Hallux Rigidus

Hallux Rigidus ICD-9

• 735.2 Hallux Rigidus
• term used to describe the symptoms commonly associated with degenerative arthritis of the 1^st MTP joint.

Hallus Rigidus Anatomy

Hallux Rigidus Clinical Evaluation

• loss of dorsiflexion of 1^st MTP joint, stiffness and pain
• average age of onset 43yrs old.  Female>male¹
• average age at time of surgery = 53yrs¹

Hallux Rigidus Xray

• typical show dorsal spur/exostosis  

Hallux Rigidus Classification / Treatment

• Coughlin Classification
• Insert table 1 from JBJS
• Grade I=mild to moderate joint osteophyte formation with joint space preservation=cheilectomy
• Grade II=moderate osteophyte formation with joint space narrowing and subchondral sclerosis=cheliectomy
• Grade III=marked osteophytie formation and diminished joint space, including inferior portion=arthrodesis. Consider metallic hemiarthroplasty.

Hallux Rigidus Treatment

• Non-operative: shoe modifications, full-length rigid orthotic, NSAIDS, activity modification (Smith, Foot ankle Int 2000;21:906)
• Intra-articular sodium hyaluronate or steriod injection. @50% will still require surgery. (Pons M, Foot Ankle Int 2007;28:38).
• Cheilectomy(excision of an irregular osseous rim that interferes with motion of a joint) is indicated for pts who fail non-operative treatement(Mann, JBJS 1988) Cheilectomy is a better than arthrodesis, resection arthroplasty, or arthroplasty with the use of a flexible implant. In older adults who present late, with more severe X-Ray changes, Keller procedure is indicated Cheilectomy technique see Pfeffer GB, Master Techniques: Foot Ankle 2nd ed, 2002
• Hallux MTP Arthrodesis (Goucher NR, Foot Ankle INt2006;27:869).

Hallux Rigidus Surgery

• indicated for intractable pain refractory to non-op treatment.
• Cheilectomy=regional anesthesia, tourniquet. 3-cm longitudinal incision centered over the MP joint on medial aspect of EHL.  Capsule incised.  Loose body.synovial debridemnet.  Estimate % of viable cartilage. Prox phalanx plantar flexed.  Osteotome off dorsal, medial and lateral osteophytes % 25% of dorsal MT head.  Excise osteophyte from dorsal prox phalanx.  Irrigate.  Bone wax prn. Capsule repair.  Closure.¹
• Arthrodesis=regional anesthesia, tourniquet.  4-5cm dorsal longitudinal incision centered over MTP joint.  Incise capsule medial to EHL.  Joint Debridement.  Prox phalanx plantar flexed, 0.62mm K-wire driven proximally into center of MT head.  Cannulated cylindrical reamer creates cylindrical MT.  Concave canulated reamer(Howmedica) creates convex cancellous MT head.  0.62mm k-wire center in base of PP.  Convex phalangeal reamers create matching surface.  Hallux placed in neutral rotation, 15 valgus, 20 dorsiflexion.  6-hole vitalium mini-compression plate and lag screw.  Irrigate.  Capsule repair.  Closure.¹

Hallux Rigidus Follow up  care

• AOFAS hallus MTP score. Kitaoka Foot Ankle Int. 1994;15:349-53
• Cheilectomy=PROM within 10 days.  Aggressive stretching.  WBAT in stiff-soled shoe. 3 months for maximal improvement. 72% Excellent, 24% Good, 4% fair, 0% poor subjective patient result
• Arthrodesis=WBAT in stiff-soled shoe on lateral aspect and heel until radiographic fusion. 3 months for maximal improvement.  87% Excellent, 13% Good, O%fair/poor subjective patient result.

Hallus Rigidus Complications

• Cheilectomy: 6% cellulits, 9% fail requiring arthrodesis
• Arthrodesis: 7% cellulits, 6% plate removal due to pain, 6% painless fibrous union.

Hallus Rigidus References

1. Coughlin MJ, Shurnas PS; Hallus Rigidus. JBJS 85A:2072-2088, 2003
2. Pfeffer GB, Master Techniques: Foot Ankle 2nd ed, 2002