Hallux rigidus

• Pain in the big-toe metatarsophalangeal joint
• Restricted upward flexion of the big-toe metatarsophalangeal joint
• Formation of bone spurs, mainly on the upper surface of the big-toe metatarsophalangeal joint
• Shoe conflict worsening symptoms due to widening of the big-toe metatarsophalangeal joint contour
• Significant limitation of physical function

• A single major injury causing varying degrees of damage to the joint surfaces of the big-toe metatarsophalangeal joint
• Repeated microtrauma
• Excessive elevation of the first metatarsal bone relative to the others
• Excessive length of the big toe
• Muscle-balance disorders
• Rheumatic diseases
• Charcot disease
• Gout
• Avascular necrosis of the head of the first metatarsal bone
• Prolonged immobilisation of the joint, for example in a plaster cast
• Shape of the head of the first metatarsal bone (flattened and approximately square)
• Iatrogenic, secondary to previously performed surgery

The development and progression of hallux valgus are influenced by the simultaneous presence of several of these adverse factors.

Conservative treatment of hallux rigidus

In the early stages of hallux rigidus, improvement may be achieved with medication, physiotherapy, appropriate insoles and shoes with a rounded, profiled sole that limits upward flexion of the big-toe metatarsophalangeal joint.

Surgical treatment of hallux rigidus

Before surgical treatment of hallux rigidus, the patient undergoes a thorough examination.

We then discuss the deformity with the patient and explain the proposed surgical options. Finally, we describe the risks of the procedure itself and possible complications during surgical treatment of hallux rigidus.

Diagnostic tests used before hallux rigidus surgery

• Radiographic examination in standard views (it is extremely important that images are taken under full weight-bearing)
• Haematological and biochemical tests
• Pedobarographic examination, still rarely used in Poland, which assesses pressure distribution on the soles while standing and walking and enables more precise planning of surgery.
• Ultrasound examination
• Computed tomography
• Magnetic resonance imaging

Depending on disease severity, various surgical treatments are used:

• Cheilectomy Surgical removal of bone spurs from the dorsal surface of the metatarsophalangeal joint. If the changes are relatively small, the procedure can be performed arthroscopically.
  The aim is to improve upward flexion of the big-toe metatarsophalangeal joint, reduce pain, prolong joint function and improve load-bearing capacity and mobility.

• Combined local biological treatment – microfractures + Hyalofast + growth factors + stem cells.
  When cartilage defects of less than 50% are found in the head of the first metatarsal bone, a combined surgical technique is used: microfractures are created in the defect, which is then covered with a hyaluronic-acid polymer membrane and locally treated with prepared blood products containing concentrated growth factors and stem cells.
  The aim is to support regeneration of damaged cartilage at the head of the first metatarsal bone and thereby improve load-bearing capacity and mobility. If bone spurs are present on the dorsal surface of the metatarsophalangeal joint together with cartilage defects at the head of the first metatarsal bone, cheilectomy can be combined with local biological treatment.

• Various osteotomies (various bone-cutting techniques) performed in the first metatarsal bone and proximal phalanx of the big toe
  The aim is to improve range of motion in the big-toe metatarsophalangeal joint, reduce pain, prolong joint function and improve load-bearing capacity and mobility.
  Osteotomies may be performed together with cheilectomy and combined local biological treatment when cartilage defects are present.

• Keller procedure This involves resection (removal) of the proximal third of the proximal phalanx and soft-tissue plasty. It should be reserved for selected cases, mainly patients over 65. Because of possible future complications, it is now used less often.
  The aim is to improve range of motion in the big-toe metatarsophalangeal joint, reduce pain and improve load-bearing capacity and mobility.

• Arthrodesis (fusion) of the big-toe metatarsophalangeal joint
  Arthrodesis is considered the ‘gold standard’ and is used for the most severe changes. It permanently joins the first metatarsal bone to the proximal phalanx of the big toe. In the most severe cases, it is currently the only effective solution.
  The aim is to free the patient from pain, remove the joint deformity causing constant friction with footwear, and improve load-bearing capacity and mobility.

• Arthroplasty of the big-toe metatarsophalangeal joint
  In recent years, prostheses for the big-toe metatarsophalangeal joint have also been used. Until recently, the complication rate reached 30%.
  With new-generation prostheses, the observed complication rate has fallen to a few percent. Currently, the prosthesis producing the best and most durable results is Cartiva prosthesis.
  The Cartiva prosthesis may be used when partial upward flexion remains and pain is present. It should not be used when movement of the big-toe metatarsophalangeal joint is severely restricted.

CARTIVA

A synthetic articular-cartilage implant is a modern metatarsophalangeal-joint implant designed to replace damaged cartilage. Cartiva is made of polyvinyl alcohol, a material used in many medical devices and implants, including contact lenses. Through its manufacturing process, the Cartiva implant closely reproduces the natural properties of cartilage.

This implant is indicated for cartilage damage in the metatarsophalangeal joint of the big toe or other toes. Destruction of the joint surface may result from primary osteoarthritis or injury.

Cartiva implantation is a safe, short surgical procedure after which, unlike arthrodesis, the patient can immediately bear weight on the operated foot. Many patients experience reduced pain from joint arthritis within the first weeks after surgery.

After the procedure, range of motion increases, pain decreases and joint function improves.

Contraindications to Cartiva implantation include severe degenerative joint changes with marked restriction of movement, local skin infections, allergy to polyvinyl alcohol and certain systemic diseases.

Rehabilitation is an important part of a patient’s rapid recovery after hallux rigidus surgery. To be effective, it should be based on the following principles:

• the patient’s condition should be assessed
• Individual recommendations should be prepared for postoperative hallux rigidus treatment
• therapy should be adapted to the patient’s abilities

Individual exercises with the patient aim to:

• improve the range of motion in the joints of the operated lower limb
• improve proprioception
• Work on improving neuromuscular coordination
• reduce swelling (soft-tissue work, lymphatic massage, kinesiotaping)
• correct gait and faulty movement habits
• physiotherapy

In foot surgery, ensuring a pain-free operation and minimising postoperative pain have always been major challenges.

It is commonly believed that recovery after foot surgery, especially hallux surgery, is very painful.

There are many options for anaesthesia during procedures on the foot.

Modern anaesthesiology aims, wherever possible, to use regional anaesthesia techniques – from central blocks such as spinal and epidural anaesthesia, commonly known as lumbar anaesthesia, to peripheral nerve blocks at various levels performed under ultrasound guidance, especially when operating on one foot.

The possibility of using a particular type of anaesthesia depends mainly on the extent of surgery and any coexisting conditions.

The final choice of anaesthesia is agreed with the patient during the preoperative assessment interview.

Using ultrasound in anaesthesiology to perform peripheral nerve blocks has enabled highly precise regional anaesthesia.

Our many years of experience have changed our perioperative approach, both to anaesthesia itself and to the postoperative period.

For foot surgery, peripheral nerve anaesthesia, known as an ankle block, means injecting a local anaesthetic around the nerves at the appropriate level.

These anaesthetics are highly precise because the nerves responsible for pain sensation are clearly visible on ultrasound and medication delivery is fully controlled.

This can substantially reduce or even eliminate the need for pain medication early after surgery.

For many patients, one of the most important advantages is that sensation above the knee is preserved in the operated leg and, most importantly, lumbar anaesthesia is avoided, which patients do not always accept.

Another important advantage is that walking can begin very soon after the procedure.

During the postoperative period, administering pain medication at regular intervals under ultrasound guidance around the nerves responsible for pain enables patients to pass through this period as comfortably and painlessly as possible.