Updated: 4/15/2019

DJD & Hallux Rigidus

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Questions
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Evidence
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Videos
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Techniques
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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
  • 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
    • 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  
 

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Questions (25)
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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? Review Topic

QID: 944
1

Cheilectomy

90%

(1846/2056)

2

Lapidus procedure

1%

(13/2056)

3

First metatarsophalangeal arthrodesis

5%

(107/2056)

4

Metatarsophalangeal resurfacing

3%

(53/2056)

5

Chevron osteotomy

1%

(27/2056)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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

QID: 3337
FIGURES:
1

Modified chevron osteotomy

1%

(38/2845)

2

Metatarsal dorsal oblique osteotomy (Helal osteotomy)

4%

(104/2845)

3

Metatarsal plantar oblique osteotomy (Weil osteotomy)

4%

(101/2845)

4

Cheilectomy

89%

(2542/2845)

5

Proximal phalanx closing wedge osteotomy (Moberg osteotomy)

2%

(44/2845)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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

QID: 3360
FIGURES:
1

Implantation of a double-stem silicone implant

1%

(21/2154)

2

Dorsiflexion osteotomy (Moberg) of the proximal phalanx

1%

(27/2154)

3

Resection arthroplasty (Keller) along with removal of osteophytes

58%

(1250/2154)

4

Cheilectomy

9%

(188/2154)

5

Arthrodesis of the first metatarsophalangeal joint

31%

(661/2154)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(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

QID: 518
FIGURES:
1

Observation

1%

(13/2120)

2

Medial sesamoidectomy

1%

(12/2120)

3

Cheilectomy and joint debridement

79%

(1678/2120)

4

1st MTP resection artrhoplasty (Keller procedure)

3%

(65/2120)

5

1st MTP fusion

16%

(340/2120)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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

QID: 3670
FIGURES:
1

Hallux rigidus

90%

(2036/2254)

2

Hallux valgus

1%

(32/2254)

3

Midfoot arthritis

4%

(83/2254)

4

Freiberg Infraction

1%

(32/2254)

5

Interdigital neuroma (Morton's)

3%

(61/2254)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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

QID: 3179
1

Hallux valgus

2%

(45/2041)

2

Hallux rigidus

91%

(1858/2041)

3

2nd metatarsophalangeal joint synovitis

3%

(70/2041)

4

Jones fracture

0%

(7/2041)

5

Hammertoe deformity

3%

(59/2041)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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

QID: 670
1

Steroid joint injection

1%

(20/1449)

2

Custom molded orthosis with recessed 1st metatarsal molding

10%

(150/1449)

3

Irrigation and debridement and IV antibiotics

1%

(8/1449)

4

Revision of silastic implant and synovectomy

12%

(171/1449)

5

Removal of implant and synovectomy

76%

(1095/1449)

ML 2

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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

QID: 909
1

Hallux rigidus

90%

(1365/1520)

2

Hallux valgus

2%

(29/1520)

3

Hallux varus

1%

(9/1520)

4

Morton's neuroma

5%

(79/1520)

5

Spring ligament rupture

2%

(29/1520)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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

QID: 1180
FIGURES:
1

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

89%

(746/839)

2

Proximal phalanx medial closing wedge osteotomy

1%

(12/839)

3

First metatarsophalangeal joint arthrodesis

5%

(46/839)

4

Medial eminence removal and resection of base of proximal phalanx

2%

(14/839)

5

First tarsometatarsal joint arthrodesis and metatarsophalangeal capsular release

2%

(15/839)

ML 1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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