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Big Toe Arthritis (Hallux Rigidus)

What Is Big Toe Arthritis (Hallux rigidus)?

Please see foot & ankle anatomy for more information about the big toe (1st MTP) joint.

Arthritis is disease (damage) of cartilage. Cartilage lines the surface of the bones where two or more bones form a joint. Cartilage allows smooth and frictionless movements. Disease of cartilage leads to roughened surfaces which causes friction and increased wear and tear in the joint. This in turn can cause inflammation, pain, and joint deformity.

Big toe arthritis (Hallux rigidus) is when arthritis involves the big toe (1st MTP) joint.

Hallux is the latin word for big toe. Rigidus is the latin word for stiff. Hallux rigidus therefore means stiff big toe which is how arthritis of the big toe typically presents.

Hallux rigidus is the second most common condition affecting the big toe after bunion (hallux valgus). It is also the most common arthritic condition in the foot.

Radiographs of the foot demonstrating: A - normal 1st MTP joint, B - mild arthritis in the 1st MTP joint (blue arrow), C - severe end stage 1st MTP joint arthritis with bone on bone changes

Radiographs of the foot demonstrating A – normal 1st MTP joint B – mild arthritis in the 1st MTP joint (blue arrow) C – severe end stage 1st MTP joint arthritis with bone on bone changes

What Can Cause It?

Any condition that damages the cartilage (joint surface) will cause big toe arthritis (Hallux rigidus) to develop.

The common conditions that cause big toe arthritis arthritis are:


Radiograph of both feet in a patient with a bunion deformity on the right foot. Note the normal 1st MTP joint (white circle) on the left and the arthritic joint (yellow circle) on the right

Radiograph of both feet in a patient with a bunion deformity on the right foot. Note the normal 1st MTP joint (white circle) on the left and the arthritic joint (yellow circle) on the right

What Are The Symptoms?

Typical symptoms of big toe arthritis (Hallux rigidus) include:

  • Pain
    • Painful stiffness in the morning
    • Eases off with activity but later becomes constant
    • Worse in cold damp weather
    • Exacerbated by weight bearing, walking and standing
    • Pain worse at push off when big toe is bent
    • Limits activities (reduced walking distance, unable to do sports)
    • Limp
    • Painful bump on top of the joint (large dorsal osteophyte)
  • Swelling
  • Reduced movement in the joint (stiffness)
  • Change in joint shape (joint deformity)
  • Numbness or nerve pain, pressure on dorsal cutaneous nerve from large dorsal osteophyte
  • Transfer metatarsalgia

Typical site of big toe (1st MTP) joint arthritis - note the swelling in the joint

Typical site of big toe (1st MTP) joint arthritis – note the swelling in the joint

Clinical picture of a patient with big toe arthritis presenting with a painful prominent bump (dorsal osteophyte)

Clinical picture of a patient with big toe arthritis presenting with a painful prominent bump (dorsal osteophyte)

 


Grading a disease in medicine is used for the following reasons:

  • Assessing the severity of a condition
  • For accurate record keeping 
  • To help monitor disease progression
  • For ease of communication between colleagues for example
  • In some cases to give information on prognosis
  • In some cases to help guide treatment

We use the following grading system at The London Foot & Ankle Clinic for big toe (1st MTP) joint arthritis:

  • Grade 0 – Some stiffness but normal joint on x-ray
  • Grade 1 – Mild pain on end range of motion with minimal x-ray findings (small dorsal bump)
  • Grade 2 – Moderate pain on end range of motion, mild to moderate x-ray changes
  • Grade 3 – Constant moderate to severe pain with severe changes on x-ray
  • Grade 4 – Severe pain throughout range of motion, very stiff, bone on bone x-ray findings

Transfer metatarsalgia

In many patients with an arthritic 1st MTP joint, the body compensates for the stiff painful joint by offloading the big toe joint.

However the big toe joint is designed to withstand approximately 40 to 50% of body weight during normal gait and this increases substantially with running and jumping. If it is no longer working (defunctioned), then the load has to borne by something else.

This happens to be the other metatarsal bones and lesser MTP joints starting with the 2nd.

Radiograph demonstrating transfer metatarsalgia

Radiograph demonstrating the load transfer in transfer metatarsalgia

Clinical picture demonstrating offloading of the left 1st MTP joint (white arrow) and increased load as a result on to the 2nd metatarsal (blue arrow)

Clinical picture demonstrating offloading of the left 1st MTP joint (white arrow) and increased load as a result on to the 2nd metatarsal (blue arrow)

What Investigations May Be Required?

Investigations help confirm the diagnosis, grade the severity of the condition and where applicable, aid in pre operative planning.


Plain radiograph (x-ray)

Plain radiographs are a quick and effective way of confirming big toe (1st MTP) joint arthritis in a joint. In the early stages of the condition, when there is inflammation with no obvious damage to the joint, radiographs may be normal. Most people however present when there is some structural damage.

The following are features of arthritis on a plain radiograph:

  • Decreased joint space
  • Subchondral sclerosis
  • Subchondral cysts
  • Osteophytes
  • Deformity (change in foot shape)
Radiograph (x-ray) of an arthritic big toe (1st MTP) joint with a massive growth of bone on the top of the joint (dorsal osteophyte)

Radiograph (x-ray) of an arthritic big toe (1st MTP) joint with a massive growth of bone on the top of the joint (dorsal osteophyte)


MRI

MRI is not generally required to make the diagnosis. Occasionally patients with early disease and minimal changes on an x-ray may benefit from an MRI as it will show damage to the cartilage and related changes of arthritis. An MRI provides excellent high definition static images.

MRI is particularly useful in assessing:

  • Cartilage loss
  • Central defects
  • Reactive bone changes
  • Effusion
  • Synovitis
  • Any other pathology
MRI of the big toe (1st MTP) joint demonstrating central area of damage to the cartilage

MRI of the big toe (1st MTP) joint demonstrating central area of damage to the cartilage


Ultrasound

Ultrasound is a quick, painless and non invasive method of assessing soft tissue structures.

Ultrasound is particularly good at ascertaining:

  • Presence of inflammation in the lining of the joint (synovitis)
  • Evidence of fluid in the joint (effusion)
  • Evidence of adjacent soft tissue structure pathology such as tenosynovitis

Can The Problem Get Worse?

The natural history of big toe (1st MTP) joint arthritis is very variable, some patients describe a rapid deterioration, while others take many years to get worse.

The changes associated with arthritis are irreversible, the joint will never return to its normal healthy state. That is not to say that all patients are symptomatic, some patients describe stiff joints with mild ache and are able to manage their symptoms with activity modification. However some patients describe significant pain and functional limitation.

You should see an Orthopaedic Foot & Ankle Surgeon if one or more of the following applies to you:

  • Pain affecting your quality of life
  • Pain affecting your ability to work
  • Your pain is getting worse
  • You have night pain
  • You have rest pain
  • You can no longer exercise or participate in sports to the level you desire
  • You have started to develop deformity in your foot or ankle
  • You have a swelling of unknown cause
  • You are unsure about the underlying diagnosis (cause of your symptoms)
  • Failure of conservative measures such as rest, time, anti-inflammatories and physiotherapy
  • Problems with footwear

As the arthritis becomes more severe and any deformity becomes fixed, adjacent joints will also become involved and become arthritic.


Transfer metatarsalgia

Patients may present with no or little pain in the big toe joint because they are not putting any load on the big toe joint, and transferring it to the other toe bones in the foot (metatarsals). Symptoms may arise due to transfer metatarsalgia.

As discussed above this occurs due to offloading of weight from the big toe and transferring it to the other metatarsal bones starting with the 2nd.

Patients with transfer metatarsalgia may present with the following problems:

Sites of problems (pathology) as a result of transfer metatarsalgia. A - 2nd MTP joint synovitis, B - 2nd metatarsal stress lesion/stress fracture, C - 2nd TMT joint arthritis, D - intermetatarsal bursitis, E - Morton's neuroma, F - toe deformity

Sites of problems (pathology) as a result of transfer metatarsalgia A – 2nd MTP joint synovitis B – 2nd metatarsal stress lesion/stress fracture C – 2nd TMT joint arthritis D – intermetatarsal bursitis E – Morton’s neuroma F – toe deformity


A - 2nd metatarsal stress fracture due to transfer metatarsalgia as a result of 1st MTP joint arthritis, B - healed 2nd metatarsal after 1st MTP joint fusion

A – 2nd metatarsal stress fracture due to transfer metatarsalgia as a result of 1st MTP joint arthritis B – healed 2nd metatarsal after 1st MTP joint fusion

Consequence of untreated 1st MTP joint arthritis A - 2nd MTP joint instability/synovitis, B - 2nd MTP joint arthritis, C - Midfoot arthritis

Consequence of untreated 1st MTP joint arthritis A – 2nd MTP joint instability/synovitis, B – 2nd MTP joint arthritis, C – Midfoot arthritis

Non-Operative Treatment Options

Non-operative management for 1st MTP joint arthritis aims at relieving pain and return to full activity including sports whenever possible. It is likely to be most effective in the early stages of the condition.

It should always be the first line of treatment. Options include:

Activity modification

A period of rest from sports and exercise that bring on symptoms. Avoiding high impact activities with lots of turning, twisting and bending of the big toe.


Footwear modification

A shoe with a stiff sole that prevents motion at the big toe joint will ease symptoms. A shoe with a wide and deep toe box that can accommodate any deformity and avoid any painful rubbing against shoes. A shoe with a rocker bottom can also ease symptoms. Avoid wearing high heels if not already doing so.


Insoles & orthotics

Custom orthotic with a stiff foot plate and big toe extension (Morton’s).


Non steroidal anti-inflammatories

The use of non-steroidal anti-inflammatory drugs (NSAIDs) can decrease discomfort in patients with big toe arthritis by reducing inflammation in the joint.


Analgesics

The use of paracetamol and other painkillers to help reduce pain levels.


Walking aids

The use of a walking stick or cane to reduce the forces going across the damaged joint.


Weight loss

Can relieve the pressure on painful damaged joints.


Dietary supplements

These are increasingly popular with people who have arthritis. The cartilage found in joints, normally contains glucosamine and chondroitin. It is thought that taking supplements of these natural ingredients may help to improve the health of damaged cartilage.

Research has provided mixed results but on the whole suggests that glucosamine sulphate is more likely to be helpful than glucosamine hydrochloride. If you are thinking of taking glucosamine, we suggest taking 1,500 mg per day of glucosamine sulphate. If you notice no improvement in your symptoms after 3 months then you should probably discontinue it. If you do find it improves your symptoms then you ned to continue taking the supplements. There is no extra benefit in taking glucosamine and chondroitin.

Remember that supplements also have side effects and it is advisable to discuss with your GP before starting any new treatment.


Other treatment options

There is no one treatment that has a reliably successful, quick and easy cure for arthritis. Therefore researchers and doctors are constantly looking for new and better ways of treating arthritis.

Many treatments have come into fashion and then gone away over the years once results had shown that the initial promise was premature and misplaced.

At The London Foot & Ankle Clinic we do not promote or discourage new treatment options for arthritis. We would however advise a cautious approach to relatively untested treatment modalities with little or no evidence to back their use. Patients undergo these treatments at their own risk.

Injections For Big Toe Arthritis

There are a number of treatments that involve an injection or series of injections for the treatment of big toe (1st MTP) joint arthritis.


Image guided steroid and local anaesthetic injection and manipulation under anaesthesia

This injection serves as both a therapeutic and diagnostic intervention. Steroids reduce inflammation and can ease painful symptoms. The local anaesthetic numbs an area of the body for roughly 12 to 48 hours.

The steroid is unpredictable in its success at easing painful symptoms but has very low risk of complications and therefore is an attractive therapeutic option prior to further more invasive surgical intervention. The local anaesthetic on the other hand is very predictable in its action. If there is an area of damage it will definitely ease symptoms for 12 to 48 hours. If symptoms do not ease during this period, one has to question whether the diagnosis is correct.

Steroids reduce inflammation and ease pain when injected directly into an arthritic joint. It is most likely to be effective in the early stages of arthritis.

We carry out almost all injections under a short general anaesthetic (1 minute) as injecting into a painful joint can be quite sore. While you are asleep and lying still a small needle is inserted into the joint and the position is confirmed using an x-ray in theatre. A small amount of dye is injected first to make sure the needle is in the correct spot and then a mixture of Depomedrone (steroid) and Bupivacaine (long lasting local anaesthetic) is injected. Undertaking the injection in this manner ensures a pain free experience for the patient and the best outcome clinically as there is no doubt about the placement of the injection.

The local anaesthetic will cause numbness in the area injected for approximately 12 to 48 hours. This action is predictable. What is not predictable is the duration of action of the steroid. It may work for one month, several months or even more than a year.

A manipulation of the joint is also carried out, the aim of this is to stretch the joint capsule and improve the range of motion.

Injections are not repeated less than 6 monthly intervals.

Please read here for more information regarding injections and possible complications.

A - Placement of fine needle in the 1st MTP joint, B - Radio-opaque dye confirms needle is in the joint

A – Placement of fine needle in the 1st MTP joint B – Radio-opaque dye confirms needle is in the joint


Image guided viscosupplementation

Normal joints have lubrication fluid called synovial fluid. A major constituent of synovial fluid is a substance called hyaluronic acid. This helps not only lubricate the joint but also act as a shock absorber easing the load across the joint.

It has been noted that people with arthritis tend to have lower concentrations of hyaluronic acid than normal.

Viscosupplementation involves injecting hyaluronic acid into arthritic joints. The procedure would be carried out as for a steroid injection under a short general anaesthetic and x-ray control.

Please read here for more information regarding injections and possible complications.

Operative Treatment Options

Surgical management is reserved for patients who have failed to respond to non operative treatment.

Patients should understand that the decision to undergo surgery should not be taken lightly.

Any intervention is considered in a step wise manner, with the least invasive procedure carried out first.

A variety of surgical options exist which need to be tailored to the individual and the stage of the disease:

  • Grade 0 to 1 – Manipulation under anaesthesia and 1st MTP joint injection
  • Grade 1 to 2 –
    • Cheilectomy – removing excess bone (osteophytes) and damaged tissue from the joint
    • Microfracture – this is a surgical technique for cartilage repair that works by creating tiny fractures in the underlying bone This causes new cartilage to develop from the resulting clot and growth factors released
    • Moberg procedure – closing dorsal wedge osteotomy
  • Grade 3 to 4 – 
    • 1st MTP joint fusion
    • 1st MTP joint hemiarthroplasty
    • 1st MTP total joint replacement

In summary patients with pain from a large bump on the top of the big toe (dorsal osteophyte and stiffness with no mid range pain are suitable for joint preservation surgery such as cheilectomy or a Moberg procedure.

Patients with constant pain and mid range pain require a 1st MTP joint fusion or a hemiarthroplasty.


Cheilectomy

Cheilectomy can be thought of as a “tidy up” operation. It involves the following:

  • Removing the large dorsal osteophyte from the 1st metatarsal head
  • Removing the dorsal 1/3 articular surface from the 1st metatarsal head
  • Synovectomy (removing the inflamed lining of the joint)
  • Removal of loose bodies
  • Removing excess bone from the dorsal aspect of the proximal hallux

This operation has a success rate of roughly 85%. Success here is defined as a pain free joint with a good range of motion. 15% of patients have persistent or recurrent symptoms due to continued progression of arthritis in the joint and presence of damaged cartilage in the middle of the joint.

The operation can be done using a minimally invasive surgical (MIS) technique or a mini open procedure. Whenever possible we attempt to carry out the procedure using MIS.

The advantage of a cheilectomy is that it is:

  • Joint preserving
  • Maintains motion at the joint
  • Maintains stability
  • Will not make any further surgery any harder or more difficult

The operation is undertaken under a general anaesthetic and as a daycase procedure.

An x-ray of the foot showing A - a large dorsal osteophyte, B - the bone removed during a cheilectomy

An x-ray of the foot showing A – a large dorsal osteophyte B – the bone removed during a cheilectomy

The operation tends to be more successful in patients who only have damaged cartilage in the periphery of the joint which is removed during the surgery. Patients with central areas of damaged joint surface tend not to do so well as the disease will continue to spread and involve a larger area of the joint.


Microfracture

This surgical technique is done in conjunction with a cheilectomy. In some patients with central small areas of damaged cartilage, fusing the joint is not desirable, especially when there is a lot of healthy cartilage still present and good range of motion in the joint.

Microfracture is a surgical technique used in hip, knee, ankle and big toe joints. It involves removing the damaged (loose, friable and unstable) cartilage and drilling the underlying bone creating microfractures. This stimulates the bone marrow underneath and forms a blood clot rich in growth factors which in turn promotes new cartilage formation. The new cartilage is called fibrocartilage and can be thought of as the equivalent of scar tissue in the skin. Not as good as the original tissue but better than nothing. It has similar characteristics and properties as normal hyaline cartilage but is not as robust and durable.

Good to excellent results can be expected in around 75% of patients in the short to mid term. Longer term results are difficult to predict. For patients not keen on a fusion or a joint replacement procedure this is a good option.


Moberg procedure – closing dorsal wedge osteotomy

The Moberg procedure is indicated in a select group of patients who require dorsiflexion of the big toe, for example runners and dancers. It may also be carried out in conjunction with or after a cheilectomy.

It involves removing a wedge of bone from the base of the big toe, which allows greater movement in dorsiflexion (lifting the big toe up), it does sacrifice movement in plantarflexion (pointing toe down).

The operation is undertaken under a general anaesthetic and as a daycase procedure.

In the Moberg osteotomy a wedge of bone is removed (yellow triangle), which allows greater movement in dorsiflexion

In the Moberg osteotomy a wedge of bone is removed (yellow triangle), which allows greater movement in dorsiflexion


1st MTP joint fusion

1st MTP joint fusion has excellent outcomes in terms of pain relief and return to activities of daily living.

It involves removing all remnants of the diseased joint (cartilage) and fusing the the bones so that no joint exists. With no more joint there will be no more movement and therefore no more pain. The aim is to sacrifice painful movement for pain relief.

The majority of patients when they first hear about this procedure are quite apprehensive. This is understandable, joints exist to allow movement. A fusion is the total opposite to this, and therefore most patients perceive it as unnatural. However contrary to what most people think, after a fusion you will be less likely to limp and be a lot more active. Please read this blog for more details.

The operation is usually carried out through one incision on the inside (medial) of the big toe joint. The operation is undertaken under a general anaesthetic and almost all cases are done as a daycase.

The main complication is non union (the bones not fusing together). This is reported in numerous studies to be around 5 to 10%. In the event of this complication, the operation is repeated with bone graft to stimulate the healing and given time most patients eventually heal.

Currently 1st MTP fusion remains the treatment of choice for end stage big toe (1st MTP) joint arthritis. There are 1st MTP total joint replacements but the indications and outcomes are controversial.

Patients who are only willing to undergo surgery once, should consider this procedure due to the higher failure rates and need for further surgery associated with 1st MTP hemiarthroplasty or total joint replacement.

After a 1st MTP joint fusion patients can wear a heel roughly 5 cm high.

A - Large bone growth (dorsal osteophyte) caused pain and difficulty wearing shoes, B - removal of bone growth along with 1st MTP joint fusion

A – Large bone growth (dorsal osteophyte) caused pain and difficulty wearing shoes B – removal of bone growth along with 1st MTP joint fusion

A - before and B - after radiographs (x-rays) of the foot after 1st MTP joint fusion (note one screw was removed as it was causing irritation)

A – before and B – after radiographs (x-rays) of the foot after 1st MTP joint fusion (note one screw was removed as it was causing irritation)

A 1st MTP joint fusion can be carried out using 1 or 2 screws or 1 screw and a plate.

Advantage of using only screws:

  • Smaller incision
  • Quicker healing
  • Less wound complications

Disadvantage of using only screws:

  • Have to remain non weight bearing for 6 weeks

 Advantage of using a 1st MTP joint plate:

  • Can weight bear immediately post surgery

Disadvantage of using a 1st MTP joint plate:

  • Larger incision
  • Potentially greater wound complications

1st MTP total joint replacement

Mr Charnley popularised the total hip replacement in the 1960s for the treatment of hip arthritis. It allowed for pain free joint movement and significant improvement in quality of life. Over the last 50 years there has been incredible advances in technology and biomaterial science. Many changes have been and continue to be made to the total hip replacement. Total hip replacements now have a success rate of around 99% at 10 years and around 90% at 15 years. It is undeniably an orthopaedic success.

Orthopaedic surgeons wish to replicate the success of the total hip replacement by creating similar joint replacements for other arthritic and damaged joints around the body.

In the 1970’s the total knee replacement was introduced and while not as effective as the total hip replacement has a success rate of around 95% at 10 years.

Since the 1990’s orthopaedic foot and ankle surgeons have been testing and developing 1st MTP total joint replacements. Currently 1st MTP total joint replacements are still considered to be “work in progress”. Studies do indicate excellent short term benefits in terms of pain relief and function. However mid to long term results are not so good and a significant proportion of patients require further revision surgery.

Most 1st MTP total joint replacements that fail will require a bigger operation than a routine 1st MTP joint fusion. Once the metal and plastic artificial joint have been removed, there will be a defect. This is typically filled with donor bone graft. A plate is then used to secure the toe to the rest of the foot. Complications and healing are much greater than a primary 1st MTP joint fusion. Anyone considering a 1st MTP joint replacment needs to bear this in mind.

So why consider a 1st MTP joint replacement?

  • Attempt to reproduce/maintain normal 1st MTP joint movement and function
  • Minimise risk of adjacent arthritic joint disease

Who would be suitable for a 1st MTP total  joint replacement?

  • Patients with primary or post traumatic 1st MTP joint arthritis
  • Low demand patients
  • Patients who meet the criteria for a 1st MTP joint fusion but reject it

Patients are not suitable for a 1st MTP joint replacement for the following reasons (contraindications):

  • Gross 1st MTP joint deformity 
  • Poor bone quality (severe osteoporosis)
  • Neuropathic  joint
  • High demand patients for example manual labourer

Complications of 1st MTP total joint replacement:

  • Loss of bone stock
  • Implant subluxation
  • Subsidence
  • Loosening
  • Infection
  • Post-operative stiffness
  • Implant breakage (Peri-prosthetic fracture)
  • Transfer metatarsalgia

The operation is usually carried out through one incision on the inside (medial) or the top (dorsum) of the big toe joint. The operation is undertaken under a general anaesthetic and almost all cases are done as a daycase.

Currently 1st MTP joint fusion and hemiarthroplasty are more predictable than a 1st MTP total joint replacement for alleviating symptoms and restoring function in patients with severe arthritis of the 1st MTP joint. Complications are also greater than with a 1st MTP joint fusion or a hemiarthroplasty.


Hemiarthroplasty

This operation has the advantages of the 1st MTP total joint replacement without its major complications. The procedure involves replacing one half (proximal hallux) of the damaged 1st MTP joint surface. Minimal bone is removed. Range of motion is maintained with this procedure. Indications, contraindications and risks are similar to those for 1st MTP total joint replacement although the incidence of complications is probably lower and the outcome better.

>Illustration demonstrating maintenance of range of motion at the 1st MTP joint following a hemiarthroplasty procedure

Illustration demonstrating maintenance of range of motion at the 1st MTP joint following a hemiarthroplasty procedure (image courtesy of Arthrex)

So why consider a 1st MTP hemiarthroplasty?

  • Attempt to reproduce/maintain normal 1st MTP joint movement and function
  • Minimise risk of adjacent arthritic joint disease

Who would be suitable for a 1st MTP hemiarthroplasty?

  • Patients with primary or post traumatic 1st MTP joint arthritis
  • Low demand patients
  • Patients who meet the criteria for a 1st MTP joint fusion but reject it

Patients are not suitable for a 1st MTP hemiarthroplasty for the following reasons (contraindications):

  • Gross 1st MTP joint deformity 
  • Poor bone quality (severe osteoporosis)
  • Neuropathic  joint
  • High demand patients for example manual labourer

Complications of 1st MTP hemiarthroplasty:

  • Implant subluxation
  • Implant malposition
  • Subsidence
  • Loosening
  • Infection
  • Post-operative stiffness
  • Transfer metatarsalgia

The operation is usually carried out through one incision on the inside (medial) or the top (dorsum) of the big toe joint. The operation is undertaken under a general anaesthetic and almost all cases are done as a daycase.

Potential Complications

It should be borne in mind that complications can result from a condition with or without surgery.


Potential complications of non-operative treatment include:

  • Worsening pain
  • Increased stiffness
  • Increasing deformity
  • Adjacent joint disease
  • Pain elsewhere, for example in the knee, hip or lower back (due to abnormal gait and compensatory mechanisms)
  • Transfer metatarsalgia
    • Stress fractures
    • Lesser toe problems
    • Midfoot arthritis

Complications can occur as with any type of surgery. Please see Complications for more detailed explanation of post surgical complications.

Potential general complications of any operative treatment include:

  • Risks and complications of anaesthesia
  • Bleeding
  • Infection (superficial and deep)
  • Blood clots
  • In the case of an MIS procedure it may be necessary to proceed to open surgery if during the operation it is felt that a better outcome will be achieved using an open technique
  • Failure to fully correct deformity (particularly if longstanding deformity)
  • Need for further surgery (revision or further treatment)
  • Persistent pain
  • Complex regional pain syndrome
  • Wound healing problems
  • Disuse osteopenia – when bone is not loaded normally it starts to weaken (similar to wasting of muscle when it is not used) this is only temporary as the bone will return to normal density once it begins normal use again

Potential specific complications of cheilectomy +/- microfracture include:

  • Stiffness
  • Continued pain and progression of arthritis

Potential specific complications of Moberg osteotomy include:

Potential specific complications of 1st MTP joint fusion include:

Potential specific complications of 1st MTP joint hemiarthroplasty and total joint replacement include:

  • Transfer metatarsalgia
  • Implant loosening 
  • Implant malpositioning
  • Implant subluxation
  • Subsidence
  • Infection
  • Post-operative stiffness
  • Implant breakage (Peri-prosthetic fracture)

A - before and B - after x-rays of a patient who had a 1st MTP joint fusion elsewhere which developed non-union, revised successfully at The London Foot and Ankle Clinic

A – before and B – after x-rays of a patient who had a 1st MTP joint fusion elsewhere which developed non-union, revised successfully at The London Foot and Ankle Clinic

X-rays of both feet 8 weeks after successful left 1st MTP joint fusion - note the disuse osteopenia (this is a temporary effect of non weight bearing and the bone will return to normal strength)

X-rays of both feet 8 weeks after successful left 1st MTP joint fusion – note the areas of disuse osteopenia (darker bone) – this is a temporary effect of non weight bearing and the bone will return to normal strength


Note – these complications are not exhaustive and are meant as a guide

Post Operative Period & Recovery

Please read the information regarding what to expect post surgery on this website.

Remember that below is a guide to recovery and that everyone heals at different rates and some people do take longer. Use this information to help you understand your condition, possible treatment and recovery. The timeframes given below are a minimum, it is important that you appreciate this when considering surgery as your healing and recovery may take longer.


Immediate post operative period

Almost all surgical procedures for big toe (1st MTP) joint arthritis will be undertaken as a day case.

You will have a bandage applied similar to this during the operation.

Post operative bandage around the foot

Post operative bandage around the foot

Please do not remove your bandages until you are seen by your surgeon Mr Malik at the two week post operative clinic appointment. You will also be provided with a stiff soled black post operative shoe. Please ensure you wear this whenever you are weight bearing.

Post operative stiff soled shoe

Post operative stiff soled shoe

Cheilectomy, Moberg procedure, 1st MTP joint fusion with a plate, 1st MTP joint hemi and total joint replacement

For the first 48 hours you will be allowed to touch weight bear using two crutches. After 48hrs you can weight bear as tolerate. The physiotherapist will guide you after your operation and before your discharge from hospital with the use of crutches and mobilising.

For the first two weeks following your surgery please keep your foot elevated to the level of your heart for 95% of the time. It is recommended you stay at home during this period.

High elevation of the foot and ankle following a surgical procedure

High elevation of the foot and ankle following a surgical procedure

Naturally most people do not have a hospital bed at home. The same effect can be achieved by lying in a bed or lengthways on a sofa, with pillows behind your back and under your foot. You cannot have your leg elevated sitting in a chair. It is strongly advised that during the first two weeks you are house bound.

To minimise risk of infection keep the foot dry and cool. Avoid humid and hot environments. Keep the foot dry and when showering wear a Limbo bag.

To minimise the risk of blood clots please move your foot and ankle at regular intervals. Please ensure you are well hydrated. If you have a risk of blood clots please notify Mr Malik who may organise for you to have blood thinning injections as a precaution.

In addition for a 1st MTP hemiarthroplasty – 

Early active and passive 1st MTP joint range of motion exercises are to commence at 48hrs post surgery. This is to ensure a good range of motion and prevent stiffening due to scar tissue. Patients are to keep their foot elevated for 95% of the time but can weight bear for short distances around the house for example when going to the bathroom.

In addition for a 1st MTP joint fusion with only screws – 

You will require to be strictly non weight bearing for 6 weeks. This does not mean you can walk on your heel, it means strictly that the foot cannot touch the ground.


Two weeks post operatively

You will be reviewed at the clinic and your dressings removed. Your wound will be checked.

Typical appearance of a wound post surgery. This patient adhered to the strict post-operative instructions.

Typical appearance of a wound post surgery. This patient adhered to the strict post-operative instructions.

The wound should be dry, minimal redness if any, slight bruising and with mild to moderate swelling. The foot will be more swollen and less well healed if it has not been kept elevated.

At this stage if the swelling has subsided sufficiently you will be advised to keep your foot in an elevated horizontal position (50-75% of the time). You will require to wear the special post operative shoe for another 4 weeks. Short trips can be made outside, within limits of pain and swelling.

Driving will be permitted for short trips if the left foot has been operated on and you drive an automatic. If the right foot has been operated on it will be at least 7 to 8 weeks before any driving is advisable. This is because the right foot is your braking foot and you need to feel safe to do an emergency stop.

Scar desensitisation should start as soon as the wound has completely healed. You can do this by massaging cream (E45 for example) into the scar and around the wound area.

Commence exercises of the lesser toes 3 weeks after surgery and continue for 3 months. These exercises included active resistive and passive toe flexion and extension. They also include intrinsic foot muscle strengthening exercises.

In addition for a 1st MTP joint fusion with only screws – 

You will require to be strictly non weight bearing for 6 weeks. This does not mean you can walk on your heel, it means strictly that the foot cannot touch the ground.


Six weeks post operatively

You will have radiographs taken just before you are seen in clinic. You will go over these with Mr Malik and compare the before and after operation images. For a fusion it will generally take at least 6 weeks to show evidence of fusion, sometimes it can take as long as 3 months particularly if you are a smoker.

At this stage if your healing is progressing satisfactorily swelling and bruising should have subsided considerably, although expect some degree of swelling for at least 3 to 4 months.

You will be able to start wearing normal footwear (swelling permitted) around 8 weeks post surgery, although stiff soled shoes are advisable.


Three months post operatively

Final clinical examination. Discharge if satisfactory.

FAQs

When can I drive?

Please see guidance above and information here. Ultimately it is the responsibility of the patient to decide if they are safe to drive. A good way of knowing is if you can stamp your right foot heavily on the ground to mimic an emergency brake. If you have any hesitation or pain then it should suggest you are not safe to drive. Remember prolonged driving involves keeping your feet in a dependant position. This will worsen the post operative swelling.

When can I return to work?

This really depends on you and your job. If you have a job that involves a lot of standing, walking and is manual it may be 8 to 12 weeks. If you have a sedentary job, for example in an office and you have a reasonable commute you may be able to go back to work at 2 weeks, although this would be exceptional and not the norm.

What should the final outcome be?

Excellent pain relief and deformity correction. Ability to participate in sports by 6 months. Sometimes up to a year before the foot feels “normal” and fully healed.

Can I play sports after a 1st MTP joint fusion?

Yes you should be able to participate in most sports. Certain activities that require the big toe to bend significantly may be difficult, for example certain Yoga positions.

A Patient's Experience - 1st MTP joint fusion - Pauline Risk October 2016

What made you decide you needed to see a foot surgeon?

I was experiencing pain in my feet.  It was worse when playing golf/walking and when wearing most shoes.  I didn’t want the pain for the rest of my life, knew the pain would only get worse and didn’t want to be in a position whereby I couldn’t do things I enjoy, like playing golf.

I spoke to a friend who has had a similar operation and recommended Mr Malik.  I visited Mr Malik and I took confidence in his assessment.  He advised me I should have the left foot operated first, as it was the worse foot.

What were your concerns and anxieties?

The thought of having an operation, the recovery and whether the operation would be successful.

What was your experience of the surgery and recovery?

The operation wasn’t as dramatic as I had anticipated.   I was surprised how quickly I recovered from the general anaesthetic and was able to go home late afternoon.   Before leaving the hospital Mr Malik  gave me guidance to ensure a speedy recovery.  He gave me his contact details in case I had any concerns.  Three days after the operation his Secretary called me to ask how I was doing, so she could feedback to Mr Malik, which I thought was a nice touch.

For the first two weeks I had to keep my foot elevated 95% of the time, took pain killers for six days and consequently didn’t experience any pain.

I purchased a small stool to put in the shower and used it beside the basin when cleaning my teeth.  I purchased a limbo bag to avoid my foot getting wet when showering.

After two weeks I visited Mr Malik who removed the dressing from the foot and I was pleased how it was recovering.  For the next four weeks I had to keep my foot elevated 75% of the time.

For the six weeks after the operation I have had to use crutches as I haven’t been able to put any weight on my foot.

The recovery at times has been frustrating as I’ve been unable to do things for myself and around the home.  I put it into perspective telling myself it’s only for six weeks, which isn’t very long.

I am now booked in to have the right foot operated.

What was the most challenging part of having your operation?

Not being able to put weight on my operated foot.

What advice would you give to future patients with a similar problem?

Don’t put off the treatment as your pain won’t improve.

Prepare yourself for the operation.  My husband doesn’t cook so I prepared meals in advanced and put them in the freezer and ensured I had lots of reading material and my ipad close to hand.

Listen to exactly what Mr Malik tells you.  Mr Malik is very passionate about his work which means patients benefit.  I highly recommend him.

 

– Pauline Risk October 2016

A Patient's Experience - 1st MTP joint Interposition Arthroplasty - H Walters March 2016

What made you decide you needed to see a foot surgeon?

I am a patient who has had rheumatoid arthritis (RA) for the last 30 years, over the years my joints have eroded away and my feet and toes have become very deformed and have caused a lot of pain, I was referred by my rheumatoid consultant to see Mr Malik.

What were your concerns and anxieties?

All types of surgery require a general anaesthetic, which gives reason for concern. Due to having a past history of sickness during anaesthetics I was concerned this would be the case again.

Whilst I could still walk although in pain, I was worried the operation may not be a success and therefore reduce my ability to walk even more.

What did you think after my first consultation?

After my first consultation with Mr Malik I knew he was a dedicated surgeon passionate about his work, he made it clear that to achieve the most successful results you had to commit to his instructions. I liked his direct honest approach, giving me all the facts pro and cons allowing me to make a decision on whether to proceed with the operation.

Why did you decide to go ahead with the surgery ?

After having numerous operations in the past due to RA, I knew that I had to have the operation to maintain my quality of life. I knew that due to my age I needed to proceed now while I am fully able to cope with the recovery.

What was the experience of the surgery and recovery ?

The surgery was done as a day patient, I was treated excellently from the moment I arrived, I was put at ease by all staff concerned.

The anaesthetist assured me he would add an anti sickness drug to the anaesthetics , this proved to be very successful as I did not experience any sickness.

Following the guidance of Mr Malik I returned home and stayed with my foot elevated above my heart for 90% of the day, although this was hard to achieve I was determined to do as instructed by Mr Malik as I wanted the operation to give the best result possible.

I was surprised that a few days after the operation the pain was minimal and required only a small amount of pain relief.

After two weeks I returned to see Mr Malik who was very pleased and knew on first glance that I had followed his instruction perfectly, as my foot and toes had no swelling and were both healing well.

I then had 4 weeks at home where I was allowed to take short breaks, but 70 % of the day I had to have my foot elevated ie on a chair / stool.

On my final visit I had the pins removed and my foot re x-rayed and the results were amazing, I left the hospital feeling happy and confident that  I will now have no fears about having the other foot operated on.

What advice would you give to future patients with a similar problem?

My advice to anyone that has RA and deformed feet like I have, is don’t put the operation off, I should have sought help earlier.

Basically don’t let any fears put you off as you are in very safe hands with Mr Malik.

A Patient's Experience - Cheilectomy - Rachel Stock February 2016

What made you decide you needed to see a foot surgeon?

I hurt my foot by falling off a step stool onto a very hard stone floor. Some weeks after the initial pain subsided I realised that the joint of my big toe was sore and maybe swollen. I didn’t think much more of it – I’m in my early/mid forties and have always thought of myself as pretty tough and too young to get joint problems. Over the next couple of months I noticed some pain and discomfort whilst walking. Eventually – mainly prompted by the fact that I could suddenly not wear heels without being in significant pain – I contacted my GP and then my medical insurers who referred me to a consultant at a different hospital – not Mr Malik – who diagnosed an arthritic toe joint and I had cortisone injections into the joint. These injections didn’t make any noticeable difference and so I thought that perhaps this was something I would just have to put up with. The surgeon (not Mr Malik) told me that the next step would be to have the 1st MTP (big toe) joint fused and I was a bit young for that.

I then happened to be chatting to my osteopath a couple of months later and mentioned my foot problem and she recommended Mr Malik who had successfully treated her. I went on to have a cheilectomy and microfracture on the toe to help remedy the problem.

What were your concerns and anxieties?

I was apprehensive about having surgery for a number of reasons. Firstly I’m more of a ‘don’t make a fuss’ person and I thought if I can walk then maybe I’m just making a fuss. And after a while I just learnt to put up with it. I was also concerned that maybe it was an unnecessary operation, and of course operations come with risks so it you can avoid having one then that must be a good thing. I also worried that maybe it wouldn’t be a success.

I think also when you live a busy life like me with children, a full time busy job in London with a long commute and a hectic social life, there are just too many reasons why it isn’t convenient in the diary and you can’t find time to recuperate.

What did you think after your first consultation?

After the first consultation with Mr Malik I realised that there was an operation – the cheilectomy – that I hadn’t previously been told about. We discussed the potential success rate and risks and the unknown nature of the outcome and I went away to think about it.

It was also at this consultation that I was told why the joint on my fourth toe was hurting as well, due to transfer metatarsalgia and I realised that the damage being done to my foot was probably more than I had considered.

Why did you decide in the end to go ahead with the surgery?

I took some time to think about it and I had a busy year with holidays and some big diary commitments at work so I delayed really thinking more about the surgery. However I began to realise that my foot was steadily getting more uncomfortable and was definitely not getting better.

I decided to go back for a second consultation at which I decided to have surgery. The decision was really prompted by the realisation that the condition was getting worse, even wearing sensible shoes and it was more likely to continue to deteriorate. I felt that an operation was now my best chance of slowing down the deterioration and possibly reversing it, and at worst it may not improve it at all.

I decided I didn’t want to regret not having it later on when perhaps the only option would be a big toe (1st MTP) joint fusion.

What was your experience of the surgery and recovery?

The surgery was very straightforward. A day case, so home the same day. And my recovery has been good, the swelling has gone down, and I only took pain relief for a few days and although I had a couple of early days when it was sore, it is a pretty bearable experience. But I did underestimate how much care I would need to take in the early days post op. I had thought that I’d be able to get into work (with my 90 min commute) maybe 2 or 3 weeks post op. That 4/6 weeks mainly off your foot, really is off your foot. And that to get the best outcome you need to really listen and follow the instructions of Mr Malik. It’s an investment to try and protect the joint and although it’s been frustrating watching people go out for long walks and grab that blue sky and sunshine whilst I sit at home with the foot elevated, the surgery would be a waste of time if I didn’t take the after care seriously. And after waiting all this time to have the operation, I’m going to do everything I can to ensure it’s a success. So 2.5 weeks post op, all good so far.

What advice would you give to future patients with a similar problem?

Have the surgery much sooner and don’t delay. Listen to your feet and don’t think ‘maybe I’m making a fuss’ or ‘maybe it’s not that bad’ and as my foot didn’t really look much different to the other one I thought it can’t really be that bad. I left it too long – and that was only a few months delay – and I should have opted to have it straight away after my first consultation.

As a result my cartilage continued to wear away and loose cartilage aggravated the rest of the joint. So my long term prognosis is less positive that it might have been if I had acted earlier. The other thing I’d say is, talk to other patients who have been through it – people like me – who can reassure you that what you think your foot is telling you, is right. Listen to your joints.

– Rachel Stock February 2016

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