Current And Emerging Techniques For Hallux Rigidus
- Volume 26 - Issue 7 - July 2013
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Researchers have also described more proximal procedures, including a plantarflexory basal osteotomy or a sagittal Z osteotomy, to plantarflex the first metatarsal. On occasion with excessive hypermobility of the first ray, one can also perform a plantarflexion Lapidus osteotomy.29,30
Surgeons have also proposed and utilized proximal phalanx osteotomies in the management of hallux rigidus. Regnauld first described this procedure in 1968 and described three variations to this procedure.31 Authors have also described other procedures such as the Moberg and Bonney-Kessel osteotomies. These procedures decompress the joint and dorsiflex the great toe. Surgeons would perform these procedures in conjunction with a cheilectomy or osteotomy of the first metatarsal.32,33
Joint destructive procedures include a resection arthroplasty (Keller bunionectomy); arthrodesis of the first MPJ; interpositional arthroplasty; and hemi- or total joint replacement. Many surgeons still advocate the arthrodesis as the gold standard to eliminate the pain and allow for a more normal, functional gait pattern. The paper by McNeil and colleagues would seem to support this opinion.22 Some surgeons believe that a fusion will ultimately result in knee pathology. However, one would assume that with hallux rigidus and the hallux actually sitting in an equinus position rather than in a traditional fusion position, the same type of problem would ensue.34
The Keller procedure is a longstanding procedure surgeons have utilized in the management of patients with hallux rigidus and hallux valgus. In a recent study, researchers reviewed 87 cases with a mean follow-up of 23 years in order to assess long-term results of the Keller resection arthroplasty for hallux rigidus.35 They found that only five feet (5 percent) needed revisional surgery and that 69 of the 73 unrevised patients (94 percent) would have the procedure done again in the same circumstances. The study authors concluded that the long-term results of the Keller resection arthroplasty compared favorably with published results of arthrodesis, cheilectomy and joint replacement, and that the Keller procedure had a lower complication rate.
Arthrodesis has been a proven and predicable procedure in the management of hallux rigidus. Many different fixation options are available for arthrodesis including K-wire fixation, crossed titanium flexible intramedullary nails and dorsal static staples, cortical screws, cannulated screws and plate fixation.36-40
Surgeons have also employed implant arthroplasty in the management of hallux rigidus. One of the earliest procedures was the use of the double-stemmed silicone flexible implant. In a 2013 study, researchers reviewed the use of the Primus double-stemmed silicone implant in 54 patients (a total of 70 implants).41 Patients with hallux rigidus had an average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score of 88.2. In terms of patient satisfaction, the average Visual Analogue Scale (VAS) rating was 8.5 out of 10. The authors also noted implant arthroplasty was particularly effective in older, less active patients with lower functional demand.
Other procedures include joint resurfacing of the base of the proximal phalanx with a titanium hemi-implant. Total joint implants are another option but in my experience, the success rates of these implants tend to vary.
A Closer Look At Emerging Surgical Advances
Recent advances in the surgical management of hallux rigidus include improved osseous preparation and internal fixation for first metatarsophalangeal joint arthrodesis. The development of dome-shaped reamers allows for improved osseous contact and precise positioning of the hallux. Fixation has included crossed screw fixation with or without a dorsal locking plate.