How To Treat Hallux Rigidus In Runners
- Volume 22 - Issue 4 - April 2009
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What Studies Reveal About Cheilectomy Procedures For Stage I Or Stage II Hallux Rigidus
One of the few papers documenting long-term outcomes of surgery on high level athletes with hallux rigidus utilized a cheilectomy procedure for relief of symptoms.16 The study authors noted good to excellent results after a five-year follow-up of 20 athletic patients and pedobarographic measurements showed improvements of pressure distribution under the forefoot with less lateral loading of the metatarsals.
The typical cheilectomy involves resection of one-third to one-fourth of the dorsal articular surface of the first metatarsal head. A modification of this involves a Valenti arthroplasty, which is a V-shaped resection of the dorsal half of the head of the first metatarsal and the base of the proximal phalanx. Papers advocating the use of an interpositional arthroplasty involving autograft or allograft tendon material have not studied results with running athletes.
It is important to restore range of motion to at least 50 degrees dorsiflexion intraoperatively. In my experience, approximately 10 to 20 degrees of dorsiflexion noted intraoperatively will be lost in the postoperative period. Therefore, if one desires an end result of 30 degrees dorsiflexion, the surgeon should obtain at least 50 degrees dorsiflexion on the operating table with any type of surgical procedure (other than arthrodesis) for hallux rigidus.
Recently, Nawoczenski, et al., published a detailed analysis of 20 patients who underwent cheilectomy for hallux rigidus and were surveyed six years after the procedure.17 The average dorsiflexion increased by 12 degrees postoperatively but the study patients did not achieve full range for normal walking. Yet the overall range of postoperative dorsiflexion was 30 degrees, which is perhaps considered “normal” for running activities.
Decompression Osteotomy: A Viable Option For Stage II Hallux Rigidus?
Restoring alignment of the first MPJ would seem to be the most straightforward, sensible surgical solution for hallux rigidus. Unfortunately, the published results of these procedures have not validated predictable success in restoring alignment and have not focused on any groups of high performance athletes.
Roukis has evaluated reports of patients undergoing either a Green-Watermann osteotomy or a Youngswick-Austin osteotomy, and concluded there were no significant changes in metatarsus primus elevatus or hallux equinus after either osteotomy.5 Furthermore, patient satisfaction with joint interposition procedures or cheilectomy is similar to joint decompression procedures, according to Roukis, yet these procedures have much less chance for complication than osteotomies of the first metatarsal.
The primary concern with first metatarsal osteotomies is potential serious complications for the running athlete. Since these procedures are designed to shorten the first metatarsal and decompress the joint, the risk of transfer metatarsalgia is significant for all patients. For running athletes, whose peak forefoot forces are amplified threefold in comparison to when they walk, increased plantar pressure under the central metatarsals can lead to capsulitis, predislocation syndrome and stress fracture of the metatarsals.
When I perform an osteotomy for relief of hallux rigidus, I make certain that the first metatarsal is either longer than the second or that there is no significant increased pressure under the second metatarsal in comparison to a preoperative measurement with a Mat Scan® analysis. The best osteotomy to restore function of the first MPJ is the modified Hohman procedure, which can maximize plantarflexion with minimal shortening.18
What About Implants For Hallux Rigidus?
Joint implants have been advocated for over 40 years for the treatment of hallux rigidus. However, there is currently no study documenting the long-term performance of any first MPJ prosthesis in running athletes. However, many manufacturers will advocate use of these implants for younger patients with active lifestyles that include vigorous running.