What To Do About Hallux Rigidus

Hallux rigidus is a degenerative type of arthritis that affects the large joint at the base of the big toe. Degenerative arthritis can result from wear and tear on the joint surface over time. The condition may follow an injury to the joint or, in some cases, may develop with no known cause.

In this review article, an orthopedic surgeon from the Hospital for Special Surgery in New York presents ways to treat this condition based on classification (severity). Nonsurgical management is always advised first and may consist of nonsteroidal antiinflammatory medications to reduce pain and swelling, shoe adaptations, and changes in activities.

The degeneration causes two problems–pain and loss of motion in the metatarsal phalangeal (MTP) joint of the big toe. Without the ability of the MTP to move enough to allow the foot to roll through a full step, walking can become painful and difficult.

A rocker type of sole allows the shoe to take some of the bending force, and may be combined with a metal brace in the sole. These features help limit the flexibility of the sole of the shoe and reduce the amount of bend in the toe during walking.

Most patients with this problem aren’t happy to wear the unfashionable shoes that might provide some pain relief for this condition. Likewise, younger adults may be unwilling to (or unhappy about) changing activity level.

When conservative care doesn’t help, surgery may be the next step. There are three main surgical choices: cheilectomy, arthrodesis (fusion), and joint replacement. Surgery has helped many people with this problem with a reported rate of patient satisfaction of up to 95 per cent.

A cheilectomy is a procedure to remove the bone spurs at the top of the joint so that they don’t bump together when the toe extends. This allows the toe to bend better and reduces the amount of pain while walking. To perform a cheilectomy, an incision is made along the top of the joint. The bone spurs that are blocking the joint from extending are identified and removed from both the bones that make up the joint. A little extra bone may be taken off to ensure that nothing rubs when the hallux is raised. The skin is closed and allowed to heal.

Many surgeons favor arthrodesis, or fusion, of the MTP joint for severe hallux rigidity. To fuse a joint means to allow the two bones that form a joint to grow together and become one bone. The joint between the two bones is removed and the two bones are held together by some type of fixation device such as staples, wires, metal plates, or screws. This results in a pain free joint but one that no longer moves.

Replacing the joint with an artificial joint is another treatment option usually recommended for moderately involved joints. (Arthrodesis or fusion still produces better results for patients with severe hallux rigidus). In the joint replacement procedure, one or both of the joint surfaces is removed and replaced with a plastic or metal surface. This procedure may relieve the pain and preserve the joint motion. The major drawback is that the artificial joint probably will not last a lifetime and will require more operations later if it begins to fail.

There are actually several different ways to accomplish a joint replacement. A total joint replacement removes and replaces both sides of the joint. This type of procedure requires a conical stem that sits down inside the toe bones on either side of the joint. The implants can be made of ceramic, titanium, cobalt-chrome, or titanium combined with polyethylene (plastic) parts.

Metatarsal hemiarthroplasty replaces just one side of the joint — between the bone closest to the big toe joint (metatarsal) and the middle phalangeal bone. Limited studies have been done using this approach but patient satisfaction is reportedly high (100 per cent) with no implant failures or need for revision surgery.

There are other surgical procedures that are slight variations of these three approaches. For example, cheilectomy may be combined with a phalangeal osteotomy. The surgeon removes a wedge-shaped piece of bone from the middle toe bone in order to take pressure off the joint. Some patients can be successfully treated with just the osteotomy procedure.

Another alternative approach (more for the younger patient) is the interpositional arthroplasty. In this procedure, the surgeon removes the base of the toe bone (phalange) and places a “spacer” in the hole left. The spacer is made up of a rolled up piece of tendon. The surgeon may have to release the tendon that inserts into the base of the phalange for this to work best. This decision is made at the time of the surgery.

The authors note that there is a need for improved implant designs and materials for joint replacements. Right now, joint replacement is not considered the best approach to the problem of hallux rigidus. Joint replacement is most likely helpful in the case of moderately involved rigid hallux. Problems with subsidence (implant sinks down into the bone), implant loosening, and implant stems poking out through the bone keep this treatment option as second best to arthrodesis (first choice). More research is also needed to find more successful, acceptable nonoperative ways to treat this problem.