What Is The Best Surgery For Hallux Rigidus?
One of the most common reasons patients present to my office for a second opinion about a proposed treatment from another practitioner is an inquiry about treatment options for hallux rigidus.
In most cases, the patient is a healthy, active individual who has serious concerns about a proposed treatment, which may include implant arthroplasty or arthrodesis of the first metatarsophalangeal joint (MTPJ) of the foot. I have been surprised by the number of patients who have sought my opinion based solely on an Internet search of the term “hallux rigidus,” which showed my article from the April 2009 issue of Podiatry Today.1
Understanding the pathomechanics and treatment of hallux rigidus remains one of the greater challenges for students and residents in podiatric surgical training. Even for the experienced podiatric physician, much misinformation and controversy exists about this topic, primarily due to the promotion of solutions by commercial entities that promote technologies for a solution of the problem with unsupported evidence for success.
This month’s issue of the Journal of Foot and Ankle Surgery (JFAS) has paid considerable attention to this subject. Of interest are three systematic reviews of published research on different types of surgical procedures for hallux rigidus. All of these systematic reviews were written by Tom Roukis, DPM, PhD, FACFAS, who has published more material on this subject than any other in the podiatric profession.2-4 Dr. Roukis points out the need for more rigorous research on this subject to allow more specific guidelines for treatment approaches.
In the end, simple cheilectomy has the best evidence for long-term outcome of hallux rigidus surgery, although this evidence is not considered high level (Level 2 or better). The literature abounds with Level 4 case studies, which lack comparative groups or significant long-term assessment of patient outcomes when evaluating results of hallux rigidus surgery. Most studies of joint implant arthroplasty of the first MTPJ fall into this category.5
One of the best reviews on surgical treatment of hallux rigidus was published by Yee and Lau in 2008.5 In this review of the literature, implant arthroplasty of the first MTPJ received the lowest rating while cheilectomy and arthrodesis received the highest rating based upon a comprehensive review of the literature.
What adds to the controversy is the failure of most studies to stratify the patient population based upon lifestyle and level of activity. The choice of surgical procedures for the running athlete requires different consideration in comparison to the sedentary patient over age 70. In these cases, the use of joint implants has not been adequately studied and the ramifications for failure in this type of patient are quite serious in comparison to the sedentary patient.
The most challenging patients with hallux rigidus are active athletes who want to return to a full level of activity with minimal risk of recurrence or complication. Certainly, the lowest risk procedure is the cheilectomy and the literature supports this conclusion. However, the success of this procedure with active athletes with Stage III or IV deformity of the first MTPJ remains questionable. There is a growing amount of evidence (still only Level 4), which suggests that active athletes with advanced stage hallux rigidus have very successful outcomes with surgical arthrodesis of the first MTPJ. My previous article in Podiatry Today (see www.podiatrytoday.com/how-to-treat-hallux-rigidus-in-runners ) provides the rationale for this surgical procedure as well as references for further review.1
I urge all readers to review the September/October 2010 issue of the Journal of Foot and Ankle Surgery and learn more about this fascinating topic of hallux rigidus. I applaud D. Scot Malay, DPM, the Editor-in-Chief of JFAS, for focusing this issue on this important and controversial topic. I look forward to your comments and experience in treating this condition in various patient populations.
1. Richie D. How to treat hallux rigidus in runners. Podiatry Today 2009; 22(4):46-56.
2. Roukis TR. The need for surgical revision after isolated cheilectomy for hallux rigidus: a systematic review. J Foot Ankle Surg 2010; 49(5):465-70.
3. Roukis TR. Outcome following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus: a systematic review. J Foot Ankle Surg 2010; 49(5):475-8.
4. Roukis TR. Outcomes after cheilectomy with phalangeal dorsiflexory osteotomy for hallux rigidus: a systematic review. J Foot Ankle Surg 2010;49(5):479-87.
5. Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int 2008; 29(6):637-646.