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.