Management of Hallux Rigidus

Abdul Arain

Khusboo Desai

Introduction

Loss of motion of first metatarsophalangeal joint (MTPJ) in adults due to degenerative arthritis
Associated with repetitive microtrauma and anatomic variations of the first metatarsal predisposing to arthritis
Dorsal osteophyte formation leads to impingement, resulting in shoe irritation and limited dorsiflexion. Patients will also have increased pain and swelling with forced dorsiflexion of the great toe and decreased push-off strength.¹

Chilectomy

Sterile instruments/equipment
- Tourniquet
- Headlight
- Dental picks and Freer elevators
- Pointed reduction clamps
- K-wires and wire driver/drill/saw
- Skin hooks and Senn retractors
Positioning
- Regional ankle block consisting of a 1:1 mixture of 0.25% bupivacaine and 1% lidocaine without epinephrine
- Intravenous (IV) antibiotics 30 to 45 minutes before the procedure
- Supine with foot at distal edge of operating table
- Prep and drape to lower calf.
- Tourniquet around calf (optional)

Approach

Dorsal approach to first MTPJ
Skin incision 3 cm proximal to MTPJ to middle of proximal phalanx (Figure 1-1)
Retract extensor hallucis longus (EHL) and dorsomedial sensory nerve laterally.
Carry incision down through dorsal capsule.
Reflect dorsal aspect of collateral ligaments to increase joint exposure.
Maximally dorsiflex hallux and resect osteophyte from base of proximal phalanx with flexible chisel (Figure 1-2).
Resect dorsal 25% to 30% of metatarsal head articular surface. Angle flexible chisel distal to proximally, exiting at the metaphyseal-diaphyseal junction.
Resect medial and lateral osteophytes as needed. Avoid destabilizing collateral ligaments.

Check metatarsophalangeal (MTPJ) range of motion after resection by maximally dorsiflexing (Figure 1-3). Resect additional bone as needed if residual impingement is encountered.

Figure 1-1. A, Dorsomedial approach to the hallux metatarsophalangeal joint. B, Identify the dorsomedial sensory nerve to the hallux and the extensor hallucis longus tendon. C, Capsulotomy after nerve and tendon are retracted. From Marks RM. Dorsal cheilectomy for hallux rigidus. In: Easley ME, Wiese SW, eds. Operative Techniques in Foot and Ankle Surgery. Philadelphia, PA: Wolters Kluwer Health; 2010:chap 18 (Tech Figure 1).

Figure 1-2. Resection of the dorsal osteophyte at the base of the proximal phalanx, performed with the hallux in maximal dorsiflexion, which will protect the remaining articular surface of the metatarsal head. From Marks RM. Dorsal cheilectomy for hallux rigidus. In: Easley ME, Wiese SW, eds. Operative Techniques in Foot and Ankle Surgery. Philadelphia, PA: Wolters Kluwer Health; 2010:chap 18 (Tech Figure 2A).

Figure 1-3. Assessment of hallux motion; should approach 90° of passive dorsiflexion. From Marks RM. Dorsal cheilectomy for hallux rigidus. In: Easley ME, Wiese SW, eds. Operative Techniques in Foot and Ankle Surgery. Philadelphia, PA: Wolters Kluwer Health; 2010:chap 18 (Tech Figure 2G).

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