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Hallux rigidus: a review
FOOT AND ANKLE
Hallux rigidus: a review
elevatus, hallux valgus, first ray hypermobility and metatarsus adductus. Current research however fails to provide a clear link with such factors and the development of this condition.4,5
Oliver Chan Clinical evaluation
Anthony Sakellariou
Patients with early hallux rigidus commonly present with pain over the dorsal aspect of the first MTPJ, mild stiffness of the joint as well as symptoms of inflammation. Cartilage loss typically begins in the dorsal aspect of the metatarsal head with subsequent development of a dorsal osteophyte.6 Such a prominence may add to the pain and inflammation from external pressure from footwear and may cause neuritic pain from compression of the dorsomedial branch of the superficial peroneal nerve.7 Patients may report worsening of their pain when performing activities that increase loading on the first MTPJ such as tip-toeing and running.8 If left untreated, the natural progression of hallux rigidus results in a severely painful joint with little residual movement. If left for long enough however, the joint may ankylose naturally and eventually become painless. Clinical examination of the patient with hallux rigidus may reveal a tender, swollen inflamed first MTPJ with a decreased range of movement. During the early stages of the condition, pain may be present at the extremes of sagittal plane motion. Pain in dorsiflexion is caused by dorsal osteophyte impingement and pain in plantar flexion caused by stretching of the dorsal capsule over the dorsal osteophyte.9 As the condition worsens, patients typically develop mid-arc pain indicating significant cartilage loss. Tinel’s sign may also be elicited if there is compression of the dorsomedial branch of the superficial peroneal nerve.7
Abstract Hallux rigidus is a degenerative joint condition affecting the first metatarso-phalangeal joint and is characterized by a painful and stiff joint. It is the most common form of arthritis in the foot and the pathophysiology is believed to be multi-factorial. In this review we discuss the clinical evaluation of the condition and explore both non-surgical and surgical treatment options. Our preferred treatment algorithm for different presentations of the condition is also included in the paper.
Keywords hallux limitus; hallux rigidus
Introduction Hallux rigidus is a degenerative joint condition affecting the first metatarso-phalangeal joint (MTPJ) and is characterized by a painful and stiff joint. It is the most common form of arthritis in the foot and the incidence is likely to increase with an ageing population.1 In this review, we discuss the pathophysiology of the condition, the clinical presentation and both surgical and non-surgical treatment options.
Pathophysiology The cause of hallux rigidus remains unclear with a significant proportion of cases being idiopathic. A number of factors however, are believed to be linked to the development of the condition. Trauma has been suggested as a significant risk factor for hallux rigidus either in the form of a single event2 or a series of micro-traumatic events.3 Similar to the development of osteoarthritis secondary to trauma in other synovial joints, direct damage may occur to the articular surface and loss of joint congruence may lead to the development of degenerative joint disease. Hyperextension injuries to the plantar plate (turf-toe injuries) may result in an increase in shear stresses across the joint and have also been linked to the development of hallux rigidus.4 A positive family history plays a role in the aetiology of hallux rigidus. A series published by Coughlin and Shurnas in 20035 suggested that roughly two-thirds of patients had a positive family history and that 95% of patients with a family history had bilateral symptoms. Several biomechanical factors have also been suggested in the pathophysiology of hallux rigidus including metarsus primus
Radiological assessment The radiological assessment of hallux rigidus should consist of weight-bearing antero-posterior (AP) and lateral radiographs as well as an oblique view. On the AP view, generalized signs of osteoarthritis may be observed including joint space narrowing, subchondral sclerosis and subchondral cyst formation. Dorsal osteophytes of the metatarsal are best visualised on the lateral radiograph as are osteophytes at the base of the proximal phalanx.
Classification Hattrup and Johnson first classified hallux rigidus in 1998.10 This was based purely on radiological findings. Coughlin and Shurnas (Table 1) later introduced a further classification system based on both radiological and clinical findings11 and is arguably the most commonly used system for hallux rigidus. There is however no correlation between this classification system and intraoperative findings.12
Non-operative management Non-operative measures should be considered as first-line treatment in the majority of patients with hallux rigidus. A retrospective review involving over 700 patients reported a success rate of 55% with conservative measures.13 Treatment modalities included footwear modification, orthotics and corticosteroid injections.
Oliver Chan MD(Res) FRCS (Tr & Orth), Specialist Registrar, Frimley Health NHS Foundation Trust, UK. Conflicts of interest: none declared. Anthony Sakellariou BSc FRCS (Orth), Consultant Foot & Ankle Surgeon, Frimley Health NHS Foundation Trust, UK. Conflicts of interest: none declared.
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Please cite this article as: Chan O, Sakellariou A, Hallux rigidus: a review, Orthopaedics and Trauma, https://doi.org/10.1016/ j.mporth.2019.11.004
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Coughlin and Shurnas’ classification system for hallux rigidus Grade
Dorsiflexion
Radiographic findings
Clinical findings
0
40e60o and/or 10e20% compared to other side 30e40o and/or 20e50% loss compared to other side
Normal
No pain; only stiffness and loss of motion on examination Mild or occasional pain and stiffness, pain at extremes of dorsiflexion and/or plantar flexion on examination
1
2
10e30o and/or 50e75% loss compared to other side
3
<10o and/or 75e100% loss compared to other side. There is notable loss of plantar flexion as well.
4
Same as in grade 3
Dorsal osteophyte is main finding, minimal joint-space narrowing, minimal peri-articular sclerosis, minimal flattening of metatarsal head Dorsal, lateral and possible medial osteophytes giving flattened appearance to metatarsal head, no more than of dorsal joint space involved on lateral radiograph, mild-tomoderate joint space narrowing and sclerosis, sesamoids not usually involved Same as in grade 2 but with substantial narrowing, possibly with periarticular cystic changes, more than of dorsal joint space involved on lateral radiograph, sesamoids enlarged and/or cystic and/or irregular Same as in grade 3
Moderate to severe pain and stiffness that may be constant; pain occurs just before maximum dorsiflexion and maximum plantar flexion on examination
Nearly constant pain and substantial stiffness at extremes of range of motion but not at midrange
Same criteria as in grade 3 BUT there is definite pain in mid-range of passive motion
Adapted from Coughlin MJ, Shurnas PJ. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg 2003; 85-A: 2072e88.
Table 1
General advice regarding analgesia and activity modification may be given to the patient. If possible avoidance of activities that cause repetitive dorsiflexion of the first MTPJ may help to alleviate symptoms. Recommended footwear should consist of shoes with a deep toe box to decrease contact on dorsal osteophytes as well as shoes with a stiff sole to limit movement at the first MTPJ. A shoe with a rocker sole may also be tried to decrease movement at this joint by causing a rolling transition between heel-strike and toe-off. Orthotics can be used to modify existing footwear. An extended shank or footplate made of spring-steel or carbon fibre can be used to stiffen the sole of the shoe14 thereby limiting dorsiflexion at the first MTPJ. A Morton’s extension limits movement at the hallux in isolation and may be better tolerated by more active patients. Intra-articular joint injection and manipulation under anaesthesia (MUA) for hallux rigidus was first described by WatsonJones in 1927 and may lead to temporary relief of symptoms. Solan et al.15 reviewed the outcome of MUA and steroid injection (40 mg depomedrone and 0.5% bupivacaine) in 31 patients and stratified their results according to radiological severity of hallux rigidus (Karasick and Wapner classification). They found that MUA and injection provided a median of 6 months symptomatic relief in patients with grade 1 disease and 3 months relief for patients with grade 2 disease. They did not observe any significant relief of symptoms in patients with severe radiological signs of hallux rigidus (Grade 3 disease) and, as such, concluded that MUA and injection was not an appropriate treatment option for such patients. A significant proportion of patients with grade 1 and 2 disease went on to require surgical intervention (one-third
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in grade 1, two-thirds in grade 2). It is therefore the authors’ opinion that MUA and steroid injection can be used in conjunction with non-operative measures to delay surgical intervention in patients with mild to moderate hallux rigidus. Hyaluronic acid intra-articular injections have been tried for patients with hallux rigidus. Currently the literature does not support its widespread use. A randomized controlled trial involving 151 patients failed to show any significant reduction in pain reduction 3 months after injection when compared to normal saline placebo.16
Operative management Surgical management of hallux rigidus may be broadly divided into joint-sparing (cheilectomy, osteotomies and joint arthroplasty) and joint-sacrificing procedures (fusion). The decision as to which procedure is appropriate is dependent on several factors including; patient expectations, severity of symptoms and radiograph findings, age, activity levels and co-morbidities. Cheilectomy An open dorsal cheilectomy was described by DuVries in 1959.17 This involves removal of dorsal osteophytes to the metatarsal head and proximal phalanx and excision of the dorsal one-third of the articular surface. Synovial debridement and removal of any loose bodies can also be undertaken. The advantages of performing a dorsal cheilectomy are preservation of joint movement and stability as well as the ability to revise to a secondary procedure such as an MTPJ fusion in the future. Positive outcomes following cheilectomy have been reported in the literature which has recorded a variety of patient-reported
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majority of patients with mild hallux rigidus, the loss of cartilage is predominantly dorsal. The Moberg osteotomy may serve to offload this area by shifting the contact pressure of the proximal phalanx in a plantar direction on the metatarsal head.27 Positive outcomes following a cheilectomy and Moberg osteotomy have been reported. Thomas and Smith reported a 99% satisfaction rate in a small cohort of patients with early mild hallux rigidus28 (Hattrup and Johnson grades 1 and 2), whilst O’Malley et al. retrospectively reviewed 81 patients who underwent this treatment for advanced hallux rigidus (Hattrup and Johnson grade 3) and reported a 85% satisfaction rate and a 4.9% conversion rate to MTPJ fusion (minimum follow-up 2 years).29 Higher levels of evidence advocating the use of a Moberg osteotomy are currently lacking. A comparative study looking at outcomes following cheilectomy with and without a Moberg osteotomy would be useful to evaluate any potential benefits of performing such an osteotomy. A potential drawback to the use of the Moberg is during conversion to MTPJ fusion. The extended position of the proximal phalanx may preclude the use of arthrodesis plates.
outcome measures (PROMs). Success rates have ranged from 72% to 97% in these case series.11,18e20 Although not conclusive, current research suggests that results following cheilectomy are more favourable in patients with less severe grades of hallux rigidus. Easley et al.,19 reported that 8 out of the 9 patients that remained symptomatic following a cheilectomy had Hattrup and Johnson grade III disease. The authors reported that all 9 patients had mid-arc pain during preoperative assessment and concluded that this finding indicated advanced degenerative disease of the joint and was therefore a negative prognostic sign. More severe disease may also be associated with a higher risk of requiring an arthrodesis procedure following cheilectomy. About 25% of patients with Hattrup and Johnson grade III disease went on to require an arthrodesis in Easley’s paper19 whilst 56% of patients with Coughlan and Shurnas grade III disease went on to require arthrodesis in another study.5 This compares with 7e9% of all patients with hallux rigidus (irrespective of grade) that go on to require an arthrodesis within 10 years.11,21 In terms of an increase in dorsiflexion after cheilectomy, this appears to be less predictable compared to the pain relieving aspect of the procedure. The range of dorsiflexion achieved intraoperatively is not indicative of the range of dorsiflexion postoperatively. Two studies report that whilst 80e90 of dorsiflexion was achievable intraoperatively. the range of dorsiflexion following recovery from surgery was measured significantly less at 21e39 .19,22 Traditionally a dorsal cheilectomy has been performed via an open approach (dorsal or mid-medial). Both arthroscopic and minimally invasive surgical (MIS) techniques have been described.23,24 The potential benefits of both are less soft tissue damage and quicker return to function although at present there is no scientific evidence to support such claims. In terms of outcomes following MIS and arthroscopic cheilectomy, only a few studies with small numbers and short-term follow-up currently exist. They show an improvement in PROMs following surgery and a comparable complication rate with open surgery.23e25 Stevens et al. retrospectively reviewed their results of MIS and open cheilectomies and found a significantly higher complication rate and higher re-operation rate in the MIS group.26 They concluded that patients should be counselled appropriately about the risks and potential benefits of both cheilectomy techniques.
Watermann osteotomy A Watermann or dorsal closing wedge osteotomy of the distal metatarsal (Figure 1, centre) can also be performed in conjunction with a dorsal cheilectomy.30 It was designed to decompress the joint through shortening and relocate the better preserved plantar articular cartilage to a more dorsal position. Few results are published regarding this technique30 and it is not currently in widespread use for the treatment of hallux rigidus. Youngswick osteotomy The Youngswick osteotomy (Figure 1, right) is a modification of the chevron osteotomy.31 A V-shaped osteotomy is performed initially, with the apex based distally and the limbs at roughly 60 to one another. Following this, a second osteotomy is performed parallel to the dorsal limb. This results in shortening of the first metatarsal osteotomy and decompression of the first MTPJ. A small degree of plantar translation also occurs which may decrease dorsal impingement. Evidence for outcomes of the Youngswick osteotomy is generally lacking although a retrospective review evaluated the results in 23 patients with end-stage hallux rigidus.32 The authors reported an improvement in pain, function and range of movement following the osteotomy.
Moberg osteotomy A Moberg osteotomy (dorsal closing wedge osteotomy of the proximal phalanx) can be performed in conjunction with a cheilectomy to shift the arc of motion of the first MTPJ into more dorsiflexion at the expense of plantar flexion (Figure 1, left). This osteotomy could therefore be considered in patients with limited dorsiflexion but with a good range of plantar flexion. In the
Keller resection arthroplasty This involves resection of the base of the proximal phalanx, thereby decompressing the joint. As a result, pain relief and an increase in dorsiflexion can be achieved at the expense of joint stability. This procedure has been shown to be an effective
Figure 1 Different osteotomies for the treatment of hallux rigidus. Left: Moberg osteotomy of the proximal phalanx. Middle: Watermann osteotomy. Right: Youngswick osteotomy.
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Polyvinyl alcohol (PVA) hydrogel hemiarthroplasty: this synthetic cartilage implant was introduced more recently (Figure 2). It is designed to sit proud of the metatarsal head by 1.5e2.0 mm and therefore functions as both a hemiarthroplasty and as an inter-positional spacer.40 It has similar material properties to human articular cartilage in terms of its Young’s modulus, water content and tensile strength41 therefore making it a suitable synthetic cartilage implant. A prospective, multi-centre randomized controlled noninferiority trial was performed comparing the use of the PVA hemiarthroplasty and arthrodesis at the first MTPJ for patients with moderate to severe hallux rigidus (Coughlin and Shurnas grades 2, 3 and 4).42 At 2 years follow-up, the cohort of patients who received the PVA implant had comparable functional outcomes, revision rates and postoperative pain levels to the arthrodesis group. Dorsiflexion improved by a mean of 6.2 degrees in the replacement group and there were no reported cases of implant fragmentation, wear or bone loss. The failure rate resulting in revision arthrodesis was found to be 9.2%. Results were equivalent to MTPJ arthrodesis irrespective of gender, age, body mass index, hallux rigidus grade, preoperative pain or symptom duration.43 Twenty-seven of the patients to receive the PVA implant in this initial study were available for prospective follow-up at 5 years.44 Pain and functional outcome scores continued to be significantly better compared to preoperative scores and only one of these patients went on to arthrodesis for continued pain. No radiological signs of implant wear, subsidence or loosening were observed. The early results of the PVA hemiarthroplasty appear promising. However more long-term data are required.
treatment for pain relief. A prospective study of 75 feet treated with a Keller resection arthroplasty revealed that 91% of patients experienced significant pain relief.33 Unfortunately, in this same cohort of patients, 41% also developed a ‘cock-up’ deformity. Other complications of this procedure include weakness with toeoff and transfer metatarsalgia secondary to a de-functioned shortened first ray.34 The other disadvantage is the bone loss from the procedure which could make revision to an arthrodesis challenging. Due to the high incidence of complications, a Keller resection arthroplasty should only be recommended for elderly and lower demand patients. MTPJ arthroplasty Initial attempts at joint replacement at the first MTPJ occurred over 25 years ago. These implants were silicone based following the success of silastic implants used in joints of the hand. Although patient satisfaction rates were quoted as between 64% and 83%, high rates of osteolysis and reports of immune reactions to such implants have prevented their widespread use in feet.35,36 Subsequent implants which include metallic implants with a polyethylene insert, ceramic implants and metal hemi-arthroplasties of the first MTPJ have also been tried but have been plagued similarly with high osteolysis rates and high revision rates.37e39 Outcomes following MTP arthroplasty have been shown to be inferior to arthrodesis. Gibson and Thomson37 performed a randomized controlled trial comparing a metallic implant arthroplasty with arthrodesis and found that fusion was associated with a significantly better functional outcome as well as greater pain relief. The arthroplasty group was also associated with a 15% revision rate at 2 years. Metatarsal hemiarthroplasties have also been shown to have decreased PROMs scores and higher pain scores when compared to patients undergoing arthrodesis.39 Such disappointing results have prevented the widespread adoption of traditional MTPJ arthroplasty in the treatment of hallux rigidus.
MTPJ arthrodesis: fusion of the first MTPJ remains the gold standard treatment for advanced hallux rigidus. A successful first MTPJ arthrodesis decreases pain, maintains length and provides stability at the expense of movement. It should also be
Figure 2 The polyvinyl alcohol hydrogel hemiarthroplasty implant. Left: Clinical picture and Right: postoperative radiograph of a patient’s foot following synthetic cartilage implant insertion for hallux rigidus.
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patients were able to return to previous activities such as golf, tennis, hiking and jogging.52
considered in patients with less arthritic change who have concomitant deformity such as hallux valgus or varus, rheumatoid arthritis and patients with neuromuscular disorders such as cerebral palsy. Joint-sparing procedures in such patients are associated with unpredictable results and the development or recurrence of deformity. Multiple techniques have been described for the fusion of the first MTPJ. These include the use of lag screws, plate constructs and a combination of both (Figure 3). In biomechanical studies, a lag screw and plate have been found to offer the most stable construct,45 displaying significantly greater stiffness and load to failure compared to two cross lag screws.46 It is worth noting however, that the clinical implications of construct stiffness and load to failure remain unknown in terms of union rates and the cost of using a plate and lag screw is significantly higher than screws alone.47 The optimal position for first MTPJ fusion should be neutral rotation, 15 of dorsiflexion relative to the floor and 5e15 of valgus.48 The use of a flat surface intraoperatively can be used to judge dorsiflexion; the plantar pad of the hallux should rest on the flat surface but allow passive elevation at the interphalangeal joint by roughly 5 mm (Figure 4). The joint surfaces can be prepared with either conical reamers or by using flat cuts according to the surgeon’s preference. Arguably, flat cuts are more technically demanding and are associated with an increased risk of shortening the first ray. The use of conical reamers may also provide greater freedom to adjust alignment of the MTPJ after debridement of cartilage. Results following fusion of the first MTPJ have been favourable. Three large prospective cohort studies using plate and lag screw constructs have reported union rates of between 92% and 98%, revision rates of 1e4% and high patient satisfaction rates.49e51 Brodsky et al. looked at the functional outcome following first MTPJ fusion. Their results revealed that the surgery was effective for relieving pain (85% of their cohort did not require any analgesia post-fusion) and that the vast majority of
Salvage arthrodesis: MTPJ arthrodesis following a failed arthroplasty, previous excision arthroplasty or infection represents a technical challenge due to the potential levels of bone loss. A bone block arthrodesis can be employed utilising either iliac crest tricortical autograft or structural allograft.53,54 Such grafts can be shaped to accommodate defects in both the metatarsal and proximal phalanx. To accommodate the large defects and bone block, it is essential that a plate with adequate working length is used. A plate that is too short will result in potentially too much strain at the fusion site and may result in surgical failure. Outcomes following bone block arthrodesis have been reported as satisfactory.53,54 Myerson et al. used iliac crest autograft to treat 24 patients with significant bone loss secondary to previous surgeries (failed arthroplasty, previous hallux valgus correction surgery and prior Keller excision arthroplasty). They reported significantly improved AOFAS scores in their cohort of patients and a union rate following bone block arthrodesis of 79%. Luk et al., utilised an interposition allograft bone block to try to fuse the first MTPJ of patients with significant bone loss. They reported a union rate of 87% and an improvement in PROMs.
Authors’ preferred treatment algorithm For patients with hallux rigidus who are refractory to nonoperative measures, patients are informed of the possible treatment options, and their respective advantages and disadvantages are made clear. Patients are informed of the likely recovery following surgical intervention and potential risks and inconveniences are highlighted. Generally speaking, patients with mild hallux rigidus and end of arc pain (dorsal and plantar impingement secondary to a dorsal cheilus) are offered a cheilectomy. We routinely do this
Figure 3 Images showing first MTPJ fusion fixation; Left: dorsal to plantar lag screws Right: lag screw and plate configuration.
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authors’ preference would be to fuse the joint with a plate and screw configuration. The removal of the hemiarthroplasty implant is straightforward and not normally associated with significant bone loss. The use of bone graft is therefore not normally required. In the setting of a salvage arthrodesis and the event of significant bone loss, we would favour the use of shaped allograft or iliac crest tricortical autograft and primary fixation with a long segment plating system. A REFERENCES 1 Dellenbaugh SG, Bustillo J. Arthritides of the foot. Med Clin N Am 2014; 98: 253e65. 2 Shurnas P, Coughlin M. Arthritic conditions of the foot. In: Surgery of the foot and ankle. Philadelphia: Elsevier, 2007; 867e909. 3 Coughlin MJ. Conditions of the forefoot. In: DeLee J, Drez D, eds. Orthopaedic sports medicine: principles and practice. Philadelphia: WB Saunders, 1994; P221e44. 4 McMaster MJ. The pathogenesis of hallux rigidus. J Bone Joint Surg Br 1978; 60B: 82e7. 5 Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2003; 24: 731e43. 6 Hattrup SJ, Johnson KA. Subjective results of hallux rigidus following treatment with cheilectomy. Clin Orthop Relat Res 1998; 226: 182e91. 7 Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int 2008; 29: 637e46. 8 Kunnasegaran R, Thevendran G. Hallux rigidus: nonoperative treatment and orthotics. Foot Ankle Clin 2015; 20: 401e12. 9 Hamid KS, Parekh SG. Clinical presentation and management of hallux rigidus. Foot Ankle Clin 2015; 20: 391e9. 10 Hattrup SJ, Johnson KA. Subjective results of hallux rigidus following treatment with cheilectomy. Clin Orthop Relat Res 1998; 226: 182e91. 11 Coughlin MJ, Shurnas PJ. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg 2003; 85-A: 2072e88. 12 Baumhauer JF, Singh D, Glazebrook M, et al. Correlation of hallux rigidus grade with motion, VAS pain, intraoperative cartilage loss, and treatment success for first MTP joint arthrodesis and synthetic cartilage implant. Foot Ankle Int 2017; 38: 1175e82. 13 Grady JF, Axe TM, Zager EJ, Sheldon LA. A retrospective analysis of 772 patients with hallux limitus. J Am Podiatr Med Assoc 2002; 92: 102e8. 14 Sammarco VJ, Nichols R. Orthotic management for disorders of the hallux. Foot Ankle Clin 2005; 10: 191e209. 15 Solan MC, Calder JD, Bendall SP. Manipulation and injection for hallux rigidus. Is it worthwhile? J Bone Joint Surg Br 2001; 83: 706e8. 16 Munteanu SE, Zammit GV, Menz HB, et al. Effectiveness of intraarticular hyaluronan (Synvisc, hylan G-F 20) for the treatment of first metatarsophalangeal joint osteoarthritis: a randomised placebo-controlled trial. Ann Rheum Dis 2011; 70: 1838e41. 17 DuVries HV. Surgery of the foot. St. Louis (MO): Mosby Year book, 1959; 392e9. 18 Harrison T, Fawzy E, Dinah F, Palmer S. Prospective assessment of dorsal cheilectomy for hallux rigidus using a patient-reported outcome score. J Foot Ankle Surg 2010; 49: 232e7.
Figure 4 The use of a flat surface intraoperatively to guide relative dorsiflexion position at the fusion site.
through a mid-medial approach and tend to avoid resecting onethird of the joint surface to preserve bone stock in case alternative surgery (interposition arthroplasty or arthrodesis) is required at a later date. For patients with mild hallux rigidus with well preserved articular cartilage, a Youngswick osteotomy can be offered to treat the restriction in dorsiflexion. If however, the patient has a good preserved range of movement but mid-arc pain, the patient is unlikely to benefit from a cheilectomy and is offered a guided injection (either ultrasound or image guided) to confirm that the pain is definitely arising from the MTPJ. A patient in whom an injection is temporarily successful is then offered either a PVA hemiarthroplasty or arthrodesis. For patients who have more severe hallux rigidus (indicated radiographically and the presence of mid-arc pain) or those who have not responded to cheilectomy the options of either a PVA hydrogel hemiarthroplasty (assuming there are no contraindications such as significant deformity, bone loss, metatarso-sesamoid arthritis, or presence of neuromuscular disease) or first MTPJ fusion are discussed. Should an arthrodesis procedure be chosen, the authors’ preferred method of fusion includes the use of conical reamers and the use of two dorsal lag screws to provide primary fixation. Intraoperatively if the hold from the lag screws is inadequate, a plating system is utilised for primary fixation. For patients that fail to improve following a PVA hemiarthroplasty, a revision procedure to an arthrodesis is offered. In this setting, the
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38 Dawson-Bowling S, Adimonye A, Cohen A, et al. MOJE ceramic metatarsophalangeal arthroplasty: disappointing clinical results at two to eight years. Foot Ankle Int 2012; 33: 560e4. 39 Raikin SM, Ahmad J, Pour AE, Abidi N. Comparison of arthrodesis and metallic hemiarthroplasty of the hallux metatarsophalangeal joint. J Bone Joint Surg Am 2007; 89: 1979e85. 40 Younger ASE, Baumhauer JF. Polyvinyl alcohol hydrogel hemiarthroplasty of the great toe: technique and indications. Tech Foot Ankle Surg 2013; 12: 164e9. 41 Baker MI, Walsh SP, Schwartz Z, Boyan BD. A review of polyvinyl alcohol and its uses in cartilage and orthopedic applications. J Biomed Mater Res B Appl Biomater 2012; 100: 1451e7. 42 Baumhauer JF, Singh D, Glazebrook M, et al. Prospective, randomized, multi-centered clinical trial assessing safety and efficacy of a synthetic cartilage implant versus first metatarsophalangeal arthrodesis in advanced hallux rigidus. Foot Ankle Int 2016; 37: 457e69. 43 Goldberg A, Singh D, Glazebrook M, et al. Association between patient factors and outcome of synthetic cartilage implant hemiarthroplasty vs first metatarsophalangeal joint arthrodesis in advanced hallux rigidus. Foot Ankle Int 2017; 38: 1199e206. 44 Daniels TR, Younger AS, Penner MJ, et al. Midterm outcomes of polyvinyl alcohol hydrogel hemiarthroplasty of the first metatarsophalangeal joint in advanced hallux rigidus. Foot Ankle Int 2017; 38: 243e7. 45 Politi J, John H, Njus G, Bennett GL, Kay DB. First metatarsalphalangeal joint arthrodesis: a biomechanical assessment of stability. Foot Ankle Int 2003; 24: 332e7. 46 Buranosky DJ, Taylor DT, Sage RA, et al. First metatarsophalangeal joint arthrodesis: quantitative mechanical testing of six-hole dorsal plate versus crossed screw fixation in cadaveric specimens. J Foot Ankle Surg 2001; 40: 208e13. 47 Hyer CF, Glover JP, Berlet GC, Lee TH. Cost comparison of crossed screws versus dorsal plate construct for first metatarsophalangeal joint arthrodesis. J Foot Ankle Surg 2008; 47: 13e8. 48 Ho B, Baumhauer J. Hallux rigidus. EFORT Open Rev 2017; 2: 13e20. 49 Goucher NR, Coughlin MJ. Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study. Foot Ankle Int 2006; 27: 869e76. 50 Bennett GL, Sabetta J. First metatarsalphalangeal joint arthrodesis: evaluation of plate and screw fixation. Foot Ankle Int 2009; 30: 752e7. 51 Doty J, Coughlin M, Hirose C, Kemp T. Hallux metatarsophalangeal joint arthrodesis with a hybrid locking plate and a plantar neutralization screw: a prospective study. Foot Ankle Int 2013; 34: 1535e40. 52 Brodsky JW, Passmore RN, Pollo FE, Shabat S. Functional outcome of arthrodesis of the first metatarsophalangeal joint using parallel screw fixation. Foot Ankle Int 2005; 26: 140e6. 53 Luk PC, Johnson JE, McCormick JJ, Klein SE. First metatarsophalangeal joint arthrodesis technique with interposition allograft bone block. Foot Ankle Int 2015; 36: 936e43. 54 Myerson MS, Schon LC, McGuigan FX, Oznur A. Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int 2000; 21: 297e306.
19 Easley ME, Davis WH, Anderson RB. Intermediate to long-term followup of medial-approach dorsal cheilectomy for hallux rigidus. Foot Ankle Int 1999; 20: 147e52. 20 McNeil DS, Baumhauer JF, Glazebrook MA. Evidence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int 2013; 34: 15e32. 21 Nawoczenski DA, Ketz J, Baumhauer JF. Dynamic kinematic and plantar pressure changes following cheilectomy for hallux rigidus: a mid-term followup. Foot Ankle Int 2008; 29: 265e72. 22 Vulcano E, Tracey 3rd JA, Myerson MS. Accurate measurement of first metatarsophalangeal range of motion in patients with hallux rigidus. Foot Ankle Int 2016; 37: 537e41. 23 Mesa-Ramos M, Mesa-Ramos F, Carpintero P. Evaluation of the treatment of hallux rigidus by percutaneous surgery. Acta Orthop Belg 2008; 74: 222e6. 24 Iqbal MJ, Chana GS. Arthroscopic cheilectomy for hallux rigidus. Arthroscopy 1998; 14: 307e10. 25 Teoh KH, Tan WT, Atiyah Z, Ahmad A, Tanaka H, Hariharan K. Clinical outcomes following minimally invasive dorsal cheilectomy for hallux rigidus. Foot Ankle Int 2019; 40: 195e201. 26 Stevens R, Davies HG, Chadwick C, Flowers M, Blundell CM, Davies MB. Minimally Invasive versus Open Cheilectomy of the first metatarso-phalangeal joint: a comparison of complication rates and need for further surgery. Foot Ankle Int 2019; https://doi. org/10.1177/1071100719873846. 27 Kim PH, Chen X, Hillstrom H, et al. Moberg osteotomy shifts contact pressure plantarly in the first metatarsophalangeal joint in a biomechanical model. Foot Ankle Int 2016; 37: 96e101. 28 Thomas PJ, Smith RW. Proximal phalanx osteotomy for the surgical treatment of hallux rigidus. Foot Ankle Int 1999; 20: 3e12. 29 O’Malley MJ, Basran HS, Gu Y, Sayres S, Deland JT. Treatment of advanced stages of hallux rigidus with cheilectomy and phalangeal osteotomy. J Bone Joint Surg Am 2013; 95: 606e10. 30 Cavolo DJ, Cavallaro DC, Arrington LE. The Watermann osteotomy for hallux limitus. J Am Podiatry Assoc 1979; 69: 52e7. 31 Youngswick FD. Modifications of the Austin bunionectomy for treatment of metatarsus primus elevatus associated with hallux limitus. J Foot Surg 1982; 21: 114e6. 32 Oloff LM, Jhala-Patel G. A retrospective analysis of joint salvage procedures for grades III and IV hallux rigidus. J Foot Ankle Surg 2008; 47: 230e6. 33 Love TR, Whynot AS, Farine I, et al. Keller arthroplasty: a prospective review. Foot Ankle 1987; 8: 46e54. 34 Beertema W, Draijer WF, van Os JJ, Pilot P. A retrospective analysis of surgical treatment in patients with symptomatic hallux rigidus: long-term follow-up. J Foot Ankle Surg 2006; 45: 244e51. 35 Cracchiolo 3rd A, Weltmer Jr JB, Lian G, Dalseth T, Dorey F. Arthroplasty of the first metatarsophalangeal joint with a doublestem silicone implant. Results in patients who have degenerative joint disease failure of previous operations, or rheumatoid arthritis. J Bone Joint Surg Am 1992; 74: 552e63. 36 Sebold EJ, Cracchiolo 3rd A. Use of titanium grommets in silicone implant arthroplasty of the hallux metatarsophalangeal joint. Foot Ankle Int 1996; 17: 145e51. 37 Gibson JN, Thomson CE. Arthrodesis or total replacement arthroplasty for hallux rigidus: a randomized controlled trial. Foot Ankle Int 2005; 26: 680e90.
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Hallux rigidus: a review
elevatus, hallux valgus, first ray hypermobility and metatarsus adductus. Current research however fails to provide a clear link with such factors and the development of this condition.4,5
Oliver Chan Clinical evaluation
Anthony Sakellariou
Patients with early hallux rigidus commonly present with pain over the dorsal aspect of the first MTPJ, mild stiffness of the joint as well as symptoms of inflammation. Cartilage loss typically begins in the dorsal aspect of the metatarsal head with subsequent development of a dorsal osteophyte.6 Such a prominence may add to the pain and inflammation from external pressure from footwear and may cause neuritic pain from compression of the dorsomedial branch of the superficial peroneal nerve.7 Patients may report worsening of their pain when performing activities that increase loading on the first MTPJ such as tip-toeing and running.8 If left untreated, the natural progression of hallux rigidus results in a severely painful joint with little residual movement. If left for long enough however, the joint may ankylose naturally and eventually become painless. Clinical examination of the patient with hallux rigidus may reveal a tender, swollen inflamed first MTPJ with a decreased range of movement. During the early stages of the condition, pain may be present at the extremes of sagittal plane motion. Pain in dorsiflexion is caused by dorsal osteophyte impingement and pain in plantar flexion caused by stretching of the dorsal capsule over the dorsal osteophyte.9 As the condition worsens, patients typically develop mid-arc pain indicating significant cartilage loss. Tinel’s sign may also be elicited if there is compression of the dorsomedial branch of the superficial peroneal nerve.7
Abstract Hallux rigidus is a degenerative joint condition affecting the first metatarso-phalangeal joint and is characterized by a painful and stiff joint. It is the most common form of arthritis in the foot and the pathophysiology is believed to be multi-factorial. In this review we discuss the clinical evaluation of the condition and explore both non-surgical and surgical treatment options. Our preferred treatment algorithm for different presentations of the condition is also included in the paper.
Keywords hallux limitus; hallux rigidus
Introduction Hallux rigidus is a degenerative joint condition affecting the first metatarso-phalangeal joint (MTPJ) and is characterized by a painful and stiff joint. It is the most common form of arthritis in the foot and the incidence is likely to increase with an ageing population.1 In this review, we discuss the pathophysiology of the condition, the clinical presentation and both surgical and non-surgical treatment options.
Pathophysiology The cause of hallux rigidus remains unclear with a significant proportion of cases being idiopathic. A number of factors however, are believed to be linked to the development of the condition. Trauma has been suggested as a significant risk factor for hallux rigidus either in the form of a single event2 or a series of micro-traumatic events.3 Similar to the development of osteoarthritis secondary to trauma in other synovial joints, direct damage may occur to the articular surface and loss of joint congruence may lead to the development of degenerative joint disease. Hyperextension injuries to the plantar plate (turf-toe injuries) may result in an increase in shear stresses across the joint and have also been linked to the development of hallux rigidus.4 A positive family history plays a role in the aetiology of hallux rigidus. A series published by Coughlin and Shurnas in 20035 suggested that roughly two-thirds of patients had a positive family history and that 95% of patients with a family history had bilateral symptoms. Several biomechanical factors have also been suggested in the pathophysiology of hallux rigidus including metarsus primus
Radiological assessment The radiological assessment of hallux rigidus should consist of weight-bearing antero-posterior (AP) and lateral radiographs as well as an oblique view. On the AP view, generalized signs of osteoarthritis may be observed including joint space narrowing, subchondral sclerosis and subchondral cyst formation. Dorsal osteophytes of the metatarsal are best visualised on the lateral radiograph as are osteophytes at the base of the proximal phalanx.
Classification Hattrup and Johnson first classified hallux rigidus in 1998.10 This was based purely on radiological findings. Coughlin and Shurnas (Table 1) later introduced a further classification system based on both radiological and clinical findings11 and is arguably the most commonly used system for hallux rigidus. There is however no correlation between this classification system and intraoperative findings.12
Non-operative management Non-operative measures should be considered as first-line treatment in the majority of patients with hallux rigidus. A retrospective review involving over 700 patients reported a success rate of 55% with conservative measures.13 Treatment modalities included footwear modification, orthotics and corticosteroid injections.
Oliver Chan MD(Res) FRCS (Tr & Orth), Specialist Registrar, Frimley Health NHS Foundation Trust, UK. Conflicts of interest: none declared. Anthony Sakellariou BSc FRCS (Orth), Consultant Foot & Ankle Surgeon, Frimley Health NHS Foundation Trust, UK. Conflicts of interest: none declared.
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Coughlin and Shurnas’ classification system for hallux rigidus Grade
Dorsiflexion
Radiographic findings
Clinical findings
0
40e60o and/or 10e20% compared to other side 30e40o and/or 20e50% loss compared to other side
Normal
No pain; only stiffness and loss of motion on examination Mild or occasional pain and stiffness, pain at extremes of dorsiflexion and/or plantar flexion on examination
1
2
10e30o and/or 50e75% loss compared to other side
3
<10o and/or 75e100% loss compared to other side. There is notable loss of plantar flexion as well.
4
Same as in grade 3
Dorsal osteophyte is main finding, minimal joint-space narrowing, minimal peri-articular sclerosis, minimal flattening of metatarsal head Dorsal, lateral and possible medial osteophytes giving flattened appearance to metatarsal head, no more than of dorsal joint space involved on lateral radiograph, mild-tomoderate joint space narrowing and sclerosis, sesamoids not usually involved Same as in grade 2 but with substantial narrowing, possibly with periarticular cystic changes, more than of dorsal joint space involved on lateral radiograph, sesamoids enlarged and/or cystic and/or irregular Same as in grade 3
Moderate to severe pain and stiffness that may be constant; pain occurs just before maximum dorsiflexion and maximum plantar flexion on examination
Nearly constant pain and substantial stiffness at extremes of range of motion but not at midrange
Same criteria as in grade 3 BUT there is definite pain in mid-range of passive motion
Adapted from Coughlin MJ, Shurnas PJ. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg 2003; 85-A: 2072e88.
Table 1
General advice regarding analgesia and activity modification may be given to the patient. If possible avoidance of activities that cause repetitive dorsiflexion of the first MTPJ may help to alleviate symptoms. Recommended footwear should consist of shoes with a deep toe box to decrease contact on dorsal osteophytes as well as shoes with a stiff sole to limit movement at the first MTPJ. A shoe with a rocker sole may also be tried to decrease movement at this joint by causing a rolling transition between heel-strike and toe-off. Orthotics can be used to modify existing footwear. An extended shank or footplate made of spring-steel or carbon fibre can be used to stiffen the sole of the shoe14 thereby limiting dorsiflexion at the first MTPJ. A Morton’s extension limits movement at the hallux in isolation and may be better tolerated by more active patients. Intra-articular joint injection and manipulation under anaesthesia (MUA) for hallux rigidus was first described by WatsonJones in 1927 and may lead to temporary relief of symptoms. Solan et al.15 reviewed the outcome of MUA and steroid injection (40 mg depomedrone and 0.5% bupivacaine) in 31 patients and stratified their results according to radiological severity of hallux rigidus (Karasick and Wapner classification). They found that MUA and injection provided a median of 6 months symptomatic relief in patients with grade 1 disease and 3 months relief for patients with grade 2 disease. They did not observe any significant relief of symptoms in patients with severe radiological signs of hallux rigidus (Grade 3 disease) and, as such, concluded that MUA and injection was not an appropriate treatment option for such patients. A significant proportion of patients with grade 1 and 2 disease went on to require surgical intervention (one-third
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in grade 1, two-thirds in grade 2). It is therefore the authors’ opinion that MUA and steroid injection can be used in conjunction with non-operative measures to delay surgical intervention in patients with mild to moderate hallux rigidus. Hyaluronic acid intra-articular injections have been tried for patients with hallux rigidus. Currently the literature does not support its widespread use. A randomized controlled trial involving 151 patients failed to show any significant reduction in pain reduction 3 months after injection when compared to normal saline placebo.16
Operative management Surgical management of hallux rigidus may be broadly divided into joint-sparing (cheilectomy, osteotomies and joint arthroplasty) and joint-sacrificing procedures (fusion). The decision as to which procedure is appropriate is dependent on several factors including; patient expectations, severity of symptoms and radiograph findings, age, activity levels and co-morbidities. Cheilectomy An open dorsal cheilectomy was described by DuVries in 1959.17 This involves removal of dorsal osteophytes to the metatarsal head and proximal phalanx and excision of the dorsal one-third of the articular surface. Synovial debridement and removal of any loose bodies can also be undertaken. The advantages of performing a dorsal cheilectomy are preservation of joint movement and stability as well as the ability to revise to a secondary procedure such as an MTPJ fusion in the future. Positive outcomes following cheilectomy have been reported in the literature which has recorded a variety of patient-reported
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majority of patients with mild hallux rigidus, the loss of cartilage is predominantly dorsal. The Moberg osteotomy may serve to offload this area by shifting the contact pressure of the proximal phalanx in a plantar direction on the metatarsal head.27 Positive outcomes following a cheilectomy and Moberg osteotomy have been reported. Thomas and Smith reported a 99% satisfaction rate in a small cohort of patients with early mild hallux rigidus28 (Hattrup and Johnson grades 1 and 2), whilst O’Malley et al. retrospectively reviewed 81 patients who underwent this treatment for advanced hallux rigidus (Hattrup and Johnson grade 3) and reported a 85% satisfaction rate and a 4.9% conversion rate to MTPJ fusion (minimum follow-up 2 years).29 Higher levels of evidence advocating the use of a Moberg osteotomy are currently lacking. A comparative study looking at outcomes following cheilectomy with and without a Moberg osteotomy would be useful to evaluate any potential benefits of performing such an osteotomy. A potential drawback to the use of the Moberg is during conversion to MTPJ fusion. The extended position of the proximal phalanx may preclude the use of arthrodesis plates.
outcome measures (PROMs). Success rates have ranged from 72% to 97% in these case series.11,18e20 Although not conclusive, current research suggests that results following cheilectomy are more favourable in patients with less severe grades of hallux rigidus. Easley et al.,19 reported that 8 out of the 9 patients that remained symptomatic following a cheilectomy had Hattrup and Johnson grade III disease. The authors reported that all 9 patients had mid-arc pain during preoperative assessment and concluded that this finding indicated advanced degenerative disease of the joint and was therefore a negative prognostic sign. More severe disease may also be associated with a higher risk of requiring an arthrodesis procedure following cheilectomy. About 25% of patients with Hattrup and Johnson grade III disease went on to require an arthrodesis in Easley’s paper19 whilst 56% of patients with Coughlan and Shurnas grade III disease went on to require arthrodesis in another study.5 This compares with 7e9% of all patients with hallux rigidus (irrespective of grade) that go on to require an arthrodesis within 10 years.11,21 In terms of an increase in dorsiflexion after cheilectomy, this appears to be less predictable compared to the pain relieving aspect of the procedure. The range of dorsiflexion achieved intraoperatively is not indicative of the range of dorsiflexion postoperatively. Two studies report that whilst 80e90 of dorsiflexion was achievable intraoperatively. the range of dorsiflexion following recovery from surgery was measured significantly less at 21e39 .19,22 Traditionally a dorsal cheilectomy has been performed via an open approach (dorsal or mid-medial). Both arthroscopic and minimally invasive surgical (MIS) techniques have been described.23,24 The potential benefits of both are less soft tissue damage and quicker return to function although at present there is no scientific evidence to support such claims. In terms of outcomes following MIS and arthroscopic cheilectomy, only a few studies with small numbers and short-term follow-up currently exist. They show an improvement in PROMs following surgery and a comparable complication rate with open surgery.23e25 Stevens et al. retrospectively reviewed their results of MIS and open cheilectomies and found a significantly higher complication rate and higher re-operation rate in the MIS group.26 They concluded that patients should be counselled appropriately about the risks and potential benefits of both cheilectomy techniques.
Watermann osteotomy A Watermann or dorsal closing wedge osteotomy of the distal metatarsal (Figure 1, centre) can also be performed in conjunction with a dorsal cheilectomy.30 It was designed to decompress the joint through shortening and relocate the better preserved plantar articular cartilage to a more dorsal position. Few results are published regarding this technique30 and it is not currently in widespread use for the treatment of hallux rigidus. Youngswick osteotomy The Youngswick osteotomy (Figure 1, right) is a modification of the chevron osteotomy.31 A V-shaped osteotomy is performed initially, with the apex based distally and the limbs at roughly 60 to one another. Following this, a second osteotomy is performed parallel to the dorsal limb. This results in shortening of the first metatarsal osteotomy and decompression of the first MTPJ. A small degree of plantar translation also occurs which may decrease dorsal impingement. Evidence for outcomes of the Youngswick osteotomy is generally lacking although a retrospective review evaluated the results in 23 patients with end-stage hallux rigidus.32 The authors reported an improvement in pain, function and range of movement following the osteotomy.
Moberg osteotomy A Moberg osteotomy (dorsal closing wedge osteotomy of the proximal phalanx) can be performed in conjunction with a cheilectomy to shift the arc of motion of the first MTPJ into more dorsiflexion at the expense of plantar flexion (Figure 1, left). This osteotomy could therefore be considered in patients with limited dorsiflexion but with a good range of plantar flexion. In the
Keller resection arthroplasty This involves resection of the base of the proximal phalanx, thereby decompressing the joint. As a result, pain relief and an increase in dorsiflexion can be achieved at the expense of joint stability. This procedure has been shown to be an effective
Figure 1 Different osteotomies for the treatment of hallux rigidus. Left: Moberg osteotomy of the proximal phalanx. Middle: Watermann osteotomy. Right: Youngswick osteotomy.
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Polyvinyl alcohol (PVA) hydrogel hemiarthroplasty: this synthetic cartilage implant was introduced more recently (Figure 2). It is designed to sit proud of the metatarsal head by 1.5e2.0 mm and therefore functions as both a hemiarthroplasty and as an inter-positional spacer.40 It has similar material properties to human articular cartilage in terms of its Young’s modulus, water content and tensile strength41 therefore making it a suitable synthetic cartilage implant. A prospective, multi-centre randomized controlled noninferiority trial was performed comparing the use of the PVA hemiarthroplasty and arthrodesis at the first MTPJ for patients with moderate to severe hallux rigidus (Coughlin and Shurnas grades 2, 3 and 4).42 At 2 years follow-up, the cohort of patients who received the PVA implant had comparable functional outcomes, revision rates and postoperative pain levels to the arthrodesis group. Dorsiflexion improved by a mean of 6.2 degrees in the replacement group and there were no reported cases of implant fragmentation, wear or bone loss. The failure rate resulting in revision arthrodesis was found to be 9.2%. Results were equivalent to MTPJ arthrodesis irrespective of gender, age, body mass index, hallux rigidus grade, preoperative pain or symptom duration.43 Twenty-seven of the patients to receive the PVA implant in this initial study were available for prospective follow-up at 5 years.44 Pain and functional outcome scores continued to be significantly better compared to preoperative scores and only one of these patients went on to arthrodesis for continued pain. No radiological signs of implant wear, subsidence or loosening were observed. The early results of the PVA hemiarthroplasty appear promising. However more long-term data are required.
treatment for pain relief. A prospective study of 75 feet treated with a Keller resection arthroplasty revealed that 91% of patients experienced significant pain relief.33 Unfortunately, in this same cohort of patients, 41% also developed a ‘cock-up’ deformity. Other complications of this procedure include weakness with toeoff and transfer metatarsalgia secondary to a de-functioned shortened first ray.34 The other disadvantage is the bone loss from the procedure which could make revision to an arthrodesis challenging. Due to the high incidence of complications, a Keller resection arthroplasty should only be recommended for elderly and lower demand patients. MTPJ arthroplasty Initial attempts at joint replacement at the first MTPJ occurred over 25 years ago. These implants were silicone based following the success of silastic implants used in joints of the hand. Although patient satisfaction rates were quoted as between 64% and 83%, high rates of osteolysis and reports of immune reactions to such implants have prevented their widespread use in feet.35,36 Subsequent implants which include metallic implants with a polyethylene insert, ceramic implants and metal hemi-arthroplasties of the first MTPJ have also been tried but have been plagued similarly with high osteolysis rates and high revision rates.37e39 Outcomes following MTP arthroplasty have been shown to be inferior to arthrodesis. Gibson and Thomson37 performed a randomized controlled trial comparing a metallic implant arthroplasty with arthrodesis and found that fusion was associated with a significantly better functional outcome as well as greater pain relief. The arthroplasty group was also associated with a 15% revision rate at 2 years. Metatarsal hemiarthroplasties have also been shown to have decreased PROMs scores and higher pain scores when compared to patients undergoing arthrodesis.39 Such disappointing results have prevented the widespread adoption of traditional MTPJ arthroplasty in the treatment of hallux rigidus.
MTPJ arthrodesis: fusion of the first MTPJ remains the gold standard treatment for advanced hallux rigidus. A successful first MTPJ arthrodesis decreases pain, maintains length and provides stability at the expense of movement. It should also be
Figure 2 The polyvinyl alcohol hydrogel hemiarthroplasty implant. Left: Clinical picture and Right: postoperative radiograph of a patient’s foot following synthetic cartilage implant insertion for hallux rigidus.
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patients were able to return to previous activities such as golf, tennis, hiking and jogging.52
considered in patients with less arthritic change who have concomitant deformity such as hallux valgus or varus, rheumatoid arthritis and patients with neuromuscular disorders such as cerebral palsy. Joint-sparing procedures in such patients are associated with unpredictable results and the development or recurrence of deformity. Multiple techniques have been described for the fusion of the first MTPJ. These include the use of lag screws, plate constructs and a combination of both (Figure 3). In biomechanical studies, a lag screw and plate have been found to offer the most stable construct,45 displaying significantly greater stiffness and load to failure compared to two cross lag screws.46 It is worth noting however, that the clinical implications of construct stiffness and load to failure remain unknown in terms of union rates and the cost of using a plate and lag screw is significantly higher than screws alone.47 The optimal position for first MTPJ fusion should be neutral rotation, 15 of dorsiflexion relative to the floor and 5e15 of valgus.48 The use of a flat surface intraoperatively can be used to judge dorsiflexion; the plantar pad of the hallux should rest on the flat surface but allow passive elevation at the interphalangeal joint by roughly 5 mm (Figure 4). The joint surfaces can be prepared with either conical reamers or by using flat cuts according to the surgeon’s preference. Arguably, flat cuts are more technically demanding and are associated with an increased risk of shortening the first ray. The use of conical reamers may also provide greater freedom to adjust alignment of the MTPJ after debridement of cartilage. Results following fusion of the first MTPJ have been favourable. Three large prospective cohort studies using plate and lag screw constructs have reported union rates of between 92% and 98%, revision rates of 1e4% and high patient satisfaction rates.49e51 Brodsky et al. looked at the functional outcome following first MTPJ fusion. Their results revealed that the surgery was effective for relieving pain (85% of their cohort did not require any analgesia post-fusion) and that the vast majority of
Salvage arthrodesis: MTPJ arthrodesis following a failed arthroplasty, previous excision arthroplasty or infection represents a technical challenge due to the potential levels of bone loss. A bone block arthrodesis can be employed utilising either iliac crest tricortical autograft or structural allograft.53,54 Such grafts can be shaped to accommodate defects in both the metatarsal and proximal phalanx. To accommodate the large defects and bone block, it is essential that a plate with adequate working length is used. A plate that is too short will result in potentially too much strain at the fusion site and may result in surgical failure. Outcomes following bone block arthrodesis have been reported as satisfactory.53,54 Myerson et al. used iliac crest autograft to treat 24 patients with significant bone loss secondary to previous surgeries (failed arthroplasty, previous hallux valgus correction surgery and prior Keller excision arthroplasty). They reported significantly improved AOFAS scores in their cohort of patients and a union rate following bone block arthrodesis of 79%. Luk et al., utilised an interposition allograft bone block to try to fuse the first MTPJ of patients with significant bone loss. They reported a union rate of 87% and an improvement in PROMs.
Authors’ preferred treatment algorithm For patients with hallux rigidus who are refractory to nonoperative measures, patients are informed of the possible treatment options, and their respective advantages and disadvantages are made clear. Patients are informed of the likely recovery following surgical intervention and potential risks and inconveniences are highlighted. Generally speaking, patients with mild hallux rigidus and end of arc pain (dorsal and plantar impingement secondary to a dorsal cheilus) are offered a cheilectomy. We routinely do this
Figure 3 Images showing first MTPJ fusion fixation; Left: dorsal to plantar lag screws Right: lag screw and plate configuration.
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Please cite this article as: Chan O, Sakellariou A, Hallux rigidus: a review, Orthopaedics and Trauma, https://doi.org/10.1016/ j.mporth.2019.11.004
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authors’ preference would be to fuse the joint with a plate and screw configuration. The removal of the hemiarthroplasty implant is straightforward and not normally associated with significant bone loss. The use of bone graft is therefore not normally required. In the setting of a salvage arthrodesis and the event of significant bone loss, we would favour the use of shaped allograft or iliac crest tricortical autograft and primary fixation with a long segment plating system. A REFERENCES 1 Dellenbaugh SG, Bustillo J. Arthritides of the foot. Med Clin N Am 2014; 98: 253e65. 2 Shurnas P, Coughlin M. Arthritic conditions of the foot. In: Surgery of the foot and ankle. Philadelphia: Elsevier, 2007; 867e909. 3 Coughlin MJ. Conditions of the forefoot. In: DeLee J, Drez D, eds. Orthopaedic sports medicine: principles and practice. Philadelphia: WB Saunders, 1994; P221e44. 4 McMaster MJ. The pathogenesis of hallux rigidus. J Bone Joint Surg Br 1978; 60B: 82e7. 5 Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assessment. Foot Ankle Int 2003; 24: 731e43. 6 Hattrup SJ, Johnson KA. Subjective results of hallux rigidus following treatment with cheilectomy. Clin Orthop Relat Res 1998; 226: 182e91. 7 Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int 2008; 29: 637e46. 8 Kunnasegaran R, Thevendran G. Hallux rigidus: nonoperative treatment and orthotics. Foot Ankle Clin 2015; 20: 401e12. 9 Hamid KS, Parekh SG. Clinical presentation and management of hallux rigidus. Foot Ankle Clin 2015; 20: 391e9. 10 Hattrup SJ, Johnson KA. Subjective results of hallux rigidus following treatment with cheilectomy. Clin Orthop Relat Res 1998; 226: 182e91. 11 Coughlin MJ, Shurnas PJ. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg 2003; 85-A: 2072e88. 12 Baumhauer JF, Singh D, Glazebrook M, et al. Correlation of hallux rigidus grade with motion, VAS pain, intraoperative cartilage loss, and treatment success for first MTP joint arthrodesis and synthetic cartilage implant. Foot Ankle Int 2017; 38: 1175e82. 13 Grady JF, Axe TM, Zager EJ, Sheldon LA. A retrospective analysis of 772 patients with hallux limitus. J Am Podiatr Med Assoc 2002; 92: 102e8. 14 Sammarco VJ, Nichols R. Orthotic management for disorders of the hallux. Foot Ankle Clin 2005; 10: 191e209. 15 Solan MC, Calder JD, Bendall SP. Manipulation and injection for hallux rigidus. Is it worthwhile? J Bone Joint Surg Br 2001; 83: 706e8. 16 Munteanu SE, Zammit GV, Menz HB, et al. Effectiveness of intraarticular hyaluronan (Synvisc, hylan G-F 20) for the treatment of first metatarsophalangeal joint osteoarthritis: a randomised placebo-controlled trial. Ann Rheum Dis 2011; 70: 1838e41. 17 DuVries HV. Surgery of the foot. St. Louis (MO): Mosby Year book, 1959; 392e9. 18 Harrison T, Fawzy E, Dinah F, Palmer S. Prospective assessment of dorsal cheilectomy for hallux rigidus using a patient-reported outcome score. J Foot Ankle Surg 2010; 49: 232e7.
Figure 4 The use of a flat surface intraoperatively to guide relative dorsiflexion position at the fusion site.
through a mid-medial approach and tend to avoid resecting onethird of the joint surface to preserve bone stock in case alternative surgery (interposition arthroplasty or arthrodesis) is required at a later date. For patients with mild hallux rigidus with well preserved articular cartilage, a Youngswick osteotomy can be offered to treat the restriction in dorsiflexion. If however, the patient has a good preserved range of movement but mid-arc pain, the patient is unlikely to benefit from a cheilectomy and is offered a guided injection (either ultrasound or image guided) to confirm that the pain is definitely arising from the MTPJ. A patient in whom an injection is temporarily successful is then offered either a PVA hemiarthroplasty or arthrodesis. For patients who have more severe hallux rigidus (indicated radiographically and the presence of mid-arc pain) or those who have not responded to cheilectomy the options of either a PVA hydrogel hemiarthroplasty (assuming there are no contraindications such as significant deformity, bone loss, metatarso-sesamoid arthritis, or presence of neuromuscular disease) or first MTPJ fusion are discussed. Should an arthrodesis procedure be chosen, the authors’ preferred method of fusion includes the use of conical reamers and the use of two dorsal lag screws to provide primary fixation. Intraoperatively if the hold from the lag screws is inadequate, a plating system is utilised for primary fixation. For patients that fail to improve following a PVA hemiarthroplasty, a revision procedure to an arthrodesis is offered. In this setting, the
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Please cite this article as: Chan O, Sakellariou A, Hallux rigidus: a review, Orthopaedics and Trauma, https://doi.org/10.1016/ j.mporth.2019.11.004
FOOT AND ANKLE
38 Dawson-Bowling S, Adimonye A, Cohen A, et al. MOJE ceramic metatarsophalangeal arthroplasty: disappointing clinical results at two to eight years. Foot Ankle Int 2012; 33: 560e4. 39 Raikin SM, Ahmad J, Pour AE, Abidi N. Comparison of arthrodesis and metallic hemiarthroplasty of the hallux metatarsophalangeal joint. J Bone Joint Surg Am 2007; 89: 1979e85. 40 Younger ASE, Baumhauer JF. Polyvinyl alcohol hydrogel hemiarthroplasty of the great toe: technique and indications. Tech Foot Ankle Surg 2013; 12: 164e9. 41 Baker MI, Walsh SP, Schwartz Z, Boyan BD. A review of polyvinyl alcohol and its uses in cartilage and orthopedic applications. J Biomed Mater Res B Appl Biomater 2012; 100: 1451e7. 42 Baumhauer JF, Singh D, Glazebrook M, et al. Prospective, randomized, multi-centered clinical trial assessing safety and efficacy of a synthetic cartilage implant versus first metatarsophalangeal arthrodesis in advanced hallux rigidus. Foot Ankle Int 2016; 37: 457e69. 43 Goldberg A, Singh D, Glazebrook M, et al. Association between patient factors and outcome of synthetic cartilage implant hemiarthroplasty vs first metatarsophalangeal joint arthrodesis in advanced hallux rigidus. Foot Ankle Int 2017; 38: 1199e206. 44 Daniels TR, Younger AS, Penner MJ, et al. Midterm outcomes of polyvinyl alcohol hydrogel hemiarthroplasty of the first metatarsophalangeal joint in advanced hallux rigidus. Foot Ankle Int 2017; 38: 243e7. 45 Politi J, John H, Njus G, Bennett GL, Kay DB. First metatarsalphalangeal joint arthrodesis: a biomechanical assessment of stability. Foot Ankle Int 2003; 24: 332e7. 46 Buranosky DJ, Taylor DT, Sage RA, et al. First metatarsophalangeal joint arthrodesis: quantitative mechanical testing of six-hole dorsal plate versus crossed screw fixation in cadaveric specimens. J Foot Ankle Surg 2001; 40: 208e13. 47 Hyer CF, Glover JP, Berlet GC, Lee TH. Cost comparison of crossed screws versus dorsal plate construct for first metatarsophalangeal joint arthrodesis. J Foot Ankle Surg 2008; 47: 13e8. 48 Ho B, Baumhauer J. Hallux rigidus. EFORT Open Rev 2017; 2: 13e20. 49 Goucher NR, Coughlin MJ. Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study. Foot Ankle Int 2006; 27: 869e76. 50 Bennett GL, Sabetta J. First metatarsalphalangeal joint arthrodesis: evaluation of plate and screw fixation. Foot Ankle Int 2009; 30: 752e7. 51 Doty J, Coughlin M, Hirose C, Kemp T. Hallux metatarsophalangeal joint arthrodesis with a hybrid locking plate and a plantar neutralization screw: a prospective study. Foot Ankle Int 2013; 34: 1535e40. 52 Brodsky JW, Passmore RN, Pollo FE, Shabat S. Functional outcome of arthrodesis of the first metatarsophalangeal joint using parallel screw fixation. Foot Ankle Int 2005; 26: 140e6. 53 Luk PC, Johnson JE, McCormick JJ, Klein SE. First metatarsophalangeal joint arthrodesis technique with interposition allograft bone block. Foot Ankle Int 2015; 36: 936e43. 54 Myerson MS, Schon LC, McGuigan FX, Oznur A. Result of arthrodesis of the hallux metatarsophalangeal joint using bone graft for restoration of length. Foot Ankle Int 2000; 21: 297e306.
19 Easley ME, Davis WH, Anderson RB. Intermediate to long-term followup of medial-approach dorsal cheilectomy for hallux rigidus. Foot Ankle Int 1999; 20: 147e52. 20 McNeil DS, Baumhauer JF, Glazebrook MA. Evidence-based analysis of the efficacy for operative treatment of hallux rigidus. Foot Ankle Int 2013; 34: 15e32. 21 Nawoczenski DA, Ketz J, Baumhauer JF. Dynamic kinematic and plantar pressure changes following cheilectomy for hallux rigidus: a mid-term followup. Foot Ankle Int 2008; 29: 265e72. 22 Vulcano E, Tracey 3rd JA, Myerson MS. Accurate measurement of first metatarsophalangeal range of motion in patients with hallux rigidus. Foot Ankle Int 2016; 37: 537e41. 23 Mesa-Ramos M, Mesa-Ramos F, Carpintero P. Evaluation of the treatment of hallux rigidus by percutaneous surgery. Acta Orthop Belg 2008; 74: 222e6. 24 Iqbal MJ, Chana GS. Arthroscopic cheilectomy for hallux rigidus. Arthroscopy 1998; 14: 307e10. 25 Teoh KH, Tan WT, Atiyah Z, Ahmad A, Tanaka H, Hariharan K. Clinical outcomes following minimally invasive dorsal cheilectomy for hallux rigidus. Foot Ankle Int 2019; 40: 195e201. 26 Stevens R, Davies HG, Chadwick C, Flowers M, Blundell CM, Davies MB. Minimally Invasive versus Open Cheilectomy of the first metatarso-phalangeal joint: a comparison of complication rates and need for further surgery. Foot Ankle Int 2019; https://doi. org/10.1177/1071100719873846. 27 Kim PH, Chen X, Hillstrom H, et al. Moberg osteotomy shifts contact pressure plantarly in the first metatarsophalangeal joint in a biomechanical model. Foot Ankle Int 2016; 37: 96e101. 28 Thomas PJ, Smith RW. Proximal phalanx osteotomy for the surgical treatment of hallux rigidus. Foot Ankle Int 1999; 20: 3e12. 29 O’Malley MJ, Basran HS, Gu Y, Sayres S, Deland JT. Treatment of advanced stages of hallux rigidus with cheilectomy and phalangeal osteotomy. J Bone Joint Surg Am 2013; 95: 606e10. 30 Cavolo DJ, Cavallaro DC, Arrington LE. The Watermann osteotomy for hallux limitus. J Am Podiatry Assoc 1979; 69: 52e7. 31 Youngswick FD. Modifications of the Austin bunionectomy for treatment of metatarsus primus elevatus associated with hallux limitus. J Foot Surg 1982; 21: 114e6. 32 Oloff LM, Jhala-Patel G. A retrospective analysis of joint salvage procedures for grades III and IV hallux rigidus. J Foot Ankle Surg 2008; 47: 230e6. 33 Love TR, Whynot AS, Farine I, et al. Keller arthroplasty: a prospective review. Foot Ankle 1987; 8: 46e54. 34 Beertema W, Draijer WF, van Os JJ, Pilot P. A retrospective analysis of surgical treatment in patients with symptomatic hallux rigidus: long-term follow-up. J Foot Ankle Surg 2006; 45: 244e51. 35 Cracchiolo 3rd A, Weltmer Jr JB, Lian G, Dalseth T, Dorey F. Arthroplasty of the first metatarsophalangeal joint with a doublestem silicone implant. Results in patients who have degenerative joint disease failure of previous operations, or rheumatoid arthritis. J Bone Joint Surg Am 1992; 74: 552e63. 36 Sebold EJ, Cracchiolo 3rd A. Use of titanium grommets in silicone implant arthroplasty of the hallux metatarsophalangeal joint. Foot Ankle Int 1996; 17: 145e51. 37 Gibson JN, Thomson CE. Arthrodesis or total replacement arthroplasty for hallux rigidus: a randomized controlled trial. Foot Ankle Int 2005; 26: 680e90.
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Please cite this article as: Chan O, Sakellariou A, Hallux rigidus: a review, Orthopaedics and Trauma, https://doi.org/10.1016/ j.mporth.2019.11.004