Hallux rigidus is a wearing-out (arthritis) of the joint at the base of the big toe. It causes pain, stiffness, and often a bony lump on top of the joint that rubs against shoes. In the early stages we treat it without surgery — using stiff-soled or roomy footwear, insoles, painkilling gels and tablets, and occasionally a steroid injection. Surgery is only considered when these measures no longer control the pain and the arthritis is severe (“end-stage”).

For end-stage arthritis there are two main operations: fusion (arthrodesis), which permanently stiffens the joint, and joint replacement. A silastic replacement removes the worn joint surfaces and inserts a small, flexible silicone spacer that works like a hinge. Its key advantage over fusion is that it preserves movement in the toe rather than stiffening it completely, while still relieving pain.

What the evidence shows

The results are reassuring. In a large study of 108 of these implants published in the Bone & Joint Journal (Clough & Ring, 2020), average pain scores fell from 7 out of 10 before surgery to about 1 out of 10 afterwards, and validated foot questionnaire scores improved dramatically. Around 9 in 10 patients (91%) said they were satisfied with their operated toe.

This procedure is most suitable for an older, non-sporty patient looking to preserve range of movement. Sporty patients will wear the implant out quickly, and it is not advised for high-impact activity due to a higher risk of implant failure, complications and the need for revision when the implant is subjected to high stresses.

Before your operation you will attend a pre-assessment appointment, where the team checks you are fit for anaesthetic and advises whether to pause any medications (for example blood thinners). You will not be able to drive straight after surgery, so arrange a lift home and some help for the first couple of weeks. Plan time off work — desk-based roles typically need 2–3 weeks, and more if you are on your feet.

Helpful items to buy in advance

• A foam leg elevator (wedge). Keeping your foot raised comfortably above the level of your heart is the single most effective thing you can do to reduce swelling and pain in the first two weeks. A firm foam wedge is far better than a stack of pillows.
• A waterproof cast/dressing protector. A product such as the “Limbo” seals over your dressing so you can shower without getting it wet, which helps keep the wound clean and dry.

Further reading before your operation:

• Download our patient leaflet on preparing for foot surgery: Preparing for Foot Surgery (PDF)
• Download our product guide for recommended recovery equipment: Recommended Product Guide (PDF)

The operation is usually carried out under a general anaesthetic (you are asleep) or a spinal anaesthetic (numb from the waist down), often with a local anaesthetic block to keep the foot comfortable afterwards. It takes around 30–45 minutes.

A small cut is made on the top of the big toe joint. The surgeon removes the worn, arthritic joint surfaces and any bony lumps, then gently shapes the ends of the two bones. A small, flexible silicone implant with two stems is slotted into the bones, one stem into each side. It sits like a cushioned hinge, taking the place of the old joint so the toe can bend without the bones grinding painfully together. The skin is closed with stitches, a supportive dressing is applied, and you are placed in a special stiff-soled shoe.

This is a day-case procedure, which means you go home the same day — usually a few hours after surgery, once you are comfortable, have eaten and drunk, and the team is happy you can move around safely on your special shoe. You can put weight through the heel and outside of the foot straight away, so you will not need to be admitted overnight in most cases.

Recovery is staged. Following the plan closely — especially the elevation in the first two weeks — makes a real difference to swelling, comfort and the final result.

Early (first 2 weeks)

Rest at home with your leg strictly elevated — foot above heart level as much as possible, coming down only for short trips to the bathroom and for food. This is the most important phase for controlling swelling. Keep the dressing clean and dry (use your waterproof protector to shower). You will be reviewed at around two weeks for a wound check and removal of stitches.

Mid-term (weeks 2–6)

From about two weeks, once the wound has healed, you move into a flat post-operative shoe with a light bandage for a further two weeks, gradually increasing how much you are on your feet. At around four weeks you can usually progress into rigid-soled trainers for the next couple of weeks, which support the toe while it settles.

Long-term (6 weeks and beyond)

By around six weeks most people are back in comfortable, supportive normal shoes and returning to everyday activities. Any residual swelling continues to settle over the following few months — this is normal and can take up to six months to fully resolve. Most patients return to low-impact exercise and sport by around three months, building up gradually. Your surgeon will guide your individual return to higher-impact activity.

Overall, this operation has low complication rates, and most problems that do occur are minor and settle with simple treatment. In the study of 108 cases, most complications did not affect the final outcome. The main risks specific to this procedure are:

Importantly, the study found 97.2% of implants were still working at around 5 years, with no sign of the progressive bone loss reported with older single-stemmed designs.

These risks are explained in more detail in our dedicated risk leaflet:

• Guide to Forefoot Surgery Risks (PDF)

Please read this in conjunction with this leaflet before signing your consent form. Mr Welck will discuss the risks that are most relevant to your individual case in clinic.

Mr Matthew Welck is a Consultant Orthopaedic Foot & Ankle Surgeon at the Royal National Orthopaedic Hospital (RNOH), Stanmore, and Honorary Associate Clinical Professor at UCL. He is widely regarded as one of the best foot and ankle surgeons in London and North London, with specialist expertise in big toe arthritis, sports injuries, complex reconstruction and total ankle replacement. He has over 50 peer-reviewed publications and is an active educator and researcher in weight-bearing CT imaging and 3D-printed surgical planning.

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