Mr Jason Hargrave

This is a very common condition, and in the foot, most often affects the big toe (1 st metatarsalphalangeal) joint. Progressive joint pain and stiffness can occur over a long period of time, although it can develop quickly following injury or even after surgery where the arthritis was preexisting. Initially, the smooth white cartilage on each side of the joint becomes thinned and roughened. The joint may start to appear to be thickened, which is due to bone lipping (osteophytosis) building up around the joint. The joint may become swollen from time to time due to inflammation of the joint lining (synovitis); and painful stiffness, especially after a period of rest, is a common complaint.

A useful classification to denote the level of joint disease, involves staging the arthritic damage
I - IV (Modified Regnauld Classification). Early stage osteoarthritis (I -II) may be improved by reconstructive surgical management, where the joint is repaired and preserved. Late stage
osteoarthritis (IIIIV) is deemed beyond reconstruction, where the surgical management
involved is unfortunately termed "destructive".

Conservative (nonsurgical) Treatment

It is important to keep the joint mobilized as much as possible, unless it is extremely painful. If
the joint is painful (and often may also be swollen) this may be due to inflammation of the joint
lining (capsule and synovium). In this case an antiinflammatory injection -corticosteroidwill
often relieve both the pain and swelling. Where osteoarthritis is present in the joint, the natural
joint lubricant (synovial fluid); can be reduced by up to 50%. A new treatment can be undertaken to revitalize the joint fluid with a course of injections to replace the depleted fluid. It is thought that this treatment may give relief for 612 months, where it may then need to be
repeated. For painful arthritic joints, stiffsoled shoes are recommended to reduce the joint
strain when walking; and some patients are helped with special insoles called orthoses. Some
evidence shows long term use of glucosamine/chondroitin/MSM tablets may be helpful in
slowing down the disease progression and maintaining the joint's movement.

Pros and cons of the above surgeries.

This information is provided so that you can make an informed decision over your treatment; it is not designed to frighten you as it should be remembered that the overwhelming majority of our procedures are very successful and all complications are treatable.

Common to all procedures:

Infection, (approximately 2% risk). The vast majority of these are softtissue infections, treatable by antibiotic tablets as an outpatient. Bone infections are very uncommon, but would require hospital admittance for treatment. Severe pain only occurs in around 7% of cases in the first 24 hour period. We use a combination of local anaesthetic techniques and compound analgesics, which is usually very effective. Rarely, patients can develop Complex Regional Pain Syndrome (cause unknown), requiring specialist treatment at a pain clinic. Swelling is common to all surgery and may take 46 months or longer to reduce. Vein clots can occur with any lower limb surgery, but in our practice they are seen in less than 1 in 200 cases (compared with general orthopaedics where the occurrence is reported as high as 4 out of 10 cases). Vein clots, or Deep Vein Thrombosis (DVT), is more common in elderly patients, diabetics, obese patients and patients where two or more immediate family members have suffered DVT, stroke or heart attack. Unsightly scarring (hypertrophic or keloid) is more common in AfroCaribbean; Middle and farEastern skintypes.
Scarring can be reduced by starting to use - 2 weeks after surgery - Boots scar reduction pads (£19.99) and also using an emollient cream at 4 weeks onwards, massaged into and across the scar. At 6 weeks following surgery, you may wish to use a hydrocortisone cream to massage vigorously along the scarline twice a day for 2weeks e.g. HC45 cream.

Specific considerations and complications:

Osteoarthritis is a progressive problem, only the fusion, implant and arthroplasty (i.e. destructive) surgeries will stop the disease by virtue of the fact that part of, or all of the joint, is removed. This means that the reconstructive surgeries will not eradicate the arthritis and occasionally the surgery may hasten the progress of the disease. The cheilectomy procedure is the simplest surgery, which has proven to yield good results, but is unlikely to increase
joint movement. The decompressive osteotomies are used to alter the mechanics of the joint by reducing the stress, which can contribute to inflammation and mechanical wear in the joint. The BonneyKessel will not increase joint movement significantly, although the WatermannGreen may do. However, with the WatermannGreen, there is a risk of increasing pressure under the adjacent 2 nd toe joint with this surgery (transfer metatarsalgia). Surgery to shorten the 2 nd metatarsal may then be required to balance the stresses on the forefoot.
It is therefore reserved for an overlong 1 st metatarsal. The WatermanGreen may appear to shorten the big toe. Sesamoid excision is a relatively new procedure; but early studies are encouraging to show that it could be a valuable technique and may increase joint motion, although some loss of flexion power may be expected. Joint fusion / arthrodesis has been undertaken for a long time with a proven track record of both stability and pain relief. There is a 7% risk of nonunion (increased threefold with smoking), which may require a second surgery to attempt refusion.
The major side effect of this surgery is that the joint will have no remaining movement, which
can alter the way patients' walk and is very restricting for footwear (especially heel height). The big toe will also be shorter following fusion and the bone screws may need to be removed. Joint implant (silicone) has been used for around 3 decades and also has a proven track record. Some newer implants (titanium, ceramic etc) are still experimental and so far may not be yielding any better results than the silicone joint. A small number of patients
may react to the implant (silicone synovitis), where it then has to be removed. These implants also have a limited life span of 1020 years and will need to be replaced when they fragment. The arthroplasty technique has been modified since its use in the early part of the 20 th Century for hallux valgus (bunion) correction. It is far more successful for the treatment of arthritis and does give good painrelief and more joint movement in a stage IIIIV joint. The big toe will be shorter and a small number of patients have a weak and loose toe following arthroplasty, although usually the joint does become stiffer and physiotherapy can strengthen the toe. Transfer metatarsalgia under the second toe joint can also occur. The main advantage of arthroplasty over the implant and fusion, is that no foreign implant material is used, and the joint does usually recover more movement than prior to the surgery.
Any stage III surgery may need to have further stage IIIIV surgery with the passing of time. A failed fusion procedure can really only be revised to further fusion; they are very rarely reversible (e.g. to an implant). Fusion revision may involve taking bone graft from the heel bone. A failed implant can be revised to a fusion, although a bone graft may also be required. A failed arthroplasty can be revised to an implant or an arthrodesis (no graft is
required).