Marie L Williams, DPM reviews the many acceptable surgical treatments available for Hallux rigidus. Dr Williams also provides a brief overview of clinical presentation and pathogenesis as well as conservative treatment options.
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Marie Williams, DPM, DHL
Director, Podiatric Medical Education
Aventura Hospital and Medical Center
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Speaker: Hello. I’m going to talk to you in a topic called hallux rigidus. Thanks for staying. I think I actually have done these lectures. Every time I do a lecture and I put them together, I learn something new so I hope I can share that new thing with you. But how can you take a subject like hallux rigidus and think about it being new? I was actually looking through probably 50 journal articles on the subject. I’m going to share something that I found that is interesting toward the end of the talk. What I’m going to tell you is not new, what it is, how it is and what to do as far as correction. But what is hallux? You’re going to have a talk on hallux limitus and we’re not going to address that at all. But just for completeness sake, when you look at the limitus and rigidus, hallux rigidus is extensive limitation of motion of the hallux at the first metatarsophalangeal joint resulting in no motion. So the end result of hallux limitus is hallux rigidus. Normally, you have 50 to 60 degrees of motion for functional gait. But with the hallux rigidus, you lose that function. You tend to change your gait and we’ll go over that. What is the etiology, several etiologies? Traumatic, structural, biomechanical, metabolic, neuromuscular problems and then of course iatrogenic. Sometimes we actually cause that with our hallux valgus procedures that can cause the joint to become stiffened and then nonfunctional. Traumatic can be many in kind. You have the osteochondral lesions of the first metatarsophalangeal joint due to trauma or injury, intraarticular fractures. This is something new, we forget about sometimes but the hallux sesamoid dysfunction where the sesamoid is actually jamming to the joint and then the hallux can’t glide or ride and becomes jammed. When you do surgery, you’ll actually see sometimes that the sesamoids are jammed up into the metatarsal head and the proximal phalanx is pushed down in a more plantarflexed attitude whereby you can’t get the actual motion of the metatarsophalangeal joint. You have malunion and nonunions, extraarticular joint problems and epiphyseal plate can get damaged in childhood causing a hallux rigidus long term. Other thing, structurally, everyone talks about that abnormally long proximal phalanx or abnormally long first metatarsal and then an elevated first metatarsal. In biomechanics, you see a hypermobile first ray and excessive pronation in the hindfoot. Metabolically, you have the arthritic conditions from seronegative arthropathies. You have gout that can cause this. You have psoriatic arthritis, ankylosing spondylitis, endstage osteoarthritis from although you get most commonly hallux valgus from a rheumatoid, sometimes will then give you a rigidus deformity. And osteochondral lesions are defects within the joint due to the metabolic disease. Neuromuscular, problems are caused by intrinsic and extrinsic muscular imbalance affecting the first ray whereby then the first ray can’t function. You don’t have push-off of the great toe and you become rigid at the first metatarsophalangeal joint. When you look at the pathogenesis, just pronation itself, you have pronation at the subtalar joint during midstance. You have midtarsal joint compensation, unstable lateral column unlocking that lateral column. The first ray becomes dorsiflexed when you have an acquired first met primus elevatus and then hypermobility of the first ray. When you actually have hypermobility of the first ray with dorsiflexion of the first metatarsal, sometimes you get inadequate plantarflexion with the peroneus longus unable to actually pull the first ray down to the ground and then you get the hallux jamming at the level of the metatarsophalangeal joint. You’ll see dorsal jamming. You’ll see degenerative changes with osteophytic proliferation and you’ll take that limitus into a rigidus as it becomes more progressive. Again, the long first metatarsal, excessive weightbearing at the first metatarsophalangeal joint overloads at the level of the first metatarsophalangeal joint with propulsion and degenerative joint disease. You have also an elevatus. The first metatarsal will become elevated relative to the second through fifth metatarsals.
Actually, if you put the foot in neutral position and then you put the hallux through range of motion in that position and you take out the pronation, you might get motion. But as soon as the foot is locked in stance position, hallux may not move, you’ll get jamming of the dorsal proximal phalanx as well. This is just a bit redundant but most important thing is, is that once you have hypermobility of the first ray and abnormal subtalar joint pronation then you have an unstable lateral column and that’s where the peroneus longus has lose its mechanical advantage to bring the first ray down to the ground for ground reactive forces and no plantarflexion at the level of the metatarsal phalanx during propulsion. When you see this, most commonly what you’ll see is someone coming in to your office with pain around the fifth metatarsophalangeal joint because when they walk, their gait is abducted and they cannot put the first ray to the ground so the way they clear the ground is by pushing off around the lateral column. So, there’s many classifications and I looked at all these classifications and we basically try to classify the classifications and then we classify those and then classify them again. I took that and I looked at some of the most common and easy classifications. Regnauld has a three-stage classification based upon extent of the joint degeneration. Then Drago and Oloff and Jacobs wrote an article that expanded it into a four-stage functional hallux limitus down into rigidus. We’re going to skip stage 2 because we’re going to have a talk all about that. But I wanted to move through the stage 2 to 4, how the joint adapts and flattened. You’ll see the flattened metatarsal, osteochondral pathology with osteochondral lesions or cartilaginous changes. You’ll also have pain at end range of motion on the metatarsophalangeal joint, limited passive range of motion, small dorsal exostosis. You’ll see subchondral changes around the head of the metatarsal and you’ll have periarticular lipping around the proximal phalanx and the first metatarsal. Stage 2 becomes more advanced, more severe flattening, more osteophytes, more narrowing of the joint which is more on a nonuniform narrowings. Some areas are more narrowed than others. Sometimes it’s more on the lateral side or medial side. You’ll definitely get that narrowing. You get more degenerative articular cartilage, crepitus, erosions, subchondral cyst and lesions, pain through the entire range of motion and it becomes maybe an acute inflammatory episode. And as you get into this ankylosing stage, now you have a severe hallux rigidus with obliteration of the joint space with loss of the majority of the cartilage. You have increased osteophytic proliferation of loose bodies in the joint with the joint space completely narrowed and/or encapsulated with these osteophytes with very little to no range of motion to total ankylosis. Clinical presentation, usually come in with pain, stiffness around the first metatarsophalangeal joint or hallux, pain at the great toe, pain at the fifth metatarsal region. Sometimes they’ll come in only with that because now the toe has become completely abnormally fused at the level of the first metatarsophalangeal joint thereby lending pain to the fifth ray or fifth metatarsal region. And you’ll get arch pain and plantar fascial pain as well. They have early heel-off in gait with a varus rotation of the foot with an abducted gait most commonly. There are other types of problems in association with the hallux rigidus. You want to look at the sesamoidal arthritis, hallux interphalangeus joint hyperextension or arthrosis, lesser metatarsalgia and inflammatory conditions, bursitis, tendinitis, synovitis. Conservatively, your goal is to reduce the inflammation around the first metatarsophalangeal joint with physical therapy and by means of antiinflammatory medications but this is more in the realm for the hallux limitus more than the rigidus. Just for completeness sake, you have your steroid injections and all antiinflammatories. Sometimes you have to do an intraarticular or periarticular injection for the acute stages for the hallux limitus and/or rigidus. Physical therapy helps, extra depth shoes. You want to avoid activities that put their foot in a dorsiflectory force and orthotic therapy. There’s orthotic therapy that really helps because you can place the first metatarsal in a more functional position. You can actually take away some of the pressure around the first ray by cutting out and using more in extension. And that is some of the types of conservative treatment.
I’m going to talk a little bit about this surgical treatment. There’s soft tissue consideration, preservation and also joint destructive procedures. Both in the further stages of hallux limitus and rigidus. Basically, soft tissue is really just cleaning up the joint, cleaning up some of the fibrosis around the joint and this might be an early beginning of a real early limitus into rigidus. We’re not going to spend a lot of time on that. Some of the joint preservation procedures, there’s a list of them. I tend to not remember so many of the guys names down there but most important is that you’re just preserving the joint and cleaning up the joint and taking away some of the hypertrophic bone that’s limiting the motion. Joint destructive procedures, more in the line of an arthrodesis. You have the Stone, the Mayo, the Keller. They actually were joint destructive procedures that also were very popular early. The Keller especially in the ‘80s was very, very popular procedure, not done as much except for in the elderly population. Arthrodesis is another one that is one of the most common. In some areas, it is the standard of care and I’m going to talk about that in a little bit. Arthrodesis is one of the good alternatives to a really badly deformed hallux rigidus. Here’s a joint, you can see it’s completely joint space narrowed with hypertrophic bone around the metatarsophalangeal joint. And you see this large bony exostosis dorsally with elevatus of the first metatarsal. This is an endstage ankylosing hallux rigidus causing severe pain. If you did an MRI, you would see this once again. Joint space narrowing, you have cystic erosions in the joint itself, as well as complete narrowing with hypertrophic bone. Just an example, you’re not going to go in there and you’re going to clean up that joint. You’re going to prepare this for an arthrodesis. You actually clean up all the ends. You can do an end-to-end. There’s a thousand procedures out there for fusion of the first metatarsophalangeal joint, plate, screws. To me, it doesn’t matter what you do as long as you have good bone-to-bone contact of the joint itself. This is an example of a two-screw fixation. To me, that’s a really simple fusion where you’re actually doing it percutaneously, placing two screws in, putting the toe in proper alignment and then fusing the joint so that you have a good end-to-end bone contact, slightly dorsiflexed so that they can roll-off or push-off with activity and has shown to have good results long term. So there you go, end-to-end arthrodesis. Soft tissue procedures are cheilectomy with fenestration. That used to be an excellent procedure where you actually open up the joint. This is called [indecipherable] [13:11]. There’re these osteophytes within the joint. Sometimes the joint cartilage is still good but these osteophytes or loose bodies need to be removed and so remove them and then clean up the joint, fenestrate the cartilage for new growth fibrocartilage. This will then actually put the - you take this person and put them through early active range of motion and they’ll get good results early on beginning of this endstage rigidus. Implant arthroplasty, another procedure that’s available to us. What’s an ideal implant? Well, something that can withstand long contact with the tissue enzymes without deterioration. It shouldn’t induce sensitivity reaction. We had these Silastic implants long ago that actually did create some problems that way. Clinically and chemically, it should be inert without any activation of response for an inflammatory or a rejection response. Noncarcinogenic of course and capable of resisting deforming forces. With all implants, we’re talking about just an ideal implant. Some of the contraindications to any type of implant especially the first MPJ-type implant would be poor bone quality, osteoporosis, vitamin D deficiency, infection, vascular insufficiency. You look at the activity level of the patient. Is the patient very active? Maybe an implant wouldn’t be beneficial, maybe a fusion would be beneficial. And the patient’s age. Someone who is elderly is more suitable for an implant because of the long life of an implant. They talk about the 10 to 15-year level. I have not read one article that actually says that these implants only last 10 to 15 years because the studies shows blah blah blah blah blah.
I haven’t seen that yet but maybe there’s one out there, I just haven’t found it. The degenerative joint disease, this is a severe osteophyte within the joint. You can see here now that the hallux is becoming more pinned into the plantar aspect of the first metatarsal with hypertrophic bone around the joint and you have osteophytes within the joint itself. In this type of a problem where you have some joint space narrowing and elevatus, you can actually do a cheilectomy with an osteotomy. It is a good alternative without implant. Here’s an example of that where you do an L-type osteotomy or some type of an osteotomy in the head to shorten it. In this patient, they had a hallux interphalangeus so that was fixed with Akin-type osteotomy. There you see where the metatarsals now dropped and the hypertrophic bone dorsally is removed and you have joint space now. This patient is now put through active range of motion early, three to four weeks they’re back in a shoe even though you did the osteotomies because you want motion. The hemi implant surgically is very simple. The key to this why I like the hemi implant is you take out very little bone. You heard about that yesterday in the ankle joint implant surgery where if you take out a small amount of bone, if it fails at least you have an alternative to fuse and that’s what this is all about, an implant that can actually be placed in there. What you’ll see is this hemi implant now is just a small spacer. You can correct from these many other deformities but you clean up the metatarsal head, you put the hemi implant in and you can get early active motion very fast. Hemi implant, I lean toward this procedure most because I like the fact that I can put a hemi implant in and I can do a metatarsal head osteotomy. When you have a lot of bone proliferation, you can see the hemi implant being put in. Once the implant is in, you can address the elevatus and the tightness of the joint if there’s still some without a lot of shortening by dropping the head and doing an osteotomy to now bring the metatarsal elevatus down and giving yourself more joint space with two-screw fixation. It’s really quite simple. Here’s an example of that where the implant is in and the screws are going in. Now you have the joint space decompression and the arthritic change taken from the implant and that’s how that looks. Here’s another example of that with the hemi. I do this in many different age groups. Some very old and some young depending on their activity and how much deformity there is to the joint. I personally haven’t done a lot of fusions because I have a lot of people who are active and want to do. I believe that first MPJ motion is important so I’ll try to keep that joint as best as I can with the idea that if the hemi implant fails, fusion is the answer. Implant versus arthrodesis, you want to get normal alignment in both the transverse and sagittal plane. Remember, you need good bone stock. We used to put these implants in there. We used to put total Silastic implants and I put minimally in my residency 500. We did them for everything. We stretch the joints, we change the joints, we thought we were doing something remarkable because we had this little space so we could put in there. You do the procedure in 5 to 10 minutes after doing so many. Over time, we realized, we were sort of just taken an implant and putting it in for all the wrong reasons. If there was sagittal plane and transverse plane, we would say, “Don’t worry, the implant will hold it straight,” and that failed and we failed miserably on that. Remember that you need normal alignment in the transverse and sagittal plane and also normal to - you don’t want a very excessively short metatarsal because you don’t want to shorten too much. Very important is the sesamoid complex. We forget about that. Remember, I told you earlier in hallux rigidus, sometimes the sesamoids are the key problem because they jam up into the head and you don’t have that glide that you need. Make sure that you don’t have a severe metabolic arthritic condition because it will fail. This is where it became interesting. What I did is I said, “Okay, you know what, I’ve spoken on this subject before. I’ve had people come up and go. You know what, you’re crazy. Arthrodesis is the only thing that’s really indicative for hallux rigidus or I never use an implant or I always use an implant.” People have all their different opinions and I thought, okay, I’m going to review a lot of the literature and find out. So this article to me is worth a read.
It was something that I felt important enough that I wanted to show it to you. It was an evidence-based analysis of the efficacy for operative treatment for hallux rigidus in the Foot & Ankle International Journal by McNeill and all his friends. They reviewed 586 articles of which 135 were relevant. That’s a lot of writing about a subject and only having 135 “relevant” articles. I found that to be quite interesting. In the 586 articles, some were case reports and some were studies, maybe they weren’t all very classified studies. So they took the 135 that were relevant. Here is how they did it. They did a comprehensive review of all the literature. They did a level of evidence 1 through 5. And 1 was a high quality randomized trial, 2 is a lesser quality randomized controlled trial, 3 was a case controlled study which we do a lot of retrospectively, 4 which is case studies, and then 5 is expert opinion which we also do a lot of. Then they took grades of the evidence and they had A through C and I. A being good evidence level, one study is with good evidence. B was fair evidence, level 2 or 3 which were consistent. And then C was a poor quality evidence level4 or 5. And then I was insufficient or conflicting evidence. They took all these articles and they read them all and then classify them. Here’s the conclusion. I thought the conclusion was great. So, the results. There is fair evidence, meaning grade B, in support of arthrodesis. There was poor evidence, grade C, in support of cheilectomy, osteotomy, implant arthroplasty, resection arthroplasty. Then there was insufficient evidence, grade 1, for cheilectomy with osteotomy. I found that to be really fascinating because we have many people who speak on these subjects and for arthrodesis, it’s the way to go. Well, here’s a fair evidence in support of arthrodesis. I tell you that implant arthroplasty with a hemi implant, with a cheilectomy and/or a metatarsal osteotomy is great in my hands. That has poor evidence in support of that type of problem. My personal conclusion was on this was that we really need to do a whole lot more and better studies to really find out what is the ideal treatment. I think that when you’re a surgeon, you’re going to do what’s best in your hands and what you think is best for the pathology at hand. I think that’s where you become very much in routine for what you do. I don’t think that’s wrong. I think that when you get to be in a point of practice where routine for you is to do it this way or that way and it works 99% of the time for you, it’s the right thing to do even if it’s not evidence based in the fair, the good or better area but the fair and the poor are quite eye opening to me. In conclusion, hallux rigidus can be treated several ways. You have all the ways you can treat it from an orthotic, nonsurgical treatment to a surgical treatment and there’s many treatments for yourself. You have all types of implants out there. You have hemi implants. You have total implants. You have osteotomies. You even have external fixators to open up the gap with the diastasis but what is it? Your real goal is to reduce the pain and increase the function of the first metatarsophalangeal joint and that’s what makes it the right thing to do. I thought that article is worth looking at and to share that information with you because you can see all kinds of fancy pictures and pretty pictures of implants and how they go in but more important, what’s best is going to be best for what’s best for you and your patients and what you do well. Thank you very much.