Hallux Rigidus

Definition

 

Painful restriction of dorsiflexion of the great toe 

- secondary to degenerative changes in MTPJ

- initially pain and synovitis

- osteophytes don't form medially or on plantar aspect

 

Epidemiology 

 

Two peaks

1.  Adolescence F > M

2.  Middle Age M > F

 

Aetiology

 

Often Idiopathic

 

Trauma

- OCD

- hyperextension injuries

 

Anatomical

- pronated foot

- abnormally long 1st MT

- pes planus

- DF 1st ray

 

Inflammatory

- gout

- CPPD

- inflammatory arthropathy

 

History

 

Pain on walking

- especially slopes & rough ground

- pain may become continuous

 

Numbness 

- compression of dorsomedial cutaneous nerve

 

Examination

 

Shoe shows excessive lateral wear

- toe off on lateral border 

- patient avoids dorsiflexion

 

Look

- hallux is usually straight

- MTPJ is enlarged

 

Feel

- synovial thickening

- palpable dorsomedial osteophyte & bunion 

- altered sensation dorsal toe / due to tethering of dorsomedial nerve by osteophytes

 

ROM

- DF restricted & painful N = 90°

- PF often reduced and painful N = 30°

 

X-ray

 

Changes of osteoarthritis

- dorsomedial osteophyte

- joint space narrowing

 

Great Toe Dorsal OsteophyteHallux Rigidus Dorsal Osteophyte

 

Management

 

Non Operative

 

Options

 

Education & Reassurance

 

Orthotics

- initially stiff soled shoes

- rockerbottom sole

- high toe box

 

NSAID

HCLA

 

Operative

 

1.  Moberg Osteotomy

 

Indication

- young patient with mild OA & > 30° PF

 

Technique

- dorsal closing wedge osteotomy of P1 

- converts PF range into functional DF

 

2.   Cheilectomy

 

Mann 1988 JBJS

 

Concept

- removal of dorsal osteophytes

- increase painless DF range (average 20°)

 

Great Toe Cheilectomy

 

Indication

- for adults with minimal degenerative changes

- normal joint space in plantar half MTPJ

 

Disadvantage

- recurrence of pain

 

Technique

- dorsal incision over MTPJ

- joint incised either side EHL

- synovectomy

- remove ~ 1/3 of dorsal MT head

- remove osteophytes from base of P1

- need DF of ~ 90°

- stiff shoe till ROS

- then flexible sole and ROM exercise

 

3.  Arthrodesis

 

Great Toe MTPJ OA

 

Great Toe MTPJ Fusion APGreat Toe MTPJ Fusion Lateral

 

Indication

- adults with significant degenerative changes

 

Disadvantage

- lateral transfer metatarsalgia

- IPJ OA

- malposition

- limitation of footwear type

- non-union

 

Technique

- dorsomedial approach

- protect dorsal cutaneous nerve

- mobilise EHL laterally and open capsule

- divide collaterals

- free P1 of soft tissue attachments

- 15° valgus

- 15° DF relative to plantar surface / 20 - 25° relative to metatarsal shaft

- dorsal plate / crossed screws

 

Results

- 30% develop asymptomatic OA IPJ

 

Hallux Rigidus Fusion 2 screws APHallux Rigidus Fusion 2 screws Lateral

 

4.  Interpositional Arthroplasty

 

Indication

- severe OA & moderate demand

- minimal bone resection

 

Technique

- imbricate dorsal & volar capsule into joint space

 

5.  Swanson Arthroplasty

 

Indication

- adults with low demands

 

Disadvantage

- breakage

- silicon synovitis

- very difficult to salvage

 

6.  Keller's Procedure

 

Indication

- for elderly with low demands

 

Disadvantages

- lose windlass mechanism

- transfer metatarsalgia

- cosmetically poor

- drifts into both DF & valgus / Cock Up deformity