Classification and Radiology.

The classification systems of hallux rigidus, including the Coughlin and Shurnas, Hattrup and Johnson, Regnauld, and Roukis classifications, allow for a comprehensive understanding of the condition's severity and aid in informed treatment decisions. The common techniques of radiological imaging, such as standard plain film radiographs, MRI, magnetic resonance arthrography computed tomography (CT), weightbearing CT, and ultrasound, which enable accurate assessment of joint degeneration and associated pathologies for optimal patient care, are reviewed.

Management of high-grade hallux rigidus: a narrative review of the literature.

Hallux rigidus is a disease characterized by an osteoarthritic degeneration of the first metatarsophalangeal joint. Aetiology of hallux rigidus is not clear in the literature. History of trauma is considered one of the most common causes of unilateral hallux rigidus. Also, repetitive microtraumas or inflammatory and metabolic causes such as gout, rheumatoid arthritis and seronegative arthropathy can cause degeneration of the joint. The aim of this literature narrative overview is to summarize and expose the great amount of management concepts and information, including the well-codified main operative procedures to treat of hallux rigidus. This may provide current information for med-school students, researchers and physicians. A comprehensive literature search using PubMed database has been performed. The management for hallux rigidus can involve a variety of therapeutic interventions, conservative or operative. High-grade hallux rigidus represents a complex disease characterized by several clinical and pathological findings, and to achieve optimal results, surgical treatment should be chosen between several surgical techniques depending on the degree of arthritis and other different clinical conditions.

Novel treatment for hallux rigidus using a temporary metal interpositional device.

BACKGROUND: The aim of this prospective study is to evaluate the results of a consecutive series of patients suffering from grade II-III hallux rigidus who underwent a mobility preserving surgical technique consisting of resection arthroplasty with implantation of a temporary metal spacer. METHODS: Thirty consecutive patients, 18 female and 12 male with a diagnosis of a grade II-III hallux rigidus, not responding to conservative treatment, underwent a minimal resection arthroplasty followed by the implantation of a temporary metal interpositional device by the same surgeon. All spacers were removed after 6 months through a minimal incision under regional anaesthesia. Patients were clinically and radiographically evaluated at 3, 6, 12 months, and 5 years after spacer removal. RESULTS: The clinical AOFAS scores improved already at first follow-up and continued to improve over time with a statistically significant change until the first year. At 3, 6, and 12 months follow-ups, the number of patients with severely limited ROM (i.e. under 30°, that means grade II-III according to Coughlin and Shaurnas classification) significantly decreased. There were only two minor complications, so defined as both of which resolved spontaneously and did not affect the procedure's effectiveness. CONCLUSIONS: We observed good to excellent results with the use of this mobility preserving surgical technique for the treatment of symptomatic grades II and III hallux rigidus. The never before published procedure is easy to perform and inexpensive. LEVEL OF EVIDENCE: Level IV.

Outcome of Distal First Metatarsal Osteotomy Shortening in Hallux Rigidus Grades II and III.

BACKGROUND: Existing techniques for operative treatment of hallux rigidus commonly combine skeletal and soft tissue interventions to obtain long-lasting relief of pain. To date, operative treatments include implant arthroplasty, cheilectomy, various osteotomies, nonimplant arthroplasty, and arthrodesis. We assessed a technique that respects the anatomy and joint function and used a shortening osteotomy of the head of the first metatarsal. METHODS: We evaluated a series of 40 consecutive patients affected by grade II and III hallux rigidus, aged 32 to 79 years, who had undergone surgery from January 2010 to January 2014. All patients were evaluated clinically and radiographically, preoperatively and postoperatively, and underwent a final follow-up at a mean of 35.4 (range = 12-51) months. For the clinical evaluation, the American Orthopaedic Foot & Ankle Society (AOFAS) clinical rating scale for the hallux metatarsophalangeal-interphalangeal joints was used. RESULTS: A patient survey revealed excellent and good overall satisfaction in 90% of the sample. Postoperative results included a significant increase (P < .001) in the median global AOFAS score, from 39 (range = 25-60) to 84 (range = 78-94). CONCLUSIONS: The technique of a shortening osteotomy of the first metatarsal head appeared to be useful for the correction of stiffness, pain relief, and an improvement in range of motion. Other advantages were that it preserved the integrity of the metatarsophalangeal joint and led to a rapid functional recovery. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Comparison of arthrodesis, resurfacing hemiarthroplasty, and total joint replacement in the treatment of advanced hallux rigidus.

The purpose of the present study was to compare the functional results of arthrodesis, resurfacing hemiarthroplasty, and total joint replacement in hallux rigidus. The data from patients treated from 2006 to 2010 for advanced stage hallux rigidus were retrospectively reviewed. A total of 38 patients who had at least 2 years (range 24 to 66 months, mean 31.1) of follow-up were included in the present study. Of the 38 patients, 12 were included in the total joint replacement group (group A), 14 in the resurfacing hemiarthroplasty group (group B), and 12 in the arthrodesis group (group C). At the last follow-up visit, the functional outcomes were evaluated using the American Orthopaedic Foot and Ankle Society-Hallux Metatarsophalangeal Interphalangeal (AOFAS-HMI) scale, visual analog scale (VAS), and metatarsophalangeal range of motion. Significant improvements were seen in the AOFAS-HMI score, with a decrease in the VAS score in all 3 groups. According to the AOFAS-HMI score, no significant difference was found between groups A and B. However, in group C, the AOFAS-HMI scores were significantly lower than in the other groups owing to the lack of motion. According to the final VAS scores, no significant difference was found between groups A and B; however, the VAS score had decreased significantly more in group C than in the other groups. No major complications occurred in any of the 3 groups. After 2 years of follow-up, all the groups had good functional outcomes. Although arthrodesis is still the most reliable procedure, implant arthroplasty is also a good alternative for advanced stage hallux rigidus.

Hallux rigidus: artropatía degenerativa metatarsofalángica del primer radio. Propuesta terapéutica. Osteotomías de Watermann-Diebold más Akin modificadas / Hallux rigidus: metatarsophalangeal degenerative arthropathy of the first ray. Watermann-Diebold osteotomy + Akin Osteotomy modified

El hallux rigidus es una afección de la articulación metatarsofalángica (MTF) del primer radio con limitación de la dorsiflexión, que evoluciona hacia la artrosis y la disfunción global del antepié. Frecuentemente afecta a población adulta joven y deportista. En la presente evaluación, proponemos como objetivo exponer los resultados a corto y mediano plazo del tratamiento en estadíos I y II combinando una doble osteotomía: distal metatarsiana (Watermann-Diebold), que libera el bloqueo dorsal y de la falange proximal del hallux (Akin de acortamiento), que descomprime axialmente el radio sin crear una insuficiencia de propulsión, posibilitando el retorno deportivo. Materiales y métodos: Se utilizó la clasificación clínico-radiológica de Regnauld para estatificar la enfermedad. Se tallo osteotomía distal metatarsiana a cuña sustractiva dorsal (Watermann-Diebold) combinada con una osteotomía proximal de la primera falange (Akin de acortamiento), fijadas con tornillos canulados de doble rosca. Se hicieron controles radiográficos en el postoperatorio inmediato, a las tres, seis y doce semanas y al año. La evaluación funcional se basó en el score AOFAS aplicado a las articulaciones metatarsofalángica e interfalángica del hallux. Resultados: Se evaluaron a 8 pacientes deportistas recreacionales tratados entre abril de 2009 y febrero de 2011, con un seguimiento entre 7 y 29 meses. La edad media fue de 42 años (entre 33 y 55 años), 5 mujeres y 3 varones. Los deportes que practicaban eran futbol en el caso de los varones y corredores de fondo y medio fondo las mujeres. De los 8 pacientes, 3 fueron clasificados como grado I, y 5 como grado II. El score AOFAS preoperatorio fue de 65 puntos y el postoperatorio de 78.80. Con una p= 0.001 y un intervalo de confianza 95 por ciento (9.17 - 21.07). Traducido clínicamente en una moderada recuperación en la excursión articular y reducción del dolor. Todos se reintegraron a la actividad deportiva. Conclusión: Si bien es una serie pequeña, la combinación de las osteotomías de Watermann-Diebold y Akin para pacientes adultos jóvenes deportistas en estadíos I y II Regnauld, descarga axialmente el primer rayo, disminuye el bloqueo dorsal mejorando la movilidad, alivia el dolor y permite la reincorporación a la práctica deportiva

Joint-preserving procedure for moderate hallux rigidus.

Hallux rigidus is a complex disorder, and numerous surgical procedures have been described for its management. Although the optimal technique has yet to be defined, it is important to individualize the degree of arthritis as well as other clinical features (metatarsal index, pain characteristics, and so forth) of each patient to achieve optimal results. The authors firmly believe that for patients with only dorsal pain, a cheilectomy is the ideal choice because good and reliable results can be achieved. When pain is also present around the joint or is combined, which is the most common scenario, their main choice now is to perform a decompressive osteotomy. The biomechanics of the joint are more adequately restored, soft tissues are relaxed, and remodeling of the contracted tissues is allowed. More investigation has still to be performed to elucidate the origin of this abnormality.

Improved ankle push-off power following cheilectomy for hallux rigidus: a prospective gait analysis study.

BACKGROUND: There is limited objective scientific information on the functional effects of cheilectomy. The purpose of this study was to test the hypothesis that cheilectomy for hallux rigidus improves gait by increasing ankle push-off power. METHODS: Seventeen patients with symptomatic Stage 1 or Stage 2 hallux rigidus were studied. Pre- and postoperative first metatarsophalangeal (MTP) range of motion and AOFAS hallux scores were recorded. A gait analysis was performed within 4 weeks prior to surgery and repeated at a minimum of 1 year after surgery. Gait analysis was done using a three-dimensional motion capture system and a force platform embedded in a 10-m walkway. Gait velocity sagittal plane ankle range of motion and peak sagittal plane ankle push-off power were analyzed. RESULTS: Following cheilectomy, significant increases were noted for first MTP range of motion and AOFAS hallux score. First MTP motion improved an average of 16.7 degrees, from means of 33.9 degrees preoperatively to 50.6 degrees postoperatively (p<0.001). AOFAS hallux score increased from 62 to 81 (p<0.007). As demonstrated through gait anaylsis, a significant increase in postoperative peak sagittal plane ankle push-off power from 1.71±0.92 W/kg to 2.05±0.75 W/kg (p<0.04). CONCLUSION: In addition to clinically increased range of motion and improved AOFAS Hallux score, first MTP joint cheilectomy produced objective improvement in gait, as measured by increased peak sagittal-plane ankle push-off power.

Surgical management of hallux rigidus.

Hallux rigidus is the most common degenerative joint pathology of the foot. Untreated, it may result in notable limitations in gait, activity level, and daily function. Positive outcomes can be achieved with nonsurgical management; surgery is recommended for the sufficiently symptomatic patient for whom nonsurgical measures are unsuccessful. Surgery is selected based on grade of involvement. Early to mid-stage hallux rigidus is best managed with cheilectomy or cheilectomy and proximal phalanx osteotomy. Arthrodesis and arthroplasty are reserved for late-stage hallux rigidus.

[Hallux rigidus]. / Hallux rigidus.

Osteoarthritis of the first metatarsophalangeal joint is termed hallux rigidus. Clinical symptoms are expressed by a painful limitation of range of motion, finally leading to an eponymous total stiffness of the joint. Conservative treatment includes drug therapy, physical therapy and orthotic devices like insoles and footwear modification. After making use of the whole range of conservative treatment options, several surgical techniques are available, which should be considered depending on stage, patient's activity level and possible comorbid diseases. Open and arthroscopic techniques addressing the cartilage and cheilectomy can be chosen in early stages of hallux rigidus. Osteoarthritis at a higher stage requires further reaching techniques, e.g. Bonney-Kessel procedure or Watermann-Green procedure. When the complete clinical picture of hallux rigidus is present, arthrodesis is the gold standard. Nevertheless, alternative surgical treatments like arthroplasty and resection arthroplasty are being discussed.

Etiology, pathophysiology, and staging of hallux rigidus.

The condition of hallux limitus is well understood and agreed on as visualized histologically and radiographically. But the historically described pathophysiology and anatomy that predisposes to hallux limitus has been challenged. Numerous investigators have proposed anatomic abnormalities of the foot as a primary cause of this condition, but perhaps trauma is the only unanimously agreed on cause. However, this accounts for only a small percentage of cases. To strive for better treatment outcomes, understanding the pathophysiology, assessing patient risk factors, and recognizing causative agents can better equip the foot and ankle surgeon in managing this condition.

Hemiarthroplasty and distal oblique first metatarsal osteotomy for hallux rigidus.

BACKGROUND: In a retrospective study, we evaluated the effect of the addition of a decompressive osteotomy to hemiarthroplasty of the great toe in terms of clinical and radiographic outcomes. MATERIAL AND METHODS: Twenty-one consecutive patients affected by Grade III hallux rigidus underwent distal oblique osteotomy of the first metatarsal and hemiarthroplasty of the hallux metatarsophalageal joint. Clinical evaluation included the American Orthopaedic Foot and Ankle Society scoring system (AOFAS) and the Short Form 36 questionnaire (SF-36), preoperatively and at followup visits. Standard weightbearing radiographs were performed to assess implant alignment, loosening, and bone loss. The mean followup was 26.4 (range, 16 to 29) months. RESULTS: The mean AOFAS score improved from 47.5 ± 11.5 preoperatively to 76.0 ± 15.5 postoperatively (p < 0.01). At the last followup the SF-36 subscales Physical functioning, Bodily pain and Emotional role scores were increased from baseline. At the last followup, six patients (28.5%) were very satisfied with the outcome, ten patients (47.6%) were satisfied and five patients (23.8%) were dissatisfied. In the dissatisfied group, two patients had persistent joint pain with stiffness and subluxation of the prosthesis. Dorsal subsidence of the implant was present in ten patients at the last radiographic followup. CONCLUSION: Hemiarthroplasty of the proximal phalanx and distal oblique metatarsal osteotomy for Grade III hallux rigidus at 2-years followup yielded mixed patient satisfaction and unsatisfactory radiographic outcome.

Gelfoam first metatarsophalangeal replacement/interposition arthroplasty--a case series with functional outcomes.

Reported below are the functional results of a case-series of Gelfoam®-based first metatarsophalangeal total joint replacements using an interposition arthroplasty technique carried out between April 1997 and December 2007. All patients who underwent Gelfoam-based arthroplasty under the care of a single surgeon were included; outcome scores and complications were recorded. A total of 31 joints in 31 consecutive patients were followed for a mean duration of 64 (range 24-150) months, and the mean patient age at the time of operation was 48±9 (range 35-80) years. Hallux rigidus was the primary diagnosis in all of the cases except one in which a failed chevron ostetomy was the indication for treatment. The mean American Orthopaedic Foot & Ankle Society Hallux-Metatarsophalangeal-Interphalangeal score increased from an average of 35 pre-operatively to an average of 74 at final follow-up (range 67-100), with 20 (64.5%) joints rated good to excellent. One (3.5%) joint was fused 6 months after the arthroplasty procedure. Based on these results, we concluded that first MTPJ total joint Gelfoam™-based interpostion arthroplasty is a cheap alternative to other joint replacement systems for the MTP joint. The results appear similar to those achieved using more expensive devices.

The need for surgical revision after isolated cheilectomy for hallux rigidus: a systematic review.

Isolated cheilectomy has been proposed for treatment of hallux rigidus due to the perceived safety, efficacy, and ability to revise with repeat cheilectomy, implant or interpositional arthroplasty, or arthrodesis. A systematic review was undertaken to better understand the need for surgical revision after isolated cheilectomy for hallux rigidus. Studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated cheilectomy or involved revision surgery of the first metatarsophalangeal joint after isolated cheilectomy, evaluated patients at mean follow-up > or = 12 months' duration, and included details of complications. Twenty-three studies, describing 706 cheilectomies, met the inclusion criteria, with 62 (8.8%) undergoing surgical revision in the form of arthrodesis (n = 23), no mention of revision procedure (n = 17), interpositional arthroplasty (n = 13), silicone implant arthroplasty (n = 4), Keller resection arthroplasty (n = 3), or repeat cheilectomy (n = 2). Twelve studies specified the grade of hallux rigidus as: 103 (19.9%) grade 1, 210 (40.6%) grade II, 189 (36.6%) grade III, and 15 (2.9%) grade IV. Six studies indicated the number of cheilectomies that required revision surgery as: 2 (20%) grade I, 8 (14.8%) grade II, 12 (9.1%) grade III, and 5 (55.6%) grade IV. These results make clear the low incidence of revision surgery after cheilectomy for hallux rigidus. Therefore, cheilectomy should be considered a first-line surgical treatment for hallux rigidus. There remains a need for methodologically sound prospective cohort studies that focus on the use of cheilectomy for specific grades of hallux rigidus.

Outcomes after cheilectomy with phalangeal dorsiflexory osteotomy for hallux rigidus: a systematic review.

Cheilectomy with phalangeal dorsiflexory osteotomy has been proposed for treatment of hallux rigidus because of its perceived safety and efficacy and because it does not prevent the ability to perform revision surgery. The author undertook a systematic review to identify material relating to the clinical outcomes after cheilectomy with phalangeal dorsiflexory osteotomy for hallux rigidus. Studies were considered only if they involved consecutively enrolled patients undergoing cheilectomy with phalangeal dorsiflexory osteotomy, evaluated patients at mean follow-up > or = 12 months' duration, included some form of objective and subjective data analysis, and included details of complications requiring surgical intervention. Eleven studies involving a total of 374 procedures were identified that met the inclusion criteria. Pain was relieved or improved in 149/167 (89.2%) procedures, and 139/217 (77%) patients related being satisfied or very satisfied with their outcomes. A total of 18 (4.8%) procedures underwent surgical revision. Six studies involving 177 procedures specified the grade of hallux rigidus as follows: grade I, 10.2% (n = 18); grade II, 72.3% (n = 128); and grade III, 17.5% (n = 31). The results of this systematic review make clear the general improvement in objective and subjective data as well as the low incidence of revision surgery required after cheilectomy with phalangeal dorsiflexory osteotomy for hallux rigidus. Therefore, cheilectomy with phalangeal dorsiflexory osteotomy should be considered a first-line surgical treatment for hallux rigidus. However, there is still a need for methodologically sound prospective cohort studies that focus on the use of this procedure for specific grades of hallux rigidus and compare the subjective and objective outcomes as well as the need for surgical revision with other procedures.

Outcome following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus: a systematic review.

Autogenous soft tissue interpositional arthroplasty has been proposed as an alternative to arthrodesis and other forms of arthroplasty for treatment of end-stage hallux rigidus because of the perceived safety and efficacy. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the outcomes following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. Information from peer-reviewed journals, as well as from non-peer-reviewed publications, abstracts and posters, textbooks, and unpublished works, were also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated autogenous soft tissue interpositional arthroplasty for the treatment of end-stage hallux rigidus, evaluated patients at mean follow-up of 12-months' duration or longer, included pre- and postoperative range of motion of the first metatarsal-phalangeal joint, determined pre- and postoperative outcomes using a scoring system, and documented any complications. Two studies involving a total of 28 autogenous soft tissue interpositional arthroplasties for end-stage hallux rigidus were identified that met the inclusion criteria. There were 12 men (52%) and 11 women (48%) with a mean age of 58.2 years followed for a mean of 21.6 months. Both studies used the AOFAS First Metatarsal-Phalangeal-Hallux Scoring System, which had a mean of 26.0 preoperatively rising to 89.4 postoperatively. First metatarsal-phalangeal joint dorsiflexion had a mean of 16.7 degrees preoperatively rising to 51.1 degrees postoperatively. Complications occurred in 4 (14.3%) feet and no feet required surgical revision. The results of this systematic review demonstrate improvement in patient outcomes and first metatarsal-phalangeal joint dorsiflexion, as well as few complications following autogenous soft tissue interpositional arthroplasty for end-stage hallux rigidus. However, there is still a need for methodologically sound prospective cohort studies that compare autogenous soft tissue interpositional arthroplasty with other forms of arthroplasty and arthrodesis for end-stage hallux rigidus.

Classification systems for hallux rigidus: a review of the literature.

BACKGROUND: Hallux rigidus (HR) is one of the most common causes of forefoot pain. A number of classification systems have been developed to evaluate HR. These systems are based on either radiological parameters alone or a combination of radiological and clinical features. The purpose of this paper is to critically evaluate HR classification systems by undertaking a detailed review using English language medical and paramedical databases. MATERIALS AND METHODS: The authors identified 18 formal HR classification systems described in the literature, some of which are variations on a theme. RESULTS: No clear consensus on the construction of HR classification systems appears to exist. Different criteria and methods are used which make comparison difficult. Furthermore, it appears that, no serious consideration has been given to their reliability and validity. Criteria used to justify inclusion of these parameters have been based mainly on clinical experience rather than formal research. CONCLUSION: For such a common condition, there is a need for a properly constructed, prospective study to develop a suitable classification system. It should include scientifically validated parameters to help stratify different stages of the disease and aid clinical and scientific communication.

[Surgical treatment of hallux rigidus]. / Die operative Therapie des Hallux rigidus.

Hallux rigidus is a deformity of the first metatarsophalangeal joint. Symptoms include a painful reduction of mobility and increasing stiffness in the big toe. Only when conservative therapeutic methods have failed should surgical options be considered. The surgical technique depends on the stage of the deformity. For stadium I and II, the joint should be retained, for example by cheilectomy. In this case, a correction osteotomy of the phalanx or first metatarsus can follow. For stadium III and IV, the usual procedure is arthrodesis. Complications can involve an incorrect positioning of the big toe, pseudoarthrosis and arthrosis of the interphalangeal joint. For less active patients, a resection arthroplasty is also possible.