Fig. 1 A, Preoperative radiograph demonstrating grade 4 hallux rigidus. B, Six-month postoperative radiograph following soft-tissue interposition arthroplasty; the patient is back to jogging and aggressive exercise.
Courtesy of Michael J. Coughlin, MD

AAOS Now

Published 10/1/2016
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Michael J. Coughlin, MD; Elizabeth H. Coughlin, MSN, NP-C

Hallux Rigidus in the Athlete

Hallux rigidus (degenerative arthritis of the great toe metatarsophalangeal [MTP] joint) is a common source of pain and dysfunction in the athletic population. Often, conservative methods such as a stiffer-soled shoe, a carbon fiber insert beneath a custom or prefabricated orthotic, and intermittent NSAIDs can mitigate symptoms and enable an athlete to continue with sporting activities.

However, some patients may continue to have symptoms that require surgical intervention. The magnitude of degenerative changes at the first MTP joint informs the selection of surgical technique. Degeneration can be graded by four stages, with the first two stages characterized by mild swelling, restricted motion, radiographic flattening of the joint, and early spur formation.

As the arthritis progresses over time, joint narrowing, large osteophyte formation, and restricted motion of greater than 50 percent occurs. This condition may be amenable to a joint débridement (cheilectomy), which can result in improved joint motion and reduced swelling and pain with athletic activities such as running. With more extensive degeneration, an MTP joint arthrodesis has been the treatment of choice. Unfortunately, although this reduces pain, in many cases it leads to further joint stiffness and reduced or modified athletic activities.

The concept of interposition arthroplasty for severe hallux rigidus has been introduced with mixed results. However, the use of aggressive joint débridement and the placement of an acellular dermal graft has been reported with encouraging results. The dermal graft is believed to provide a regenerative tissue matrix for fibrous tissue at the metatarsal/phalangeal articulation. The sesamoid articulation is also addressed with the tubular allograft that covers the metatarsal head in a circumferential fashion.

This method enables maintenance of joint motion because it combines the soft-tissue interposition with an aggressive cheilectomy or actual reaming of the metatarsal articular surface back to subchondral bone. Early motion may be initiated at 3 weeks following surgery, with return to sporting activity at 8 to 12 weeks following surgery. In one report of nine patients, pain was markedly reduced and function improved at a mean 1 year follow-up. Our personal experience is similar, with gratifying results at 1 to 2 years following surgery.

This technique differs markedly from a Keller resection arthroplasty, in which the intrinsic insertions are released from the base of the proximal phalanx, leading to substantial weakening of the first ray. The interposition technique leaves the arthrodesis option open should it fail to improve motion or relieve joint pain.
For younger athletic patients who wish to maintain an active lifestyle, cheilectomy or joint interposition arthroplasty may provide an alternative to joint fusion.

Treatment protocol FAQs

  1. Who is the ideal patient for these procedures?

Patients with less severe arthrosis of the first MTP joint (Grades 1, 2, or 3) are candidates for a cheilectomy. Elite athletes who have restricted motion and pain with severe hallux rigidus are also candidates for a cheilectomy. Younger, more athletic patients with more severe arthritis (Grade 4) are candidates for an arthrodesis or a soft-tissue interposition arthroplasty. Those who prefer to avoid the stiffness associated with a fused first MTP joint may consider a soft-tissue interposition arthroplasty.

  1. What conservative treatment should a patient try prior to consideration of a cheilectomy or joint interposition arthroplasty?
Fig. 1 A, Preoperative radiograph demonstrating grade 4 hallux rigidus. B, Six-month postoperative radiograph following soft-tissue interposition arthroplasty; the patient is back to jogging and aggressive exercise.
Courtesy of Michael J. Coughlin, MD
Michael J. Coughlin, MD and Elizabeth H. Coughlin, MSN, NP-C

Both changes in shoe wear and orthotic measures may benefit patients with early hallux rigidus. A stiffer-soled shoe that diminishes forefoot motion and full-length orthotics with a graphite or carbon fiber insole may allow continued athletic activity.

  1. Are there any patients who should not be considered for these procedures?

The lack of long-term follow-up on soft-tissue interposition arthroplasty makes it questionable for higher-level athletes. A patient with more severe arthritis may have limited gain from a cheilectomy. Patients who require motion of the great toe joint, especially yoga enthusiasts, may find a first MTP arthrodesis limits their activities.

  1. What are the advantages and disadvantages when comparing a cheilectomy and a joint interposition arthroplasty?

A cheilectomy removes peripheral joint osteophytes to allow greater joint excursion. In the presence of substantial chondrolysis of the joint surface, motion may be painful and limited even after a cheilectomy; thus it is contraindicated in the presence of more severe disease. In this situation, either an arthrodesis or soft-tissue interposition arthroplasty addresses the more severe joint arthritis.

  1. Are these procedures surgical options for all athletic individuals with hallux rigidus or just runners who experience significant hallux rigidus?

Typically these procedures are used for younger athletic patients who desire or require motion in the great toe. An MTP joint arthrodesis substantially reduces joint pain and has high patient satisfaction levels in those who have become used to restricted motion or whose activities do not require joint motion. Runners may accept a joint arthrodesis and can do well with this procedure. Early diagnosis of hallux rigidus often allows a cheilectomy to be the preferable procedure. Most patients can be treated with cheilectomy early on and arthrodesis for more severe disease. The patient with Grade 4 disease may opt for a soft tissue interposition to maintain motion; if it fails, a joint arthrodesis is still a viable option.

  1. What is the postoperative regimen for these procedures?

The foot is wrapped in a gauze-and-tape compression dressing, which is changed every few days. Passive and active range of motion may be initiated 3 to 4 days following surgery. Full weight-bearing ambulation on the outside of the operated foot is allowed during the first week, and plantigrade ambulation is initiated at 3 weeks following surgery.

Postoperative swelling typically diminishes by the third week, and dressings may be discontinued at 6 weeks following surgery. Return to more aggressive activity depends upon pain, swelling, and soft tissue healing. Usually, brisk walking is allowed at 6 weeks after surgery, and full running activity is acceptable at 12 weeks following surgery.

Michael J. Coughlin, MD, is an orthopaedic surgeon practicing at the University of California San Francisco and director of the Coughlin Foot and Ankle Clinic at Saint Alphonsus Hospital in Boise, Idaho. He is a past president of the American Orthopaedic Foot and Ankle Society and the International Federation of Foot and Ankle Societies.

Elizabeth Coughlin is a registered nurse and a candidate in the masters of science in nursing program at Emory University in Atlanta.

References:

  1. Coughlin MJ, Shurnas PS: Hallux rigidus: Demographics, etiology, and radiographic assessment. Foot Ankle Int 2003;24:731–743.
  2. Coughlin MJ, Shurnas PS: Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg Am 2003;85:2072–2088.
  3. Coughlin MJ, Shurnas PS: Hallux rigidus. J Bone Joint Surg Am 2004;86(Suppl 1[Pt 2]):119–130.
  4. Hamilton WG, O'Malley, MJ, Thompson FM, Kovatis PE: Roger Mann Award 1995. Capsular interposition arthroplasty for severe hallux rigidus. Foot Ankle Int 1997;18:68–70.
  5. Coughlin MJ, Shurnas PS: Soft-tissue arthroplasty for hallux rigidus. Foot Ankle Int 24(9):661–672, 2003.
  6. Barca F: Tendon arthroplasty of the first metatarsophalangeal joint in hallux rigidus: Preliminary communication. Foot Ankle Int 1997;18:222–228.
  7. Berlet, GC; Hyer, CF; Lee, TH, et al.: Interpositional arthroplasty of the first MTP joint using a regenerative tissue matrix for the treatment of advanced hallux rigidus. Foot Ankle Int 2008;29:10–21.