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Hallux Rigidus Surgery
Hallux rigidus usually develops in adults between the ages of 30 and 60 years. We don’t know why it appears in some people and not others. Hallux rigidus is a disorder of the joint located at the base of the big toe. It causes pain and stiffness in the joint, and with time, it gets increasingly harder to bend the toe. Hallux refers to the big toe, while rigidus indicates that the toe is rigid and cannot move. It may result from an injury to the toe that damages the articular cartilage or from differences in foot anatomy that increase stress on the joint. If wear-and-tear or injury damage the articular cartilage, the raw bone ends can rub together. A bone spur, or overgrowth, may develop on the top of the bone. This overgrowth can prevent the toe from bending as much as it needs to when you walk. The result is a stiff big toe or hallux rigidus.
Hallux Rigidus Symptoms
Most patients present with a complaint of pain in the big toe joint while active, especially when pushing off to walk. Others note swelling and stiffness around the big toe joint or an inability to bend the toe up or down. A bump, like a bunion or bone spur, can develop on top of the big toe joint and be aggravated by rubbing against the inside of a shoe.
Cause of Hallux Rigidus
The true cause of hallux rigidus is unknown. However, several risks factors have been identified and include an abnormally long or elevated first foot bone (metatarsal), differences in foot anatomy, prior traumatic injury to the big toe and family history. Most of these risk factors cause damage to the surfaces of the bone and lead to wear and tear of the joint, which in turn leads to arthritis.
In many cases, the diagnosis of hallux rigidus can be made by a Podiatrist on physical examination alone. He or she will examine the foot for evidence of bone spurs and check the MTP joint by moving it up and down to see how much motion is available without pain. X-rays may be performed to help understand the extent of joint degeneration and to show the location and size of bone spurs.
Nonsurgical techniques can often be used to successfully treat patients with varying degrees of severity of hallux rigidus. However, when the condition is refractory to nonoperative treatment methods, there are a number of procedures that can be employed as treatment. The choice of operation depends on the degree of involvement, the range-of-motion (ROM) limitations, the individual’s activity level, and the surgeon’s and patient’s preference. Options include the following:
Joint-sparing procedures, such as cheilectomy, with or without proximal phalanx osteotomy (Moberg procedure)
Metatarsal (MT) osteotomy
- Infection: Risk is less than 1%. Antibiotics are given before surgery to prevent infection.
- Bone healing problems: Uncommon. The risk is increased in smokers and people who are too active after surgery.
- Wound healing problems: Uncommon. The risk is increased in people with Diabetes, poor blood supply, and smokers.
- Allergic reaction to medications: Uncommon.
- Blood clot: Rare. In fact, the risk of taking blood thinners to prevent a blood clot is greater than the risk of getting a blood clot after foot surgery; therefore, blood thinners are only used in patients who have a history of blood clots and are at high risk of developing another blood clot.
- Anesthetic or Medical problems and Death: Very rare. The risk depends on how many and what kind of medical problems each patient has. Death is extremely rare.
- Malposition of the toe: This occurs infrequently with fusion due to technical issues of trying to position the toe for standing and walking while the surgery is done with the patient lying on the operating table.
- Continued pain or stiffness: This does not occur with fusion, but may occur with the cheilectomy and joint resurfacing.
Outpatient Surgery: Surgery is performed in a free-standing outpatient surgery center or hospital. Usually, patients go home one to two hours after surgery when they are awake, eating, drinking, and using the restroom without difficulty. After surgery, the foot is covered with a bulky, compressive bandage. It is common to see blood on the bandage and it may seem like a lot of blood! But it isn’t. It seems like a lot of blood because the blood spreads out as it is absorbed by the cotton gauze bandage – much like a drop of water spreads out on a paper towel. Do not worry about blood on the bandage. If the presence of blood is uncomfortable or bothers you, call the office and we will arrange a time for you to come in to have the bandage changed.
Anesthesia: “Local MAC,” general or spinal anesthesia can be used depending on your preference and particular circumstance. Local MAC stands for Local anesthetic andMonitored Anesthesia Care. An IV is started and an anesthesiologist gives you medication that makes you very drowsy but allows you to breathe on your own. A local anesthetic is used to numb the foot. The local anesthetic usually lasts well beyond the time it takes to perform the surgery; therefore, helps with postoperative pain.
Pain Control: Typically, you will take your first dose of pain medicine before you go home, often before pain is experienced. The best way to control pain is to “stay ahead” of the pain. The local anesthesia used during surgery usually controls the pain for 6 to 8 hours after surgery. This gives you a head start on controlling the pain. For the best pain control, pain pills should be taken every 4 hours for the first 2 days after surgery. At night, set a single dose of pain medication and a glass of water on your bedside table. If you wake up during the night, take the medication. On the 3rd day after surgery, begin taking the pain medication on an “as needed” schedule. Remember, to stay ahead of the pain, the medication must be taken before the pain gets out of control. Once the pain gets out of control, it is very difficult to “catch up” with the pain. Don’t worry about using a lot of pain medication the first week after surgery. You won’t become addicted to pain medication by using it for a week or two!
Nausea: Nausea is a common side effect of anesthetic and pain medications. Therefore, nausea medication is prescribed routinely. During the first 2 days after surgery, take the nausea medication regularly. If you have a history of severe post-op nausea, please let us know. There are additional measures we can take to minimize this unpleasant side effect.
Walking: In most cases, you will be allowed to walk on the operated foot immediately. Even though you are allowed to walk on the operated foot, it may be uncomfortable, so bring a walker or crutches. Please to rent a walker or crutches before surgery and plan to use them for the first week or two after surgery.
Swelling: It is common to have swelling after foot surgery and often it lasts much longer than you would like! The best way to control swelling is to elevate the foot above your heart as much as possible during the first two weeks after surgery. It is best to take two weeks off work after surgery so that the foot can be elevated and swelling minimized.Getting back into regular shoes may take several months because of swelling.
Healing: Bone typically takes 6 weeks to heal so you will wear a stiff post-op shoe or protective boot for a minimum of 6 weeks after surgery. During this time, avoid excessive or unnecessary walking. If you like to exercise, riding a stationary bike, placing your heel on the pedal is OK.
Driving: Do not drive until you are able to respond in an emergency (i.e. slam on the brakes). This usually occurs after the bone has healed – 6 weeks.
Shoes: Expect to wear “foot friendly shoes” when the bone is healed and the swelling has decreased. Sometimes swelling persists beyond 6 or 8 weeks. In the summertime, sandals are a good option. In the winter, buy a pair of roomy shoes that fit the swollen foot. If the shoe for the non-operated foot is too big, buy an inexpensive cushion insole to put into the shoe. Most shoes that you wore before surgery will fit after the swelling goes down, but it is best to get rid of tight shoes and shoes that have a narrow, pointed toe box.
Dr. Ahmadi offers the most advanced state of the art techniques for pain-free surgical and non-surgical treatment of any foot and ankle pathology. His goal for each patient is painless and pleasing results with early return to activity. Dr. Ahmadi offers services in a wide variety of foot and ankle deformities and pathology such as: