Hallux Rigidus and Cheilectomy : Wheeless' Textbook of Orthopaedics

- 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.