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What is hallux rigidus?

Hallux rigidus (Latin for a ‘stiff big toe) is a condition caused by arthritis at the big toe joint. It causes pain and stiffness as well as disability. This results in problems with upward bending of the big toe. It is noticeable when walking, running and sporting activity.

The condition can also result in a bump on top of the big toe and deformities such as a bunion. These deformities can put pressure on the other toes and cause problems with footwear and crowding or crossing over of toes.

It is therefore possible to have both a bunion and hallux rigidus.

What are the treatment options?

Not all cases of big toe arthritis need surgery. It is advisable to initially treat it without surgery, and leave surgery as a last resort.

Some of the non-operative treatments include:

  • Avoiding high heels

  • Avoiding exacerbating activities and sports.

  • Insoles and orthotics – stiffened insoles to minimize movement in the big toe or stiff soled shoes.

  • Painkillers and anti-inflammatory gels

Surgery options:

  1. Cheilectomy

  2. Joint replacement surgery

  3. Fusion surgery (joining the big toe joint together).

What is a cheilectomy?

A cheilectomy is an operation to remove the extra bump of bone on top of the big toe. This bump is usually due to early arthritis. It may increase joint movement and can help with pain in patients with less severe arthritis. The range of motion may however not be normal and your symptoms may worsen in the future. If cheilectomy fails, then it is possible to do a fusion at a later date. The recovery following a cheilectomy is usually quicker than the recovery from a fusion.

What is a joint replacement procedure?

In some cases, you and your surgeon may feel that a joint replacement procedure is an option to treat your arthritis. This procedure usually preserves some of the big toe range of motion. However it is important to understand that the range of motion is unlikely to be like a normal joint (there will be some stiffness following the procedure). Some patients may also find that they may still not be able to tolerate wearing high heels. Joint replacement surgery is generally not advised if there is a deformity present. These issues can be discussed with your surgeon.

What is a fusion?

A fusion is an operation to join the big toe joint together, producing a stiff joint. Any bony bumps are trimmed at the same time. It straightens the big toe and reduces pain. It does result in a permanently stiff joint.

What are the benefits of a cheilectomy?

The aim of surgery is to ease your pain and discomfort.

Summary of a cheilectomy.

The surgery is usually performed as a day case. It is usually performed under a general anaesthetic. Local anaesthetic is often given at the end of surgery to help with pain relief. The bony bump is removed and the joint will be inspected and washed out.

The picture shows the bony lump knocking against each other. The shaded portion is removed (cheilectomy procedure) to help with the range of motion in the joint.

After your surgery

Your foot will be in a bulky bandage and wearing a post-surgical shoe. You may be given a nerve block for pain relief which can last for 24 hours or more. You should keep your foot elevated on a chair/pillow and take regular painkillers.

Advice after surgery

The foot should be strictly elevated for the first 2 weeks to avoid excessive swelling which could compromise the wound. Aim to keep the foot elevated for 55 minutes of every hour

The dressings should not be disturbed unless there is a concern with the wound. At around 2 weeks after surgery, you will return to the clinic to have the bandages and stitches removed. After this the wound can be dressed with a simple light dressing.

You may shower the limb after the stitches have been removed and the wound is fully healed. Keep the wound and surrounding area dry and clean.

You are allowed to bear weight in the post op shoe. You may need crutches. The physiotherapist will show you how to use them. You will need to wear the shoe for 4-6 weeks. After this time, you can wear flat soled shoes.

It may take several weeks before you can drive. Please check with your insurer. 

Going back to work depends on the activity undertaken at work and should be discussed with your surgeon.

It usually takes 4-6 weeks to feel like you’re making a good recovery from your surgery. It may take 3-6 months before swelling subsides and when you can resume light sporting activities. This is a normal recovery. Often a full recovery takes much longer than one would expect. If you are slower than these times do not panic, they are only averages, but let your surgeon know when you attend clinic.

What are the risks with a cheilectomy?

The general risks with surgery include

  • Bleeding – rarely may there be bleeding with results in a collection of blood under the wound. Bruising is common after this procedure

  • Swelling – common after surgery and can take many months to eventually settle down. Elevation is key to reducing this.

  • Stiffness – exercises are important to reduce the stiffness in the big toe after surgery

  • Infection – infections can be treated with antibiotics. Deeper infections which are much rarer may require further surgery

  • Nerve damage – This can result in numbness over the scar but is generally not a problem. Occasionally a scar may be sensitive.

  • Clots in leg/lung – your risk of clots will be assessed prior to surgery and appropriate treatment/advice will be given.

The specific risks to this surgery include

  • Worsening of symptoms – In a small proportion of patients, their symptoms may be made worse and this may require further surgery.

  • Deterioration – the arthritis may progress with time and further surgery may be required

  • Chronic regional pain – This is excessive pain after surgery and is a very rare complication.

If I have any questions or concerns?

These guidelines are to help you understand your operation. This level of detail may cause concern, anxiety, or uncertainty. Please let your doctor or nurse know so that we may address these issues.

We aim to see you back in the clinic at regular intervals to monitor your progress and answer any questions you may have during your recovery.

If there is concern regarding the wound, such as increased redness, pus, discharge, or pain, then seek medical attention either at your GP or nearest Emergency department.

Above all else, please do not proceed with surgery unless you are satisfied and understand all you want to know about the operation.

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