Hallux Rigidus

How far to trust it. The grade organises the treatment decision sensibly, and nothing better has replaced it. Its clean link to outcome, however, comes from Coughlin and Shurnas's own series, in which the grade was assigned at the follow-up visit, so its predictive performance has never been tested prospectively. Radiographic grade also correlates poorly with the cartilage found at operation, which is why the final decision is made intraoperatively.

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Where it fits. Hattrup-Johnson is simpler for general communication and appears frequently in the research literature, but it is less used in clinical practice. Coughlin-Shurnas has five grades against three and discriminates more finely between treatments, particularly in Grade 2, where management is most nuanced.

The operation. Cheilectomy preserves the joint. The dorsal osteophyte and the dorsal 25-30% of the metatarsal head are removed to decompress the joint, and it works only while there is healthy plantar cartilage to keep.

Indications

• Coughlin-Shurnas Grade 1-2, mild to moderate arthritis
• A dorsal osteophyte causing impingement
• Preserved plantar cartilage, with loss confined to the dorsal third of the joint
• At least 30 degrees of dorsiflexion remaining
• An active patient who wants to preserve joint motion
• Failed conservative management

Contraindications

• Circumferential cartilage loss, an intraoperative finding
• Severe stiffness, under 20 degrees of dorsiflexion
• Grade 3-4 disease, with the selected Grade 3 exception above
• Sesamoid arthritis

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Outcomes. Coughlin's series reported 92% of 93 cheilectomies successful for pain relief and function at a mean 9.6 years, but that is one surgeon's retrospective practice with the grade assigned at follow-up, so treat it as the upper bound. Pain relief is predictable and the gain in range is variable. Durability is not quantified by any source cited here. A failed cheilectomy can proceed to arthrodesis without compromise.

The idea. A biological spacer between the arthritic joint surfaces, to maintain motion and reduce pain. The indications are controversial:

• Coughlin-Shurnas Grade 2, moderate disease
• A young, active patient who wants to preserve motion
• Inadequate cartilage for cheilectomy alone
• A patient who refuses arthrodesis

Contraindications

• Grade 3-4 disease, where arthrodesis is superior
• Low functional demand, where arthrodesis is simpler
• Inflammatory arthropathy

Capsular interposition. After cheilectomy the dorsal capsule is folded plantarly between the joint surfaces and secured with suture anchors. It is autologous with no donor site, a theoretical advantage, but the evidence is limited.

Tendon interposition. Extensor hallucis brevis, the most common choice, or gracilis allograft is harvested, rolled into a ball, placed in the joint space and secured to the metatarsal head with suture anchors. It gives more bulk than capsule.

Synthetic spacer. Acellular dermal matrix is commercially available, with concerns over cost, limited long-term data and a potential inflammatory response.

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Evidence. High-quality evidence is limited. Small studies show 60-80% satisfaction at mid-term (2-5 years), inferior to cheilectomy for Grade 1-2 and to arthrodesis for Grade 3. The one comparative series cited here, Lau and Daniels, used interposition in Grade 3 disease, and its authors regard it as a salvage procedure. Its role is unclear: consider it for the Grade 2 patient who wants to keep motion and accepts a higher risk of re-operation. Most surgeons go directly from a failed cheilectomy to arthrodesis rather than to interposition.

The gold standard for advanced disease. Fusion trades motion for reliable, durable pain relief.

Indications

• Coughlin-Shurnas Grade 3-4, advanced arthritis
• Failed cheilectomy or arthroplasty
• Circumferential cartilage loss
• Inflammatory arthropathy (rheumatoid, psoriatic)
• Severe pain with functional limitation

Relative contraindications

• A young, high-demand athlete: discuss the loss of push-off power
• Ipsilateral ankle arthrodesis, which limits compensation
• An expectation of normal gait

Position is everything. The hallux is fused in 10-15 degrees of valgus relative to the first metatarsal, 15-20 degrees of dorsiflexion relative to the ground with the foot plantigrade, and neutral rotation. Too much dorsiflexion (over 20 degrees) or too little (under 15 degrees) both cause symptomatic malunion, and excessive dorsiflexion cannot be compensated and makes shoe wear difficult.

The dorsiflexion debate. The dorsiflexion target is not settled: the AO technique guidance on this page aims for 10-15 degrees, and the functional reference, the plantigrade foot on a block, matters more than the absolute number.

Fixation. A dorsal or dorsomedial locking plate, giving stable compression with a low profile, has been the preferred construct on the grounds of superior biomechanics. Crossed lag screws (2-3), with an optional dorsal plate, use less hardware but carry a risk of malposition. The meta-analysis of 1,035 toes found no significant difference in union between the two, only marginally faster fusion with the plate, so a plate cannot be chosen for a lower nonunion rate; bone quality, cost and preference decide.

Outcomes. In the randomised trial cited on this page all 38 arthrodeses united, at a mean dorsiflexion of 26 degrees and with few complications. Pain relief is predictable and reliable; motion is sacrificed, but gait normalises with minor adaptations. Malunion is the complication that matters most, because position is everything; nonunion and hardware irritation rates are not quantified by any source cited on this page.

The types. A hemiarthroplasty replaces the metatarsal head or the phalangeal base, not both. Total joint replacement uses a metal-polyethylene implant, or silicone, as in the radiograph below.

The theory. Replacement preserves motion, avoids the concerns of fusion position, and could allow bilateral procedures.

The reality. Implant loosening runs at 20-30% at 5 years and failure at 20-40% at 10 years. Synovitis and osteolysis follow, especially with silicone, and revision is difficult because of significant bone loss, which also makes conversion to arthrodesis challenging. Unlike hip and knee arthroplasty, current first MTP implants lack proven durability, while arthrodesis gives 85-90% satisfaction.

Where that leaves it. First MTP arthroplasty is not recommended as routine treatment, and most foot and ankle surgeons avoid it.

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Position. Supine on a standard table, with a bump under the ankle to rotate the leg internally and expose the medial side of the first MTP joint. The other leg lies flat or in a frog-leg position. The same set-up and approach serve cheilectomy and arthrodesis.

Tourniquet. Thigh or ankle; the ankle is preferred for better access. Exsanguinate with an Esmarch or by elevation, and inflate to 250-300 mmHg at the ankle or 100 mmHg above systolic at the thigh.

Draping. Free-drape the foot and ankle from the toes to mid-calf, with room for the C-arm to take AP and lateral views of the first MTP joint.

The approach

1. Incision: a longitudinal dorsomedial incision along the medial aspect of the first MTP joint, from the proximal phalanx to mid-metatarsal, slightly curved along the medial border of the hallux; a dorsal longitudinal incision is also used for cheilectomy. 3-4 cm for cheilectomy, 4-5 cm for arthrodesis.
2. Superficial dissection: identify and protect the dorsal sensory nerves, the medial dorsal cutaneous nerve, which branches at the level of the incision, and the lateral cutaneous branch. Retract gently or keep them in the flap, then incise the deep fascia longitudinally.
3. Capsulotomy: a longitudinal incision over the dorsum of the joint, reflected medially and laterally, with the capsule preserved for repair.
4. Exposure: plantarflex the hallux to expose the dorsal metatarsal head for cheilectomy, or the whole joint for arthrodesis, with retractors protecting the soft tissues.

1. Assess the cartilage. Plantarflex the hallux maximally to see the whole metatarsal head. If cartilage is preserved on the plantar two-thirds, proceed with cheilectomy; if erosion is circumferential, convert to arthrodesis.
2. Mark the resection. Mark the dorsal 25-30% of the metatarsal head with electrocautery or a marking pen. Lateral fluoroscopy should place the line at the junction of the dorsal and middle thirds.
3. Resect. Remove the dorsal metatarsal head from medial to lateral with an oscillating saw or osteotome, in a single cut parallel to the plantar surface or several passes, making sure the whole dorsal ridge goes. Remove the dorsal phalangeal osteophytes the same way and smooth the edges with a rongeur.
4. Check the sesamoids. If their articulation is arthritic, debride the osteophytes. Do not excise the sesamoids, which destabilises the joint.
5. Release and move. Release the dorsal capsular adhesions and manipulate gently to 60-70 degrees of dorsiflexion, confirming the gain before closure. Forced manipulation risks fracture and damage to the plantar cartilage.

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Getting the resection right. The key to success is adequate but not excessive resection, 25-30% of the dorsal head, with the plantar cortex preserved because it is critical for stability. Under-resection leaves impingement and recurrent symptoms. Over-resection, beyond 30%, risks metatarsal fracture, instability and transfer metatarsalgia. Confirm the level on fluoroscopy before closing, and if plantar disease has been missed, expect a poor outcome and consider conversion.

1. Prepare the joint. Remove all cartilage to healthy, bleeding subchondral bone. Planar cuts with an oscillating saw give flat surfaces and easier positioning; cup-and-cone reaming gives a congruent fit and rotational stability. Use a curette or burr on sclerotic bone until it bleeds.
2. Position provisionally. Set the valgus, dorsiflexion and neutral rotation described under Management, with plantar cortical contact at the apex for compression, and hold with pointed reduction clamps or K-wires.
3. Confirm alignment. With the foot plantigrade on a sterile block, the hallux should clear the ground by 1-2 cm and its tip should point between the 2nd and 3rd toes. AP, lateral and oblique fluoroscopy confirms the valgus and dorsiflexion angles; adjust if needed.
4. Fix. A dorsal or dorsomedial locking plate applying compression across the fusion, with 2-3 bicortical screws on each side; or 2-3 crossed lag screws, medial-lateral and dorsal-plantar, with an optional neutralisation plate. Compression is mandatory. Check screw length to avoid plantar penetration, avoid short screws, which risk pull-out, and countersink to keep hardware low-profile.
5. Verify. Final fluoroscopy in all views: valgus on the AP, dorsiflexion on the lateral, rotation on the oblique. Remove the K-wires and clamps, stress gently to confirm stability, and ensure adequate compression.

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1. Drain: typically not needed for cheilectomy or arthrodesis; consider one after extensive soft-tissue dissection or with a bleeding diathesis.
2. Capsule: after cheilectomy, repair it loosely with 2-0 absorbable suture, because a tight closure restricts dorsiflexion. After arthrodesis, repair it if possible; arthritis often leaves inadequate capsular tissue.
3. Skin: irrigate; 3-0 absorbable subcutaneous sutures, then subcuticular 4-0 Monocryl or interrupted nylon, and Steri-Strips.
4. Dressing: a soft gauze dressing. After cheilectomy, a wooden or post-operative shoe for 2 weeks with immediate weight-bearing; after arthrodesis, a posterior slab or CAM boot, non-weight-bearing.

Union depends on the patient complying with the protected weight-bearing protocol.