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Wednesday, March 7, 2012

Hallux Rigidus Surgery: Email Response When Initial Surgery Unsuccessful

This email was sent as a comment to one of my postings on Hallux Rigidus. Thank you for adding to the overall knowledge. Dr Rich Blake


I have this condition as well. And, it is very painful. My Dr. gave me orthotics and I wore them for a few years to try to stave off a progressively worse joint and surgery. Well, after 5 years I had bone spurs and had only 30% of the cartilage left. I had the surgery to remove the bone spurs and clean up the joints more than 3 months ago. I refused the fusion. I have had nothing but increased pain since. If I walk on that foot, then that joint hurts - worse than ever. I now walk on the outside of my foot and limp. My back is a mess. My Dr. says that fusing is the next step, but I'm not about to have more surgery since the last one only made me worse. What are my choices? He didn't seem too enthusiastic about joint replacement.


By Anonymous on 3/7/12
 
Dear Anonymous: This result unfortunately happens probably close to 30% with joint clean out procedures, although the amount of pain can be from 1-2 to 10 on the pain scale of 0 to 10. You are definitely on the more painful side unfortunately. When you have joint pain before the surgery, it can be hard for a surgeon to decide what the cause of the pain is, and whether the surgery will fix it. In clear cut cases the pain is limited to the spurs on the top of the foot, so removal and joint clean out makes sense. But if the pain is due to the pressure of the first metatarsal on the base of the big toe, surgery is less predictable. Since you only had 30% of the joint surface before surgery, and the bone spur removal allows the joint to move a lot more, you are probably moving across bad cartilage and you are not happy. I believe it is impossible to predict who should have a fusion, although I am sure it can be done. Joint fusions to my knowledge can not be reversed, and you still have many options available at this point. You made the right choice even though it did not work out at this point.
 
So, what to do now? There is no right or wrong answer, but logically you have 2 choices. Choice #1: Go back to surgery and have a partial or total joint implant, unless xrays or CT scans can find another source of your pain that a simple revision of the first surgery would solve. The choice of partial or total joint implant would depend if the cartilage on the base of the toe is good. Choice #2: Go into a removable cast to create a pain free environment for the next 3 monthes to see if you can get the joint calmed down.The removable boot may need orthotics or accommodations within to achieve the painfree environment. The joint is probably really angry with added surgical scar tissue, and does not want to be moved right now. During that time, avoid cortisone shots or even anti-inflammatory medications which can slow bone healing, and relie on ice packs or baths 3 times daily. Learn how to do spica taping and try to get your orthotics adjusted for better protection. Avoid any mobilization of the joint, it does not want to be moved? Get out of pain, even if it needs crutches also for a while.  Is it the weight bearing or the bend of your toe that hurts more? Is it shoe pressure that hurts? What is the physical therapist or doctor saying about why you are hurting now? Any clues to finding why you hurt can help in calming the joint down?
 
Walking to the outside of your foot is called over supination or under pronation and can be devastating on your back. Temporary you may not be able to walk on you big toe, but moving through the 2nd and 3rd toes would be great. If you can the removable boot, definitely get an EvenUp to balance your spine better.
 
I sure hope this helps. I am sorry you are in the 30%. When you are in pain, it is easy to make illogical decisions. It is hard to make objective decisions with your own body in pain. Almost impossible!! Do you have someone that can help you think clearly through this? Sure hope this helps you somewhat.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.