Hallux Rigidus

Epidemiology

  • 2x more common in women
  • Often bilateral but not always symptomatic
  • Wide age range from teens to elderly

Aetiology

  • Idiopathic
  • Inflammatory arthropathy
    • RA, Gout
  • Post Traumatic
  • Infective

Natural History

  • Often do not get worse and may improve – 50% in RCT (Pon’s)

Clinical Features

Symptoms

  • Pain over big toe – usually dorsal
  • Pain on dorsiflexion
  • Block to dorsiflexion
  • May have more pain on plantarflexion – capsule stretching over osteophyte
  • Stiffness & painful locking of MTPJ
  • Dorsal prominence, soft tissue swelling, or ulceration

Examination

  • General foot and ankle exam
  • Tiptoeing pain
  • ROM – blocks; pain; stiffness
  • Concurrent Hallux Valgus present?

Classification

  • Based on XR changes
    • Mild osteophyte formation with preserved joint space
    • Moderate osteophytes with diminished dorsal joint space
    • Marked osteophytes with complete joint space degeneration
  • Can be subclassified depending on ROM and pain

Management

Non-Operative

  • Good results in a large number of patients
  • NSAIDs, activity modification, accommodative footwear

Injection & MUA

  • Diagnostic & therapeutic
  • Long-lasting in many patients with minimal XR changes

Surgical

  • Motion Preserving or Motion Sacrificing
    • Cheilectomy
    • Osteotomy
    • Arthroplasty
    • Arthrodesis

Dorsal Cheilectomy

  • Motion preserving – good for more active patients with milder disease
  • For mild disease or patients with only dorsal symptoms from osteophyte
  • Dorsomedial incision
    • Take care to avoid medial dorsal cutaneous nerve
    • Capsulotomy
    • Oblique resection of 30-50% of joint
    • Need to resect 30% to improve ROM reliably
    • Concurrent PP cheilectomy or dorsal osteotomy of PP possibly
  • Results are good in correct patients
  • Cheilectomy is viable for more severe disease if pain is dorsal over osteophyte and some ROM is retained
    • Clinical evaluation essential in deciding treatment

Interposition Arthroplasty

  • Limited PP resection and infolding of dorsal capsule
  • OK results but there are better motion-sparing operations

Dorsiflexion Phalangeal Osteotomy

  • Idea is to reduce pressure on dorsum of MTPJ

Metatarsal Osteotomy

  • Plantarflexing osteotomy reduces dorsal impingement
  • No reports regarding metatarsalgia but is a problem in theory
  • For early hallux rigidus
  • Outcomes no better than Cheilectomy, which is much easier

Arthroplasty

  • Silastic (Swanson) arthroplasty had many complications
  • Currently Hemi and Total joint arthroplasties available
  • No data proving better results than fusion
  • Specific Complications:
    • Early wear – main issue
    • Synovitis
    • Dislocation
    • Cock-up toe
    • Loss of bone stock – more difficult to salvage

Arthrodesis

  • Gold Standard – good for grade 2-3 symptomatic cases
  • Multiple methods
  • Dorsomedial incision
  • Prepare articular surfaces – key step
  • Parallel cuts or ice cream cone reamers
  • Parallel cuts shown to be more stable
  • Can address concurrent Hallux Valgus with the cuts
  • Fixation with cross screws, pins, low-profile plates
  • Positioning:
    • 10° valgus, neutral rotation & pulp just off the floor with foot in a plantigrade position
    • Use flat board intra-operatively
  • Disadvantages:
    • Relatively contraindicated if DIPJ arthrosis
    • Can’t wear high heels
    • Gait pattern altered
    • Pivoting sports more difficult

Excision Arthroplasty

  • Keller’s – for older low-demand patients

Overall Procedure Choice

No significant or very mild XR findings

  • Injection and MUA

Mild – moderate dorsal osteophytes with retention of ROM and main symptoms dorsal

  • Cheilectomy

More significant degeneration with diffuse pain and stiffness

  • Fusion
    • Also for inflammatory arthritis
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