quantitative review of operative management of hallux rigidus · quantitative review of operative...

Quantitative review of operative management

of hallux rigidus

Nicola Maffulli†*, Rocco Papalia‡, Alessio Palumbo‡, Angelo Del Buono‡, andVincenzo Denaro‡

†Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry,Mile End Hospital, 275 Bancroft Road, E1 4DG London, UK, and ‡Department of Orthopaedicand Trauma Surgery, Campus Biomedico University of Rome, Via Alvaro del Portillo, Rome, Italy

Surgical techniques for the management of hallux rigidus include cheilectomy,

Keller resection arthroplasty, arthrodesis, Silastic implantation, phalangeal or

metatarsal osteotomy, capsular arthroplasty, partial or total joint replacement,

interposition arthroplasty. However, the optimal management is controversial.

We performed a comprehensive search of CINAHL, Embase, Medline and the

Cochrane Central Registry of Controlled Trials, from inception of the database to

2 November 2010. Sixty-nine articles published in peer reviewed journals were

included in this comprehensive review. Cheilectomy and first metatarsal or

phalangeal corrective osteotomy may provide better outcome for patients with

early and intermediate hallux rigidus (Stages I–II), while arthrodesis or

arthroplasty are indicated to manage more severe conditions. The Coleman

Methodology Score showed great heterogeneity in terms of study design,

patient characteristics, management methods and outcome assessment and

generally low methodological quality. Definitive conclusions on the use of these

techniques for routine management of patients with hallux rigidus are not

possible. Given the limitations of the published literature, especially the

extensive clinical heterogeneity, it is not possible to compare outcomes of

patients undergoing different surgical procedures and determine clear

guidelines. To assess whether benefits from surgery, validated and standardized

measures should be used to compare the outcomes of patients undergoing

standard surgical procedures. There is a need to perform appropriately powered

randomized clinical trials of using standard diagnostic assessment, common

and validated scoring system comparing reported outcomes and duration of

follow-up .2 years.

Keywords: hallux rigidus/arthrodesis/cheilectomy/osteotomy/arthroplasty

Accepted: November 24, 2010

British Medical Bulletin 2011; 1–24

DOI:10.1093/bmb/ldq041

& The Author 2011. Published by Oxford University Press.

All rights reserved. For permissions, please e-mail: [email protected]

*Correspondence address.

Centre for Sports and

Exercise Medicine, Barts

and The London School

of Medicine and

Dentistry, Mile End

Hospital, 275 Bancroft

Road, E1 4DG London,

UK. E-mail: n.maffulli@

qmul.ac.uk

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Introduction

Hallux rigidus is a common and progressive painful osteoarthritis ofthe first metatarsophalangeal joint (MTPJ) with reduced range ofmotion (ROM) and function.1–5 Surgery is usually indicated forpatients unresponsive to conservative management, including non-steroidal anti-inflammatory and cortico-steroid drugs, physiotherapy,activity modification, shoe modifications. Surgical techniques for man-agement of painful hallux rigidus include cheilectomy, Keller resectionarthroplasty, arthrodesis, silastic implants, dorsiflexion phalangealosteotomy, metatarsal osteotomy, capsular arthroplasty, joint replace-ment. Though arthrodesis of the MTPJ is considered the gold standardin the management of severe hallux rigidus, cheilectomy and first meta-tarsal or phalangeal corrective osteotomy may provide better outcomeat earlier stages.4,6–9 Cheilectomy involves the alleviation of theosseous impaction of the proximal phalanx and metatarsal headthrough debridement of the articulating joints.10,11 Metatarsal andproximal phalangeal osteotomy is a joint preserving procedure requir-ing presence of viable hyaline cartilage on the more anteriorplantaraspects of the first metatarsal head, as this portion of the articularsurface migrates towards the dorsal aspect of the joint margin.12,13

Among arthroplasty procedures, Keller’s resection arthroplasty can becomplicated by stress fractures of the lesser metatarsals, cock-updeformities and transfer metatarsalgia.14 Numerous variations of thisprocedure exist, including capsular interposition arthroplasty,15 tendoninterposition arthroplasty16,17 and Valenti arthroplasty.18 Capsularinterposition arthroplasty aims to correct the deformity, reducepain, improve function and prevent transfer metatarsalgia whileavoiding first MTP arthrodesis. Tendon arthroplasty, in addition,avoids shortening of the metatarsal,18 and therefore push-off strengthis maintained. Valenti arthroplasty is a sagittal dorsally based closingwedge osteotomy of the first metatarsal and of the proximal phanlanx.It is used as an alternative to joint destructive procedures when apatient refuses or is not suitable for long-term immobilization and non-weight bearing.18 Implant arthroplasty aims to replace the first MTPJwhilst maintaining stability and function19. Arthrodesis fuses the firstMTPJ, provides pain relief but does not restore a normal pressurepattern,20,21 denying the theoretical and clinical principles of energyefficient gait.22

Different classifications are used to assess osteoarthrosis of the firstMTP joint, making it difficult to compare the various studies fromdifferent centres. Hattrup and Johnson’s classification and Coughlinand Shurnes’s classification are the most used scales. Hattrup and

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Johnson23 classified the radiographic status of hallux rigidus accordingto three grades: Grade I is characterized by mild-to-moderate formationof osteophytes with no joint space involvement; Grade II, by moderateformation of osteophytes, joint space narrowing and subchondral scler-osis; and Grade III, by marked formation of osteophytes and loss ofthe joint space with or without subchondral cysts. The Coughlin andShurnes classification is a reliable five-level clinical-radiographicgrading system that incorporates the features of classification systemintroduced by Hattrup and Johnson.23

Grade 0 is characterized by normal radiographic findings,mild-to-moderate stiffness and loss motion, with no pain; Grades 3and 4 connote comparable advanced arthritic changes but differentclinical findings (nearly constant pain, not at mid-ROM in Grade 3;pain throughout the range of movement in Grade 4).4

Among different scores used to assess satisfactory outcome, theAOFAS hallux MTP score24 is the most commonly administered. Thisis a 100-point score, composed of separate sections for pain (40points), function (45 points) and alignment (15 points). Concerningthe pain section, 40 points are given for no pain; 30 points for mild,occasional pain; 20 points for moderate, daily pain and 0 points forsevere, constant pain. The function section allows for activity, shoewear, motion and stability. Finally, in the alignment section, 15 pointsare given for a well-aligned hallux; 8 points for fair alignment, somedeformity, but no symptoms and 0 points for symptomatic malalign-ment. The Foot Function Index (FFI) is a 23 items validated self-administered scoring system with three subscales involving pain,disability and activity limitation.25 The score was firstly introduced toevaluate foot functions in rheumatoid arthritis patients.

We present a comprehensive quantitative review of the published lit-erature on the surgical management of hallux rigidus. The ColemanMethodology Score (CSM)26 was used to assess the methodologicalquality of the articles included in this systematic review (Fig. 1,Table 1).

Materials and methods

Study selection

A comprehensive search of CINAHL, Embase, Medline and theCochrane Central Registry of Controlled Trials, from inception ofthe database to 31 October 2010, was conducted to identify articlesreporting outcomes of patients who had undergone surgical manage-ment of hallux rigidus. The keywords used were ‘hallux rigidus’,

Operative management of hallux rigidus

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‘surgical treatment of hallux rigidus’, ‘osteoarthritis of hallux’, ‘oper-ative hallux treatment’ and ‘hallux’. Subheadings used were‘surgery’, ‘outcomes’, ‘pathology’, ‘physiology’ and ‘operation’. Alljournals were considered, and all relevant articles retrieved. Takingin count the authors’ linguistic capabilities, the search includedarticles in English, Spanish, French, Portuguese and Italian. Casereports, literature reviews, letters to editors and articles not reportingclinical outcomes were excluded from the study. In this review, datawere extracted regarding surgical technique, reported outcomes, com-plications and methodological design. Additionally, every adoptedoutcome measure assessed three basic fields, namely pain, halluxfunction and patient satisfaction. As outcome data resulted to beclassified as ‘excellent’, ‘good’, ‘fair’ and ‘poor’ in most includedstudies, success was defined as the percentage of ‘excellent’ and‘good’ outcomes, and failure rate was calculated as the percentage of‘fair’ and/or ‘poor’ outcomes.

Quality assessment

We scored each scientific article using the CMS26 system, an accurateand reproducible 10 criteria method assessing the study methodologicalquality, ranging from 0 to 100. The score 100 would represent aperfect well-designed study with no influence of bias, chance or con-founding factors (Table 1). Two investigators (RP and AP) scored eacharticle independently and then discussed any score which differed, untila consensus score was reached.

Fig. 1 Flow chart of studies identified for the systematic review.

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Table 1 Criteria used to compute the CMS.

Section Number or factor Score

Part A: only one score to be given for each of the seven sections

1. Study size: number of subjects (n) (if multiple follow-up,

multiply n by number of times subjects followed up)

.60 10

41–60 7

20–40 4

,20, non-stated 0

2. Mean follow-up (months) .24 5

12–24 2

,12, not stated, or unclear 0

3. Number of different surgical procedures included in each

reported outcome. More than one surgical technique may be

assessed but separate outcomes should be reported

One surgical procedure only. More than one surgical procedure, but .90% of subjects

undergoing the one procedure

10

7

Not stated, unclear, or ,90% of subjects undergoing the one procedure 0

4. Type of study Randomized control trial 15

Prospective cohort study 10

Retrospective cohort study 0

5. Diagnostic certainty (use of preoperative ultrasound, MRI, or

postoperative histopathology to confirm diagnosis)

In all 5

In .80% 3

In ,80%, no, not stated, or unclear 0

6. Description of surgical procedure given Adequate (technique stated and necessary details of that type of procedure given) 5

Fair (technique only stated without elaboration) 3

Inadequate, not stated, or unclear 0

7. Description of postoperative rehabilitation Well described with .80% of patients complying 10

Well described with 60–80% of patients 5

Complying 0

Part B: scores may be given for each option in each of the three sections if applicable

1. Outcome criteria (if outcome criteria is vague and does not

specify subjects’ sporting capacity, score is automatically 0 for this

section)

Outcome measures clearly defined 2

Timing of outcome assessment clearly stated (e.g. at best outcome after surgery or at follow-up) 2

Use of outcome criteria that has reported good reliability 3

Use of outcome with good sensitivity 3

2. Procedure for assessing outcomes Subjects recruited (results not taken from surgeons’ files) 5

Investigator independent of surgeon 4

Written assessment 3

Completion of assessment by subjects themselves with minimal investigator assistance 3

3. Description of subject selection process Selection criteria reported and unbiased 5

Recruitment rate reported .80% or ,80% 5

Eligible subjects not included in the study satisfactorily accounted for or 100% recruitment 5

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Statistical methods

Regression analysis was used to assess the extent of agreement betweenthe Coleman scores26 of the two independent assessors and the intra-class correlation coefficient score was calculated.

Results

A total of 70 studies (10 prospective,12,20,27–34 58 retrospec-tive,1,5,10,11,15,16,18,21,22,35–83 1 prospective/retrospective study84 and 1randomized trial85) published from 1957 to 2010 reported postopera-tive outcome related data of patients undergoing surgery for manage-ment of hallux rigidus.

Clinical and radiographic assessment

Hallux rigidus was defined according to different radiographic andclinical classification grading systems.10,12,18,20,22,27–32,59–66,68–83,85

Coughlin and Shurnes’s4 classification was used in 24studies1,27,31,33,34,37,39,40,42,44–46,49,61–64,67,68,73,75,78,83,85 (Table 2),The Hattrup and Johnson’s23 classification in1312,29,30,35,38,43,47,52,53,70,72,76,79 (Table 3), the Drago, Oloff, Jacobs’sclassification86 in 6 studies50,51,71,74,81,82 (Table 4), Regnauld’s classifi-cation87 in 6 studies10,11,22,36,59,65 (Table 5), Roukis’s classification28

in 2 studies,28,84 American College of Foot and Ankle surgeons classifi-cation55 and Hanft’s classification18 were used in 1 study each.Seventeen studies had no reported classifi-cation.5,15,16,20,21,32,41,48,54,56–58,60,65,68,69,71 Radiographic and ROMevaluations were performed for clinical and radiological assessment inall studies.

Satisfactory outcome

To assess satisfactory outcomes, the AOFAS scale was administered in38 studies (Tables 2–5), the University of Maryland questionnaire in 3studies,56,71,81 Kitaoka score in 2 studies,69,65 the Foot Health StatusQuestionnaire (FHSQ),75 Koenig score,63 FFI score,68 Modified HalluxMetatarsophalangeal-Interphalangeal Joint Scale84 and theManchester-Oxford Foot and Ankle Questionnaire (MOXFQ)33 in 1study each.

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Table 2 Coleman score of different studies.

Author Year Coleman

Aas et al.5 (2008) 38

Grondal80 (2005) 39

Iqbal and Chana53 (1998) 42

Ozan et al.45 (2010) 46

Taylor et al.46 (2004) 46

Maher75 (2008) 47

Tauro67 (2000) 47

Myerson et al.57 (2000) 47

Becher and Kilger.30 (2005) 48

Sinha et al.35 (2010) 49

Reize et al.41 (2007) 49

Thomas and Smith52 (1999) 49

Blyth et al.11 (1998) 49

Barca16 (1997) 49

Lau et al.38 (2001) 50

Brewster et al.49 (2010) 50

Harisboure et al.79 (2009) 51

Rees et al.72 (2006) 52

Coughlin and Shurnas4 (2003) 53

Lombardi et al.22 (2001) 53

Carpenter et al.47 (2010) 53

Dickerson et al.50 (2002) 53

Kurtz et al.51 (1999) 53

Cosentino54 (1995) 53

Hamilton et al.15 (1997) 53

Mackay et al.10 (1997) 54

Van Diijk et al.66 (1998) 54

Waizy et al.65 (2009) 54

Malerba et al62 (2008) 54

Can Akgun et al.37 (2008) 54

Coughlin and Shurnas39 (2003) 54

Olms and Dietze42 (1999) 54

Selner et al.55 (1997) 54

Mackey et al.58 (2010) 54

Townley60 (1994) 55

Oloff Lawrence74 (2008) 56

Ronconi et al.71 (2000) 56

Giannini et al.1 (2004) 56

Ettl et al.44 (2003) 56

Lin and Murphy48 (2009) 56

Southgate and Urry21 (1997) 56

Raikin et al.73 (2007) 58

Ess et al.32 (2002) 58

Harrison et al.33 (2010) 58

Derner et al.82 (2005) 59

Gonzalez et al81 (2004) 59

Roukis and Townly28 (2003) 59

Schenk et al.29 (2009) 59

Hahn et al.61 (2009) 59

Beertema et al.36 (2006) 59

Berlet et al.40 (2008) 59

Morandi et al.56 (2009) 59

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Age and follow up

A total of 2739 patients (2905 ft) underwent surgery at an average ageof 49.8 years (from 2753 to 6172). The average length of follow-up was41.1 months (ranged from 780 to 252 weeks58,83).

Type of procedure and postoperative rehabilitation

In 59 studies, 1 single operative technique was performed, while �2surgical procedures were compared in 11studies.1,12,21,29,36,58,65,73,77,83,85 The surgical technique was adequatelydescribed in 40 studies, fairly in 27 and inadequately in 3. The post-operative rehabilitation programme was described for almost allpatients (.80%) in 10 studies, for 60–80% of patients in 32 studies.There was no description or it was defined for ,60–80% of patientsin 28 studies.

Subject selection, outcome criteria and outcome assessment

The ‘outcome assessment’ section scored fairly in 52 of 70 articles, andpoorly in the remaining 18 of 70 articles. Comparing pre- and post-operative status of 838 patients (925 ft) reviewed accordingly to theCoughlin and Shurnes’s classification. The mean reported AOFASscores improved from 47 (3673–6083) preoperatively to 74 (5064–

Table 2 Continued.

Author Year Coleman

Arbuthnot et al.27 (2008) 60

Hyer et al.77 (2008) 60

Saxena18 (1995) 61

Taranow et al.68 (2005) 61

Hasselman78 (2008) 62

Sorbie and Saunders59 (2008) 62

Kennedy et al.76 (2004) 63

DeFrino et al.20 (2002) 63

Mesa-Ramos et al.34 (2008) 63

Wassink and Van den Oever64 (2009) 64

Konkel et al.63 (2008) 64

Daniilidis et al.31 (2010) 64

Seeber69 (2007) 66

Roukis et al.84 (2003) 66

San Giovanni et al.70 (2007) 69

Gibson and Thomson85 (2005) 74

Easley et al.43 (1999) 74

Kilmartin12 (2005) 80

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Table 3 Studies that have used Coughlin’s classification.

Author Grade Treatment Satisfactory outcome ROM

Arbuthnot et al.27 I, II, III, IV Hemiarthrosplasty AOFAS: 3 months 82.20+9.5; 12 months

87+10; 24 months 84.20+10.69; 36

months 95

3 Months: 48.60+12.288; 12 months

45.50+12.728; 24 months 33.30+17.198; 36

months 38.60+15.018Berlet et al.40 III Interpositional arthroplasty (regenerative

tissue matrix)

AOFAS: 87.9 38.4+5.58

Brewster et al.49 III/IV Arthrosplasty (Moje ceramic-on-ceramic) AOFAS: 74/100 (range: 9–100) 50% of patients 308, 9.38% of patients 758Satisfaction: 9.38% excellent, 31.25% good,

28.13% fair, 31.25% poor

Can Akgun et al.37 III, IV Modifield oblique Keller procedure

(osteotomy)

AOFAS: 93.6 51.98

Satisfaction: 100% good-excellent results

Coughlin and

Shurnas39

IV Soft-tissue arthroplasty AOFAS: 86; satisfaction: 100%

good-excellent results

348

Coughlin and

Shurnas4

I, II, III, IV I–III; cheilectomy III (,50% of cartilage)

and IV arthrodesis

AOFAS: I 95.7; II 92.9; III 89.8; IV 88.9 Cheilectomy 63.78 (15–110), arthrodesis 08

Daniilidis et al.31 III Arthrosplasty AOFAS: 82.5+14.5 52.7+15.78Satisfaction: 91.3% excellent/good

Ettl et al.44 III Arthrodesis AOFAS: 53 (5–84)

VAS: 27/100

Giannini et al.1 0, I, III Cheilectomy vs. I, osteotomy vs. III,

arthrodesis or arthroplasty (DL-lattic acid)

AOFAS: 81+ 75+88

Gibson and

Thomson85

I, II, III, IV Arthrodesis vs. total replacement

arthroplasty

RX: arthrodesis 100% (24 months),

arthroplasty 50% no lucency (24 months)

Arthrodesis 26+128; arthroplasty. 28+148

Hahn et al61 IV Arthrosplasty AOFAS: 77.8/100 Dorsiflex 48.1–56.88; plantarf. 28.1–33.38Harrison et al.33 IV Cheilectomy MOXFQ: 9.6/64 (95% CI 1

4 6.0–13.2)

Hasselman78 II, III Hemiarthrosplasty AOFAS: 82.1 658

Konkel et al.63 III, IV Hemiarthrosplasty AOFAS score: Tot 83 (62–100); Grade III: 84

(62–100); Grade IV

648 (30–100)

Grade III: 92% satisfied; 85% at 8 years

Maher75 III, IV Arthrodesis FHSQ: 20.95

Malerba et al62 III Osteotomy AOFAS: 82 (80–100) 78% good-excellent Dorsiflex 448 (15–558)Mesa-Ramos

et al.34

I, II, III Percutaneus cheilectomy þ osteotomy AOFAS: 92.36: grade I: 100; grade II 93;

grade III: 90

VAS: grade I: 1.00; grade II: 1.80; grade III:

1.60

Olms and Dietze42 III, IV Arthroplasty Questionnaire: 81% no pain TOT: 508 (range: 40–608)Ozan et al.45 III, IV Interposition arthroplasty AOFAS: 85.3+8.7 TOT: 32.4+4.48

Satisfaction: very good 47.4%, good 36.8%,

moderate 5.3%, poor 10.5%

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Table 3 Continued.


Raikin et al.73 III, IV Hemiarthrosplasty vs. arthrodesis Hemiarthrosplasty: 24% excellent, 33%

good, 10% fair, 33% poor

Arthrodesis: 78% excellent, 4% good, 15%

fair, 4% poor. (P ¼ 0.006)

Taranow et al.68 II, III Hemiarthrosplasty Satisfaction: 23 patients satisfied, 3 patients

satisfied with reserves, 2 patients dissatisfied

Tauro67 I, II, III, IV Arthrodesis Satisfaction: 72%; satisfactory with reserves

28%, NO satisfactory

88 (4–128)

Taylor et al.46 No

reported

Arthrodesis (two screw) Questionnaire: 64.7% excellent, 23.5%

good, 11.8% poor

82.4% procedure done again

Wassink and Van

den Oever64

No

reported

Arthrodesis AOFAS-HMI: 56: 50/60 (men), 10/60 (women)

96.3% complete union

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Table 4 Studies that have used Hattrup/Johnson’s classification.


Becher and

Kilger30

II, III Cheilectomy AOFAS: Grade II: 84 (65–100) Grade II: 518 (20–758)

Grade III: 71 (35–87) Grade III: 338 (5–558)Carpenter

et al.47

II, III Arthroplasty AOFAS: 89.31 (range: 70–100) (P , 0.001)

Easley et al.43 I, II, III Cheilectomy AOFAS: 85 (Grade I: 89+12, Grade II: 84+14, Grade III: 84+19) 648 (Grade I: 76+178, Grade II:

62+178, Grade III: 52+128)Harisboure

et al.79

I, II, III Osteotomy AOFAS: Grade I: 83.4/100 (75–100), Grade II: 81.5/100 (53–100),

Grade III: 86.4/100 (67–100). No pain: 94%

Grade I: 578 (45–908); Grade II: 51.88(50–808) Grade III: 25.68 (0–558)

Iqbal and

Chana53

I/II Arthroscopic, cheilectomy Satisfaction: 60% very satisfied, 40% satisfied. Not satisfied 69.38 (range: 60–808)

Kennedy

et al.76

I, II Arthroplasty AOFAS: 78.4 /100 punti, SF 36: 96.3 points 648 (range: 25–708)

Kilmartin12 II Phalanx osteotomy vs. MT

osteotomy

AOFAS: phalanx osteotomy 88+10, MT osteotomy 88+6.8 Phalanx osteotomy 35+88 (dorsiflex),

MT osteotomy 42+98 (dorsiflex)

Lau et al.38 II, III Cheilectomy vs. interpositional

arthroplasty

AOFAS: cheilectomy 77.3, interposition arthroplasty 71.6.

Satisfaction: cheilectomy 87.5 %, interpositional arthroplasty 72.7%

30.2+7.98 cheilectomy, 30.9+88interpositional arthroplasty

Rees et al.72 I, II, III Osteotomy AOFAS: Grade I: 50 % Grade II: 70% Grade III: 78% satisfied 418 (5–808) (dorsiflex)

Rx foot: good 85%

San Giovanni

et al.70

II Hemiarthrosplasty AOFAS: 80.4/100. 67% need second surgery procedure; final

outcome: 94% excellent/good; 5% good; 1% poor

538 (dorsiflex)

Schenk et al.29 I, II Interposition arthroplasty vs.

resection arthroplasty

AOFAS: interposition arthroplasty: 89/100; resection arthroplasty: 88/

100

Interposition arthroplasty: 66.58,resection arthroplasty: 52.28

Outcome: interposition arthr: 63% excellent, 14% good, 18% poor,

5% fair; resection Arthr: 63% excellent, 10% good, 17% poor, 10%

fair

Sinha et al.35 III Arthroplasty AOFAS: 62 (range: 10–82); satisfaction: 58 % good-excellent

Thomas and

Smith52

No

reported

Proximal phalanx osteotomy PAIN: 58% no pain and 42% mild pain. 100% union rate of the

osteotomy

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Table 5 Studies that have used Regnauld’s classification.


Beertema

et al.36

I, II,

III

Cheilectomy vs. arthroplasty vs.

arthrodesis

AOFAS: Cheilectomy: Grade I 87, Grade II 82 arthroplasty:

Grade I 94, Grade II 83, Grade III 87; arthrodesis: Grade I 81,

Grade II 73

Cheilectomy: Grade I 61+9.18, Grade II 46+23.98;arthroplasty: Grade I 70+8.28, Grade II 57+18.58,Grade III 65+11.28; arthrodesis 08:

Blyth et al.11 I, II Osteotomy Pain: 44.5%. (P ¼ 0.00014) 478Patient activity level: 72.3% unlimited; 27.7% limitation

Lombardi

et al.22

III Arthrodesis 1 MTF with screw AOFAS: 75.6 Rx foot: IM angle 8.58; an angle of declination

MT 17.38; talo-metatarsal angle 58; angle of abduction of

the big 118 (P ¼ 0.001)

Mackay

et al.10

I, II,

III

Cheilectomy Pain: Grade I: 61% no pain, 33% pain in sport, 6% walking;

Grade II: 60% no pain, 40% pain in sport; Grade III: 33% no

pain, 33% pain in sport, 17 % walking, 17% constant

Dorsiflex 58.92+11.398; Plantaflex 4.24+6.928

Satisfaction: 100% Grade I, 66% Grade II, no Grade III

Sorbie and

Saunders59

III Hemiartroplasty AOFAS: 88.2+18.7

Waizy et al.65 III, IV Cheilectomy vs.

cheilectomy þ osteotomy

(Kessel-Bonney)

Cheilectomy: 21.7% (2 follow-up), total satisfaction, 23.9%

(2 follow-up) satisfaction, 4.4% (2 follow-up), dissatisfied;

cheilectomy þ osteotomy: 32.6%, total satisfaction, 15.2%

satisfaction, 15% 2.2% (2 follow-up), dissatisfied

Cheilectomy Grade I 43.68, Grade II 38.278, Grade III;

cheilectomy þ osteotomy: Grade I 408, Grade II 368,Grade III 32.58

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10064,67,83) postoperatively after arthrodesis, from 43 (range from29.137 to 5834) to 88.5 (from 811 to 10037) in patients who had under-went osteotomy technique, from 48 (2483–7083) to 85.3 (6783–10083)in patients who had undergone cheilectomy and from 35 (2627–4627)to 85 (7173–10027,73,78) following hemiarthroplasty, from 55 (4639–63.940) to 86.4 (8545–10040) in those who had received arthroplasty(Table 2). Regarding 576 patients (671 ft) who were assessed accordingto the Hattrup/Johnson’s classification, the AOFAS scores improvedfrom an average preoperative value of 48 (range from 3012 to 7279) toan average postoperative score of 89 (from 7812 to 10012,72,79) afterosteotomy, from a mean of 46 (1830–7530) to 77 (3530–10030) aftercheilectomy, from 53 (4970–5729) to 82 (6235–10070) after arthro-plasty. (Table 3) and from 58.45 to 92.36 after combined cheilectomyand osteotomy.34

The average preoperative and postoperative AOFAS scores in patients treated by differentprocedures and evaluated according to different grading systems are reported in Table 6

The mean preoperative Kitaoka score of 25.5 points improved to anaverage of 8169 points postoperatively. Concerning the University ofMaryland questionnaire,56,71,81 preoperative data were not reported,but postoperative scores ranged from 75 to 100.81 The FFI score was76.1 for pain (range: 28.4–100), 73.4 for discomfort (range: 11.1–98.8), 29.3 (range: 11.1–95.6) for activity, 18.8 (range: 1.6–77.8) forpostoperative pain, 18.4 (range: 0–79) for discomfort and 8.1 (range:0–42.2)68 for activity. The average FHSQ score improved from 41.65preoperatively to 20.95 postoperatively,75 while the Modified HalluxMetatarsophalangeal-Interphalangeal improved from 25.0+15 to85.8+12.0 postoperatively84 (P , 0.001). The MOXFQ changedfrom 33/64 preoperatively to 9.6/64 postoperatively.33 Reported meanpostoperative Koenig scores rated 85 (range: 64–96)63 in Grade IIIpatients were assessed by using the Hattrup/Johnson’s classification.

Range of movement

Range of movement (ROM) data were extracted from 29 of 70 studies.The preoperative ROM of 2781 improved postoperatively to 6443 in542 patients receiving a cheilectomy.1,10,30,33,34,36,43,48,53,55,56,65,83

Comparing pre- and postoperative ROM measures in 530 patients whohad undergone an osteotomy, the preoperative mean of 20.18 (range:6.537–33.582)28,1,11,12,18,21,29,34,55,62,71,79,82 improved to postoperativemean of 39.38 (range: 23.518–72.182).1,11,18,21,28,29,34,36,50,51,55,62,71,79,82





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Table 6 Studies that have used DRAGO, OLOFF, Jacobs’s classification.


Derner et al.82 II, III Osteotomy plantar

displacement

AOFAS: 78.1/100 85% excellent/good, 8% good, 4% poor,

4% fair

TROM: 72.18 (range: 50–1008)

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et al.50

No

reported

Green-Watermann

Osteotomy

Pain: 30/32 (94%) significantly relieved. Dorsiflex 588 (range: 44–858); plantarflex98 (range: 5–

208)Satisfaction: excellent (90–100) 50%; good (70–89) 37.5%;

fair (60–69) 0%; poor (,60) 22.5%

Gonzalez

et al.81

II, III Hohman osteotomy Questionary ‘The University of Maryland’: 96% excellent

(90–100), 4% good (75–89)

Dorsiflex 58.92+11.398; plantaflex 4.24+6.928

Kurtz et al.51 I, II, III Valenti osteotomy AOFAS: 84 (range: 45–100) 57.88 (range: 33–1008), dorsiflex: 44.88 (range: 25–

808), plantarflex 13.08 (range: 5–228)Questionnaire: 81.8% improved pain, 66% continued pain,

33.3% no pain, 45.5% occasional pain

Oloff

Lawrence74

III, IV Osteotomy 1 MT AOFAS: 55 (14–70) 58 (0–108)

Final satisfaction: 85.71 % pcs

Ronconi

et al.71

I, II Osteotomy 1 MT

(triplane)

Questionnaire: 84% excellent-good, 7% poor, 9% fair Dorsiflex: 458, plantarlfex: 188

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With regard to 572 patients undergoing arthroplasty, ROMincreased from a preoperative average of 24.88 (range: 4.927–47.229)1,15,16,27–29,31,32,39,40,42,45,57,58,61,63,69,70,76,78,84,85 to apostoperative average of 458 (range: 16.827–66.529).1,15,16,27–29,31,32,36,39,40,42,45,54,58,61,63,69,70,76,78,84,85 ROMdecreased postoperatively to an average 01,21,36,58,83,85 in 289 patientsundergoing an arthrodesis (Tables 2–5). The average preoperative andpostoperative ROM in patients treated by different procedures arereported in Table 7.

CMSs and statistical results

The means of the CMSs for each section are listed in Table 8: theaverage CMS score was 56.7 (range: 385–8012).

Reported outcomes and complications, different methods of report-ing results, have been used in almost all the articles. A 74% successrate (ranged from 4053 to 100%10) has been reported after cheilectomy,69% (ranged from 46%65 to 82%62) after osteotomy, 73.2% (rangedfrom 64.7%46 to 78%73) after arthrodesis, 70.2% (ranged from 24%73

to 93%31,60) after arthroplasty and 73.4% (from 47.4%45 to 100%39)after interpositional arthroplasty.

Complications and associated findings

Among 530 patients undergoing an osteotomy, 7 (1.3%) developed aninfection: a localized infection which resolved spontaneously wasreported in 1 patient,72 after positioning of bioreabsorbable poly(DL-lattic acid) implant,1 while a re-operation was performed in 4patients. Metatarsalgia was diagnosed in 16 of 530 patients(3%),11,29,37,55,82 sesamoiditis55 in 1 (0.2%), toe hypoesthesia in 5(0.9%),11,29,34 floating hallux in 4 (0.8%),29 persistent pain in 3(0.6%),29 and algodistrophy in 1 (0.2%).29 Orthotics were needed in 2of 530 patients (0.4%),55 pin breakage56 was observed in 3 cases(0.6%) and a stress fracture in 1 (0.2%).37

Among 572 patients who had undergone arthroplasty, 2 (0.3%) hadinfection and 3 (0.5%) superficial infection41,68,78 Additionally, meta-tarsalgia was reported in 5 patients (0.9%),42 sesamoid pain in 4(0.7%),42 periarticular ossification in 3 (0.5%),42 hallux valgus andoedema in 1 (0.2%) patient each.41 Six patients (1%) had Morton’sneuroma.27,29

Among 91 patients who had undergone interposition arthroplasty,metatarsalgia39,45 and loss of ground contact of the hallux45 were





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Table 7 Pre–postoperative AOFAS score and classifications grading systems.

AOFAS

Coughlin and Shurnes’s 838

patients (925 ft)

Hattrup/Johnson’s 576

patients (671 ft)

Drago, Oloff, Jacobs’s 163

patients (184 ft)

Regnaul d’s 140 patients

(144 ft)

Roukis’s 44 patients (47 ft)

Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative

Arthrodesis 47 (36–60) 74 (50–100) – – – – 39.1 84 (75.6–100) – –

Osteotomy 43 (29.1–58) 88.5 (81–100) 48 (30–72) 89 (78–100) 25.8 78 (52–100) – – 54.4 84.6

Cheilectomy 48 (24–70) 85.3 (67–100) 46 (18–75) 77 (35–100) – – – – – –

Hemiarthroplasty 35 (26–46) 85 (71–100) – – – – – – 51.1 77.8

Arthroplasty 55 (46– 63.9) 86.4 (85–100) 53 (49–57) 82 (62–100) – – – – – –

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Table 8 Pre-post operative ROM and classifications grading systems.

ROM

Arthrodesis, 289 patients Osteotomy, 530 patients Cheilectomy, 542 patients Hemiarthroplasty Arthroplasty, 572 patients

Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative Preoperative Postoperative

178 08 20.18 (6.5–33.58) 39.38 (23.5–72.18). 278 648 – – 24.88 (4.9–47.28) 458 (16.8–66.58)

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found in 15 patients each (16.5%), hypoesthesia of the hallux in 3(3.3%), haematoma, hallux valgus and continuous pain each present in1 patient (1.1%).54

Regarding 289 patients who received arthrodesis, screws and hard-ware were, respectively, removed in 8 (2.8%) and 2 (0.7%) cases forintolerance or pain,22,46,57 a non-union developed in 16 ft(5.6%),5,22,46 and a delayed union in 3 patients (1%).46 Seven of 289(2.4%) patients received antibiotics for management of cellulitis,83 2(0.7%) had infection46,80 and 7 (2.4%) a superficial infection, includ-ing a myocardial infection.46,57 Bone was destroyed in 5 patients(1.7%),36 9 patients (3.1%) had poor quality of missing36 and 4(1.4%) had metatarsalgia.46

After cheilectomy, 7 of 542 patients (1.3%) underwent antibiotictherapy for management of cellulitis while superficial infection wasobserved in 2 patients (0.4%).43,48,83 Postoperative paresthesiae wereevident in 6 of 542 patients (1.1%).34,43 Eleven of 542 patients (2%)required further intervention for procedure failure,33,83 and 2 (0.4%)underwent arthrodesis for postoperative stiffness.83 Chondrolysis wasdetected on radiographic assessment in 2 patients (0.4%).83

Discussion

The first MTPJ acts as a fulcrum able to sustain high pressures andloading forces during the bipedal motion.88,89 When local structuresbecome insufficient, compensatory mechanisms need to be utilized. Asaetiology, symptoms, duration of symptoms, biomechanics, systemicconditions, type of pain, personal/social level have to be considered,there is currently no agreement on the management of this complexbut common condition.12,18,90

The present review reports on outcomes of patients undergoingsurgery for management of hallux rigidus. Most findings have beenpresented in reasonable fashion, either reporting on biomechanicaleffects or postoperative symptoms, resulting in marked benefits for thequality of life of the operated patients. If surgical success rates are notconclusive, morbidity, complication, failure rates and early return towork activity were considered. According to the published literature,there are no standard procedures to manage different grades of halluxrigidus.

As no consensus has been reached on clinical classification gradingsystems, it is difficult to compare postoperative outcomes.

The results could be influenced by the experience of surgeons andvariability in patients’ selection process. The heterogeneity in terms ofstudy design, length of follow-up, classification grading systems,

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radiological and clinical findings did not allow to compare extracteddata. The large variety of scales assessing the clinical status limited thestatistical power of the study. Additionally, non-validated scoringsystems assessing satisfactory outcomes were used in manyreports.64,71,72

Concerning the methodological assessment, we used the CMS, a vali-dated reliable scoring system.26

The heterogeneity of included studies precluded the intention toperform a meta-analysis.

Despite these limitations, according to reported data, an average74% (range from 40%53 to 100%10) success rate has been reportedafter cheilectomy, a mean of 69% (range from 46%65 to 82%62) afterosteotomy, 73.2% (range from 64.7%46 to 78%73) after arthrodesis,70.2% (range from 24%73 to 93%31,60) in patients who underwentarthroplasty, and 73.4% (from 47.4%45 to 100%39) after interposi-tional arthroplasty.

The surgical criteria are based on the deformity grading, classifiedaccording to different scales categorizing the hallux rigidus.4,18,23,72,87

The indications for surgical management of hallux rigidus are unclear.However, regardless of classifications, if cheilectomy and first metatar-sal or phalangeal corrective osteotomy should be performed in earlystaged hallux rigidus (Stages I–II), arthrodesis or arthroplasty are indi-cated to manage Stages III–IV.91

Although several complications have been observed, mostly afterosteotomy, significantly improved ROM has been reported in patientsundergoing osteotomy for management of intermediate staged halluxrigidus, regardless of classifications.12,18,62,71,72,74,79,81,82

Cheilectomy has been used for each grade of hallux rigidus in severalstudies,10,30,33,38,43,65,79 but the best results have been obtained inGrade I or early Grade II hallux rigidus, where the pathology involvedonly the dorsal aspect of the first MTP joint.4,10,30 Loss of motion andprogression of first metatarsal–sesamoid joint disease have beenreported in a high percentage of Grade II and III patients followed for2 years or longer.30,43,79

Kilmartin12 reported whether the shortening of the 1st MT or proxi-mal phalanx targets primarily to restore MT alignment, increasing thebase of the hallux. Several studies62,71,72,79,81 reported decreased painand improved ROM performing an additional osteotomy after cheilect-omy for patients with conserved mid-ROM.65 However, patients withsevere arthritic changes and pain throughout the ROM have pooreroutcomes with these procedures, and are better served by proceduressuch as excisional arthroplasty, interposition arthroplasty and implantarthroplasty and arthrodesis.





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The Valenti arthroplasty allows recovery of dorsal-flexion in cases ofmoderate hallux rigidus.18,51 Although Keller’s arthroplasty of the firstMTP joint provides good AOFAS outcomes and short postoperativerecovery time,37 hallux shortening and the loss of motion may be unac-ceptable complications.29,37 Excisional arthroplasty techniques are bestindicated for low demand patients92 with lower grades of halluxrigidus, as they involve short surgical and recovery time.29

Satisfactory AOFAS score and improved ROM have been observed inhigher graded hallux rigidus (III–IV according to Coughlin andShurnes and II–III according to Hattrup and Johnson) after interposi-tion arthroplasty, but longer follow-up studies should be conducted toassess the long-term complications29,40,45.

Good-excellent AOFAS score and high improvement of ROM wereobserved after positioning of a prosthetic joint replacement for man-agement of both early stage47,76 and late stage1,31,35,42,49,61 of halluxrigidus.

Regardless of grading, high rate of satisfactory outcomes associatedwith ROM preservation have been obtained after implantation ofhemiarthroplasty.27,59,63,68,70,73,78 Since there is a lack of long-termfollow-up studies, up to date hemiarthroplasty can be considered analternative to fusion only in patients who wish to maintain a functionalROM for severe hallux rigidus.

Arthrodesis eliminated the joint painful motion improving the clinicalscores in patients with diffuse osteoarthrosis of the firstMTP.4,19,22,64,67,75,77,80 On the basis of available findings, arthrodesisof the first MTP joint is best indicated for active patients, when jointpreserving procedures are contraindicated, for revision of failed exci-sion arthroplasty and implant arthropalsty.22,36,64 The effects ofarthrodesis vs. joint preserving arthroplasty for the advanced stage ofhallux rigidus in older and physically lower demand patients are stilldebated. Should motion of the joint be sacrificed for stability of thehallux, and for consistent, predictable and reliable outcome of the pro-cedure? There are no validated functional studies comparing the limit-ation of function and activities after arthrodesis and arthroplasty.Additionally, controlled prospective studies of patients undergoingarthrodesis and the newer versions of modified arthroplasty areneeded.

No study reported on the return to preoperative activity, and there islack of information on the role of rehabilitation exercises to improvethe clinical and functional status. As surgery alone is not enough toreturn to full activity, physiotherapy and duration of postoperativeimmobilization should be taken into account. Finally, the role thepostoperative footwear or anti-inflammatory drugs should be clarified.In conclusion, evidence-based guidelines are needed to establish the

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use of standard surgical procedures for the management of halluxrigidus.

References

1 Giannini S, Ceccarelli F, Faldini C et al. What’s new in surgical options for hallux rigidus?J Bone Joint Surg Am 2004;86-A (Suppl. 2):72–83.

2 Mann RA, Coughlin MJ. Surgery of the Foot Arthritides, 5th edn. Mosby: St Louis,1986,158–79.

3 McMaster MJ. The pathogenesis of hallux rigidus. J Bone Joint Surg Br 1978;60:82–7.

4 Coughlin MJ, Shurnas PS. Hallux rigidus. Grading and long-term results of operative treat-ment. J Bone Joint Surg Am 2003;85-A:2072–88.

5 Aas M, Johnsen TM, Finsen V. Arthrodesis of the first metatarsophalangeal joint for halluxrigidus—optimal position of fusion. Foot (Edinb) 2008;18:131–5.

6 Yee G, Lau J. Current concepts review: hallux rigidus. Foot Ankle Int 2008;29:637–46.

7 Horton GA. Surgical treatment options in hallux rigidus. Oper Tech Sports Med1999;7:32–5.

8 Harrison WJ, Loughead JM. Silastic metatarsophalangeal arthroplasty: very long-term resultsof single stem implants in degenerative joint disease. Foot 2003;13:146–50.

9 Beeson P. The surgical treatment of hallux limitus/rigidus: a critical review of the literature.

The Foot 2004;14:6–22.10 Mackay DC, Blyth M, Rymaszewski LA. The role of cheilectomy in the treatment of hallux

rigidus. J Foot Ankle Surg 1997;36:337–40.11 Blyth MJ, Mackay DC, Kinninmonth AW. Dorsal wedge osteotomy in the treatment of

hallux rigidus. J Foot Ankle Surg 1998;37:8–10.

12 Kilmartin TE. Phalangeal osteotomy versus first metatarsal decompression osteotomy for thesurgical treatment of hallux rigidus: a prospective study of age-matched and condition-matched patients. J Foot Ankle Surg 2005;44:2–12.

13 Cavolo DJ, Cavallaro DC, Arrington LE. The Watermann osteotomy for hallux limitus. J AmPodiatry Assoc 1979;69:52–7.

14 McLaughlin EK, Fish C. Keller arthroplasty: is distraction a useful technique? A retrospectivestudy. J Foot Surg 1990;29:223–5.

15 Hamilton WG, O’Malley MJ, Thompson FM et al. Roger Mann Award 1995. Capsular

interposition arthroplasty for severe hallux rigidus. Foot Ankle Int 1997;18:68–70.16 Barca F. Tendon arthroplasty of the first metatarsophalangeal joint in hallux rigidus: prelimi-

nary communication. Foot Ankle Int 1997;18:222–8.17 Miller D, Maffulli N. Free gracilis interposition arthroplasty for severe hallux rigidus. Bull

Hosp Jt Dis 2005;62:121–4.

18 Saxena A. The Valenti procedure for hallux limitus/rigidus. J Foot Ankle Surg1995;34:485–8; discussion 511.

19 Fadel GEA, Abboud RJ, Rowley DI. Implant arthroplasty of the hallux metatarsophalangealjoint. The Foot 2002;12:1–9.

20 DeFrino PF, Brodsky JW, Pollo FE et al. First metatarsophalangeal arthrodesis: a clinical,

pedobarographic and gait analysis study. Foot Ankle Int 2002;23:496–502.21 Southgate JJ, Urry SR. Hallux rigidus: the long-term results of dorsal wedge osteotomy and

arthrodesis in adults. J Foot Ankle Surg 1997;36:136–40; discussion 161.22 Lombardi CM, Silhanek AD, Connolly FG et al. First metatarsophalangeal arthrodesis for

treatment of hallux rigidus: a retrospective study. J Foot Ankle Surg 2001;40:137–43.

23 Hattrup SJ, Johnson KA. Subjective results of hallux rigidus following treatment with chei-lectomy. Clin Orthop Relat Res 1988;226:182–91.

24 Kitaoka HB, Alexander IJ, Adelaar RS et al. Clinical rating systems for the ankle-hindfoot,

midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15:349–53.25 Budiman-Mak E, Conrad KJ, Roach KE. The Foot Function Index: a measure of foot pain

and disability. J Clin Epidemiol 1991;44:561–70.





Dow

nloaded from


26 Coleman BD, Khan KM, Maffulli N et al. Victorian Institute of Sport Tendon Study Group.

Studies of surgical outcome after patellar tendinopathy: clinical significance of methodologi-cal deficiencies and guidelines for future studies. Scand J Med Sci Sports 2000;10:2–11.

27 Arbuthnot JE, Cheung G, Balain B et al. Replacement arthroplasty of the first metatarsopha-langeal joint using a ceramic-coated endoprosthesis for the treatment of hallux rigidus. J FootAnkle Surg 2008;47:500–4.

28 Roukis TS, Townley CO. BIOPRO resurfacing endoprosthesis versus periarticular osteotomyfor hallux rigidus: short-term follow-up and analysis. J Foot Ankle Surg 2003;42:350–8.

29 Schenk S, Meizer R, Kramer R et al. Resection arthroplasty with and without capsular inter-position for treatment of severe hallux rigidus. Int Orthop 2009;33:145–50.

30 Becher C, Kilger R. Results of cheilectomy and additional microfracture technique for the

treatment of hallux rigidus. Foot Ankle Surgery 2005;11:155–60.31 Daniilidis K, Martinelli N, Marinozzi A et al. Recreational sport activity after total replace-

ment of the first metatarsophalangeal joint: a prospective study. Int Orthop 2010;34:973–9.32 Ess P, Hamalainen M, Leppilahti J. Non-constrained titanium-polyethylene total endoprosth-

esis in the treatment of hallux rigidus. A prospective clinical 2-year follow-up study. Scand JSurg 2002;91:202–7.

33 Harrison T, Fawzy E, Dinah F et al. Prospective assessment of dorsal cheilectomy for halluxrigidus using a patient-reported outcome score. J Foot Ankle Surg 2000;49:232–7.

34 Mesa-Ramos M, Mesa-Ramos F, Carpintero P. Evaluation of the treatment of hallux rigidusby percutaneous surgery. Acta Orthop Belg 2008;74:222–6.

35 Sinha S, McNamara P, Bhatia M et al. Survivorship of the bio-action metatarsophalangealjoint arthroplasty for hallux rigidus: 5-year follow-up. Foot Ankle Surg 16:25–7.

36 Beertema W, Draijer WF, van Os JJ et al. A retrospective analysis of surgical treatment in

patients with symptomatic hallux rigidus: long-term follow-up. J Foot Ankle Surg2006;45:244–51.

37 Can Akgun R, Sahin O, Demirors H et al. Analysis of modified oblique Keller procedure forsevere hallux rigidus. Foot Ankle Int 2008;29:1203–8.

38 Lau JT, Daniels TR. Outcomes following cheilectomy and interpositional arthroplasty in

hallux rigidus. Foot Ankle Int 2001;22:462–70.39 Coughlin MJ, Shurnas PJ. Soft-tissue arthroplasty for hallux rigidus. Foot Ankle Int

2003;24:661–72.

40 Berlet GC, Hyer CF, Lee TH et al. Interpositional arthroplasty of the first MTP joint using aregenerative tissue matrix for the treatment of advanced hallux rigidus. Foot Ankle Int2008;29:10–21.

41 Reize P, Schanbacher J, Wulker N. K-wire transfixation or distraction following theKeller-Brandes arthroplasty in Hallux rigidus and Hallux valgus? Int Orthop2007;31:325–31.

42 Olms K, Dietze A. Replacement arthroplasty for hallux rigidus. 21 patients with a 2-year

follow-up. Int Orthop 1999;23:240–3.43 Easley ME, Davis WH, Anderson RB. Intermediate to long-term follow-up of

medial-approach dorsal cheilectomy for hallux rigidus. Foot Ankle Int 1999;20:147–52.

44 Ettl V, Radke S, Gaertner M et al. Arthrodesis in the treatment of hallux rigidus. Int Orthop2003;27:382–5.

45 Ozan F, Bora OA, Filiz MA et al. Interposition arthroplasty in the treatment of halluxrigidus. Acta Orthop Traumatol Turc 2010;44:143–51.

46 Taylor DT, Sage RA, Pinzur MS. Arthrodesis of the first metatarsophalangeal joint. Am JOrthop (Belle Mead NJ) 2004;33:285–8.

47 Carpenter B, Smith J, Motley T et al. Surgical treatment of hallux rigidus using a metatarsal

head resurfacing implant: mid-term follow-up. J Foot Ankle Surg 2010;49:321–5.48 Lin J, Murphy GA. Treatment of hallux rigidus with cheilectomy using a dorsolateral

approach. Foot Ankle Int 2009;30:115–9.

49 Brewster M, McArthur J, Mauffrey C et al. Moje first metatarsophalangeal replacement—acase series with functional outcomes using the AOFAS-HMI score. J Foot Ankle Surg2010;49:37–42.

50 Dickerson JB, Green R, Green DR. Long-term follow-up of the Green-Watermann osteotomyfor hallux limitus. J Am Podiatr Med Assoc 2002;92:543–54.

N. Maffulli et al.




Dow

nloaded from


51 Kurtz DH, Harrill JC, Kaczander BI et al. The Valenti procedure for hallux limitus: a long-

term follow-up and analysis. J Foot Ankle Surg 1999;38:123–30.52 Thomas PJ, Smith RW. Proximal phalanx osteotomy for the surgical treatment of hallux

rigidus. Foot Ankle Int 1999;20:3–12.53 Iqbal MJ, Chana GS. Arthroscopic cheilectomy for hallux rigidus. Arthroscopy

1998;14:307–10.

54 Cosentino GL. The Cosentino modification for tendon interpositional arthroplasty. J FootAnkle Surg 1995;34:501–8.

55 Selner AJ, Bogdan R, Selner MD et al. Tricorrectional osteotomy for the correction of late-stage hallux limitus/rigidus. J Am Podiatr Med Assoc 1997;87:414–24.

56 Morandi A, Dupplicato P, Sansone V. Results of distal metatarsal osteotomy using absorbable

pin fixation. Foot Ankle Int 2009;30:34–8.57 Myerson MS, Schon LC, Francis X et al. Result of arthrodesis of the hallux metatarsophalan-

geal joint using bone graft for restoration of length. Foot Ankle Int 2000;21:297–306.58 Mackey RB, Thomson AB, Kwon O et al. The modified oblique keller capsular interposi-

tional arthroplasty for hallux rigidus. J Bone Joint Surg Am 2010;92:1938–46.

59 Sorbie C, Saunders GA. Hemiarthroplasty in the treatment of hallux rigidus. Foot Ankle Int2008;29:273–81.

60 Townly CO. A metallic Hemiarthroplasty resurfacing prothesis for the Hallux

Metatarsophalangeal Joint. Foot Ankle Int 1994;15:575–80.61 Hahn MP, Gerhardt N, Thordarson DB. Medial capsular interpositional arthroplasty for

severe hallux rigidus. Foot Ankle Int 2009;30:494–9.62 Malerba F, Milani R, Sartorelli E et al. Distal oblique first metatarsal osteotomy in grade 3

hallux rigidus: a long-term follow-up. Foot Ankle Int 2008;29:677–82.

63 Konkel KF, Menger AG, Retzlaff SA. Mid-term results of Futura hemi-great toe implants.Foot Ankle Int 2008;29:831–7.

64 Wassink S, van den Oever M. Arthrodesis of the first metatarsophalangeal joint using asingle screw: retrospective analysis of 109 feet. J Foot Ankle Surg 2009;48:653–61.

65 Waizy H, Czardybon MA, Stukenborg-Colsman C et al. Mid- and long-term results of the

joint preserving therapy of hallux rigidus. Arch Orthop Trauma Surg 2010;130:165–70.66 van Dijk CN, Veenstra KM, Nuesch BC. Arthroscopic surgery of the metatarsophalangeal

first joint. Arthroscopy 1998;14:851–5.67 Tauro T. Dowel technique for metatarsophalangeal joint arthrodesis in hallux rigidus. Foot

2000;10:75–77.

68 Taranow WS, Moutsatson MJ, Cooper JM. Contemporary approaches to stage II and IIIhallux rigidus: the role of metallic hemiarthroplasty of the proximal phalanx. Foot AnkleClin 2005;10:713–28, ix-x.

69 Seeber E. Treatment of hallux rigidus with the TOEFIT-PLUSTM joint replacement system.Interact Surg 2007;2:77–85.

70 San Giovanni T, Shields N, Graf URS et al. Pain relief and functional improvement withmetatarsal resurfacing in Hallux Rigidus. Preliminary results in multicenter case series with asurgical alternative to joint fusion. Arthrosurface.com/LiteratureRetrieve. February 2007.

71 Ronconi P, Monachino P, Baleanu PM et al. Distal oblique osteotomy of the first metatarsalfor the correction of hallux limitus and rigidus deformity. J Foot Ankle Surg2000;39:154–60.

72 Rees RJ, Northover JR, Hartley RH et al. Extension osteotomy for hallux rigidus with dorsalimpingement. Foot 2006;16:125–9.

73 Raikin SM, Ahmad J, Pour AE et al. Comparison of arthrodesis and metallic hemiarthro-plasty of the hallux metatarsophalangeal joint. J Bone Joint Surg Am 2007;89:1979–85.

74 Oloff LM, Jhala-Patel G. A retrospective analysis of joint salvage procedures for grades IIIand IV hallux rigidus. J Foot Ankle Surg 2008;47:230–6.

75 Maher AJ. First MTP joint arthrodesis for the treatment of hallux rigidus: results of 29 con-

secutive cases using the foot health status questionnaire validated measurement tool. Foot2008;18:123–30.

76 Kennedy JG, Chow FY, Dines J et al. Outcomes after interposition arthroplasty for treatmentof hallux rigidus. Clin Orthop Relat Res 2006;445:210–5.





Dow

nloaded from


77 Hyer CF, Glover JP, Berlet GC et al. Cost comparison of crossed screws versus dorsal plate

construct for first metatarsophalangeal joint arthrodesis. J Foot Ankle Surg 2008;47:13–8.78 Hasselman CT. Resurfacing of the first metatarsal head in the treatment of Hallux Rigidus.

Foot Ankle Surg 2008;7:31–40.79 Harisboure A, Joveniaux P, Madi K et al. The Valenti technique in the treatment of hallux

rigidus. Orthop Traumatol Surg Res 2009;95:202–9.

80 Grondal L. Fusion of the first metatarsophalangeal joint, a review of techniques and consider-ations. Presentation of our results in 22 cases. Foot 2005;15:86–90.

81 Gonzalez JV, Garrett PP, Jordan MJ et al. The modified Hohmann osteotomy: an alternativejoint salvage procedure for hallux rigidus. J Foot Ankle Surg 2004;43:380–8.

82 Derner R, Goss K, Postowski HN et al. A plantar-flexor-shortening osteotomy for hallux

rigidus: a retrospective analysis. J Foot Ankle Surg 2005;44:377–89.83 Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic assess-

ment. Foot Ankle Int 2003;24:731–43.84 Roukis TS, Landsman AS, Ringstrom JB et al. Distally based capsule-periosteum interposi-

tional arthroplasty for hallux rigidus. Indications, operative technique, and short-term

follow-up. J Am Podiatr Med Assoc 2003;93:349–66.85 Gibson JN, Thomson CE. Arthrodesis or total replacement arthroplasty for hallux rigidus: a

randomized controlled trial. Foot Ankle Int 2005;26:680–90.

86 Drago JJ, Oloff L, Jacobs AM. A comprehensive review of hallux limitus. J Foot Surg1984;23:213–20.

87 Regnauld E. The Foot: Pathology, Aetiology, Semiology. Clinical Investigation andTreatment. Berlin: Springer, 345–59.

88 Dananberg HJ. Gait styles as an etiology to chronic postural pain. Part I. Functional Hallux

Limitus. J Am Pod Med Assoc 1993;83:433–41.89 Dananberg HJ. Gait styles as an etiology to chronic postural pain. Part II. Functional Hallux

Limitus. J Am Pod Med Assoc 1993;83:615–24.90 Hetherington VJ, Johnson RE, Albritton JS. Necessary dorsiflexion of the first metatarsopha-

langeal joint during gait. J Foot Surg 1990;29:218–22.

91 Dereymaeker G. [Surgical treatment of hallux rigidus]. Orthopade 2005;34:742–4, 746–7.92 Keiserman LS, Sammarco VJ, Sammarco GJ. Surgical treatment of the hallux rigidus. Foot

Ankle Clin 2005;10:75–96.

N. Maffulli et al.




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