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Bilateral hallux rigidus

Posted by Janet A on 8/08/02 at 07:46 (091917)

I have tried all conservative methods for hallux rigidus, cortisone shots, orthotics, and now surgery is my only hope for relief. I was an avid
runner and bicycler. Can I hear from someone who has had surgery for this problem and their experiences after surgery? I hurt so bad and don't know what to do. Thanks Janet A

Re: Bilateral hallux rigidus

Dr. David S. Wander on 8/08/02 at 08:23 (091923)

Janet,

Hallux rigidus surgery should provide you with significant relief. Just make sure that your surgeon is experienced and discussed the proposed procedures in detail with you. There are many surgeries to correct this condition, from simply removing the portion of bone blocking motion, to surgically realigning the bone. Hallux rigidus can occur from arthritis, trauma, an abnormally long metatarsal bone, a long phalanx (toe bone), elevation of the first metatarsal bone, etc. The most important factor is correctly addressing the CAUSE of the hallux rigidus. If the bone is elevated, it must be surgically lowered, if the bone is too long, it must be decompressed or shortened, etc. If the joint is destroyed, a fusion may be indicated. Depending on your age and activity level, artificial joints can be used, which are rarely used in very active patients. Discuss your concerns with your doctor, and let me know what city you live in and I may be able to recommend some doctors in your area, (only if you don't have confidence in your present doctor). I have a paper that I wrote on hallux rigidus/hallux limitus and would be happy to send it to you if requested.

Re: Bilateral hallux rigidus

Janet A on 8/08/02 at 08:54 (091933)

Dr. Warner, thanks so much for your perspective. I live near Los Lunas, New Mexico. I WOULD REALLY APPRECIATE IT IF YOU COULD RECOMMEND SOME EXPERIENCED DOCTORS THAT WOULD THINK ALONG YOUR LINES. Also, where do you practice? I would also love to read your paper on hallux rigidus/hallux limitus.

Again, thanks! J

Re: Bilateral hallux rigidus

elliott on 8/08/02 at 09:22 (091939)

Since you're on this topic, at least part of the problem in my right foot was diagnosed by an orthopedist as an elevated first metatarsal (there is also some hallux arthritis, if that's important), causing my foot to nearly collapse at times, as well as causing discomfort most of the time in my heel and lateral instep. If the orthotics I am now trying do not satisfactorily resolve my problems how long must I wait to see my maximal improvement), the surgery indicated would be right navicular cuneiform fusion (or medial cuneiform osteotomy), medial calcaneal osteotomy, advancement of PT tendon, and possibly removal of accessory navicular (got that too!). Sounds scary. From what I've read, the chief thing that can go wrong with this surgery is malunion or nonunion. Can you tell me what should be expected from this surgery (by any chance complete return to previous running level?), what are the real not inflated odds of success, and what happens if you have mal- or non-union (I know, there's always ESWT!). Thanks.

--

Re: Bilateral hallux rigidus

Dr. David S. Wander on 8/08/02 at 20:45 (092024)

Janet, thanks, but my name is Wander (not Warner). I practice in Philadelphia, PA and would be happy to send you information on hallux limitus/rigidus, if you would send me your address. I won't be back in my office until Monday, and at that time I'll look up some docs in your area.

Re: ELLIOTT

Dr. David S. Wander on 8/08/02 at 20:54 (092026)

Elliott,

I know that you're a mathematician, but I there aren't always clear cut 'odds' of success. Surely you must understand that there are too many variables to give any number. Some variables include the skill of the surgeon, the experience of the surgeon, the health of the patient, the compliance of the patient, the complexity of the procedures, the particular surgical technique used (there's more than one way to skin a cat!), etc. If I give you a number, you'll never be satisfied or convinced that it's not an 'inflated' number. You must ask YOUR particular surgeon for his/her success rate with these procedures. If the surgery is a success, and after a prolonged healing time, you may be able to return to your previous running level, though I don't know what your previous level was. I actually resent that you keep asking for the 'real, not inflated odds of success'. That infers that unless you asked for the real odds, I'd give you bogus numbers of inflated success. Everything I state on this site is based on my experience without inflating or exaggerating success rates. I'm not hear to sell my services, and have never received any compensation or patients from the time that I VOLUNTEER on this site, therefore I have no reason to 'inflate' success rates. If you want to ask an intelligent question, simply state.. 'what are the realistic expectations'. If a malunion or non-union do occur, this can be handled with prolonged immobilization, electric bone stimulators or surgical intervention. What are the real, not inflated odds that you'll be satisfied with this answere?

Re: Dr. Wander

elliott on 8/08/02 at 22:40 (092035)

Sure there's a lot of variables that go into a study. There's also good studies and very questionable studies. For a number of reasons, I'd say there's plenty of the latter, and so common sense says to inquire. Given the cost of ESWT, I don't think it unreasonable to want to see the study. If anything's surprising, it's that I'm virtually the only one here asking to see it.

On these boards you come across as someone who really knows his stuff. No, I'm not insinuating anything against you. Here's the context of my asking for 'real, not inflated' odds of success. The big-name surgeon who explained to me the surgery I mentioned has written a paper on it giving the odds of success in his study. A second big-name surgeon familiar with the work of the first, besides disagreeing with some of the recommended surgery, said if you'd see what the true results are of that study with appropriate followup, you'd find the success rates inflated, and that the real uninflated success rates are quite lower than what they appear to be. Whom do I trust?

The surgeon who did my first foot gave me 90% odds of total success. His surgery left my foot nearly crippled with problems I didn't have pre-surgery, so much so that I regret having had this surgery; I am still struggling with this foot today, three years later. The surgeon who did my second foot gave me 75% odds; here I am two years later struggling with that one as well (although I have hope). So much for trusting the odds. I'd rather get on your nerves a little and make sure I get this decision right rather than get it wrong and find myself completely crippled. So you see, I don't trust the odds, not because I'm a mathematician, but because I'm a patient who's been burned by them. Thanks for your advice.

---

Re: hallux rigidus

Ed Davis, DPM on 8/11/02 at 11:56 (092195)

Elliott:

I have avoided going 'off topic' on this board so I have not answered questions on this diagnosis. Nevertheless, hallux rigidus surgery is one of the most common procedures I do and is somewhat of a bigger interest area for me than heel pain.

Obtaining estimates for success rates gets more complicated when multiple procedures are used as in the situation you are bringing forth. This is a situation ( help me with the statistical discusssion) where one cannot view each procedure as an independent event, that is, the outcome of one 'subprocedure' influences the results of the next but the percentage of influence is hard to estimate.

The set of procedures which you have listed is logical, in theory. Unfortunately, any procedure in the sequence that does not work adversely effects the others. I have often argued for a simpler approach which, conceptually, is not as good, but after one considers all possible outcomes (via a grid contructed to view all possibilities) the chance of success is higher. It is basically a comparison of a complex system which, works very well if all systems are soing exactly what they are supposed to vs. a simpler, less sophisticated system which has lower performance but much higher 'up' time because there is much less to go wrong and far fewer scenarios that can lead the system to fail.
Ed

Re: hallux rigidus

Janet A on 8/11/02 at 22:27 (092260)

What is usually the course and outcome of the cheilectomy operation? My doctor said that according to x-ray there was a great deal of damage with bone on bone and a large spur, but he moved my toe in all directions and the only part that hurts is my toe nail. I also have a large spur on top of my foot in the middle. The other foot is exactly the same. Can these spurs also cause tightness in the ankle. Do you have to wear some kind of orthotics after the operation? I would love to talk to a patient who has underwent the procedure. Thanks Janet A

Re: Bilateral hallux rigidus

Dr. David S. Wander on 8/08/02 at 08:23 (091923)

Janet,

Hallux rigidus surgery should provide you with significant relief. Just make sure that your surgeon is experienced and discussed the proposed procedures in detail with you. There are many surgeries to correct this condition, from simply removing the portion of bone blocking motion, to surgically realigning the bone. Hallux rigidus can occur from arthritis, trauma, an abnormally long metatarsal bone, a long phalanx (toe bone), elevation of the first metatarsal bone, etc. The most important factor is correctly addressing the CAUSE of the hallux rigidus. If the bone is elevated, it must be surgically lowered, if the bone is too long, it must be decompressed or shortened, etc. If the joint is destroyed, a fusion may be indicated. Depending on your age and activity level, artificial joints can be used, which are rarely used in very active patients. Discuss your concerns with your doctor, and let me know what city you live in and I may be able to recommend some doctors in your area, (only if you don't have confidence in your present doctor). I have a paper that I wrote on hallux rigidus/hallux limitus and would be happy to send it to you if requested.

Re: Bilateral hallux rigidus

Janet A on 8/08/02 at 08:54 (091933)

Dr. Warner, thanks so much for your perspective. I live near Los Lunas, New Mexico. I WOULD REALLY APPRECIATE IT IF YOU COULD RECOMMEND SOME EXPERIENCED DOCTORS THAT WOULD THINK ALONG YOUR LINES. Also, where do you practice? I would also love to read your paper on hallux rigidus/hallux limitus.

Again, thanks! J

Re: Bilateral hallux rigidus

elliott on 8/08/02 at 09:22 (091939)

Since you're on this topic, at least part of the problem in my right foot was diagnosed by an orthopedist as an elevated first metatarsal (there is also some hallux arthritis, if that's important), causing my foot to nearly collapse at times, as well as causing discomfort most of the time in my heel and lateral instep. If the orthotics I am now trying do not satisfactorily resolve my problems how long must I wait to see my maximal improvement), the surgery indicated would be right navicular cuneiform fusion (or medial cuneiform osteotomy), medial calcaneal osteotomy, advancement of PT tendon, and possibly removal of accessory navicular (got that too!). Sounds scary. From what I've read, the chief thing that can go wrong with this surgery is malunion or nonunion. Can you tell me what should be expected from this surgery (by any chance complete return to previous running level?), what are the real not inflated odds of success, and what happens if you have mal- or non-union (I know, there's always ESWT!). Thanks.

--

Re: Bilateral hallux rigidus

Dr. David S. Wander on 8/08/02 at 20:45 (092024)

Janet, thanks, but my name is Wander (not Warner). I practice in Philadelphia, PA and would be happy to send you information on hallux limitus/rigidus, if you would send me your address. I won't be back in my office until Monday, and at that time I'll look up some docs in your area.

Re: ELLIOTT

Dr. David S. Wander on 8/08/02 at 20:54 (092026)

Elliott,

I know that you're a mathematician, but I there aren't always clear cut 'odds' of success. Surely you must understand that there are too many variables to give any number. Some variables include the skill of the surgeon, the experience of the surgeon, the health of the patient, the compliance of the patient, the complexity of the procedures, the particular surgical technique used (there's more than one way to skin a cat!), etc. If I give you a number, you'll never be satisfied or convinced that it's not an 'inflated' number. You must ask YOUR particular surgeon for his/her success rate with these procedures. If the surgery is a success, and after a prolonged healing time, you may be able to return to your previous running level, though I don't know what your previous level was. I actually resent that you keep asking for the 'real, not inflated odds of success'. That infers that unless you asked for the real odds, I'd give you bogus numbers of inflated success. Everything I state on this site is based on my experience without inflating or exaggerating success rates. I'm not hear to sell my services, and have never received any compensation or patients from the time that I VOLUNTEER on this site, therefore I have no reason to 'inflate' success rates. If you want to ask an intelligent question, simply state.. 'what are the realistic expectations'. If a malunion or non-union do occur, this can be handled with prolonged immobilization, electric bone stimulators or surgical intervention. What are the real, not inflated odds that you'll be satisfied with this answere?

Re: Dr. Wander

elliott on 8/08/02 at 22:40 (092035)

Sure there's a lot of variables that go into a study. There's also good studies and very questionable studies. For a number of reasons, I'd say there's plenty of the latter, and so common sense says to inquire. Given the cost of ESWT, I don't think it unreasonable to want to see the study. If anything's surprising, it's that I'm virtually the only one here asking to see it.

On these boards you come across as someone who really knows his stuff. No, I'm not insinuating anything against you. Here's the context of my asking for 'real, not inflated' odds of success. The big-name surgeon who explained to me the surgery I mentioned has written a paper on it giving the odds of success in his study. A second big-name surgeon familiar with the work of the first, besides disagreeing with some of the recommended surgery, said if you'd see what the true results are of that study with appropriate followup, you'd find the success rates inflated, and that the real uninflated success rates are quite lower than what they appear to be. Whom do I trust?

The surgeon who did my first foot gave me 90% odds of total success. His surgery left my foot nearly crippled with problems I didn't have pre-surgery, so much so that I regret having had this surgery; I am still struggling with this foot today, three years later. The surgeon who did my second foot gave me 75% odds; here I am two years later struggling with that one as well (although I have hope). So much for trusting the odds. I'd rather get on your nerves a little and make sure I get this decision right rather than get it wrong and find myself completely crippled. So you see, I don't trust the odds, not because I'm a mathematician, but because I'm a patient who's been burned by them. Thanks for your advice.

---

Re: hallux rigidus

Ed Davis, DPM on 8/11/02 at 11:56 (092195)

Elliott:

I have avoided going 'off topic' on this board so I have not answered questions on this diagnosis. Nevertheless, hallux rigidus surgery is one of the most common procedures I do and is somewhat of a bigger interest area for me than heel pain.

Obtaining estimates for success rates gets more complicated when multiple procedures are used as in the situation you are bringing forth. This is a situation ( help me with the statistical discusssion) where one cannot view each procedure as an independent event, that is, the outcome of one 'subprocedure' influences the results of the next but the percentage of influence is hard to estimate.

The set of procedures which you have listed is logical, in theory. Unfortunately, any procedure in the sequence that does not work adversely effects the others. I have often argued for a simpler approach which, conceptually, is not as good, but after one considers all possible outcomes (via a grid contructed to view all possibilities) the chance of success is higher. It is basically a comparison of a complex system which, works very well if all systems are soing exactly what they are supposed to vs. a simpler, less sophisticated system which has lower performance but much higher 'up' time because there is much less to go wrong and far fewer scenarios that can lead the system to fail.
Ed

Re: hallux rigidus

Janet A on 8/11/02 at 22:27 (092260)

What is usually the course and outcome of the cheilectomy operation? My doctor said that according to x-ray there was a great deal of damage with bone on bone and a large spur, but he moved my toe in all directions and the only part that hurts is my toe nail. I also have a large spur on top of my foot in the middle. The other foot is exactly the same. Can these spurs also cause tightness in the ankle. Do you have to wear some kind of orthotics after the operation? I would love to talk to a patient who has underwent the procedure. Thanks Janet A