DJD & Hallux Rigidus

Author: Daniel Hatch

Topic updated on 06/01/13 1:30pm

Introduction

A condition characterized by loss of motion of first MTP joint in adults due to degenerative arthritis
- osteophyte formation leads to dorsal impingement
Pathoanatomy
- primary etiology unknown
- acute trauma and repetitive microtrauma predispose to arthritic changes
- anatomic variations of first metatarsal may play a yet unproven role in arthritic predisposition

Classification

Hallux Rigidus Classification
	Exam Findings	Radiographic Findings
Grade 0	Stiffness	Normal
Grade 1	mild pain at extremes of motion	mild dorsal osteophyte, normal joint space
Grade 2	moderate pain with range of motion increasingly more constant	moderate dorsal osteophyte, <50% joint space narrowing
Grade 3	significant stiffness, pain at extreme ROM, no pain at mid-range	severe dorsal osteophyte, >50% joint space narrowing
Grade 4	significant stiffness, pain at extreme ROM, pain at mid-range of motion	same as grade III

Presentation

Symptoms
- first ray and 1st MTP pain and swelling worse with push off or forced dorsiflexion of great toe
- shoe irritation due to dorsal osteophytes and compression of dorsal cutaneous nerve may lead to paresthesias
- pain becomes less severe as the disease progresses
Physical exam
- limited dorsiflexion
- pain with grind test

Imaging

Radiographs
- recommended views
  - AP, lateral, and oblique views
- findings
  - osteophytes, especially dorsal
  - joint space narrowing
  - subchondral sclerosis and cysts

Treatment

Nonoperative
- NSAIDS, activity modification & orthotics
  - indications
    - grade 0 and 1 disease
  - activity modifications
    - avoid activities that lead to excessive great toe dorsiflexion
  - types of orthotics
    - Morton's extension with stiff foot plate is the mainstay of treatment
    - stiff sole shoe and shoe box stretching may also be used
Operative
- joint debridement and synovectomy
  - indications
    - patients with acute osteochondral or chondral defects
- dorsal cheilectomy
  - indications
    - grade 1 and 2 disease (controversial)
    - pain with dorsiflexion is an indicator of good results with dorsal cheilectomy
    - shoe wear irritation from dorsal prominence and pain (ideal candidate)
    - contraindicated when pain located in the mid-range of the joint during passive motion
  - technique
    - remove 25-30% of the dorsal aspect of the metatarsal head along with dorsal osteophyte resection
    - the goal of surgery is to obtain 70% to 90% dorsiflexion intraoperatively
- Moberg procedure (dorsal closing wedge osteotomy of the proximal phalanx)
  - indications
    - runners with reduced dorsiflexion (60° is needed to run)
    - failure of cheilectomy to provide at least 30 to 40 degrees of motion
  - technique
    - increases dorsiflexion by decreasing the plantar flexion arc of motion
- Keller Procedure (resection arthroplasty)
  - indications
    - elderly, low demand patients with significant joint degeneration and loss of motion
    - contraindicated in patients with pre-existing rigid hyperextension deformity of 1st MTP joint
  - technique
    - involves removing the base of the first proximal phalanx
    - risk of hyperextension (cock-up deformity), weakness with push-off, and transfer metatarsalgia (decreased with capsular interposition)
- MTP arthroplasty
  - indications
    - indications controversial
  - technique
    - capsular interpositonal arthroplasty gaining popularity
    - silicone implants are not recommended due to poor long-term results
  - outcomes
    - silicone implants may have a good short term satisfaction rate
    - osteolysis and synovitis cause mid to long term pain and joint destruction
- MTP joint arthrodesis
  - indications
    - grade 3 and 4 disease (significant joint arthritis)
    - most common procedure for hallux rigidus
  - outcomes
    - 70% to 100% fusion rate
    - 15% of patients experience degeneration of IP joint after surgery (mostly asymptomatic)

Techniques

MTP joint arthrodesis
- dorsal plate with compression screw is biomechanically strongest construct
- preferred surgical alignment
  - 10 to 15 degrees of valgus in relation to the metatarsal shaft
  - 15 degrees of dorsiflexion in relation to the floor
- fusion in excesssive dorsiflexion causes pain at tip of the toe, over the IP joint, and under the 1st metatarsal with excessive dorsiflexion
- fusion in excessive plantar flexion causes increased pressure at the tip of the toe
- fusion in excessive valgus increases the risk of IP joint degeneration

Complications

Failed arthroplasty
- treatment
  - implant resection, synovectomy if there is isolated great toe pain
  - implant resection, bone grafting, and arthrodesis if there is great toe pain with lesser toe metatarsalgia

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Qbank (9 Questions)

TAG

(OBQ11.247) Which of the following foot conditions is most appropriately treated with the orthotic shown in Figure A? Topic

Review Topic

FIGURES: A

1. Hallux rigidus
2. Hallux valgus
3. Midfoot arthritis
4. Freiberg Infraction
5. Interdigital neuroma (Morton's)

PREFERRED RESPONSE ▶

DISCUSSION: Figure A demonstrates a Morton's extension orthotic. It is a stiff insert with a rigid extension under the 1st ray. This extension is used to conservatively treat conditions such as hallux rigidus, sesamoid disorders, and 1st MTP sprains (turf toe), as it limits extension of the 1st MTP joint during the push-off phase of gait.

Yee et al provide a complete review of hallux rigidus which outlines the clinical presentation and treatment options, including indications and the evidence to support them. Hallux rigidus refers to degenerative arthritis of the first metatarsophalangeal (MTP) joint. Patients commonly present with pain and stiffness at the first MTP joint. In the early stages, the discomfort is predominant with 1st MTP dorsiflexion and there is a positive grind test of the MTP joint. Cheilectomy, Moberg dorsiflexion osteotomy, and 1st MTP fusion are surgical options depending on the severity of the hallux rigidus if conservative treatments fail.

Illustration A is a radiograph demonstrating hallux rigidus with moderate osteophyte formation and joint space narrowing combined with subchondral sclerosis.

Illustrations: A

REFERENCES:

1. Berberian WS, Najarian RG. Midfoot and forefoot arthritis and hallux rigidus. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:201-214.

2. Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int. 2008 Jun;29(6):637-46. PMID:18549766 (Link to Abstract)

Question Authors:

Michael Hughes MD, John Badylak MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 7 Ratings

TAG

(OBQ10.91) A shoe orthotic with a Morton's extension is indicated for which of the following conditions? Topic

Review Topic

1. Hallux valgus
2. Hallux rigidus
3. 2nd metatarsophalangeal joint synovitis
4. Jones fracture
5. Hammertoe deformity

PREFERRED RESPONSE ▶

DISCUSSION: A Morton's extension is a stiff insert with a rigid extension under the 1st ray. This extension is used to conservatively treat conditions such as hallux rigidus, as it limits extension of the 1st MTP joint during the push-off phase of gait. The first referenced article by Shereff et al is a review of hallux rigidus, including diagnosis, staging, and treatment. The second referenced article by Sammarco et al is a review of the orthotic management of different problems around the hallux, including rigidus. Illustration A is a photo of a commonly available Morton's extension.

Illustrations: A

REFERENCES:

1. Shereff MJ, Baumhauer JF. Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint. J Bone Joint Surg Am. 1998 Jun;80(6):898-908. PMID:9655109 (Link to Abstract)

2. Sammarco VJ, Nichols R. Orthotic management for disorders of the hallux. Foot Ankle Clin. 2005 Mar;10(1):191-209. PMID:15831266 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, John Badylak MD,

Please Rate Educational Value!

3.0

Average 3.0 of 18 Ratings

TAG

(OBQ10.238) A 45-year-old construction worker reports pain in the first toe with the maneuver found in Figure A. The radiographs in Figure B and C reveals mild osteoarthritis of the first metatarsophalangeal joint and a dorsal osteophyte. Orthotics have failed to provide relief. What surgical procedure is the most appropriate next step in management? Topic

Review Topic

FIGURES: A

1. Modified chevron osteotomy
2. Metatarsal dorsal oblique osteotomy (Helal osteotomy)
3. Metatarsal plantar oblique osteotomy (Weil osteotomy)
4. Cheilectomy
5. Proximal phalanx closing wedge osteotomy (Moberg osteotomy)

PREFERRED RESPONSE ▶

DISCUSSION: Cheilectomy, as shown in Illustration A, will relieve dorsal impingement pain associated with Grade 1-2 MTP arthritis. Cheilectomy is offered after conservative management has failed (including NSAIDs and orthotics such as a rigid Morton's extension foot orthosis). Moberg osteotomies are closing wedge osteotomies of the proximal phalanx that remove a dorsal wedge of bone to improve the functional range of motion arc of the MTP. A Weil osteotomy is an intra-articular osteotomy that achieves longitudinal decompression through shortening. In a Weil osteotomy the metatarsal (MT) is exposed and the direction of shortening runs mostly parallel to the plantar aspect of the foot. The Weil osteotomy is fixed by means of a screw running perpendicular to the osteotomy line. The Helal osteotomy has no form of fixation and is made more proximally. Illustration B compares the Helal (A) and Weil (B) osteotomies and they are often used as shortening procedures in the treatment of MTP dislocations. Arthrodesis is treatment of choice following failed cheilectomy or where advanced degenerative changes are present.

The review article by Sammarco and Nichols discuss orthotic options for hallux rigidus, hallux valgus, sesamoiditis, and 1st ray hypermobility.

The article by Yee and Lau is a current concepts review of hallux rigidus.

Illustrations: A

REFERENCES:

1. Sammarco VJ, Nichols R. Orthotic management for disorders of the hallux. Foot Ankle Clin. 2005 Mar;10(1):191-209. Review PMID:15831266 (Link to Abstract)

2. Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int. 2008 Jun;29(6):637-46. Review. PMID:18549766 (Link to Abstract)

Question Authors:

Michael Hughes MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 11 Ratings

TAG

(OBQ10.272) An 80-year-old female presents with a painful great toe MTP joint. She is minimally ambulatory, and has failed conservative treatment. A physical exam reveals a plantarflexed great toe which does not allow for comfortable shoe wear. AP and lateral radiographs of the foot are shown in Figures A and B. What is the most appropriate surgical treatment that will allow for the fastest rehabilitation? Topic

Review Topic

FIGURES: A

1. Implantation of a double-stem silicone implant
2. Dorsiflexion osteotomy (Moberg) of the proximal phalanx
3. resection arthroplasty (Keller) along with removal of osteophytes
4. Cheilectomy
5. Arthrodesis of the first metatarsophalangeal joint

PREFERRED RESPONSE ▶

DISCUSSION: Yee et al provide a complete review of hallux rigidus which outlines the clinical presentation and treatment options, including indications and the evidence to support them. They state that a resection arthroplasty (Keller) is the best option for the treatment of advanced hallux rigidus in older, low demand patients. Silicone implants are less desirable due to the potential for synovitis and implant failure, and salavage operations are difficult. A Moberg dorsiflexion osteotomy of the proximal phalanx is indicated in the rare situation where there is symptomatic hyperextension of the interphalangeal joint due to a stiff, but pain-free MTP joint. Cheilectomy alone would not address the significant joint degeneration, and an arthrodesis is an accepted surgical option for advanced-stage hallux rigidus, particularly in younger and more active patients. Gibson et al performed a RCT to evaluate outcomes after first MTPJ arthrodesis and replacement arthroplasty. Outcomes after arthrodesis were superior, and there was an unacceptably high incidence of loosening of the arthroplasty components. Illustration A depicts a standard Keller procedure.

Illustrations: A

REFERENCES:

1. Gibson JN, Thomson CE. Arthrodesis or total replacement arthroplasty for hallux rigidus: a randomized controlled trial. Foot Ankle Int. 2005 Sep;26(9):680-90. PMID:16174497 (Link to Abstract)

2. Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int. 2008 Jun;29(6):637-46. PMID:18549766 (Link to Abstract)

Question Authors:

Joshua Blomberg MD,

Please Rate Educational Value!

2.0

Average 2.0 of 19 Ratings

TAG

(OBQ08.132) You are seeing a 60-year-old male for pain in his great toe that has increased in severity over the past year despite the use of an insole with a Morton's extension. His great toe plantar/dorsiflexion range of motion is limited to a 35 degree arc with pain at the extremes of motion. Radiographs are seen in Figures A & B. What treatment do you suggest? Topic

Review Topic

FIGURES: A

1. Observation
2. Medial sesamoidectomy
3. Cheilectomy and joint debridement
4. 1st MTP resection artrhoplasty (Keller procedure)
5. 1st MTP fusion

PREFERRED RESPONSE ▶

DISCUSSION: This patient has hallux rigidus, or arthritis of the first metatarsal phalangeal joint. He has moderate limitations in motion, and mild joint space narrowing on radiographs. Therefore, she would be classified as Type 2, and the most appropriate treatment would be cheilectomy and joint debridement.

Coughlin et al broke hallux rigidus down into grades 0 thru 4, based on range of motion, radiographic, and clinical findings. They describe 97% good to excellent results with cheilectomy for grade 1 or 2 disease.

Mann et al describe their excellent results (inproved mobility and decreased pain) in treating 25 patients with cheilectomy and describe that cheilectomy offers a better functional treatment for hallux rigidus. They reported that no repeat surgery was needed at greater than 4 year follow up of cheilectomy.

Illustration A shows the different grades described by Coughlin et al.

Illustrations: A

REFERENCES:

1. Mann RA, Clanton TO. Hallux rigidus: treatment by cheilectomy. J Bone Joint Surg Am. 1988 Mar;70(3):400-6. PMID:3126190 (Link to Abstract)

2. Coughlin MJ, Shurnas PS. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg Am. 2003 Nov;85-A(11):2072-88. PMID:14630834 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, Ben Taylor MD, Patrick McCulloch MD,

Please Rate Educational Value!

3.0

Average 3.0 of 10 Ratings

TAG

(OBQ07.9) A 70-year-old sedentary female underwent a silastic arthroplasty of the right 1st metatarsophalangeal joint 15 years ago. She now presents with pain, swelling and erythema of the MTPJ. She is afebrile, bloodwork reveals normal ESR, CRP and WBC, and her erythema resolves with elevation. NSAIDs and activity modification have failed to provide relief. What is the best option to treat her painful toe? Topic

Review Topic

1. Steroid joint injection
2. Custom molded orthosis with recessed 1st metatarsal molding
3. Irrigation and debridement and IV antibiotics
4. Revision of silastic implant and synovectomy
5. Removal of implant and synovectomy

PREFERRED RESPONSE ▶

DISCUSSION: This patient with a silastic arthroplasty has late stage synovitis from the implant. Normal laboratory values involving the white blood cell count, crp and esr help rule out infection as well as the clinical finding that the erythema mostly resolves with elevation.

Kitaoka et al showed that removal of the implant and synovectomy of failed silastic arthroplasties of the 1st metatarsophalangeal joint was an effective first line surgical treatment. Of the 10 patients they were able to get follow up on, 7 had excellent results, 1 had good results, one had fair results, and 1 did poorly. Kitaoka et al showed that lateral forefoot pressures increased following implant removal, but there was no significant change in overall alignment.

More recent studies and review articles such as by Esway et al have shown that implant removal and synovectomy can improve patient satsifaction after a failed arthroplasty. The decision to treat a failed arthroplasty with arthrodesis versus just implant removal depends on the functional demands of the patient and alignment of the foot.

REFERENCES:

1. Kitaoka HB, Holiday AD Jr, Chao EY, Cahalan TD. Salvage of failed first metatarsophalangeal joint implant arthroplasty by implant removal and synovectomy: clinical and biomechanical evaluation.Foot and Ankle, 13:1992 al, PMID:1624187 (Link to Abstract)

2. Coughlin MJ: Arthritides, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 560-650

3. Esway JE, Conti SF. Joint replacement in the hallux metatarsophalangeal joint. Foot Ankle Clin. 2005 Mar;10(1):97-115. PMID:15831260 (Link to Abstract)

Question Authors:

Jan Szatkowski MD, Michael Hughes MD, Dave Marcu MD,

Please Rate Educational Value!

3.0

Average 3.0 of 15 Ratings

TAG

(OBQ07.248) A Morton's extension orthotic is used for which of the following conditions? Topic

Review Topic

1. Hallux rigidus
2. Hallux valgus
3. Hallux varus
4. Morton's neuroma
5. Spring ligament rupture

PREFERRED RESPONSE ▶

DISCUSSION: Hallux rigidus refers to degenerative arthritis of the first metatarsophalangeal (MTP) joint. Patients commonly present with pain and stiffness at the first MTP joint. In the early stages, the discomfort predominates at the dorsal aspect of the joint and becomes more diffuse with the progression of the disease. Walking worsens the pain, particularly during heel-rise and toe-off. CAM boot, AFO, and hard soled shoes are not recommended first line treatment options. The use of a Morton’s extension (see illustration) will restrict motion. Other non surgical treatments include modifications in shoewear, limitations in activity, and injections with corticosteroid. Operative treatment includes joint salvage and joint destructive procedures. These include cheilectomies, osteotomies, arthrodesis, or arthroplasty.

The reference by Yee and Lau covers the current concepts behind hallux rigidus, including the aforementioned staging and treatment options.

Illustrations: A

REFERENCES:

1. Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int. 2008 Jun;29(6):637-46. PMID:18549766 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, Ben Taylor MD,

Please Rate Educational Value!

3.0

Average 3.0 of 4 Ratings

TAG

(OBQ05.58) A 45-year-old carpenter reports pain and restricted dorsiflexion of the great toe. An x-ray reveals mild osteoarthritis of the first metatarsophalangeal joint and a prominent dorsal osteophyte. Orthotics have failed to provide relief. What is the most appropriate intervention at this time? Topic

Review Topic

1. cheilectomy
2. Lapidus procedure
3. first metatarsophalangeal arthrodesis
4. metatarsophalangeal resurfacing
5. chevron osteotomy

PREFERRED RESPONSE ▶

DISCUSSION: Cheilectomy (1st metatarsal osteotomy) for treatment of hallux rigidus will relieve dorsal impingement that is usually the source of pain in patients with this condition. Cheilectomy is recommended for mild to moderate deformity, ie. Grade1-2 and some 3’s. Arthrodesis is treatment of choice following failed cheilectomy or where advanced degenerative changes are present such as Grade 4 hallux rigidus and Grade 3 where <50% of the metatarsal head cartilage remains at the time of surgery. Patient can also try nonoperative options such as molded shoe inserts or rocker bottom shoes.

REFERENCES:

1. Coughlin MJ, Shurnas PS. Hallux rigidus. J Bone Joint Surg Am. 2004 Sep;86-A Suppl 1(Pt 2):119-30. PMID:15466753 (Link to Abstract)

Question Authors:

Greg Galano MD, Patrick McCulloch MD,

Please Rate Educational Value!

3.0

Average 3.0 of 8 Ratings

TAG

(OBQ04.75) A 54-year-old male carpenter is having pain and stiffness in his great toe on the right foot that is exacerbated when he kneels down on his right knee. The skin over the dorsal surface of the 1st metatarsophalangeal joint reveals shoe-wear irritation. He has attempted wearing a carbon fiber shank in his shoe and a trial of meloxicam without relief of symptoms. Radiographs are shown in Figures A and B. What is the next most appropriate step in management? Topic

Review Topic

FIGURES: A

1. Resection of dorsal osteophyte and 25% of the dorsal aspect of the metatarsal head
2. Proximal phalanx medial closing wedge osteotomy
3. First metatarsophalangeal joint arthrodesis
4. Medial eminence removal and resection of base of proximal phalanx
5. First tarsometatarsal joint arthrodesis and metatarsophalangeal capsular release

PREFERRED RESPONSE ▶

DISCUSSION: Hallux rigidus describes a degenerative arthritic process that leads to functional limitation of motion in the first MTP joint. Patients have tenderness over the dorsum of the first MTP joint and limited dorsiflexion. Most patients with grades I and II changes can be treated with cheilectomy with removal of the dorsal osteophyte and 25% of the dorsal aspect of the metatarsal head. The cheilectomy allows dorsiflexion of the proximal phalanx on the metatarsal head. The goal is to obtain 70° to 90° of dorsiflexion intraoperatively. A patient whose main complaint is shoe wear irritation from the prominence or pain with dorsiflexion is the best candidate for cheilectomy.

Lau et al present Level 4 evidence of 19 patients with grade 2 and 11 patients with grade 3 hallux rigidus. The grade 2 arthritis patients were treated with a cheilectomy whereas the grade 3 were treated with interpositional arthroplasty. AOFAS scores were higher in the cheilectomy group.

Feltham et al present Level 4 evidence of 67 patients treated with cheilectomy with 91% being better than prior to surgery and patient age did not affect clinical outcome.

A diagram of the above described cheilectomy is provided in Illustration A.

Illustrations: A

REFERENCES:

1. Lau JT, Daniels TR. Outcomes following cheilectomy and interpositional arthroplasty in hallux rigidus. Foot Ankle Int. 2001 Jun;22(6):462-70. PMID:11475452 (Link to Abstract)

2. Feltham GT, Hanks SE, Marcus RE. Age-based outcomes of cheilectomy for the treatment of hallux rigidus. Foot Ankle Int. 2001 Mar;22(3):192-7. PMID:11310859 (Link to Abstract)

Question Authors:

Michael Hughes MD, John Badylak MD, Ben Taylor MD,

Please Rate Educational Value!

4.0

Average 4.0 of 13 Ratings

Posts

	Hallux rigidus. Grading and long-term results of operative treatment. Coughlin MJ, Shurnas PS J Bone Joint Surg Am. 2003 Nov;85-A(11):2072-88. PMID: 14630834 (Link to Pubmed) Foot & Ankle - Journal Club - DJD & Hallux Rigidus	5/10/2013 39 responses 4
	Arthroscopic cheilectomy for hallux rigidus? There are not many studies in the literature discussing arthroscopic cheile... Foot & Ankle - Surgical Techniques - DJD & Hallux Rigidus	10/1/2011 27 responses 0

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Evidence & References Show References

Level of Evidence 4 (Case Series)

Coughlin MJ, Shurnas PS. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg Am. 2003 Nov;85-A(11):2072-88. PMID:14630834 (Link to Abstract)
Feltham GT, Hanks SE, Marcus RE. Age-based outcomes of cheilectomy for the treatment of hallux rigidus. Foot Ankle Int. 2001 Mar;22(3):192-7. PMID:11310859 (Link to Abstract)
Lau JT, Daniels TR. Outcomes following cheilectomy and interpositional arthroplasty in hallux rigidus. Foot Ankle Int. 2001 Jun;22(6):462-70. PMID:11475452 (Link to Abstract)
Mann RA, Clanton TO. Hallux rigidus: treatment by cheilectomy. J Bone Joint Surg Am. 1988 Mar;70(3):400-6. PMID:3126190 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Esway JE, Conti SF. Joint replacement in the hallux metatarsophalangeal joint. Foot Ankle Clin. 2005 Mar;10(1):97-115. PMID:15831260 (Link to Abstract)
Kitaoka HB, Holiday AD Jr, Chao EY, Cahalan TD. Salvage of failed first metatarsophalangeal joint implant arthroplasty by implant removal and synovectomy: clinical and biomechanical evaluation.Foot and Ankle, 13:1992 al, PMID:1624187 (Link to Abstract)
Shereff MJ, Baumhauer JF. Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint. J Bone Joint Surg Am. 1998 Jun;80(6):898-908. PMID:9655109 (Link to Abstract)
Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int. 2008 Jun;29(6):637-46. PMID:18549766 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Berberian WS, Najarian RG. Midfoot and forefoot arthritis and hallux rigidus. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:201-214.
Coughlin MJ: Arthritides, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 560-650

Undefined

Sammarco VJ, Nichols R. Orthotic management for disorders of the hallux. Foot Ankle Clin. 2005 Mar;10(1):191-209. Review PMID:15831266 (Link to Abstract)
Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int. 2008 Jun;29(6):637-46. Review. PMID:18549766 (Link to Abstract)
Coughlin MJ, Shurnas PS. Hallux rigidus. J Bone Joint Surg Am. 2004 Sep;86-A Suppl 1(Pt 2):119-30. PMID:15466753 (Link to Abstract)
Gibson JN, Thomson CE. Arthrodesis or total replacement arthroplasty for hallux rigidus: a randomized controlled trial. Foot Ankle Int. 2005 Sep;26(9):680-90. PMID:16174497 (Link to Abstract)
Sammarco VJ, Nichols R. Orthotic management for disorders of the hallux. Foot Ankle Clin. 2005 Mar;10(1):191-209. PMID:15831266 (Link to Abstract)

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DJD & Hallux Rigidus

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