Hallux Rigidus, Plate/Screw Fusion, and Osteotomy
|Hallux not labeled but visible at upper left.|
Table of Contents
I don't know whether old injuries, bad genes, ambient radiation, invisible trolls, 40+ years in ski boots, or a failed astrological chart are to blame, but I have really, really bad arthritis in the main joint of both big toes. The only reason I'm sharing all this personal information is that I finally reached the point where my left toe(s) demanded serious intervention and I thought it might be interesting for some folks to follow along with my experience. The problems I'm having are somewhat common, particularly with skiers, so it's kind of therapy and tracking for me and perhaps will help some other people learn what to expect if they find themselves in a similar situation in the future. We're all getting older and my problems are ones that accumulate with age.
My intent in sharing share my symptoms, diagnosis, treatment, and results is so anyone else dealing with this will have a point of reference of at least one person's experiences. There's quite a lot of information, so I'll try to keep it organized.
As background, here are the stats:
I'm now 62.5 years old, 6'1", weigh 195#. I live in Jackson Hole and am very active physically. I love to ski and typically do alpine and backcountry skiing for a total of around 130 days a year or more. I also participate in hiking, biking, extreme flyfishing (that just means I tend to not believe in trails very much), watersports, and a lot of other stuff where feet are relatively important.
What I have is osteoarthritis in the main joint of both big toes. It's important to establish right off the bat that I do NOT have bunions. It doesn't have the same causes as bunions and is not treated the same way as bunions. It sometimes LOOKS like bunions, but it's not.
The technical term for what I have is hallux rigidus. Here's a really good explanation from Wikipedia:
Degenerative arthritis and stiffness due to bone spurs that affects the MTP joint at the base of the hallux(big toe) is called Hallux rigidus or stiff big toe.
Although the condition is a degenerative condition, it can occur in patients who are relatively young particularly active sports people who have at some time suffered trauma to the joint (turf toe). A notable example is NBA star Shaquille O'Neal who returned to basketball after surgery.
Non-surgical treatment Early treatment for mild cases of Hallux rigidus may include prescription foot orthotics, shoe modifications (to take the pressure of the toe and/or facilitate walking), medications (anti-inflammatory drugs), injection therapy (corticosteroids to reduce inflammation and pain) and/or physical therapy.
Surgical treatment In some cases, surgery is the only way to eliminate or reduce pain. There are several types of surgery for treatment of Hallux rigidus. The type of surgery is based on the stage of hallux rigidus. Stage 1 hallux rigidus involves some loss of range of motion of the big toe joint or first MTP joint and is often treated conservatively with prescription foot orthotics. Stage 2 hallux rigidus involves greater loss of range of motion and cartilage and may be treated via cheilectomy in which the metatarsal head is reshaped and bone spurs reduced. Stage 3 hallux rigidus often involves significant cartilage loss and may be treated by an osteotomy in which cartilage on the first metatarsal head is repositioned, possibly coupled with a hemi-implant in which the base of the proximal phalanx (base of the big toe) is resurfaced. Stage 4 hallux rigidus, also known as end stage hallux rigidus involves severe loss of range of motion of the big toe joint and cartilage loss. Stage 4 hallux rigidus may be treated via fusion of the joint (arthrodesis) or implant arthroplasty in which both sides of the joint are resurfaced or a hinged implant is used. Fusion of the joint is often viewed as more definitive but may lead to significant alteration of gait causing postural symptomatology. The implants termed "two part unconstrained" implants in which a "ball" type device is placed on the first metatarsal head and "socket" portion on the base of the big toe do not have a good long term track record. The hinged implants have been in existence since the 1970s, have been continually improved and have the best record of improving long term function.
It first appeared in my right foot over 20 years ago, about a year after I did a minor fracture to that toe by whacking in on the door to the bathroom in the middle of the night.
The right toe actually started bothering me in 1991. At that time, I was told by an orthopaedic surgeon in Des Moines (where I was living at the time) that my big toe joint had severe osteoarthritis and I needed a joint replacement. Well, I immediately sought out a second opinion. I sent all the details to Dr. John Feagin, who at that time was doing knee research at Duke University. I had known John from my days as a backcountry ski guide at Jackson Hole and John had done a patellar graft reconstruction of my left ACL a year earlier. John asked me questions about how much pain that toe was causing and whether it was prohibiting me from doing any of the things I wanted to. I told him the pain was mostly mild to moderate and it didn't hold me back much. He then replied, "Well, if I were you, I'd wait until I either couldn't stand the pain or until I couldn't do the things I loved." That seemed like good advice and I pretty much put up with the pain - and increasing deformity of the joint - for the next 15 years.
I finally broke down and had something done in June of 2006. It had reached the point where I had such large calcium deposits and bone spurs (osteophytes is the tech term) that I could barely get my foot into a ski boot. Matter of fact, in order to ski during the 05/06 season, I had to cut the entire area above that big toe joint out of my ski boot liner to accommodate the size of the joint. By June, I knew I needed to have something done and went to a foot/ankle surgeon here in Jackson, Heidi Jost, who recommended a cheilectomy. A cheilectomy is essentially a removal of all the excess bone spurs and deposits. It's not any sort of cure for hallux rigidus - rather it treats the symptom of pain from pressure, etc. The alternative would have been a fusion of the joint but I didn't want to go there at that point.
For a little perspective, here's a photo of my right big toe about a week before that surgery.
And here's the junk she removed from around the joint:
THere is a fairly detailed thread about this 2006 surgery here: http://www.epicski.com/t/41050/hallux-rigidus-anyone/60
The reaction to that thread is a big part of the reason I started this one. Over the six years that have gone by since I posted that thread, I've received a great many emails from people (a lot of them non-skiers) who found that thread through Google searches on hallux rigidus and wrote to ask me questions. It's pretty amazing how many people I've heard from and how prevalent this problem is.
So to finish up on that episode, the surgery went great, rehab was not very difficult, and fourteen weeks later I joined my wife and some friends in climbing this Via Ferrata route of a Dolomite peak called the Civetta near Cortina in Italy (our up-route is marked in red, down-route in blue):
It was a huge day of about 6,000 vertical feet up and 6,500 vertical feet down and my foot/toe did just fine. And at that point, my right toe was doing well and my LEFT big toe wasn't showing any symptoms at all, so I was a very satisfied customer.
Flash forward to the summer of 2010, and I could tell that things were starting to happen with the left big toe. It was becoming progressively more sore after hiking and I could tell that the size of the joint was increasing. Based on my experience with the right foot, however, I was figuring I would have 10 or 15 more years before the symptoms became serious enough to have to deal with. So much for what I know.
By the spring of 2011, my left big toe joint was significantly larger and it was becoming more painful to walk and hike. At the end of June last year, I went on a really excellent backcountry ski tour here in Jackson Hole to ski Jackson Peak. Jackson Peak is one of the classic spring-skiing adventures around here, and we had a fantastic time (here's the thread on the trip report).
The tour involved about an hour of hiking (in hiking shoes) before reaching the snow line. While hiking back down in my hiking shoes, I stepped hard on a sharp rock with the area just to the left of my left big toe joint. I felt a sharp pain but just chalked it up to the big toe that was sore anyway.
As it turned out, by a few days later that portion of the bottom of my foot was very painful and it didn't go away. I had to stop hiking for exercise and even walking was fairly painful. I went back to see my doc, who told me that the left toe joint had developed a great deal of arthritis and that this joint also was manufacturing bone spurs and calcium deposits. The difference between the right big toe (which had been pretty successfully treated by removing the osteophytes) and the left toe was that the left toe osteophytes were more widely spaced and the joint was actually GROWING to the point where it was shoving the second toe joint sideways and out of place. A chilectomy would not work for that foot.
Last summer, we decided on a non-surgery approach that involved cortisone shots, a very aggressive custom orthotic to better distribute weight on that foot, stiffer-soled shoes, and reduced activity. While that diminished the pain somewhat during regular activities and regular walking, whenever I would start hiking on uneven terrain the pains would come right back. I was basically reduced to not being able to hike in the mountains in the off-season, which had been my main way of getting and staying in shape for skiing.
By November of 2011, it was obvious to me that the foot was not improving and was probably getting worse. I called up my old friend Dr. Feagin, who is no longer practicing surgery but does consult now with the Steadman Clinic in Vail. He recommended that I come see Dr. Thomas Clanton, who is the foot and ankle specialist at Steadman's. He's also a past president of the American Foot and Ankle Orthopaedic Society. So, I made an appointment for the morning of December 2 to see Dr. Clanton.
Once we got about a week away from the appointment, I realized that I had scheduled my appointment for EXACTLY the time the World Cup Downhill race was scheduled to start at the Birds of Prey course in Beaver Creek. It would have been very cool to go watch the race, but by that time I couldn't reschedule the appointment, so my wife and I drove down to Vail on December 1 as planned.
I met with Dr. Clanton and he checked out the toes. His diagnosis was:
A. I had really severe osteoarthritis in the joint of the big toe. It was advanced to the point where there was essentially no cartilage at all remaining on the bone surfaces, so I have been bone-on-bone in that joint for probably over a year. There were also all kinds of osteophytes surrounding the joint as well as - this was a surprise - a "floating" piece of bone that had become detached at some point. He asked if this was an old injury but I told him I had no recollection of ever injuring that toe. So who knows where that came from?
B. The OA had irritated the joint to the point that all these bone spurs and whatnot had expanded. The direction this expansion took was sideways toward the outside of my foot. Over time, this "growth" of the big toe joint had actually displaced the second toe joint. Related to that displacement (and perhaps to the rock I stepped on during my hike down from Jackson Peak) was a significant tearing of the plantar plate that runs under the joint and protects and stabilizes the joint. There is a good explanation of a plantar plate tear here: http://www.northcoastfootcareblog.com/plantar-plate-tears/
Given that diagnosis and also given that I had already tried most of the conservative methods of treating my foot, he recommended two surgeries (to be done at the same time);
A. The first would be a full fusion of the big toe joint. That involves removal of all of the osteophytes, floaters, and any remaining cartilage. Once the joint is "cleaned up", he would place a metal plate on top of all the bones (and beneath the skin) and then screw everything together. It's a pretty common surgery and fairly straightforward. The object is to have all of the bone surfaces "heal" together to form one elongated bone mass. The obvious downside of this surgery is that the big toe will no longer flex in any direction. The upside is that this is supposed to eliminate the pain, inflammation, and bone spur production that's associated with the osteoarthritis.
B. The other surgery is called a Weil's Osteotomy and that would be done on the bone in the second toe. That amounts to basically cutting the bone in a diagonal direction just behind the joint, removing a few millimeters of the bone, and then screwing the now-shortened bone back together. The purpose of this is to restore that toe to the position it belongs. Because that joint had been displaced by my big toe joint and the plantar plate had been torn, the toe was "longer" than it should be and was angling over the big toe. The osteotomy should get the toe back where it belongs and restore some of the cushioning beneath the bones and the joint. Here's a rather disgusting YouTube video of what the operation is like, although this operation is the 3rd toe and mine was the second:
So that was the recommendation. Given that I felt that the big toe was definitely getting significantly worse and it had already caused major problems with the second toe, I decided to go ahead and plan on having the surgery.
Dr. Clanton told me that there was no urgent reason to have the surgery right away and I could wait until after the ski season if I wanted to. That meant sometime in April or May. Because April is typically good skiing AND fishing in Jackson Hole and because the rivers streams tend to be blown out with runoff during May and therefore not fishable, I decided to have it done in May.
According to Dr. Clanton, the recovery would be something like this:
Day 1: Surgery as an outpatient. The two operations would take a combined time of around an hour. General anesthesia and a short-term pain block. After coming out of anesthesia and being released from the clinic, I would leave on two crutches with a walking boot on my left foot and spend the night at our hotel. 2 percoet every four hours for pain. Almost constant elevation. Boot on at all times.
Day 2: Leave Vail and ride back to Jackson. Pain medication as needed. Constant elevation. Boot on.
First week: No weight-bearing for the first few days, transitioning to slight weight on the heel but continuing with two crutches. Elevation as much as possible. Boot on all times.
7-10 days post-op: Return for removal of stitches, change of dressing, x-rays to confirm everything okay. Return to Jackson. Elevation as much as possible. Boot on at all times.
Next 6 weeks: One crutch, mild to moderate weight-bearing, still on the heel of the boot. Boot on at all times.
7th week: Return to Vail for followup. X-rays to determine degree of healing in the fusion and in the osteotomy. Depending on level of bone repair, it's possible that I can get rid of the crutch, wear the boot only for protection, and get rid of the crutch.
8th week: POSSIBLE ski trip to Mt. Hood to ski on the last day of June. The doc and I would negotiate on that one.
So that was the plan and the anticipated recovery. Through the winter, I skied a great deal (something like 126 days on my resort pass and about 15 more in non-resort backcountry. As the winter wore on, I learned that skinning in particular became very painful. For whatever reason, when I would skin up somewhere on a traverse that had my left foot as the lower leg, the foot would really start to hurt. Booting was also very painful if I booted for more than about half an hour. That was surprising because simply skiing at the resort in my alpine boots really wasn't any problem at all. It actually felt better than walking in my hiking shoes. So, by the end of April it was time to go get it done.
After a great morning of skiing at A-Basin with a bunch of EpicSki members on Tuesday, May 1, we went over to Vail for my pre-op appointment. That all went pretty much as planned and they again outlined how the two surgeries were expected to go and what my post-op care would be. I was scheduled to be Dr. Clanton's first surgery the next day at 7:00am, so they wanted me at the clinic at 6. Yikes. We went back to our hotel, had a nice dinner at Bully restaurant at the Sonnenalp hotel and crashed.
Up early the morning of surgery. I had to shower with some antibiotic soap called Hibiclens (actually had been for three days) and the we went to the operating room. I had about six different nurses and techs and docs and so on come in and ask me what my name is, why was I there, what procedure(s) were we having done, etc. It got a little funny after awhile because I'll never be able to answer all those questions for future surgeries once my Alzheimer's really kicks in. On a more serious note, all of the questions and answers seem to indicate that they really do take all this stuff seriously at the Steadman Clinic and they're not going to make any mistakes if there's any way they can avoid it.
Eventually, the anesthesiologist and Dr. Clanton came in. We discussed the anesthesia and post-op pain control. If there were ANY mistakes made, I think that *I* made one at that point. The anesthesiologist told be he could give me pain blocks post op that would last for a few hours, or 24 hours, or 48 hours (I think). I told them that in my previous surgeries I had seldom had much pain after surgery and I should be fine with a minimal deal. Well, they took me at my word.
That's pretty much the last thing I remember until waking up in the recovery room looking at my wife. My foot was all bandaged up and sitting elevated on some pillows and I felt pretty good. Ruthie said that Dr. Clanton had talked to her after the surgery and he had told her that the "cleanout" of the bone spurs and whatnot had been pretty involved. There was a lot of junk to get rid of, apparently. Other than that, everything had gone very smoothly and he felt it was very successful.
It did involve one hell of a lot more hardware than I expected, although I never really asked what "plate and screws" actually meant. It turned out there is a plate and EIGHT screws in my big toe and one screw in my second toe. Here are a couple of post-op x-rays:
It looks like the kind of carpentry would that *I* would do.
I had to stay in recovery until I felt somewhat lucid (which wasn't happening super quickly) and I also had to pee before they would let me leave. After about 30-45 minutes, I felt reasonably alert and went to the bathroom. At that point, the guy came with the walking boot and showed me how to put it on and secure it. Well, moving the foot around to get it into the boot (which he was very good about) sort of woke me up to the fact that my foot did, indeed, hurt. Quite a bit. Like more than quite a bit.
Das boot (next to das ski boot, ha ha):
Better shot of the boot:
And here's what it looked like bootless:
So, they gave me two percocet and told me I could be on a 2 percocet every four hours schedule. Then we trundled me into a wheelchair, wheeled me out the door, and loaded me in the back of the Trailblazer for the 5-minute ride to the hotel. By that time, the painkillers were kicking in and I started feeling okay again. Crutching (on two, no weight-bearing at this point) to the room wasn't bad but I was glad to collapse on the bed and prop my foot up.
So that's where I stayed for the rest of the day and overnight. By the third hour, the pain was starting in pretty good again and I jumped the gun a little by taking one percocet at 3.5 hours and the other at 4. By early evening, the pain was definitely there but essentially under control with the percocet. The next problem, though, was itching. I started getting very itchy on my back and one side and I'm sure that's a reaction to the percocet. My brain probably wasn't working all that well at that point, because 24 hours later I remembered having a somewhat similar reaction to percocet 20 years ago when I had the acl surgery. That ancient history didn't occur to me the night after surgery, so I pretty much just laid there and tried not to scratch my skin off.
I didn't sleep a whole lot that night (aren't painkillers supposed to knock you out???) but got through the night okay. By morning, the pain was dropping off and I was on more of a 1 percocet every three hours sort of thing. I kind of got cleaned up and Ruthie loaded me in the back of the car at 8:00 and we took off for Jackson. We had brought pillows and a thermarest for the back of the car, so I could lie there very comfortably with my leg elevated and things went pretty well (except for the very twisty highway that cuts northwest toward Craig, Colorado from just west of Vail. Ruthie did her best to keep the car from rocking, but it was a little like a roller-coaster ride for the first fifty miles or so.
Dr. Clanton had told us to be sure to stop and get me out of the car and moving around a little every hour or so, so that made for a fairly long ride home. Sometime along the way (while trying not to itch too much, I remembered the whole thing about my past experience with percocet. I remembered that they had switched me to vicodin back then and it had worked much better for me. We called a Jackson doc who ordered me a vicodin prescription that we picked up when we got back in town. From that moment on, whatever level of discomfort I had went away. I slept MUCH better with the vicodin (I was now down to one every four hours), the pain was pretty much going away, and so was the itching.
That's how things went for several days. I pretty much quit with the pain stuff by the fourth day. The foot didn't feel great, but as long as I had it elevated it was fine. I started walking around on the two crutches quite a bit and was able to drive myself by the fifth day. That worked okay because the car is an automatic, it's fairly roomy, and it's my left foot. I could tell that my "feel" through the boot would be pretty sketchy if I was trying to drive with an injured right foot instead of left.
We had scheduled a followup appointment for May 11, which was nine days post-op. By that time, I was definitely cheating and using one crutch a fair amount of the time and also doing mild weight-bearing on the heel of the boot. I kept elevating it as much as possible, however, and I really think that's key to staying pretty comfortable.
So the morning came to remove the dressings and take out the stitches. Here's the first look:
Not too bad, really.
CLEANUP ON AISLE TEN:
Stitches coming out:
So then Dr. Clanton came in to examine and look at the new x-rays. He said he could see "bridging" already, which apparently is a sign that the bones are healing together. I couldn't see that in the x-rays, of course, all I could see was that huge-ass plate and all those screws.
So then we had "the conversation".
I explained how I had been skiing every month for a long time and I would like to be able to continue at the end of June if possible. As he smiled and shook his head slightly, I told him that IF it was possible for me to try it, I was going to go to Mt. Hood on the last day of June, ride up a chair, make one run on a groomer, and that would be it. No boot-hiking up a boulder field or anything like that, just nice, low-impact skiing on a groomed hill. He chuckled a little, got out a calendar, and started figuring out how many weeks that would be.
He then proposed a compromise. If I would come back at six weeks so he could physically see the toes and run his own x-rays, he'd keep an open mind. BUT, I had to agree that his decision was final. If he felt that the bones had healed sufficiently that I wasn't in any danger of breaking things up if I fall, then he'd give me the okay. If he doesn't feel at that point that it's safe, then I have to bag it and the consecutive-month thing is over. I said that's fair and that's how we left it.
He did say, however, that I have to keep using the single crutch right up until when I see him again. Bummer.
I'm home now. It's a little over two weeks post-op. I feel like it's going well and I'm optimistic.
Today is 5 weeks post-op. The foot feels better and better. I'm sure I'm breaking the rules slightly because I seldom use the crutch now unless I'm going to be walking or standing for awhile. I've noticed that being up and about on it doesn't cause nearly as much swelling and discomfort as it did just a few days ago.
I'm still wrapping it in gauze and wearing the boot all the time, except that I take the boot off quite a bit when I'm sitting around with the foot elevated. I'm still putting ice on the toes three or four times a day and that seems to make everything feel better.
When the boot is off and the toes are "free", so to speak, I'm finding it more and more tempting to try to flex the toes. I think I'm probably not supposed to do that yet, so I'm trying to resist, but it seems that the basic healing is definitely moving along.
I see the doc for my folllowup x-rays and exam on June 18. That's when I find out if I can ski by the end of the month. Just judging by the difference in how much better it feels from a week ago to now, I can't imagine that I won't be prancing and skipping around by the end of June.
Here's a photo from today:
Comparing to the previous set of photos, you can see that there's much less swelling and discoloration. I'm feeling good about it.
- Pain and stiffness in the joint at the base of the big toe during use (walking, standing, bending, etc.)
- Difficulty with certain activities (running, squatting)
- Swelling and inflammation around the joint
by Bob Peters
Jackson Hole, WY