hallux rigiditis

Question 1

What is hallux rigiditis ?

Answer 1

• Loss of motion of the 1st metatarsal joint in adults due to degenerative disease
• Ostephyte formation -> dorsal impingement

Question 2

What is it aetiology ?

Answer 2

• Unknown
• Acute trauma - repetitive microtrauma predispose to arthritic changes
• Anatomical variations of 1st MT may play a yet unproven role in arthritic predisposition

Question 3

Describe the classification ? What grades are there?

Answer 3

O-4

• Grade 0
  
  • ​ stiffness but X-ray normal
• Grade 1
  
  • ​Mild pain extreme motion
  • X-ray - mild Dorsal osteophytes, normal joint space
• Grade 2
  
  • ​ moderate pain with rom increasingly more constant,
  • xray-moderate dorsal osteophytes,
• ​Grade 3
  
  • ​significant stiffness, pain at extreme rom no pain at mid-range
  • ​xray- severe dorsal osteophytes, joint space
• ​Grade 4
  
  • sig stiffness, pain thru all rom- X-ray as like 3

Question 4

What are the tx options for grade 0?

Answer 4

Conservative

• Activity modification - avoid activities that leads to excessive great toe dorsiflexion
• NSAIDs
• Morton extension with stiff sole plate
• Stiff sole shoe and shoe box stretching may also be used

Question 5

What imaging is useful in hallux rigiditis?

Answer 5

Xrays

• AP, Lateral, Oblique views
• See
  
  • Osteophytes especially dorsal
  • joint space narrowing
  • subchondral sclerosis and cysts

Question 6

What are the tx options for grade 1-2?

Answer 6

Consx- as before

Operative

• Joint debridement and synovectomy
  
  • pt with acute osteochondral/ chondral defects
• Dorsal Cheilectomy
  
  • ​Pain w dorsiflexion is an indicator of gd result with cheilectomy
  • CI when pain in mid range
  • remove 25-30% dorsal aspect of metatarsal head & dorsal osteophytes
  • Goal is to obtain 70-90% dorsiflexion intraoperatively
• MOBERG PROCEDURE
  
  • Dorsal closing wedge osteotomy of proximal phalanx
  • runners with reduced Dorsiflexion (60^o required to run)
  • ​Increases df by increasing plantar flexion arc of motion- aim for runners and failed CHEILECTOMY

Question 7

What are the tx options for grade 3-4?

Answer 7

• MTPJ arthoplasty - contraversial!
• Popular capsular interpositional cf silicone ( gd short term but synovitis in long term )
• MTPJ ARTHRODESIS
  
  • most common using dorsal plate and compression screws- mechanical strongest
  • 700-100% fusion rates
  • 15% pts experience degeneration of IPJ post surgery

Question 8

What position to do an arthrodesis of 1st mtpj ?

Answer 8

• 15^oDorsiflexion in relation to floor
• 10-15^o valgus in relation to MT shaft
• fusion in excessive dorsiflexion-> pain at tip of toe, over IPJ under 1st MT
• fusion in excessive plantarflexion->increased pain at tip of toe
• Fusion in excessive valgus-> increases risk of IPJ degeneration

Question 9

What to do for failed Arthroplasty ?

Answer 9

• implant resection, + SYNOVECTONY if isolated great toe pain
• implant resection , bone graft and arthrodesis if great toe pain and lesser toe metatarsalgia

Question 10

What are the symptoms and signs of hallux rigiditis?

Answer 10

Symptoms

• First ray and 1st MTPJ Pain and swelling worse with push off or forced dorsiflexion of great toe
• Shoe irritation due to dorsal osteohytes adn compressionof dorsal cutaneous nerve may lead to parathesia
• Pain becomes less severe as disease progresses

Signs

• Limited Dorsiflexion
• Pain with grind test

Question 11

What are the indications for a keller’s procedure?

Answer 11

• A keller’s is a resection arthroplasty
• For- Elderly, low demand pts with significant joint degeneration and loss of motion
• CI is pts with pre-exisiting rigid hyperextension deformity of 1st MTPJ

Keller’s technique

• involves removal the base of the first proximal phalanx
• risk of hyperextension- cock uop deformity of toe, weakness of psuh-off and transfer metatarsalgia