Joint Preservation Surgery for the Ball of the Foot (Hallux Rigidus)

Hallux rigidus (“rigid big toe”) is a form of arthritis that affects the big toe joint. Over time, the cartilage wears down, leading to stiffness, swelling, and pain, especially when pushing off (let’s call this “toe-off”) or walking down steps. When symptoms start to interfere with day-to-day life, there are several ways to reduce discomfort and preserve movement before considering a fusion of the joint.

We would of course ensure that nonoperative management (treatment without surgery) is attempted first before going down the surgical management path.

Fusion (arthrodesis) remains the most reliable option for severe arthritis, but it removes all motion at the joint. I perform fusions in this joint using a key-hole approach which I believe can lead to a more speedy recovery. But before taking that step, there are joint-preserving procedures that can improve movement, reduce pain, and slow further degeneration in the right patient.

Joint-Preserving Options

1. Minimally Invasive First Metatarsal and proximal phalanx Cheilectomy

This procedure removes bone spurs around the joint through very small incisions. It creates more space for the joint to move and helps reduce jamming of the big toe during walking.

How it helps:

  • Improves end-range movement

  • Reduces pain from bone spurs

  • Keeps the joint surfaces intact

2. M1 Weil Osteotomy

A Weil osteotomy shortens and repositions the first metatarsal slightly. In selected cases, this helps reduce pressure across the joint and improve alignment, especially when the metatarsal is long or overloaded.

How it helps:

  • Reduces joint loading

  • Improves mechanics during push-off

  • Can complement the benefits of a cheilectomy

3. Moberg Osteotomy (Proximal Phalanx)

This small cut in the proximal phalanx tilts the bone to improve upward movement of the toe (dorsiflexion). It’s useful when upward motion is limited even after removing bone spurs.

How it helps:

  • Increases functional range of motion

  • Reduces pain during activities that require toe-off

4. Akin Osteotomy

An Akin osteotomy straightens the toe when there is a mild deformity. It’s often used alongside other procedures to optimise alignment.

How it helps:

  • Improves overall toe positioning

  • Enhances the effect of the other joint-preserving procedures

What These Procedures Aim to Achieve

Joint preservation isn’t suitable for everyone, but when performed in the right situation, these techniques can:

  • Improve big toe motion

  • Reduce pain during walking and exercise

  • Delay the progression of arthritis

  • Potentially postpone or avoid joint fusion

Fusion remains appropriate for advanced arthritis or when joint-preserving surgery is unlikely to provide lasting benefit. Many patients prefer to try less invasive options first if the joint still has some preserved cartilage and motion.

Risks to Be Aware Of

Every surgery carries some risk. For these procedures, potential issues include:

  • Incomplete pain relief

  • Persistent stiffness

  • Progression of arthritis over time

  • Nerve irritation or numbness

  • Delayed bone healing (particularly with osteotomies)

  • Need for future surgery, including possible fusion

These risks are uncommon, and most patients recover well with the correct rehabilitation.

Recovery and Postoperative Plan

Day Surgery

These procedures are usually done as day surgery using a minimally invasive technique. Most patients can go home the same day.

Walking

You can walk immediately in a postoperative shoe, which protects the foot and reduces pressure on the operated area.

Elevation

When you’re not walking, keep the foot elevated (foot above knee) as much as possible during the first week. This helps reduce swelling and pain.

Two-Week Review

At the two-week mark you’ll return for a wound check. Most people can begin gentle movement exercises as advised.

Transition to Normal Footwear

From around week four, many patients can transition into comfortable runners. Swelling may take several months to settle fully ( I usually tell everyone that with foot surgery it can take up to 12 months for the swelling to completely settle and some people may even experience some residual swelling), but most people return to normal daily activities fairly quickly.