Hallux Rigidus (MTP joint arthritis) - Foot & Ankle (2024)

• 2.5% of patients older than 50 years

• most common location of osteoarthritis in the foot

• females > males (2:1)

• most commonly noted in the 5th and 6th decade of life

• history of trauma to the 1st MTP joint

  • noted in ~80% of patients with unilateral disease

• high impact sports

• 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

    • metatarsal head morphology

    • long first metatarsal

    • hallux valgus or hallux varus

• orthopedic conditions

  • sesamoid arthritis

• medical conditions

  • gout

  • rheumatoid arthritis

  • seronegative arthropathies

• first metatarsal

  • shortest and widest

• medial branch of the medial dorsal cutaneous nerve overlies 1st MTP joint

  • can become irritated by dorsal osteophytes

• plantarmedial hallucal nerve also supplies the MTP articulation

• the first MTPJ carries up to ~120% of an individual's body weight with each step

• pain

• swelling

• gait abnormalities

• difficulty with shoe wear

• 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

• 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

  • skin irritation and redness from shoe wear

• 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

    • may have tinel sign

• provocative tests

  • TTP over the first MTP

  • pain with grind test

    • indicative of severe disease with central chondral wear

• recommended views

  • weight-bearing AP, lateral, sesamoid and oblique views of the foot

• findings

  • dorsal osteophytes

  • joint space narrowing

  • subchondral sclerosis and cysts

• indications

  • rarely needed

  • suspected osteochondral lesion with normal radiographs

  • can better characterize mild osteoarthritis

• findings

  • osteochondral lesions

• 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

      • up to 55% treated successfully without surgery

• dorsal cheilectomy

  • indications

    • grade 1 and 2 disease

    • 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

    • positive grind test

    • patients with sesamoid arthritis

    • medical comorbidities precluding surgery (poorly controlled diabetes, vascular disease)

  • outcomes

    • pain with terminal dorsiflexion is an indicator of good results with dorsal cheilectomy

    • Grade 1 and 2: up to 97% excellent results with 92% with pain relief at 10 years

    • At higher grades, 25-56% require conversion to arthrodesis

• Osteotomy (e.g. Moberg procedure)

  • indications

    • runners with reduced dorsiflexion (60° is needed to run)

    • failure of cheilectomy to provide at least 30 to 40 degrees of motion

  • technique

    • dorsal closing wedge osteotomy of the proximal phalanx

  • outcomes

    • 88% satisfaction in patients treated with combined cheilectomy and osteotomy at 2 years follow-up

    • limited literature on outcomes of osteotomy alone

• Resection arthroplasty (Keller procedure)

  • 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

    • patients with sesamoid arthritis

  • outcomes

    • good results have been noted in low demand elderly patients

      • when coupled with interposition arthroplasty, up to 90% with improvement in pain and only 4% requiring additional surgery at 4.5 years follow-up

    • significant risk of joint instability for younger and more active patients

• Prosthetic Arthroplasty

  • indications

    • grade 3 and 4 disease for patients who wish to preserve joint motion

  • contraindications

    • active infection

    • insufficient bone stock

    • hallux sesamoid arthritis

    See Also

    Treatment Options for Degenerative Joint Disease of the Hip

  • technique

    • may be hemiarthroplasty or total joint arthroplasty

  • 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

      • largely abandoned

    • 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

      • mid-term and long-term results demonstrated loosening and need for complex revisions due to bone loss

    • worse long-term outcomes than primary fusion

      • arthroplasties requiring secondary fusions have worse outcomes than primary fusion

• Arthrodesis

  • indications

    • standard of care

    • grade 3 and 4 disease (significant joint arthritis)

    • most common procedure for hallux rigidus

  • procedure

    • 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.

  • outcomes

    • 90-100% fusion rate

    • 95% satisfaction rate

    • high rate of return to hiking (92%), golf (80%), jogging (75%), tennis (75%)

• activity modifications

  • avoid activities that lead to excessive great toe dorsiflexion

• intra-articular injections

  • both corticosteroid and sodium hyaluronate injections have been shown to significantly improve pain scores at 4 and 8 week follow-up 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

• technique

  • dorsal approach with complete synovectomy

  • 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

• technique

  • increases dorsiflexion by decreasing the plantar flexion arc of motion

  • may be performed with cheilectomy to increase dorsiflexion

• technique

  • involves removing the base of the first proximal phalanx

  • interposition

  • risk of hyperextension (co*ck-up deformity), weakness with push-off, and transfer metatarsalgia (decreased with capsular interposition)

• 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

• 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

  • 5 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

• structural bone grafting

  • technique

    • structural bone graft used to restore metatarsal length

      • tricortical iliac crest allograft most commonly used

• 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

• may occur after cheilectomy

  • conversion to arthrodesis needed in 7-9% of patients within 10 years

Failed arthroplasty

• risk factors

  • early generation implants (especially silicone implants)

    • silicone implants have been abandoned

    • other designs have failed due to loosening, osteolysis, technical errors, and persistent pain

• 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

• incidence

  • 16% after arthrodesis

• may lead to

  • transfer metatarsalgia

  • arthritis of the hallux interphalangeal joint and difficulty with push off

• incidence

  • 5-10% after arthrodesis

    • < 40% of patients with a nonunion are symptomatic

• treatment

  • revision arthrodesis with bone grafting

• risk factors

  • keller resection arthroplasty

• treatment

  • first MTP joint arthrodesis

• incidence

  • 15% of patients following hallux MTP joint arthrodesis

• risk factors

  • hallux MTP joint arthrodesis

• treatment

  • usually asymptomatic

• may occur after excessive resection during a cheilectomy

• < 2% of cases

• radiographic progression may not always correlate with symptom progression

• 96% patient satisfaction rate with respect to post-operative activity level

• high rate of return to hiking (92%), golf (80%), jogging (75%), tennis (75%)