First Report of Alternate Treatment for Hallux RigidusDegenerative arthritis of the big (great) toe is referred to as hallux rigidus. The joint affected is the metatarsophalangeal joint (where the main bone in the foot meets the first bone of the big toe). The condition is characterized by degeneration of the articular cartilage (lining the joint), bone spurs called osteophytes, and significant narrowing of the joint space.
Treatment for painful, limiting hallux valgus is surgical. In early stages (mild to moderate disease), there is a wide range of surgical approaches that can be taken. The surgeon can simply remove the bone spurs or take out the damaged portion of the joint surface. Sometimes releasing the soft tissue (capsule or synovium) is sufficient.
In more advanced cases, arthrodesis (fusion) of the joint is advised. In this report, surgeons from the Hospital for Special Surgery in New York City report on 64 patients who had a combination of two surgical procedures for advanced hallux rigidus.
Joint reconstruction (referred to as cheilectomy) using one or several of the methods described was combined with a second procedure known as proximal phalangeal osteotomy. After removing one-third of the big toe's metatarsal head, a wedge-shaped piece of bone was cut out of the phalange (toe bone). By moving the two remaining pieces of bone apart, it was possible to lengthen the metatarsal, thereby maintaining the length of the toe after removing the metatarsal head.
By combining these two techniques, the surgery is considered a joint-sparing (saving) procedure. By keeping the joint and avoiding a fusion procedure, patients are able to walk right away. They use special (stiff-soled) shoes to protect the osteotomy site until the bone heals.
But the results are well-worth it as the surgeons report a 100 per cent success rate (bone healing). And the procedure makes it possible for the first toe to bend as it should so that when walking, the patient can properly roll over the big toe to push the foot off the floor. This motion is called dorsiflexion. In order to preserve metatarsophalangeal dorsiflexion (toe bend before toe off), the patient does lose a portion of the opposite motion (toe pointing called plantar flexion.
These results are a significant improvement over foot function reported after an arthrodesis (fusion) procedure. As the long-term follow-up of this group of patients showed, no one had to eventually have a fusion. Foot function was maintained (at least in the early to mid-term results). It is speculated that joint degeneration may develop over time (perhaps even in the first 10 years after the surgical procedure). These patients will be followed longer to see just what does happen in the long-term period.
In conclusion, it is possible to use combination surgery to preserve the joint when surgically treating advanced cases of hallux rigidus. By using the standard tissue removal of bone spurs and damaged or degenerative bone and joint (cheilectomy) and then combining it with a lengthening osteotomy of the proximal phalangeal, motion and function of the joint can be saved. Patients are able to return to nearly normal weight-bearing almost immediately.
Martin Joseph O'Malley, MD, et al. Treatment of Advanced Stages of Hallux Rigidus with Cheilectomy and Phalangeal Osteotomy. In The Journal of Bone and Joint Surgery. April 3, 2013. Vol. 95A. No. 7. Pp. 606-610.
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