallux Rigidus is essentially an arthritic joint at the base of the Big toe. It usually affects the top (dorsal) component of the joint the most. Arthritis involves loss of joint cartilage (gristle) and the formation of bony osteophytes (protuberances); it becomes worse with time. The joint becomes stiff so that when the toe dorsi-flexes (moves up) with walking the osteophytes jam or impinge reducing motion causing pain, stiffness and inflammation. Often the bony mass will causes pain by rubbing on shoe wear.
Usually surgery is not essential
The disease is not of itself dangerous and therefore treatment is determined by the symptoms. Surgical treatment is optional. Non-surgical treatment involves the modification of shoes so that there is enough room to fit the foot in the shoe without undue pressure as well as stiffening the sole of the shoe so that less movement of the joint occurs hence reducing impingement. Other options involve modification of activities, the use of an external rocker and the use of anti-inflammatory drugs.
The primary aim of surgery is to relieve pain & improve function
The aims of surgery are to relieve pain, to decrease its’ bulk and to maintain or improve function.
Appearance is not a reason to operate. Surgery aims to maintain power of the great toe & reduce pain
I avoid surgery, which weakens function of the big toe (for instance Keller’s procedure) as with time it not infrequently causes problems with the small toes because the force normally expended by the great toe is transferred here.
There are several surgical options. I avoid surgery, which weakens function of the big toe (for instance Keller’s procedure) as with time it not infrequently causes problems with the small toes because the force normally expended by the great toe is transferred here.
Dorsal Cheilectomy and Moberg Osteotomy.
Probably the least destructive operation is the combined operation of Dorsal Cheilectomy and Moberg osteotomy. It aims to reduce the mass of the toe, improve movement and reduce pain whilst maintaining powerful function.
Dorsal Cheilectomy resects arthritic joint and debulk the toe reducing impingement
Dorsal Cheilectomy involves the excision of the osteophytes and degenerate joint surface from the dorsal (top) section of the joint. This serves to debulk the mass and reduce rubbing on the shoe causing pain. It also decompresses the joint and prevents impingement (jamming) with dorsi-flexion (upward movement of the toe). It usually is fixed with wires.
Moberg osteotomy realigns the joint hence reducing impingement
Moberg osteotomy involves resection of a wedge of bone from the dorsum (top) of the first bone (proximal phalanx) of the great toe. It again decompresses the joint but also realigns it so that even though movement of the joint remains limited, that movement is in a more useful arc.
Movement of the toe is emphasised once the foot has stabilised
Ultimately I aim for decreased great toe mass (and hence less abrasion of the toe on the shoe) and increased (but not normal) movement of the toe.
Symptoms may return after some years
Pain is reduced and function improved for ten years or so in the majority of moderate cases. The arthritic change will progress with time and symptoms may return. In this situation further surgery or arthrodesis may be required. Clearly not all cases are improved with operation and some are made worse. Other than persistence or recurrence of symptoms potential problems include nerve injury, infection and stiffness.
Great Toe Fusion.
Fusion permanently stiffens the joint but is surprisingly well tolerated
This operation is used in severe cases; it results in a stiff toe. It gives a powerful foot; pain due to arthritis of the toe is eliminated. The result is permanent and reliable. Probably the greatest drawback is that the use of a high-heeled shoe is made difficult. The joint is excised through either the dorsum (top) or side of the toe. The joint is held in a corrected position and held there (typically by screws or wires). Frequently bone graft is used to facilitate healing and I usually take this graft from the foot.
Walking progressively improves during the post-operative phase
Most patients have lasting improvement with surgery but a few are made worse
This is a reliable and lasting operation providing permanent relief of Hallux rigidus. Not all cases are improved with operation and a few are made worse. Potential problems include infection and nerve injury. Occasionally the arthrodesis is either delayed or fails (more common in those who smoke) but this does necessarily mean that pain is not relieved. Sometimes screws become prominent and need to be removed. Probably the greatest difficulty is setting correct toe alignment at the time of operation.
Great toe arthroplasty (replacement)
In an arthroplasty (replacement) the joint surfaces are removed and an artificial joint is implanted. It may relieve pain and preserve joint function.