Hallux Rigidus and Cheilectomy

- Discussion:
    - hallux rigidus results from degenerative changes at the first MTP joint;
    - this may be more disabling than hallux valgus, because pt is unable to achieve relief even when not wearing shoes;
    - it is a frequent complaint of runners;
    - there is limitation of motion and pain at the MTP joint of the great toe secondary to repetitive trauma and DJD;
          - because the great toe has limited dorsiflexion, puff of during ambulation can be painful;
          - loss of motion is due to new growth of bone around dorsal articular surface of first metatarsal head;

- Epidemiology:
    - Most common osteoarthritic joint in the foot
    - 2nd most common great toe condition to Hallux Valgus
    - 1 in 40 individuals over 50 y.o. develop Hallux Rigidus (Gould, et al)
    - Females > Males  (2:1)
    - Nilsonne (1930) described two distinct age groups: adolescent and adult Adolescent: localized chondral/osteochondral lesions in articular surface of
                MT head Adult: diffuse, more generalized arthrosis whose severity correlates with age
                - ref: Hallux rigidus: cheilotomy or implant?

- Clinical History:
    - Insidious onset of pain and stiffness about the great toe
    - Standing, walking & heels aggravate
    - worse at toe-off gait
    - relieved with rest
    - burning pain or paresthesia

- Exam:
    - skin irritation due to pressure from footwear over dorsal exostosis
    - on exam, decreased ROM, esp dorsiflexion, is common;
    - limitation of motion and pain at the MTP joint secondary to prominent marginal osteophytes, absence of passive MTP DF, often normal or adequate PF; 
    - affected feet are often long, narrow, & pronated with unstable arches, frequently with a hyper-mobile or elevated (and long) first MT;
    - need to rule out "pseudo-hallux rigidus"
            - nodular swelling of of the proximal FHL which limits hallux dorsiflexion;
            - FHL becomes constricted withing the fibro-osseous tunnel;
            - hallux motion is restored when ankle is plantar flexed;

- X-ray:
    - non-uniform joint space narrowing
    - widening/flattening 1st MT head + base proximal phalanx
    - subchondral sclerosis or cysts
    - horseshoe shaped osteophytes
    - lateral > medial osteophytes
    - sesamoid hypertrophy

- Non Operative Treatment:
    - includes molded stiff inserts w/ rigid bar or rocker bottom shoe;

- Surgical Treatment:
    - surgical inidications:
          - cheilectomy for treatment of hallux rigidus will relieve dorsal impingement that is usually the source of pain in patients w/ this condition;
          - cheilectomy is recommended for mild to moderate deformity;
          - arthrodesis is treatment of choice following failed cheilectomy or where advanced degenerative changes are present;
                   - ref: Study: Arthrodesis most reliable technique to treat hallux rigidus
    - outcomes:
          - in the study by Muller T, et al (1999), there were 14 excellent, 7 good, and one fair result, and radiographic progression was seen in 7/13 patients;
    - operative technique:
          - removal of bone spurs alone is usually not sufficient for pain relief;
          - cheilectomy, which includes not only excision of dorsal spur & dorsal 1/3  the metatarsal head, gives long-term pain relief in most patients;
          - it important to remove the dorsal 20-30% of metatarsal head, along with any spurs that may have formed along lateral side of the joint;
                 - when performing a cheilectomy, most common error is to remove dorsal exostosis in line with dorsal surface of metatarsal  rather than
                           remove dorsal 20% to 30% of bone;
          - a large portion of the motion achieved intra-operative will be lost post-operatively, hence supra-normal amounts of dorsiflexion of great toe is needed;
                 - some surgeons will shoot for 60-80 deg of dorsiflexion;
          - range of motion of the hallux should be initiated soon after surgery
          - Results after cheilectomy in athletes with hallux rigidus.

Hallux rigidus: cheilotomy or implant.

Hallux rigidus: treatment by cheilectomy.

Hallux rigidus: a review of the literature and a method of treatment.

Subjective results of hallux rigidus following treatment with cheilectomy.

Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint. 

Soft-tissue arthroplasty for hallux rigidus.

Hallux Rigidus. Grading and Long-Term Results of Operative Treatment.

Prospective gait analysis in patients with first metatarsophalangeal joint arthrodesis for hallux rigidus.

The Modified Oblique Keller Capsular Interpositional Arthroplasty for Hallux Rigidus

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Monday, September 9, 2013 10:12 am