Stiff big toe surgery (Hallux Rigidus)

Hallux rigidus (HR) is stiffness (rigidity) of the joint at the base of the big toe (hallux), which is called the great metatarsophalangeal joint. The usual cause of a stiff big toe is arthritis or wear and tear of the smooth cartilage that covers the joint, but it can also be caused by a previous injury to the big toe or it can be part of some systemic disease, e.g. clinical pictures of gout. Often the cause is unknown, especially in the elderly.

Hallux rigidus is manifested by stiffness and pain in the big toe. If the symptoms are severe, it can limit the length of walking and jeopardize the individual’s work and recreational activities. Bony growths (osteophytes) develop around the metatarsophalangeal joint and can cause pain from pressure from shoes that are too tight. Surgical intervention aims to reduce or stop pain, as well as improve the overall quality of life due to greater and easier mobility.

When is surgery for a stiff thumb (hallux rigidus) performed?

Milder forms often do not require surgical treatment. Simple lifestyle and activity modifications, losing weight, using a walking aid, taking pain medication, and wearing appropriate footwear and insoles can help. High heels and shoes with narrow toe spaces should be avoided. Surgery is considered when the above measures do not give satisfactory results.

How is the surgery for a stiff thumb (hallux rigidus) performed?

There are three main surgical options to relieve pain and improve quality of life in cases of stiff thumb, namely joint debridement, metatarsophalangeal joint arthrodesis or fusion, and interposition arthroplasty. Which of these options will be best for a patient depends on many factors, including the severity of the arthritis, the patient’s age and functional requirements, and the presence of arthritis in adjacent joints. The final choice is a joint decision between the surgeon and the patient.

• Joint debridement: in cases of mild thumb stiffness, when only the upper part of the joint is affected, that upper part is removed and the joint cleaned. This is often combined with a realignment procedure (Moberg osteotomy) of the bone at the base of the big toe. This can provide long-term pain relief with improved movement in some patients.
• Metatarsophalangeal joint arthrodesis (fusion): this is the gold standard among procedures for cases of moderate to severe big toe stiffness. The remaining cartilage in the joint is removed, the bones on both sides of the joint are joined and connected with screws or a plate. Pain relief will be felt by 95% of patients and for this reason this is the procedure of choice for active people. However, the ankle is stiff and this limits the wearing of high heels. There is a small risk of developing arthritis in the next joint along the toe, but this is quite rare.
• Arthroplasty: This approach may be considered if the arthritis is moderate to severe, but there is considerable range of motion in the metatarsophalangeal joint, and the individual still wishes to wear heeled shoes. Cartilage is removed only from the base of the big toe on one side of the joint, and the gap in the joint is filled with surrounding soft tissue or a hamstring graft taken from the patient himself. This has the advantage of preserving some motion in the joint, however the degree of pain relief, while still significant, is less than compared to arthrodesis.

Recovery after hallux rigidus surgery

Swelling and pain often remain after surgery for two to three weeks. Patients are generally advised to wear a special shoe postoperatively for four weeks, after which normal free walking is usually allowed.
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