NB This page is from the 2005 Hyperbook.
Last evidence check November 2004.
“Hallux rigidus” is a term accredited to Cotterill in 1887 and refers to degenerative disease of the first metatarsophalangeal joint with stiffness and deformity. It is the second commonest problem of the 1 st MTP joint (hallux valgus is first). Other terms in the literature include “hallux limitus” (used by podiatrists to refer to limited movement in the 1st MTPJ), “hallux flexus” (flexion deformity with reduced dorsiflexion) and “dorsal bunion”.
These are based on a cadaveric study by Ahn et al. (1997)
The average suface contact area within the joint decreases as the proximal phalanx dorsiflexes on the first metatarsal head. In the neutral position, average surface contact area is 0.38cm 2; however at full dorsiflexion it decreases to 0.04cm 2. The contact point on the proximal phalanx articular cartilage remains constant, however the contact point on the head of the first metatarsal shifts dorsally with increasing toe extension (see diagram). This fits with the observed chondral erosions and degenerative changes that affect the dorsal aspect of the joint. In addition implant arthroplasty of this joint tends to fail from dorsal loading.
HR may be secondary to trauma, gout, infection or other inflammatory arthropathy. Degeneration may begin dorsally with limitation of dorsiflexion and impingement as the predominant features, or begin as a central crater spreading to the whole joint. Joint destruction may be worse on the lateral side producing a “hallux rigidus et valgus”.
Camasta (1996) proposed a series of conclusions on the natural history of the disease based on clinical examination and radiographic findings.
However, he did not offer any data to support these hypotheses.
In addition the sesamoids are subject to degeneration. Hypertrophy of the sesamoids in due to chronic traction, disuse osteopenia is seen, and degeneration parallels that of the MTP joint.
Hallux rigidus is a fairly benign condition. Smith et al (2000) reviewed 22 patients 12-19 years after a diagnosis of hallux rigidus. Although there had been radiographic progression in most patients, few had noticed deteriorating symptoms, and only 25% wished to consider surgery at final review.
This is important in counselling patients, as they are often concerned about progressive disease and keen to “get something done before it gets worse”. We can reassure them that in most people it does not “get worse” and that treatment can be based on current problems rather on an attempt to stave off future disability.
Pain is the commonest feature. In the early stages the pain is mainly felt dorsally and is provoled by dorsal impingement. Later it is felt generally within the joint and is provoked by movement at any point in the range. Some patients have predominantly plantar pain, probably due to sesamoid-metatarsal OA. The pain may radiate down the hallux or up the first ray, and occasionally is felt mainly at a site distant from the MTPJ, but can be provoked by MTPJ movement.
The next commonest complaint is of pain related to a prominent dorsal osteophyte, especially where it rubs on the shoe. There may be a bursa, or the skin may be subject to abrasion, breakdown or infection. Occasionally a patient presents with an ulcer over the osteophyte which communicates with the MTPJ.
A few patients complain mainly of the stiffness, or of the compensatory hyperextension of the IPJ that often develops as the MTPJ get stiffer. Some patients complain the joint locks – this is probably due to synovial impingement as loose bodies are rare.
Patients tend to walk off a painful first ray and may complain of pain under the lateral metatarsals or down the lateral foot border.
There may also be other features of a systemic condition such as gout or rheumatoid disease.
As usual, it is important to determine the exact problem the patient is complaining of. A patient who is bothered only by the osteophyte may be a candidate for a cheilectomy even if the joint is fairly poor. A patient whose main complaint is stiffness may find it difficult to accept that there is no reliable way to improve this.
The patient’s functional demands also have a major influence on management:
The standard radiographs are weight-bearing AP and lateral views. Look for:
Other imaging techniques are not usually necessary. Occasionally an acute presentation, usually with a history of trauma, may be due to an osteochondral injury of the metatarsal head – an MR can be useful in this setting.
A clinical/radiographic grading system was described by Regnauld and appears mainly in the European literature. Hattrup and Johnson (1988) described a radiographic classification which has become standard, and in fact corelates quite well with the Regnauld grading:
Coughlin et al (2003) modified the Hattrup and Johnson classification. He introduced a grade 0, with stiffness and loss motion, but no pain or radiographic changes. Grade 3 was divided into those with advanced arthritic changes but pain only in dorsiflexion or plantarflexion (new grade 3) and those with pain throughout the range of movement (grade 4). This was useful to guide treatment, as cheilectomy was shown to fail in grade 4, but had a variable outcome in grade 3. In addition, Coughlin made the criteria for grading more complex, which often makes gradings less reproducible. There has been no study of the reproducibility of this or other gradings.
One of the most important non-surgical interventions is advice and explanation of the natural history. Patients are generally relieved to hear that this is normally a benign, non-progressive condition and that they can continue any desired activities, including sports, as they are able without any concern that they are storing up trouble for the future.
Choice of shoes which accommodate the stiff joint and dorsal exostosis, and use of a stiff-soled shoe are also useful, as are simple analgesics. Orthoses can be useful in the group of patients (relatively small in our experience) with overpronation and hypermobile first rays. We would not consider further intervention until these simple measures have been tried.
Some patients find steroid injections useful in the short to medium term. There have been no reports of the use of viscosupplementation in the 1st MTP joint.
There are few papers on the non-surgical management of hallux rigidus. Grady et al (2002) reported that 56% of 772 patients with hallux rigidus were successfully treated non-operatively, using a combination of orthoses, shoe alterations and steroid injections. Our experience is that a larger proportion of patients require only non-surgical treatment.
Solan et al (2001) reported the results of MUA and steroid injection in 29 patients. Eight of 12 patients with grade 1 and 6 of 18 with grade 2 radiographs had not required any other surgery, but all 5 with grade 3 changes had undergone definitive surgery. It is impossible to tell whether the MUA or injection, or both, were effective. This seems to be a technique of limited use in patients with early disease.
The joint is opened dorsally and a variable amount of the dorsal part of the first MT head excised. Some authors remove only the osteophytes, others up to 50% of the metatarsal head. One biomechanical study (Heller et al 1997) shows that 30% cheilectomy increases range of movement in hallux rigidus, although this is achieved by abnormal hinging at the dorsal lip, but there are no clinical studies comparing outcome with different techniques.
There have been a large number of series of cheilectomies reported, amounting for over 300 patients. The largest series and the longest follow-up (10 years) was by Coughlin (2003). In many series the surgical methods and outcome measures are reported in a general way. Success rates vary from 72%-100%. Most series report poorer results in patients with severe, grade 3, disease. However, even in grade 3 good results were obtained in the majority. Coughlin distinguished between patients with severe radiographic change but no mid-range pain (in whom cheilectomy was successful in 32/34 patients and the mean AOFAS score was 90) and those with severe changes and mid-range pain (in whom only 1/9 patients who chose cheilectomy got a satisfactory result, five were revised to arthrodesis and the mean AOFAS score in the remainder was 70). The reported results are similar irrespective of the amount of metatarsal head resected. Feltham et al (2001) reprted better results in patients over 60. Mulier et al (1999) reported results in athletes similar to those in general populations.
Cheilectomy has a definite role in treatment of mild-moderate hallux rigidus and is probably the procedure of choice in this group. Comparative trials with osteotomies of the phalanx and metatarsal would be useful in evaluating definitive best therapy. Cheilectomy is an acceptable option for Grade 3 hallux rigidus where the patient wishes to preserve movement and accepts the slightly higher failure rate, but not where there is pain throughout the range of movement.
In patients with a reasonable range of residual motion, a dorsal wedge osteotomy of the phalanx increases dorsiflexion at a theoretical cost of loss of plantarflexion. Thomas and Smith also found that the dorsal space in the joint was increased by osteotomy. Originally this was described as an extra-articular procedure and this was said to be one of the advantages, but more recent series have combined the procedure with limited cheilectomies.
Four series, all with small numbers but two with follow-up of over 10 years, have reported satisfactory pain relief in 72-100%. Dorsiflexion increases by an average of 10deg, and Thomas and Smith (1999) also found a small increase in plantarflexion.
Phalangeal osteotomy has a role in management of mild-moderate hallux valgus. Comparative trials against cheilectomy are required.
The concept of metatarsus primus elevatus as a major aetiological factor in the development of hallux rigidus has led to the use of procedures which plantarflex the first metatarsal head, often with shortening to decompress the joint. Osteotomies have been performed proximally and distally, including the Youngswick procedure, which is basically a modification of the chevron osteotomy with a slice removed from the dorsal limb to slide the head down and proximally, and straight or oblique osteotomies of the head similar to the Weil procedure. The Waterman-Green osteotomy removes a wedge from the dorsum of the metatarsal head, aiming to rotate the better cartilage on the lower part of the head up into the metatarsal-phalangeal articulation.
These procedures are intended for use in early hallux rigidus and hence should be compared with the much simpler cheilectomy. Unfortunately, few results have been published (Roukis et al 2003, Gonzalez et al 2004) in these procedures, and no comparative series. Their place in the management of hallux rigidus is uncertain, but as they are more complex than the cheilectomy and based on a theory of the cause fo hallux rigidus for which there is little if any evidence, only good comparative studies will show if they have a useful place.
There are few series which presents the outcome of 1st MTPJ fusion for hallux rigidus alone - most series are combined with hallux valgus and/or revision cases.
Earlier series reported non-union rates of up to 40%, but recent series using compression screws report 5% or fewer non-unions, especially where a dorsal plate was also used. A variety of low-profile plates have reduced the hardware problems with dorsal plate fixation, and Politi et al (2003) found this was twice as stable as a lag screw alone.
A randomised controlled trial by O’Doherty et al (1990) found no difference in functional outcome between arthrodesis and Keller arthroplasty in 81 patients over the age of 45 (some of whom had hallux valgus in addition to OA). The technique of fusion in this series was not one that most surgeons would use but non-union made little difference to the result. The results of Keller's procedures were better in this study than in many others but this may reflect the standards which can be achieved with care.
Modern series report pain is improved in the majority of patients, with mean AOFAS forefoot scores 75-89/90 and satisfaction in 90% of patients. DeFrino et al (2002) found restoration of the weightbearing function of the first ray on gait analysis 3 years after fusion, with reduction in step length and reduction in ankle torque and power in late stance phase. Interphalangeal arthritis was not a problem at a mean of 6 years’ follow-up in Coughlin’s (2003) series.
Hamilton et al (1997) described a capsular interposition arthroplasty for advanced hallux rigidus which included a limited resection of the proximal phalanx and suture of a dorsal capsular flap to the plantar structures - it may therefore be viewed as a modification of the Keller procedure. 34 feet in 30 patients were reviewed; duration of follow-up is not stated. There were improvements in the pain and function sections of the AOFAS hallux score and 28/30 patients were subjectively satisfied. Battaglia and Basile reported a technique which is not entirely clear but included limited resection and reshaping of the metatarsal head. At 5-year follow-up 91% had useful improvement in pain and function.
Capsular arthroplasty offers an alternative to arthrodesis, implant arthroplasty or Keller procedure for advanced hallux rigidus. Evaluation of its place in practice requires prospective randomised trials against one or more of these procedures.
Silastic interposition arthroplasties were originally introduced to improve the stability of the Keller arthroplasty. Both single-stemmed and double-stemmed implants have been used. The Swanson double stemmed implants now come with metal grommets to reduce fretting against bone edges.
Silastic arthroplasty has a reputation for high wear, loosening, silastic synovitis and lymphadenitis and failure. Medium term studies in double-stemmed implants, however, have not borne this out, with fewer than 10% of implants revised at 5-9 years and little prosthetic subsidence or bone destruction (Sebold 1996, Bankes 1999). Single-stem implants, however, have a higher failure rate, with over 10% revised at 10 years, overall clinical failure in 25-35% of patients and granulomas in 70% (Broughton 1989, Rahman and Fagg 1993, Shankar 1995)
Double-stem silastic arthroplasty is an acceptable treatment for severe hallux rigidus. It is usually recommended for older, less active patients. Grommets may reduce the incidence of silastic synovitis but require better-designed studies to evaluate this further. Single-stem arthroplasty should probably be abandoned.
Titanuim hemiarthroplasty has been reported in one large, long-term study (279 patients followed for 8 months-33 years, although only 1/3 were followed >5 years). 95% clinical success was reported and this implant seems worthy of further comparative study.
Total joint replacements of metal and plastic or ceramic have also been reported (Ess et al 2002, David-West and Moir 2002, Roukis et al 2003) with satisfactory early results. The place of such procedures is not yet clear and requires long-term follow-up and comparative trials against fusion, which remains the gold standard in advanced hallux rigidus.
Resection of the base of the proximal phalanx and soft-tissue reconstruction is intended to decompress the joint and improve pain and range of movement. The Keller procedure may lead to great toe weakness, cock-up deformity and metatarsalgia. Most series (eg O'Doherty et al 1990, Blewitt and Greiss 1993) are mixed populations of hallux rigidus and valgus. Results are probably better for rigidus than valgus.
The Keller procedure remains an acceptable treatment for end-stage hallux rigidus. Further trials against better methods of arthrodesis and against silastic and other implants are required.