Andrew D. Beischer

Abstract

Hallux rigidus is an arthritic condition affecting predominantly the dorsal aspect of the first metatarsal head with cartilage loss of dorsal spur formation. In early and moderate involvement (grade I–III) where the arthritis causes limited and painful dorsiflexion of the first metatarsophalangeal joint, a surgical debridement of the arthritic portion of the joint and spurs can be performed. The procedure, called cheilectomy after the Greek term Cheilos meaning “lip,” removed the dorsal 30% of the metatarsal head and corrected the problem in about 90% of cases.

Keywords: hallux rigidus, cheilectomy, dorsal cheilus

13.1 Indications

• Primary osteoarthritis of the first metatarsophalangeal joint (MTPJ) often starts with a loss of cartilage over the dorsal aspect of the first metatarsal (MT) head.

• Frequently, a dorsal first MT osteophyte develops, and these two pathologies combined result in a painful restriction of dorsiflexion, particularly during the push-off phase of gait.

• The dorsal osteophyte, when large, may also cause the symptom of painful rubbing against the upper of a closed shoe.

• As the arthritis process progresses, the cartilage loss occurs in the more central and eventually plantar aspects of the joint.

• First MT head cheilectomy is appropriate when the loss of cartilage is confined to the dorsal third of the joint.

13.1.1 Clinical Evaluation

• Clinical evaluation is important to help select which patients suffering from osteoarthritis of the first MTPJ are appropriate candidates for this procedure.

• The ideal candidate reports painful dorsiflexion of the joint with walking. Rubbing of the dorsal osteophyte against the shoe may also be a presenting symptom.

• On examination, there should ideally be at least 40 to 50 degrees of total motion of the joint.

• The axial load grind test should be used to identify irritability of the joint in the midrange of motion; if present, this is indicative of central first MT head chondral loss, which is a relative contraindication for this procedure.

• An interesting common observation is that with passive range of motion of the joint, pain is induced particularly with plantar flexion of the great toe. This is likely caused by stretching of the inflamed capsule over the dorsal osteophyte.

• Digital compression under each sesamoid with passive motion of the toe can be used to illicit pain from an arthritic sesamoid—first MT articulation, which, if present, is a relative contraindication to this procedure.

13.1.2 Radiographic Evaluation

• In general, all that is required to assess the patient is a standard series (anteroposterior, lateral, and internal oblique view) of weight-bearing X-rays of the foot.

• The internal oblique view in particular is useful to assess how much of the plantar joint space is preserved.