HALLUX RIGIDUS

Mostafa Benyahia
Division of Foot & Ankel Surgery
Hospital Hvidovre ,University of Copenhagen
Normal function first MTP
joint
 Cam-shaped condylar hinged joint
 Alignment varies 5 degrees varus to 15
degrees valgus
 Normal range of motion
 40-100 degrees dorsiflexion
 3-45 degrees plantarflexion

70-90 degrees

45 degrees
Hallux Rigidus Definition

• Arthritic condition characterized by stiff painful

1st MTP joint

• Early stages – involvement dorsal aspect

articular cartilage with prominent dorsal
osteophyte

• Later stages – central and plantar aspects of

articular cartilage involved

X-rays – Almost always underestimate the extent of

disease
Pathogenesis:Hallux Rigidus

 Traumatic: intra-articular fracture, crush,

direct jamming to MTP joint
 Idiopathic: predisposing factors may cause
increased joint stresses with subsequent
swelling, synovitis, joint degeneration
 Metatarsus elevatus
 OCD
 Long first ray
 Pes planus
Clinical Features H.R.
 Painful, stiff MTP joint
 Shoewear difficult due to
dorsal osteophytes
 Difficulty with pushoff during gait
 Dorsiflexion impingement occurs at
spur with pain and stiffness
 Painful plantarflexion
 Stress transfer (transfer metatarsalgia)
with first ray unloading
 Dorsal skin irritation due to spur
Hallux Rigidus

 Localized first MTP arthritis

 Decreased range of motion (DF), deformity,
pain
Grading (Hattrup & Johnson)

 Grade I
 Joint space maintained
 Minimal osteophytes
 Grade II
 Larger osteophytes
 Subchondral sclerosis
 Grade III
 Complete loss of visible joint space
 Subchondral cysts
 Osteophytes
 Hypertrophy of sesamoids
Grading (Coughlin & Shurnas)

 Grade 0
 40-60 degrees dorsiflexion or 10% to 20% less DF than
opposite side
 Normal xrays
 No pain, only stiffness
 Grade 1
 30-40 degrees dorsiflexion or 20% to 50% less DF than
opposite side
 Dorsal osteophytes
 Minimal narrowing
 Periarticular sclerosis or head
flattening
 Mild or occasional pain at extremes
of motion
(Coughlin & Shurnas)

 Grade 2
 10-30 degrees dorsiflexion or 50%
to 70% less than opposite side
 Dorsal, lateral, +/- medial
osteophytes
 Less than 25% of dorsal joint
space involved
 Mild-to-moderate joint space
narrowing
 Moderate-to-severe pain at
extremes of motion
 Grade 3
 <10 degrees of dorsiflexion or 75% to
100% loss
 Sustantial joint space narrowing
 Periarticular cysts
 >25% of joint involved
 Constant pain and substantial
stiffness at extremes but not
midrange of motion
 Grade 4
 Same criteria as grade 3 but with pain
at mid-range of motion
Grading - Regnauld
 Grade I – functional limitation of MTP joint, no
radiographic degenerative changes
 Grade II – flattening of MT head, osteochondral
defect, pain on end ROM, mild dorsal
prominence
 Grade III – severe flattening of MT head,
osteophyte formation, narrowing of joint space,
articular degeneration, pain on full ROM
 Grade IV – obliteration of joint space,
osteophytes + loose bodies, less than 10 degrees
ROM, deformity
Radiographic Features of HR
 Early – xrays may be normal,
soft-tissue swelling and dorsal
osteophytes on oblique view
 Moderate – squaring of MT
head, dorsal osteophytes,
narrowed dorsal joint space
 Advanced – minimal joint
space, osteophytes,
asymmetric joint narrowing,
subchondral cysts
 Treatment
 Nonoperative
 Operative: four basic types
 Debridement/cheilectomy
 Osteotomy
 Arthroplasty (soft-tissue,
implant)
 Arthrodesis
Evidence for decision-
making:Problematic
 Lack of high quality studies
 Different grading scales employed for both
preoperative severity and postoperative function
 Preoperative Scales
 Hattrup & Johnson
 Coughlin & Shurnas
 Regnauld
 Postoperative Function
 Patient satisfaction
 VAS
 AOFAS score
AOFAS MTP Scale

Pain

Function

Alignment
Non-Operative Treatment

 Rocker bottom/shoe mods

 Orthotics with medial forefoot stiffness
 Activity mods :Avoid kneeling or extremes of
DF at 1st MTP joint
Surgical Options
Cheilectomy

 Involves excision of spurs that limit motion

(DF)
 Goal is to achieve at least 90 degrees DF
intra-operatively
 Free up any Contracted scar/adhesions
 Indicated for mild/moderate xray changes
MacKay et al (1997)

Cheilectomy results
 3.8 year F/U of grade 1, 2 and 3 treated with
cheilectomy
 Footwear selection greatly improved in
patients with grade 1 and 2, but not 3
 Significant improvements in pain, ROM,
tiptoe and activity level- all patients
Cheilectomy:Indications

 Most authors recommend:

 Mild/moderate xray changes
 Young or active patients
 Less than 50% articular cartilage loss (dorsal)
Débridement/Cheilectomy

 Grade I or II involvement
 Simple procedure
 Quick recovery
 Usually not a permanent solution*
 2010 systematic literature review
 Cheilectomy revision rates
 Grade I – 20%
 Grade II – 15%
 Grade III – 9%
 Grade IV – 56%
Cheilectomy:Contradindications
(Coughlin & Shurnas)

 Extensive degenerative arthritis of first MTP

joint
 Articular cartilage degeneration >50% of
metatarsal head
Osteotomy: phalangeal/metatarsal
 Reshaping orientation creates more joint
space (joint “decompression”)
 Longer recovery
 Complications – residual pain, reduced
push-off strength, transfer of forces
laterally
 2010 systematic review of the literature
 73% of patients satisfied
 23% required revision
 31% developed metatarsalgia or stress
fracture
 Authors recommendations “…should be used
with caution or not at all.”
 2005 study – phalangeal and MT
osteotomies
 54% satisfaction with MT osteotomies, 65%
with phalangeal osteotomies
Moberg (proximal phalanx)
Osteotomy
 Closing wedge dorsal osteotomy of proximal
phalanx
 Increased DF by translating the arc of motion
from PF to DF
 Increases functional ROM of MTP to more
dorsal position
 Requires adequate preoperative PF
Moberg Indications?

 Running athletes? (Inc DF Needs)

 Intra-op cheilectomy that has not achieved
adequate DF on O.R. table
Moberg Osteotomy:Complications

 Decreased push-off power

 Accelerated progression of DJD
 Nonunion, malunion
 Elevated resting position of 1st toe
Metatarsal Osteotomies for
Hallux Rigidus

Not indicated
High rates of joint contracture
Stress fractures
 Transfer lesions
Acceleration of DJD
Arthrodesis of 1st MTP Joint

 Eliminates pain
 Allows weight bearing on first
MT
 Long recovery/Non-union rate
 Permanent loss of motion
 Limited shoe wear selection
(no high heels)
Arthrodesis: Contraindications
(Coughlin & Shurnas)
 Patient in whom absence of MTP joint
motion is unacceptable!!!
 Severe osteopenia that prevents adequate
internal fixation
 Less severe hallux rigidus with >50% of MT
head articular cartilage remaining
Arthrodesis Complications

 Nonunion (5-10%)
 Malposition (“Malunion”)
 Excess DF at fusion site causes IP joint flexion
 Excess PF at fusion site causes IP joint
hyperextension

 Accelerated arthritis at IP and TMT joints

 Shorter step length
 Less ankle power/torque
Arthroplasty - Interpositional

 2011 study –satisfactory

results in 75% of 25 feet
with grade III/IV hallux
rigidus
 Weakness, transfer of
forces laterally
 Osteophyte recurrence ?
Excisional/Interpositional
Arthroplasty

Literature review Numerous complications

 Floppy big toe
 Hallux weakness/push-off weakness
 Transfer lesions under 2nd MTP
 Elevation/clawing/shortened 1st toe
Silicone Interpositional
Arthroplasty

 Silicone does not possess adequate structural

durability to withstand severe shear and
tension stresses/ambulation
 Severe synovitis and osteolysis at 1st MTP
 Silicone granulomatous disease
Arthroplasty – Implant
Evolution

 1st generation: material – silicone, design –

hemi and total
 2nd generation: material – improved silicone,
design – hemi and total with grommets
 3rd generation: material – metallic, design –
hemi and total press fit
 4th generation: material – metallic, design –
hemi and total with threaded stem
1ST MTP Total Joint
Arthroplasty - Implants
 Biomet total toe system - 83% excellent
results subjectively – but no postop ROM or
length of follow-up reported (Koenig &
Horwitz)
 Bio-Action great toe implant – areas of bone
resorption indicative of early loosening (Olms
& Dietz)
 ReFlexion – 60% satisfactory results –
malalignment, stiffness, revision (Ess et al.)
Hemiarthroplasty - Implants

 Few studies with sufficient numbers, follow-

up
 Significant lack of comparative studies
 Criteria for grading results mixed: objective vs
subjective
Hemiarthroplasty - Implant

 Biopro – longest follow-up, largest numbers

 Implant loosening and plantar cutout
commonly reported
 Wrong side of joint?
 Osteophyte recurrence?
Biopro Implant
HemiCAP DF(Arthrosurface) –new
form 1st MTP hemiarthroplasty
Addresses side of joint most affected
 “Patient matching” of mtp anatomy
with cobalt chrome articular
implants -
 Central fixation component
 Instrumentation used to map the
native joint surface, prepare the
joint/bone and implant the
prosthesis.
 Precise alignment of surface of
implant to the contour of the
patient’s articular surface
Screw Fixation Design

Titanium screw coated with plasma spray for bony ingrowth

Bone ingrowth to prosthetic interface – (basic science pics)
UHZ Sports Medicine Institute
Contraindications: HemiCap

 Hx of septic joint/Active infection/Osteomyelitis

 Neuropathic Joint

 Systemic Arthritis

 Severe Sesamoid - Metatarsal arthritic disease

 Nickel Allergy

 Unrealistic Patient Expectations

 Design Rationale
• Based on anatomy and unique
kinematics of the 1st MTP joint
• Dorsal flange with receding
dorsal slope
• “Great toe dorsal roll-back”

UHZ Sports Medicine Institute

DF Implant: Advantages
 For the patient
 Designed for patients who live longer, are more
active
 Outstanding pain relief, rapid recovery
 Outpatient procedure
 Preserves joint and surrounding bone
 Maintains joint biomechanics
DF
 Toe DF Design
1. Created dorsal flange
geometry on articular
component that covers
dorsal aspect of met
head preventing
osteophyte formation

2. Create compound
curve articular surface
that is continuous and
increases joint space
with increasing dorsi-
flexion

UHZ Sports Medicine Institute

 Toe DF Design
• Compound articular
curvature based on
clinical literature

• Changing center of
curvature along
articular surface

• Dorsal curve
segment is tangent to
neutral curve segment
at approximately 12
degrees of dorsal
flexion
UHZ Sports Medicine Institute
 Technical Pearls/Musts for
Successful DF Surgery
• ACHIEVE 90 DEGREES OF DF ON OPERATING ROOM TABLE
• ADEQUATE SOFT TISSUE RELEASE**
this is a contracted tight scarred ankylosed joint
Dr Hasselman TKA –TIGHT SOFT TISSUE POST CAPSULE
FLEXION CONTRACTURE ANALOGY

TAKE DOWN JT ADHESIONS SUBPERIOSTEALLY

COLLATERALS,SCARRING AT SESAMOIDS ETC

IF STILL NOT 90 DEGREES SUBPERIOSTEAL FLEXOR HALLICUS

BREVIS ETC
FLEXOR HALLICUS BREVIS
 • CENTER YOUR ALIGNMENT OF THE
IMPLANT /ARTICULAR SURFACE
INTERFACE ON THE INFERIOR
PORTION OF THE MET HEAD SO IN
DORSIFLEXION THE SESAMOIDS
WONT CLICK OR RUB AT INTERFACE
OF METAL/CARTILAGE

UHZ Sports Medicine Institute

 FAVOR VIGOROUS AND ADEQUATE SOFT
TISSUE RELEASE OVER DECOMPRESSION
Iatrogenic shortening
transfer metatarsalgia

Employ soft tissue interposition on proximal

phalanx articular surface if required (use of
redundant dorsal capsule /ecrb)

Aggressive rom and joint mobilization of MTP

joint in 1st postoperative week

UHZ Sports Medicine Institute

 • Perform adequate resection of dorsal spur of
1st metatarsal head

New DF has a bit of “idiot-proofing “

appreciated in Austin Texas

UHZ Sports Medicine Institute

 Classic vs DF

UHZ Sports Medicine Institute

HemiCAP DF: Advantages
 For the surgeon
 Short learning curve
 Procedure intuitive, reproducible
 Outpatient procedure, approx. 1 hour
 Maintains soft-tissue envelope, joint mechanics –
preserves future surgical/options
 Bail out (fusion)would be good
success
 Precision instrumentation
CLINICAL RESULTS
Arthrosurface
HemiCap Classic
 Giovanni 86 patients/97 implants
 8-month follow-up
 94% excellent to good results
 64% improvement in AOFAS scores
 No revisions
2010 Carpenter et al 32 patients with avg 27
months f/u
No failures and all pts satisfied
AOFAS scores avg 89.31

Grade 3 pts :AOFAS score 91.43 vs Grade 2 at 83.89

Hasselman/Shields 2008 25 patients at avg of
20 months f/u
All patients satisfied and avg AOFAS score of 82.1
Range of motion increase an avg of 42 degrees

No loosening or subsidence
88% survivorship at 5 yrs, rest same/more satisfied
Converted pts would still go thru resurfacing again
 Summary HemiCap
 Addresses side of joint most affected
 Only implant with Morse taper screw interlock
design does not show loosening like typical
stemmed/pegged implant
 Only implant that factors in the changing radii
curvature of dorsal articular surface, allows
prox. phalanx to glide with “dorsal roll-back”
 High patient satisfaction – pain relief,
improvement in motion
Thank you
 32 implants/30 patients
 Grade II and III hallux rigidus
 Average follow-up 23 months
 All patients happy with outcome
 Mean AOFAS score improved by 58.5 points
 No implants revised or removed
Giovanni 36 pts at an avg of 45 months f/u

80% pt satisfaction w/ avg 26 degrees ROM increase

No loosening, superior results vs other hemi’s