The influence of first ray instability and hindfoot valgus in the development of hallux rigidus: state of art.

Hallux rigidus (HR) is a painful condition associated with degenerative arthritis of the first metatarsophalangeal (MTP1) joint, leading to a progressive loss of dorsiflexion. The etiological factors leading to the development of the condition are not yet fully understood in the literature. When the hindfoot is aligned in excessive valgus, the medial border of the foot tends to roll over, which brings to increased stress on the medial side of the MTP1 joint, and consequently on the first ray (FR), thus potentially influencing the development of HR deformity. This state of art aims to analyze the influence of FR instability and hindfoot valgus in HR development. From the results of the analyzed studies, it appears that a FR instability may predispose the big toe to increased stress and to narrow the proximal phalanx motion on the first metatarsal, which brings to compression and ultimately degeneration of the MTP1 joint, mostly in advanced stages of disease, less in mild or moderate HR patients. A strong correlation between a pronated foot and MTP1 joint pain was found; forefoot hypermobility during the propulsion phase may promote MTP1 joint instability and increase pain. Thus, the increased moment of pronation of the foot with the overload of the medial column, when present, should be corrected conservatively or surgically; this, most likely, would be useful not only to eliminate or at least limit the painful symptoms but above all to prevent the worsening of the condition, also after the surgical treatment of HR.

Turf Toe, Traumatic Hallux Valgus, and Hallux Rigidus -What Can I Do After an Metatarsophalangeal Fusion?

Turf toe injuries should be recognized and treated early to prevent long-term disability. The accurate clinical assessment and radiological evaluation of appropriate cases is important. Both conservative and surgical treatments play a major role in getting athletes back to their preinjury level. There are more recent reported case series and systemic reviews that encourage operative treatment as early as possible for grade III turf toe injury. If the patient presents late from a traumatic hallux injury with subsequent degenerative changes or has hallux rigidus from other etiologies, a first metatarsophalangeal arthrodesis should be considered to minimize pain and improve function.

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.

A semi-quantitative technique to assess excursion of the flexor hallucis longus.

BACKGROUND: Recent research indicates that restriction in excursion of flexor hallucis longus (FHL) contributes to hallux rigidus development. As described in the literature, clinical evaluation of FHL excursion has poor interobserver reliability. A simple, inexpensive, easily used FHL relative excursion measurement device was developed and tested. METHODS: 64 subjects were enrolled with shoe size, height, weight, BMI, and age compared. Using a footplate and series of mechanical wedges, maximum ankle dorsiflexion was measured with the great toe in 15°, 30°, and 45° of dorsiflexion. RESULTS: Ankle dorsiflexion decrease with progressive hallux dorsiflexion increase was statistically significant with a linear correlation (r2=.814 p<.001) and was not statistically related to shoe size, height, weight, BMI, or age. CONCLUSIONS: This technique provides consistent assessment of the limitation to ankle dorsiflexion incurred by decreased FHL excursion, establishing groundwork for future studies to assess the relationship between diminished FHL excursion and FHL pathology.

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.

Tratamiento del Hallux Rigidus. A propósito de un caso / Treatment of Hallux rigidus. A propos of a case

En este artículo se describió la definición, la anatomía, la etiología, la clínica, el diagnóstico y las estrategias terapéuticas utilizadas en la actualidad, ya sean conservadoras o quirúrgicas, del Hallux Rígidus. En él se presentó la resolución de un caso clínico atendido en nuestra consulta donde la paciente presentaba dolor unilateral en el recorrido del Músculo Tibial Posterior de un año de evolución y ausencia total de la movilidad de la primera articulación metatarso-falángica del pie izquierdo. Se le diagnosticó de Hiperpronación de Retropié Bilateral y de Hallux Rígidus secundario del pie izquierdo. El objetivo principal fue reducir la sintomatología que presentaba la paciente, a su vez, conseguir disminuir la hiperpronación del retropié y favorecer una mayor funcionalidad en el primer segmento dígito-metatarsal(AU)

This article describes the definition, anatomy,etymology, clinical, diagnostic and the therapeutic strategies currently used, both chirurgic and palliative, for Hallux Rigidus. The methodology used to describe all of the above terms was the resolution of a real clinical case at the University of Barcelona Podiatrist Hospital during my last year of studies forthe degree of Podiatry at the same University. The patient who agreed to be part of the study suffered from unilateral pain in posterior tibial muscle and total lack of mobility of the first articulation metatarsal-phalanges of the left foot. The symptoms appeared a year before this study was conducted. The diagnosis of the patient was bilateralr-pronation of the bilateral and with secondary Hallux Rigidus in the left foot. The main objective of the study was to reduce the symptoms suffered by the patient; the secondary objective was to find an appropriate treatment that would reduce the patient’s overpronation to gain some functionality of the first segment(AU)

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.

The cheilectomy and its modifications.

Hallux rigidus occurs in 10% of persons aged 20 to 34 years but in as much as 44% of people older than 80 years. Surgical intervention has been suggested for cases of hallux rigidus that have failed using conservative methods. The modified cheilectomy is considered by many the first-line treatment for this disease, given the procedure's inherent ability to eliminate degenerate bone and cartilage and decompress the intra-articular space, while sparing considerable cubic content of bone. Once the cheilectomy has been performed, there remains a sufficient volume of bone to perform a more definitive reconstruction if necessary.

First metatarsophalangeal arthrodesis for hallux rigidus.

Hallux rigidus leads to a restricted and painful motion at the first metatarsophalangeal (MTP 1) joint. Decision making of the appropriate surgical procedure mainly refers to the stage of hallux rigidus. If conservative measures fail, operative procedures can be taken into consideration. Arthrodesis of the MTP 1 joint is widely accepted as the gold standard for end-stage hallux rigidus. Despite the fusion of a key joint, there is little adverse effect on gait, and weight bearing of the first ray can be restored.

Hallux rígidus: etiología, diagnóstico, clasificación y tratamiento / Hallux rígidus: aetiology, diagnosis, classification and treatment

El hallux rígidus es una patología degenerativa y progresiva de la articulación metatarsofalángica del hallux, cuyo principal síntoma es el dolor y la pérdida de la movilidad articular. Existen distintos mecanismos etiológicos que se han involucrado en su desarrollo y la anamnesis clínica y los exámenes radiológicos son indispensables para llegar a su preciso diagnóstico y poder concretar el correcto estadio evolutivo, con la finalidad de efectuar un adecuado tratamiento en cada caso. El tratamiento quirúrgico está indicado en la mayoría de casos y es indispensable tener un amplio conocimiento de las diversas técnicas quirúrgicas para realizar el tratamiento correcto a cada paciente (AU)

Hallux rígidus is a degenerative and progressive disease of the metatarsal phalangeal joint of the hallux, with its main symptoms being pain and loss of joint movement. Different aetiological mechanisms are involved in its development, and clinical anamnesis and radiological examinations are essential for an accurate diagnosis and to be able to establish the correct stage of progression, with the aim of giving suitable treatment in each case. Surgical treatment is indicated in most cases and is necessary to know all the surgical techniques to make the right treatment for each patient (AU)

Review of 107 hallux MTP joint arthrodesis using dome-shaped reamers and a stainless-steel dorsal plate.

BACKGROUND: The purpose of this study was to retrospectively review the results of patients treated with hallux MTP joint arthrodesis using dome-shaped reamers for joint preparation and a precontoured dorsal stainless steel plate for internal fixation. MATERIALS AND METHODS: A series of 145 patients (155 feet) were identified. Postoperative evaluation included weightbearing radiographs, physical examination, and chart review. Outcomes were assessed with a pain visual analog scale, AOFAS hallux score, as well as a detailed questionnaire and a subjective satisfaction survey. RESULTS: Ninety-eight patients (107 feet) met the criteria for the study. The mean followup was 61 weeks. Revision cases accounted for 18.7% (20/107). Rheumatoid arthritis (RA) was present in 32.7% (35/107). The average postoperative AOFAS hallux score was 79.7 and pain VAS was 19. The average pre- and postoperative hallux valgus angle was 26.5 and 12.3 degrees, respectively (p < 0.05). Eighty-nine of 107 patients (83.1%) reported good to excellent results at final followup. Discomfort related to prominence of the plate occurred in 14.9% (16/107). The nonunion rate was 12.1% (13/107). The nonunion rate for patients with/without RA was 22.9% (8/35) and 6.9% (5/72), respectively (p < 0.05). Patients with a nonunion noted more hardware related pain than those with a union (p < 0.05). CONCLUSION: First MTP joint arthrodesis using this technique achieves a high union rate. RA patients have a lower union and higher complication rate.

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

Isolated Valenti arthroplasty has been proposed for treatment of moderate to severe hallux rigidus because of the perceived safety and efficacy. Furthermore, it has been proposed that undergoing isolated Valenti arthroplasty does not prevent the ability to perform revision surgery consisting of Keller resection arthroplasty, prosthetic implant arthroplasty, or arthrodesis. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the need for surgical revision after isolated Valenti arthroplasty for hallux rigidus. Information from peer-reviewed journals as well as non-peer-reviewed publications, abstracts, and posters was 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 Valenti arthroplasty, if they evaluated patients in person at mean follow-up > or = 12 months' duration, and if they included details of complications after Valenti arthroplasty requiring surgical intervention. Three studies involving isolated Valenti arthroplasty were identified that met the inclusion criteria. Therefore, a total of 44 isolated Valenti arthroplasties were identified that met the inclusion criteria, with 2 (4.6%) undergoing surgical revision in the form of Keller resection arthroplasty (n = 1) and 1 plantarflexory base osteotomy (n = 1). No studies provided detailed information regarding complications specific to the exact grade of hallux rigidus in patients who underwent isolated Valenti arthroplasty. The results of this systematic review make clear the low incidence of revision surgery required after isolated Valenti arthroplasty for hallux rigidus. However, there is still a need for methodologically sound prospective cohort studies that focus on the use of isolated Valenti arthroplasty for specific grades of hallux rigidus and compare this procedure with other accepted forms of surgical treatment for moderate to severe hallux rigidus.

The importance of the length of the first metatarsal and the proximal phalanx of hallux in the etiopathogeny of the hallux rigidus.

The purpose of this study was to determine if the relative length of the first metatarsal and the proximal phalanx of the hallux, in respect to the total foot length, were associated with the incidence of hallux rigidus. For this retrospective study, lateral radiographs from 132 cases with hallux rigidus and a control group of 132 normal feet were reviewed. We measured the following parameters: the index between the foot length and first metatarsal length, the proximal phalanx of the hallux length, and the sum of the first metatarsal length and the proximal phalanx of the hallux length. We found a statistically significant difference (p: 0.002) between the two groups in the Foot L/1st Mtt L index, and no statistical difference in the Foot L/Phalanx L index. We think that a greater length of first metatarsal is involved in the etiopathogeny of hallux rigidus.

Hallux rigidus: etiology, biomechanics, and nonoperative treatment.

Hallux rigidus is a degenerative osteoarthritic process characterized by progressive loss of metatarsophalangeal joint range of motion and notable dorsal or periarticular osteophyte formation. Documented factors associated with hallux rigidus are a flat or chevron-shaped joint, hallux valgus interphalangeus, metatarsus adductus, bilaterality in persons with a positive family history, trauma history in unilateral cases, and female gender. Elevation of the first ray noted radiographically is thought to be a sign of worsening metatarsophalangeal joint function. Nonoperative care is aimed at improving comfort of the toe and foot with roomy shoes, selective joint injections, taping, and selective use of orthotics.

A finite-element analysis study of the metatarsophalangeal joint of the hallux rigidus.

Hallux rigidus was first described in 1887. Many aetiological factors have been postulated, but none has been supported by scientific evidence. We have examined the static and dynamic imbalances in the first metatarsophalangeal joint which we postulated could be the cause of this condition. We performed a finite-element analysis study on a male subject and calculated a mathematical model of the joint when subjected to both normal and abnormal physiological loads. The results gave statistically significant evidence for an increase in tension of the plantar fascia as the cause of abnormal stress on the articular cartilage rather than mismatch of the articular surfaces or subclinical muscle contractures. Our study indicated a clinical potential cause of hallux rigidus and challenged the many aetiological theories. It could influence the choice of surgical procedure for the treatment of early grades of hallux rigidus.

Positive hindfoot valgus and osteoarthritis of the first metatarsophalangeal joint.

BACKGROUND: The aim of this retrospective cohort study was to evaluate the association between increased hindfoot valgus and the subsequent development of osteoarthritis of the first metatarsophalangeal (MTP) joint. Specifically, our hypothesis was that among individuals free from first MTP joint osteoarthritis, those who have positive hindfoot valgus are more likely to develop first MTP joint osteoarthritis than are those individuals with normal hindfoot alignment. METHODS: Our sample consisted of 1592 men and women, 40 years of age or older, participating in the Clearwater Osteoarthritis Study (1988 to 2001). Biennial physical examinations, including serial radiographs, were conducted. The Kellgren and Lawrence ordinal scale was used to determine radiographic evidence (grades 2+) of the study outcomes and incidence of first MTP joint osteoarthritis. Standing hindfoot valgus was assessed visually by a registered nurse, with a hindfoot valgus measurement of more than 5 degrees classified as a positive hindfoot valgus. RESULTS: Individuals with hindfoot valgus were 23% more likely to subsequently develop first MTP joint osteoarthritis than were those without hindfoot malalignment (risk ratio = 1.23; p-value < 0.006). This risk estimate reflects the potential influence of age, gender, and body mass index. CONCLUSIONS: Our data suggest that hindfoot valgus may increase the risk of developing foot osteoarthritis. The association of hindfoot valgus with first MTP joint osteoarthritis in this epidemiological assessment is supportive of the mechanical theory for the development of osteoarthritis. The authors speculate that future, related studies may determine that osteoarthritis prevention strategies can be broadened to include individuals with positive hindfoot valgus.