Viva Hallux rigidus

Question 1

Describe the X-ray

Answer 1

• This is a radiograph of a right foot showing osteoarthritis of the first
  metatarsophalangeal joint (MTPJ) with narrowing of joint space, osteophytes
  formation and subchondral sclerosis.
• This condition is called Hallux rigidus

Question 2

What is hallux rigidus ?

Answer 2

• Hallux rigidus is a degenerative arthritic disease of the 1st MTP joint.
• It leads to significant limitation in the ROM of the first MTP joint.
• Like other degenerative arthritic diseases, the formation of
  osteophytes is quite common. These osteophytes can lead to a
  mechanical obstruction of the MTP joint dorsiflexion

Question 3

What is the etiology of this
condition?

Answer 3

• No primary aetiology has been defined.
• However, it is believed that repetitive microtrauma or an acute traumatic event
  can be the cause.
• Also it is related to 1st ray hypermobility

Question 4

Are you aware of any classification
system for this condition?

Answer 4

Question 5

How would you manage this
condition?

history

Answer 5

First of all I would need to take history:
Ø Main complaints: pain- stiffness-swelling-paraesthesia
Ø Compression of the dorsal cutaneous nerve between the osteophyte and the shoe
can lead to paraesthesia.
Ø Shoe wear irritation on the dorsum of the MTP joint.
Ø Patient’s activity level

Question 6

How would you manage this
condition?

Examination

Answer 6

Examination:
Ø Difficulty in push off. Limitation of the 3rd rocker.
Ø Assess the skin integrity
Ø Assess the presence of marginal osteophytes, which are typically dorsally and laterally
Ø Assess ROM of 1st MTP (limited dorsiflexion of the first MTP joint)
Ø Check whether the patient has pain limited to the extremes of motion or throughout the
arc of motion
Ø I also need to assess the motion and look for any degenerative changes at the
interphalangeal joint (IPJ). (A fusion of the first MTPJ may accelerate degeneration in the
surrounding joints so if the IPJ is already symptomatic a joint-preserving procedure of the MTPJ may
be more appropriate)
Ø Assess the neurovascular status

Question 7

How would you manage this
condition?

non-operative management

Answer 7

I would start with non-operative management:
Ø Reassurance: The radiological stage does not always correlated with clinical
symptoms, which may progress slowly
Ø Activity modification
Ø NSAIDs
Ø Orthotic devices that increase the rigidity of the forefoot portion of the shoe to
limit MTPJ dorsiflexion (Morton extension) or rocker bottom shoes.
Ø MUA and intra-articular steroid injection may provide relief of symptoms in mild/
moderate cases. Not proven to be effective if severe changes are present.

Question 8

How would you manage this
condition?

Surgical treatment Joint preserving procedures

Answer 8

Surgical treatment depends on the grade of the disease
v Joint preserving procedures:
Ø Joint debridement and synovectomy in an acute chondral or osteochondral injuries.
Ø Cheilectomy (resection of the dorsal osteophyte along with removal of 25% to 30% of the dorsal
aspect of MT head). Pain at extremes of motion of MTP joint is an indicator of good prognosis.
Cheilectomy does not work when hallux rigidus is severe, if degenerative changes present, then
increased ROM can lead to more symptoms.
Ø Dorsal closing wedge osteotomy of the proximal phalanx(Moberg) is used to increase dorsiflexion
of the MTP joint. Usually combined with cheilectomy and is indicated if cheilectomy doesn’t
provide at least 30 to 40 degrees of dorsiflexion

Question 9

How would you manage this
condition?

Surgical treatment Joint sacrificing procedures:

Answer 9

Surgical treatment depends on the grade of the disease
Joint sacrificing procedures:
Ø Resection arthroplasty (keller’s procedure) involves removal of the base of the proximal phalanx. It
can destabilize the joint leading to cock up deformity, weakness during push off and transfer
metatarsalgia. Used in elderly or sedentary patients
Ø MTP joint replacement (hemi/total): Limited long-term evidence to support use
Ø Arthrodesis of the MTPJ. The most commonly used procedure. The preferred alignment is 10 to 15
degrees valgus- 15 degrees dorsiflexion-neutral rotation to ensure an effective plane of motion of
the IPJ, using two cannulated screws. The IP joint should be mobile (accelerates IP joint arthritis