Arthritis of the big toe (Hallux Rigidus)

You have been given this leaflet because your doctors think you have arthritis in your big toe. This information may help you understand the condition and what to expect from the available treatment.

What causes Hallux Rigidus?

Arthritis of the big toe may happen following trauma (you have an injury), infection, an episode of gout, or from inflammatory arthritis / osteoarthritis.

What are the treatment options?

• Painkillers (such as paracetamol and ibuprofen) and non-steroidal inflammatory medication may help with your pain and swelling.

• In the earlier stages of arthritis, a steroid injection into the joint may help.

• Making changes to your footwear may also help. For example, a soft shoe for the toe box will relieve pressure on your toe, and a stiff-sole or rocker-bottom shoe will relieve your pain by reducing the movement of your joint.

• Surgery should only be considered after the treatment options listed above have been tried.

What surgical options are available?

• In the early stages of arthritis, when the main complaint is pain from the osteophytes (bone spurs) rather than general arthritic pain, there is an option to just remove the osteophytes (cheilectomy) and keep the joint. However, if this procedure is not successful then a fusion procedure may be needed.

• In more advanced arthritis, a fusion procedure is thought to be the best option. With this procedure an incision (cut) is made on the top of your toe and the bones on either side of your joint are joined together. This is usually held together with either screws, plates, or a combination of both. Once healed, the joint remains stiff and the pain goes, as the joint surfaces no longer rub on each other.

• In some cases, particularly with those patients who do not move around much, a silastic joint replacement can be considered, but there is no long-term evidence to support this treatment.

You will discuss these procedures with your surgeon before any treatment is decided. Your surgeon will discuss which is more appropriate for your condition, and you will have an opportunity to ask any questions or raise any concerns you may have.

Will I have a general anaesthetic?

The surgery is normally carried out under general anaesthesia (you will be asleep).

You will be given instructions at your preassessment appointment about when to stop eating / drinking, what to do with your medications, and where to come on the day of your surgery.

What happens if I ignore my condition?

The reason(s) why you came to the appointment may not get better and sometimes can get worse. It is difficult to predict.

You will be given painkillers to help with any discomfort after your operation. Everyone reacts to the anaesthetic differently. Feeling sick afterwards is common and we do our best to avoid this.

How long will I have to stay in hospital?

Most of these procedures are performed as day surgery. However if you are having fusion surgery you may be kept in hospital for one night.

You will need someone to drive you home after your surgery and someone must stay with you overnight.

What happens when I arrive at the hospital?

When you arrive at the hospital you will be seen by the nurses, a physiotherapist, and doctors who will explain your procedure. Please use this time to ask any questions.

You will be asked to change into a hospital gown and stockings.

Will I have a follow-up appointment?

You should have your wound checked in clinic two weeks after your surgery. If you had fusion surgery you will have another appointment at six weeks, when we will take an x-ray of your toe.

When will my bandages be removed?

Your bandaging will be removed at your two week appointment and your dressings changed.

When can I stop wearing my surgical shoe?

If you have had a joint replacement, the surgical shoe can be removed at your two week appointment and you can start to wear a normal comfortable shoe instead (often a size up from your normal size).

If you had fusion surgery, you will need to keep wearing the surgical shoe when you put weight on your toe for approximately five to six weeks.

Will I need physiotherapy after my surgery?

The physiotherapist will see you on the day of your surgery to make sure you are safe in your surgical shoe and crutches. Usually no further physiotherapy is needed but an appointment can be made if needed.

When can I start driving again?

This is a difficult question to answer as it varies between patients. Your healthcare professionals are not able to take responsibility for this. You will need to check with your insurance company as to when they will be willing to insure you to drive again. It is important not to be in a cast or boot when driving, and you must be able to do an emergency stop safely before driving again.

When can I return to work?

This will depend on how much your work needs you to put weight on your affected toe. If your work is sedentary (you mainly sit at a desk) and you can keep your foot elevated, then you can return to work after two weeks. If this is not possible, and your job is more active, you should expect to return to work after six weeks.

What are the risks?

As with any surgery there are risks, and these will be discussed in more detail when you speak with your surgeon. However, common complications include the following.

• You can expect swelling for up to 12 months, particularly in the evenings.

• The position of your ankle and foot may not be satisfactory after fusion. Although this is rare, it can be significant if it does happen and you may need further surgery.

• Infection rates are low, and antibiotics are given before any surgical treatment begins. However, if infection does happen this can cause significant problems. If you get a skin infection, this can be managed with antibiotics. If there is a deep infection, it may be necessary to remove all the metalwork and unhealthy bone, combined with a long course of antibiotics.

• Nerve injury can result in numbness or tingling over your foot. This is usually temporary, but in a small number of cases this may become permanent.

• Non-union (when the bones do not join together successfully) can sometimes happen with fusion surgery. There is increased risk of this happening in smokers and it may result in pain if the metalwork then loosens. If you smoke we recommend that you stop before surgery and do not start again until the fusion has healed or, better still, quit altogether.

• Although rare, metalwork can become noticeable through your skin and cause pain from irritation. If this continues the metalwork may need to be removed.

• Complex Regional Pain Syndrome (CRPS) can develop when the nerves around the operation site become overly sensitive. Swelling, skin changes, and stiffness can happen and make you feel weak. This is rare but if it does happen it is usually managed by a specialist in pain management.

• Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) is rare with this surgery. However anticoagulation medication is given after surgery to try to prevent clots forming whilst you are not able to move your leg. This is a preventative measure, but a clot can still form despite this.

What if I have any questions or concerns once I return home?

You can contact the team secretary through the hospital switchboard if you have any questions before your surgery (please refer to your appointment letter).

After surgery you can call the team secretary, the ward, or your GP if you have any further concerns or questions. If you are concerned and cannot get in touch with anyone go to your nearest Emergency Department.