Hallux Rigidus

Big toe arthritis, also called 1st metatarsophalangeal (MTP) arthritis or hallux rigidus, is a common condition affecting the foot and ankle. It is the most common site for arthritis in the foot. Patients typically develop symptoms between age 30 and 60, and females are more commonly affected than men.

Presentation
Patients typically develop stiffness and decreased range of motion at the big toe, which affects walking, running, and other athletic activities. Some patients develop large bone spurs on the top of the foot, which can cause pain with shoe wear and discomfort when going up on the toes.

Causes
Sometimes trauma (a fracture or crush injury) can lead to this condition, but for most patients there is no specific inciting event. Some patients are more likely than others to develop big toe arthritis, either because of some anatomic abnormality or because of genetic predisposition.

Diagnosis
A clinical exam and x-rays can confirm the diagnosis. Generally, advanced imaging like MRI or CT scan is not required.

Treatment
Non-surgical options include anti-inflammatories, shoe wear modifications, and over-the-counter or custom inserts (orthotics). Physical therapy can be helpful to maintain range of motion. Occasionally cortisone injections into the joint can decrease inflammation for a period of time.

Surgery can be used to treat cases that fail non-operative treatment. Traditionally, a procedure called a cheilectomy can be used to remove bone spurs from the top of the big toe joint. This is recommended for mild to moderate cases of hallux rigidus. This is a joint-sparing procedure. Recovery involves walking in a surgical sandal for about 3-4 weeks after the surgery.

For moderate to severe arthritis, a fusion has until recently been the only proven surgical option. This is a joint-sacrificing procedure, in which the bones on either side of the joint are fused together with screws and possibly a plate.

This reliably addresses pain symptoms but eliminates all motion at the joint. Recovery involves a period of non- or heel- weight bearing followed by fully weight bearing in a surgical sandal for 8 weeks or more after the surgery.

Summary

Hallux rigidus is a common condition that involves pain, swelling, stiffness and decreased range of motion of the big toe. Diagnosis is often straightforward and involves a clinical examination and x-ray. Several non-operative treatments exist, including NSAIDs, shoe wear modifications, shoe inserts, and injections. When non-operative treatment fails, surgery is an appropriate option.

Mark Reed, MD is a fellowship-trained foot and ankle orthopedic surgeon who has undergone training on the Cartiva procedure and has incorporated it in his practice. Please contact OSS to schedule an appointment for an in-depth evaluation.

What Is Arthritis of the Knee?

The word “arthritis” basically means “inflammation of the joint”. Inflammation is the body’s natural reaction to injury or disease. With inflammation, the area involved develops stiffness, pain, and swelling and it can last for a long time or recur, leading to tissue damage.

A joint is where two bones join together. The knee is the largest joint of the body. The bones of a joint are covered with a spongy material called cartilage to allow a cushion for the bones so the joint can move without pain. With arthritis, the area in and around the joint becomes inflamed and the cartilage cushion may be damaged, making mobility difficult.

Is There More than One Type of Arthritis?

There are more than one-hundred types of arthritis but the most common type is osteoarthritis. Two other common types include rheumatoid arthritis and gouty arthritis.

Osteoarthritis: Osteoarthritis occurs when the cartilage covering the bone ends gradually wears away, thus earning it the name “wear-and-tear arthritis.” When the cartilage is damaged, the bones begin to rub against each other leading to swelling and pain. Osteoarthritis can occur in any of the joints in the body, but it affects the knee most commonly.

Rheumatoid Arthritis: Also called RA, Rheumatoid arthritis is a long-lasting disease that leads to deformities and destruction of the joints. It most commonly involves the knees, wrists, and hands. With rheumatoid arthritis, the body’s immune system mistakenly attacks itself causing the joint lining to swell and ache. The inflammation associated with RA spreads to the surrounding tissues and will eventually damage bone and cartilage. This leads to an unstable joint, pain with movement, and profound stiffness.

Gouty Arthritis: Gout is a painful condition of the joints where the body cannot eliminate uric acid or produces too much uric acid. This natural substance builds up and forms needle-like crystals in the joint leading to severe pain and swelling. Gouty arthritis most often affects the big toe, but can involve other joints including the knee and the wrist joints.

What Are the Symptoms of Arthritis?

The various kinds of arthritis produce different symptoms and it really depends on the severity from person-to-person. The most common symptoms are swelling, pain, stiffness, tenderness, warmth of the joint, and redness.

How Is Arthritis Diagnosed?

Most forms of arthritis are diagnosed with a complete medical history and various imaging techniques. Your orthopedic specialist will take X-rays or MRIs to evaluate the condition of your joints. Sometimes it is necessary for your doctor to do tests on your blood, urine, and joint fluid to determine the type of arthritis you have.

How is Knee Arthritis Treated?

Your orthopedic specialist cares about your health so the goal of treatment is to provide pain relief for you and to increase your mobility and strength in the knee joint. Treatment options include exercises, medications, heat compresses, cold therapy, or knee surgery.

What is Involved in Surgical Treatment?

If your arthritis does not respond to the nonsurgical therapies your orthopedic specialist tries, you may benefit from surgery. There are many surgical options available. The first is knee arthroscopy where the orthopedic surgeon uses fiber optic technology to view inside the joint, repair what is damaged, and perform necessary surgical techniques.

Another procedure is an osteotomy that cuts the shinbone or the thighbone to improve the alignment of the joint. Sometimes it is necessary for the doctor to do a total or partial knee arthroplasty to replace the severely damaged knee joint cartilage with plastic and metal prostheses. Finally, there is cartilage grafting that is done when the knee has limited cartilage or loss of cartilage.

Wound Care

• You will have a sterile gauze dressing covered with tape. Please keep the dressing clean and dry. You may take a sponge bath, or shower with waterproof plastic wrap over the surgical area (use tape at the edges to prevent leaks).
• Remove the dressing 3 days after surgery to inspect the incisions. Some clear, yellow, or bloody drainage from the incision is normal. If this happens, keep the incision covered with gauze and change the dressing daily until there is no further drainage. If there is no drainage you may leave the hip open to air. You may get the incision wet 5 days after surgery, but do not submerge in water. Sutures will be removed at your follow up appointment.
• Occasionally there is excessive bloody drainage; please change the dressing when it becomes completely saturated. Sterile gauze is available at the pharmacy. If you continue to have saturated dressings beyond the first few dressing changes, please call the office.
• If the incisions are draining pus (opaque, thick, white fluid), or if there is redness that worsens over the next 1-2 days, call the office immediately. Do not apply any ointments or creams.

Activity

You may be weight bearing as tolerated with the use of crutches to assist your operative leg. Please continue to use both crutches at all times for the first 2-4 weeks after surgery. You may gradually increase the amount of time you spend standing and walking. Formal outpatient physical therapy is typically not required.

Avoid heavy lifting, exercising, stretching, running, climbing, squatting, and any jarring activities. Please use pain as your guide; any activity that causes severe pain should be avoided.

Controlling your pain and inflammation

Some pain, swelling, and bruising is expected after surgery. It is usually most severe for the first 2-3 days. The following strategies are especially important during this time.

• Rest — Take things easy for the first few days, try to rest and avoid prolonged walking or standing.
• Ice – Apply an ice pack (or a cold therapy machine if you have one) to your operative hip to reduce pain and inflammation. Take care not to put ice directly on the skin. Ice for 30 minutes at a time, and remove for 30 minutes in between sessions. You should continue this for the first 2-3 days or longer if you still have pain and swelling.
• Elevate – Put pillows under your operative leg, or lie on your opposite hip to elevate. This will help to drain fluid from the leg and reduce swelling.
• Medication — You may have received a prescription for narcotic and/or anti-inflammatory medication. Please take them as instructed. The medication is most helpful if taken 30-45 minutes prior to any planned activity.

Follow up appointment
If an appointment has not already been scheduled, please call the office at 206-633-8100 and schedule an appointment for 7-10 days after your surgery. During this visit we will examine the surgical incisions, remove sutures if necessary, and take xrays.

Returning to work
You may return to work when it is safe to do so within the above activity restrictions. Please note that your employer may prohibit narcotics while at work. Please continue to rest and ice while at work. You may need to ask for frequent breaks in order to avoid prolonged standing or walking. A doctor’s note or a Duty Status form can be provided during your follow up appointment.

Driving
For those who had LEFT hip surgery, you may drive an automatic transmission once it is comfortable to do so and you are no longer taking narcotic medication. For the RIGHT hip, or those with manual transmission, it may take anywhere from 2-4 weeks depending on your pain level, strength, etc. Please wait to drive until after your follow up appointment so that we can assess your progress.

Medications and common side effects:

• Narcotics (oxycodone, hydrocodone, etc.) – prescription medication for reducing pain. They may cause drowsiness, confusion, nausea, and constipation. To avoid constipation, increase your intake of fiber, fruits, and vegetables, and stay hydrated. Over the counter laxatives can be taken to treat constipation while on narcotics; please see separate handout or ask your pharmacist.
• Anti-inflammatories (Ibuprofen, Naproxen, etc.) – available over-the-counter to reduce pain and inflammation. Avoid them if you have diagnosed kidney disease or active ulcers. This medication can cause upset stomach; please take them with food. To treat an upset stomach, take an over-the-counter antacid or proton-pump inhibitor (ask your pharmacist for assistance).
• Acetaminophen (Tylenol) – Used to reduce pain and decrease fever. Avoid taking this medication if you have liver dis-ease. Taking more than the recommended dose can lead to liver damage. For an adult, it is safe to take up to 3-4,000 milligrams each day (24 hour period). Avoid taking with Percocet, Vicodin, Norco; these prescription narcotics already have acetaminophen in them. It is safe to take Tylenol and an anti-inflammatory at the same time.
• Antihistamines (e.g., benadryl, hydroxyzine) – Used to treat some side effects from narcotic use, such as itching and nausea. Can cause drowsiness and confusion.

Please call the office if you have the following:

• Fever above 101°, pus draining from wound, worsening redness or rash
• Difficulty breathing
• Continuous bleeding from wound (see “wound care” above)
• Numbness or weakness of the leg
• Intolerable pain when the above strategies for pain control have failed.

Activity

It takes about 2 months for your hip prosthesis to heal in place. During these first 2 months:

• Be extra careful not to fall.
• Avoid strengthening exercises, stretching, or heavy lifting (above 25 pounds or so). Avoid any high impact or jar¬ring activities (jumping, jogging, sports, etc).
• Outpatient Physical Therapy is not routinely prescribed unless you have a specific issue that requires it. We can discuss the need for therapy at your next visit.

Gentle motion of the hip can be helpful for your recovery. There are 3 activities that we encourage:

• Walking—You can walk as much as your pain will allow. Avoid overdoing it; try not to walk to the point of fatigue or soreness. Watch for uneven surfaces. It’s a good idea to begin with level ground before progressing to hills.
• Stationary bike (recumbent is fine) – Begin with zero or low resistance. Start with a few minutes at a time, and progress slowly.
• Pool activities — Wait 2 weeks before using the pool. Practice gentle walking, side-stepping, or marching in place. Avoid kicking or lap-swimming for the first 2 months

You may transition from your walker or crutches at your own pace. Try to increase your weight bearing by practicing a normal gait every day. As a rule of thumb, continue to use a cane or crutch until you can walk without a limp.

Wound Care

You may shower 24 hours after your sutures have been removed. Please leave steri-strips in place until they begin to fall off. Call the office if you notice ongoing drainage or increasing redness near the incision. Keep the incision dry until there is no drainage.

Pain control

You may continue to ice and elevate as long as it is helpful. Over the counter anti-inflammatory medication, and Tylenol, are recommended. Narcotics may be necessary for uncontrollable pain, but try to wean from them as soon as possible.

Preventing blood clots

Continue to take Aspirin for the first month after surgery to decrease the risk of blood clots (unless otherwise instructed). Avoid long periods of immobility (for example, long trips in a car or plane).

You may stop using TED compression stockings, unless otherwise instructed.

Driving

Avoid driving while on narcotic medication. Otherwise you may drive when it is not painful to do so, and your strength, stamina, and reflexes have improved

Dentist

Antibiotics are recommended prior to certain dental procedures for the first 2 years after joint replacement. Call the of¬fice for a prescription. If possible, avoid elective dental procedures for the first 3 months after surgery.

Follow Up Appointment
Please follow up with Dr. Downer 8 weeks after surgery unless otherwise instructed.

1. You may shower tonight, letting soapy water run over your incision(s) and patting them dry with a towel. You should avoid submerging the leg (bath, pool, hot tub, etc.) for at least one week.
2. You will continue strict non-weightbearing in the boot for 2 more weeks. After 2 weeks, you will start progressive weight bearing in boot. Please refer to the separate handout.
3. Use an ace bandage or a thick sock to prevent the boot from rubbing on the incision(s).
4. You will wear the boot at all times (including sleeping), except for the following:
   • Bathing, showering
   • Exercises
   • In a completely controlled environment, for the purpose of icing
5. You will start doing exercises for the ankle to maximize your post-op flexibility. You will do these twice daily, once in the morning and once in the evening:
   • Write the alphabet with your foot. Do two repetitions.
   • Stretch the Achilles by placing a towel across the ball of your foot and pulling up. Hold each stretch for a five-count and do five repetitions.
6. You will continue to ice and elevate the leg as much as possible. Elevating the leg above the level of the heart will reduce the amount of time required to bring down the swelling.
7. You should continue taking the blood clot prevention medication (aspirin or equivalent) as prescribed until you are at least 4 weeks post-op.
8. Formal physical therapy will begin at 4 weeks post-op. A referral will be provided today in clinic.
9. I would like to see you back in 2 weeks for an incision check.