Hallux Rigidus

Epidemiology

• 2x more common in women
• Often bilateral but not always symptomatic
• Wide age range from teens to elderly

Aetiology

• Idiopathic
• Inflammatory arthropathy
  • RA, Gout
• Post Traumatic
• Infective

Natural History

• Often do not get worse and may improve – 50% in RCT (Pon’s)

Clinical Features

Symptoms

• Pain over big toe – usually dorsal
• Pain on dorsiflexion
• Block to dorsiflexion
• May have more pain on plantarflexion – capsule stretching over osteophyte
• Stiffness & painful locking of MTPJ
• Dorsal prominence, soft tissue swelling, or ulceration

Examination

• General foot and ankle exam
• Tiptoeing pain
• ROM – blocks; pain; stiffness
• Concurrent Hallux Valgus present?

Classification

• Based on XR changes
  • Mild osteophyte formation with preserved joint space
  • Moderate osteophytes with diminished dorsal joint space
  • Marked osteophytes with complete joint space degeneration
• Can be subclassified depending on ROM and pain

Management

Non-Operative

• Good results in a large number of patients
• NSAIDs, activity modification, accommodative footwear

Injection & MUA

• Diagnostic & therapeutic
• Long-lasting in many patients with minimal XR changes

Surgical

• Motion Preserving or Motion Sacrificing
  • Cheilectomy
  • Osteotomy
  • Arthroplasty
  • Arthrodesis

Dorsal Cheilectomy

• Motion preserving – good for more active patients with milder disease
• For mild disease or patients with only dorsal symptoms from osteophyte
• Dorsomedial incision
  • Take care to avoid medial dorsal cutaneous nerve
  • Capsulotomy
  • Oblique resection of 30-50% of joint
  • Need to resect 30% to improve ROM reliably
  • Concurrent PP cheilectomy or dorsal osteotomy of PP possibly
• Results are good in correct patients
• Cheilectomy is viable for more severe disease if pain is dorsal over osteophyte and some ROM is retained
  • Clinical evaluation essential in deciding treatment

Interposition Arthroplasty

• Limited PP resection and infolding of dorsal capsule
• OK results but there are better motion-sparing operations

Dorsiflexion Phalangeal Osteotomy

• Idea is to reduce pressure on dorsum of MTPJ

Metatarsal Osteotomy

• Plantarflexing osteotomy reduces dorsal impingement
• No reports regarding metatarsalgia but is a problem in theory
• For early hallux rigidus
• Outcomes no better than Cheilectomy, which is much easier

Arthroplasty

• Silastic (Swanson) arthroplasty had many complications
• Currently Hemi and Total joint arthroplasties available
• No data proving better results than fusion
• Specific Complications:
  • Early wear – main issue
  • Synovitis
  • Dislocation
  • Cock-up toe
  • Loss of bone stock – more difficult to salvage

Arthrodesis

• Gold Standard – good for grade 2-3 symptomatic cases
• Multiple methods
• Dorsomedial incision
• Prepare articular surfaces – key step
• Parallel cuts or ice cream cone reamers
• Parallel cuts shown to be more stable
• Can address concurrent Hallux Valgus with the cuts
• Fixation with cross screws, pins, low-profile plates
• Positioning:
  • 10° valgus, neutral rotation & pulp just off the floor with foot in a plantigrade position
  • Use flat board intra-operatively
• Disadvantages:
  • Relatively contraindicated if DIPJ arthrosis
  • Can’t wear high heels
  • Gait pattern altered
  • Pivoting sports more difficult

Excision Arthroplasty

• Keller’s – for older low-demand patients

Overall Procedure Choice

No significant or very mild XR findings

• Injection and MUA

Mild – moderate dorsal osteophytes with retention of ROM and main symptoms dorsal

• Cheilectomy

More significant degeneration with diffuse pain and stiffness

• Fusion
  • Also for inflammatory arthritis