Behind the scenes stories

This series covers stiff toes surgery and different patient stories taken from their own words. All had stiff big toe joint pain and some had bunions as well. Surgery was successful in the main but as shown there are no guarantees. When things don’t go to plan what do you need to know? Blue highlights will take you to different links and help build a picture depending upon the detail you need. Throughout, clinician comment will elaborate on the story line and provide further information. Please read the other cases on ConsultingFootPain. Each story will paint a different picture.Launching 1st July 2021 and on successive days this week.

Please note that techniques described and advice will vary between surgeons and centres. The variety of options on the market is very broad. This author only describes techniques that patients have reported in connection with their stiff toe stories.


Read each patient’s story covering the stiff toe:
Leah- both feet fusion surgery (arthrodesis) 3rd July
Tom – fusion surgery after an implant  4th July
Rachel – both feet – implant surgery after an osteotomy 7th July


The patient tells their story

Nothing resonates better than a patient telling their own story. We learn more from an undiluted tale than one which is sanitized. I certainly felt strongly when I wrote and published a book about the bunion and bunion surgery. It is a fact that at most conferences I have attended, clinicians speak about successes not their problems. One reason I am keen to raise awareness is that we learn from problems and how to solve these. I had back surgery twice, the second was a revision. It is a fact that surgery does not always work and revision is necessary. With litigation at an all time high, the more lay people understand about why things don’t work may alleviate much of the grief that follows unsuccessful results. I call this ‘behind the scenes’ because some conversations are not always as clear. It is worth reading Tom was not a patient of mine and his case developed from an interview in 2019. 

ConsultingFootPain (CFP) has already published advice on bunions as well as some information around the common stiff toe. Protecting the skin and reducing pain can be achieved, but there comes a time when surgery is required. Leah had both her big toes operated to fix her pain. Tom and Rachel needed revision surgery. I will follow these patients as they record their own story. I started off interviewing and gathering their initial journey notes and charted their progress. All may not seem as it should be. Each patient was operated on by 3 different foot surgeons, orthopaedic and podiatric. It is not the purpose to advise which surgeon to seek out but clearly surgeons who are dedicated and employed to operate on feet should be chosen over general surgeons. Not all orthopaedic surgeons specialise in feet while podiatric surgeons do. I will use more information to describe the various techniques later in this article using selected video film.


Key words: hallux rigidus (stiff big toe), hallux valgus (bent toe), synovitis (inflamed), osteophyte (bony spur), arthrodesis (surgical stiffening), osteotomy (surgical bone cut), prosthetic joint (non-biological material supplement).


Why stiff toes develop

stiff toes may be predictable with bumps

Damage to joints involve the cartilage (arthrosis), the joint lining (synovitis) and also bony bar formation (osteophytes). These are the bumps (shown) and ridges. Once the toe distorts and becomes mishappen, shoewear comfort reduced with increased skin pressure. Corns form and in the winter chilblain threatens to ulcerate. For many, the way forward is to select surgery. Foot surgeons, that is orthopaedic and podiatric surgeons will try to preserve the joint.  Injections in joint spaces are performed under x-ray or ultrasound imaging. As the joint stiffens the space between the two bone ends makes introducing any substance nigh impossible. Getting the injection into the joint is one problem, but lack of any movement means the substance fails to move around the lining. The end result is failure. The joint is usually x-rayed before an intended injection treatment. Some may use different methods like ultrasound and bone scans. Over 70% of bunions (hallux valgus) have some cartilage damage.

INJECTIONS INCLUDE STEROID (ANTI-INFLAMMATORY), PROLOTHERAPY (DEXTROSE/SALINE) AND SODIUM HYALURONATE

Spasm leading to pain and stiffness

If the joint is stiff but is held tightly bound because of spasm from smaller muscles, this part of the problem could very well be helped with an injection of anaesthetic and steroid. This condition is often associated with the sesamoid. The specialist does need to see the foot and examine the toe to make this judgement. This is not something that the average GP practice can offer unless orthopaedic tutored.

What operations can a surgeon use?

There are three main operations and one simple surgery. Simple surgery means that little more than the bone is trimmed flat and is called an exostectomy or cheilectomy. Both work the same way. Pain may be relieved but stiffness can result which does not matter if pain has disappeared. 

Does the cheilectomy work?

https://www.innovativefootandankle.com/2018/04/cheilectomy-a-surgery-for-arthritis-in-the-big-toe-joint/

Bone shaving surgery reduces pressure around the joint so the skin can recover and shoes may fit better. However it does nothing for cartilage damage and can increase painful movement. My tip is to try protecting the foot first with cushioning sleeves and covers or change any tight fitting shoes.  Many cheilectomies are performed for their perceived simplicity and most foot surgeons will attest to failures and revisions! The three main operations today include opening the joint to give it a bigger gap (osteotomy). The joint can be made permanently stiff (arthrodesis) and lastly the joint can be replaced with a new surface (prosthetic replacement). All foot surgeons learn about different techniques but will develop their preferred procedures over time. In each case described in this series the right decisions were made.

The arthrodesis

Leah had an arthrodesis which means the end of bone cartilage was removed and the two ends of bone are pushed together and fixed to heal as if the bone had been broken. End to end bone knits well, becomes solid and is good to walk on. The key points to be aware of is that patients who kneel for an occupation are unable to perform as well. Sometimes the metal fixation, shown as a plate, may need to be removed later. This does not affect the result unless the bone bonding fails.

Osteotomy

Rachel had an osteotomy. Osteotomies are cuts made in different parts of the bone and then allowed to heal as would a fracture. It is a procedure that does not damage the joint directly but moves the bone in such a way to create a gap so the joint can recover movement. The cartilage is preserved. Osteotomies [Video] need to be fixed with screw(s) and sometimes plates which have been described in two of our patient stories. This type of fixation allows early mobility. The illustration shows one of the more straight forward techniques called a Chevron osteotomy. This is depicted in the short animated film 1′ 30” long and has no gory sights.

Prosthetic Replacement

Swanson implant (silicone) C/O Wright Medical

A new joint surface spacer was given to Tom and Rachel, where the cartilage was heavily damaged. The spacer was made from a medical grade silicone material (illustrated). A standard information sheet from Hereford Podiatry is available. Joints can be made from other materials including high density plastic, metal and less popular ceramic material. A cap or plug can also be inserted into defective cartilage areas to resurface the joint. This technique is gaining popularity. Another replacement technique includes grafting cartilage into different sites to generate normal cartilage growth. This has been popular in knee arthrosis and continues to develop. 

 

 

Many films can be found on YouTube. Some are out of focus, too long and in many the language may be too complex for most people to understand. In this video U.S podiatrist Jennifer Boeri from the Holy Cross Institute has put a 5’35” video film together explaining the complexities of the rigid toe problem. The film covers many options for those wishing for more information.


What was the outcome?

What could go wrong and what would our patients each need to know before agreeing to have surgery performed? Did surgery work out for all of them and if not what happened? Please read further to learn more… You can also read my bunion operation advice sheet – the big five.


Thanks for reading ‘Painful Stiff Toes and Patient Stories’ by David R Tollafield

A Behind the Scenes Patient Journey Series

Why not read more about the bunion (hallux valgus) and behind the scenes on this website or buy the e-book/paperback by the same author?

Published by Busypencilcase Reflective Communications Est. 2015
2nd July 2021

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