Current And Emerging Techniques For Hallux Rigidus
Given the relatively common nature of hallux rigidus, this author offers insights from the literature on current modalities as well as emerging surgical advances.
Hallux rigidus is a very common disorder affecting the first metatarsophalangeal joint. Hallux rigidus is characterized by arthritic changes of the joint resulting in osteophyte formation, limitation in joint range of motion and painful ambulation. It tends to affect men more frequently than women and reportedly affects 10 percent of people 20 to 34 years of age and 44 percent of people over 80 years of age.1
Researchers have found a greater negative impact on health status among patients with hallux rigidus in comparison to those with hallux valgus.2 This would certainly correspond with what one frequently sees in clinical practice where many patients with hallux valgus report few or no symptomatic problems related to the deformity. Alternately, a majority of individuals with hallux rigidus present with a complaint of joint pain or compensatory gait issues resulting in lateral foot pain, lower leg, lateral knee, hip or back pain.3,4
While the exact cause of hallux rigidus is not completely understood, there are a number of factors that appear to result in the development of this joint deformity. It is likely a combination of structural and biomechanical influences that result in an alteration of normal joint kinematics and the subsequent development of osteoarthritis.
The cause of hallux rigidus is multifactorial. A common cause is pes planovalgus in which there is a hypermobility of the first ray resulting in transverse and frontal plane motion of the first metatarsal and subsequent trauma to the joint resulting in joint cartilage erosion and osteophyte formation.5 Other factors include an elongated first metatarsal, a metatarsus primus elevatus, trauma to the first MPJ, post-surgical complications from procedures for hallux valgus in which preexisting osteoarthritis existed, osteochondral fractures of the first MPJ and a squared first metatarsal head.6,7
Clinical examination of the first MPJ will reveal an enlargement of the joint with localized erythema and edema. Upon palpation to the margins of the joint, one can feel osteophyte formation around the first metatarsal head and the base of the proximal phalanx dorsally. Dorsiflexion is restricted and often as the condition progresses, the hallux will maintain an equinus position. Joint range of motion is restricted with limitation of dorsiflexion, the primary factor in the ambulatory pain. Patients will also notice a lack of flexion of the great toe due to osteoarthritic changes that occur within the sesamoid complex. Joint range of motion can often be painful, particularly end arc range of motion at the end of dorsiflexion.
A weightbearing examination will often demonstrate a hallux that is sitting in a slight varus orientation as the individual attempts to flex the great toe against the ground in order to stabilize it. Gait examination will often demonstrate an antalgic gait with lateralization due to a lack of dorsiflexion or pain within the joint.
Pertinent Insights On The Diagnostic Workup
Plain film radiographs are essentially all that is necessary when diagnosing hallux rigidus. One will note joint space narrowing, joint space irregularity, subchondral sclerosis, marginal osteophyte formation and osteophyte formation around the margins of the sesamoid bones. Often, a loose body is present in the dorsal aspect of the joint as the osteophyte on the dorsal aspect of the base of the proximal phalanx fractures away. On the lateral projection, one may note a metatarsus primus elevatus. On an AP view, clinicians may often recognize a long first metatarsal with a squared-off metatarsal head.
Other forms of diagnostic imaging are usually not required. However, on occasion, one can utilize a CT scan to determine if there is an osteochondral lesion in an early-stage hallux rigidus deformity.8,9
There are a number of classification or grading systems that utilize both biomechanical features and X-ray criteria to stage hallux rigidus. The most useful classification system for hallux rigidus was suggested by Roukis and Jacobs, and combines criteria from the systems proposed by Drago and Oloff, Hanft and Mason and Kravitz and colleagues.10-13 The classification described by Roukis and Jacobs combines grades according to a four-stage hybrid hallux rigidus radiographic grading system.13
Can Conservative Care Have An Impact For Hallux Rigidus?
Non-operative management is still the mainstay of treatment for hallux rigidus with studies demonstrating a 50 percent success rate.14
The pain and lack of dorsiflexion associated with hallux rigidus makes ambulation and propulsion difficult. Custom foot orthotics with a first ray extension will limit dorsiflexion of the first metatarsophalangeal joint. Having the patient wear a stiff soled shoe or fitting a carbon graphite gait plate under the shoe’s insole will eliminate the need for dorsiflexion at the first MPJ. Other modifications to footwear can include a forefoot rocker or shoes that are fabricated with a natural forefoot rocker. One may utilize a deep toe box to eliminate pressure on the dorsal prominence.15,16 Medical options include the use of oral and topical non-steroidal anti-inflammatories and intra-articular cortisone injections.17
Researchers have discussed the use of viscosupplementation in the management of symptomatic hallux rigidus. In a study to evaluate the effectiveness of a single intra-articular injection of hylan G-F 20 (Synvisc, Genzyme) for first MPJ osteoarthritis, researchers in Australia assessed 151 patients who received up to a 1 mL intra-articular injection of either hylan G-F 20 or a placebo (saline).18 The study authors found no statistically significant differences in foot pain (as measured by the Foot Health Status Questionnaire) between the groups at three months. They noted few statistically significant differences in the secondary outcome measures including first MPJ pain and stiffness, first MPJ dorsiflexion range of motion, hallux plantarflexion strength and changes in plantar pressures. They also noted no significant difference in adverse effects. Accordingly, the study authors concluded that an intra-articular injection of hylan G-F 20 was no more effective than placebo in reducing symptoms in people with symptomatic first MPJ osteoarthritis.
For the management of hallux rigidus, clinicians may utilize physiotherapy consisting of a comprehensive intervention program that includes great toe mobilization, flexor hallucis longus and brevis strengthening and sesamoid mobilization.19 Researchers have also demonstrated that chiropractic manipulation provides symptomatic relief with regular manipulation and joint range of motion.20
What The Literature Reveals About Surgical Procedures For Hallux Rigidus
Hallux rigidus by its very nature is a complex disorder with various authors describing numerous surgical procedures for management of the disorder. The goal of surgical management is to eliminate pain.
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
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.
In a study of this technique, Goucher and Coughlin examined the use of dome-shaped reamers to prepare the joint surfaces and a low-profile dorsal titanium plate for internal fixation.42 The study involved 50 patients (54 feet) who had first MPJ arthrodesis. The study authors employed dome-shaped power reamers to facilitate congruous, cancellous bone surfaces and used a dorsal titanium plate with preset valgus and dorsiflexion. Researchers assessed the patients at an average follow-up of 16 months and a minimum of one year.
In terms of results, Goucher and Coughlin reported a 31 point increase in the AOFAS score from an average 51 points preoperatively to 82 points postoperatively, and a significant reduction of pain from a preoperative mean of 6.3 on the VAS to a mean of less than one point postoperatively.42 Thirty-two patients (35 feet) rated their outcome as “excellent” while 16 patients (16 feet) had “good” results. The researchers also reported a 92 percent union rate and a 4 percent revision rate.
Hyer and colleagues demonstrated similar findings in a retrospective review of 45 patients who had a locking plate with a compression screw for fixation of hallux rigidus correction.43 They reported a mean time to union of 51.1 days and a 93 percent fusion rate (42 out of 45 feet) with three nonunions. Researchers have also demonstrated that this technique allows for immediate postoperative ambulation.44
Metallic resurfacing of the metatarsal side of the metatarsophalangeal joint has shown promising results as an alternative to arthrodesis. Arthrodesis can result in difficulty squatting or kneeling, running and wearing shoes with a high heel. The patient population developing hallux rigidus appears to be younger than previously reported. This is likely due to increased activity and the type of sports that they are playing. These patients are often resistant to the idea of an arthrodesis and are looking for alternatives to maintain joint motion.
Kline and Hasselman reviewed 26 patients (30 implants) with stage II or III hallux rigidus who had metatarsal head resurfacing with the HemiCAP® implant.45 At 27 months post-op, the researchers noted improvements in mean active range of motion (from 10.7 to 47.9 degrees), mean passive range of motion (from 28 to 66.3 degrees) and mean AOFAS scores (from 51.5 to 94.1). The average time for returning to work was seven days, according to the study. All patients reported excellent satisfaction at 60 months and the study authors also noted an 87 percent implant survivorship at this time.
Another promising technique in preservation of the first MPJ is the use of a human acellular dermal regenerative matrix as an interpositional arthroplasty graft. Berlet, Hyer and colleagues evaluated this procedure in which they placed the graft in the joint via a parachute technique covering the head of the first metatarsal head and the sesamoid complex.46 Of the first nine consecutive patients in the original study cohort, six patients were available for follow-up. There were no reported complications at the mean follow-up of 12.7 months and the authors noted an increased mean AOFAS score from 63.9 to 87.9. In a subsequent study of these patients with an average follow-up of 5.43 years, the authors found that all patients were satisfied with their results and no patient had a subsequent fusion or additional procedure on the first MPJ.47 The study authors recommend this technique for the treatment of active patients with advanced hallux rigidus who want to delay a fusion of their first MPJ.
Hallux rigidus remains a complex problem that affects a seemingly larger segment of the population. The desire to maintain joint range of motion is common among individuals facing surgical intervention. Studies continue to support the role of arthrodesis with its predictable outcome but advances in procedures aimed at preserving range of motion appear to be promising.
Dr. Haverstock is an Assistant Clinical Professor of Surgery in the Section of Podiatric Surgery within the Department of Surgery with the University of Calgary Faculty of Medicine in Calgary, Alberta. He is the Director of the Diabetic Limb Salvage Service at the Peter Lougheed Centre, a Fellow of the American College of Foot and Ankle Surgeons, and a Fellow of the American Society of Podiatric Dermatology.
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41. Lawrence BR, Thuen E. A retrospective review of the Primus first MTP joint double-stemmed silicone implant. Foot Ankle Spec. 2013;6(2):94-100.
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45. Kline AJ, Hasselman CT. Metatarsal head resurfacing for advanced hallux rigidus. Foot Ankle Int. 2013;34(5):716-25.
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47. Hyer CF, Granata JD, Berlet GC, Lee TH. Interpositional arthroplasty of the first metatarsophalangeal joint using a regenerative tissue matrix for the treatment of advanced hallux rigidus: 5-year case series follow-up. Foot Ankle Spec. 2012;5(4):249-52.
For further reading, see “Point-Counterpoint: Hallux Rigidus Surgery In Active Adults: Implant Arthroplasty Or First MPJ Arthrodesis?” in the July 2011 issue of Podiatry Today or the DPM Blog “Dispelling The Myths And Misconceptions About Hallux Rigidus” at http://tinyurl.com/d8tdlsd .