Current And Emerging Techniques For Hallux Rigidus
Surgical procedures are either classified as joint preservation procedures or joint destructive procedures. When making the decision on procedure selection, one needs to consider the patient’s age, activity level, location of the joint pain, severity of the joint damage and the expectations of the patient.21 Some patients electing to undergo surgery may opt for a joint preservation procedure understanding that over time the joint disease may progress, ultimately requiring another procedure. Other patients may elect to choose a procedure that will provide them with a permanent solution.
Recently, investigators reviewed and assessed the quality of the literature regarding surgical interventions for hallux rigidus.22 With the 135 studies they deemed to be relevant for surgical procedures for hallux rigidus, the investigators assigned a level of evidence to denote the quality of the studies as well as a grade of recommendation as to whether the study supported or refuted the merits of surgical intervention.
The study authors found fair evidence in support of arthrodesis for the treatment of hallux rigidus.22 They noted poor evidence in support of cheilectomy, osteotomy, implant arthroplasty, resection arthroplasty and interpositional arthroplasty for treatment of hallux rigidus. There is insufficient evidence for cheilectomy with osteotomy for the treatment of hallux rigidus. The researchers concluded that there are currently no consistent findings in comparative studies to allow any definitive conclusions on which procedure is best.
Joint preservation procedures such as a cheilectomy or a Valenti procedure — in which one aggressively removes the spur formation from the dorsal margins of the joint — will result in the reduction or elimination of dorsal joint pain, and the reestablishment of joint dorsiflexion. Researchers have suggested using a cheilectomy or a Valenti procedure for grade I and II hallux rigidus conditions.23 Other authors have also suggested employing cheilectomy for patients who only have dorsal pain as surgeons can achieve good and reliable results.24,25
Several metatarsal osteotomies are designed to correct the structural abnormality of either the first ray or the metatarsophalangeal joint itself. In the presence of metatarsus primus elevatus, one may perform a plantarflexion osteotomy with a joint debridement and sesamoid release. Procedures include the Waterman osteotomy, Hohmann osteotomy and modifications to traditional Austin osteotomies.26,27
In a retrospective study, Derner and colleagues assessed a plantarflexor shortening first metatarsal osteotomy for the treatment of hallux rigidus.28 They evaluated 26 patients (33 feet) with a mean follow-up of 34.4 months. The study authors noted a mean increase of 38.6 degrees in the total range of motion for the first MPJ. Post-op radiographs revealed 1 to 4 mm of plantarflexion of the first metatarsal head and a mean of 6.1 mm shortening of the first metatarsal. Derner and colleagues also reported high patient satisfaction with 85 percent of patients citing “very good to excellent” results. No patient required revisional surgery for hallux rigidus.
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