by Richard A. Miller, MD
Richard A. Miller, MD, is associate professor, department of orthopaedic surgery, chief of foot and ankle service, University of New Mexico, Albuquerque.
Hallux rigidus is a form of degenerative arthritis of the great toe metatarsophalangeal joint (MTP). Prominent osteophytes form dorsally which may limit great toe extension. Osteophytes may be seen medially and laterally as well. Cartilage degeneration with synovitis and joint space narrowing may develop. Patients generally present with pain at the joint which may develop for the following reasons: shoes rubbing the dorsal osteophyte, impingement of the osteophyte during extension or joint degeneration.
When nonoperative treatment has been unsuccessful in relieving pain and restoring function, surgery may be indicated. Since hallux rigidus represents a spectrum of joint pathology and symptomatology, it is not surprising that there is not one universally successful operative procedure for this condition. The most commonly employed procedures include cheilectomy, arthrodesis, Keller's resection arthroplasty, Silastic joint replacement and proximal phalangeal dorsiflexion osteotomy. Evaluation of the patient's symptoms, activity demands, source of pain and radiographs are critical in order to determine which procedure to use.
In this article, I will discuss my approach to symptomatic hallux rigidus with the use of case examples.
A 36-year-old active female presents with a painful great toe MTP joint. The alignment of the toe is normal; however, there is a dorsal prominence which is painful with shoewear and dorsiflexion. Radiographs reveal a prominent osteophyte on the metatarsal head. The remainder of the joint space appears normal.
A cheilectomy would be the most appropriate procedure for this patient. This can provide pain relief and increased joint motion without destroying the joint. A cheilectomy maintains the stability and function of the first ray and facilitates salvage of a failed procedure with an arthrodesis. Adequate bone should be removed from the metatarsal head in order to achieve increased dorsiflexion of the MTP joint. In addition, if osteophytes are present at the base of the proximal phalanx or on the sides of the metatarsal head, these must be removed. Great toe motion is started within the first week after surgery.
In 1988, Mann and Clanton reported satisfactory results in 90 percent of patients treated with a cheilectomy. Hattrup and Johnson demonstrated less satisfactory results when degenerative changes were present within the joint.
A 50-year-old male presents with a painful great toe MTP joint. He walks with a limp and is unable to perform his usual recreational activities due to pain. In addition, he has pain at rest. Radiographs show dorsal osteophytes with advanced degenerative changes.
An arthrodesis is indicated in this case. Although one may elect to perform a cheilectomy when there is mild to moderate degenerative changes present, good pain relief is not likely with more advanced changes and symptoms that this patient demonstrates.
Arthrodesis maintains stability and weightbearing of the first ray. Many successful techniques have been described. I prefer to use a dorsal plate. The great toe should be placed in approximately 15 degrees of dorsiflexion and valgus. Many of these patients have little motion of the MTP joint preoperatively, and the arthrodesis places the toe in a more functional position. Individuals with a fused MTP joint can maintain a high level of activity and participate in a variety of sports. In 1990, Coughlin reported significant pain relief and improved ambulation after MTP joint arthrodesis.
An 80-year-old female presents with a painful great toe MTP joint. Her activities are limited. A physical exam reveals a plantarflexed great toe which does not allow for comfortable shoe wear. Radiographs show dorsal osteophytes and joint space narrowing.
In this case, I would recommend the Keller procedure along with removal of any prominent osteophytes. The Keller procedure (resection of the base of the proximal phalanx) is effective in the older patient who has limited ambulatory activities. In the more active individual, the results are less predictable due to the possibility of instability and drifting of the great toe. The first ray also may lose its weightbearing function after this procedure with subsequent development of transfer metatarsalgia.
There exist many clinical situations that do not ideally fit these three case examples for which the surgeon must counsel the patient regarding the treatment options and come to a decision regarding which would be the most appropriate procedure. Although cheilectomy, arthrodesis and the Keller procedure are the operations which I most commonly utilize in the treatment of hallux rigidus, there are others which deserve mention here.
Some surgeons have had good results with use of a Silastic implant in the MTP joint; however, the potential for synovitis and implant failure make this a less desirable procedure. If failure occurs, salvage procedures are more difficult. In 1995, Shankar reported 36 percent unsatisfactory long-term results with the use of Silastic single-stem implants in the treatment of hallux rigidus. In 1992, Cracchiolo reported on the use of double-stem silicone implants in patients with degenerative joint disease and hallux rigidus. Although 82 percent of the patients were completely satisfied with the result, the implant was not used in patients who wished to maintain very active use of the foot.
A dorsiflexion osteotomy of the proximal phalanx is indicated in the unusual situation where there is symptomatic hyperextension of the interphalangeal joint due to a stiff, but pain-free MTP joint. The osteotomy also can be used after a cheilectomy in which adequate dorsiflexion is not obtained. Given the importance of early motion after a cheilectomy, this procedure is not advised at the same time. Moberg reported good short-term results with this procedure on eight patients in 1979.
Radiographs show that in addition to a dorsal osteophyte significant joint destruction is present.