Houston Methodist. Leading Medicine

Foot FAQ

Question:

I have a foot condition known as hallux rigidus. I just call it a "tight toe". Over time, I've noticed it's actually getting worse. I've been told if I wait too long, I may end up with a joint fusion when I could have had a repair job. How do they decide when a joint like this is too far gone?

Answer:

Degenerative arthritis of the big (great) toe called hallux rigidus affects the metatarsophalangeal joint (where the main bone in the foot meets the first bone of the big toe). The condition is characterized by degeneration of the articular cartilage (lining the joint), bone spurs called osteophytes, and significant narrowing of the joint space. Treatment for painful, limiting hallux valgus is surgical. In early stages (mild to moderate disease), there is a wide range of surgical approaches that can be taken. The surgeon can simply remove the bone spurs or take out the damaged portion of the joint surface. Sometimes releasing the soft tissue (capsule or synovium) is sufficient. In more advanced cases, arthrodesis (fusion) of the joint is advised. Deciding when joint reconstruction (referred to as cheilectomy) using one or several of the methods described depends on several factors. Your symptoms (e.g., pain, difficulty standing and walking) are usually what send you to the surgeon's office in the first place. X-rays are used to determine the severity of the condition. There are different methods used to assign a "grade" to the condition (e.g., Grade I, II, III, IV). The grade depends on how much of the joint surface has been destroyed. For example, lower grades (I and II) describe a joint with less than half of the surface damaged. Higher grades (III and IV) refer to patients with extensive degeneration of the joint (more than half destroyed). In the past, cheilectomy was used for patients with Grades I and II and arthrodesis (fusion) was reserved for Grades III and IV. But more recently, surgeons have been trying to combine two surgical procedures for advanced hallux rigidus in order to preserve (save) the joint and motion. Joint reconstruction (referred to as cheilectomy) using one or several of the methods described combined with a second procedure known as proximal phalangeal osteotomy has been described in a new study. After removing one-third of the big toe's metatarsal head, a wedge-shaped piece of bone was cut out of the phalange (toe bone). By moving the two remaining pieces of bone apart, it was possible to lengthen the metatarsal, thereby maintaining the length of the toe after removing the metatarsal head. Keeping the joint intact and avoiding a fusion procedure, makes it possible for patients to walk right away. They use special (stiff-soled) shoes to protect the osteotomy site until the bone heals. But the results are well-worth it as the surgeons involved reported a 100 per cent success rate (bone healing). The combined procedures make it possible for the first toe to bend as it should so that when walking, the patient can properly roll over the big toe to push the foot off the floor. This motion is called dorsiflexion. In order to preserve metatarsophalangeal dorsiflexion (toe bend before toe off), the patient does lose a portion of the opposite motion (toe pointing called plantar flexion. These results are a significant improvement over foot function reported after an arthrodesis (fusion) procedure. As the long-term follow-up of this group of patients showed, no one had to eventually have a fusion. Foot function was maintained (at least in the early to mid-term results). It is speculated that joint degeneration may develop over time (perhaps even in the first 10 years after the surgical procedure). These patients will be followed longer to see just what does happen in the long-term period. An orthopedic surgeon can evaluate you and help you plan a treatment that will meet your personal and physical goals. As with many health care conditions, earlier treatment often yields better results so at least getting a baseline evaluation is always a good idea. Martin Joseph O'Malley, MD, et al. Treatment of Advanced Stages of Hallux Rigidus with Cheilectomy and Phalangeal Osteotomy. In The Journal of Bone and Joint Surgery. April 3, 2013. Vol. 95A. No. 7. Pp. 606-610.

*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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