Reassessing Surgical Options For Recalcitrant Hallux Limitus In An Active Population
Hallux limitus is generally responsive to conservative care consisting of anything from changing foot gear, changing activity and exercises to orthoses, injections, anti-inflammatory medication and physical therapy.1 When these things fail, surgery is necessary.
It has long been believed that arthrodesis is the optimum procedure of choice to resolve any painful arthritic joint. Coughlin and Shurnas cite “97% good or excellent results” in 110 patients.2 They found predictable success to treat grade 1, grade 2 and selected grade 3 cases. When it comes to patients with Grade 4 or Grade 3 hallux rigidus who have less than 50 percent of the metatarsal head cartilage remaining at the time of surgery, Coughlin and Shurnas noted that these patients “should be treated with arthrodesis.”2
Although arthrodesis is a good way for the surgeon to get a patient with severe hallux rigidus comfortable, it is obviously not a good way to get mechanical improvement. In order to achieve optimal function, we should try to avoid arthrodesis as much as possible. I also think we have overextended the surgery as many patients with Grade 1 and 2 hallux limitus do not need surgery and are not even experiencing enough pain to warrant surgery. Generally, these are the type of patients who respond to conservative care.
In addition, those with Stage 3 and Stage 4 hallux rigidus are the patients who have surgery and often have very little or no cartilage. Yet surgeons can salvage the joint with arthroplasty instead of arthrodesis in many of these cases.
For years, I have been using a progressive cheilectomy to arthroplasty for Stages 1 through 4 hallux rigidus that are symptomatic. Obviously, most symptomatic hallux ridigus that is not responsive to conservative care would be in the Stage 3 to Stage 4 categories. Nevertheless, there are occasional cases that are not responsive to conservative care in the Stage 1 and 2 categories. While I do cheilectomy primarily for Stages 1 and 2 (which seems standard), I do a more aggressive form of arthroplasty for Stages 3 and 4. While I first started doing this as a Valenti procedure, I have modified this and the procedure doesn’t resemble a Valenti at all anymore.3,4
Expanding The Possible Options Beyond Arthrodesis And Implant Arthroplasty
It has been the case for years that foot and ankle surgeons have dealt with hallux limitus as if it was an “all or none” problem. Either it is beyond the scope of a simple cheilectomy or it needs arthrodesis. Based on my own experience, there are very few patients who would not desire another option.
Although arthrodesis makes people comfortable, it does cause problems in mobility and agility. In addition, implant arthroplasty is equally bad in that it causes a transfer of weight, less than adequate range of motion and its own set of problems with implant failure and displacement. I have found that five years after an implant, patients rarely maintain joint motion and functionality.
Many authors have theorized as well that the longevity of implants decreases with high degrees of activity, rendering implant arthroplasty less than the procedure of choice when considering highly active individuals. I also think that one cannot achieve functional independence as easily with an implant — particularly subject to these problems — as it could be with other types of surgical arthroplasty.