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.