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Hallux rigidus is defined as end-staged arthrosis of the first metatarsophalangeal joint. Although the literature supports arthrodesis as being the gold standard for the treatment of end-staged hallux rigidus, there are several other treatments available that can either prolong the life of the remaining joint or artificially mimic the original biomechanics by replacing a portion of or the entire joint with the added advantage of preserving joint mobility. There are several new and emerging joint preservative techniques that may delay or prevent the need for a joint-destructive procedure, such as arthrodesis or arthroplasty., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction To date, there is no unified approach to the choice of tactics in surgical treatment of osteoarthritis of the first metatarsophalangeal joint (OA of the first MTP joint). On the other hand, it is known that the technique of autologous matrix-induced chondrogenesis has been successfully used for osteochondral defects in the hip, knee and ankle joints. Therefore, we have proposed to use this technique in the treatment of patients with OA of the first MTP joint. Purpose To study the possibility of surgical treatment of patients with OA of the first MTP joint with the use of chondroplasty utilizing the technique of autologous matrix-induced chondrogenesis, to demonstrate the immediate and mid-term results of such operations. Materials and methods Chondroplasty was performed in 15 patients (16 feet) with OA of the first MTP joint. The examination determined the range of motion in of the first MTP joint; the condition was assessed according to such scales as VAS for pain, AOFAS, FFI. Chondroplasty in of the first MTP joint was performed with the technique of induced chondrogenesis using a collagen matrix. The results of the operations were evaluated after 3, 6 and 12 months. Results As early as 3 months after the operation, there was a marked significant increase in the range of motion and a decrease in pain of the first MTP joint. Moderate positive dynamics were observed after 6 and 12 months. Conclusion The results of the operations showed that chondroplasty of the first MTP joint is an effective method of surgical treatment that provides pain relief and significantly improves the quality of life of patients with OA of the first MTP joint. However, it is necessary to study long-term results.

Hallux rigidus can be treated with a proximal hemiarthroplasty (HemiCAP®) to preserve the motion in the first metatarsophalangeal joint and reduce pain. This study examines the functionality, and survival rates of HemiCAP® implants, with or without a dorsal flange. One hundred and five patients were treated with a HemiCAP® (N = 116 HemiCAPs®) between 2006 and 2014. Revision rates, arthrosis score, hallux valgus (HV), intermetatarsal (IM), distal metaphyseal articular angle (DMAA), visual analog scale (VAS) (1-10 points), American Orthopaedic Foot and Ankle Score (AOFAS) MTP-IP (AOFAS 0-100 points), SF-12, range of motion (ROM), and radiographs were analyzed pre- and postoperatively. Statistics: Kaplan-Meier survival analysis, Cox-regression, and paired t tests. At 2, 4, and 6 years, the implant survival was 87%, 83%, and 81%, respectively. All revised due to pain. Dorsal flange, gender, arthrosis, HV, IM, and DMAA did not influence the results. At the mean 5-year follow-up (n = 47) median (range) dorsal ROM was 45° (10°-75°), AOFAS was mean 87.2 ± 10.8, VAS was 2 ± 1.6, and SEFAS was 42 ± 6 points. The dorsal flange made no significant difference for ROM or patient-reported outcome measures compared to the HemiCAP® with no dorsal flange. Twenty-three patients with preoperative data were re-examined, and preoperative dorsal ROM mean difference (confidence interval [CI]) increased 20.7° (13.9°-27.4°), VAS decreased with a mean difference (CI) of −4.7 (−5.8 to 3.5), and AOFAS increased with a mean difference (CI) 26.2 (20.2-32.2) (for all p <.001). The 6-year survival rate of the HemiCAP® implant was 81%. The design change to dorsal flange was not evident clinically. Unrevised patients had significantly less pain, greater ROM, and better foot and ankle function than preoperatively. [ABSTRACT FROM AUTHOR]

At present, there is no general approach to choosing surgical tactics for hallux rigidus. Many surgical procedures are used to treat osteoarthritis (OA) of the first metatarsophalangeal joint (FMPJ), which are relevant at different stages of the disease. Nevertheless, this fact also suggests that all proposed methods have one or other disadvantages. At the same time, FMPJ arthrodesis that relieves pain and is functionally inferior to joint-sparing surgery remains the gold standard. However, due to the fact that not only persons over the age of 50 years, but also younger patients often suffer from FMPJ OA, the most non-damaging option of joint-sparing surgery is cheilectomy with chondroplasty of the FMPJ, which allows restoration of painless joint motions, thus sparing the anatomy of the foot. Chondroplasty using the authologous matrix-induced chondrogenesis (AMIC®) technique for knee, hip, and ankle cartilage defects is described. There are no reports on FMPJ chondroplasty with the AMIC method in either Russian or foreign literature.

Intra-articular steroid injection is a common treatment modality for relief of pain and inflammation associated with degenerative joint disease. Use of injectable steroid preparations is widely accepted as safe and effective for the treatment of osteoarthritis of the 1 st metatarsophalangeal joint. Despite the frequency of use, literature specific to pathology of the 1 st metatarsophalangeal joint is sparse. The aim of this systematic review was to determine if good quality research exists to enable clinicians to adopt an evidenced based approach to corticosteroid injection of the 1 st metatarsophalangeal joint. Despite the frequency of use, this review found no high quality studies that support the use of intra-articular corticosteroid injection of the 1 st metatarsophalangeal joint in osteoarthritis. [ABSTRACT FROM AUTHOR]

Hallux rigidus is a painful condition of the great toe characterized by restriction of the metatarsophalangeal range of motion and progressive osteophyte formation. Many etiologies have been postulated including excessive length of the first ray, trauma, abnormally elevated first metatarsal and a positive family history. However, most cases are likely idiopathic. Plain radiographs are used to grade the severity of hallux rigidus. The more comprehensive grading is represented by Coughlin and Shurnas' system that introduced a four-grade classification. When nonoperative treatment fails to provide relief, surgery should be performed. The goal of surgery is to relieve pain, maintain stability of the first metatarsophalangeal joint and improve function and quality of life. Operative treatments can be divided into joint sparing (e.g., cheilectomy with or without associated osteotomies) versus joint sacrificing (e.g., arthroplasty or arthrodesis). There are a variety of osteotomies available for treatment of hallux rigidus (phalanx and/or metatarsal osteotomies). Newer techniques of interpositional arthroplasty as well as new hemi-arthroplasty designs, including synthetic cartilage implants, offer promising options for preservation of motion. The choice of procedure is based on the condition of the joint, patient's goals and expectations of the surgical outcome, and patient's motivation. This article discusses various procedures along with clinical outcomes and complications. The advantages and disadvantages of each procedure are discussed. [ABSTRACT FROM AUTHOR]

Abstract Dorsiflexory phalangeal osteotomy has been shown to be an effective treatment for mild to moderate hallux rigidus in short- to medium-term follow-up studies. It is speculated that the procedure alters the mechanical function of the joint and reduces the demand for hallux dorsiflexion by elevating the proximal phalanx into a more dorsiflexed position. However, it has been demonstrated that the first metatarsophalangeal (MTP) joint space and joint range of motion are reduced by the procedure, calling into question the long-term effectiveness of the operation. This study reviewed 27 dorsiflexory phalangeal osteotomy cases at an average of 11 years postoperatively. Twenty-one (77%) patients reported that they were completely satisfied with the results of their surgery; 4 (15%) patients reported that they were satisfied with reservations; and 2 (7%) patients reported that they were dissatisfied. The patients who were satisfied with reservations complained of interphalangeal (IP) joint pain or stiffness. One patient developed second MTP joint metatarsalgia after surgery, and in 1 patient first MTP joint pain returned at 24 months after surgery. One dissatisfied patient complained of second MTP joint metatarsalgia, and a second patient required revision excisional arthroplasty for continued joint pain. Ten patients (38%) reported stiffness of the first MTP joint, but only 2 patients reported any restriction of activity. Footwear restrictions were reported by 15 (58%) patients preoperatively and by 9 (35%) patients at final follow-up. Dorsiflexory phalangeal osteotomy maybe a reliable long-term treatment for grade II or moderate hallux rigidus and is a safe and effective alternative to first MTP joint fusion in joints where movement is still present and joint cartilage is viable. [ABSTRACT FROM AUTHOR]

Background: First metatarsophalangeal joint (MTPJ1) hemiarthroplasty using a novel synthetic cartilage implant was as effective and safe as MTPJ1 arthrodesis in a randomized clinical trial. We retrospectively evaluated operative time and recovery period for implant hemiarthroplasty (n=152) and MTPJ1 arthrodesis (n=50).Methods: Perioperative data were assessed for operative and anaesthesia times. Recovery and return to function were prospectively assessed with the Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) subscales and SF-36 Physical Functioning (PF) subscore.Results: Mean operative time for hemiarthroplasty was 35±12.3min and 58±21.5min for arthrodesis (p<0.001). Anaesthesia duration was 28min shorter with hemiarthroplasty (p<0.001). At weeks 2 and 6 postoperative, hemiarthroplasty patients demonstrated clinically and statistically significantly higher FAAM Sport, FAAM ADL, and SF-36 PF subscores versus arthrodesis patients.Conclusion: MTPJ1 hemiarthroplasty with a synthetic cartilage implant took less operative time and resulted in faster recovery than arthrodesis.Level Of Evidence: III, Retrospective case control study. [ABSTRACT FROM AUTHOR]

Purpose: Treatment options for hallux rigidus include several conservative and surgical measures. The aetiology leading to the disease has not sufficiently been examined so far. Materials and methods: We analysed the anatomical configuration of the first metatarsal head of 120 metatarsal bones of different collectives aiming to find a possible correlation between the geometry of the first metatarsophalangeal joint and manifestation of hallux rigidus. Wet human cadaveric specimens and macerated dry specimens served as material. The relevant parameters used for analysis were an axis running through the metatarsal head, the anatomical longitudinal axis, and the radius of curvature of the first metatarsal bone. Results: A significant difference was found in the radius of curvature of osteoarthritic and healthy subjects. Using the binary logistic regression, we were able to predict the probability of an occurence of hallux rigidus in dependence of the radius of curvature. Furthermore, we were enabled to calculate a correct prediction for the appearance of osteoarthritis in 85 % of the healthy subjects, and 73 % of the osteoarthritic subjects. Conclusions: A consolidated view of the factors indicates that persons with a high risk for the appearance of hallux rigidus should be identified by measuring the radius of curvature in conventional radiographs and preventive measures to postpone the occurrence of clinically relevant hallux rigidus considered. [ABSTRACT FROM AUTHOR]

Abstract: Isolated periarticular osteotomy of the first metatarsal has been proposed for treatment of hallux rigidus due to the perceived ability to “decompress” the first metatarsophalangeal joint through axial shortening, as well as plantar displacement of the first metatarsal head to correct purported elevation. Additionally, isolated periarticular osteotomy of the first metatarsal has been proposed for treatment of hallux rigidus because of the perceived safety and efficacy. Furthermore, it has been proposed that undergoing isolated periarticular osteotomy of the first metatarsal does not prevent the ability to perform revision surgery. The author undertook a systematic review of electronic databases and other relevant sources to identify material relating to the clinical outcomes and need for surgical revision after isolated periarticular osteotomy of the first metatarsal for hallux rigidus. Information from peer-reviewed journals, as well as from non-peer–reviewed publications, abstracts and posters, and unpublished works, was also considered. In an effort to procure the highest quality studies available, studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated periarticular osteotomy of the first metatarsal for hallux rigidus, involved a prospective study design, included some form of objective and subjective data analysis, evaluated patients at a mean follow-up ≥12 months’ duration, and included details of complications requiring surgical intervention. Four studies involving 93 isolated periarticular osteotomies of the first metatarsal followed up for a weighted mean of 18.6 months were identified that met the inclusion criteria. Peak dorsiflexion range of motion of the first metatarsophalangeal joint for the entire cohort of 93 patients increased 10.4°. The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scoring Scale for the entire cohort of 93 patients increased 39 points from a weighted mean of 47.2 preoperatively to 86.2 postoperatively. For the two studies that included it, complete satisfaction or satisfaction with reservations was reported in only 55/75 (73.3%) patients, with the remainder being dissatisfied. A total of 21 (22.6%) procedures underwent surgical revision in the form of hardware removal (n = 8), lesser metatarsal surgery for intractable postoperative metatarsalgia (n = 7), no mention of revision procedure (n = 3), Keller resection arthroplasty (n = 2), and treatment of infection with revision of non-union (n = 1). Two studies specified the grade of hallux rigidus that underwent revision surgery after isolated periarticular osteotomy of the first metatarsal as follows: grade I, 16.7% (n = 3/18) and grade II, 30.5% (n = 18/59). Finally, a total of 30.5% (n = 18/59) of patients developed postoperative metatarsalgia or stress fracture. Additional prospective studies involving validated subjective and objective outcome measurement tools with computerized gait analysis and long-term follow-up after isolated periarticular osteotomy of the first metatarsal for the various grades of hallux rigidus, as well as with comparison with isolated cheilectomy and Valenti arthroplasty, would be beneficial. Based on the high incidence of complications until these studies can be completed, routine use of isolated periarticular osteotomy of the first metatarsal for hallux rigidus should be performed with caution or not at all. [Copyright &y& Elsevier]

Isolated cheilectomy has been proposed for treatment of hallux rigidus due to the perceived safety, efficacy, and ability to revise with repeat cheilectomy, implant or interpositional arthroplasty, or arthrodesis. A systematic review was undertaken to better understand the need for surgical revision after isolated cheilectomy for hallux rigidus. Studies were eligible for inclusion only if they involved consecutively enrolled patients undergoing isolated cheilectomy or involved revision surgery of the first metatarsophalangeal joint after isolated cheilectomy, evaluated patients at mean follow-up ≥ 12 months'' duration, and included details of complications. Twenty-three studies, describing 706 cheilectomies, met the inclusion criteria, with 62 (8.8%) undergoing surgical revision in the form of arthrodesis (n = 23), no mention of revision procedure (n = 17), interpositional arthroplasty (n = 13), silicone implant arthroplasty (n = 4), Keller resection arthroplasty (n = 3), or repeat cheilectomy (n = 2). Twelve studies specified the grade of hallux rigidus as: 103 (19.9%) grade 1, 210 (40.6%) grade II, 189 (36.6%) grade III, and 15 (2.9%) grade IV. Six studies indicated the number of cheilectomies that required revision surgery as: 2 (20%) grade I, 8 (14.8%) grade II, 12 (9.1%) grade III, and 5 (55.6%) grade IV. These results make clear the low incidence of revision surgery after cheilectomy for hallux rigidus. Therefore, cheilectomy should be considered a first-line surgical treatment for hallux rigidus. There remains a need for methodologically sound prospective cohort studies that focus on the use of cheilectomy for specific grades of hallux rigidus. [Copyright &y& Elsevier]

The general consensus regarding the postoperative management of patients who have undergone first metatarsophalangeal joint arthrodesis is to maintain non–weight bearing for 4 to 6 weeks. However, a number of studies indicate that immediate postoperative weight bearing does not result in a higher rate of nonunion. A retrospective case series investigation was performed to evaluate the fusion rate of first metatarsophalangeal joint arthrodesis using various forms of pin and wire fixation, and a postoperative protocol that involved immediate weight bearing with a padded surgical shoe. The impetus behind allowing immediate postoperative weight bearing stems from the desire to avoid difficult non–weight-bearing forms of ambulation in patients at risk for falling, and to enhance postoperative rehabilitation in patients at risk for other joint maladies, as in those suffering with rheumatoid and other polyarticular forms of arthritis. A total of 22 fusions (20 patients) were reviewed. Nonunion developed in 2 feet (9.1%), and a delayed union occurred in 1 additional foot (4.55%), for a total complication rate of 13.64% (3/22 cases) and a fusion rate of 86.36%. The remaining patients demonstrated radiographic consolidation of the arthrodesis. A crude rough comparison to previously published reports, wherein weight bearing was initiated anywhere from immediately to up to 2 weeks postoperative, showed that the rate of fusion observed in the patients described in this report was similar. This study demonstrated that immediate ambulation following first metatarsophalangeal joint fusion with wire fixation was safe and effective. Level of Clinical Evidence: 4 [Copyright &y& Elsevier]

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First metatarsophalangeal joint hemi-implant arthroplasty is commonly used for 1-sided degenerative joint disease. This study examined outcomes in patients that underwent hemi-arthroplasty using the BioPro® hemi-implant. Twenty-three of 30 patients completed the 12-month follow-up between October 2001 and June 2003. Repeated measures multivariate analysis of covariance was used to consider the influence of the implant on a number of dependent variables, while controlling for the amount of first metatarsal head cartilage degeneration. The average amount of first metatarsal head cartilage degeneration visualized intra-operatively was 71.8% ± 21.7%. From the preoperative to postoperative periods, the average hallux abductus angle went from 12.6° ± 6.5° to 10.2° ± 5.3° (P = 0.521), the average first intermetatarsal angle went from 11.0° ± 2.3° to 10.5° ± 2.0° (P = 0.434), the average first metatarsal declination angle went from 18.5° ± 4.1° to 18.3° ± 4.1° (P = 0.297), the average ACFAS score went from 41.2 ± 11.6 to 80.4 ± 8.8 (P = 0.003), average dorsiflexion went from 12.6 ± 12.4 to 50.0 ± 8.7 (P = 0.009), and average plantarflexion went from 8.0 ± 8.0 to 17.5 ± 6.7 (P < 0.001). Despite the presence of first metatarsal head cartilage degeneration, the ACFAS outcome score and the range of motion improved following implant arthroplasty, and these findings support the use of this procedure as a useful salvage intervention even in patients with pre-existing double-sided first metatarsophalangeal joint disease. Level of Clinical Evidence: 4 [Copyright &y& Elsevier]