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.

1. HALLUX RIGIDUS & DJD
Prepared by:
Dr. Abdullah K. Ghafour
3rd year IBFMS trainee
Supervised by:
Dr. Hamid Ahmed Jaff

2. 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

3. 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.

4. 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

5. 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

6. PRESENTATION
 Radiographs:
 recommended views
 AP, lateral, and oblique views
 findings
 osteophytes, especially dorsal
 joint space narrowing
 subchondral sclerosis and cysts

7. CLASSIFICATION
Coughlin and Shurnas Classification
Exam Findings Radiographic Findings
Grade 0 Stiffness 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

9. 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.

10. 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.

11. TREATMENT
 Operative
 joint debridement and synovectomy
 indications
 patients with acute osteochondral or chondral defects

12. 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

13. 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

14. 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)

15. 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

16. 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)

17. 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.

18. 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

19. 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.

20. THANKS