Extract
The term hallux rigidus is used to describe a condition
characterized by pain and a reduction in the range of motion, especially
dorsiflexion, at the first metatarsophalangeal
joint1-3.
According to the etiology, hallux rigidus can be classified as primary (hallux
limitus) or secondary (Table
I)1,2,4-8.
The term hallux rigidus is used to describe a condition
characterized by pain and a reduction in the range of motion, especially
dorsiflexion, at the first metatarsophalangeal
joint1-3.
According to the etiology, hallux rigidus can be classified as primary (hallux
limitus) or secondary (Table
I)1,2,4-8.
Functional Consequences
With normal locomotion, the amount of hallux dorsiflexion during propulsion
must approximate 65° to
75°9. With
hallux rigidus, dorsiflexion of the first metatarsophalangeal joint is
restricted9. As a
consequence, during the propulsive phase of gait, functional limitation and
pain lead to an internal rotation of the forefoot, reducing push-off and
creating transfer metatarsalgia (Fig.
1)9,10.
Indications for Surgery
The indication for surgery is pain combined with degenerative changes of
the first metatarsophalangeal joint. Because there is no correlation between
reduction of dorsiflexion and radiographic findings in hallux rigidus, we
believe that the most useful parameter for the choice of a specific surgical
technique is the extent of arthritis of the metatarsophalangeal joint as seen
radiographically with use of a classification system described by Coughlin and
Shurnas11 and
modified by us (Table II)
(Fig. 2).
Patient Factors
The surgical strategy has to be planned according to the arthritis
classification and must include consideration of other patient factors
(Table III). The goal of
surgery is to relieve pain, improve function, reduce the progression of
arthritis, and correct any associated deformity.
Aim of the Report
The purpose of this report is to present guidelines for the surgical
treatment of hallux rigidus by presenting the results of the treatment of a
consecutive series of 111 feet.
One hundred and eleven feet with hallux rigidus in eighty-six patients were
treated consecutively between 1992 and 2000. There were sixty-seven female and
nineteen male patients, and they had a mean age of 53 ± 12 years. At
admission, all patients were evaluated clinically with regard to pain, range
of motion, and alignment. In all patients, the range of motion of the first
metatarsophalangeal joint was measured with use of a goniometer and according
to the method of Ronconi et
al.12, with the
foot at 90° to the leg in a non-weight-bearing state, and the value was
recorded. Beginning in 1995, the patients were asked to complete the American
Orthopaedic Foot and Ankle Society
questionnaire13.
Anteroposterior and lateral weight-bearing radiographs were evaluated.
Surgical Technique
Surgical treatment was performed with the patient under general, spinal, or
local block anesthesia. A tourniquet was applied, according to the anesthetic
technique, at the thigh or ankle level. All patients were discharged the day
of surgery if they were treated with local anesthesia or the day after surgery
if they were treated with general anesthesia, and weight-bearing was permitted
in a postoperative shoe. Antibiotic therapy was given for two days, and
antithromboembolic therapy (low-molecular-weight heparin) was given until the
time of suture removal.
Grade-0 Hallux Rigidus
In seven feet affected by hallux rigidus associated with grade-0 arthritis
of the metatarsophalangeal joint, a plantar release alone was
performed14. For
these patients, the approach is medial, proceeding through the skin,
subcutaneous tissue, and capsule directly to the bone. The capsule is
released. A synovectomy is performed first, and then the plantar plate is
completely detached from the plantar surface of the base of the proximal
phalanx with use of a blade or a small periosteal elevator
(Fig. 3). The sesamoid bones
are released from the metatarsal head. The great toe is then manipulated until
90° of dorsiflexion can be achieved. The capsule is then closed with
0-gauge reabsorbable sutures, avoiding excessive tension of the capsule. A
compressive gauze dressing is applied for two weeks, and early active and
passive motion is then begun.
Grade-1 Hallux Rigidus
In eighteen feet affected by hallux rigidus associated with grade-1
arthritis of the metatarsophalangeal joint, one of two decompressive
osteotomies (both achieving shortening and plantar displacement of the
metatarsal head) was
performed15,16.
Ten feet without any deformity of the hallux and with grade-1 hallux rigidus
received a sliding decompressive oblique
osteotomy15
(Fig. 4). Through a dorsal
approach to the metatarsophalangeal joint, after retracting the extensor
hallucis longus medially, the dorsal aspect of the capsule is incised. By
forcing the hallux into extreme plantar flexion, the metatarsal head is
exposed. After performing a plantar release and removing any osteophytes, the
osteotomy is performed in a distal-to-proximal direction beginning from
approximately 3 mm inside the articular surface. The head fragment is
displaced proximally by 3 to 5 mm, and the consequent plantar displacement is
approximately 1 to 2 mm. The head is fixed temporarily with use of a 1.6-mm
Kirschner wire. Definitive fixation is then obtained with a 2.7-mm
hydroxyapatite-coated cancellous bone screw. The dorsal spike of the proximal
fragment is resected tangentially.
Eight feet with deformity of the great toe (seven with valgus alignment and
one with varus) and grade-1 hallux rigidus underwent a modified chevron
decompressive
osteotomy16
(Fig. 5). With use of a medial
approach, the medial eminence of the head is removed. After performing a
plantar release, a chevron-shaped osteotomy is made. A 3-mm slice of bone is
dorsally cut and removed to achieve plantar and proximal displacement of the
head combined with lateral or medial displacement as needed to correct the
deformity. Fixation is achieved with a 1.8-mm percutaneous Kirschner wire. In
the case of a valgus deformity, any medially protruding portion of the
proximal fragment is also resected tangentially. A compressive gauze dressing
is applied for four weeks. The Kirschner wire is then removed, and active and
passive range-of-motion exercises are begun.
Grade-2 Hallux Rigidus
Thirty-three feet with hallux rigidus associated with grade-2 arthritis of
the metatarsophalangeal joint were treated with a
cheilectomy17-20.
A medial or dorsal approach is used. After plantar release, all osteophytic
prominences surrounding the metatarsal head and the base of the proximal
phalanx are excised. Next, resection of 25% to 30% of the dorsal aspect of the
metatarsal head is performed according to the technique of Mann and
Clanton18
(Fig. 6). A compressive gauze
dressing is applied for two weeks, and early active and passive motion
exercises are advised.
Grade-3 Hallux Rigidus
In fifty-three feet affected by hallux rigidus associated with grade-3
arthritis of the metatarsophalangeal joint, an arthrodesis or resection
arthroplasty with a bioreabsorbable poly (DL-lactic acid) spacer was
performed6,21-23.
In thirty-one feet with grade-3 hallux rigidus in young patients with high
functional demands or in patients with severe deformity, regardless of age, an
arthrodesis of the first metatarsophalangeal joint was
performed6,21,22.
The approach is medial, proceeding through the skin, subcutaneous tissue, and
capsule directly to the bone. After release of the metatarsal head and the
base of the proximal phalanx, all osteophytes are removed. A resection of the
joint through two parallel cuts is then performed. The toe must be placed in
the proper position. In the sagittal plane, the arthrodesis angle must be
equal to the metatarsal inclination angle with the toe parallel to the ground
(Fig.
7)24.
In the horizontal plane, the arthrodesis angle should be 5° to 15° of
valgus deviation, and, in the frontal plane, the rotation of the toe must be
neutral (Fig.
8)24.
Screw fixation in the correct alignment is obtained with use of a 1.8-mm
percutaneous Kirschner wire in order to control the rotation and a 3.5-mm
hydroxyapatite-coated lag screw to create compression across the arthrodesis.
A compressive gauze dressing is applied for one month, and the Kirschner wire
is then removed. The day after removal of the wire, full weight-bearing and
physical therapy (range-of-motion exercises of the interphalangeal joint and
hydrotherapy) is advised.
In three feet in young patients with severe shortening of the toe, a
lengthening arthrodesis was performed with use of an autologous bone graft
harvested from the iliac crest or from the proximal aspect of the ipsilateral
tibia. Fixation in these feet was achieved with two 1.8-mm Kirschner
wires.
In twenty-two feet with grade-3 hallux rigidus (eighteen feet in elderly
patients or in patients with low functional demands, three feet in young
patients who refused arthrodesis, and one foot in a professional soccer
player), an arthroplasty with a bioreabsorbable poly(DL-lactic acid) spacer
was performed23
(Fig. 9).
Through a medial approach, after release of the base of the proximal
phalanx and of the metatarsal head and removal of all osteophytes, a minimal
resection of the head is carried out. Then the medullary canal is prepared to
accommodate the stem of the spacer, which is cannulated to enable the passage
of a 1.4-mm Kirschner wire. The spacer is positioned in the joint and is then
stabilized by running the Kirschner wire from the end of the toe through the
spacer and along the entire first ray. A compressive gauze dressing is applied
for two weeks. The Kirschner wire and sutures are then removed, and physical
therapy is begun.
Postoperative Evaluation
Outcomes were assessed with use of the American Orthopaedic Foot and Ankle
Society foot
score13,
range-of-motion measurements, and findings on anteroposterior and lateral
radiographs. Preoperative and postoperative data (mean duration of follow-up,
four years; range, three to eight years) were compared with the Student t test
and the chi-square test (p < 0.001).
Clinical Results
The mean score (and standard deviation) on the American Orthopaedic Foot
and Ankle Society scale was 42 ± 14 points preoperatively and 81
± 9 points at the time of follow-up (p < 0.05)
(Fig. 10). The mean range of
motion of the metatarsophalangeal joint was 27° ± 17°
preoperatively and 75° ± 8° at the time of follow-up for all
patients who had not had a metatarsophalangeal arthrodesis (p < 0.001)
(Fig. 11). No intraoperative
complications were observed. One foot with a bioreabsorbable poly(DLlactic
acid) implant had a localized infection at the metatarsophalangeal joint with
sinus formation. The implant did not require revision, but the infection
resulted in ankylosis in an acceptable position. Five feet had inflammation
around the Kirschner wire, which resolved spontaneously after the wire was
removed. Four patients experienced deep venous thrombosis, and in one of them
it was complicated by a pulmonary embolism. Ten patients required a second
operation on the involved foot (Table
IV).
Radiographic Results
Three of the seven feet with grade-0 arthritis of the metatarsophalangeal
joint demonstrated a worsening of the arthritis at the time of the final
follow-up. In the eighteen feet affected by grade-1 arthritis, all of the
osteotomies healed well. Necrosis of the metatarsal head was not seen. In
eight of the eighteen feet, the arthritis became more severe. In twelve feet
with grade-2 arthritic changes, a worsening of the arthritis was observed. In
the thirty-one feet with grade-3 arthritis that were treated with arthrodesis,
two demonstrated a delayed union and one had a nonunion. In two of the
twenty-two feet with grade-3 arthritis that were treated with a poly(DL-lactic
acid) implant, bone reabsorption at the metatarsophalangeal joint was
observed.
This stepwise approach to the surgical treatment of hallux rigidus enabled
us to achieve satisfactory results while maintaining the mobility of the first
metatarsophalangeal joint and achieving considerable pain relief in most of
the eighty-six patients at a mean duration of follow-up of four years.
Plantar release as an isolated procedure appears to be an adequate
technique to treat hallux rigidus associated with grade-0 arthritis of the
metatarsophalangeal joint; in fact, at four years postoperatively, the
clinical results remained satisfactory even though two patients required an
arthrodesis of the first metatarsophalangeal joint because of rapid and severe
progression of the arthritis (Figs.
12-A and
12-B).
Osteotomies of the distal aspect of the first metatarsal can produce an
adequate decompression of the joint with relief of pain in patients with
grade-1 arthritis (Figs. 13,
14-A, and
14-B), and cheilectomy
provides optimal clinical results in hallux rigidus associated with grade-2
arthritis.
In some patients in all groups, progression of the arthritis was observed.
We believe that this occurred as a result of incorrect grading of the
arthritis leading to an inadequate surgical approach or to insufficient
removal of bone.
When arthrodesis was indicated and the patient accepted the treatment,
satisfactory results were achieved. An alternative for elderly patients, or
when arthrodesis is not accepted by the patient, may be the reabsorbable
implant. The spacer resorbs slowly over six months, facilitating the formation
of a fibrous union that can maintain the stability and length of the toe
(Fig.
15)23.
In conclusion, hallux rigidus is a complex disorder characterized by
several clinical and pathological findings. For this reason, to achieve
optimal results, surgical treatment should be individualized with use of
different surgical techniques depending upon the degree of arthritis and other
clinical considerations.
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