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 role in arthritic predisposition Classification Coughlin and Shurnas 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 transfer metatarsalgia Physical exam limited dorsiflexion pain with grind test inverted gait decreased push-off strength 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 select patients with grade 3 disease may benefit from cheilectomy pain with terminal 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 70-90% of 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) MTP joint arthrodesis with structural bone graft indications for structural bone graft 1st MT shortening that cannot be adequately rebalanced with a lesser metatarsal osteotomy (usually shortening > 5 mm) most commonly seen with failed MTP arthroplasty significant proximal phalanx bone loss with inadequate remaining bone for fixation without compromising IP joint, 1st MT shortening with loss of medial support of the 2nd toe predisposing to varus at the 2nd MTP joint. 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 Best way to assess this introperatively is with foot plate to simulate weight bearing with 4-8mm of clearance of toe from plate fusion in excessive 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 Nonunion uncommon following 1st MTP arthodesis, union rate is 90+% 32% of patients with a nonunion are asymptomatic treatment revision with bone grafting
Technique Guide Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. First MTP Joint Arthrodesis Orthobullets Team Foot & Ankle - DJD & Hallux Rigidus
QUESTIONS 1 of 29 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12FA.57) A 32-year-old runner presents with persistent left great toe pain that has been ongoing for 6 months. She's tried a rigid-sole running shoe, anti-inflammatories, and orthotics with no relief. She has pain at extremes of dorsiflexion and with pushoff, but no midrange pain. She has 10 degrees of dorsiflexion. She decides to take time off running and undergo a dorsal cheilectomy. Figures A and B show her preoperative images. Intraoperatively the surgeon removes the dorsal 30% of the metatarsal head and is able to achieve 20 degrees of dorsiflexion. What is the next best step in management? Review Topic | Tested Concept QID: 3864 FIGURES: A B Type & Select Correct Answer 1 Wound closure and weight bearing as tolerated in a post op shoe 56% (1254/2237) 2 Flexor digitorum longus to extensor digitorum longus tendon transfer 7% (150/2237) 3 Moberg procedure 26% (590/2237) 4 Keller procedure 6% (133/2237) 5 Metatarsophalangeal joint arthrodesis 4% (81/2237) L 5 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.247) Which of the following foot conditions is most appropriately treated with the orthotic shown in Figure A? Review Topic | Tested Concept QID: 3670 FIGURES: A Type & Select Correct Answer 1 Hallux rigidus 90% (2305/2560) 2 Hallux valgus 1% (36/2560) 3 Midfoot arthritis 4% (97/2560) 4 Freiberg Infraction 1% (37/2560) 5 Interdigital neuroma (Morton's) 3% (73/2560) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (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? Review Topic | Tested Concept QID: 3337 FIGURES: A B C Type & Select Correct Answer 1 Modified chevron osteotomy 1% (42/3092) 2 Metatarsal dorsal oblique osteotomy (Helal osteotomy) 4% (114/3092) 3 Metatarsal plantar oblique osteotomy (Weil osteotomy) 4% (113/3092) 4 Cheilectomy 89% (2755/3092) 5 Proximal phalanx closing wedge osteotomy (Moberg osteotomy) 2% (52/3092) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (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 plantar-flexed 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? Review Topic | Tested Concept QID: 3360 FIGURES: A B Type & Select Correct Answer 1 Implantation of a double-stem silicone implant 1% (24/2435) 2 Dorsiflexion osteotomy (Moberg) of the proximal phalanx 1% (32/2435) 3 Resection arthroplasty (Keller) along with removal of osteophytes 56% (1372/2435) 4 Cheilectomy 9% (215/2435) 5 Arthrodesis of the first metatarsophalangeal joint 32% (785/2435) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (OBQ10.91) A shoe orthotic with a Morton's extension is indicated for which of the following conditions? Review Topic | Tested Concept QID: 3179 Type & Select Correct Answer 1 Hallux valgus 2% (51/2260) 2 Hallux rigidus 91% (2048/2260) 3 2nd metatarsophalangeal joint synovitis 4% (81/2260) 4 Jones fracture 0% (7/2260) 5 Hammertoe deformity 3% (70/2260) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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. A radiograph is shown in Figure A. What treatment do you suggest? Review Topic | Tested Concept QID: 518 FIGURES: A Type & Select Correct Answer 1 Observation 1% (15/2446) 2 Medial sesamoidectomy 1% (19/2446) 3 Cheilectomy and joint debridement 79% (1921/2446) 4 1st MTP resection artrhoplasty (Keller procedure) 3% (79/2446) 5 1st MTP fusion 16% (395/2446) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (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? Review Topic | Tested Concept QID: 670 Type & Select Correct Answer 1 Steroid joint injection 2% (25/1630) 2 Custom molded orthosis with recessed 1st metatarsal molding 11% (173/1630) 3 Irrigation and debridement and IV antibiotics 1% (12/1630) 4 Revision of silastic implant and synovectomy 13% (205/1630) 5 Removal of implant and synovectomy 74% (1209/1630) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review tested concept (OBQ07.248) A Morton's extension orthotic is used for which of the following conditions? Review Topic | Tested Concept QID: 909 Type & Select Correct Answer 1 Hallux rigidus 90% (1567/1746) 2 Hallux valgus 2% (33/1746) 3 Hallux varus 1% (12/1746) 4 Morton's neuroma 5% (93/1746) 5 Spring ligament rupture 2% (32/1746) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ05.58) A 45-year-old carpenter reports pain during terminal dorsiflexion and restricted range of motion 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? Review Topic | Tested Concept QID: 944 Type & Select Correct Answer 1 Cheilectomy 89% (2354/2658) 2 Lapidus procedure 1% (19/2658) 3 First metatarsophalangeal arthrodesis 6% (154/2658) 4 Metatarsophalangeal resurfacing 3% (77/2658) 5 Chevron osteotomy 2% (41/2658) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (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? Review Topic | Tested Concept QID: 1180 FIGURES: A B Type & Select Correct Answer 1 Resection of dorsal osteophyte and 25% of the dorsal aspect of the metatarsal head 89% (1042/1175) 2 Proximal phalanx medial closing wedge osteotomy 1% (15/1175) 3 First metatarsophalangeal joint arthrodesis 6% (71/1175) 4 Medial eminence removal and resection of base of proximal phalanx 2% (19/1175) 5 First tarsometatarsal joint arthrodesis and metatarsophalangeal capsular release 2% (22/1175) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept
FREE PDF Foot & Ankle Orthopaedics 2018, Vol. 3(2) 1-11 Current Concepts Review: Hallux Rigidus Michael R. Anderson DO Bryant S. Ho MD Judith F. Baumhauer MD Foot & Ankle - DJD & Hallux Rigidus Michael R. Anderson DO, 3 views
All Videos (3) Podcasts (2) Login to View Community Videos Login to View Community Videos California Orthopaedic Association Annual Meeting - 2018 Surgical Treatment of Great Toe Arthritis Expert Panel Discussion / Q&A (COA 2018, 4.3) Foot & Ankle - DJD & Hallux Rigidus 8/30/2018 289 views (1) Login to View Community Videos Login to View Community Videos California Orthopaedic Association Annual Meeting - 2018 Surgical Treatment of Great Toe Arthritis: Implant Arthroplasty - Tyler Gonzalez, MD (COA 2018, 4.2) Tyler Gonzalez Foot & Ankle - DJD & Hallux Rigidus 8/30/2018 349 views (3) Login to View Community Videos Login to View Community Videos 2017 Current Solutions in Foot & Ankle Surgery Treatment of 1st MTP Arthritis: Cheilectomy, Fusion, Interpositional Arthroplasty: Bruce Cohen, MD (CSFA #5, 2017) Foot & Ankle - DJD & Hallux Rigidus 5/12/2017 649 views (5) Question Session⎪DJD & Hallux Rigidus and Fibrous Dysplasia Orthobullets Team Foot & Ankle - DJD & Hallux Rigidus Listen Now 15:17 min 11/6/2019 17 plays (1) Foot & Ankle⎪DJD & Hallux Rigidus Team Orthobullets 4 Foot & Ankle - DJD & Hallux Rigidus Listen Now 8:51 min 10/15/2019 167 plays (4)