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Minimally Invasive Correction of Big Toe Arthritis (Hallux Rigidus)

What is big toe arthritis (Hallux Rigidus)?

Big toe arthritis is a common and painful condition affecting the joint at the base of the great toe. Patients usually suffer from pain at bony prominence on the top of the base of the big toe together with stiffness and limited shoe options. Symptoms are usually aggravated by tight shoes, high heels, and those with flexible soles. The condition often progresses slowly as cartilage degenerates and bone spurs grow.

What is the treatment for big toe arthritis?

Arthritis of the big toe can be treated by numerous methods. Patients may find relief by avoiding activities with repeated bending of the first metatarsophalangeal joint such as dancing and turf sports. Anti-inflammatory medications can also help relieve pain from inflammation. Shoes with more stable soles or carbon-fiber inserts are helpful to avoid re-injury to the joints with activities. Cortisone injections are effective in providing pain relief but the results are temporary.

There are several treatment options available to treat big toe arthritis including an open cheilectomy, realignment osteotomy, joint replacement, interposition arthroplasty, and joint fusion. Joint fusion is an effective treatment for pain and swelling but the joint motion is sacrificed. Joint replacement with prostheses has not been successful due to the small surface area available for high loading forces. Interposition arthroplasties with polyvinyl alcohol or soft tissue graft are emerging techniques with encouraging results. Open cheilectomy is a time-tested surgery often combined with a realignment osteotomy with the goal of mitigating pain from impingement while improving alignment and motion. All of the surgical options described here usually require open surgical dissection and postoperative immobilization making postoperative scarring and stiffness one of the challenges for patients.

What is a minimally invasive bunion correction of big toe arthritis (MIS)?

Minimally invasive correction (MIS) has been around for decades. It is based on the philosophy that the goals of the surgery can be met with the least amount of collateral damage possible. It is comparable to cardiac catheterization to fix a clogged artery rather than having a formal open thoracotomy. Dr. P's philosophy for the correction of big toe arthritis includes the MIS techniques for cheilectomy and realignment osteotomy. The surgery is performed using special tools and combined with arthroscopic control through 3-mm incisions. While the surgery appears attractive, this MIS surgery is extremely technical and each surgeon performing it must go through rigorous and multistage training in sawbones and cadavers prior to real patients.     

What are the risks and benefits of MIS correction of big toe arthritis?

Risks: nerve damage, residual stiffness, persistent pain, nonunion, hardware symptoms

Benefits: Minimal postoperative pain, immediate weight-bearing, cosmesis, less scarring, less swelling, improved motion, faster recovery

What is the recovery after a MIS correction of big toe arthritis?

Dr. P’s postoperative protocols include immediate weight-bearing using 100% body weight starting on the day of surgery. A patient may achieve this by either using crutches or a walker to assist with balance while putting weight on a provided post-op shoe. Patients will do weight-bearing for light ADLs such as going to the bathrooms or kitchen or short walking inside the house. Full weight-bearing is healthy for the foot as it allows the bone and soft tissue to self-adjust to the flat surface. The amount of walking can be gradually increased, and a walker or crutches can be weaned off at 2 weeks. The patient can return to normal running or tennis shoes at 6 weeks. Sports and higher impact activities can start at 10 weeks. Patients will not need to do any dressing change themselves but will return to the clinics at 2 and 4 weeks for postoperative dressing by Dr. P. Driving can normally resume when the patient stops taking pain medication and can walk comfortably; a trial of driving under family-member supervision is recommended.

Author: Phinit Phisitkul, MD

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