Hallux Rigidus

 

Introduction

  • The 1st MTPJ carries ~120% of body weight with each step
  • Hallux rigidus is primarily idiopathic, familial predisposition, often bilateral
  • Trauma is a common cause, especially when unilateral
  • Risk factors include:
    • metatarsal head shape
    • long 1st metatarsal
    • metatarsal adductus
    • hallux valgus interphalangeus
    • inflammatory / metabolic conditions (e.g. RA, gout)
  • Progression disrupts joint mechanics, eccentric gliding of proximal phalanx, dorsal osteophyte formation and decrease in dorsiflexion 

 

Clinical Presentation

  • Pain and stiffness exacerbated by activities involving dorsiflexion of the big toe
  • Altered gait due to 1st MT off-loading can cause:
    • transfer metatarsalgia / plantar callosities
    • lesser toe clawing
    • lesser MT stress fractures
  • Discomfort during ambulation, particularly during toe-off and propulsion
  • Relief with stiff-soled shoes and worse with flexible footwear
  • Bony prominences causing difficulty with footwear

 

Examination

  • Localised tenderness dorsally
  • Palpable dorsal osteophytes
  • Reduced / restricted range of motion
  • Pain with dorsiflexion (bony or soft tissue impingement) and plantarflexion (traction of EHL tendon)
  • Pain during "grind testing" and mid-range motion indicative of advanced arthritis
  • Hyperextension of the interphalangeal (IP) joint as compensation
  • Look for associated hallux valgus or lesser toe abnormalities and plantar callosities

 

Imaging

  • Standing anteroposterior (AP), lateral and oblique radiographs
  • Radiographic signs include:
    • reduced joint space
    • flattening / widening of the MT head
    • dorsal osteophytes
    • cysts
  • CT, USS, MRI not usually necessary

 

Classification

  • >18 classification systems described
  • Coughlin and Shurnas is the most widley accepted

Coughlin and Shurnas Classification

 

EXAMINATION

RADIOGRAPHY

GRADE 0

Stiffness

Normal

  

GRADE 1

Mild pain at extremes of motion

Mild dorsal osteophyte, normal joint space

  

GRADE 2

Moderate, more constant pain with range of motion

Moderate dorsal osteophyte, <50% joint space narrowing

  

GRADE 3

Significant stiffness, pain at end-range, no mid-range pain

Severe dorsal osteophyte, >50% joint space narrowing

  

GRADE 4

Grade 3 + pain at mid-range

Same as Grade 3

  

 

Treatment

Conservative

Always offer non-operative treatment first:

  • Activity modification:
    • avoid impact sports / jumping / running
    • avoid professions involving kneeling
    • if left foot, consider an automatic car
  • Analgesia – paracetamol or NSAIDs
  • Systemic treatment (e.g. for gout, RA)
  • Orthotics:
    • limit joint motion, cushion, pressure distribution
    • stiff (carbon fibre) footplate or Morton’s extension
    • high / wide toe box to accommodate dorsal osteophytes
    • rocker-bottom soles to reduce bending forces through the foot
  • Injections:
    • steroid – evidence suggests temporary relief only, less effect with increased Coughlin grade
    • hyaluronic acid – some good evidence
    • PRP – limited evidence
  • Physiotherapy – may help with ROM and gait training in early stages

Surgical Treatment

​Choice of procedure: based on the condition of the joint, patient’s expectations and surgeon’s experience

Aims of surgery: improve pain, function, quality of life and to maintain joint stability

Cheilectomy

  • Reserved mainly for early-stage OA
    • involves dorsal wedge resection up to 30% of the MT head and PP base
    • remove surrounding osteophytes to enhance dorsiflexion, improve gait, and increase ankle push-off power
  • Avoid over-resection (>30%) to prevent dorsal instability of the PP
  • Ideal candidates:
    • young, active
    • mainly dorsal impingement symptoms; large dorsal osteophytes; <50% joint space narrowing
    • pain at extremes of range of motion (ROM)
    • caution with positive grind test / mid-range pain
  • Coughlin reported on 89 patients with 97% good to excellent results and 92% improvement in pain and function at mean of 9 years
  • Counsel for high conversion rate (~50%) to further surgery

Cheilectomy with Moberg osteotomy

  • Moberg = dorsal closing wedge osteotomy of the proximal phalanx:
    • offloads contact pressure over damaged cartilage
    • enhances dorsiflexion
    • facilitates gait cycle rocker
  • Conversion to arthrodesis after Moberg may be challenging due to the altered shape of the PP

Arthrodesis

  • Remains the 'gold-standard' treatment for severe and end-stage hallux rigidus
  • Improves pain, propulsion, function, and gait stability
  • Techniques include:
    • flat cuts: more technically demanding, more 1st ray shortening(?)
    • conical reamers: allows greater flexibility in joint positioning
  • Fixation methods:
    • crossed compression screws
    • cross compression screw with a dorsal plate: biomechanically more stable, earlier weight-bearing, although increased cost
  • Studies show excellent results with many returning to professional sport
  • Complications include:
    • non-union (many are asymptomatic)
    • mal-union (includes patients unhappy with the position)
    • prominent metalwork
    • interphalangeal or adjacent joint OA

Arthroplasty

  • Metallic / ceramic implants
    • Historically poor results
    • High rate of loosening / subsidence
    • Likely due to very high loads through small surface area
    • Subsequent high revision rate
    • Conversion to fusion difficult due to bone loss
  • Hemiarthroplasty
    • High failure and revision rates
  • Silastic implants
    • early generations displayed high rates of osteolysis, implant subsidence, and immune reactions
    • 3rd generation have shown much better results:
    • Clough reported excellent results in 83 patients (108 feet), at 8 years’ follow-up; 90% improvement in pain, function, and overall satisfaction
  • Other arthroplasty
    • joint-sparing options, preserving joint motion
    • Keller resection arthroplasty
      • removes up to 50% of the proximal phalanx base
      • risks joint destabilization, cock-up deformity, transfer metatarsalgia
      • now rarely performed and reserved for low demand patients
    • Inter-position arthroplasty
      • limited PP base resection with use of spacer (autograft / allograft)
      • better results reported than Keller’s alone
  • Synthetic Cartilage Implants
    • Cartiva = polyvinyl alcohol hydrogel implant
    • promising early results with easier conversion to arthrodesis
    • subsequent systematic review showed high failure and revision rate at 2 years

 

References

  • Baumhauer JF et al. Prospective, Randomized, Multi-centered Clinical Trial Assessing Safety and Efficacy of a Synthetic Cartilage Implant Versus First Metatarsophalangeal Arthrodesis in Advanced Hallux Rigidus. Foot Ankle Int 2016; 37: 457-469
  • Coughlin MJ, Shurnas PS. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg Am 2003; 85-A: 2072-2088.
  • Morgan S, Ng A, Clough T. The long-term outcome of silastic implant arthroplasty of the first metatarsophalangeal joint: a retrospective analysis of one hundred and eight feet. Int Orthop. 2012;36:1865–1869.
  • Politi J, John H, Njus G, Bennett GL, Kay DB. First metatarsalphalangeal joint arthrodesis: a biomechanical assessment of stability. Foot Ankle Int 2003; 24: 332-337.
  • Hyer CF, Glover JP, Berlet GC, Lee TH. Cost comparison of crossed screws versus dorsal plate construct for first metatarsophalangeal joint arthrodesis. J Foot Ankle Surg 2008; 47: 13-18.
  • Nagy MT, Walker CR, Sirikonda SP. Second-Generation Ceramic First Metatarsophalangeal Joint Replacement for Hallux Rigidus. Foot Ankle Int 2014; 35: 690-698.
  • Aynardi MC et al. Outcomes After Interpositional Arthroplasty of the First Metatarsophalangeal Joint. Foot Ankle Int 2017; 38: 514-518.
  • Grady JF, Axe TM, Zager EJ, Sheldon LA. A retrospective analysis of 772 patients with hallux limitus. J Am Podiatr Med Assoc 2002;92:102-108.
  • Schneider W, Kadnar G, Kranzl A, Knahr K. Long-term results following Keller resection arthroplasty for hallux rigidus. Foot Ankle Int 2011;32:933-939.
  • Pulavarti RS, McVie JL, Tulloch CJ. First metatarsophalangeal joint replacement using the bio-action great toe implant: intermediate results. Foot Ankle Int 2005;26:1033-1037.
  • Nagy MT, Walker CR, Sirikonda SP. Second-generation ceramic first metatarsophalangeal joint replacement for hallux rigidus. Foot Ankle Int 2014;35:690-698.
  • Dawson-Bowling S, Adimonye A, Cohen A, et al. MOJE ceramic metatarsophalangeal arthroplasty: disappointing clinical results at two to eight years. Foot Ankle Int 2012;33:560-564.
  • Goucher NR, Coughlin MJ. Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study. Foot Ankle Int 2006;27:869-876.
  • Brodsky JW, Passmore RN, Pollo FE, Shabat S. Functional outcome of arthrodesis of the first metatarsophalangeal joint using parallel screw fixation. Foot Ankle Int 2005;26:140-146.
  • Glazebrook M et al. Midterm Outcomes of a Synthetic Cartilage Implant for the First Metatarsophalangeal Joint in Advanced Hallux Rigidus. Foot Ankle Int. 2019 Apr;40(4):374-383).
  • Butler JJ, Dhillon R, Wingo T, Lin CC, Samsonov AP, Azam MT, Kennedy JG. Polyvinyl alcohol hydrogel implant for the treatment of hallux rigidus is associated with a high complication rate and moderate failure rate at short-term follow-up: a systematic review. Eur J Orthop Surg Traumatol. 2024 Mar 30