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Stiff Big Toe??
Hallux Rigidus/Limitus
What is it?
Hallux Rigidus
• Cotterill first coined the term hallux rigidus in
1887.1 Hallux rigidus is now the most
universally accepted description of a condition
in which there is a combination of restricted
range of motion and degenerative arthrosis of
the first metatarsophalangeal joint (MPJ).
Hallux Rigidus
• Caused by DJD of first MTP joint in adults
osteophyte formation leads to dorsal
impingement
Hallux limitus
• The term “functional hallux limitus,” originally
described by Laird, should apply to a separate
group of individuals who do not have
degenerative changes of their great toe
joints.2 However, it is recognized that
functional hallux limitus may be one of the
etiologic factors of hallux rigidus.
Etiology
•
Systemic arthrosis, trauma, inflammatory
disorders, neuromuscular disorders, congenital
abnormality and iatrogenic events.
• The prevailing thinking is that abnormality in
dynamic foot function is the primary etiology of
hallux rigidus. However, the true mechanism of
dysfunction of the great toe joint during gait
remains poorly understood.
Mechanism
• caused by osteochondral
injury in adolescents
• trauma history more
common in unilateral
disease
• family history more common
in bilateral disease
Big Toe is the key to Proper Foot
Mechanics
Mechanism
• Overpronation of the
foot
• Excessive hyerextension
of great toe
Pronation and Supination
Presentation
• first ray pain worse
with push off or
forced dorsiflexion
of great toe
• pain becomes less
severe as disease
progresses
Imaging
• Radiographs
– osteophytes, especially
dorsal
– joint space narrowing
• widening or flattening
of metatarsal head
Classification & Treatment Overview
Loss of motion
Joint space narrowing
Treatment
Type I
mild
none
Morton bar (nonoperative)
Type II
moderate
mild
Cheilectomy
Type III
severe
complete
Arthodesis
Runners
any
any
Cheilectomy and Moberg
Treatment
Nonoperative
NSAIDS, activity
modification & Morton
extension
indicated in Stage I disease
may also use stiff sole
shoe and shoe box
stretching
Activity Modification
• involves avoiding
activities that lead to
excessive great toe
dorsiflexion
Operative
– dorsal cheilectomy
• indications Stage II disease
• pain with dorsiflexion is a indicator of good results with dorsal cheilectomy
• technique is resection of 20-30% of metatarsal articular surface
– MTP joint arthrodesis
• indicated in stage III disease (significant joint arthritis)
• dorsal plate with compression screw is biomechanically strongest construct
– Moberg procedure (dorsiflexion osteotomy of proximal phalanx)
• indicated in runners with reduced dorsiflexion (need 60° to run)
– Capsular interpositonal arthroplasty
• gaining popularity
– Keller Procedure
• indicated in elderly, low demand patients with significant joint degeneration and loss of
motion
• can lead to hyperextension deformity and transfer metatarsalgia
• not indicated in patients with pre-existing rigid hyperextension deformity of 1st MTPJ
MTP arthroplasty
• remains controversial
• results
– silastic implants have a good short term satisfaction rate
– osteolysis and synovitis may cause mid-long term pain
• complications
– failed arthroplasty
» treatment
• implant resection & synovectomy
• reserved for sedentary patients
• implant resection & arthrodesis
• leads to overall good satisfaction rates
• arthrodesis usually requires bone graft after resection
Joint replacement
• Joint replacement has been tried for over 20
years in the first MP joint. To date, the results still
remain very poor. A recent study compared joint
replacement to fusion of the first MP joint,
showing that even patients who had a successful
joint replacement still had a lower function score
than the patients with a fusion. The complication
rate from the joint replacement is unacceptably
high and to this date we have not perfected joint
replacement of the first MP joint.
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