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My Excellent Toe Surgery Adventure - Hallux Rigidus, Plate/Screw Fusion, and Osteotomy

post #1 of 746
Thread Starter 

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.

 

The point of this thread is to share my symptoms, diagnosis, treatment, and results 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'm going to add posts to this thread over the next few days.

 

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 something right off the bat...

 

What I have is NOT 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:

 

 

Hallux rigidus

From Wikipedia, the free encyclopedia
 
 
Hallux rigidus
Classification and external resources

Hallux not labeled but visible at upper left.
ICD-10 M20.2
ICD-9 735.2
DiseasesDB 33134
eMedicine orthoped/125
MeSH D020859
Hallux rigidus

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.

[edit]Symptoms

  • 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

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.

[edit]Treatment

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.

 

Got to go right now.  More to come in the next couple days.

post #2 of 746

Thanks for the info ... look forward to the updates. Curious about what it's like to put on a ski boot with a fused toe, because I am headed toward a fusion eventually, I think.

 

I will always be curious about the "why" as well. I've not had any major trauma, and apparently it's unusual that I was in such bad shape at such a young age without it. I do have two parents with it, so genetically I was already in danger, but the doctors think I'm weird. ;-) They keep asking, "Are you SURE you never broke it?" I really do think I'd remember that. I did play a lot of soccer, and after I quit formal competition, I played a lot barefoot. That probably wasn't a good idea, in hindsight.

post #3 of 746

Hi Bob,

 

Thanks for starting this thread.  I also look forward to the updates and information that you share. It is really helpful.

 

I also have hullux rigidits and my orthopedic surgeon told me that I probably injured my great toe when I was younger and repeatedly stressed it.  I skated competively when I was younger and I'm sure that contributed to my HR. I never fractured my toe and I don't recall ever hurting it when I was skating but it is my right foot and I used that foot more skating.  I had a cheilectomy in January of 2012 and it was a slow recovery but I have dorsiflexion in that toe now and I am very thankful!

post #4 of 746

It'd be interesting to hear your ongoing treatment and if surgery is needed.

 

So, overall do you have a guess on what you think were the primary contributors?   I always figure genetics is the primary driver for most conditions, least wise pre-dispose us towards an issue.   But I also wonder given your quite active, but older if your general nutritional care has over 40+ yrs been on the leading trends or standard North American in nature.   Equipment - boots and such adding issue?   I'd imagine over the yrs boots are more forgiving of issue as years ago they seem as if they may induce issue.  To mind comes the issues women have with High Heels .... though they do make a calf look good!

 

I don't wish to imply that one was reckless with nutrition but I find as I grow older and learn more, that I foregone a lot of good nutrition for processed food. I somewhat found it entertaining my mother read and subscribed to then crazy "prevention magazine" but now think I should of listened a bit more ...

 

I've known too folks who had horrible arthritic issues that at the age of 17, 18 was quite unbelievable but real ...

 

I guess my question is more overall, what factors do you figure contributed, and of course I'm interested in how the prognosis goes and what course of action you take. 

 

Wishing you well, hope all goes as well as possible.

post #5 of 746

Bob, thanks for sharing your journey.  Will be curious to see how you progress.  I am on the same path.  Osteo and Hallux Rigidus in both toes, Need cheilectomy and have been given the choice of either joint resurfacing or fusion. Very much on the fence as to which to choose.  Both have upsides and downsides.  I am 48 years old and this been very tough to deal with emotionally (and physically!!).  My arthritis is likely due to genetics (lots of osteo in my family) as well as 20 yrs in a downtown office environment wearing high heels all day every day.  Oh, if I could only go back and do things differently....

 

Look forward to your future posts.

post #6 of 746

Hi Cicixsmith,

 

I totally agree with you on going back and doing things differently.  I would have NEVER skated.  There is no one else in my family with OA in the big toe.  Although most folks have OA at some point in there life but at 48 my big toe had SEVERE OA - to much wear and tear. From what I understand couch potatoes don't get HR. 

 

You mentioned a joint resurfacing - what exactly is that?  Is that the big toe joint replacement?   Here is what my orthopedic surgeon at Duke University in Durham, NC said about big toe joint replacements -  Don’t think that is a good idea.  Something I have played around with.  Done more in the Podiatry Community than Orthopedic Community but I do more surgery to remove those rather than putting new ones in by far so I would recommend against that.

post #7 of 746
Thread Starter 

Thanks for the nice comments, everyone.  I'll reply a little more specifically after this post.

 

So to continue...

 

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.

 

0b0e7374_1-Bobtoewithdimebeforesurgery6-6-06.jpeg

 

And here's the junk she removed from around the joint:

 

e8489596_ToeOsteophytes-6-6-06-web.jpeg

 

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):

 

FerattaRouteAlleghesi9-13-06-Marked.jpg?

 

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).

 

346dcdc6_JacksonPeakfromNorth-routemarked.jpg

 

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 and my wife and I drove down to Vail to see Dr. Clanton on December 1 of 2011.

 

That's where I'll continue the story in my next post.

post #8 of 746
Thread Starter 
Quote:
Originally Posted by segbrown View Post

 They keep asking, "Are you SURE you never broke it?" I really do think I'd remember that.

 

I get asked that a lot, too.  While it's true that I did have a minor fracture in my right big toe and that toe DID develop OA much earlier, to my knowledge I've never, ever injured the left big toe and that's now the one causing the more significant problems.

 

Quote:
Originally Posted by Lashes2011 View Post

 

I also have hullux rigidits and my orthopedic surgeon told me that I probably injured my great toe when I was younger and repeatedly stressed it.  I skated competively when I was younger and I'm sure that contributed to my HR. I never fractured my toe and I don't recall ever hurting it when I was skating but it is my right foot and I used that foot more skating.  I had a cheilectomy in January of 2012 and it was a slow recovery but I have dorsiflexion in that toe now and I am very thankful!

 

The literature does say that there SEEMS to be a relationship between injuries and OA, but I suspect it's like everything else in life.  The problems are the culmination of a whole lot of seemingly unrelated (and unremembered things).  Bottom line  - sometimes things suck.

 

More important bottom line (which I try to remind myself of regularly) - this isn't cancer or heart disease.  It's annoying and painful and keeps me from doing some of the things I want, but it's not going to kill me (unless I trip on my crutches and fall in front of a bus).

 

Quote:
Originally Posted by pete View Post

It'd be interesting to hear your ongoing treatment and if surgery is needed.

 

So, overall do you have a guess on what you think were the primary contributors?   I always figure genetics is the primary driver for most conditions, least wise pre-dispose us towards an issue.   But I also wonder given your quite active, but older if your general nutritional care has over 40+ yrs been on the leading trends or standard North American in nature.   Equipment - boots and such adding issue?   I'd imagine over the yrs boots are more forgiving of issue as years ago they seem as if they may induce issue.  To mind comes the issues women have with High Heels .... though they do make a calf look good!

 

You could, you know, make the opposite observation as well.  The calf that sacrificed the leather for the high heels helps make the legs look good.

 

See above as far as contributors.  I think there's lots of conjecture and very little certainty.

 

Quote:
Originally Posted by cicixsmith View Post

Bob, thanks for sharing your journey.  Will be curious to see how you progress.  I am on the same path.  Osteo and Hallux Rigidus in both toes, Need cheilectomy and have been given the choice of either joint resurfacing or fusion. Very much on the fence as to which to choose.  Both have upsides and downsides.  I am 48 years old and this been very tough to deal with emotionally (and physically!!).  My arthritis is likely due to genetics (lots of osteo in my family) as well as 20 yrs in a downtown office environment wearing high heels all day every day.  Oh, if I could only go back and do things differently....

 

Look forward to your future posts.

 

Hi, cici.

 

Every joint is different and every person's hoped-for result is different.  For me when I had the chilectomy on the right foot, the bone spur deformities were so pronounced in one spot that it seemed that a chilectomy was the lesser-evil approach.  As I say above, my doc made it very clear that the chilectomy does nothing to address the primary problem of arthritis in the joint surfaces, but it does (can is probably a better word) relieve external pressure caused by the bone spurs.  While the toe that had the chilectomy has done very well since (it's now six years), it IS growing again and I'll have to deal with it again sooner or later.  I'm glad I had the chilectomy rather than a fusion, but I'll probably have to have a fusion on that toe at some point in the future.

 

For my LEFT toe (the one I just had surgery on), a chilectomy really wasn't indicated.  The damage was too widespread and the enlarged big-toe joint had already displaced the next joint over.  So on this toe, fusion was my surgeon's recommended path.

 

Good luck to all of you with your toes.  icon14.gif

 

More to come.

post #9 of 746

Geez, Bob.  You're making my feet hurt just reading this.

post #10 of 746
Thread Starter 
Quote:
Originally Posted by SpikeDog View Post

Geez, Bob.  You're making my feet hurt just reading this.

 

Ha!

 

I don't really think I can get away with suggesting that it sucks to be me.

 

It is pretty annoying and I certainly wouldn't wish it on anyone else, but obviously I've been able to live with it.  

 

The good news this past winter was that the foot actually felt better in an alpine ski boot than it did in a shoe and skiing felt better than walking.  That's not all bad, is it?

post #11 of 746
Quote:
Originally Posted by Bob Peters View Post

the foot actually felt better in an alpine ski boot than it did in a shoe and skiing felt better than walking.  

 

This is SO true ... It's a really good excuse to ski a lot more than I probably should.

post #12 of 746
Thread Starter 
Quote:
Originally Posted by segbrown View Post

 

This is SO true ... It's a really good excuse to ski a lot more than I probably should.

 

I'm sure you could get one of the many EpicSki doctors to write a prescription for you.  Then you could tell everyone that you really don't WANT to ski, but you have to because it's part of your treatment for the toe issues.

post #13 of 746

I don't think a ski prescription would get me out of work.  It sure would be nice to use sick leave to ski, tho.

 

Bob, how did you keep your monthly ski streak going in '06?  I thought the streak was a couple of decades long.

post #14 of 746
Thread Starter 

So when we left off, I was on my way to see Dr. Thomas Clanton at the Steadman Clinic in Vail for an MRI and an evaluation.  I set that appointment for the morning of December 2, 2011.  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.

 

Anyway, 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.  wink.gif

 

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.  That's where the next post will pick up.

post #15 of 746
Thread Starter 
Quote:
Originally Posted by SpikeDog View Post

I don't think a ski prescription would get me out of work.  It sure would be nice to use sick leave to ski, tho.

 

Bob, how did you keep your monthly ski streak going in '06?  I thought the streak was a couple of decades long.

 

Hi, SD.

 

Not quite two decades.  As of this May, I've skied 176 months (or just over 14 years).  

 

When I had the '06 surgery, I actually skied (on Teton Pass) the morning of the surgery, which was about the second of June.  Because that surgery didn't involve any bones fusing or anything, by the sixth week or so I was able to walk or do anything else as long as I could take any pain that was involved.  At the end of July, my wife and I hiked from the top of the JH tram over to the Powder 8 face on Cody Bowl.  There was a pretty long snowfield there and I hiked up and skied it.  The foot didn't feel very good and I was glad to get off it once we got back, but it didn't do any harm at all.

 

The difference this time is that the bones have to fuse before the doc will let me do anything.  I've promised to be a good patient and let him make the call on whether I'm healed enough to do some very basic lift-served skiing at the end of June.  We'll see what happens.

post #16 of 746

Thanks, this is very helpful, and best of luck with everything.

 

To the extent that you do technical climbing after the fusion, while it's not ski-related per se, could you say what you do in terms of shoes, etc.?  For things like Teewinot, are you just going to always go for rigid soles? 

 

Has this affected your wading at all when fishing? 

 

What will you be doing for hiking boots for the future? 

 

Your right big toe was pretty impressive pre-op!

post #17 of 746
Thread Starter 

Okay, on to the surgery.

 

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:

 

Bob Left Toe Surgery Big Diagonal View 5-2-2012.jpg

 

Bob Left Toe Surgery Side View 5-2-2012.jpg

 

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):

 

IMG_9445.jpg

 

Better shot of the boot:

 

IMG_9555.jpg

 

And here's what it looked like bootless:

 

IMG_9560.jpg

 

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:

 

IMG_9569.jpg

 

Not too bad, really.

 

CLEANUP ON AISLE TEN:

 

IMG_9582.jpg

 

Stitches coming out:

 

IMG_9584.jpg

 

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.

 

More to come as the saga continues.

post #18 of 746
You got more screws than I did, Bob.

140719844.jpg


Glad to hear you're coming along well. Follow your surgeon's orders.
post #19 of 746

Thought this might be interesting  ... Lleyton Hewitt had his left toe fused a couple of months ago (and is already back on court! wow)

WHEN Lleyton Hewitt walks on to a Roland Garros court for his opening match at the French Open next week, it will be with steps rarely taken by a professional tennis player.

Hewitt has undergone radical surgery to prolong his career and remove the constant pain that has accompanied his every court appearance over the past two years, with two screws and a metal plate now locking permanently into place in the big toe on his left foot.

Hewitt's toe, chronically arthritic and misshapen after years of digging into hard courts to launch his service action, is now reconstructed and irreversibly fused. Whatever cartilage there was in the first metatarsophalangeal (MTP) joint has been removed and painful bone spurs shaved off. The toe no longer moves, but nor should it give Hewitt any more grief.

For the first time that he can remember, Hewitt is without pain when he begins each day. If his luck holds, he may even start finishing tennis matches the same way.

The dramatic change in outlook has prompted Hewitt to reset his remaining career sights on a full-time return to the tour this year, a competitive campaign next year, and perhaps beyond.

Hewitt's manager David Drysdale, although reluctant to discuss the medical procedure in detail, told The Weekend Australian: "The X-rays look like something out of Bunnings."

The toe fusion surgery, performed by Melbourne foot and ankle specialist Harvinder Bedi, is common enough as a remedy for degenerative arthritic conditions but extremely rare, if not unknown, for a tennis player still trying to earn a living on the professional tour.

When Hewitt was deciding whether to undergo the procedure, he was warned there was a significant chance he might not be able to play again. The biggest unknowns were whether having the toe set in place would allow Hewitt to push up into his serve or push off hard from his forehand in a baseline rally.

Hewitt opted to go under the knife anyway, reasoning he would need it at some stage for a pain-free retirement. Such was his frustration with the time he has been forced to spend off court in recent years, he calculated it was a risk worth taking......

 

http://www.theaustralian.com.au/sport/tennis/my-new-left-foot-lleyton-hewitts-radical-surgery-revealed/story-fnbe6xeb-1226367415352

post #20 of 746

That is a pretty cool news story. 

I'm guessing that he was changing how he put pressure on that foot to accommodate the pain, so a rigid toe without pain isn't much of a compromise. 

 

I'm not much for tennis, but I'll probably follow him in the months ahead. 

post #21 of 746
Thread Starter 

Thanks for the link, Seg.  That was inspiring for me because it sounds like Hewitt was dealing with a big toe that was pretty similar to mine.

 

Speaking of mine, it's now been four weeks since the surgery and things seem to be on track.  I'm probably spending more time running around on it than I should and it still definitely gets somewhat swollen and stiff when I go too long without elevating and icing it.  Overall, though, it seems to feel more stable and strong with each day.  

 

The stitches have pretty much healed, with just a little bit of dead skin and scabs yet to drop off:

 

IMG_0193 5-30-2012.jpg

 

I'm still wearing the boot pretty much 24x7 and I'm using a single crutch, although I don't use it when I'm going short distances.  I suspect the doc would disapprove of me not using the crutch ALL the time, but I'm keeping all my weight on the heel and it feels fine.

 

My return appointment with the doc is about 2.5 weeks from now, June 18.  At that point, I guess I'll find out how well the bones are fusing.

 

Thanks.

post #22 of 746
Thread Starter 

Just another progress report...

 

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:

 

Left Toe 5 Weeks after Surgery 6-6-2012.jpg

 

Comparing to the photo in the next post up, you can see that there's much less swelling and discoloration.  I'm feeling good about it.

post #23 of 746
Looking better, Bob. I'll bet your wanting to wiggle is like having an itch inside a cast, Eh? You're probably wiggling in your sleep. You don't wear the boot then do you?
post #24 of 746
Thread Starter 
Quote:
Originally Posted by Kneale Brownson View Post

Looking better, Bob. I'll bet your wanting to wiggle is like having an itch inside a cast, Eh? You're probably wiggling in your sleep. You don't wear the boot then do you?

 

You're right - it's pretty similar.

 

Yeah, I'm wearing the boot while I sleep.  The doc told me he would prefer that I wear the boot AND elevate the foot while I sleep for the entire time until my last followup.  Seems like overkill to me, but I'm doing it.  

 

On the plus side, my wife says I haven't snored at all since I started sleeping with the foot elevated.  Weird.

post #25 of 746
Quote:
Originally Posted by Bob Peters View Post

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.  

 

So have you stuck your foot into a ski boot yet?  My guess is you have.....rolleyes.gif

 

Does this mean another liner popped in the oven?  There must be alot of room in your old liner for that knobby toe.

post #26 of 746

Wow - Bob your toe and foot looks great for 5 weeks postop. Hope your follow-up appointment on 6/18 goes well, and he releases you to ski.  Elevating and ice is the key.  Thanks so much for starting this thread.  It has been so helpful. 

post #27 of 746

Segbrown - thanks for this information.  What a great athlete.  It is so encouraging. 

post #28 of 746

Bob - just wanted to see how you are doing.  I know in an earlier post you had a doctor's appointment on 6/18 (I think you are about 7 weeks postop now).  How did you visit go?  Are you in PT?  You might still be in Vail since your appointment was yesterday.  Do you have any new photos?  What was the verdict on skiing at the end of the month?  I wish you the best. 

post #29 of 746
Thread Starter 

Hi, Lashes et al.

 

We just got back from Vail last night.  We took a little detour and drove through Rocky Mountain National Park on Trail Ridge Road.  Neither of us had ever done that before, and I would HIGHLY recommend the drive for anyone who's never been there.  It's an incredibly beautiful drive way above timberline.  We passed numerous snowfields, a few of which had ski tracks.  It was very cool.

 

Today is week # 7.  Sitting here right now, it's hard to imagine that 49 days have gone by since the surgery.

 

I met with Dr. Clanton (and his surgical fellow who also stood in at the surgery) on Monday and the news was all very good.  The x-rays showed that new bone has bridged across nearly all of the fused points on the big toe.  The plate and all of the screws are still exactly where they should be and I'm feeling no pains associated with any of the incisions, hardware, etc..  The two docs actually got pretty aggressive about moving the two toes around.  I was surprised at how much they moved the toes.  At first, it hurt a little bit (I think I was consciously resisting any movement) to have the toes moved, but that went away quickly and everything felt good.

 

I still have this sort of unconscious impulse to try to bend the fused toe. That doesn't work AT ALL, but it also doesn't seem to hurt when I do it now.  The doc said that impulse gradually goes away as the body adjusts to the new circumstances.

 

After showing me the x-rays, Dr. Clanton told me it was okay if I go skiing on June 30.  He went to great length to try to impress on me that it's definitely outside the "normal" recovery process to let me go ski (it will end up being a few days more than 8 weeks post-op) and I'm supposed to do pretty much as minimal a ski outing as I could.  I promised to be as light on my feet/foot as possible. 

 

From a more practical sense, here's where I am right now:

 

*  As of Monday I no longer have to use the one crutch.  I was cheating on that quite a bit anyway, but now I'm officially off the crutch.

 

*  I'm being weaned off the walking boot.  Starting this past Monday, I'm supposed to be wearing it about 3/4 of the time during the day and I no longer have to sleep with it.  YAY!  By the end of this week, I should be using the boot 1/2 the time, dropping to 1/4 of the time by the middle of next week and off the boot entirely by July 1, which would be almost 9 weeks post-op.

 

*  Still not allowed to do a lot of walking.  He doesn't want me on the foot a huge amount until the 10-week stage.  At that point, I can start walking/hiking on fairly flat, fairly smooth surfaces for short to moderate distances.  By week 12, I can start walking/hiking for exercise and add uneven surfaces and elevation.

 

*  What I actually CAN do is ride a bike.  I've been riding an exercise bike with mild resistance since about week three (30 minutes per day), but now I can ride outside.  He said he likes what the biking motion does for circulation of the foot, etc.  He just told me that if I'm going to fall off the bike, I have to land on my right foot instead.  wink.gif

 

*  I'm wearing tennis shoes, sandals, and hiking shoes now when I'm not in the boot.  All of those feel pretty good.  I'm supposed to go to a shoe store and buy some pretty hard-soled shoes. That's what I need to use when I start hiking as those will protect the fusion better.

 

*  It definitely still swells a fair bit when I'm on my feet for fairly long periods.  That goes away when I elevate and ice it.  He said the swelling would probably continue for at least another four to six weeks.

 

*  No real physical therapy required.  The big toe isn't going to flex (ever again), so there's no need for range-of-motion exercises.  He gave me a few really basic instructions for the second toe, but that one seems to be doing fine already.  He gave me a prescription for PT, but said there's no big need for it if I don't want to go.  

 

*  He even agreed to let me go fishing.  I can put my foot into my waders, put the wader in the walking boot, and go out and wade around in streams to my heart's content.  That's cool. 

 

**  The part I like the best - at this stage anyway -  is that in the mild walking that I'm now doing without the boot, I can tell that the area underneath my second toe doesn't hurt like it did pre-surgery.  That's the area where the plantar plate was torn and I was getting a great deal of inflammation and pain from walking.  That pain was what was prohibiting me from walking or hiking and that pain was the main reason I decided to have the surgery.  Obviously, I still have a lot of healing to do and a fair amount of time before I can actually start hiking in the mountains again.  It may turn out that the pain will still be there once I'm more active, but for right now that area is pain-free.  That's a big, big improvement.

 

So, the bottom line is that things seem to me on track.  No complications have shown up from the surgery and the healing process seems to be going very well.

 

I'll post a photo later today or tomorrow.

 

Thanks!

post #30 of 746
Quote:
Originally Posted by Bob Peters View Post

Hi, Lashes et al.

 

We just got back from Vail last night.  We took a little detour and drove through Rocky Mountain National Park on Trail Ridge Road.  Neither of us had ever done that before, and I would HIGHLY recommend the drive for anyone who's never been there.  It's an incredibly beautiful drive way above timberline.  We passed numerous snowfields, a few of which had ski tracks.  It was very cool.

 

 

So, the bottom line is that things seem to me on track.  No complications have shown up from the surgery and the healing process seems to be going very well.

 

Hey Bob, my brother's going to be driving that road in a few days.  From your report it sounds like the Ft. Collins fires have not affected RMNP in any way??

Glad your foot is doing well.

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