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Hallux RigidusGrading and Long-Term Results of Operative Treatment
Michael J. Coughlin, MD1; Paul S. Shurnas, MD2
1 901 North Curtis Road, Suite 503, Boise, ID 83706. E-mail address: footmd@aol.com
2 Regional Orthopaedic Health Care, No. 3 Medical Plaza, Mountain Home, AR 72653
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The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at St. Alphonsus Regional Medical Center, Boise, Idaho

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2003 Nov 01;85(11):2072-2088
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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.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Michael J. Coughlin M.D.
    Posted on August 04, 2004
    Drs. Coughlin and Shurnas respond:

    To the Editor:

    We appreciate the opportunity to respond to Dr Webb’s letter regarding our study. While Dr. Webb suggests that hindfoot valgus, pes planus, and gastrocsoleus tightness lead to first ray hypermobility and metatarsus primus elevatus, his supporting references (1,2,3,4,5) offer no objective proof of his notion. In a separate report that we published (6) on the demographics and radiographic data concerning the same cohort of patients in the current study, we reported an 11% incidence of pes planus and concluded that pes planus is no more common in patients with hallux rigidus than in the normal population.

    While Bingold (7) suggested an association of hallux rigidus and Achilles tendon contracture, there were only four patients in the series (6) who had five degrees or less of ankle dorsiflexion with the knee extended and the foot in neutral alignment. We concluded that a tight Achilles tendon is not associated with hallux rigidus.

    Several reports have suggested an association of first ray hypermobility and hallux rigidus (1,7,8,9,10,11,12,13) although objective data was not presented in any of these reports. In our report (6), we used an external caliper (Klaue’s device)(14) to quantify first ray mobility. We noted an average first ray mobility of between 5 and 6 mms, and reported no association between first ray hypermobility and hallux rigidus. Using Klaue’s criteria (14) for determining hypermobility, only 1/127 feet were considered hypermobile.

    Many reports (1,5,9,10,11,15,16,17,18,19) have endorsed the concept of metatarsus primus elevatus with little or no objective data. Several techniques have been described to measure elevatus including Seiberg’s technique (using two reference points)(22), Horton’s technique (using one reference point)(23), and angular measurements (first metatarsal declination angle-1-MDA)(24). We found Horton’s technique to give a reliable and repeatable estimation of the first metatarsal elevatus.

    In our report on the demographics of this cohort of patients (6), we also measured the first metatarsal declination angle. We reported a correlation between the 1-MDA and the metatarsus primus elevatus as measured with Horton’s technique. (r=.6, p=.03). While we found elevatus to be uncommon, we observed increasing elevatus with an increasing grade or severity of hallux rigidus. Based on this information, we believe that elevatus is a secondary change rather than a primary cause of hallux rigidus.

    Lastly, Dr. Webb suggests that differences in the x-ray tube angle can lead to distortion of the radiographic image (25) and suggests this as a further explanation of why our data do not support his contention of an association of hallux rigidus and metatarsus primus elevatus. During the twenty-three years of this study, radiographs were taken in our office with the same standardized technique. We suggest that while one might propose numerous reasons why our data do not demonstrate an association of hallux rigidus and metatarsus primus elevatus, the objective data are clear. Based on the results of our study, we believe that procedures such as first metatarsal osteotomies to treat elevatus are rarely indicated and are aimed at correcting a secondary rather than a primary problem. We further conclude that the two procedures we have described (cheilectomy and arthrodesis) yield predicable, reliable and long-term successful results when used with the grading system we described.

    Sincerely yours,

    Michael J. Coughlin M.D. Idaho Foot and Ankle Fellowship Program Boise, Idaho

    Paul S. Shurnas M.D. Columbia Orthopaedic Group Columbia, MO


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    Brad S Webb
    Posted on July 08, 2004
    Metatarsus Primus Elevatus and Hallux Rigidus
    St. Josephs Regional Medical Center Podiatric Surgical Residency Program

    To The Editor,

    While we agree with many of the points brought forth in the article, Hallux Rigidus Grading and Long-Term Results of Operative Treatment, by Coughlin et al., others bring up questions.

    The authors indicated that metatarsus primus elevatus was not present in the majority of the patients included in their study. However, their method of measuring the distance between the dorsal cortices of the first and second metatarsals to evaluate metatarsus primus elevatus is susceptible to error. A study by Camasta (1) illustrated that differences in the x-ray tube head angle can cause distortion of the radiographic image. We believe, therefore that the authors' conclusion that metatarsus primus elevatus is not a factor in the etiology of hallux rigidus should be reconsidered.

    Seiberg (2) described a reproducible radiographic method of evaluating metatarsus primus elevatus that measures the difference between the dorsal cortices of the first and second metatarsals at two sites. The first measurement is 1.5cm distal to the first metatarsal cuneiform joint and the second is 1.5cm proximal to the 1st metatarsal head. If the distal value is greater than the proximal one then a true metatarsal elevation is present.

    Coughlin et al. also do not mention whether they evaluated patients for certain deformities that are associated with the development of hallux rigidus. These include compensated forefoot and hindfoot valgus, and gastrocnemius or gastroc-soleal equinus. These deformities can cause the subtalar joint to be abnormally pronated in the stance phase of gait. Such abnormal pronation leads to hypermobility of the 1st ray caused by inability of the peroneus longus to stabilize the ray when it loses its mechanical advantage. This causes the 1st metatarsal to be in an elevated position, which inhibits dorsiflexion of the proximal phalanx on the 1st metatarsal during toe off (3,4,5,6,7). We feel, therefore that failure of the authors to address the most common causes of this deformity leads to an oversimplified picture of this complex condition.


    1. Camasta, C.A., Pontius J., Boyd RB. Quantifying magnification in pedal radiographs. J Am Podiatr Med Assoc 1991; 81: 545-548. 2. Seiberg M, Felson S, Colson JP, et al. Closing base wedge versus Austin bunionectomies for metatarsus primus adductus. J Am Podiatr Med Assoc, 1994; 84:548-563. 3. Camasta, C.A., Radiographic evaluation and classification of metatarsus primus elevatus. In Reconstructive Surgery of the Foot and Leg Update 94 pp.122-127. Edited by C.A. Camasta, The Podiatry Institute, Tucker, GA. 1994. 4. Roukis T., Jacobs, Dawson, Erdmann, Ringstrom A prospective Comparison of Clinical, Radiographic, and Intraoperative Features of Hallux Rigidus Journal of Foot and Ankle Surgery, Vol. 41 (2) March/April 2002: 76-95. 5. Root, M.L., Orien, W.P., Weed, J.H. Normal and abnormal function of the foot. In Clinical Biomechanics, Vol. II, Clinical Biomechanics Corp., Los Angeles, 1977. 6. Shereff M., Baumhauer J., Hallux Rigidus and Osteoarthritis of the first Metatarsal Phalangeal Joint, JBJS, Vol. 80 A(6) June 1998: 898- 908. 7. Vanore, Christensen, Kravitz, Shuberth, Thomas, Weil, Zlotoff, Coutute, Diagnosis and Treatment of First Metatarsal Phalangeal Joint Disorders. Section 2: Hallux Rigidus. JFAS, vol. 42 (3) May/June 2003: 124 -136.

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