THE VARIOUS TREATMENTS FOR HALLUX RIGIDUS
It is never possible to actually cure hallux rigidus, which is a matter of joint wear – and we have no means of renewing cartilage. Certain treatments, however, can still be considered.
Wide-toed shoes that do not rub against the humps on the top of the toe, with rigid soles to limit big-toe motion and action, are preferable. Patients should also walk barefoot or in slippers at home.
Injections will not cure the disease, but can temporarily relieve onset of pain. They are best performed by a radiologist under radiological or ultrasound control, using cortisone-based or viscosupplementation drugs.
In first line, joint-sparing procedures can be tried. Bone debris can be removed from within the joint, as can exostoses (“bone spurs”, or “osteophytes”); this is known as “trimming”, or “arthrolysis”. This is suited to patients with footwear problems but well able to walk barefoot.
The joint synovium can also be removed (synovectomy), to reduce inflammation, especially in patients with rheumatoid episodes and synovitis.
Finally, the big-toe phalanx can be shortened, to restore suppleness by relaxing the stiff and painful toe. Results are never sure, but progression and final treatment can be delayed, keeping a certain mobility, but at the price of reoperation.
Osteotomy can also be performed to lower and retract the first metatarsal head, especially in case of excessive elevation (“metatarsus primus elevatus”). Here again, results vary, but the joint is temporarily spared and some mobility retained.
There are two non-conservative options: joint replacement, or fusion (arthrodesis). Hip and knee replacements have long proved superior to arthrodesis, but results in the big toe are less clear-cut.
Big-toe implants may be the way of the future, but for the moment there is no scientific evidence of benefit or even of superiority over arthrodesis. They may, for example, be proposed in bilateral cases, elderly patients or when all other options are refused.
They are strictly contraindicated following infection, in case of certain bone morphologies or of deformation or destruction of the bone.
Fusion is always the safest bet. It welds the joint. After freshening the joint surfaces and removing wear debris, the big toe is positioned straight and fixed by screws, plates, etc.
This procedure has been used for decades, and is suitable in all cases.
Obviously, a joint is being sacrificed, but only a very diseased and incurable one. The outcome is reliable, and the patient can walk, and wear normal footwear – except for high heels; 4-to-5 cm heels (1½ to 2 inches) are no problem.