What treatments options are available for hallux rigidus?
The options are between operative or non-operative management.
A combination of the level of pain, radiographic stage of degeneration, the presence of deformity and the chance of success versus the degree of restriction following treatment helps to reach an informed decision as to which of the many therapies will be most appropriate.
- Injection/manipulation : This can be useful in the early stages of arthritis. The effects are often temporary.
- Arthroscopic debridement: A minimally invasive technique, generally for patients with moderately severe symptoms but lesser degrees of x-ray changes.
- Open debridement: See below
- Kellers/Hamiltons arthroplasty: A good option in the less mobile, more elderly patient. This involves removal of one side of the painful joint. This stops the pain of the arthritic joint but the big toe sometimes becomes floppy.
- Big Toe Fusion: See below.
- Replacement: See below.
The principle with orthotic management is to offload the big toe during walking. During normal walking the front part of the foot acts as a rocker (Diagram 1), this requires the big toe joint to both extend and take weight. By modifying a normal shoe to add a subtle rocker to the sole at the location of the joint, as well as stiffening the sole here so it doesn't bend the foot can progress forwards normally with little big toe movement and reduced forces through it. The shoe "takes the strain". (Diagram 2)
This only works when appropriately modified shoes are worn and will make little difference to a patient suffering pain at rest.
What are the most common operations for hallux rigidus?
For early arthritis the big toe debridement.
For advanced arthritis the big toe fusion.
What is a big toe debridement and how does it work ?
This involves accessing the joint internally, either with keyhole surgery or a standard "open" approach.
Medial open approach to big toe joint. Metatarsal head (1).
Any loose cartilage within the joint is removed and any discreet areas lacking cartilage are drilled with fine wires. This respectively removes irritants from the inside of the joint as well as allowing new, though poor quality cartilage, to form in drilled areas. In addition the excess arthritic bone (osteophyte) which forms on the top edge of the joint (2) is removed. This should allow an increased range of extension (upwards movement) post-operatively.