End-Stage Hallux Rigidus

Cheilectomy, Implant, or Arthrodesis?

Ruth A. Peace, DPM ^a, Graham A. Hamilton, DPM ^b^,^*

^a Kaiser San Francisco Bay Area Foot and Ankle Residency Program, Kaiser Foundation Hospital, 280 West MacArthur Boulevard, Oakland, CA 94611, USA

^b Department of Orthopedics and Podiatric Surgery, Kaiser Permanente Medical Center, 3400 Delta Fair Boulevard, Antioch, CA 94801, USA

^* Corresponding author.

E-mail address: Graham.A.Hamilton@kp.org

Abstract

End-stage arthritis of the first metatarsophalangeal joint (MTPJ) typically results in anexophytic process with marked limitation of motion. Pain may occur from the degenerative process itself and/or the bone spur formation that may become directly inflamed from shoe gear. The best surgical treatment for end-stage arthrosis of the big toe joint continues to be a controversial topic despite hallux rigidus being recognized clinically for more than 100 years. Although joint-sparing procedures are considered, arthrodesis is recommended, as this procedure is definitive and produces predictable results.

Keywords

• Hallux rigidus • Hallux limitus • Arthrodesis • Cheilectomy • First metatarsophalangeal joint

End-stage arthritis of the first metatarsophalangeal joint (MTPJ) typically results in an exophytic process with marked limitation of motion. Pain may occur from the degenerative process itself and/or the bone spur formation that may become directly inflamed from shoe gear. The best surgical treatment for end-stage arthrosis of the big toe joint continues to be a controversial topic despite hallux rigidus being recognized clinically for more than 100 years. Although joint-sparing procedures are considered, joint destructive procedures are recommended, as they are definitive and produce predictable results.

History of hallux rigidus

Hallux rigidus refers to the limitation of motion at the first MTPJ with particular limitation of hallux dorsiflexion. In 1887, Davies-Colley ¹ observed this limitation of motion, calling it hallux flexus, because of the relative plantar flexed position of the proximal phalanx in relation to the metatarsal head. Later that same year, Cotterill² coined the term hallux rigidus, still the most commonly used expression for the condition. In 1937, Hiss³ described the same condition and developed the phrase hallux limitus. Although some surgeons consider hallux rigidus and limitus as distinct entities, others consider hallux limitus as an earlier stage of degenerative joint disease, in a continuum of joint degradation.

The painful restricted motion at the first MTPJ is often associated with a mechanical block caused by periarticular osteophytes. The exostosis of the first metatarsal head articulates against an osteophyte at the base of the proximal phalanx leading to mechanical impingement.

Etiology

The cause of hallux rigidus has not been determined, although multiple predisposing factors have been revealed. Hallux rigidus has been described in 2 different populations: a congenital form and an adult-acquired degenerative form. The congenital form usually presents in the teenage years through the 20s, from a predisposing anatomic factor, such as flattening or squaring of the metatarsal.⁴ The adult degenerative form typically presents in a relatively older population in their 40s and 50s, usually as a result of predisposing high-impact activities such as running or dancing. The adult form may be a continuation of the congenital form, although in most cases the exact cause is unknown. The incidence of hallux rigidus in men at age 50 is 31.7% and 40.9% in women of the same age. By age 65, those percentages increase to 51.0% and 67.8%, respectively.⁵ Forty-three is shown to be the average age at onset, and the average age at time of surgery is 50 years.⁶

Classification

Numerous investigators have proposed grading systems determined by radiographic changes only, or a combination of clinical and radiographic criteria. Although there are more than 7 classifications used to describe the progressive level of joint arthrosis, none have effectively offered prognostic value, but do offer useful treatment guidelines. The most common clinically used classification system is the Regnauld classification system (Box 1).

Surgical treatment

Since the original description of hallux rigidus, numerous surgical procedures have been described. Surgical reconstruction for this condition falls into 2 broad categories: those procedures in which the joint is spared and joint-destructive procedures. The latter is typically reserved for joints showing advanced osteoarthritis. Joint-sparing procedures include cheilectomy, phalangeal osteotomy, and first metatarsal osteotomy. Joint-destructive procedures include excisional arthroplasty, implant arthroplasty, and arthrodesis. Newer procedures include a category referred to as cartilage resurfacing: interpositional arthroplasty and arthrodiastasis. The medium-term to long-term efficacy for these procedures by independent researchers has yet to be determined.

Surgery involving the first MTPJ has been present for more than 100 years. Arthrodesis was initially described in 1852 by Broca, but was not popularized for use as treatment for hallux rigidus until 1952 by McKeever.⁷ DuVries described the modified cheilectomy,⁸ which has remained a popular initial surgical treatment for hallux rigidus. It was not until the 1970s that Swanson popularized the silicone implant.

Although cheilectomy, arthrodesis, and joint replacement are the standards for treatment of this condition, controversy exists as to what stage of hallux rigidus each procedure is best suited. It is well accepted that cheilectomy is indicated in a patient who is in the early stages of clinical symptoms and radiographic joint damage. The joint-destructive procedures are recommended for advanced disease, of which arthrodesis has remained the gold standard.

Cheilectomy

Since the original description of hallux rigidus in 1887 by Davies-Colley,¹ variations have existed in the surgical methods of decompressing the MTPJ. It was not until 1959 that DuVries⁸ gave a detailed description of the cheilectomy that with modifications is still used by surgeons today. The cheilectomy has become a popular procedure for the treatment of early stages of hallux rigidus in which the major pathology is located at the dorsal aspect of the joint. The procedure is described as the resection of the dorsal 20% to 30% of the metatarsal head.^6,^9,¹⁰ Joint decompression offers relief of pain while preserving some motion, power, and stability. It also avoids prolonged healing time and it is easily revised, if necessary (Fig. 1).¹¹^–¹³

Fig. 1 (A, C) Preoperative anteroposterior and lateral radiographs of a 57-year-old woman with mild arthrosis at the first MTPJ. There is no evidence of joint space narrowing (grade I hallux rigidus). (B, D) Postoperative anteroposterior and lateral radiographs after resection of the dorsal third of the metatarsal head (arrow at metatarsal head).

The decision as to 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. Some investigators recommend cheilectomy as a treatment of lower grades only,^6,¹⁴^–¹⁷ whereas others reported successful results even for higher grades of hallux rigidus.^11,^12,¹⁸ Blitz¹⁴ suggests that cheilectomy is indeed an option for end-stage arthrosis because the dorsal osteophyte is responsible for most pain, and removing this allows for enough pain reduction to satisfy patients’ expectations. Nonetheless, cheilectomy is clearly indicated for early stages, grades I and II, using the Regnauld classification scheme.^19,²⁰ Coughlin and Shurnas, however, do not recommend cheilectomy for stages III and IV of their 5-grade classification scheme.⁶

A primary issue associated with cheilectomy is the recurrence of chondrolysis and exostosis as well as further joint deterioration. Easley and colleagues ¹⁸ performed 75 cheilectomies using the Hattrup and Johnson classification and American Orthopaedic Foot and Ankle Society (AOFAS) scoring system to evaluate results. The number of patients with grade III increased from 12 to 40 at the 2-year follow-up. Thirty-eight patients worsened at least 1 grade. They also found that the higher the grade at the time of surgery, the less predictable the AOFAS scores became. Patients undergoing cheilectomy should be counseled that given the progressive nature of osteoarthritis, future revisional surgery may be required.

Rates of satisfaction after cheilectomy have been favorable, ranging from 72% and 90%.^11,^12,¹⁸ Cheilectomy is still a “no bridges burned” type of approach to early-stage hallux rigidus. If the results of cheilectomy prove unsatisfactory, salvage with arthrodesis or resection arthroplasty can be performed in the future.