CHAPTER SYNOPSIS:

Mild and moderate forms of hallux rigidus can be successfully treated with first metatarsophalangeal joint decompression. The surgical procedure is relatively simple consisting of resection of the dorsal osteophyte and the dorsal third of the metatarsal head. When combined with proximal phalanx dorsal closing wedge osteotomy, dorsiflexion can be further improved. Long-term follow-up shows high rates of patient satisfaction, less pain, and increased first metatarsophalangeal range of motion. If the results of cheilectomy prove unsatisfactory, salvage with an arthrodesis or resection arthroplasty can be performed.

IMPORTANT POINTS:

Indications:

• 1
  

  Hallux rigidus—Grades I and II, and grade III when the metatarsal head articular surface covers more than 50%.

  
  
• 2
  

  Young athletic patients, even when more advanced disease is present.

  
  
• 3
  

  A relative indication is a patient who desires to avoid the morbidity of more extensive procedure or the loss of first metatarsophalangeal joint motion.

  
  
• 4
  

  Adolescent patient with mild arthritic changes may benefit from isolated phalangeal osteotomy.

  
  
• 5
  

  Failure of previous nonsurgical treatment.

Contraindications:

• 1
  

  Severe hallux rigidus—Grade III with loss of more than 50% of the metatarsal head articular surface, and grade IV.

  
  
• 2
  

  Avoid proximal phalanx osteotomy if the interphalangeal joint has decreased plantarflexion.

SURGICAL PEARLS

• 1
  

  Two-stage resection: First, the dorsal osteophyte, and then 25% to 33% of the metatarsal head.

  
  
• 2
  

  Remove medial and lateral osteophytes.

  
  
• 3
  

  Remove the dorsal osteophyte from the proximal phalanx.

  
  
• 4
  

  Phalangeal osteotomy can be added routinely but should be combined if dorsiflexion is less than 70 degrees after cheilectomy.

  
  
• 5
  

  Proper fixation of the phalangeal osteotomy will not interfere with weight-bearing and early motion.

  
  
• 6
  

  Early passive and active range-of-motion exercises.

SURGICAL PITFALLS

• 1
  

  Cheilectomy will have less favorable results with more advanced disease: grade III with less than 50% articular coverage and grade IV.

  
  
• 2
  

  Inadequate bone resection will result in persistent impingement and reduced range of motion.

  
  
• 3
  

  Excessive resection may destabilize the joint to create a cock-up deformity.

  
  
• 4
  

  Tight postoperative dressing and prolong immobilization will result in joint stiffness.

VIDEO AVAILABLE:

• •
  

  Surgical treatment for hallux rigidus

HISTORY/INTRODUCTION/SCOPE OF THE PROBLEM

Hallux rigidus is a common disorder that affects the first metatarsophalangeal (MTP) joint. It alters joint kinematics and causes patients to change gait patterns for symptomatic relief. Cheilectomy has become a popular procedure for the treatment of early stages of hallux rigidus where the major pathology is located at the dorsal aspect of the joint. First MTP joint decompression by the removal of the dorsal osteophytes offers relief of pain while preserving some motion, power, and stability. It also avoids prolonged healing time and it is easily revised, if necessary.

In 1930, Nilsonne was the first to report on the removal of exostosis in two patients. Later, in 1952, Bonney and MacNab reported on the removal of exostosis in nine patients with hallux rigidus. Both concluded that the surgical procedure is unsuccessful for the treatment of hallux rigidus. These early failures are not considered as true cheilectomies, but more of exostosis shaving. In 1959, DuVries was the first to describe what is now considered to be a cheilectomy. He advocated removal of the dorsal proliferative bone to allow at least 45 degrees of dorsiflexion intraoperatively. He had 90% satisfactory results, but no long-term follow-up was reported. In 1979, Mann, Coughlin, and DuVries used the same surgical technique where the dorsal third of the metatarsal head is removed. They reported on satisfactory results with this procedure in 20 patients who had been followed for an average of 67.6 months.

Another surgical treatment for early stages of hallux rigidus is the proximal phalanx dorsal closing wedge osteotomy. This procedure was mainly reported in adolescents when limited dorsiflexion was found with no significant osteophyte formation or degenerative changes. The procedure was first proposed by Bonney and MacNab, and in 1979, Moberg reported using proximal phalanx osteotomy in adults. As a result, this is often known as the Moberg procedure. By using the available plantarflexion at the MTP joint, the osteotomy transfers plantarflexion to dorsiflexion. Moberg reported no complications in eight adult cases. One step further is the use of both surgical procedures. In early stages of hallux rigidus, the dorsal proliferative bone on the metatarsal head and proximal phalanx can be removed to eliminate impingement. Still, range of motion may be insufficient and the addition of a proximal phalanx dorsiflexion osteotomy may help to improve dorsiflexion by translating the arc of motion into the more normal zone of the joint.

INDICATIONS/CONTRAINDICATION

The decision whether cheilectomy is the appropriate surgical treatment for a specific patient who has hallux rigidus depends on a number of variables. The patient’s age, activity level, expectations, and prior treatment history are important but are not considered as important as the severity of degenerative arthritis. Most of the reports on the surgical outcome of cheilectomy consider hallux rigidus grade as the leading differentiator for recommendation and indication for surgery. Several grading systems for hallux rigidus have been proposed. They have incorporated radiographic findings, clinical symptoms, or a combination of both. Hattrup and Johnson used radiographic criteria to separate hallux rigidus into three grades. Grade I involves the formation of minimal dorsal osteophytes with a preserved joint space. Grade II has moderate dorsal osteophytes with sclerosis and joint space narrowing. In grade III, there is significant osteophyte formation with obliteration of the joint space. Coughlin and Shurnas further refined this grading system and added clinical variables. Grade 0 has normal radiographic appearance and no pain but has stiffness and loss of motion as compared with the normal side. Grades I to III have the same radiographic appearance as in the Hattrup and Johnson grading system. Grade I has 20% to 50% loss of dorsiflexion and mild pain, grade II has 50% to 75% loss of dorsiflexion with moderate to severe pain, and grade III has less than 10 degrees of dorsiflexion and nearly constant pain at extremes of range of motion. They also added a grade IV, which has the same radiographic and range of motion criteria as grade III, but there is pain at mid range of passive motion. Coughlin and Shurnas reported the correlation between their grading system and outcome on a series of 140 patients and found that the system appeared to be reliable as it correctly predicted a successful or poor outcome of cheilectomy. They concluded that cheilectomy is indicated in all levels of disease except for grade IV and grade III when intraoperatively the metatarsal head articular coverage is found to be less than 50%. But even a reliable grading system cannot solve the differences in outcome among different authors, and the indications for performing a cheilectomy are still controversial. Some authors recommend cheilectomy as a treatment of lower grades only, whereas others reported successful results even for higher grades of hallux rigidus. However, it is well accepted that cheilectomy is indicated for early stages—grades I and II.

Patient evaluation before surgery is important. Active and passive range of motion at the first MTP should be quantified, and the presence of pain should be recorded as being only at ends of range of motion or at mid range. Typically, pain is noted during terminal heel rise and is experienced on the dorsal aspect of the joint. When pain is localized to the plantar aspect of the first MTP, it may indicate advanced degeneration of the joint. Mechanical impingement of the dorsal exostosis against the toe-box of the shoe may be considered another indication for cheilectomy. Weight-bearing anteroposterior (AP), oblique, and lateral radiographs should be obtained ( Figs. 35-1 and 35-2 ). The lateral radiograph reveals that most of the changes are localized to the dorsal aspect of the joint and allows the determination of the joint space, which is often obscured on the AP or oblique views. Loose bodies may also be seen on the lateral radiograph. The AP radiograph shows joint space narrowing and may reveal medial or lateral osteophytes. The oblique radiograph is used to determine the extent of joint space narrowing.

Preoperative lateral radiograph demonstrate a grade II hallux rigidus.

Preoperative anteroposterior radiograph demonstrates a grade II hallux rigidus.

Intraoperative findings are part of the patient evaluation and should assist in decision making. Patients who have a stiff joint may benefit from a combined closing wedge osteotomy of the base of the proximal phalanx and cheilectomy. Keiserman et al. advocated that if after performing a cheilectomy, the first MTP range of dorsiflexion is less than 90 degrees, then proximal phalanx osteotomy is indicated.

Intraoperative findings may help to determine the best type of treatment for patients with grade III disease who have the same radiographic findings and minimal pain at maximum plantarflexion and dorsiflexion. As advocated by Coughlin and Shurnas, the decision whether to perform a cheilectomy or MTP joint arthrodesis is made during surgery after inspection of the first metatarsal head articular coverage. If the articular coverage is more than 50%, cheilectomy is performed; otherwise, arthrodesis is done. Such patients need to be consulted before surgery and if they understand the differences between the surgical options, they need to give consent for both arthrodesis and cheilectomy. The surgeon then chooses the procedure at the time of operation.

Some patients will still be candidates for cheilectomy even though the degree of joint arthritis is advanced. These are usually young athletic patients and patients who want to avoid the risk and morbidity of more extensive procedures.

Isolated proximal phalanx osteotomy has a role in the treatment of hallux rigidus for the adolescent patient without significant arthritic changes (grades 0 and I). It was reported as a successful procedure in several small series. By translating plantarflexion motion to dorsiflexion, the hallux is under less stress at push-off and more motion is translated to the plantar aspect of the metatarsal head, reducing the dorsal impingement. More dorsal joint decompression may be achieved by the dorsal closing wedge osteotomy, which creates larger dorsal joint space. However, this procedure is contraindicated when plantarflexion motion is restricted.