HALLUX RIGIDUS & DJD Prepared by:

Dr. Abdullah K. Ghafour3rd year IBFMS trainee

Supervised by:Dr. Hamid Ahmed Jaff

INTRODUCTION First MTP joint:

Cam-shaped condylar hinged joint Alignment varies 5 degrees varus to 15

degrees valgus

Normal range of motion 40-100 degrees dorsiflexion 3-45 degrees plantarflexion

INTRODUCTION Hallux rigidus:

A condition characterized by loss of motion of first MTP joint in adults due to degenerative arthritis

second most common condition affecting the big toe after hallux valgus

most common arthritic condition in the foot. females are more commonly affected in all age

groups and is very often bilateral.

PATHOANATOMY primary etiology has not bee determined,

although multiple predisposing factors have been revealed.

acute trauma and repetitive micro-trauma predispose to arthritic changes

anatomic variations of first metatarsal may play a yet unproven role in arthritic predisposition

In adolescents osteochondritis dissecans may led to development of hallux rigidus.

The congenital form usually presents in the teenage years from a predisposing anatomic factor such as flattening or squaring of the metatarsal

PRESENTATION Symptoms;

first ray and 1st MTP pain and swelling worse with push off or forced dorsiflexion of great toe shoe irritation due to dorsal osteophytes and

compression of dorsal cutaneous nerve may lead to paresthesias

pain becomes less severe as the disease progresses

Physical exam; limited dorsiflexion pain with grind test

PRESENTATION Radiographs:

recommended views AP, lateral, and oblique views

findings osteophytes, especially dorsal joint space narrowing subchondral sclerosis and cysts

CLASSIFICATIONCoughlin and Shurnas Classification

  Exam Findings Radiographic FindingsGrade

0Stiffness Normal

Grade 1

mild pain at extremes of motion mild dorsal osteophyte, normal joint space

Grade 2

moderate pain with range of motion increasingly more constant

moderate dorsal osteophyte, <50% joint space narrowing

Grade 3

significant stiffness, pain at extreme ROM, no pain at mid-range

severe dorsal osteophyte, >50% joint space narrowing  

Grade 4

significant stiffness, pain at extreme ROM, pain at mid-range of motion

 same as grade III

CLASSIFICATION

Hattrup and Johnson radiographic classification:

Grade I demonstrates mild to moderate formation of osteophytes with joint preservation.

Grade II is characterized by moderate formation of osteophytes and narrowing of the joint space with subchondral sclerosis.

Grade III is marked by complete loss of joint space.

TREATMENT Nonoperative

NSAIDS, activity modification & orthotics Indications:

grade 0 and 1 disease  activity modifications

avoid activities that lead to excessive great toe dorsiflexion

types of orthotics Morton's extension with stiff foot plate is the mainstay of

treatment stiff sole shoe and shoe box stretching may also be used

Intermittent attacks of pain can be relieved by an intra-articular injection of corticosteroid and local anaesthetic.

TREATMENT Operative

joint debridement and synovectomy

indications patients with acute osteochondral or chondral

defects

TREATMENT dorsal cheilectomy       

indications  grade 1 and 2 disease (controversial) pain with dorsiflexion is an indicator of good results with dorsal cheilectomy shoe wear irritation from dorsal prominence and

pain (ideal candidate) contraindicated when pain located in the mid-range

of the joint during passive motion technique

remove 25-30% of the dorsal aspect of the metatarsal head along with dorsal osteophyte resection

the goal of surgery is to obtain 70% to 90% dorsiflexion intraoperatively

TREATMENT Moberg procedure (dorsal closing wedge

osteotomy of the proximal phalanx): indications

runners with reduced dorsiflexion (60° is needed to run)

failure of cheilectomy to provide at least 30 to 40 degrees of motion

technique increases dorsiflexion by decreasing the plantar

flexion arc of motion

TREATMENT Keller Procedure (resection arthroplasty) 

indications

elderly, low demand patients with significant joint degeneration and loss of motion

contraindicated in patients with pre-existing rigid hyperextension deformity of 1st MTP joint

technique involves removing the base of the first proximal

phalanx risk of hyperextension (cock-up deformity),

weakness with push-off, and transfer metatarsalgia (decreased with capsular interposition)

TREATMENT MTP arthroplasty

indications indications controversial

technique capsular interpositonal arthroplasty gaining

popularity silicone implants are not recommended due to poor

long-term results outcomes

silicone implants may have a good short term satisfaction rate

osteolysis and synovitis cause mid to long term pain and joint destruction

TREATMENT MTP joint arthrodesis

indications grade 3 and 4 disease (significant joint arthritis) most common procedure for hallux rigidus

outcomes 70% to 100% fusion rate 15% of patients experience degeneration of IP joint

after surgery (mostly asymptomatic)

TREATMENT MTP joint arthrodesis with structural bone

graft  indications for structural bone graft

1st MT shortening that cannot be adequately rebalanced with a lesser metatarsal osteotomy (usually shortening > 5 mm) 

significant proximal phalanx bone loss with inadequate remaining bone for fixation without compromising IP joint, 

1st MT shortening with loss of medial support of the 2nd toe predisposing to varus at the 2nd MTP joint. 

TREATMENT Techniques of MTP joint arthrodesis:

dorsal plate with compression screw is biomechanically strongest construct

preferred surgical alignment 10 to 15 degrees of valgus in relation to the metatarsal

shaft 15 degrees of dorsiflexion in relation to the floor

fusion in excessive dorsiflexion causes pain at tip of the toe, over the IP joint, and under the 1st metatarsal with excessive dorsiflexion

fusion in excessive plantar flexion causes increased pressure at the tip of the toe

fusion in excessive valgus increases the risk of IP joint degeneration

REFERENCES • Coetzee J. C., Hurwitz S. R. , [ 2009] Arthritis & arthroplasty.

The foot and ankle , Saunders, an imprint of Elsevier Inc. , Philadelphia, Pennsylvania, USA.

• Solomon L., Warwick D. , Nayagam S.,[2010] Apley’s System of Orthopaedics and Fractures, 9th ed. Hodderarnold comp.,London, UK.

• Miller M. , Thompson S. , Hart J. ,[2012] REVIEW OF ORTHOPAEDICS [PDF], 6th ed. by Saunders, an imprint of Elsevier Inc. , Philadelphia, USA.

• Canale S. , Beaty J. , [2007] Campbell’s Operative Orthopaedics [PDF], 11th ed. By Mosby, An Imprint of Elsevier , Tennessee, USA.

• ORTHOPAEDIC REVIEW [2015] by orthobullets, [PDF], Collected By Islam Gomaa Beltage.

THANKS