Abstract
Background: There have been few long-term studies documenting the
outcome of surgical treatment of hallux rigidus. The purposes of this report
were to evaluate the long-term results of the operative treatment of hallux
rigidus over a nineteen-year period in one surgeon's practice and to assess a
clinical grading system for use in the treatment of hallux rigidus.
Methods: All patients in whom degenerative hallux rigidus had been
treated with cheilectomy or metatarsophalangeal joint arthrodesis between 1981
and 1999 and who were alive at the time of this review were identified and
invited to return for a follow-up evaluation. At this follow-up evaluation,
the hallux rigidus was graded with a new five-grade clinical and radiographic
system. Outcomes were assessed by comparison of preoperative and postoperative
pain and AOFAS (American Orthopaedic Foot and Ankle Society) scores and ranges
of motion. These outcomes were then correlated with the preoperative grade and
the radiographic appearance at the time of follow-up.
Results: One hundred and ten of 114 patients with a diagnosis of
hallux rigidus returned for the final evaluation. Eighty patients
(ninety-three feet) had undergone a cheilectomy, and thirty patients
(thirty-four feet) had had an arthrodesis. The mean duration of follow-up was
9.6 years after the cheilectomies and 6.7 years after the arthrodeses. There
was significant improvement in dorsiflexion and total motion following the
cheilectomies (p = 0.0001) and significant improvement in postoperative pain
and AOFAS scores in both treatment groups (p = 0.0001).
A good or excellent outcome based on patient self-assessment, the pain
score, and the AOFAS score did not correlate with the radiographic appearance
of the joint at the time of final follow-up. Dorsiflexion stress radiographs
demonstrated correction of the elevation of the first ray to nearly zero.
There was no association between hallux rigidus and hypermobility of the first
ray, functional hallux limitus, or metatarsus primus elevatus.
Conclusions: Ninety-seven percent (107) of the 110 patients had a
good or excellent subjective result, and 92% (eighty-six) of the ninety-three
cheilectomy procedures were successful in terms of pain relief and function.
Cheilectomy was used with predictable success to treat Grade-1 and 2 and
selected Grade-3 cases. Patients with Grade-4 hallux rigidus or Grade-3 hallux
rigidus with <50% of the metatarsal head cartilage remaining at the time of
surgery should be treated with arthrodesis.
Level of Evidence: Therapeutic study, Level IV (case
series [no, or historical, control group]). See Instructions to Authors for a
complete description of levels of evidence.
Hallux rigidus is a term used to describe symptoms commonly
associated with degenerative arthritis of the first metatarsophalangeal joint.
Surgical treatment of protracted symptomatic hallux rigidus includes
cheilectomy1-13,
excisional
arthroplasty14-20,
interposition
arthroplasty13,21-25,
phalangeal
osteotomy26-30,
first metatarsal
osteotomy16,31-40,
implant
arthroplasty16,41-47,
and
arthrodesis14,48-68.
Cheilectomy has been recommended in a number of
reports1-4,6-8,11-13,69;
however, in many of the studies, the duration of follow-up was less than one
year2,3,12,69
or some or all of the patients were not examined at the time of final
follow-up12,69.
In some studies, a substantial number of patients were lost to final
follow-up11,13;
in others, cheilectomy was combined with phalangeal
osteotomy13,27,29,
metatarsal
osteotomy34, or
interposition
arthroplasty23.
Some authors reported a technique consisting solely of the removal of the
osteophytes in line with the dorsal metatarsal
cortex2,6,8-10,12,16,21,23,27,29,48,
and several of them recommended cheilectomy as a treatment for early disease
only2,6,8,12.
Although Nilsonne21
and Bonney and
Macnab70 found
cheilectomy to be unsuccessful, others have reported successful results with
cheilectomy for all levels of
disease3,7,11
and have recommended a more aggressive resection of the metatarsal head.
Radiographic signs of deterioration of the metatarsophalangeal joint over time
have been reported after
cheilectomy1,4,7,8,
but continued good clinical function despite the worsening radiographic
appearance has been noted in these studies.
Arthrodesis of the first metatarsophalangeal joint has been evaluated as a
treatment for hallux rigidus by several
authors48-68.
However, in many series, the duration of follow-up was less than one
year50,51,55-57,
multiple surgeons were
involved52,56,61,
or more than one technique was
performed53,56.
Some studies included patients with other diagnoses such as rheumatoid
arthritis or hallux
valgus49,52,55,57,58,67,
and others provided inadequate information on the patients or the method of
evaluation48,51,53,56,58,59,65-67
or patients were not evaluated at the time of final
follow-up66. We
found only two
reports50,68
that dealt exclusively with the treatment of hallux rigidus, and both included
patients with less than one year of follow-up.
On the basis of their individual beliefs about the etiology of hallux
rigidus, authors have proposed several grading systems with either
three1,2,12,22,71-73
or four
stages35,41,50,71,74
determined according to radiographic criteria
only12,71
or a combination of clinical and radiographic
criteria1,2,17,22,41,50,72,73.
Several of these grading systems add modifications to an existing
scheme2,4,6,8,11,69,
while in others the grades or treatment recommendations are based on poorly
studied concepts such as metatarsus primus
elevatus41,50,71
or functional hallux
limitus17,41,50.
All of these variations make comparisons between studies difficult.
The purpose of the present study was to evaluate the predictability of a
clinical-radiographic grading scale for choosing a surgical procedure, and to
examine the long-term results of cheilectomies and arthrodeses performed by
one surgeon.
One hundred and forty consecutive patients were treated, by the senior
author (M.J.C.), with either a cheilectomy or an arthrodesis of the first
metatarsophalangeal joint as surgical treatment for a symptomatic hallux
rigidus deformity between November 1981 and November 1999. Twenty-one patients
were excluded from the present study because of a diagnosis of gout,
rheumatoid arthritis, systemic lupus erythematosis, poliomyelitis, or previous
pyarthrosis, and five other patients died during the study period. Of the 114
remaining patients with a diagnosis of hallux rigidus, four were unavailable
or had moved away; 110 (96%) returned for a final follow-up evaluation.
Of these 110 patients (127 feet), eighty (ninety-three feet) were treated
with cheilectomy and thirty (thirty-four feet) were treated with arthrodesis.
Thirteen patients had bilateral cheilectomy, and four patients had bilateral
arthrodesis. No patient underwent a cheilectomy on one side and an arthrodesis
on the contralateral side. Sixty-nine (63%) of the 110 patients were female.
The average age at the onset of symptoms was forty-three years (range,
thirteen to seventy years), and the average age at surgery was fifty years
(range, sixteen to seventy-six years).
Grading
At the time of final follow-up, the patients were evaluated with a
five-level clinical-radiographic grading system
(Table I and Figs.
1-A and
1-B,2-A and
2-B,3-A and
3-B,4-A and 4-B)
that incorporates many features of all of the classification systems used by
previous
authors1,2,12,22,72,74
but is not based on hypothetical concepts or
notions17,41,50,71.
All range-of-motion measurements used in the system refer to passive motion.
Pain at mid-range of passive motion refers to pain that is elicited
not only at the extremes of passive dorsiflexion and plantar flexion of the
metatarsophalangeal joint but also in between. Loose bodies or osteochondral
defects can occur with any grade. Their presence does not affect the assigned
grade. There is intentional overlap of the ranges of motion of the different
grades as range of motion is only one of the three general factors determining
the eventually assigned grade of hallux rigidus. Range-of-motion, clinical,
and radiographic examinations are utilized to determine the individual
grade.
Preoperative Findings
The indication for surgery was intractable pain isolated to the first
metatarsophalangeal joint that was refractory to shoe modifications, use of
rigid shoe inserts, nonsteroidal anti-inflammatory medications, and
modification of activities. Symptoms referable to the great toe and foot were
compiled from a chart review. The operative reports were also evaluated to
record the estimated percentage of the cartilage surface of the metatarsal
head that remained, which had been observed and routinely recorded at the time
of surgery. A cheilectomy was always recommended for Grade-1 and Grade-2
hallux rigidus, whereas a cheilectomy or an arthrodesis was recommended for
Grade-3 hallux rigidus. An arthrodesis was recommended when radiographs
demonstrated end-stage arthrosis and the clinical examination demonstrated a
painful range of motion. When an arthrodesis was performed, such patients were
typically found to have <50% of the cartilage surface remaining on
inspection at surgery. Determining the best type of treatment was the most
difficult for patients with similar radiographic findings who had minimal pain
during the range of motion except at maximum plantar flexion and dorsiflexion.
If it was acceptable to them, such patients gave consent for both arthrodesis
and cheilectomy, and the surgeon chose the procedure at the time of the
operation on the basis of the amount of cartilage surface that remained.
Although an arthrodesis was always recommended to patients with end-stage
arthritis, which we later characterized as Grade-4 hallux rigidus, eight of
these patients refused the arthrodesis and underwent cheilectomy instead.
Early in the study, the magnitude of preoperative pain was quantified as
none, mild, moderate, severe, or quite severe; later, a visual analog scale
was used by the patients to quantify the level of pain numerically. In order
to compare the preoperative and postoperative pain scores in the treatment
groups (cheilectomy and arthrodesis) on the basis of the 10-point visual
analog score that was eventually used, a number was assigned retrospectively
to the preoperative pain described by the patients seen early in the study.
None was quantified as 0; mild, as 3; moderate, as 6; severe, as 9; and quite
severe, as 10.
Preoperatively, twenty-one patients had moderate pain and the remainder had
severe or quite severe pain. Although the AOFAS (American Orthopaedic Foot and
Ankle Society) hallux metatarsophalangeal
scale75 was not
available until 1994, the chart information and radiographs allowed us to also
calculate a preoperative AOFAS score retrospectively for each patient.
Follow-up Evaluation
The mean duration of follow-up was 9.6 years (range, 2.3 to 20.3 years)
after the cheilectomies and 6.7 years (range, 2.1 to 12.2 years) after the
arthrodeses. At the time of follow-up, patients were assessed with a
standardized questionnaire and examination.
Patients were asked to characterize their postoperative pain as none, mild,
moderate, severe, or quite severe and also to rate it on a 10-point visual
analog scale in which 0 indicated no pain and 10 indicated the most severe
pain. Patients were also asked to localize the pain, if they had any, and to
specify their main symptom (pain, stiffness, cosmetic appearance, locking, or
a gait problem). In addition, patients were questioned about their clinical
history, including use of orthotics, age at the onset of the symptoms, and
duration of pain or other symptoms.
Patients were asked to rate their satisfaction with the result of the
surgery according to a previously published
scale76. In that
scale, a result is considered excellent if the patient has no problems related
to the foot, is very satisfied, has mild or no pain, walks with mild or no
difficulty, and would have the surgery again under similar circumstances. A
result is considered good if the patient has a few problems, is satisfied, has
mild pain, walks with no or mild difficulty, and would have the surgery again
under similar circumstances. A fair result means that the patient has moderate
pain, some difficulty with walking, and reservations about the success of the
surgery. A poor result indicates that the patient has continued pain, has
little or no improvement in walking, and regrets having had the surgery.
More specific questions regarding shoe wear were asked to determine whether
the patient could wear fashionable shoes (a 2-in [5-cm] or higher heel)
postoperatively, felt pressure from constricting shoes, or had any other
difficulty with shoe wear. Patients were asked to characterize their shoe-wear
restrictions (preoperatively and postoperatively) as none (could wear
fashionable shoes), could wear comfortable shoes only, or required modified
custom shoes or orthotic devices.
Patients were asked if they could walk on tiptoe and the time to maximal
comfort and recovery from the surgery. They were asked to characterize any
activity restrictions (preoperatively and postoperatively) as none (no
restriction of sports or recreational activity), mild (not enough to interfere
with everyday activity but some limitation of sports or recreational
activity), moderate (limitation of daily and recreational or sports activity),
or severe (major limitation of any activity).
The physical examination included inspection and palpation of the foot with
attention to posture, sensation, motion, motor function, strength, and
appearance. Both feet of all patients were examined. Stance and gait were
assessed with attention to the position of the foot when the patient walked.
Passive motion of the metatarsophalangeal and interphalangeal joints of the
great toe was measured with a goniometer, with the plantar aspect of the foot
considered to be neutral. These joints were then assessed for stability in the
sagittal plane. Pain that occurred in the mid-range, between maximum plantar
and dorsiflexion, of a passive range of motion of the hallux
metatarsophalangeal joint was noted. The plantar aspect of the foot was
assessed for callosities or areas of tenderness. Motor strength of the hallux
was quantitated on a 5-point scale in which 1 indicated no strength; 2, active
movement with gravity eliminated; 3, active movement against gravity only,
without resistance; 4, active movement against gravity with some resistance;
and 5, active movement against gravity with full resistance.
An AOFAS hallux metatarsophalangeal
score75 was
determined for all patients at the time of final follow-up. This is a
100-point scale composed of separate sections for pain (40 points), function
(45 points), and alignment (15 points). In the scale for pain, 40 points is
given for no pain; 30 points, for mild, occasional pain; 20 points, for
moderate, daily pain; and 0 points, for severe, constant pain. Function is
graded on the basis of activity (10 points for no limitation, 7 points for
limitation of recreational activity but not daily or job-related activities, 4
points for limitation of daily and recreational activities, and 0 points for
severe limitation of daily and recreational activities), shoe wear (10 points
for the ability to wear fashionable and regular shoes with no insert, 5 points
for the ability to wear only comfortable shoes or the need for an insert, and
0 points for the need to wear modified shoes or a brace), motion (dorsiflexion
plus plantar flexion) of the metatarsophalangeal joint (10 points for
=75°, 5 points for 30° to 74°, and 0 points for <30°),
motion (plantar flexion) of the interphalangeal joint (5 points for no
restriction and 0 points for <10°), stability (in all directions) of
the metatarsophalangeal joint (5 points for stable and 0 points for unstable),
and callus related to the metatarsophalangeal and interphalangeal joints (5
points for no or an asymptomatic callus and 0 points for a symptomatic
callus). In the alignment section of the scale, 15 points is given for a
well-aligned hallux; 8 points, for fair alignment with some deformity but no
symptoms; and 0 points, for symptomatic malalignment. With use of this scale,
90 points is the highest score attainable after an arthrodesis.
Radiographic Evaluation
Standardized preoperative weight-bearing
radiographs77 were
reviewed and compared with standardized postoperative weight-bearing
radiographs made at the time of the final follow-up. The width of the
metatarsophalangeal joint was determined by a summation method based on six
separate measurements (Figs. 5-A and
5-B). Recurrence of the dorsal osteophyte was assessed on the
lateral radiograph by drawing a line along the dorsal cortex of the metatarsal
and measuring any osteophyte above that line in millimeters.
Interphalangeal joint arthritis was graded on the anteroposterior
radiograph with use of a previously described
method78. With this
method, Grade 1 indicates no degenerative changes; Grade 2, mild changes with
<1 mm of chondrolysis; Grade 3, moderate changes with 1 to 2 mm of
chondrolysis; and Grade 4, severe changes with malalignment, cysts, and/or
joint destruction. Periarticular sclerosis at the metatarsophalangeal joint
was recorded as 0 (no sclerosis), +1 (mild), +2 (moderate), or +3 (severe), as
seen on the preoperative and postoperative anteroposterior radiographs of the
patients treated with cheilectomy.
Elevation of the first ray (metatarsus primus elevatus) was measured on the
weight-bearing lateral
radiograph79. The
difference between the dorsal cortices of the first and second metatarsals
measured at the head-neck junction was recorded in millimeters. A normal value
is =8 mm79. The
first metatarsal declination angle was measured as
well79. Normal
values are reported to range from 19° to
25°80
(Fig. 6). A dorsiflexion stress
lateral radiograph was made for all
feet3. This is a
weight-bearing lateral radiograph made with manual dorsiflexion stress applied
by grasping the proximal phalanx and passively extending the
metatarsophalangeal joint (Figs.
7-A and
7-B). The dorsiflexion measured
on the weight-bearing stress radiograph was compared with the dorsiflexion
measured with a goniometer without weight-bearing, and any discrepancy was
recorded in order to measure the magnitude of functional hallux
limitus81-83.
In addition, metatarsus primus elevatus was measured on the stress radiograph
and compared with the metatarsus primus elevatus on the non-stress standard
weight-bearing lateral radiograph to evaluate the extent to which the
metatarsus primus elevatus was a secondary change.
Surgical Techniques
A cheilectomy is performed with use of regional anesthesia and with an
Esmark bandage (Medline Industries, Mundelein, Illinois) employed as a
tourniquet1,3,7.
A 3-cm dorsal longitudinal incision is centered over the metatarsophalangeal
joint and is deepened through the capsule on the medial aspect of the extensor
hallucis longus tendon. The capsule is preserved for later repair.
Hypertrophic synovial tissue and loose bodies are fully débrided from
the joint, and the percentage of viable cartilage remaining on the metatarsal
head is estimated. The proximal phalanx is plantar flexed, exposing the
metatarsal head. An osteotome is used to remove the dorsal, medial, and
lateral osteophytes along with 25% to 33% of the metatarsal head dorsally.
Usually, all or almost all of the cartilage-deficient surface of the
metatarsal head is resected. At least 70° of dorsiflexion should be
achieved intraoperatively. The osteophytes are then removed from the dorsal
aspect of the base of the proximal phalanx, and the joint is lavaged. Bone wax
is applied to the dorsal region of the metatarsal head. The capsule is
repaired beneath the extensor hallucis longus tendon with interrupted
absorbable sutures, and the skin is approximated in a routine fashion.
A gauze-and-tape compression dressing is applied at the conclusion of the
surgery and is changed every ten days. Passive range-of-motion exercises are
begun within ten days after surgery, and aggressive stretching is allowed as
pain and swelling subside. Walking is permitted following surgery with the
patient wearing a stiff-soled postoperative shoe and bearing weight as
tolerated.
Arthrodesis of the first metatarsophalangeal joint is performed with use of
regional anesthesia and with use of an Esmark bandage as a
tourniquet1,52,76,84.
A dorsal longitudinal incision, 4 to 5 cm long, is centered over the
metatarsophalangeal joint and is deepened through the capsule on the medial
aspect of the extensor hallucis longus tendon. The capsule is preserved for
later repair. The joint is débrided, and osteophytes and loose bodies
are removed. The proximal phalanx is plantar flexed, a 0.62-mm Kirschner wire
is proximally centered on the first metatarsal articular surface and driven
in, and an appropriately sized cannulated cylindrical reamer is used to create
a cylinder-shaped metatarsal. A concave cannulated metatarsal reamer (small
joint reamer; Howmedica, Rutherford, New Jersey) is then utilized to create a
convex cancellous metatarsal surface. The Kirschner wire is removed, and
attention is then directed to the proximal phalanx. A Kirschner wire is
centered on the articular surface of the base of the proximal phalanx and is
driven distally to prepare for cannulated reaming. Convex phalangeal reamers
are used to create a concentric matching surface on the phalangeal base to
match the metatarsal head. The hallux is placed in neutral rotation, 15°
of valgus, and 20° of dorsiflexion in reference to the axis of the first
metatarsal. It is stabilized with a six-hole Vitallium mini-compression plate
and a lag screw. A gentle dorsal bend in the plate allows better conformity to
the dorsal osseous surfaces to achieve approximately 20° of dorsiflexion.
Closure is identical to that used for a cheilectomy.
A gauze-and-tape compression dressing is applied at the conclusion of the
surgery and is changed every ten days for eight to twelve weeks, until there
is radiographic evidence of a successful fusion. The foot is placed in a
stiff-soled postoperative shoe after surgery, and weight-bearing on the heel
and the lateral aspect of the involved foot is permitted. The first ray is
unweighted in this fashion until there is radiographic evidence of a
fusion.
Statistical Analysis
Descriptive and comparative statistical analysis was performed with use of
InStat software (GraphPad Software, San Diego, California). Standard
chi-square analysis was performed on continuous variables. Pearson and binary
correlation coefficients were used to evaluate the noncontinuous data, and
positive coefficients (r values) closer to one indicate strong correlation
while values closer to zero indicate weak or no correlation. Differences were
considered to be significant when the p value was =0.05.
Eighty patients (ninety-three feet) treated with a cheilectomy and thirty
patients (thirty-four feet) treated with an arthrodesis were evaluated at the
final examination. At the time of follow-up, at a mean of 9.6 years
postoperatively, seven (8%) of the ninety-three cheilectomies had failed. At
the time of follow-up, at a mean of 6.7 years postoperatively, thirty-two
(94%) of the thirty-four arthrodeses had successfully fused.
There were sixteen associated surgical procedures, including four repairs
to treat a hammertoe deformity of the second toe, nine repairs to treat
capsular instability of the second metatarsophalangeal joint, and three Akin
phalangeal osteotomies performed for severe hallux valgus interphalangeus at
the time of metatarsophalangeal joint arthrodesis.
Historical Data(Table
II)
The most common primary preoperative symptoms were metatarsophalangeal
joint pain (fifty-five patients) and a painful dorsal bump (fifty-five
patients). These symptoms decreased postoperatively in both treatment groups.
Interestingly, the same number of patients listed their primary symptom as
metatarsophalangeal joint pain both preoperatively and postoperatively.
However, there was a significant reduction (p = 0.0001) in the postoperative
pain score indicated on the visual analog scale. Postoperatively, patients no
longer complained of a dorsal bump or pressure from the shoe, but they
continued to have metatarsophalangeal joint pain. The time to maximum
postoperative improvement averaged 2.4 months (range, one to 4.5 months) after
the cheilectomies and 2.8 months (range, 1.5 to four months) after the
arthrodeses.
Clinical Scores(Table
III)
One hundred and seven (97%) of the 110 patients had an excellent or good
self-assessment (subjective) score at the time of follow-up, whereas all
patients had a fair or poor score preoperatively (as estimated
retrospectively). A good or excellent outcome based on the patient
self-assessment score, visual analog score for pain, and AOFAS score did not
correlate with the radiographic appearance of the joint (loss of joint space)
at the time of final follow-up (r = 0.08, p = 0.34).
At the time of final follow-up, the mean AOFAS score was significantly
improved in both the group treated with cheilectomy (p = 0.0001, difference in
the means = 45.7, 95% confidence interval = 43.3 to 48.1) and the group
treated with arthrodesis (p = 0.045, difference in the means = 50.4, 95%
confidence interval = 46.5 and 54.4). The cheilectomy group had a
significantly higher preoperative mean AOFAS score than did the arthrodesis
group (45 compared with 38 points, p = 0.025, difference in the means = 6.6,
95% confidence interval = 1.8 and 9.1), but there was no difference in the
mean postoperative AOFAS scores (89 compared with 90 points, p = 0.3).
However, the maximum possible AOFAS score in the arthrodesis group was 90
points, as 10 points are unavailable because of loss of motion.
When the patients treated with cheilectomy were grouped according to the
grade of the hallux rigidus, a significant difference in both preoperative and
postoperative AOFAS score was found among the subgroups (r = 0.3, p = 0.02).
Also, a correlation was found between increasing grade and lower preoperative
AOFAS scores (r = 0.4, p = 0.01).
Results of Clinical Examination(Table
IV)
The total range of motion of the metatarsophalangeal joint at the time of
final follow-up after the cheilectomies averaged 64°: the average
dorsiflexion of the metatarsophalangeal joint improved from 14.5°
preoperatively to 38.4° postoperatively (p = 0.0001, difference in the
means = 23.8°, 95% confidence interval = 20.9° to 26.6°).
Postoperatively, no significant difference was noted between passive
dorsiflexion and dorsiflexion with stress at either the metatarsophalangeal or
the interphalangeal joint of the hallux (p = 0.4, difference in the means =
1.2°). Dorsiflexion of the interphalangeal joint averaged 8° in both
treatment groups at the time of final follow-up. Motor strength was graded as
5/5 (normal) in all subjects. All first metatarsophalangeal joints were stable
on manual examination following cheilectomy. Three patients had a Tinel sign
over the dorsal-medial aspect of the metatarsophalangeal joint preoperatively,
but no patient had a sensory disturbance postoperatively.
Radiographic Data(Table
V)
Comparison of the extent of arthritic changes in the interphalangeal joint
between the preoperative and postoperative radiographs demonstrated no
progression of arthritis in either treatment group.
There was significant progression of periarticular sclerosis of the
metatarsophalangeal joint (p = 0.0001, difference in the means = 0.5, r =
0.84, 95% confidence interval = 0.3 to 0.6) and of loss of the
metatarsophalangeal joint width (p = 0.0001, difference in the means = 0.4 mm,
r = 0.8, 95% confidence interval = 0.25 and 0.46) in the cheilectomy group.
Twenty-one metatarsophalangeal joints were noted to have a loose body on
preoperative radiographs and confirmatory findings at the time of surgery, but
no loose bodies were noted on final follow-up radiographs. The average size of
the recurrent dorsal osteophytes was 0.72 mm (range, 0 to 3 mm) after the
cheilectomies and 0 mm after the arthrodeses.
Grading of the Hallux Rigidus(Table
VI)
In the cheilectomy group, the mean clinical-radiographic grade of the
hallux rigidus was 2.50 (range, 1 to 4) preoperatively compared with 2.59
(range, 1 to 4) postoperatively (p = 0.1). Nine patients had an increase of
one grade at the time of final follow-up. In the cheilectomy group, patients
with a lower grade preoperatively had a better AOFAS score both preoperatively
and postoperatively. No patient had an increase in the grade after an
arthrodesis, and no patient in the series had an increase of more than one
grade. Following the cheilectomies, the patients with Grade-1 hallux rigidus
had a mean AOFAS score of 95.7 points and a mean pain score on the visual
analog scale of 1.1 points, and all four feet were subjectively rated as
excellent. Patients with Grade 2 had a mean AOFAS score of 92.9 points and a
mean pain score on the visual analog scale of 1.5 points; of the thirty-eight
feet, thirty-five were rated as excellent and three were rated as good.
Patients with a Grade-3 rating had a mean postoperative AOFAS score of 89.8
points and a mean pain score on the visual analog scale of 1.7 points; of the
thirty-four feet, twenty-nine were rated as excellent and five were rated as
good.
Integrity of the Articular Surface at the Time of Surgery
As estimated by inspection of the metatarsophalangeal joint at the time of
surgery, an average of 17% (range, 0% to 40%) of the articular surface of the
metatarsal head remained in the arthrodesis group and an average of 60%
(range, 55% to 90%) remained in the cheilectomy group. There was a correlation
between an estimation of <50% of the metatarsal head cartilage remaining
and failure of cheilectomy (p = 0.002, r = 0.4). Also, an estimation of
>50% of the metatarsal head cartilage remaining in a patient undergoing a
cheilectomy correlated with a long-term AOFAS score of >80 points and a
good or excellent subjective score (p = 0.01, r = 0.4) at the time of final
follow-up.
Metatarsus Primus Elevatus(Table
VII)
There was good correlation between the first metatarsal declination angle
and metatarsus primus elevatus in both treatment groups (r = 0.6, p = 0.01).
Preoperatively, 120 (94%) of the 127 feet had <8 mm of elevation, which was
within the range of normal.
The mean preoperative and postoperative measurements of elevatus were 5.3
mm and 6.1 mm in the cheilectomy group. There was a correlation between the
postoperative grade and the amount of elevatus (r = 0.44, p = 0.02). Moreover,
the elevatus reduced to a mean of 1.2 mm on dorsiflexion stress examination in
the cheilectomy group at the time of final follow-up. This value was
significantly different from the measurements of elevatus on weight-bearing
lateral radiographs both preoperatively (p = 0.001, difference in the means =
3.9 mm, 95% confidence interval = 1.6 to 5.2 mm) and postoperatively (p =
0.001, difference in the means = 4.5 mm, 95% confidence interval = 1.3 to 5.1
mm).
Both before and following cheilectomy, an increased value for elevatus was
associated with a higher grade of hallux rigidus (p = 0.04, r = 0.44). In
addition, elevatus decreased postoperatively in patients with Grade-1 or 2
hallux rigidus but it increased in those with Grade-3 or 4. The mean
preoperative elevatus in the arthrodesis group was 5.6 mm, and this was
significantly reduced postoperatively to 1.7 mm (p = 0.009, difference in the
means = 3.9 mm, 95% confidence interval = 2.7 to 4.9 mm).
Complications
Five of the eighty patients in the cheilectomy group and two of the thirty
in the arthrodesis group required oral antibiotics for the treatment of mild
postoperative cellulitis. There were no deep wound infections. No patient in
either group had tenodesis or scarring of the extensor hallucis longus,
concerns about the cosmetic appearance of the foot, neuritis, or a
hypertrophic dorsal scar.
Seven failed cheilectomies in six patients resulted in seven additional
surgical procedures. There were two outcomes that were unexpected on the basis
of the grades assigned with our rating system during the study period. These
two outcomes consisted of rapid chondrolysis (within one year after the
surgery), and both patients had a metatarsophalangeal joint arthrodesis (at
seven and eight years following the cheilectomy). The other four patients
(five feet) in which the cheilectomy failed had originally been advised to
have an arthrodesis for the treatment of Grade-4 disease; a
metatarsophalangeal joint arthrodesis was eventually performed in these four
patients. The other four patients with Grade-4 changes (who did not have
additional surgery after the initial cheilectomy) had a mean long-term AOFAS
score of 74 points (range, 67 to 80 points); three rated the result as fair
and one rated it as good after a mean duration of follow-up of 7.4 years
(range, 2.5 to 8.4 years). Thus, of the nine feet with Grade-4 changes for
which arthrodesis was recommended but cheilectomy was performed at the
patient's request, five had failure of the procedure and later underwent
arthrodesis (at a mean 6.9 years after the cheilectomy) as initially
recommended. The other four had inferior subjective results (three fair and
one good) at the time of follow-up but had radiographic signs of deterioration
of the joint space and a mean pain score of 4.7 points on the visual analog
scale.
Two plates were removed because of pain following a successful fusion. Two
of the thirty-four feet that had undergone arthrodesis had a painless fibrous
union, and the AOFAS score was 90 points for both of these feet at the time of
follow-up.
Grading System
The grading system used in this study had been modified on the basis of the
findings of Easley et
al.1 in order to add
Grade 4 for advanced hallux rigidus. A grade-0 stage was also added to include
asymptomatic patients with early loss of metatarsophalangeal joint motion. The
initial grading system was a clinical-radiographic scheme described by one of
us (M.J.C.)73.
The classification system shown in Table
I and Figures 1-A and
1-B,2-A and
2-B,3-A and
3-B,4-A and 4-B
incorporates many of the best elements of prior grading
systems1,12,22,72
and requires both subjective and objective examination and radiographic data
to determine the grade. When applied retrospectively, the system appeared to
be reliable as it correctly predicted a successful outcome in 108 of 110
patients. Moreover, it accurately predicted a fair or poor outcome in patients
with Grade-4 hallux rigidus treated with cheilectomy. Its key utility was in
the distinction between Grade-3 and Grade-4 hallux rigidus. Cheilectomy
uniformly failed in patients with Grade-4 hallux rigidus, as predicted; five
of the nine feet in which Grade-4 hallux rigidus was treated with cheilectomy
subsequently had an arthrodesis, and two of the four remaining patients had
moderate to severe metatarsophalangeal joint pain (mean pain score, 4.4
points). However, the cheilectomy unexpectedly failed in two of thirty-four
patients with Grade-3 hallux rigidus. Both had radiographic evidence of
chondrolysis within one year after the surgery, with progressive pain, and
subsequently underwent arthrodesis of the metatarsophalangeal joint at seven
and eight years following the cheilectomy.
To improve the accuracy and predictability for Grade-3 hallux rigidus, the
percentage of metatarsal head cartilage remaining, as estimated with direct
surgical inspection, should be considered, as <50% of the cartilage
remaining correlated with failure.
The indications for cheilectomy described in the literature have varied
greatly. While some authors have recommended cheilectomy for early disease
only2,12,
others have used the procedure to treat both early and moderate
disease4,5;
still others have used it for all levels of
disease3,7,11,69.
The results of this study support the use of cheilectomy for all levels of
disease except Grade 4.
As a result of all of the different grading systems (or a lack of grading)
and differences in the technique of cheilectomy, it is difficult to compare
the results of different studies. However, rates of satisfaction after
cheilectomy have been favorable, ranging from 72% to
90%2-4,11-13,69.
We favor a uniform grading system to allow comparisons between studies and to
distinguish between a Grade-3 and a Grade-4 metatarsophalangeal joint.
Of interest was a significant progression in objective evidence of
periarticular sclerosis as well as loss of joint space width in our patients
who had undergone cheilectomy; however, there was no correlation between loss
of joint width and the AOFAS score, pain score, or patient
self-assessment.
Recurrence and Chondrolysis
Easley et al.1
reported that dorsal osteophytes recurred in twenty-one of sixty-eight feet
following cheilectomy, although the authors did not specify how the recurrence
was quantified. Several authors have noted that the metatarsophalangeal joint
deteriorates radiographically following
cheilectomy1,4,7,11.
Others have reported that cheilectomy hastens deterioration of the
joint2, and still
others have reported that deterioration is
uncommon3. Smith et
al.85 reported on
the natural history of hallux rigidus treated nonoperatively and observed that
the metatarsophalangeal joint deteriorated radiographically and clinically
with time (in sixteen of twenty-four feet). The results of our study support
the finding of those authors that a metatarsophalangeal joint with hallux
rigidus naturally deteriorates if followed for a long enough period of time.
Cheilectomy does not appear to alter the natural progression of the disease
process, but it enables a patient to be more comfortable during the course of
degeneration.
Metatarsophalangeal Joint Motion
Improved metatarsophalangeal joint motion following cheilectomy has been
emphasized in several
studies1,2,6,11.
Dorsiflexion has reportedly been improved by 28° to 50°, depending on
the individual study and the specific surgical technique used for the
cheilectomy1,3,7,13.
Authors using the technique described by Mann et
al.3 have reported
20° to 30° improvements in dorsiflexion and total range of
motion1,3,4,7,11,13,
whereas those using a minimal resection technique have reported about 50% less
improvement in
dorsiflexion2,6,12.
Several authors have reported diminishing improvements in motion with
increases in the grade of the
disease2,6,12,
whereas others1,
including us, have found fairly uniform improvement in motion even in patients
with more advanced disease. We reported an increase in mean dorsiflexion from
14.5° preoperatively to 38.4° postoperatively and an increase in mean
total motion from 39.2° to 64°. This improvement occurred consistently
across all grades, and it corresponds very closely with the findings reported
by several
authors1,3,7,11,13,
confirming the reliability of our cheilectomy technique.
Thus, it appears that minimal resection techniques are not as versatile,
especially for more advanced grades of
disease2,6,8,12.
With our more aggressive resection technique, the indications can be extended
to include more advanced disease without compromising the result or creating
an unstable
joint3,7,13,69.
Pain Relief
Pain relief has been reported consistently following
cheilectomy1,3,7,69,
but some authors have noted less pain relief with higher grades of
disease2,12,13.
A cheilectomy alters the joint in some fashion, providing pain relief even in
the presence of more advanced disease. However, there is a point (Grade-4
disease) at which reliable results are more difficult to obtain. We support
the notion of Easley et
al.1 that a clinical
finding of pain at the mid-range of motion (Grade 4) is a harbinger of a poor
result following cheilectomy and that it is critical to recognize this finding
especially in the presence of advanced radiographic changes. However, as noted
by
others7,69,
radiographic findings alone do not correlate with the final clinical result,
and we believe that purely radiographic grading systems should be
discarded.
Arthrodesis
There is little information on the performance of arthrodesis solely for
the treatment of hallux
rigidus52,53,57,58.
Fitzgerald53
reported that arthritis developed in the interphalangeal joint when the
metatarsophalangeal joint had been fused in <15° of valgus. One of us
(M.J.C.)78
previously reported that arthritis was more common in interphalangeal joints
when the metatarsophalangeal joint had been fused in <22° of
dorsiflexion. Other studies have shown progression of interphalangeal joint
arthritis after metatarsophalangeal joint
arthrodesis78,86,87.
However, these studies included a large number of patients with rheumatoid
arthritis. In the current study, which dealt only with hallux rigidus, we
noted no progression of degenerative changes in the interphalangeal joint
following cheilectomy or arthrodesis.
Complications
Arthrodesis resulted in a 94% fusion rate, and neither of the fibrous
unions was painful. Two patients underwent hardware removal because of pain.
There were no failures of hardware or other complications.
Although Easley et
al.1 suggested that
a medial approach is preferable for cheilectomy because of the risk of
tenodesis or scarring of the extensor hallucis longus tendon, because of
cosmetic concerns, and to avoid creating a hypertrophic dorsal scar, we found
no evidence of these complications in any patient.
Metatarsus Primus Elevatus
The concept of metatarsus primus elevatus as a cause of hallux rigidus has
been endorsed in several
reports2,8,23,28,30,34,36,37,41,50,70,81,82,88,89,
whereas radiographic evidence to the
contrary79,80,90
has also been reported. Functional hallux limitus (reduction of dorsiflexion
of the first metatarsophalangeal joint with loading of the foot compared with
passive dorsiflexion with non-weight-bearing) has also been proposed as a
cause of hallux
rigidus81-83.
Attempts to quantitate the magnitude of elevatus have been made with use of
two different measurements, the first metatarsal declination
angle80 and the
difference in elevation between the dorsal cortices of the first and second
metatarsals as seen on a weight-bearing lateral
radiograph79,90.
Normal elevatus is considered to be =8 mm, and the normal first
metatarsal declination angle has been reported to be between 19° and
25°79,90.
The mean preoperative elevatus was 5.5 mm in our patients, well within the
limits of normal. Moreover, the mean first metatarsal declination angle was
within normal limits both preoperatively and postoperatively in our
patients.
Metatarsus primus elevatus is rarely a structural problem that needs to be
corrected by an osteotomy, as has been recommended by
others32,34,36-39,74.
In our series, it consistently decreased after cheilectomy in patients with
lower grades of disease. We noted that these patients had the least amount of
elevatus. Elevatus corrected to nearly zero with the dorsiflexion stress test
(with any grade of hallux rigidus). While the elevatus decreased with passive
dorsiflexion stress, we found no difference between first metatarsophalangeal
joint motion with the dorsiflexion stress test and passive metatarsophalangeal
joint motion. These findings call into question the concept of functional
hallux limitus that has been reported in the
literature81-83.
However, we hypothesized that functional hallux limitus may represent the
residual elevatus that we occasionally noted on the dorsiflexion stress
radiographs of patients with more advanced disease.
This study demonstrates that a simple procedure such as cheilectomy tends
to reduce elevation of the first ray as the joint functions more normally. We
believe that when the joint has deteriorated clinically to the point where
elevation of the first ray is pronounced, it is an indication for
metatarsophalangeal arthrodesis because first-ray elevation significantly
diminished after arthrodesis in our series.
Our study had the longest mean duration of follow-up after both cheilectomy
and arthrodesis for the treatment of hallux rigidus. Ninety-six percent of the
patients followed for an average of 9.6 years after cheilectomy and 100% of
those followed for an average 6.7 years after arthrodesis had a good or
excellent subjective result. Pain scores in both groups were significantly
reduced compared with the preoperative scores, and AOFAS scores were
significantly improved.
The clinical-radiographic grading system used in this study appears to be
reliable. We believe that cheilectomy can be used with success for Grades 1,
2, and 3 hallux rigidus (Figs. 8-A and
8-B), but patients with Grade 4 or with <50% of the cartilage
surface of the metatarsal head remaining at the time of surgery should be
treated with arthrodesis (Figs. 9-A,
9-B, and 9-C). For
patients who desire preservation of motion and are willing to accept less than
total pain relief, cheilectomy provides a high proportion of good and
excellent long-term results. However, arthrodesis should be considered for
patients who clearly have pain in the mid-range of motion on examination. A
high proportion of these patients can be expected to have a good or excellent
long-term result after arthrodesis performed with the technique described in
this study.
Note: The authors thank Mary Sampson, MS, for assistance with
the statistical analysis.
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