Updated: 8/18/2020

DJD & Hallux Rigidus

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https://upload.orthobullets.com/topic/7009/images/Hallux rigidus_moved.jpg
https://upload.orthobullets.com/topic/7009/images/grade 1 ap..jpg
https://upload.orthobullets.com/topic/7009/images/grade 2 ap..jpg
https://upload.orthobullets.com/topic/7009/images/grade 3 ap..jpg
https://upload.orthobullets.com/topic/7009/images/grade 4 ap..jpg
https://upload.orthobullets.com/topic/7009/images/mortons extension_moved.jpg
Introduction
  • Overview
    • A condition characterized by loss of motion of the first MTP joint in adults due to degenerative arthritis
      • management depends on chronicity and degree of symptoms
  • Epidemeololgy
    • 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
  • 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 
  • 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
    •  

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

 

 
 

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Questions (31)
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(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? Tested Concept

QID: 4810
FIGURES:
1

Cheilectomy and Moberg procedure

14%

(427/3073)

2

Interpositional arthroplasty using joint capsule, and flexor hallucis brevis release

5%

(155/3073)

3

Metatarsal hemiarthroplasty

1%

(20/3073)

4

Total joint arthroplasty

3%

(86/3073)

5

Arthrodesis

77%

(2367/3073)

L 2 B

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(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? Tested Concept

QID: 3864
FIGURES:
1

Wound closure and weight bearing as tolerated in a post op shoe

56%

(1278/2296)

2

Flexor digitorum longus to extensor digitorum longus tendon transfer

7%

(153/2296)

3

Moberg procedure

27%

(621/2296)

4

Keller procedure

6%

(133/2296)

5

Metatarsophalangeal joint arthrodesis

4%

(82/2296)

L 5 B

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

QID: 3670
FIGURES:
1

Hallux rigidus

90%

(2329/2590)

2

Hallux valgus

1%

(36/2590)

3

Midfoot arthritis

4%

(100/2590)

4

Freiberg Infraction

1%

(38/2590)

5

Interdigital neuroma (Morton's)

3%

(75/2590)

L 1 A

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(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? Tested Concept

QID: 3337
FIGURES:
1

Modified chevron osteotomy

1%

(44/3134)

2

Metatarsal dorsal oblique osteotomy (Helal osteotomy)

4%

(118/3134)

3

Metatarsal plantar oblique osteotomy (Weil osteotomy)

4%

(114/3134)

4

Cheilectomy

89%

(2787/3134)

5

Proximal phalanx closing wedge osteotomy (Moberg osteotomy)

2%

(55/3134)

L 1 A

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(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? Tested Concept

QID: 3360
FIGURES:
1

Implantation of a double-stem silicone implant

1%

(25/2456)

2

Dorsiflexion osteotomy (Moberg) of the proximal phalanx

1%

(34/2456)

3

Resection arthroplasty (Keller) along with removal of osteophytes

56%

(1380/2456)

4

Cheilectomy

9%

(216/2456)

5

Arthrodesis of the first metatarsophalangeal joint

32%

(794/2456)

L 3 B

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

QID: 3179
1

Hallux valgus

2%

(53/2313)

2

Hallux rigidus

91%

(2096/2313)

3

2nd metatarsophalangeal joint synovitis

4%

(83/2313)

4

Jones fracture

0%

(7/2313)

5

Hammertoe deformity

3%

(71/2313)

L 1 B

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(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? Tested Concept

QID: 518
FIGURES:
1

Observation

1%

(15/2474)

2

Medial sesamoidectomy

1%

(19/2474)

3

Cheilectomy and joint debridement

79%

(1943/2474)

4

1st MTP resection artrhoplasty (Keller procedure)

3%

(80/2474)

5

1st MTP fusion

16%

(400/2474)

L 2 A

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(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? Tested Concept

QID: 670
1

Steroid joint injection

2%

(25/1648)

2

Custom molded orthosis with recessed 1st metatarsal molding

11%

(176/1648)

3

Irrigation and debridement and IV antibiotics

1%

(12/1648)

4

Revision of silastic implant and synovectomy

13%

(209/1648)

5

Removal of implant and synovectomy

74%

(1219/1648)

L 2 C

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

QID: 909
1

Hallux rigidus

90%

(1613/1797)

2

Hallux valgus

2%

(33/1797)

3

Hallux varus

1%

(12/1797)

4

Morton's neuroma

5%

(98/1797)

5

Spring ligament rupture

2%

(32/1797)

L 1 B

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(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? Tested Concept

QID: 944
1

Cheilectomy

89%

(2391/2701)

2

Lapidus procedure

1%

(19/2701)

3

First metatarsophalangeal arthrodesis

6%

(158/2701)

4

Metatarsophalangeal resurfacing

3%

(79/2701)

5

Chevron osteotomy

2%

(41/2701)

L 1 B

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(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? Tested Concept

QID: 1180
FIGURES:
1

Resection of dorsal osteophyte and 25% of the dorsal aspect of the metatarsal head

89%

(1067/1203)

2

Proximal phalanx medial closing wedge osteotomy

1%

(15/1203)

3

First metatarsophalangeal joint arthrodesis

6%

(73/1203)

4

Medial eminence removal and resection of base of proximal phalanx

2%

(19/1203)

5

First tarsometatarsal joint arthrodesis and metatarsophalangeal capsular release

2%

(22/1203)

L 1 B

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