Category Archives: Foot and Ankle

“Hallux” mean big toe and “Rigidus” mean stiff. It is a medical term, describing degeneration of the joint at the base of the big toe – called metatarsophalangeal, or MTP joint. It is the most common site of arthritis in the foot region. It is an important joint, as it has to bend every time you walk and propelling your body forward. Walking can be painful or limited as it is degenerated and stiffened. Most of the time, a bony overgrow (osteophyte) can cause a painful bump over the dorsal base of the big toe, resulted in painful impinging shoe-wear.

Hallux rigidus usually develops in adults at the ages between 30 and 60 years. No exact cause is agreed so far. It can be secondary to previous trauma, or due to the underlying abnormal foot anatomy, abnormal joint surface, surrounding soft tissue imbalance that increases stress on the joint. It is more common in distant runner or dancer who have repeatedly exert hyperextension of the big toe.

The patient may experience pain in the joint when you walk, especially as you push-off on the toes when walking up/ down stair.   There is swelling around the base of the big toe, especially over the dorsum (top) of the big toe with an associated bony bump. The joint will be stiff at a late stage due to the degeneration and the dorsal bony bump.

History: pain, stiff, dorsal bunion

Examination: Limited big toe bending, especially on upward movement, bump over the top of the base of the big toe. The physician will try to differentiate if the symptom is arising from the bony bump, or the joint so as to decide the type of surgery if indicated.

X-ray: Narrowing of the MTP joint due to wear of joint cartilage, bony spurs (osteophyte). They are clinically graded into early stage (with the joint still preserved) and late stage (with the joint being obliterated).

Non-surgical treatment

• Non-steriodal anti-inflammatory drug (NSAID) such as ibuprofen may help reduce the active swelling and pain relief.
• Ice packs or taking contrast baths may help for a short period of time.
• Shoe modification with a widen toe box to accommodate the bump, stiff-soled shoe with a rocker bottom design may help to prevent bending force on the joint. Orthotic with a steel shank or metal brace in the sole can be measured with similar action. These are not effective to stop the condition from progressing but just symptomatic relief.
• Injections – a. Steroid, b. hyaluronic acid.

Surgical treatment: Different types of surgical treatment are commonly practiced depending on the clinical examination and radiological grading of degeneration.

• Cheilectomy operation: This is a simple operation to remove the osteophytes that limit the range of motion. It improves range of motion for wearing higher heel shoes or for running, and, though it often reduces pain, this is not guaranteed. It takes 3 months to recover 80% and 6 months to fully recover. Naturally, this does not alter the natural history of the underlying problem of arthritis; it merely reduces the pain from impingement of the osteophytes, which are caused by the arthritis. The potential problem is risk of further joint degeneration and require further surgical procedure, it is however a buy-time procedure.

• Autologous interposition arthroplasty: It is using a free ipsilateral gracilis tendon graft is for patients with severe hallux rigidus with moderate to high activity levels and who do not wish to undergo fusion.

• Fusion operation. This is a procedure to remove the joint and join the bones of the foot and toe together. This reliably removes pain and allows one to return to running.This is a procedure indicated for those with pain due to both bony spur and the joint. It is a more assuring procedure as the diseased joint is converted to a stable one-piece bone. The trade-off is the big toe become stiff, but we usually fused it in a physiological position for walking. A plate and screws are used to stabilize the fixation for the bone surface to heal by 6-8weeks.

• Arthroplasty (excision of the whole joint +/- replacing with a spacer or an artificial prosthesis) is a joint replacement, which significantly reduces pain and allows good function. It may have a limited life of approximately 10 years and require revision or a fusion operation later. This is an alternative procedure to arthrodesis for those older people who place few functional demands on the feet. It is not well accepted as the potential risk of prosthesis complications eg. wear, dislocation, loosening, etc.

Surgery is usually done under general / spinal / regional anaesthesia. This includes a general risk of anaesthetic drug and specific risks which our anaesthetist will explain to you before the operation accordingly. General surgical risk includes infection, nerve injury, tourniquet risk, swelling and stiffness

• Specific risk for Cheilectomy: recurrence / progression of symptom
• Specific risk for Arthrodesis: stiff joint, implant loosening, impingement, non-union, delayed union. Shortening of big toe.
• Specific risk for Arthroplasty: prosthesis dislocation / loosening

Steriod injection is done by some GP / Surgeon, but it is only a temporary effect and potential risk of infection, bony necrosis. Minimal invasive with percutaneous screw fixation is advocated but only short-term and small series report.

Cheilectomy: Since there is no joint procedure done, but only bone spur excision, immediate return to normal walking is allowed. The wound will usually take 10-14 days to heal. Early passive big toe movement is advised to prevent the joint stiffness is the main physiotherapy recommended. Takes months to settle.

Arthrodesis: This requires longer rehabilitation as it involves timing for stable bone growth, which usually takes 6-8 weeks. Patient will be protected with cast immediate post-operation and educated for non-weight bearing walking during initial 6 weeks. Radiological check will make at around 6 weeks to confirm if full weight bearing walking is advisable. Patient will be unable to wear high-heeled shoes due to the stiffened big toe (or we sometimes modify the position of fusion so as to tailor the patient’s reasonable need in terms of shoewear).

Arthroplasty: The rehabilitation is similar as arthrodesis, but early mobilization is essential to keep with the surgical benefit. Weight bearing is avoided for soft tissue stabilization, which usually takes 4-6 weeks.

It depends on the type of procedure as well as the occupation requirement of the individual. 2 – 6 weeks as mentioned under different procedures.

Yes with both cheilectomy and arthrodesis, but with limited big toe flexibility in the later case.

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Joint Replacement Surgery Hospital India offers highest quality bone and joint health care with attentiveness, care and compassion to meet the needs of the patients and their loved ones. The medical team includes board-certified orthopedic surgeons who are familiar with all the aspects of the musculoskeletal system. Our hospital uses the most advanced technologies available for the orthopaedic procedures and has a lower complication rate.

• After obtaining medical evaluation from your primary care provider you are admitted to the hospital for elective surgery. An anesthetic is placed and the ankle joint is exposed by careful separation of the tendons, vessels and nerves in front of the joint. The diseased portion of the ankle is precisely removed and the replacement is impacted into position. The layers are closed and a dressing is applied. Additional procedures may be performed at the same time as necessary. The procedure lasts 2 to 3 hours.

When compared to the other major joints, arthritis of the ankle is uncommon. Many people know of someone who has found pain relief from hip or knee replacement, but few know someone who has had an ankle replacement. It is true that ankle replacement is not as common as hip and knee replacement, but the number of procedures is growing fast.

• As with any surgical procedure, experience matters. Ankle replacement is a complex procedure, and is best performed by a surgeon who specializes in foot and ankle surgery, and not just knee and hip replacement.

The typical patient spends one or two nights in the hospital after ankle replacement. However, the length of the hospital stay can depend on many other factors. Your surgeon will advise you on what he/she believes is likely for your specific situation.

A foot and ankle surgeon who is experienced in ankle replacement surgery can evaluate your particular situation and determine whether you are a candidate for the procedure. All patients must exhaust other non-surgical treatment methods prior to proceeding with ankle replacement. No age limits have been established for the ankle replacement, but the performance of a prosthetic joint and how long it will last depends on many factors, including the type of implant used, your physical condition, bone quality, activity level and lifestyle.

It is very important that your surgeon be aware of all medications that you are taking, especially, steroids and blood thinners. You will be advised if you need to make any changes in your medication schedule. Generally, patients are advised to stop taking prescription or over the counter anti-inflammatory medication, including aspirin or ibuprofen five days before surgery. These medications thin the blood and can lead to excessive bleeding during surgery.

The arthritic ankle is expected to be less swollen but not completely normal. Also, there will be a visible scar on the front of the ankle from the incision.

There are several components that make up the ankle replacement device. All of the parts are made from highly biocompatible materials, including titanium and cobalt chrome metals on the tibial and talus sides of the joint. Between those two components, a third component made of a biocompatible plastic called polyethylene is attached to the tibial component to help the components glide against each other. These are identical materials to those used in hip and knee replacements. All of the materials have a long and successful track record for use in human joint replacements.

Advances in technology and materials have made ankle replacement more and more reliable. An increasing number of foot and ankle surgeons are using ankle replacement surgery with confidence to relieve pain and restore mobility in patients with compromised ankle function.

Although still a small niche segment, the ankle replacement market is growing rapidly. In 2009, about 2,300 procedures were performed in the US alone.

How long an ankle replacement lasts depends on many factors, including the type of implant used, and the patient’s physical condition, activity level and lifestyle.

While prosthetic joints can provide increased mobility and pain relief for many years, it is a fact that they are mechanical bearings and may not last for the rest of the patient’s life. Most patients can expect their ankle replacement to last 10-20 years.

The components used for ankle replacement are not different for men and women specifically; what differs is simply the size of the components based on the patient’s anatomy. During the procedure, the surgeon carefully chooses the components that best match your ankle joint. The implants are available in a range of sizes and combinations for a customized fit.

Sedentary patients may be better served by an ankle fusion. Increased body mass index (BMI) is just one factor that will be carefully considered by your surgeon. Increased BMI can be associated with mechanical failure of the implant.

As with any surgery, there is always a risk of complications. Risks include nerve injury, vessel injury, tendon injury, bone injury, infection, failure and persistent pain.

All patients will experience some level of pain after surgery. Many patients are off prescription pain medication five to seven days after surgery. After the initial pain from the surgery subsides, you should not have any chronic pain as a result of the implant. You may have some soreness, but that will begin to improve in the weeks and months following surgery. Call your physician if you have any increased pain, swelling, fever or abnormal incision drainage.

Although the recovery program varies by patient and surgeon preference, many patients are in the hospital for 1 to 3 nights. The stitches used to close the incision are removed between 10 and 21 days after surgery. Once stitches are removed the patient is allowed to move the ankle. Bearing weight on the ankle is allowed 6 weeks after surgery, at that time, physical therapy is started to accelerate the resolution of swelling, pain and stiffness and to eventually improve strength and coordination. Protective devices such as a cast boot or brace, along with physical therapy, are discontinued 12 weeks after surgery. Your physician will schedule regular follow-up appointments with you during that time.

Physical therapy is critical to the success of your new ankle. Your rehabilitation program often begins as early as the day of your surgery, when your health care team advises about the rehabilitation process. You will be instructed in the exercises to perform at home, which are designed to gradually increase the use of your ankle. It is important to follow your doctor’s instructions exactly and do your exercises regularly. In general, initial therapy involves stretching to help regain the normal ankle range of motion. Later, strengthening exercises are added if necessary. Your surgeon will provide you with any specific restrictions based upon your individual situation. It is important to follow those restrictions closely.

Most people are able to return to normal everyday activities such as dressing themselves and grooming within the first 2 weeks after successful ankle replacement surgery. Your ambulation will be restricted for 6-8 weeks until you start your rehabilitation therapy. Your doctor will advise you on specific limitations, including the amount of walking you can do on the ankle that was operated on. Many surgeons restrict their patient’s ambulation for a period of time. Your doctor will also let you know when you can begin ambulating more freely, and when you can return to other activities. Contact sports may be restricted in the long term.

• Once you return home, it’s a good idea to have a family member or friend available to help you with daily activities such as washing, dressing and preparing meals.

This is especially important during the first week or two following surgery. If you do not have home support, ask your health care provider about an agency or facility that may be able to provide the help you need.

You must be off all pain medication before you consider returning to driving. Patients with minimal discomfort and access to a vehicle with an automatic transmission can usually return to driving about two months following surgery.

The decision to return to work is individualized and is influenced by your job, your employer and your post-operative course. In most circumstances, patients can return to office work in 2 to 3 weeks if accommodations are made for transportation, parking, office access, rest and foot elevation. Patients that perform physical work may return to work once they recover endurance for standing and walking, this is at least three to four months after surgery.

The recovery of full ankle function may take up to 6 months, provided you followed the recommended physical therapy regimen. Most improvements are maximized by six months after surgery and residual swelling persists for 6 to 12 months.

People who have had an ankle replacement are generally advised to avoid contact sports and to refrain from repetitive impact activities that will accelerate wear of the implant, as these can place too much strain on your ankle implant. Consult your physician about the specific activities that might affect your new ankle.

It is impossible to state how much motion will recover after ankle replacement. However, patients with severely restricted motion that has been present for many years may be unable to achieve full motion despite a properly performed operation and dedicated physical therapy.

Ankle replacement surgery can help you return to normal daily activities that were previously limited by the ankle disease. Even though the ankle replacement addresses the most likely pain source, other sources of pain remain in the ankle and foot. Pain is likely to be reduced but it is not always eliminated.

When ankle arthritis pain begins limiting your daily activities, causing you to lose sleep, and is not responding to other treatment alternatives, it may be time to consider ankle replacement surgery. By waiting too long, your range of motion can become severely limited, making the surgery more difficult and the results less certain. It is a good idea to discuss your condition early on with a foot and ankle surgeon, and learn about the options and timing that might be right for you.

Early recommendations for arthritis treatment may include rest, walking with a cane in the opposite hand, over the counter or prescription anti-inflammatory medications, and medication for pain relief. Physical therapy may be prescribed in the early stages, although this can become less effective and even damaging as the arthritis advances. Cortisone injections can provide temporary relief of pain, although this is not generally considered a long-term solution. Occasionally, arthroscopic surgery is used to remove bone spurs and debris from the joint. When these solutions are not effective, your foot and ankle surgeon may discuss surgical alternatives with you, such as ankle fusion or ankle replacement surgery.