HALLUX RIGIDUS
First MTP Joint Arthritis | Carp Classification | Grading-Based Treatment Algorithm
Carp Classification (Most Common)
Critical Must-Knows
- Grading (Carp) determines treatment: Grade 1-2 = cheilectomy, Grade 3-4 = arthrodesis
- Cheilectomy requires at least 30 degrees dorsiflexion to be effective
- Arthrodesis fusion position: 10-15 degrees valgus, 15-20 degrees dorsiflexion, neutral rotation
- Cheilectomy contraindicated if cartilage loss extends beyond dorsal third of joint
- First MTP arthrodesis has 90-95% fusion rate with high satisfaction
Examiner's Pearls
- "Distinguish from hallux valgus (lateral deviation vs stiffness/pain on dorsiflexion)
- "Grind test (compression + rotation) reproduces pain from joint arthritis
- "Dorsal osteophyte causes impingement in toe-off phase of gait
- "Failed cheilectomy can proceed to arthrodesis without major compromise
Clinical Imaging
Imaging Gallery
Critical Hallux Rigidus Exam Points
Key Pathophysiology
Degenerative arthritis of first MTP joint. Primary (70%) or secondary to trauma, gout, inflammatory arthropathy. Dorsal osteophyte blocks dorsiflexion needed for toe-off.
Classification Drives Treatment
Carp grading (0-4) based on radiographic changes and ROM. Grade 1-2 = cheilectomy, Grade 3-4 = arthrodesis. Hattrup-Johnson simpler (3 grades) but less granular.
Treatment Algorithm
Conservative first for all grades. Surgical: cheilectomy if dorsal disease only, arthrodesis for advanced disease, arthroplasty controversial due to high failure.
Critical Surgical Decision
Cheilectomy requires adequate cartilage on plantar surface. If cartilage loss extends beyond dorsal third, proceed directly to arthrodesis. Check intraoperatively.
Quick Decision Guide
| Patient Scenario | Carp Grade | First-Line Surgical | Key Pearl |
|---|---|---|---|
| Early, active patient, minimal symptoms | Grade 0-1: Dorsal spurring, mild JSN | Cheilectomy (30% dorsal head + osteophyte) | 80-90% good results, preserves joint |
| Moderate disease, preserved plantar cartilage | Grade 2: 50-75% JSN, moderate ROM loss | Cheilectomy vs Interposition arthroplasty | Intraop assessment crucial - check cartilage |
| Advanced arthritis, circumferential cartilage loss | Grade 3: Over 75% JSN, severe stiffness | First MTP arthrodesis (gold standard) | 90-95% fusion, 85-90% satisfaction |
| Grade 3 plus hallux valgus or varus deformity | Grade 4: Advanced disease plus deformity | First MTP arthrodesis | Correct alignment: 10-15° valgus, 15-20° dorsiflexion |
CARPHallux Rigidus Classification Systems
Memory Hook:CARP - like a fish mouth that can't open (rigid joint)!
DORSALCheilectomy Indications
Memory Hook:DORSAL disease = cheilectomy removes the DORSAL bump!
VDNFirst MTP Arthrodesis Fusion Position
Memory Hook:VDN - Very Deliberate Numbers for fusion position!
Overview and Epidemiology
Why Hallux Rigidus Matters
Hallux rigidus is the most common arthritic condition of the foot, second only to hallux valgus as a disorder of the first MTP joint. Unlike hallux valgus (deformity-driven), hallux rigidus is pain and stiffness-driven, significantly affecting gait and quality of life. Treatment is grading-based with predictable outcomes.
Demographics
- Age: Bimodal - adolescent (osteochondritis) and 40-60 years (degenerative)
- Gender: Males twice as common as females
- Bilateral: 50-80% of cases
- Occupation: Higher in athletes, dancers, manual laborers
Etiology and Impact
- Primary (70%): Idiopathic, likely multifactorial (genetics, mechanics, anatomy)
- Secondary (30%): Trauma, inflammatory arthritis (gout, RA), osteochondritis dissecans
- Gait impact: Painful toe-off, compensatory external foot progression angle
- Function loss: Unable to squat, difficulty with stairs, impaired running
Pathophysiology and Mechanisms
First MTP Joint Biomechanics
The first MTP joint undergoes 2-3 times body weight during normal gait, increasing to 8 times body weight with running. Normal dorsiflexion of 65-75 degrees is required for toe-off. Hallux rigidus reduces this to typically under 30 degrees, forcing compensatory mechanisms that alter gait mechanics.
| Structure | Normal Anatomy | Hallux Rigidus Changes | Clinical Significance |
|---|---|---|---|
| Articular cartilage | Smooth, covers entire joint surface | Erosion starts dorsal, progresses plantar | Dorsal-only disease amenable to cheilectomy |
| Dorsal capsule | Allows 65-75° dorsiflexion | Contracted, fibrotic, thickened | Capsular release improves ROM post-cheilectomy |
| Sesamoid complex | Glides smoothly under metatarsal head | Arthritic changes in advanced disease | Consider sesamoid debridement if involved |
| Dorsal osteophyte | Absent | Progressive spurring blocking extension | Primary cause of impingement pain |
Normal Gait Mechanics
- Heel strike: Foot plantigrade
- Mid-stance: First MTP joint neutral
- Toe-off: Requires 65-75° dorsiflexion
- Push-off: 60% body weight through hallux
Hallux Rigidus Compensation
- Toe-off altered: Cannot achieve normal dorsiflexion
- External rotation: Foot turns out to avoid MTP dorsiflexion
- Lateral weight shift: Loads lesser toes abnormally
- Pain cycle: Dorsal impingement reinforces stiffness
Classification Systems
Carp Classification (Most Commonly Used)
| Grade | Radiographic Findings | Clinical ROM | Treatment |
|---|---|---|---|
| 0 | Dorsal osteophyte, no JSN | 10-20% loss, over 60° dorsiflexion | Conservative, consider cheilectomy if symptomatic |
| 1 | Mild spurring, 20-50% JSN, minimal sclerosis | 20-50% loss, 40-60° dorsiflexion | Cheilectomy first-line, excellent results |
| 2 | Moderate spurring, 50-75% JSN, subchondral sclerosis | 50-75% loss, 20-40° dorsiflexion | Cheilectomy if plantar cartilage OK, or interposition |
| 3 | Severe spurring, over 75% JSN, cysts, loose bodies | Over 75% loss, under 20° dorsiflexion | Arthrodesis gold standard |
| 4 | Grade 3 changes plus hallux valgus or varus | Severe stiffness plus deformity | Arthrodesis with deformity correction |
Carp Grading Key Distinction
The critical decision point is Grade 2: if intraoperative assessment shows cartilage preservation on the plantar surface, cheilectomy can succeed. If cartilage loss is circumferential, proceed directly to arthrodesis. Do not compromise with inadequate debridement.
This classification system correlates well with treatment outcomes and provides clear decision-making framework.
Clinical Assessment
History
- Pain: Dorsal MTP, worse with toe-off, stairs, squatting
- Stiffness: Progressive loss of dorsiflexion
- Gait: External foot progression angle to avoid dorsiflexion
- Footwear: Difficulty with heels, dress shoes, athletic shoes
- Activities: Reduced running, dancing, sports participation
- Previous treatments: Orthotics, injections, activity modification
Examination
- Look: Dorsal prominence, skin irritation over osteophyte
- Feel: Tenderness over dorsal MTP, osteophyte palpable
- Move: Measure dorsiflexion (normal 65-75°), grind test positive
- Deformity: Assess for hallux valgus/varus component (Carp Grade 4)
- Gait: Observe toe-off phase, external rotation compensation
- Neurovascular: Ensure intact (dorsalis pedis, sensation)
Grind Test - Key Diagnostic Maneuver
Compress the first MTP joint while rotating the hallux. Pain reproduction indicates intra-articular pathology (arthritis). Compare with dorsal impingement pain (pain only at end-range dorsiflexion). Grind test specificity distinguishes arthritis from isolated dorsal impingement.
| Finding | Hallux Rigidus | Hallux Valgus | Turf Toe |
|---|---|---|---|
| Primary complaint | Pain and stiffness | Deformity and bunion pain | Acute traumatic pain |
| Deformity | Dorsal osteophyte, usually straight alignment | Lateral deviation, medial eminence | Swelling, ecchymosis |
| ROM | Restricted dorsiflexion, painful | Variable, often normal early | All motion painful acutely |
| Radiographs | Dorsal osteophyte, JSN, sclerosis | Hallux valgus angle, 1-2 IM angle | Often normal, may show avulsion |
Investigations
Imaging Protocol
Essential views for grading and planning. AP shows joint space narrowing, medial/lateral osteophytes. Lateral shows dorsal osteophyte (key for cheilectomy planning), assess dorsal 30% of metatarsal head.
Sesamoid assessment. Evaluates sesamoid arthritis which may require debridement at surgery. More sensitive than AP for lateral osteophytes.
CT: Preoperative planning for complex deformity or failed surgery. MRI: If concern for osteochondritis dissecans (young patient) or to assess cartilage (not routine).
Radiographic Features (Progressive)
- Early (Grade 1): Dorsal osteophyte, maintained joint space
- Moderate (Grade 2): Flattening of metatarsal head, 50% JSN
- Advanced (Grade 3): Severe JSN, subchondral sclerosis, cysts
- Late (Grade 4): Near ankylosis, loose bodies, deformity
Pre-Operative Planning
- Measure dorsal osteophyte: Extent of resection for cheilectomy
- Assess joint space: Plantar cartilage preservation?
- Check sesamoids: Arthritic changes requiring debridement?
- Measure alignment: Hallux valgus/varus for fusion correction
Non-Operative Management
Conservative Management Role
All patients should trial non-operative management before surgery, unless severe pain or functional limitation. Success rates vary: 20-30% achieve satisfactory symptom control with conservative measures. Duration of trial: 3-6 months.
Conservative Treatment Algorithm
Wide toe box, stiff sole. Rigid sole reduces MTP dorsiflexion demand. Rocker-bottom sole shifts toe-off proximal. Avoid high heels (increase dorsiflexion demand).
Morton's extension orthotic (carbon fiber plate extending to hallux tip) prevents MTP dorsiflexion. Turf toe plate similar effect. Padding over dorsal osteophyte for shoe pressure.
Avoid high-impact activities, running, jumping. Low-impact alternatives: cycling, swimming. Occupational modifications for prolonged standing/walking.
NSAIDs for pain and inflammation. Oral or topical. Caution in elderly, renal disease. Not disease-modifying, symptom control only.
Corticosteroid (+ local anesthetic). Diagnostic: confirms intra-articular source. Therapeutic: 3-6 months relief common. Maximum 2-3 injections. Consider hyaluronic acid (less evidence).
When to Abandon Conservative Management
Indications for surgical referral: Failure of 3-6 months conservative treatment, severe pain limiting daily activities, progressive deformity (Grade 4), significant gait disturbance affecting work/recreation. Emphasize to patients that surgery is elective but highly effective.
Management Algorithm
Cheilectomy - Joint-Preserving Procedure
Indications:
- Carp Grade 1-2 (mild to moderate arthritis)
- Dorsal osteophyte causing impingement
- Preserved plantar cartilage (critical!)
- At least 30 degrees dorsiflexion remaining
- Failed conservative management
Contraindications:
- Circumferential cartilage loss (intraop finding)
- Severe stiffness (under 20 degrees dorsiflexion)
- Grade 3-4 disease
- Sesamoid arthritis
Cheilectomy Technique
Dorsal longitudinal incision over first MTP joint, 3-4 cm. Protect dorsal sensory nerves (medial and lateral cutaneous branches). Incise capsule longitudinally, preserve for repair.
Intraoperative cartilage evaluation. Plantarflex hallux to expose dorsal metatarsal head. Assess cartilage: if intact on plantar two-thirds, proceed with cheilectomy. If circumferential loss, convert to arthrodesis.
Remove dorsal 25-30% of metatarsal head. Use oscillating saw or osteotome. Resect from medial to lateral, ensuring complete removal of dorsal ridge. Smooth with rongeur. Remove phalangeal osteophytes.
Release dorsal capsular adhesions to improve dorsiflexion. Gentle manipulation to achieve at least 60-70 degrees dorsiflexion. Avoid forced manipulation (fracture risk).
Repair capsule loosely (over-tightening limits dorsiflexion). Subcuticular skin closure. Soft dressing, wooden shoe or post-op shoe for 2 weeks.
Pearls
- 30% rule: Remove dorsal 30% to decompress joint
- Check motion: Aim for 60-70° intraoperative dorsiflexion
- Preserve plantar cortex: Critical for stability
- Early mobilization: Start ROM at 2 weeks
Pitfalls
- Under-resection: Inadequate decompression, recurrent impingement
- Over-resection: Metatarsal fracture, instability, transfer metatarsalgia
- Missed plantar disease: Poor outcome, consider conversion
- Forced manipulation: Fracture, damage plantar cartilage
Cheilectomy Outcomes
Grade 1-2 disease: 80-90% good-excellent results at 5 years. Pain relief predictable, ROM improvement variable (average 20-30 degree gain). Satisfaction high. Durability: 70-80% avoid further surgery at 10 years. Failed cheilectomy can proceed to arthrodesis without compromise.
These outcomes make cheilectomy an excellent first-line option for appropriate candidates.
Surgical Technique
Patient Positioning
Setup Checklist
Supine on standard operating table. Ankle bump to internally rotate leg, expose medial aspect of first MTP joint. Contralateral limb: flat on table or frog-leg position.
Thigh or ankle tourniquet. Ankle preferred for better access. Exsanguinate with Esmarch or elevation. Inflate to 250-300 mmHg (ankle) or 100 mmHg above systolic (thigh).
Foot and ankle free-draped. Expose from toes to mid-calf. Ensure C-arm access for lateral and AP views of first MTP joint.
Standard positioning allows both cheilectomy and arthrodesis through same approach.
Complications
| Complication | Incidence | Risk Factors | Management |
|---|---|---|---|
| Recurrent stiffness/pain post-cheilectomy | 15-20% at 5-10 years | Under-resection, progression of arthritis, Grade 3-4 disease | Revision cheilectomy if residual osteophyte, or convert to arthrodesis |
| Malunion (arthrodesis) | 10-15% (most common complication) | Technical error, inadequate fluoroscopy, poor positioning technique | If symptomatic: revision arthrodesis with osteotomy |
| Nonunion (arthrodesis) | 5-10% | Smoking, diabetes, inadequate fixation, poor bone quality | Revision arthrodesis with bone graft, biologics, rigid fixation |
| Hardware irritation (arthrodesis) | 10-15% | Prominent plate, low-profile skin, patient factors | Hardware removal after union (typically 6-12 months) |
| Transfer metatarsalgia | 5-10% | Over-resection (cheilectomy), malunion (arthrodesis) | Orthotics, metatarsal pads, rarely osteotomy |
| Infection | 1-3% | Diabetes, smoking, immunosuppression | Antibiotics, wound care, rarely debridement or hardware removal |
| Nerve injury (sensory) | 5-10% temporary, 1-2% permanent | Dorsal medial/lateral cutaneous nerves | Usually resolves, neuropathic pain management if persistent |
Preventing Malunion - Most Common Arthrodesis Complication
Malunion is the most common significant complication of first MTP arthrodesis. Prevention requires meticulous intraoperative technique: use sterile block to simulate weight-bearing, check hallux alignment (should point between 2nd-3rd toes), ensure 15-20 degrees dorsiflexion (1-2 cm ground clearance), confirm 10-15 degrees valgus. Fluoroscopy in multiple planes before final fixation. Do not accept suboptimal position - reposition and re-fix if needed.
Postoperative Care and Rehabilitation
Cheilectomy Rehabilitation
Dressing and footwear: Soft dressing, wooden shoe or post-op shoe. Weight-bearing: Immediate weight-bearing as tolerated in protective shoe. Activity: Elevate foot, ice, minimal walking. Pain control: Oral analgesics, NSAIDs after 48 hours.
ROM exercises: Start gentle dorsiflexion exercises at 2 weeks (critical!). Manual stretching, active ROM. Goal: regain 60-70 degrees. Footwear: Transition to stiff-soled athletic shoe. Weight-bearing: Full weight-bearing. Activity: Walking, avoid running/jumping.
Strengthening: Toe curls, marble pick-up, resistance band dorsiflexion. Proprioception: Balance exercises. Activity: Gradual return to sports, impact activities. Footwear: Normal shoes, avoid high heels initially.
Return to sport: Running, jumping, cutting at 3 months if ROM adequate. Long-term: Expect 90% recovery by 6 months. Maintain ROM with daily stretching. Avoid excessive high heels long-term.
Critical Cheilectomy Rehab Point
Early ROM exercises are critical to cheilectomy success. Start at 2 weeks - capsular adhesions form quickly. Goal: 60-70 degrees dorsiflexion. Aggressive physiotherapy improves outcomes. Stiffness post-cheilectomy often reflects inadequate rehabilitation, not surgical failure.
Early mobilization maximizes the motion-preservation benefit of cheilectomy.
Outcomes and Prognosis
| Procedure | Best For | Success Rate | Advantages | Disadvantages |
|---|---|---|---|---|
| Cheilectomy | Grade 1-2, dorsal disease | 80-90% satisfaction at 5 years | Motion preserved, simple procedure, low morbidity | May fail (15-20% at 10 years), arthritis progression |
| Interposition Arthroplasty | Grade 2, young patient | 60-80% satisfaction at 5 years | Motion preserved, no implant | Higher failure than cheilectomy or arthrodesis, limited evidence |
| Arthrodesis | Grade 3-4, failed cheilectomy | 85-90% satisfaction long-term | Predictable pain relief, durable, low revision rate | Loss of motion, malunion risk, longer recovery |
| Arthroplasty | Limited role (elderly, low demand) | 60-80% at 5 years, 60% at 10 years | Motion preserved (theoretically) | High failure, loosening, revision difficult, not recommended |
Predictors of Poor Outcome
Cheilectomy: Grade 3-4 disease (wrong procedure), circumferential cartilage loss, inadequate debridement. Arthrodesis: Malunion (affects function, satisfaction), nonunion (5-10%), smoking. General: Inflammatory arthropathy, worker's compensation, unrealistic patient expectations. Patient selection and meticulous technique are critical to optimal outcomes.
Evidence Base and Key Trials
Systematic Review - Cheilectomy Outcomes
- Systematic review of cheilectomy for hallux rigidus
- Overall satisfaction: 82% (range 60-100%)
- Pain relief more predictable than ROM improvement
- Better results in earlier grade disease (Grade 1-2)
- Average ROM improvement: 20-30 degrees
- Durability: 70-80% avoid further surgery at 10 years
First MTP Arthrodesis - Long-Term Outcomes
- Retrospective series: 118 first MTP arthrodeses
- Fusion rate: 93% (110/118)
- Patient satisfaction: 87% at mean 4.5 years
- Complications: malunion 12%, nonunion 7%, hardware removal 15%
- Most malunions were asymptomatic or minimally symptomatic
- Revision rate: 8% (mostly for nonunion)
Plate vs Screw Fixation for First MTP Arthrodesis
- Meta-analysis: 16 studies, 1,348 arthrodeses
- Plate fixation: 95% union rate vs screw fixation: 88% union (statistically significant)
- Plate: higher hardware removal rate (18% vs 8%)
- No difference in pain scores or patient satisfaction
- Plate provides superior biomechanical stability
Interposition Arthroplasty - Systematic Review
- Systematic review: 18 studies, various interposition materials
- Overall satisfaction: 60-85% (highly variable)
- Better outcomes in younger patients (under 60 years)
- Inferior to cheilectomy for Grade 1-2 disease
- Inferior to arthrodesis for Grade 3-4 disease
- Limited long-term data (most studies under 5 years follow-up)
Australian Podiatric Medicine Guidelines - Hallux Rigidus
- Conservative management recommended for all grades initially
- Footwear modification and orthotics first-line
- Cheilectomy for Grade 1-2 disease with failed conservative care
- Arthrodesis for Grade 3-4 disease
- Arthroplasty not routinely recommended due to high failure rates
- Multidisciplinary approach including podiatry, physiotherapy, orthopaedics
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Classification and Initial Management (2-3 min)
"A 55-year-old male accountant presents with 2 years of progressive pain and stiffness in his right great toe. Pain is worse with walking, particularly when pushing off. He has tried wider shoes and ibuprofen with minimal relief. On examination, there is a dorsal prominence at the first MTP joint, tenderness on palpation, and dorsiflexion limited to 25 degrees (plantarflexion full). Grind test is positive. Weight-bearing radiographs show a dorsal osteophyte, 60% joint space narrowing, and mild subchondral sclerosis. What is your assessment and management?"
Scenario 2: Surgical Technique - Arthrodesis (3-4 min)
"A 62-year-old female with severe hallux rigidus (Carp Grade 3, over 75% joint space loss, dorsiflexion 10 degrees) has failed conservative management and wants definitive treatment. You plan a first MTP arthrodesis. Walk me through your surgical technique, focusing on achieving optimal fusion position."
Scenario 3: Complication Management (2-3 min)
"A 48-year-old male underwent cheilectomy for Grade 2 hallux rigidus 18 months ago. He returns with recurrent pain and stiffness. Dorsiflexion is now only 20 degrees. Radiographs show progression to Grade 3 disease with near-complete joint space loss and a small residual dorsal osteophyte. How do you manage this patient?"
MCQ Practice Points
Anatomy Question
Q: What is the normal dorsiflexion range of the first MTP joint required for normal gait? A: 65-75 degrees. This range is required for toe-off phase of gait. Hallux rigidus typically reduces this to under 30 degrees, causing compensatory gait alterations (external foot progression angle, lateral weight shift).
Classification Question
Q: What are the key features distinguishing Carp Grade 2 from Grade 3 hallux rigidus? A: Grade 2: 50-75% joint space narrowing, moderate dorsal/lateral osteophytes, 20-50% ROM loss. Treatment: cheilectomy if plantar cartilage OK. Grade 3: Over 75% joint space narrowing, severe osteophytes, subchondral cysts, over 75% ROM loss (under 20 degrees dorsiflexion). Treatment: arthrodesis. The distinction guides surgical decision-making.
Treatment Algorithm Question
Q: What is the critical intraoperative decision point during cheilectomy for Grade 2 hallux rigidus? A: Assessment of plantar cartilage status. If cartilage is preserved on the plantar two-thirds of the joint, proceed with cheilectomy (30% dorsal head resection). If cartilage loss is circumferential, convert to arthrodesis. Do not compromise with inadequate debridement - this leads to poor outcomes.
Surgical Technique Question
Q: What is the optimal fusion position for first MTP arthrodesis? A: VDN mnemonic: Valgus 10-15 degrees (relative to first metatarsal axis), Dorsiflexion 15-20 degrees (relative to ground with foot plantigrade), Neutral rotation. Check alignment with foot on sterile block - hallux should clear ground by 1-2 cm and point between 2nd-3rd toes. Malunion is the most common complication and is position-dependent.
Outcomes Question
Q: What are the evidence-based success rates for cheilectomy vs arthrodesis in hallux rigidus? A: Cheilectomy (Grade 1-2): 80-90% satisfaction at 5 years, 70-80% avoid further surgery at 10 years. Arthrodesis: 90-95% fusion rate, 85-90% patient satisfaction long-term. Arthrodesis has slightly higher satisfaction but sacrifices motion. Both are evidence-based, appropriate procedures when used for correct indications.
Complication Question
Q: What is the most common significant complication of first MTP arthrodesis and how is it prevented? A: Malunion (10-15%) is the most common complication. Prevention requires meticulous intraoperative technique: use sterile block to simulate weight-bearing, check hallux alignment (between 2nd-3rd toes), ensure 15-20 degrees dorsiflexion (1-2 cm ground clearance), confirm 10-15 degrees valgus, fluoroscopy in multiple planes before final fixation. Do not accept suboptimal position.
Australian Context and Medicolegal Considerations
Australian Practice Patterns
- Public system: Conservative management first-line (3-6 months trial)
- Surgical referral: Typically after failed physiotherapy, orthotics, injections
- Wait times: Public system 6-12 months for elective foot surgery
- Private: Faster access, patient choice of surgeon/timing
Australian Guidelines
- Australian Podiatry Association: Conservative-first approach
- RACS Guidelines: Shared decision-making for elective procedures
- ACSQHC: Informed consent including alternatives, risks, outcomes
- Antibiotic prophylaxis: Single dose cefazolin (eTG guidelines)
Medicolegal Considerations
Key documentation requirements:
- Conservative management trial documented (footwear, orthotics, injections, duration)
- Informed consent: procedure options (cheilectomy vs arthrodesis), fusion position (loss of motion), outcomes (satisfaction rates, revision rates), complications (malunion, nonunion, infection, nerve injury)
- Realistic expectations: cheilectomy may fail (15-20% at 10 years), arthrodesis sacrifices motion but reliable pain relief
- Intraoperative decision-making: if converting from cheilectomy to arthrodesis based on cartilage status, document finding and rationale
- Malunion prevention: document intraoperative checks (sterile block, fluoroscopy, alignment confirmation)
Common litigation issues: Malunion (position not verified intraoperatively), infection (antibiotic prophylaxis), nerve injury (medial cutaneous nerve), unrealistic expectations (motion after arthrodesis).
HALLUX RIGIDUS
High-Yield Exam Summary
Key Anatomy
- •First MTP joint: 2-3x body weight in gait, 8x with running
- •Normal dorsiflexion: 65-75 degrees (required for toe-off)
- •Hallux rigidus: Typically under 30 degrees dorsiflexion
- •Dorsal osteophyte: Blocks dorsiflexion, causes impingement pain
Carp Classification
- •Grade 0: Dorsal osteophyte, no JSN = Conservative
- •Grade 1: 20-50% JSN, mild spurring = Cheilectomy
- •Grade 2: 50-75% JSN, moderate spurring = Cheilectomy or Interposition
- •Grade 3: Over 75% JSN, severe changes = Arthrodesis
- •Grade 4: Grade 3 plus hallux valgus/varus = Arthrodesis
Treatment Algorithm
- •Conservative first (all grades): Stiff shoes, orthotics, NSAIDs, injections
- •Cheilectomy: Grade 1-2, plantar cartilage preserved, 80-90% satisfaction
- •Arthrodesis: Grade 3-4, failed cheilectomy, 90-95% fusion rate
- •Arthroplasty: Limited role, high failure rates (20-40% at 10 years)
Surgical Pearls
- •Cheilectomy: Remove dorsal 30% metatarsal head, achieve 60-70° intraop dorsiflexion
- •Arthrodesis position (VDN): 10-15° Valgus, 15-20° Dorsiflexion, Neutral rotation
- •Use sterile block to simulate weight-bearing when checking fusion position
- •Plate fixation: 95% union vs screws 88% (meta-analysis)
- •Intraop cartilage assessment determines cheilectomy vs arthrodesis
Complications
- •Malunion (arthrodesis): 10-15%, most common, position-dependent
- •Nonunion (arthrodesis): 5-10%, smoking major risk factor
- •Recurrent pain (cheilectomy): 15-20% at 10 years, disease progression
- •Hardware irritation: 10-15%, may require removal after union
- •Transfer metatarsalgia: Over-resection or malunion