Fig. 1 End-stage hallux rigidus (shown in these radiographs) can be treated with dorsal cheilectomy or fusion.
Courtesy of Alexander J. Pappas, MD


Published 10/1/2008
Jennie McKee

Loosening up a stiff toe

Fusion isn’t the only option for end-stage hallux rigidus

What treatments can an orthopaedic surgeon offer a patient with end-stage hallux rigidus? Is hallux metatarsophalangeal (MTP) fusion—a procedure that relieves pain but leaves the patient unable to bend the toe—the only viable surgery? No, according to Alexander J. Pappas, MD, of Strand Orthopaedic Consultants, LLC, in Myrtle Beach, S.C.

Dr. Pappas recommends that orthopaedists consider dorsal cheilectomy, a procedure that has traditionally been used in patients with mild to moderate hallux rigidus.

During his presentation at the American Foot and Ankle Society’s (AOFAS) 24th annual summer meeting, Dr. Pappas reported on the results of a study in which most patients had excellent or very good surgical outcomes after undergoing dorsal cheilectomy for late-stage hallux rigidus.

Collecting data
Dr. Pappas and his colleagues at the OrthoCarolina Foot and Ankle Institute in Charlotte, N.C., performed an Institutional Review Board-approved retrospective review of 273 patients who underwent a dorsal cheilectomy of the first MTP joint between January 2001 and January 2007. After reviewing the patients’ charts and preoperative radiographs, they found 115 patients (121 feet) who met the inclusion criteria of having grade 3 or grade 4 hallux rigidus according to the Coughlin & Shurnas rating system (113 feet were classified as grade 3, and 8 were classified as grade 4).

Researchers were able to contact 91 patients by phone (84 patients with grade 3 and 7 with grade 4 hallux rigidus) at an average of 31.3 months after surgery (range:

8 to 72 months). The average age of the patients was 56 years (range: 20 to 78 years). Participants were asked about level of pain relief, satisfaction, complications, and shoe wear limitations.

Reduced pain, few complications
Sixty-five percent of the patients contacted rated their surgical outcome as excellent or very good, 21 percent said their surgical outcome was good, and 14 percent responded that their outcome was fair or poor.

Improved pain relief was reported by 81 percent of those surveyed, and 69 percent said they had fewer shoe wear limitations than they did before surgery. About one third of the patients required additional procedures: 11 percent required a lateral wedge osteotomy of the proximal phalanx combined with excision of the medial eminence (Akin procedure); 7 percent required dorsal angulation of the proximal phalanx (Moberg procedure), and 15 percent had a combination Moberg-Akin procedure.

Fig. 1 End-stage hallux rigidus (shown in these radiographs) can be treated with dorsal cheilectomy or fusion.
Courtesy of Alexander J. Pappas, MD

Dr. Pappas noted that the complication rate was low.

“We had a 6.6 percent rate of complications,” he said. “Two of the patients required conversion to MTP arthrodesis, two required postoperative injections for persistent pain, one patient developed sesamoiditis, and one had a superficial wound infection that resolved with antibiotics.”

After analyzing this data, Dr. Pappas and his colleagues performed a 5-year follow-up study of the 22 patients from the original survey group who had the longest follow-up time, all of whom had been diagnosed with grade 3 hallux rigidus. In this cohort of patients, 82 percent reported total or improved pain relief, 73 percent rated their satisfaction level as excellent or very satisfied, and 86 percent said they had fewer shoe wear limitations. None of the patients in the subgroup underwent arthrodesis following dorsal cheilectomy.

“We recommend dorsal cheilectomy as a surgical option in the treatment of later stage hallux rigidus (Fig. 1),” stated Dr. Pappas, who said the procedure’s advantages when compared to arthrodesis include “shorter recovery time, no restrictions in shoe wear after surgery, and, theoretically, less stress transmitted to surrounding joints.”

Dr. Pappas noted that not all patients with end-stage hallux rigidus are good candidates for dorsal cheilectomy.

“Patients with pain throughout their hallux MTP range-of-motion (grade 4) are likely best served by arthrodesis,” he said.

Dr. Pappas was the presenter and lead author of the study, “Results of Dorsal Cheilectomy for the Treatment of Advanced Stage Hallux Rigidus.” Co-authors include Robert B. Anderson, MD; Pedro Cosculluela, MD; Florian Nickisch, MD; Bruce Cohen, MD; and W. Hodges Davis, MD.

Jennie McKee is a staff writer for AAOS Now. She can be reached at

Drs. Pappas and Anderson reported ties to Wright Medical Technology, Inc. Dr. Anderson also has ties to DJ Orthopaedics. Dr. Nickisch has ties to Zimmer, Synthes, Medtronic, Biomed, Depuy, and Smith & Nephew. Dr. Cohen has ties to DJ Orthopaedics, Wright Medical Technology, Inc., Arthrex, Inc., and Integra LifeSciences. Dr. Davis has ties to DJ Orthopaedics, Wright Medical Technology, Inc., Arthrex, Inc., and Smith & Nephew. Dr. Cosculluela has nothing to disclose.