Big toe arthritis surgery

Do you have a painful joint at the base of your big toe? Is it stiff, or does it hurt if you try to run or walk too far? Is your big toe joint swollen, or rubbing in your shoes?

If so, you might have a wear and tear form of arthritis (osteoarthritis) in the big toe joint (metatarsal phalangeal joint).  When the toe becomes very stiff, we called it ‘Hallux Rigidus’.

Big toe arthritis surgery may be an option for you.

Big toe arthritis

 

Big toe arthritis is more common in people who’ve led a very active life and have played lots of sports, and it’s more common if you’ve ever had trauma to your toe.

As the joint wears, the articular cartilage that lines the joint deteriorates, and the body responds by producing bony growths (called osteophytes), which limit the movement of the joint.

When we meet, I’ll be asking you lots of questions about how your toe is affecting your life, and I’ll examine your foot, and also take some X-rays.

 

What are the treatment options for big toe arthritis?

 

In the early stages, patients can often be helped with a steroid or hyaluronic acid injection to settle the joint, and physiotherapy and podiatry to improve the toe’s function.

With time and disease progression, this becomes no longer sufficient, and so we may need to consider active intervention.

There are three kinds of procedures that we may consider:

 

Minimally invasive cheilectomy

 

This is a surgery to essentially remove the bony bumps (osteophytes) at the top of the joint that are blocking the movement of the big toe joint, and it’s a day case surgery that’s carried out under a local or light general anaesthetic. It’s carried out through a single tiny incision around the toe joint  - around 3mm long – and under X-ray guidance, I removed the bony bumps using specialised instruments.

After this operation, you’ll get back to being active really quickly.  You can walk on your foot straight away and wear normal shoes after 48 hours. There will be a single suture that I’ll remove when we meet again at 2 weeks after the surgery. The aim is to get a toe that is less painful. It won’t totally take the pain away, but it will make it very much less intrusive. You can go back to running and other sports as soon as it’s comfortable enough. In fact, with this type of surgery, the more you do with it quickly, the better the results. Its low risk and has very little down time.

Most surgeons still do this operation the standard open way which although achieves the same goal, does increase the recovery time as a much larger wound has to heal and increases the risk of a wound infection. Although it is technically still possible, I have not yet had a patient who suffered with a wound infection from a minimally invasive cheilectomy.

Cartiva Implant

 

 

If the big toe is particularly worn, and a cheilectomy isn't able to help, then previously the only option available was a procedure to fuse the toe bones together (a 1st MTP fusion).  Another option is now available which is called a Cartiva implant.  Not every specialist offers this procedure.

The Cartiva is an implant made of PVA, which is designed to perform in the way that the natural articular cartilage would perform. It acts like a plastic spacer between the toe bones that make up the big toe joint, and the implant is placed into a hole drilled into the head of the metatarsal bone. It’s a day case procedure, and it’s carried out under a local or light general anaesthetic. It has a relatively fast recovery time. You can walk on the foot straight away but have to take things easy for the first two weeks with lots of rest and elevation while the wound heals.

The implant is designed to reduce pain and preserve mobility to the joint. You can run and do sports once the foot has fully healed, which is at around 12 weeks.

Sometimes the implant may fail, either when it eventually wears out, of if the bone around the implant fails to support it, and the implant subsides.

It can take several months before you fully benefit from the procedure, and in my experience, the majority of patients do very well with this procedure provided they have strong enough bone to support the implant. Read more about the cartiva implant surgery.

 

 

Big toe Fusion

 

Sometimes the big toe becomes so worn, that it becomes necessary to fuse the joint. When there is wear in a joint, and those worn surfaces are moving around, it becomes very painful. If we stop the joint moving, we can significantly decrease the pain.

The surgery is a day case surgery carried out under local or a light general anaesthetic.  I make an incision on the top of the toe, over the joint, and I prepare the ends of the joint by removing the remaining worn cartilage, so that fresh bone is exposed, and healing can occur once the joint is fused. It’s a bit like repairing a broken bone. I then place a metal plate across the joint, which is held in place with screws.

After the surgery your foot will be numb for several hours (as I will have placed some nerve ‘blocks’ around the ankle),  and your foot will have a dressing on it, which you must keep dry and leave on for two weeks  - when we’ll meet again.

You’ll leave hospital with an orthopaedic shoe which keeps the foot straight; you’ll be allowed to walk on your foot, and when you’re home, I’d like you to rest with your foot elevated as much as you can for 6 weeks.

You can return to a desk-based job after a week or two, but if you’re expected to be on your feet a great deal or if you have a very manual job, you may want to give it up to six weeks before you return to work.

Whilst it is possible to get back to sports and impact activities such as running, it’s best to wait until at least four months has gone by from the time of surgery.

A 1st MTP fusion is the currently still the most predictable way to treat painful big toe arthritis but it does have the longest recovery time out of the previous options. It also has risks which need to be weighed up in the decision making process such as the risk of non-union (the bone not healing together) or infection.

If you suffer with painful 1st MTP or big toe arthritis and are not sure which option is right for you, I can help you weigh up the pros and cons, see the risks and potential benefits of each procedure and guide you to understand your condition, the options available for you and enable you to make the right decision.

I have been under the care of Mr Ajis for the past two years, during which time I have had two operations. I have arthritis in my big toe, which doesn't sound too serious but which has caused me great distress as I was unable to walk any distance without severe pain. Mr
Ajis has always been very encouraging and always gave me the confidence to believe that he could sort problem out in the end. Three months after the second operation I am now walking almost normally and although not totally pain free, I am hoping that it will improve even more over the next few months. The worsening arthritis means that I may have to have more treatment further down the road, and if I do, I will definitely be going back to Mr Ajis. I am very grateful to you, Mr Ajis, for your kindness and your skill.

I am a 60 year old lady who has always been fit and active. I had a consultation with Mr Ajis in October 2017 following more and more discomfort with Hallux Ridigus on both feet. I was very apprehensive before the consultation but Mr Ajis immediately put me at ease with his calm and reassuring manner. He informed me he could carry out keyhole surgery (Cheilectomy) under general anaesthetic to remove the Hallux Rigidus on both feet and assured me that I would be mobile almost immediately.

In January 2018, I had my operation at 8am and was back in my room before 9am. The anaesthetist and all the staff at Goring Hall Hospital were excellent. After a nice cup of tea, the recovery from the general anaesthetic was very quick. The Physio arrived very soon after and had me on my feet and walking in some special shoes. I was amazed to be walking so quickly and not long after was released from hospital. I walked to the car in my new special shoes to be taken home to rest. I rested with my feet up for 3 days then followed the exercise programme and other advice Mr Ajis gave me. I have recovered extremely well and cannot believe the pain I had been experiencing had vanished and the flexibility in both big toes are amazing.

 
Helen Arnold

I am a 60 year old lady who has always been fit and active. I had a consultation with Mr Ajis shaved a painful bone spur from beneath my big toe joint which had been causing intense pain when walking. All was well but the pain returned so Mr Ajis decided to completely replace the big toe joint. I attended hospital at 7.30am and was back home by 1.00pm ...no
crutches, full weight bearing, minimum discomfort and I only had to wear a surgical shoe for two weeks whilst the wound healed. Within one month of the operation i had and no pain whatsoever and full joint movement. Brilliant!
At my recent post operative appointment with Mr Ajis, he made time to inquire after the arthritic ankle on my other leg which is now being assessed with the view to a total ankle replacement. A very caring surgeon who always finds time to inquire and to listen to a patient's concerns.

Hear what our patients have to say

Patient stories

Mr Ajis is a great surgeon, he listens to any concern you may have and explains what is going to happen also gives great care... He suggested a fairly new procedure that wasn't available on the NHS but he pushed me through and he and his team have worked wonders, I am now healing very well and pain-free in my ankle after 6 years!

Written by a patient at BMI Goring Hall Hospital

Mr Ajis was very informative and reassuring about my surgery. He was professional at all times and allowed time for me to have all my questions answered without feeling rushed.

Written by a patient at BMI Goring Hall Hospital

I saw Mr Ajis after sustaining a fracture of my 5th metatarsal which had not healed after a year. The pain was unbearable. He saw me promptly and took the time to explain my condition with the help of x-ray images with assurances that he could fix the problem. I was advised by other clinicians to be patient and wait for the fracture to heal on its own. Mr Ajis said that healing would be highly unlikely without intervention. After numerous emails and 'phone calls to him he constantly...

...spent the time reassuring me and patiently going over the intended procedure. To date after seeking advice and guidance from Mr Ajis, his secretary and the Physio Team and the insertion of a plate my fracture has united I walk well, without pain and I have joined a walking group. In summary, he is the best foot consultant the South of England can provide. In fact, I travelled from both the IoM and the IW to West Sussex to see him.