Hallux Rigidus Grade Research Articles

Modern Treatment of Hallux Rigidus by Cheilectomy: A Systematic Review of Minimally Invasive Patient-Reported Outcomes

Category: Arthroscopy; Midfoot/Forefoot Introduction/Purpose: Hallux rigidus is a degenerative disorder of the first metatarsophalangeal (MTP) joint. Patients with this condition experience symptoms including pain, stiffness, and reduced range of motion of the 1st MTP joint. Cheilectomy is a surgical treatment option that removes dorsal periarticular osteophytes to alleviate pain and improve range of motion. Minimally invasive cheilectomy is becoming a more prominent surgical approach due to its clinical benefits including smaller incisions, reduced complications, and faster return to function. This systematic review aims to analyze and present the current literature on patient-reported outcomes (PROs) following MIS cheilectomy for mild to moderate hallux rigidus. Methods: A systematic review of the literature was conducted using articles pulled from PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus databases in December 2023 using the search term “cheilectomy.” ​​This systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered in Prospero (Blinded ID:XX). Articles were included in the systematic review if they reported on preoperative or postoperative patient-reported outcomes in patients undergoing minimally invasive cheilectomy (MIS) in English. Minimally invasive was defined as an arthroscopic or percutaneous approach. The primary outcome measure was scored patient-reported outcomes. The secondary outcome measures included complications, secondary surgeries, surgical techniques, qualitative patient experiences, and grades of hallux rigidus. Results: Eight studies met the inclusion criteria, and a total of 284 patients were evaluated. 130/284 underwent an MIS percutaneous approach with burr, 70/284 underwent arthroscopy with shaver, and 84/284 had a combination of both techniques. Most patients (79%) had Coughlin-Shurnas grade one or two hallux rigidus (range: 1-3). The mean American Orthopaedic Foot & Ankle Society scores improved from 57.7 (range: 43-71) to 90.1 (range: 87-97). The mean range of motion (dorsiflexion) improved from 28.5 (range: 8-42) to 49.5 (range: 30-73) degrees. Complication rates were low at 18/284 (6%). The most common complication was numbness, affecting 6/284 (2%) patients. Four out of eight articles reported zero complications. 113/125 (90.4%) patients would recommend the procedure. Conclusion: Treatment of hallux rigidus with MIS cheilectomy appears to result in favorable and safe outcomes when performed for patients with early degenerative disease who have failed conservative treatment. Patients reported high satisfaction rates, significant symptomatic improvements, and experienced low complication rates.

Modern Treatment of Hallux Rigidus by Cheilectomy: A Systematic Review of Patient-Reported Outcomes in Minimally Invasive Techniques.

Minimally invasive cheilectomy is becoming a more prominent surgical approach in the management of mild to moderate hallux rigidus. This systematic review aims to analyze and present the current literature on patient-reported outcomes following minimally invasive (MIS) cheilectomy for mild to moderate hallux rigidus. PubMed, Cochrane Central Register of Controlled Trials, and Scopus databases were searched in April 2024. Inclusion criteria consisted of articles evaluating patients undergoing cheilectomy through an MIS approach either using fluoroscopy or arthroscopy, studies that reported patient-reported outcomes, and studies written in English. The primary outcome measure was scored patient-reported outcomes. The secondary outcome measures included complications, secondary surgeries, surgical techniques, return to activity, patient satisfaction, and grades of hallux rigidus. Eight studies met the inclusion criteria, and a total of 296 patients were evaluated. Overall, 36 of 296 (12.2%) underwent arthroscopy with a shaver, 130 of 296 (43.9%) underwent an MIS percutaneous approach with burr, and 130 of 296 (43.9%) had a combination of both techniques. The mean reported range of motion (dorsiflexion) improved from 32.4 degrees (range, 6.3-50.0 degrees) to 61.2 degrees (range, 47.6-89.6 degrees). All studies that reported patient outcomes scores demonstrated improved outcomes regardless of surgical technique. Overall combined reported complication rate was 18 of 296 (6.1%), with the most common complication being dorsomedial cutaneous nerve problems, affecting 6 of 296 patients (2.0%). Minimally invasive cheilectomy results in positive patient outcomes, patient satisfaction, preserves range of motion, and has low complication rates for the treatment of mild to moderate hallux rigidus.

Cheilectomy and the Shortening PelCO for the Treatment of Low-grade Hallux Rigidus

Hallux rigidus is a degenerative condition of the first metatarsophalangeal joint resulting in stiffness and pain. Surgical treatments can be divided into joint-sparing and joint-sacrificing procedures. Cheilectomy has been recommended as an isolated procedure for the treatment of low-grade hallux rigidus (I and II, even III in some articles). First metatarsal shortening osteotomies are indicated in low-grade hallux rigidus. The Shortening Percutaneous, Intra-articular, Chevron Osteotomy resembles the Green-Watermann procedures regarding shortening and decompression. Shortening Percutaneous, Intra-articular, Chevron Osteotomy provides excellent clinical and functional results and represents a viable treatment option to decrease pain, improve function, and maintain motion for hallux rigidus grade I and II. Level of Evidence: Diagnostic level IV.

Modified Youngswick Osteotomy for Treatment of Hallux Rigidus in Athletes

Category: Midfoot/Forefoot; Sports Introduction/Purpose: Hallux rigidus is a common condition that affects athletes, particularly those who engage in high-impact sports. This condition results in pain and limited range of motion in the big toe, and can significantly affect an athlete's performance. The goal of treatment is to alleviate pain, improve function, and return the athlete to their sport. There are various surgical options available for treating hallux rigidus, one of which is the Youngswick osteotomy. This procedure involves realigning the bones of the big toe to relieve pressure and improve range of motion. Methods: A retrospective study was conducted to evaluate the effectiveness of the modified Youngswick osteotomy in treating hallux rigidus in athletes. The study included 40 patients, with a median follow-up of 40 months. The patients were divided into two groups based on sex: 29 female and 11 male. The side affected was also recorded, with 26 patients having the condition on their right foot and 14 on their left. The grade of hallux rigidus was also recorded, with 25 patients having grade II and 15 patients having grade III. Results: The study found that the median preoperative American Orthopaedic Foot & Ankle Society (AOFAS) score was 39, with a range of 25-60. After the Youngswick osteotomy, the median AOFAS score improved to 81.8, with a range of 50-90. This improvement was statistically significant (p < .0001). The range of motion (ROM) of the big toe also improved after the surgery, with the median preoperative ROM being 15.4 degrees and the median postoperative ROM being 54 degrees. Subjective satisfaction with the surgery was also recorded, with 80% of patients reporting excellent results, 10% good results, 7.5% fair results, and 2.5% poor results. The study found that there was no significant difference in the results based on sex or the side affected. Conclusion: The results of this study suggest that the Youngswick osteotomy is an effective treatment option for hallux rigidus in athletes. The procedure significantly improves pain, range of motion, and overall function, allowing athletes to return to their sport. The results of this study provide valuable information for clinicians who are considering the modified Youngswick osteotomy for their patients with hallux rigidus. However, it should be noted that further research is needed to confirm these findings and to determine the long-term outcomes of this procedure.

Sliding Oblique Metatarsal Osteotomy Fixated With K-Wires Without Cheilectomy for All Grades of Hallux Rigidus: A Case Series of 76 Patients.

Studies on decompression metatarsal osteotomy without cheilectomy for hallux rigidus are limited. This study aimed to review the data of patients who underwent this surgery for all grades of hallux rigidus. The medical records of patients who underwent this surgery between August 2017 and January 2021 were retrospectively reviewed. The outcomes were assessed using the visual analog scale (VAS), the Japanese Society for Surgery of the Foot (JSSF) score, and the hallux dorsiflexion angle. Patients who were followed up for more than 2 years were included. The plantar shift of the first metatarsal head (PS) and the shortening of the first metatarsal (SH) were measured to supplementally investigate the associations with other measurements. A total of 76 patients (female, 42; male, 34; mean age, 60.3 years; mean body mass index, 23.1) with 80 feet were enrolled. Six patients (7.5%) were grade 1, 20 (25.0%) were grade 2, 30 (37.5%) were grade 3, and 24 (30.0%) were grade 4. The mean follow-up duration was 3.5 years. Overall, the mean VAS score improved from 63.2 to 6.2, the mean JSSF score from 59.0 to 82.6, and the mean dorsiflexion angle from 37.3 to 56.3 degrees. These measures improved for all grades, but the dorsiflexion angles and JSSF scores decreased as the grade advanced. No clear associations were found between the postoperative VAS and the PS and SH. Eight patients (10.5%) had complications: 4 (5.2%) had occasional plantar discomfort under the metatarsal head, 2 (2.6%) required shoe modification, 1 (1.3%) had wound pain, and 1 (1.3%) experienced breakage of a K-wire. The VAS scores, dorsiflexion angles, and JSSF scores improved for all grades of hallux rigidus within a relatively short period of follow-up; however, the dorsiflexion angles and JSSF scores decreased as the grade advanced. Level IV, retrospective case series.

A Patient-Reported Outcome Based Comparison of Cheilectomy with and without Proximal Phalangeal Dorsiflexion Osteotomy for Hallux Rigidus

Category: Midfoot/Forefoot Introduction/Purpose: Cheilectomy with and without Moberg osteotomy is used to improve function and remove pain in early- moderate stage hallux rigidus. The rise of patient-reported outcome measurements allows greater precision in comparing treatments as value-driven paradigms become increasingly important in clinical decision-making. This study provides the first comparison of patient-reported outcomes between isolated cheilectomy (C) and cheilectomy with Moberg (CM) osteotomy for hallux rigidus. We compared one and two-year PROM scores between patients who underwent C and CM for hallux rigidus using PROMIS, a validated patient-reported outcomes measurement system, and compared rates of complications and subsequent operations between the two groups. We hypothesized that patients who underwent CM would experience better clinical outcomes and fewer returns to the operating room than patients undergoing cheilectomy alone. Methods: A single-center, retrospective registry search identified all patients with preoperative PROMIS scores who underwent cheilectomy, with and without concomitant proximal phalangeal dorsiflexion osteotomy, for hallux rigidus between January 2016 and December 2020. An a priori power analysis determined that 24 patients per cohort were needed to detect a previously published minimum clinically important difference of 5.8 points on the PROMIS Physical Function scale with alpha = .05 and 80% power. However, all C patients were included. Because there were far fewer isolated cheilectomies (62), all C patients were compared with a commensurate number of consecutive CM cases (67) using preoperative, one-year, and two-year PROMIS scores for Physical Function, Pain Interference, Pain Intensity, Global Physical Health, Global Mental Health, and Depression, as well as complication and revision data from chart review. Age, sex, BMI, preoperative radiographic hallux rigidus grade, and preoperative range of motion were compared between the two cohorts. Results: PROMIS outcome data is given in Table 1. Both groups demonstrated statistically significant improvements in PROMIS Physical Function, Pain Interference, Pain Intensity, and Global Physical Health (P <.001 for all, both preoperative to one-year and preoperative to two-year), but not Global Mental Health or Depression. There were no differences between groups among the demographic and preoperative variables compared. The CM cohort reported worse Pain Interference scores preoperatively (58.1+- 5.9 vs. 52.4 +- 7.01, P < .001) and at one year (50.0 +- 9.3 vs. 45.1 +- 9.8, P = .01), while the C cohort reported worse Pain Intensity scores preoperatively (55.6 +- 7.3 vs. 49.6 +- 6.8, P < .001) and at one year (45.9 +- 8.0 vs. 39.9 +- 8.2, P < .001). These differences were no longer significant at two years postoperatively. There were no statistically significant differences between cohorts for additional PROMIS scores or complications data. Conclusion: The addition of a Moberg osteotomy does not appear to significantly change short-medium term outcomes of cheilectomy for hallux rigidus treatment. Our data contradicts the notion that addition of a Moberg osteotomy increases the likelihood of postoperative complications. The overall good results found for both procedures, as well as the general similarity between outcomes between them, suggest that external considerations like recovery time, comfort level with a more invasive osteotomy, and overall goals with surgery may be of greater importance than short-term clinical outcomes when deciding on the appropriate course of treatment for a given patient.

Early Outcomes, Revisions, and Patient Satisfaction Following Synthetic Cartilage Implant for Hallux Rigidus

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:Hallux rigidus is a common condition estimated to affect 1 in 40 adults older than 60 years old. Patients experience functional limitations secondary to progressive pain and stiffness of the 1st metatarsophalangeal (MTP) joint.Historically, 1st MTP arthrodesis has been considered the gold-standard treatment for end-stage hallux rigidus. In 2016, the US Food and Drug Administration (FDA) approved the use of a synthetic cartilage implant (SCI) for the treatment of hallux rigidus grades 2-4 with an aim to improve pain and preserve range of motion at the 1st MTP joint. Studies evaluating patient satisfaction and need for reoperation have varied considerably (4-20%). We aim to evaluate outcomes, complication rate, revision rate, and overall satisfaction for patients undergoing primary SCI for hallux rigidus.Methods:In a single-institution retrospective study, we evaluated patients undergoing primary SCI for hallux rigidus between August 2016 to May 2020 by three fellowship-trained foot and ankle surgeons. Preoperatively, patient demographics, age at the time of surgery, laterality, body mass index (BMI), hallux rigidus grade, hallux valgus angle, and first-second intermetatarsal angle were collected. Operative reports were reviewed for concomitant procedures and implant size. Postoperatively, we recorded all additional treatments for continued pain or stiffness and need for revision surgery or conversion to arthrodesis. Patients were surveyed via email or telephone by an author not previously involved in their care administering patient reported outcomes (PROs): PROMIS physical function (PF), and pain interference (PI) surveys, foot and ankle SANE score, and a satisfaction survey.Results:A total of 59 feet in 56 patients underwent a primary SCI procedure for hallux rigidus. Patients were classified as grade 2 (32%), 3 (59%), or 4 (2%). Nineteen (34%) patients underwent additional procedures, and 8 (14%) had a history of prior surgery to the MTP joint. Forty-five patients (80%) completed surveys at an average of 19.5-month follow-up. The majority (58%) considered surgery a success and 42% reported being unsatisfied or very unsatisfied. Mean (+-SD) post-operative foot and ankle SANE, PROMIS PF and PI scores were 57 (+-27), 48 (+-7) and 54 (+-9), respectively. The overall revision rate was 11% (6/56) with 3 patients undergoing conversion to arthrodesis. The majority of patients (61%) stated they would undergo the procedure again.Conclusion:Consistent with existing literature, we found that the majority of patients undergoing the procedure were satisfied and would undergo the procedure again. Further, post-operative PRO scores were favorable, even when factoring in patients who were less satisfied. While our revision rate (11%) is consistent with early studies of the implant, 42% reported being unsatisfied or very unsatisfied with their procedure. These findings emphasize the importance of preoperative patient counseling regarding post- operative limitations, risks, satisfaction, and revisions rates. Further investigation into factors that may predict successful outcomes is needed to inform surgical decision-making and appropriate patient selection for this procedure.

Sliding Oblique Metatarsal Osteotomy Fixated With a K-Wire Without Cheilectomy for Hallux Rigidus

The current study aimed to assess the outcomes of sliding oblique metatarsal osteotomy fixated with a K-wire without cheilectomy for hallux rigidus. Pre- and postoperative variables, including dorsiflexion angle, visual analog scale score, and Japanese Society for Surgery of the Foot scale score, were assessed using the Wilcoxon signed-rank test. In addition, the surgical effects among the four grades were compared using the Kruskal-Wallis test. In total, 43 patients, including 11, 11, 15, and 6 with grade 1, 2, 3, and 4 hallux rigidus, respectively, were enrolled in this analysis. The mean age of the participants was 56.2 years, and the mean follow-up period was 3.0 years. Mean pre- and postoperative dorsiflexion angles were as follows: overall, 53.0° to 66.5° (p < .001); grade 1, 66.8° to 79.1°; grade 2, 59.1° to 68.6°; grade 3, 43.3° to 61.0°; and grade 4, 40.8° to 53.3°. Mean pre- and postoperative visual analog scale scores were as follows: overall, 70.1 to 6.5 (p < .001); grade 1, 74.2 to 3.0; grade 2, 66.4 to 7.6; grade 3, 69.5 to 8.4; and grade 4, 71.2 to 6.0. Finally, mean pre- and postoperative Japanese Society for Surgery of the Foot scale scores were as follows: overall, 61.2 to 86.6 (p < .001); grade 1, 63.8 to 93.6; grade 2, 68.3 to 85.9; grade 3, 54.4 to 83.1; and grade 4, 60.5 to 83.5. There was no statistically significant difference in the surgical effects among the four grades. Decompressive metatarsal osteotomy without cheilectomy was found to be effective. Moreover, the procedure could be performed for all grades of hallux rigidus.

Comparison of Outcomes of Cheilectomy with and without Synthetic Hydrogel Interposition (Cartiva®)

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:Cheilectomy and arthrodesis are the primary surgical treatments of hallux rigidus. While cheilectomy preserves limited motion, that motion can be the source of persistent pain that later requires arthrodesis. Cheilectomy with interposition arthroplasty using a synthetic hydrogel implant (Cartiva) has been proposed as an alternative to arthrodesis. Previous studies compared Cartiva to arthrodesis, but Cartiva is really a modification of cheilectomy, meant to improve its results by distracting the bony surfaces of the first MTP joint. This study compared outcomes of cheilectomy with Cartiva to cheilectomy alone.Methods:A retrospective cohort study assessed the results at 1-year minimum follow-up, identifying patients by CPT code for cheilectomy with (28291) and without (28289) Cartiva interposition. There were forty-five patients: 26 in the Cartiva group and 19 in the cheilectomy group. Tabulated data included: age, gender; preoperative, 6-month, and final postoperative total first MTP ranges of motion (ROM); preoperative and final postoperative VAS and SF-36 scores; and reoperation information. Hallux rigidus grade was assessed by Coughlin and Shurnas criteria. First MTP joint space was measured at the medial, midline, and lateral portions of the joint on both AP and lateral radiographs before, immediately following, and at maximum postoperative follow-up (16 month mean). For analysis, medial, midline, and lateral joint measurements were averaged to generate a composite measure of radiographic joint space. Follow-up means were 23 months for all patients, 18 for Cartiva and 28 for cheilectomy.Results:Mean age was 54. Mean preoperative grade was 2.6 for Cartiva and 2.1 for cheilectomy (p=0.037). Mean preoperative ROM was 44°. At 1 year follow-up, ROM was 39° for Cartiva and 47° for cheilectomy (p=0.95). Mean VAS improved from 5.8 to2.0 and 3.0 for Cartiva and cheilectomy, respectively, at final follow-up (p=0.002, p=0.004). Following Cartiva, two week postoperative joint space means increased: AP midline 1.4 to 2.6 mm, AP composite 1.4 to 2.2 mm, and lateral midline 1.3 to 2.7 mm (p<0.001). At final follow-up, joint space measures returned to levels similar to cheilectomy: AP midline 1.3 vs. 1.2 mm, AP composite 1.1 vs. 1.2 mm, and lateral midline 1.6 vs. 1.2 mm (p>0.3). Five patients in each group (22%) underwent revision.Conclusion::Cartiva offers similar intermediate-term ROM preservation and pain relief as cheilectomy in a cohort with higher grade hallux rigidus. Joint distraction gained by synthetic hydrogel interposition subsides with time to levels similar to cheilectomy. Revision surgery for persistent pain is common in both groups.

Short Term Radiographic Analysis of the Cartiva Implant for Hallux Rigidus

Category:Midfoot/ForefootIntroduction/Purpose:Cartiva (Wright Medical Group N.V.) was developed as an implantable interposition device for the treatment of hallux rigidus. It is performed along with a limited cheilectomy and serves as a joint preserving alternative to arthrodesis. In some patients, we have noticed gradual decreases in the joint space after surgery with Cartiva, presumably representing subsidence of the implant. The aim of this study is to report a radiographic analysis of visible joint space in surgical cases of hallux rigidus where dorsal cheilectomy and Cartiva were used.Methods:A prospectively collected patient database was queried for CPT code 28291 and those patients in which Cartiva was implanted were determined. The pre-operative and post-operative radiographs were analyzed for hallux rigidus grade, and measurements of visible joint space prior to and after Cartiva was implanted were performed at two weeks, one month, three months, and six months post-operatively. The percentage of visible joint space increase or decrease after implantation of Cartiva was calculated for each post-operative time point.Results:A total of 79 Cartiva were implanted in 74 patients between April 2017 and Sept 2018. The procedure was performed for Grade I hallux rigidus in 11% of patients (n=9), 66% grade II (n=52), 23% grade III (n=18). Mean pre-operative visible joint space measured 1.1 mm (n=79). Visible joint space measured at two weeks post-surgery was 2.2 mm (n=74); one month, 1.6 mm (n=65); three months, 1.2 mm (n=64); six months, 1.0 mm (n=30). Implantation of Cartiva resulted in 100% increase in visible joint space compared to pre-operative measurements at two weeks post-surgery, 45% increase at one month, 9% at three months, and a 9% decrease in visible joint space at six months.Conclusion:Cartiva implantation and limited cheilectomy for patients with symptomatic hallux rigidus provided a 100% increase in visible joint space on radiographs taken two weeks post operatively. However at six months post-surgery there was an overall 9% decrease in visible joint space presumably representing a subsidence of the Cartiva implant with time.

Long-term Follow-up of Cheilectomy for Treatment of Hallux Rigidus.

Hallux rigidus is the most common arthritic condition in the foot. First metatarsophalangeal joint cheilectomy produces satisfactory results in retrospective studies with reported good to excellent results in up to 97% and pain relief and function in 92%. The results of cheilectomy for higher grades of hallux rigidus are less favorable. The purpose of this study was to evaluate the long-term functional results and survivorship of cheilectomy for treatment of hallux rigidus. This was a retrospective, questionnaire-based study investigating the long-term results of cheilectomy for treatment of hallux rigidus. The preoperative arthritic grade was graded retrospectively according to the Hattrup and Johnson (H&J) grading system. A questionnaire was administered via email or telephone that included questions regarding pain recurrence following surgery, current functional status, and satisfaction with the operation. Kaplan-Meier survival analysis was performed to estimate survival time between arthritic grades. We reviewed 165 patients (169 feet) with an average follow-up of 6.6 (5.0-10.9) years. The overall survival rate (painless at the time of last follow-up) was 70.4% (119 feet), with no significant difference between the 3 H&J arthritic grades. Most of the recurrences (28 feet, 75%) were at the first 2 years following the surgery. Nine feet (5.3%) had a second procedure at a mean postoperative time of 3.6 (range, 1.6-7.4) years. Of the 169 feet, 117 (69.3%) reported being satisfied or very satisfied and 127 (75.1%) indicated they would repeat the operation under the same circumstances. Our study supports the use of cheilectomy for treatment of hallux rigidus (grade 1-3 Coughlin and Shurnas) as a reliable procedure with favorable results. At long-term follow-up, patients who underwent cheilectomy had a low revision rate and a moderately low rate of pain recurrence. Level IV, retrospective case-series.

Is metatarsus primus elevatus truly observed in hallux rigidus? Radiographic study using mapping methods

BackgroundHallux rigidus and metatarsus primus elevatus (MPE) are associated, but their causal relationship remains unknown. Several surgical approaches for treating hallux rigidus are available. We evaluated morphological characteristics of hallux rigidus with different grades to determine the optimal surgical approach. The amount of degenerative change in the metatarsophalangeal joint on the preoperative roentgenograms was graded on a scale of 1–3. We analyzed the morphology of hallux rigidus using X-ray image mapping developed by our team. MethodsThis study involved weight-bearing, dorsoplantar, and lateral foot X-rays of 36 feet from 26 patients underwent surgery for hallux rigidus (Group R) at our institution, and 26 normal feet (Group N). A two-dimensional coordinate system was used to analyze the sharps of these feet by converting each dot on the radiographs into X and Y coordinates. Diagrams of the feet from each group were drawn for comparison. Feet with grades 2 (Group R2) and 3 (Group R3) hallux rigidus and normal feet were compared by Kruskal–Wallis test. ResultsMapping revealed that the tip of distal phalanges of the second, and third toes in Group R medially shifted (P < 0.05) in dorsoplantar image of the feet, and that the medial point, a part of the talus, navicular, cuneiform, and first metatarsal bone in Group R, shifted lower (P < 0.05) in lateral feet images of the feet. Multiple comparisons revealed a significant navicular bone depression in grade 3 hallux rigidus compared with normal feet. A significant difference was observed between Group N and R3 but not between Group R2 and N or R3. ConclusionsX-ray morphological analysis of the foot revealed MPE in Group R. Elevation gradually increased as hallux rigidus grade worsened. Therefore, osteotomy combined with cheilectomy, whereby the first metatarsal bone can be tilted toward the plantar side, are useful for treating a higher-grade hallux rigidus. Level of evidenceLevel III, comparative study.

Osteochondral Defects in Hallux Rigidus

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus, or 1st metatarsophalangeal (MTP) joint degeneration, is commonly encountered in foot and ankle practice. Operative management can include a dorsal cheilectomy, a motion sparing procedure to reduce impingement. Hallux rigidus affects patients across all age groups, and etiologies may include trauma, first ray hypermobility, pes planus, or hallux valgus. First MTP joint trauma may result in an osteochondral defect (OCD). Literature is sparse regarding OCD management in the 1st MTPJ, as is follow-up data on cheilectomy using validated outcome measures. We hypothesize that the presence of an OCD is associated with symptomatic hallux rigidus at a lower Coughlin and Shurnas grade. We also hypothesize that OCD treatment concurrent with cheilectomy leads to outcomes equivalent to patients treated with isolated hallux rigidus. Methods: A retrospective review of prospectively collected data was performed. All patients of a single surgeon were reviewed based on the CPT code (28289) for cheilectomy from 1/1/2011 to 12/31/2015. Demographic data, presence/drilling of an OCD on operative reports, and Coughlin grading were recorded. All patients had taken the FAAM and SF-36 preoperatively per the surgeon’s routine preoperative data collection. After approval by the institutional review board, all patients were contacted by telephone for follow-up and answered the FAAM, SF-36 and Patient Acceptable Symptom State (PASS) questionnaires. Visual analog scores (VAS), patient satisfaction, complications, and whether they would opt for surgery again were recorded.Paired T-tests were performed to evaluate improvement in FAAM activity of daily living (ADL), FAAM sport, SF-36 physical component scores (PCS), and SF-36 mental component scores (MCS). Two-tailed T-tests were performed to evaluate the difference in groups with and without OCDs. Results: Seventy-one patients met inclusion criteria. Follow-up was obtained from 28 patients (29 feet) for analysis, 10 with OCDs. Mean responder age was 53.1 years (32.6-70.9), with average 4 year follow-up (minimum 2 years). Patients with OCDs had lower Coughlin grade (p&lt;0.01) and trended towards lower age (p=0.07), but similar improvement in FAAM sport (p=0.43), SF-36 PCS (p=0.33), and MCS (p=0.46). Patients with OCDs trended towards greater improvement in FAAM ADL (p=0.07). The entire cohort demonstrated significant improvements (p&lt;0.01) in ADL, Sport, PCS, and MCS after cheilectomy. ADL and Sport scores met the MCID of 8 and 9 points, respectively. MCID is not well-defined for SF-36. One patient required subsequent fusion. Conclusion: Cheilectomy is an effective surgical option for improving function and pain in the setting of hallux rigidus, as measured at intermediate-term follow-up with validated patient outcome measures. Patients with a 1st MTP joint OCD become symptomatic at a younger age and with a lower radiographic grade of hallux rigidus. These patients demonstrate equivalent improvements in the FAAM sport, SF-36 PCS and MCS while trending towards greater improvement in the FAAM ADL score as those without OCDs. The presence and treatment of a 1st MTP joint OCD should be considered in younger patients with symptomatic hallux rigidus and lower radiographic severity.

Hallux Rigidus Grade Does Not Correlate With Foot and Ankle Ability Measure Score.

Classification systems for hallux rigidus imply that, as radiographic changes progress, symptoms will concurrently increase in severity. However, symptom intensity and radiographic severity can be discordant for many patients. We studied the correlation between hallux rigidus grades and the Foot and Ankle Ability Measure (FAAM) scores to better understand this relationship. We retrospectively reviewed weight-bearing radiographs of the foot and FAAM Activities of Daily Living (ADL) questionnaires for 84 patients with hallux rigidus. The Spearman rank coefficient was used to correlate clinical-radiographic hallux rigidus grade with FAAM ADL scores. In 84 patients, the clinical-radiographic grade for hallux rigidus showed no relationship with FAAM ADL score (r = -0.10; P = 0.36) but did show moderate correlation with patient age (r = 0.63; P < 0.001). Advancing radiographic changes in hallux rigidus did not correspond with patient symptoms as measured via FAAM ADL scores. The reliability and validity of current grading criteria for hallux rigidus may require further exploration. Level III.

The Influence of Patient Factors on the Outcome of Synthetic Cartilage Implant Hemiarthroplasty versus First Metatarsophalangeal Joint Arthrodesis

Category: Midfoot/Forefoot Introduction/Purpose: Many studies have compared the outcomes of MTPJ1 hemiarthroplasty and arthrodesis, but there is a paucity of data on the influence of patient factors on clinical outcomes. A prior prospective, randomized, clinical trial compared the efficacy and safety of first metatarsophalangeal joint (MTPJ1) hemiarthroplasty with a synthetic polyvinyl alcohol hydrogel implant (Cartiva®) and MTPJ1 arthrodesis for moderate to severe hallux rigidus. The current study evaluated the data from this clinical trial to determine the impact of numerous patient variables, including osteoarthritis grade, hallux valgus angle, preoperative range of motion (ROM), gender, body mass index (BMI), preoperative duration of symptoms, and preoperative pain level, on the success or failure of MTPJ1 hemiarthroplasty and arthrodesis. Methods: Patients =18 years diagnosed with hallux rigidus grade 2, 3, or 4 were randomized and treated with synthetic cartilage implant MTPJ1 hemiarthroplasty (n=129) or arthrodesis (n=47). Outcome measures included a pain visual analogue scale (VAS), Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) scores, and Short Form-36 Physical Functioning (SF-36 PF) subscore, obtained preoperatively and at 2, 6, 12, 24, 52 and 104 weeks postoperatively. Great toe active dorsiflexion motion, secondary procedures, radiographs and safety parameters were evaluated. A patient’s outcome was deemed successful if composite primary endpoint criteria for clinical success (pain, function and safety) were met at 24 months. Predictor variables included: osteoarthritis grade; hallux valgus angle; preoperative ROM; gender; body mass index (BMI); preoperative symptom duration; prior surgery; and preoperative pain level. Two-sided Fisher’s Exact test was used to assess the impact of these variables on success of surgery (p&lt;0.05). Results: Standard patient demographics and baseline outcome measures were similar for both groups; both procedures demonstrated equivalent pain relief and functional outcomes.1 There was no significant difference (p&gt;0.05) in success rates (i.e., VAS pain reduction ≥ 30%, maintenance/improvement in function, freedom from radiographic complications, and no secondary surgical intervention) between synthetic cartilage implant MTPJ1 hemiarthroplasty and arthrodesis when stratified by osteoarthritis grade, degree of preoperative hallux valgus, extent of preoperative ROM, gender, BMI, duration of symptoms, prior MTPJ1 surgery status, and preoperative pain VAS score (Table 1). Notably, patients with minimal ROM and mild hallux valgus had equivalent success rates for both procedures. Males tended to have greater clinical success with implant hemiarthroplasty versus arthrodesis, but this difference was not statistically significant. 1Baumhauer et al., FAI, 2016;37(5):457-69. Conclusion: Synthetic cartilage implant hemiarthroplasty is an appropriate treatment for patients with hallux rigidus of Coughlin grade 2, 3 or 4. Its results in those with associated mild hallux valgus (&lt;20 degrees) and in those with a high degree of preoperative stiffness are equivalent to MTPJ1 fusion, irrespective of gender, BMI, osteoarthritis grade, or preoperative pain or duration of symptoms, in contrast to what might have been expected.

Revision of Implant to Great Toe Fusion

Category: Midfoot/Forefoot Introduction/Purpose: A prospective, randomized, non-inferiority clinical trial demonstrated that first metatarsophalangeal joint (MTPJ1) hemiarthroplasty with a synthetic polyvinyl alcohol hydrogel implant (Cartiva®) had equivalent pain relief and functional outcomes to MTPJ1 arthrodesis at 2 years. Despite 91% success, there was a 9.2% rate of implant removal and conversion to fusion. Other implants with more bone resection have demonstrated poorer outcomes after conversion to fusion than if a primary arthrodesis was performed. Since bone loss with synthetic cartilage implant hemiarthroplasty is minimal, we hypothesized that outcomes following implant removal and conversion to fusion would be similar to those following primary arthrodesis. We determined the outcomes of revision of synthetic implant hemiarthroplasty of the great toe to MTPJ1 arthrodesis and compared these outcomes to the primary arthrodesis cohort. Methods: In the original pivotal trial, 152 patients &gt;/=18 years diagnosed with hallux rigidus grade 2, 3, or 4 underwent synthetic cartilage implant MTPJ1 hemiarthroplasty, as previously described (Baumhauer et al., Foot Ankle Int. 2016;37(5):457-69). Outcome measures including the Foot and Ankle Ability Measure (FAAM), pain visual analogue scale (VAS), and Short Form-36 Physical Functioning (SF-36 PF) score were obtained preoperatively, and at 2 weeks, 6 weeks, and 3, 6, 12 and 24 months postoperatively. Revision surgery of the MTPJ1 was performed using the original surgical incision. The medial and lateral capsule was released, the metatarsal head was exposed to permit implant removal, and the void was filled with cancellous autograft or bone graft substitute. Joint compression was achieved using two crossed screws or a compression plate. Patients were non-weightbearing for six weeks. Union was confirmed on radiographs. Patients were followed post-conversion and assessed for pain and functional outcomes. Results: Fourteen patients (9.2%) underwent implant removal and conversion to MTPJ1 arthrodesis. Mean time to revision surgery was 12.8 (range: 1.8-24.2) months. The removed implants demonstrated no signs of wear, fragmentation, fracture or other defects; the cause for failure was patient-reported pain. Eleven revision patients were followed up for mean 11.6 (range 3.1- 22.9) months. Pain VAS decreased by mean 65.2 (range: 19.5-96.0) mm from baseline (i.e., prior to implant hemiarthroplasty). The FAAM ADL and Sports scores increased by mean 39.0 (range: 2.4-73.8) points and 49.2 (range: 5.8-90.6) points, respectively (Figure 1), compared to baseline, with minimal clinically important differences (MCIDs) of 8 and 9 points, respectively. The SF-36 PF subscore improved by mean 37.8 (range: 10-65) points from baseline, with MCID of 3.3 points. Conclusion: Patients who underwent implant removal and conversion to MTPJ1 arthrodesis exhibited outcome measure scores statistically similar (p&gt;0.05 for all scores) to those of the MTPJ1 fusion cohort at 24 months in the original pivotal trial (Figure 1). These results indicate that removal of the synthetic cartilage implant does not “burn a bridge” to having excellent pain relief and a successful functional outcome with a subsequent fusion procedure, if needed. The amount of bone loss with synthetic implant hemiarthroplasty is minimal, as the original joint surface length is maintained.

2017 Roger A. Mann Award Winner

Category: Midfoot/Forefoot Introduction/Purpose: Hallux rigidus (HR) is a very common symptomatic problem affecting one in 40 patients over the age of 50 years. A variety of treatment options exist and, as is common in surgery, grading systems are used to assess severity of the condition and aid in the guidance of treatment. The most commonly used grading system for HR uses radiographic images, great toe range of motion and clinical symptoms. This study examines the relationship of radiographic and motion findings to observed intra-operative cartilage loss in patients with HR and explores hallux rigidus grade and cartilage loss as predictive variables for treatment outcomes. Methods: A prospective, randomized non-inferiority study examining outcomes of arthrodesis compared to hemiarthroplasty of the first metatarsal phalangeal joint (Cartiva®) was performed.2 All randomized and treated patients were included in this study. Patients underwent pre-operative clinical examination, including measures of joint motion, radiographic assessment and HR grade. Operatively, observations of cartilage loss on the metatarsal head and opposing proximal surfaces were recorded. All patients’ data, irrespective of treatment, were aggregated and Spearman Rank Correlation coefficients used to assess for strength of correlation of active peak dorsiflexion and cartilage loss to HR grade. Outcomes data were then separated by treatment group and two-sided Fisher’s Exact test assessed these variables’ impact on clinical success (p&lt;0.05). Results: In 202 patients, 59 (29%), 110 (55%), and 33 (16%) were classified as Coughlin1 Grades 2, 3, and 4, respectively. There was no correlation between grade and active peak dorsiflexion (-0.02, p=0.78). While rank correlations between grade and cartilage loss on the proximal phalanx and metatarsal head statistically significantly differed from zero, the magnitudes of the correlations were small, 0.176 (p=0.01) and 0.224 (p=0.001), respectively (Table 1). Among Grade 4 patients, 36.4% had no metatarsal cartilage remaining; but this was also found in 8.5% of Grade 2 patients. Similarly, 52.5% of Grade 2 patients had ≥50% metatarsal cartilage remaining; but this was also found in 21.2% of Grade 4 patients. None of the observed factors were significantly associated with likelihood of achieving composite success. Conclusion: This study examines the relationship of motion and intra-operative cartilage loss findings with a commonly used clinical and radiographic grading system for hallux rigidus. This study population included only candidates with HR considered a candidate for arthrodesis based on review of clinical symptoms however the Grade assigned maybe Coughlin Grade 2, 3 or 4. Irrespective of the Grade, positive outcomes were demonstrated within both treatment groups. The weak correlations of preoperative motion and intra-operative cartilage loss to grade suggests that clinical symptoms should be a significant determinant guiding the treatment option rather than radiographic or range of motion factors.

Accurate Measurement of First Metatarsophalangeal Range of Motion in Patients with Hallux Rigidus

Category: Midfoot/Forefoot Introduction/Purpose: The reliability of range of motion (ROM) measurements has not been established for the hallux metatarsophalangeal (MTP) joint in patients with hallux rigidus. The aim of the present study was to prospectively assess the clinical versus radiographic difference in ROM of the arthritic hallux MTP joint. Methods: One-hundred consecutive patients who presented with any grade of hallux rigidus were included in this prospective study to determine the hallux MTP dorsiflexion. Clinical range of motion using a goniometer and radiographic range of motion on dynamic xrays was recorded. Inter and intra-rater reliability were calculated. Results: The mean difference between clinical and radiographic dorsiflexion was 13°. This difference was statistically significant. For all measurements clinical dorsiflexion was equal or less than radiographically-measured dorsiflexion. The difference was significantly greater in patients with a clinical dorsiflexion of less than 30° than in patients with 30° or more. Radiographic measurement of hallux dorsiflexion had an excellent intra- and inter-observer reliability. Conclusion: This study describes a reliable, reproducible, and straightforward method of measuring hallux MTP ROM that eliminates the “human” component of measuring clinical ROM and all the variables that are encountered when making said measurement.

First Metatarsophalangeal Arthrodesis Fixation with an Intramedullary System

Category: Midfoot/Forefoot Introduction/Purpose: Artrhrodesis is a commonly and successfully used procedure to deal with advanced hallux rigidus, severe hallux valgus, inflammatory and posttraumatic arthritis and as a salvage of previous failed surgeries. Many different techniques, in terms of joint preparation and fixation constructs, have been reported. The purpose of this study is to evaluate our short time results with an intramedullary device to perform the first metatarsophalangeal (MTP) arthrodesis. Methods: A descriptive observational study with prospective follow-up was developed. We included 21 arthrodesis using an Intramedullary Fusion Device, which consists in a 6.5 mm intramedullary metatarsal implant and a hooked 4.0 mm lag screw. The indications were hallux rigidus grade 4 in 10 cases, severe hallux valgus in 7, two patients with hallux varus and two cases of salvage surgery of a previous Keller Brandes. Clinical outcomes were assessed with American College of Foot and Ankle Surgeons (ACFAS) scoring scale preoperatively and at the time of the radiological fusion. The degree of satisfaction of patients was also evaluated using the Coughlin and Mann scale. Results: Fusion was achieved at five to twelve weeks in 19 patients. The grade of satisfaction was excellent and good in 18 patients. In two cases, implant breakage occurred. ACFAS score improved 40 points respect to preoperative status. No complications related to infection were reported. Conclusion: Dorsal plate fixation augmented with plantar lag screw fixation is nowadays the reference technique to perform first MTP arthrodesis, nevertheless titanium staples and crossed screws have also reported good results. In these constructs, sometimes is necessary a second surgery to remove some disturbing material. An intramedullary device would avoid the soft tissue irritation due to the underlying material and seems reliable to provide a strong fixation to achieve early MTP fusion with good short-term evolution.

Accurate Measurement of First Metatarsophalangeal Range of Motion in Patients With Hallux Rigidus

The reliability of range of motion (ROM) measurements has not been established for the hallux metatarsophalangeal (MTP) joint in patients with hallux rigidus. The aim of the present study was to prospectively assess the clinical versus radiographic difference in ROM of the arthritic hallux MTP joint. One hundred consecutive patients who presented with any grade of hallux rigidus were included in this prospective study to determine the hallux MTP range of motion. Clinical range of motion using a goniometer and radiographic range of motion on dynamic x-rays was recorded. The mean difference between clinical and radiographic dorsiflexion was 13 degrees (P < .001). For all measurements, clinical dorsiflexion was equal to or less than radiographically measured dorsiflexion. The difference was significantly greater in patients with a clinical dorsiflexion of less than 30 degrees than in patients with 30 degrees or more. Radiographic measurement of hallux dorsiflexion had an excellent intra- and interobserver reliability. We describe a reliable, reproducible, and straightforward method of measuring hallux MTP ROM that improved upon measuring clinical ROM. Level II, prospective comparative study.