summary Hallux rigidus is a common foot condition characterized by pain and loss of motion of the 1st MTP joint in adults due to degenerative arthritis. Diagnosis is made with orthogonal radiographs of the foot that may show joint space narrowing and dorsal osteophytes of the 1st MTP joint. Treatment of early disease consists of a trial of nonoperative management with a Morton's extension orthotic. Operative management is indicated for higher grade disease and varies depending on chronicity of symptoms and severity of osteoarthritis. Epidemiology Incidence 2.5% of patients older than 50 years most common location of osteoarthritis in the foot Demographics females > males (2:1) most commonly noted in the 5th and 6th decade of life Risk factors history of trauma to the 1st MTP joint noted in ~80% of patients with unilateral disease Etiology Pathophysiology primary etiology unknown acute trauma and repetitive microtrauma predispose to arthritic changes pathoanatomy osteophyte formation and degeneration of the cartilage occur dorsally in early stages and progress to involve the entire joint anatomic variations of first metatarsal may play a role in arthritic predisposition metatarsus adductus long first metatarsal Associated conditions orthopedic conditions sesamoid arthritis medical conditions gout rheumatoid arthritis Anatomy Osteology first metatarsal shortest and widest Neurovascular medial branch of the medial dorsal cutaneous nerve overlies 1st MTP joint can become irritated by dorsal osteophytes Biomechanics the first MTPJ carries up to ~120% of an individual's body weight with each step 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 joint pain worse with push off or lift-off phase of gait dorsal medial foot paresthesia due to dorsal osteophytes and compression of medial dorsal cutaneous nerve transfer metatarsalgia Physical exam inspection swelling of the 1st MTP joint dorsal prominence over the 1st MTP joint (due to dorsal osteophytes) severe disease may present with hyperextension deformity motion limited dorsiflexion pain with terminal dorsiflexion as disease progresses, patient develops pain throughout arc of motion inverted gait neurovascular decreased push-off strength decreased sensation over distal aspect of medial dorsal foot provocative tests pain with grind test indicative of severe disease with central chondral wear Imaging Radiographs recommended views AP, lateral, sesamoid and oblique views of the foot findings dorsal osteophytes joint space narrowing subchondral sclerosis and cysts CT indications suspected osteochondral cysts with normal radiographs can better characterize mild osteoarthritis Treatment Nonoperative NSAIDS, activity modification, intra-articular injections & Morton's extension orthotic indications grade 0 and 1 disease outcomes good short and mid-term pain relief noted in low-grade disease Operative dorsal cheilectomy indications grade 1 and 2 disease select patients with grade 3 disease with primarily pain with terminal dorsiflexion shoe wear irritation from dorsal prominence and pain (ideal candidate) contraindications when pain located in the mid-range of the joint during passive motion outcomes pain with terminal dorsiflexion is an indicator of good results with dorsal cheilectomy 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 Keller Procedure (resection arthroplasty) indications elderly, low demand patients with significant joint degeneration and loss of motion that allows for rapid rehabilitation contraindications patients with pre-existing rigid hyperextension deformity of 1st MTP joint outcomes good results have been noted in low demand elderly patients significant risk of joint instability for younger and more active patients MTP joint arthroplasty indications grade 3 and 4 disease for patients who wish to preserve joint motion contraindications active infection insufficient bone stock hallux sesamoid arthritis outcomes silicone implants may have a good short term satisfaction rate but have high long term failure rate osteolysis and synovitis cause mid to long term pain and joint destruction current implant designs with 80-90% survival rates at ~5 years no difference in functional outcomes, complications or satisfaction rates between hemiarthroplasty and total joint arthroplasty MTP joint arthrodesis indications grade 3 and 4 disease (significant joint arthritis) most common procedure for hallux rigidus outcomes 90-100% fusion rate 95% satisfaction rate 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 NSAIDS, activity modification, intra-articular injections & Morton's extension orthotic activity modifications avoid activities that lead to excessive great toe dorsiflexion intra-articular injections both corticosteroid and sodium hyalurate injections have been shown to significantly improve pain scores at 4 and 8 week followup in low-grade disease types of orthotics Morton's extension with stiff foot plate is the mainstay of treatment extends past the first MTP joint providing a stiff construct that allows minimal dorsiflexion at the articular surface stiff sole shoe and shoe box stretching may also be used Dorsal cheilectomy technique remove up to 30% of the dorsal aspect of the metatarsal head along with dorsal osteophyte resection resection > 30% may lead to joint subluxation the goal of surgery is to obtain 70-90% of dorsiflexion intraoperatively Moberg procedure (dorsal closing wedge osteotomy of the proximal phalanx) technique increases dorsiflexion by decreasing the plantar flexion arc of motion Keller Procedure (resection arthroplasty) technique involves removing the base of the first proximal phalanx interposition risk of hyperextension (cock-up deformity), weakness with push-off, and transfer metatarsalgia (decreased with capsular interposition) MTP joint arthroplasty technique hemiarthroplasty unipolar implant designed to replace the articular surface of metatarsal head or proximal phalanx base benefits compared to total joint maintains length of first ray easier conversion to arthrodesis if necessary total joint arthroplasty first and 2nd generation silastic implants (silicone rubber) high failure rate (~60%) with silicone wear, osteolysis and implant failure third generation metal implants with press-fit fixation fourth generation metal implants with threaded stem fixation MTP joint arthrodesis technique compression and internal fixation can be achieved with wires, pins, lag screws, dual crossed screws and plates 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 intraoperatively is with foot plate to simulate weight bearing with 4-8mm of clearance of toe from plate complications 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 MTP joint arthrodesis with structural bone graft technique structural bone graft used to restore metatarsal length tricortical iliac crest allograft most commonly used Complications Failed arthroplasty risk factors early generation implants (specially silicone implants) 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 incidence 5-10% after arthrodesis 33% of patients with a nonunion are asymptomatic treatment revision arthrodesis with bone grafting First MTP joint cock-up deformity risk factors keller resection arthroplasty treatment first MTP joint arthrodesis Hallux IP joint osteoarthritis incidence 15% of patients following hallux MTP joint arthrodesis risk factors hallux MTP joint arthrodesis treatment usually asymptomatic Prognosis Natural history of disease radiographic progression may not always correlate with symptom progression Return to activity 96% of patient satisfaction rate after first MTP joint arthrodesis with respect to post-operative activity level
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. First MTP Joint Arthrodesis Orthobullets Team Foot & Ankle - DJD & Hallux Rigidus
QUESTIONS 1 of 37 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 30 31 32 33 34 35 36 37 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.98) You are performing an arthrodesis for the condition shown in Figure A. Following instrumentation, the tip of the toe is found to clear the footplate by 5mm (Figure B). Based on this information, the next best step would be to: QID: 212994 FIGURES: A B Type & Select Correct Answer 1 Perform a moberg osteotomy 8% (120/1497) 2 Perform a superior capsulotomy 9% (135/1497) 3 Add a medial-to-lateral compression screw 1% (17/1497) 4 Revise to a plate with less dorsiflexion 15% (230/1497) 5 Irrigate and close 65% (980/1497) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ18.97) Figure A demonstrates an arthroplasty technique commonly used for rheumatoid arthritis. This material has also been used in an attempt to alleviate the condition shown in Figure B. What has been shown to be a long term complication of this technique that complicates revision arthrodesis surgery? QID: 212993 FIGURES: A B Type & Select Correct Answer 1 Recurrent deformity 6% (85/1528) 2 Infection 2% (28/1528) 3 Osteolysis 70% (1067/1528) 4 Chronic Synovitis 15% (230/1528) 5 Floating toe 7% (112/1528) N/A Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ18.23) A 48-year-old woman who runs marathons has been having worsening foot pain. Her AP radiograph is shown in Figure A. She has been wearing the orthotic shown in Figure B. What type of motion is this orthosis designed to limit? QID: 212919 FIGURES: A B Type & Select Correct Answer 1 Midfoot arch collapse 4% (84/2208) 2 Hindfoot varus 1% (14/2208) 3 Hallux MTP dorsiflexion 67% (1475/2208) 4 Hallux MTP plantarflexion 26% (582/2208) 5 Hallux MTP adduction 1% (33/2208) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic 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 (OBQ13.175) A 50-year-old recreational tennis player complains of increasing pain in his big toe. Radiographs are seen in Figure A. He has tried abstaining from sports for 1 year, and is using the orthotic shown in Figure B. He wishes to return back to sports. What is the most appropriate treatment plan? QID: 4810 FIGURES: A B Type & Select Correct Answer 1 Cheilectomy and Moberg procedure 14% (502/3630) 2 Interpositional arthroplasty using joint capsule, and flexor hallucis brevis release 5% (179/3630) 3 Metatarsal hemiarthroplasty 1% (32/3630) 4 Total joint arthroplasty 3% (117/3630) 5 Arthrodesis 77% (2779/3630) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic 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.65) A 41-year-old male laborer presents with worsening left great toe pain, associated plantar lesser toe pain, and callosities. Examination reveals a well-healed incision with no erythema and 35° of dorsiflexion. Radiographs of the left foot are shown in Figure A. Laboratory testing reveals normal ESR, CRP, and white blood cell count from joint aspiration. He has failed all conservative measures and states he would like to proceed with surgical intervention. Which of the following is the next best step in surgical management? QID: 3872 FIGURES: A Type & Select Correct Answer 1 Revision arthroplasty with a long-stemmed prosthesis 2% (38/1891) 2 Removal of hardware and conversion to silastic implant 1% (19/1891) 3 Removal of hardware, I&D, antibiotic spacer placement, and delayed reimplantation 1% (16/1891) 4 Implant removal and synovectomy 1% (13/1891) 5 Implant removal, synovectomy, structural bone grafting, and arthrodesis 94% (1784/1891) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic 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? QID: 3864 FIGURES: A B Type & Select Correct Answer 1 Wound closure and weight bearing as tolerated in a post op shoe 53% (1471/2752) 2 Flexor digitorum longus to extensor digitorum longus tendon transfer 7% (186/2752) 3 Moberg procedure 29% (808/2752) 4 Keller procedure 6% (157/2752) 5 Metatarsophalangeal joint arthrodesis 4% (97/2752) L 5 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic 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 (OBQ11.247) Which of the following foot conditions is most appropriately treated with the orthotic shown in Figure A? QID: 3670 FIGURES: A Type & Select Correct Answer 1 Hallux rigidus 90% (2614/2913) 2 Hallux valgus 2% (45/2913) 3 Midfoot arthritis 4% (113/2913) 4 Freiberg Infraction 1% (40/2913) 5 Interdigital neuroma (Morton's) 3% (87/2913) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 3337 FIGURES: A B C Type & Select Correct Answer 1 Modified chevron osteotomy 1% (52/3570) 2 Metatarsal dorsal oblique osteotomy (Helal osteotomy) 4% (136/3570) 3 Metatarsal plantar oblique osteotomy (Weil osteotomy) 4% (138/3570) 4 Cheilectomy 89% (3160/3570) 5 Proximal phalanx closing wedge osteotomy (Moberg osteotomy) 2% (66/3570) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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? QID: 3360 FIGURES: A B Type & Select Correct Answer 1 Implantation of a double-stem silicone implant 1% (26/2638) 2 Dorsiflexion osteotomy (Moberg) of the proximal phalanx 1% (37/2638) 3 Resection arthroplasty (Keller) along with removal of osteophytes 55% (1459/2638) 4 Cheilectomy 8% (223/2638) 5 Arthrodesis of the first metatarsophalangeal joint 34% (885/2638) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ10.91) A shoe orthotic with a Morton's extension is indicated for which of the following conditions? QID: 3179 Type & Select Correct Answer 1 Hallux valgus 2% (63/2600) 2 Hallux rigidus 90% (2338/2600) 3 2nd metatarsophalangeal joint synovitis 4% (99/2600) 4 Jones fracture 0% (11/2600) 5 Hammertoe deformity 3% (85/2600) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic 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? QID: 518 FIGURES: A Type & Select Correct Answer 1 Observation 1% (18/2828) 2 Medial sesamoidectomy 1% (22/2828) 3 Cheilectomy and joint debridement 79% (2235/2828) 4 1st MTP resection artrhoplasty (Keller procedure) 3% (92/2828) 5 1st MTP fusion 16% (444/2828) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 670 Type & Select Correct Answer 1 Steroid joint injection 2% (29/1844) 2 Custom molded orthosis with recessed 1st metatarsal molding 12% (215/1844) 3 Irrigation and debridement and IV antibiotics 1% (14/1844) 4 Revision of silastic implant and synovectomy 13% (231/1844) 5 Removal of implant and synovectomy 73% (1348/1844) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ07.248) A Morton's extension orthotic is used for which of the following conditions? QID: 909 Type & Select Correct Answer 1 Hallux rigidus 89% (1860/2082) 2 Hallux valgus 2% (43/2082) 3 Hallux varus 1% (14/2082) 4 Morton's neuroma 6% (118/2082) 5 Spring ligament rupture 2% (37/2082) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 944 Type & Select Correct Answer 1 Cheilectomy 88% (2669/3024) 2 Lapidus procedure 1% (24/3024) 3 First metatarsophalangeal arthrodesis 6% (186/3024) 4 Metatarsophalangeal resurfacing 3% (87/3024) 5 Chevron osteotomy 1% (44/3024) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? 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% (1349/1521) 2 Proximal phalanx medial closing wedge osteotomy 1% (18/1521) 3 First metatarsophalangeal joint arthrodesis 6% (96/1521) 4 Medial eminence removal and resection of base of proximal phalanx 2% (24/1521) 5 First tarsometatarsal joint arthrodesis and metatarsophalangeal capsular release 2% (26/1521) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic
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 0.0
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