hallux rigidus
This is a thread posted in category: Ask the Foot Doctors . . View All Heel Pain CategoriesPosted by Dr. Ed on 5/15/07 at 07:40
It is important to review the grading system for hallux rigidus (painful arthritic first MTP joint with restricted motion).
Stage 1: Early degenerative changes. May be treated via orthotics, shoe modifications (distal rocker sole), possibly physical therapy.
Stage 2: Moderate degenerative changes. May be treated via orthotics but orthotic therapy must proceed cautiously as the goal of orthotics is to increase range of motion of the joint which can only be attempted if degenerative changes are not too advanced and if there is sufficient range of motion to work with. Distal rocker soles added to shoes cna be very helpful. Surgical treatment may include the cheilectomy coupled with osteochondral drilling used to attempt to stimulate new fibrocartilage ingrowth to replace osteochondral defects (divots in the cartilage).
Stage 3: Advanced degenerative changes with significantly restricted range of motion. Orthotics are contraindicated. Cheilectomies may be attempted but often fail at this stage. The reason for cheilectomy failure is that that procedure allows increased range of motion at a joint in which that new motion is likely to be painful. Two surgical options may be considered. (1)A plantarflexory osteotomy of the first metatarsal head (repositions the cartilage to a more functionally advantageous position) coupled with osteochondral drilling. (2) Plantarflexory osteotomy coupled with a hemi-implant. A hemi-implant is an implant, often metallic (cobalt-chrome or titanium) which serves to resurface only the phalangeal (big toe) side of the joint.
Stage 4: 'End stage' hallux rigidus. Minimal motion is left at the joint and minimal cartilage remains. This may be adapted conservatively to a shoe with a moderate distal rocker sole, possibly with a carbon fiber plate. Surgically, the joint may be fused or a total joint implant. The total implants that are two piece, that is, are designed as a two piece ball and socket have poor longevity. The total implants that are designed as a hinge function very well, and offer a relatively rapid recovery and restoration of function. We are now on the third generation of such implants with advanced biomaterials and design such that the longevity of such implants is not known. I have yet to see one fail and be replaced by a fusion. I use the Primus flexible big toe implant by Futura Biomedical (recently purchased by another company http://www.nexaortho.com/futura/primus.php
I have had runners return to training within two months after use of this implant. It allows ambulation with a surgical shoe within 48 hours and return to a running shoe within about 3 weeks. Should the implant 'break' it is not a large procedure to remove it and replace it with another one since the original placement can be achieved without a significant amount of bone removal. Dr. Bruce Lawrence, the designer of the implant and its predecessors had placed the first generation of such hinged implants about 30 years ago and still has some of those patients in his practice. He noted that despite the fracture of the hinge of the implant over the decades, the two ends of the implant still allowed pain free range of motion. He offered such patients replacement of the implant but most refused stating that they had little or no pain and adequate function.
There are biomechanical reasons why patients get hallux rigidus. The surgeon must be more than a surgeon but must have a good understanding of podiatric biomechanics in order to assess how a given procedure will affect gait and the mechanics of walking. Additionally, each set of procedures can be modified or custom tailored to suit the biomechanical function of a particular patient. The failure rate tends to go up when a 'cookie cutter' approach to many of such procedures is used as opposed to a flexible approach in which the surgeon/biomechanist adjusts technique to suit the individual patients
requirements.
Dr. Ed
Posted by Dr. David S. Wander on 5/15/07 at 08:40
I will give you my opinion based on my 21 years of experience. I am not an orthopedic surgeon, but I'm a podiatric surgeon that has significant experience treating this condition.
Depending on the condition of the first MTPJ, and most importantly the findings at the actual time of surgery, the choices of procedures really are:
1) Cheilectomy: This is a procedure which is basically a simple 'cleaning up of the joint' and removes any bony proliferation of the joint surfaces that is hindering joint motion. It will not increase the joint space and will sometimes alleviate a significant amount of pain for a given amount of time. It often 'buys' the patient some time. It is by far the 'simplest' procedure and can often result in very satisfying temporary relief.
2) Cheilectomy with osteotomy: This is the same as above, but with a cutting and realignment of the bone. This can only be performed IF there is enough healthy cartilage remaining on the joint surfaces to allow this procedure to be performed. This procedure is based on the theory that it is realigning the joint to a more functionally 'correct' position, to allow the joint to align more correctly and articulate more correctly, eliminating the situation that caused the original problem. This usually is done by lowering the metatarsal bone and/or shortening the metatarsal bone, because many times hallux limitus is caused by an elevated first metatarsal or excessively long first metatarsal. Therefore, by lowering or shortening the first metatarsal, it 'decompresses' the joint and allows for increased motion, decreased pain and a more anatomically correct alignment.
However, recently there has been some controversy regarding the long term benefits of these osteotomies and whether the altered biomechanics caused by this procedure are beneficial in the long run.
3) Joint implants: There are basically three types of implants. Silicone implants that fell out of favor years ago because the silicone was breaking down. Then the manufacturers came up with a solution by making small metal 'grommets' that fit over the ends of the implants to prevent erosion. The second type of implant is a 'hemi', which only replaces one portion of the joint, usually the base of the large toe and is metallic. The third type of implant mimics total knee implants and is a two piece non constrained implant with one piece going into the base of the large toe and one piece going into the metatarsal head.
I am NOT a big fan of first MTPJ implants, ESPECIALLY the two piece implants. I have not seen impressive results with these and have seen some disastrous results with joint jamming, implant loosening and I have personally removed A LOT of these put in by other surgeons. I would stay away from the two piece implant.
4) Fusion/Arthrodesis: This is an end stage and non reversible procedure that fuses the joint in a set position and eliminates motion and eliminates pain. It is usually a VERY successful procedure which eliminates pain and usually has very few complications. If your joint is non-salvageable, I would probably opt for a fusion over an implant, since a fusion is basically forever, and most implants will have to be replaced in about 10-15 years if you are active.
5) Keller type procedure: this is a joint destructive procedure that does not involve a fusion or an implant, but does remove the diseased portion of bone and simply has soft tissue interposed in the area. This procedure is usually reserved for more elderly, less active patients due to biomechanical changes following the procedure.
6) There are more esoteric/exotic procedures that I will not discuss at this time, such as joint distraction procedures, etc., which are beginning to gain popularity but are not yet the 'norm', and other less popular procedures that don't warrant discussion.
Take this information and discuss it with your doctor, who knows your case better than anyone.
Posted by GraceG on 11/07/08 at 22:59
I am wondering what you would recommend for me. I have a biocompatible, non metal, hydrophylic implant in the MTP joint. (hallux rigidus as a result of stepping into a hole in 2001, and toe was bent completely back). The implant was placed into a divot in the metatarsal bone, in 2006. The toe will bend downward completely, but upward only about 20 degrees. I think that because the toe does not bend completely, pressure is put on other parts of the foot, like the outside, and the heel specifically,causing considerable pain. I would appreciate your advice.
Thanks.
Posted by GraceG on 11/07/08 at 23:00
I am wondering what you would recommend for me. I have a biocompatible, non metal, hydrophylic implant in the MTP joint. (hallux rigidus as a result of stepping into a hole in 2001, and toe was bent completely back). The implant was placed into a divot in the metatarsal bone, in 2006. The toe will bend downward completely, but upward only about 20 degrees. I think that because the toe does not bend completely, pressure is put on other parts of the foot, like the outside, and the heel specifically,causing considerable pain. I would appreciate your advice.
Thanks.
Posted by Tracey on 6/01/09 at 14:40
Posted by Karen on 10/05/09 at 14:14
Posted by Mara H. on 3/30/10 at 23:15
If cheilectomy is used early on in hallus rigidus cases, does that reduce the likelihood that the patient will need more drastic surgeries, such as joint fusion, later on?
Worded otherwise, if a patient with moderate hallus rigidus does not take some sort of surgical step, like cheilectomy, is he likely to need more drastic surgery (like fusion) in later years?
Thanks!
Posted by AMY H on 5/05/10 at 14:19
This post was deleted because it didn't adhere to the posting agreement.
