Footmed - Footmed Foot and Ankle Clinics

Surgery for minor to moderate arthritis of the joint of the big toe

Your big toe has a bony enlargement or bone spur across the top of the joint often referred to as a dorsal bunion. The joint is also worn and is referred to as stage 2 or 3 hallux rigidus or osteoarthritis. The big toe joint remains in a straight position but has progressively become stiffer and stiffer over time. It is now very stiff and unable to bend very well during walking. This causes you to walk on the outside of your foot or to walk with your hip turned outwards in an attempt for your body to compensate. The skin and tissue on the bump can become inflamed, swollen, and painful. This joint is already arthritic & is likely to get worse still over time.

Dorsal bunions are most often caused by faulty mechanics of the foot. If the dorsal bunion deformity is hereditary other family members are also likely to have the same problem. That is, a certain foot type makes a person prone to developing arthritis in the big toe joint. Research is pointing to a long first metatarsal and long proximal phalanx of the big toe as a possible cause. One in forty people over 50 is effected, mostly men. Injury is a common cause amongst men, especially if just one foot is involved.

In the early stages pads, rigid footplate, foot orthoses, manipulation under anaesthesia (MAU), extra depth shoes, rocker bottom shoes and avoiding high-heeled shoes can be beneficial. Studies show that MAU relieves pain fort about 6 months. Anti-inflammatory and pain medication can also relieve pain temporarily. A particularly good study revealed that foot problems are a risk factor for falls as you get older. If you’re big toe joint continues to interfere with daily activities and your quality of life, its time to discuss surgical options with your surgeon.

The degree of arthritis affecting your big toe joint is considered mild to moderate. This means that less than 50% of the joint cartilage has been worn away down to the level of bone. This is usually the top 1/2 of the joint. A ‘ V ‘ cut is made to remove the top 1/2 of the arthritic joint. This allows more movement at this previously stiff joint. Unfortunately full range of motion is unlikely to be regained.

It is sometimes difficult to determine the real extent of damage to the joint until it is opened up and visible while in theatre. Both feet can be operated on at the same time, but this does further limit your mobility after surgery.

The bandages will need to be kept dry. You will be given an appointment to return to have the foot redressed in 1 week. You may be able to return to work from 4-6 weeks after the operation, depending on whether you need to stand or walk around a lot for your job. You will not be able to drive until you come out of the post-operative shoe.

This procedure offers an alternative to having the joint completely stiffened or fused (arthrodesis). The Valente Chielectomy provides some movement in the joint. Patient satisfaction varies from 72% to 100% according to studies.

It will take about 3 months before you feel the real benefits of this procedure. To ensure success it is important that you exercise the joint early in your recovery. The surgeon will discuss this in more detail with you.

It is important to understand that you will not regain full normal motion back in the joint.

• Swelling (for up to 6-9 months)
• Infection (smoking increases risk by 16X)
• Wound problems (slow to heal)
• Scar sensitivity
• Nerve Injury (Nerves can be bruised which resolves but you can be left with permanent numbness)
• CRPS = Complex Regional Pain Syndrome (Rare <1%)
• Deep Vein thrombosis (clot in deep vein in the legs)
• Continuing symptoms (if the toe still remains a problem then other surgical options may need to be considered)

Following surgery allow the foot a good 12 months to fully settle down. The surgeon will explain any particular individual risks that you may have.

The operation is usually day surgery but you may need to stay overnight if you have a medical condition or social reason that requires this. The surgeon will discuss this with you. You will be given a special shoe to wear over your bandages, which you must wear whenever you want to walk. If you had a chielectomy or interpositional arthroplasty we prefer you to return to activity as early as possible (2 weeks) and begin exercising the big toe joint. The surgeon will discuss this with you in greater detail.

You may begin increasing your activity to tolerance almost straight away, and resting/elevating the foot as required on 2 pillows. Let how your foot is feeling judge how long you remain on it. You should be able to return to normal footgear in about 2-4 weeksx  

Verrucae

Surgery for removal of plantar wart or verrucae

What is wrong with my foot?

Warts (also known as Plantar Warts, Verrucae, or Verrucae Pedis) are caused by a viral infection. They can occur anywhere on the body, but are most frequently found on the hands and feet. If they occur on the bottom of the foot—Plantar wart —they can be very painful. They are often covered by thickened hard skin or callus and are painful when over weight bearing areas.

Plantar warts may present in either single, multiple or mosaic type pattern. The mosaic type wart tends to be more resistant to treatment.

Why has this happened?

Warts are caused by a type of virus called the Human Papilloma Virus (HPV), which

invades the skin through small cuts and abrasions. Other predisposing factors include the use of communal bathing facilities, sport centers, swimming pools and gymnasiums. Once the skin is infected with the virus it may remain latent within the skin, or develop into a wart, and become clinically observable.

Warts can affect any age group, but most commonly affect children and young adults. A weakened immune system may also make you more susceptible.

Are Warts Contagious?

Yes, but the risk of passing them on to others is low. You need close skin-to-skin contact. You are more at risk of being infected if your skin is damaged, or if it is wet and macerated, and in contact with roughened surfaces. For example, in swimming pools and communal washing areas. 
 You can also spread the wart virus to other areas of your body. For example, warts may spread round the nails, lips and surrounding skin if you bite warts on your fingers, or nearby nails, or if you suck fingers with warts on. If you have a poor immune system you may develop lots of warts, which are difficult to clear.

To reduce the chance of passing on warts to others:

• Don't share towels
• When swimming, cover any wart with a waterproof plaster
• If you have a wart, wear thongs in communal shower rooms and don't share shoes or socks
• To reduce the chance of warts spreading to other areas of your body:
  • Don't scratch warts
  • Don't bite nails or suck fingers that have warts

What treatments are available?

Warts may resolve spontaneously between months, and a few years, but this is unpredictable. Debridement and application of a caustic chemical is often very effective in curing warts. This may involve weekly treatment for 5 weeks. Freezing warts with liquid nitrogen is also popular.

Curettage is usually recommended when topical chemical treatment or dry ice treatment has failed. This procedure is also used when a wart is extremely painful to treat or if the patient would prefer a one off treatment.

What will the ‘curettage’ operation involve?

The operation involves cutting around the wart to include the normal skin margin. The incision is through the full thickness of the skin but no deeper. The surgeon will avoid cutting into the next layer called the dermis, as this is more likely to cause scarring.

A curette is then used to loosen underneath the wart so it can be scooped out as one piece. 

Phenol (mild acid) is then applied on the dermis where the wart was sitting to ‘mop up’ any viral particles remaining.

A crater will be left this area, but it will slowly fill in over the next 3-4 weeks.

The operation is usually day surgery and can be often performed in the surgeons office under a local anaesthetic. You will be given a special sandal to wear over your bandages, which you must wear whenever you want to walk for the first 1-2 weeks.

You can start walking straight away, but it is best to limit your activity for the first 1-2 days. You will be able to wear an enclosed shoe after the heavy bandages are removed in 1 week.

Are there any risks associated with the operation?

• Infection (smoking increases risk by 16X)
• Wound problems (slow to heal)
• Scar sensitivity
• Re-growth of wart

Hammertoes

What is a hammertoe?

Hammertoe is a contracture – or a bending – of the middle joint of the second, third, fourth, or fifth toes. The toes have buckled making the top of the joint prominent. This causes rubbing on the joints making them red and painful. Painful corn or callus often develops at these pressure sites. If the toes have been in this position for a long time then arthritis can add to the pain experienced. Hammertoes can also create pressure, pain and callus under the ball of the foot referred to as metatarsalgia.

Why has this happened?

The most common cause of hammertoe is a muscle/tendon imbalance. This imbalance, which leas to bending of the toe, results from mechanical (structural) changes in the foot that occurs over time in some people. Shoes that don’t fit properly often aggravate hammertoes. In some cases, ill-fitting shoes can actually cause the contracture. A hammertoe may develop if a toe is too long and is forced into a cramped position when a shoe is worn. Occasionally, hammertoe is caused by some kind of trauma such as a broken toe. In some people, hammertoes are inherited and can be due to diabetic myopathy, osteoarthritis and rheumatoid arthritis. Special consideration is necessary when a bunion accompanies a second hammertoe deformity. Bunion correction to minimise the risk of recurrence of the second toe is needed.

Do I have to have an operation?

Pads, splints, foot orthoses, anti-inflammatory medication, debriding corns/callus and extra width/depth shoes can be used to provide comfort but is unlikely to straighten the toe. You can also chose to live with the problem. If the hammertoes interfere with daily activities and is effecting your quality of life despite these measures, its time to discuss surgical options with your surgeon.

What will the operation involve?

The most common surgical procedure performed to correct a hammertoe is called an arthroplasty. In this procedure, the surgeon removes a small section of the bone from the affected joint. If the contracture is severe it will require additional release of the joint capsule and tendon further up the front of the foot requiring a longer incision. Digital arthroplasty is always performed for a fifth hammertoe deformity to allow flexibility.

Another surgical option is fusion (arthrodesis), which is usually reserved for more rigid toes or severe cases, such as when there are multiple joints or toes involved usually associated with a bunion deformity. Arthrodesis is a procedure that involves a fusing of a small joint in the toe to straighten it. A pin or other small fixation device is typically used to hold the toe in position while the bones are healing. The pins will usually have to be left in place for 6-8 weeks.

How successful is the operation?

The operation for severe hammertoe deformity requiring joint fusion has been shown to be satisfactory in a number ofstudies. Those conducted by Coughlin (1) revealed 84% patient satisfaction after 5 yrs and 87% by Alvine & Galvin (2This operation (neurectomy) by a dorsal approach has shown good to excellent patient satisfaction rates (78-84%) in two good studies (1,2). The Coughlin & Pinsonneault (1) study is a long term follow up after 11 years.

Are there any risks associated with the operation?

• Prolonged swelling (sausage toe)
• Floating toe
• Infection (smoking increases risk by 16X)
• Wound problems (slow to heal)
• Scar sensitivity
• Nerve Injury (Nerves can be bruised which resolves but you can be left with permanent numbness)
• CRPS = Complex Regional Pain Syndrome (Rare <1%)
• Deep Vein clots

Quite often hammertoes can be performed using a local anaesthetic, so we can reduce the risks associated with a general anaesthetic.

What will happen after the operation?

The operation is usually day surgery but you may need to stay overnight if you have a medical condition or social reason that requires this. If only 1 or 2 toes need surgery then this may be done under a local anaesthetic in the surgeon’s office, where a room is dedicated solely for surgical procedures. A friend or family member must accompany you after any surgical procedure. The surgeon will discuss this with you. You will be given a stiff soled shoe to wear over your bandages, which you must wear whenever you want to walk.

The bandages will need to be kept dry. You will be given an appointment to return to have the foot redressed in 1 week. You may be able to return to work from 4-6 weeks after the operation, depending on whether you need to stand or walk around a lot for your job.

You may begin increasing your activity to tolerance almost straight away, and resting/elevating the foot as required on 2 pillows. Let how your foot is feeling judge how long you remain on it. You should be able to return to normal footgear in about 4 weeks

References:

1). Coughlin MJ: Operative repair of fixed hammertoe deformity. Foot Ankle Int 21:94–104, 2000.

(2). Alvine F, Garvin K: Peg and dowel fusion of the proximal interphalangeal joint. Foot Ankle 1:90–94,1980.

(3). Frey C, ed. (2005). Toe deformities section of Foot and ankle. In LY Griffin, ed., Essentials of Musculoskeletal Care, 3rd ed., pp. 703–707. Rosemont, IL: American Academy of Orthopaedic Surgeons.

Mark Heard

Mark Heard graduated from the University of South Australia in 1991. He initially practiced in a large clinic in Hobart, Tasmania for 2 1/2 years.

In 1994 he returned to Adelaide to commence post-graduate studies & surgical training. During this time he assisted several Podiatric Surgeons in a broad range of surgical foot & ankle procedures.

In 1997 he traveled to the Philippines with a group of Australian & American Podiatrists on a medical & surgical mission providing care to the underprivileged of the Philippines. This has been a highlight of his career so far.

Mark has been a councilor with the Australian Podiatry Association.

His professional interests include general podiatric medicine of the foot & lower leg & business management. He has also been Podiatrist to Woodville-West Torrens Football Club.

Mark practices at Woodville & Burnside. 

His main interest outside of Podiatry is his involvement with Aid Indonesia - a not-for-profit organisation set up after the 2004/2005 earthquake/tsunami in Indonesia to care for orphaned children. He has made 4 trips to the region of Sumatra to help oversee the development of an orphange that cares for almost 50 children & is vice-Chairman of the Australian board that oversees the project.