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Updated: Jan 7 2023

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/mtpj_arthroplasty..jpg
https://upload.orthobullets.com/topic/7009/images/bone-block_artrhrodesis.jpg
  • 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
          • 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
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