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Hallux Rigidus and Cheilectomy

- Discussion:
    - hallux rigidus results from degenerative changes at the first MTP joint;
    - this may be more disabling than hallux valgus, because pt is unable to achieve relief even when not wearing shoes;
    - it is a frequent complaint of runners;
    - there is limitation of motion and pain at the MTP joint of the great toe secondary to repetitive trauma and DJD;
          - because the great toe has limited dorsiflexion, puff of during ambulation can be painful;
          - loss of motion is due to new growth of bone around dorsal articular surface of first metatarsal head;

- Epidemiology:
    - Most common osteoarthritic joint in the foot
    - 2nd most common great toe condition to Hallux Valgus
    - 1 in 40 individuals over 50 y.o. develop Hallux Rigidus (Gould, et al)
    - Females > Males  (2:1)
    - Nilsonne (1930) described two distinct age groups: adolescent and adult Adolescent: localized chondral/osteochondral lesions in articular surface of
                MT head Adult: diffuse, more generalized arthrosis whose severity correlates with age
                - ref: Hallux rigidus: cheilotomy or implant?

- Clinical History:
    - Insidious onset of pain and stiffness about the great toe
    - Standing, walking & heels aggravate
    - worse at toe-off gait
    - relieved with rest
    - burning pain or paresthesia

- Exam:
    - skin irritation due to pressure from footwear over dorsal exostosis
    - on exam, decreased ROM, esp dorsiflexion, is common;
    - limitation of motion and pain at the MTP joint secondary to prominent marginal osteophytes, absence of passive MTP DF, often normal or adequate PF; 
    - affected feet are often long, narrow, & pronated with unstable arches, frequently with a hyper-mobile or elevated (and long) first MT;
    - need to rule out "pseudo-hallux rigidus"
            - nodular swelling of of the proximal FHL which limits hallux dorsiflexion;
            - FHL becomes constricted withing the fibro-osseous tunnel;
            - hallux motion is restored when ankle is plantar flexed;

- X-ray:
    - non-uniform joint space narrowing
    - widening/flattening 1st MT head + base proximal phalanx
    - subchondral sclerosis or cysts
    - horseshoe shaped osteophytes
    - lateral > medial osteophytes
    - sesamoid hypertrophy

- Non Operative Treatment:
    - includes molded stiff inserts w/ rigid bar or rocker bottom shoe;

- Surgical Treatment:
    - surgical inidications:
          - cheilectomy for treatment of hallux rigidus will relieve dorsal impingement that is usually the source of pain in patients w/ this condition;
          - cheilectomy is recommended for mild to moderate deformity;
          - arthrodesis is treatment of choice following failed cheilectomy or where advanced degenerative changes are present;
                   - ref: Study: Arthrodesis most reliable technique to treat hallux rigidus
    - outcomes:
          - in the study by Muller T, et al (1999), there were 14 excellent, 7 good, and one fair result, and radiographic progression was seen in 7/13 patients;
    - operative technique:
          - removal of bone spurs alone is usually not sufficient for pain relief;
          - cheilectomy, which includes not only excision of dorsal spur & dorsal 1/3  the metatarsal head, gives long-term pain relief in most patients;
          - it important to remove the dorsal 20-30% of metatarsal head, along with any spurs that may have formed along lateral side of the joint;
                 - when performing a cheilectomy, most common error is to remove dorsal exostosis in line with dorsal surface of metatarsal  rather than
                           remove dorsal 20% to 30% of bone;
          - a large portion of the motion achieved intra-operative will be lost post-operatively, hence supra-normal amounts of dorsiflexion of great toe is needed;
                 - some surgeons will shoot for 60-80 deg of dorsiflexion;
          - range of motion of the hallux should be initiated soon after surgery
          - Results after cheilectomy in athletes with hallux rigidus.

Hallux rigidus: cheilotomy or implant.

Hallux rigidus: treatment by cheilectomy.

Hallux rigidus: a review of the literature and a method of treatment.

Subjective results of hallux rigidus following treatment with cheilectomy.

Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint. 

Soft-tissue arthroplasty for hallux rigidus.

Hallux Rigidus. Grading and Long-Term Results of Operative Treatment.

Prospective gait analysis in patients with first metatarsophalangeal joint arthrodesis for hallux rigidus.

The Modified Oblique Keller Capsular Interpositional Arthroplasty for Hallux Rigidus