What is Big Toe Arthritis?
Arthritis describes a joint that is inflamed. The big toe can be affected by inflammatory arthritis, when the body attacks one component of the joint, or by osteoarthritis, when wear and tear changes occur within the joint. The wear and change variety is commonly called Hallux Rigidus, as the joint becomes stiff.
Big toe arthritis is most commonly the result of osteoarthritis. The joint can become painful due to chemicals released by damage to the joint. Extra bone forms around the joint. This can limit the movement of the joint. Also, a nerve running over the joint becomes stretched, especially with downward bending of the toe.
Movement of the joint is required to allow normal walking. If the joint is painful, the foot may compensate by adopting an abnormal position, such as walking on the outer border of the foot. The extra pressure on the balls of the foot can be painful. Also, if upward bending is limited, the foot tends to turn outwards to allow ‘toeing off’ in walking.
The joint can become progressively more painful, and the extra bone around the joint may prevent normally sized shoes being worn.
If you have big toe arthritis, it is best to see an orthopaedic surgeon who specialises in foot and ankle surgery. You should have x-rays taken in a standing position – this will show the position of the bones in your walking position, and help decide what treatment you need.
How is the Surgery Performed?
If you have an arthritic big toe, then several different operations are possible, but the choice depends on how much pain you have, how much you want to keep movement, and how much risk you are willing to accept from surgery.
If you have pain, but there is no visible sign of arthritis or only very early signs of arthritis on an xray, then a camera examination of the joint through keyhole surgery may confirm the diagnosis and allow treatment.
If there are spurs on the bones around the joint, then the joint movement and pain may be relieved with a trimming of the spurs. This is called cheilectomy.
If the joint is completely worn out, then you may choose to have the joint fused or replaced.
Pain arises in the joint from rubbing of two worn surfaces. Fusion aims to join the bones together surgically so that there is no movement and hence no pain. This is the gold standard operation as it is the most reliable. However, movement in the joint is lost permanently. It is still perfectly possible to walk long distances without any problems.
Replacement of the joint aims to maintain movement of the joint – for sports and recreation. This is less reliable for pain relief, and if pain persists to a level that interferes with day to day activities, then a fusion operation is all that is possible. Joint replacements in the foot are not as advanced and reliable as joint replacements in the hip or knee, and should not be thought of as equivalent.
The choice of fusion or replacement hinges on the advantages and disadvantages of each and what your own requirements are from surgery. Fusion is the most reliable for pain relief, and does not lead to an abnormal walking pattern.
Often, surgery is required for hammer toes or metatarsalgia if this exists, and it will be performed at the same time.
Surgery is carried out under general anaesthetic, but can be carried out with local anaesthetic injections behind the knee or around the ankle. The injections are normally given while you are asleep for your comfort. They can give good pain relief for the first day after the operation. You can go home the same day in the evening.
Risks of Surgery
Bleeding, infection, poor bone healing, poor skin healing, injury to tendons, injury to nerves, recurrence, and a need for further surgery.
There is a small risk of blood clots in the legs or lungs (DVT and PE), and there are also risks from anaesthesia – the process of being put to sleep for your operation.
Risks of Anaesthesia
The injection behind your knee is given using an ultrasound machine to guide the needle. There is a less than 1% chance of injury to the nerve. General anaesthetic also carries risks. These risks are proportional to your general health. You will need to be assessed for your fitness for surgery and an Anaesthetist will be able to advise you on your individual risk.
What Happens After Surgery?
The rehabilitation that you require depends on the operation that you have had, and how severe the arthritis is. If you have had the joint shaved , or had a camera examination, or had a joint replacement, then you will have a flat postoperative shoe and you will need to perform exercises immediately. If you have the big toe joint fused, then you will have a wedged heel postoperative shoe, and will not need to perform any exercises.
You will have had injections to numb your foot so that you are not in pain after the operation. This injection will wear off after 18-24 hours, so you must take regular painkillers so that you are not in severe pain when the injection wears off. Ibuprofen and Diclofenac should not be used for more than a few days after the operation as they can interfere with bone healing.
The pain will settle over a few weeks. You may see blood stains on the dressings. This is normal and not a cause for alarm. If blood is dripping from the dressings however, return to hospital.
The foot will be swollen as well as sore. You should keep the foot elevated as much as possible for the first two weeks. Keep walking down to a minimum – going to the toilet or for meals. Letting the leg hang down will cause the foot to become more swollen. Most of the swelling will settle within the first few months, but swelling can continue for up to one year.
If you are resting on your sofa, keep your foot elevated on the back rest or arm rest. If you are resting in bed, then place a few pillows under the foot to keep it elevated.
You have been given a special shoe that does not allow you to put weight on the front of the foot. This is because the re-set bone is held together by two screws, and putting weight on it can dislodge the screws holding the bone. You should wear this continuously for the first two weeks, including in bed. After that, you should wear it whenever you are walking, even at home. Crutches are for balance only.
Immediately after joint shaving and joint replacement surgery, you should be performing the exercises shown to the left to prevent any joint stiffness. You should hold the toe firmly and bend the toe up as far as possible and then down as far as possible. Repeat this exercise ten times, four times every day.
No exercises should be performed on a joint that has been fused, as this may stop the bones from fusing together.
After two weeks, you will be seen in the clinic and the stitches will be removed.
RETURNING TO WORK
If you have had a fusion, you will be wearing the special shoe for six weeks, and we will then take an xray. If you have had a joint shaving or replacement, then you can wear flexible soled shoes such as training shoes as soon as the stitches have been removed. I advise that you do not return to work before this, especially if you are on your feet all day at work. Most people can drive after 8 weeks. Remember that not everyone is the same, and some people take a longer time to recover from their surgery. Please request a sick note before you leave hospital, if you need one.