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Daniel E.

Greenan, DPM, FACFAS

Decreased/absent 1st MPJ ROM
Normal gait requires 65 to 75 degrees of dorsiflexion at

the 1st MPJ A progressive disorder characterized by decreased ROM and degenerative alteration of the 1st MPJ Secondary to faulty biomechanics or structural pathology

2nd most common painful affliction of the great toe

joint Affects up to 10% of adults Most commonly seen unilateral May be secondary to osteochondritis dessicans in the adolescent patient

This is the nuts and bolts of Hallux Rigidus
Most can diagnose Hallux Rigidus, but true

understanding is properly identifying the cause and offering appropriate treatment options Being able to do so will show the examiner that you have mastery of the condition

Etiology of Hallux Rigidus

Long 1st metatarsal (structural)
Hypermobile 1st ray (functional). Faulty biomechanics

can lead to hypermobility Immobility of 1st ray 1st ray elevatus Trauma Arthritis

Physical Exam subtleties

End range of 1st MPJ dorsiflexion is usually abrupt
Look for interphalangeal joint hyperextension Less pain with ankylosis

Plantar hallux hyperkeratosis

Transfer metatarsalgia

Classification Systems of Hallux Rigidus

Hanft Roukis/Jacobs


General Staging of Hallux Rigidus:

Stage I: Limited motion with weightbearing, mild

pain, no DJD, functional hallux limitus Stage II: Limited motion, pain at end ROM, early DJD, flattening of 1st metatarsal head, small osteophytosis, subchondral eburnation Stage III: Limited motion, pain with ROM, DJD, subchondral cyst formation, asymmetric joint space narrowing, osteophytosis, crepitus Stage IV: Ankylosis
ACFAS Clinical Practice Guideline

Conservative Options for Hallux Rigidus

Orthoses : Mortons Extension, 1st ray cut out
Shoe modifications or shoe quality: metatarsal bar,

rocker bottom sole, stiff sole Graphite plate Injection therapy NSAIDS

Surgical Options (joint specific/joint preserving)

Osteotomies Arthrodiastasis


Surgical Options (joint specific/joint destructive)

Implant Arthrodesis

Comparison of Arthrodesis, Implant and resectional arthroplasty

Similar long-term (average 3 years) patient satisfaction

scores for treatment of end stage Hallux Rigidus.

Procedure selection did not appear to be related to age All hemi-implants were placed in the base of the proximal


Kim PJ, Hatch D, DiDomenico LA, Lee MS, Kaczander B, Count G,

Kravette M. A Multicenter Retrospective Review of Outcomes for Arthrodesis, Hemi-Metallic Joint Implant and Resectional Arthroplasty in the Surgical Treatment of End-Stage Hallux Rigidus. J Foot Ankle Surg. 2012; 51: 50-56

Surgical Options (global considerations)

Ankle joint ROM?
Mobility of 1st Ray?


Do you need to consider other surgical procedures to

address any faulty biomechanics? Gastrocnemius recession or Lapidus Arthrodesis?

Surgical Considerations
Age of patient and longevity of procedure
Activity level of patient Etiology of Hallux Rigidus

Degree of joint degeneration

Biomechanical findings Patient expectations Surgeon experience

Daniel E. Greenan, DPM Slide #15 in your syllabus

Objectives of Talk
Present possible, realistic case scenarios involving

Hallux Rigidus that may be similar to those encountered in the oral portion of the ABPS Certification Exam To reinforce to you that all oral questions may be approached in a similar manner The key to success is being comfortable with the workup

Hallux Rigidus
Should be a familiar topic to all of us
There are many ways to address this problem, which makes

for a great exam question

Be confident in your approach Difficult to find a consensus: (AGE AND ETIOLOGY) Remember that an exam question usually involves several


While studying for Hallux Rigidus:

Think big picture
Is it functional or structural? What are the potential complications?

What is plan B if the initial treatment/procedure does

not work?

Grade I Hallux Rigidus Functional limitation of motion

Grade II Hallux Rigidus Joint adaptation

Grade III Hallux Rigidus Joint space narrowing, subchondral cysts and osteophytosis

Grade IV Hallux Rigidus Ankylosis of Joint

The History Card

Flip it over and read it out loud
All information present and not present is key Have your system in place and stay consistent

Exam Approach
Read yellow card out loud
Ask for any details in history that were not covered

(nature of pain, location, onset, duration, etc.) Ask for PMH, PSH, Medications, Allergies Ask for Family History, Social History, ROS Ask for Vitals if not given Physical Exam: ask in general terms, but may be steered to problem focused

Exam Approach

Stay consistent even though the examiner will

often move you along

Oral Exam Question # 1

A 42 year old, otherwise healthy female presents

complaining of pain in her great toe for approximately one year. She denies any acute trauma, but relates it started after she began running for exercise. She denies any previous treatment.

Oral Exam Question #1

A 42 year old, otherwise healthy, female presents complaining of pain in her great toe for approximately one year. She denies any trauma, but relates that it started after she began running for exercise. She denies any previous treatment.

Where do we go from here? We are told she is healthy

Oral Exam Question #1

Any other pertinent findings in the history? Non

contributory Any medications? None Any allergies? NKDA Family/Social History? History of CAD, type 2 diabetes. Patient denies ETOH, tobacco or other drug use. Single, lives alone ROS? Non-contributory

Oral Exam Question #1

Still have got to ask. Get the points for being

thorough. The examiner will move you along if there are not any other points to obtain Being consistent with your approach will ensure that you are not missing any chances at potential points Being consistent with your approach will also keep your management of the question focused and reproducible


Integument is intact.
Pedal pulses are +2/4 bilateral Intact neurological sensation. Achilles tendon and patellar

tendon reflexes are +2/4 bilateral right foot

Pain with palpation of the dorsal 1st metatarsal-phalangeal joint Pain at end range of dorsiflexion of 1st MPJ No crepitus

Oral Exam Question #1: Physical Exam Findings

1st ray range of motion is WNL Ankle joint dorsiflexion is decreased with the knee

extended and subtalar joint in neutral bilaterally Patient exhibits +5/5 strength 15 degrees of 1st MPJ dorsiflexion with the 1st ray loaded and 35 degrees of 1st MPJ dorsiflexion with the 1st ray unloaded
This may be given to you or you may need to walk

through it

Oral Exam Question #1: WHAT IS NEXT?

Ask what the foot looks like..
You may be handed a Photo or given a description

Foot appears to have a global Metatarsus

adductus alignment

Oral Exam Question #1: What is Next?

Have a systematic, reproducible approach to reading


Oral Exam Question #1

Ask for foot and ankle films

XRAY Exam 1st ray elevatus, no plantar gaping of 1st met-cuneiform joint, small osteophyte

What else may be needed?

Joint Fluid analysis? Other imaging?

Examiner will either give it to you or say non-

contributory or not available

Consider what you know

42 year old healthy female
Painful 1st MPJ Decreased ROM of 1st MPJ

Gastrocnemius equinus
Imaging findings First Ray? We were told ROM of 1st Ray was normal,

but what else needs to be considered?


Hallux Rigidus
May or may not need to stage..

Consider patient compliance, age, expectations,

biomechanical findings, xrays (joint integrity, 1st metatarsal length)

Dont Forget Conservative Care

Even though this is a surgical board question be

prepared to give conservative care options

Ask if conservative care has been exhausted If they move you along, go to your surgical options

Surgical Treatment
Be prepared to mention several options and explain

rational. This may be an area of concentration for obtaining points in the exam.
Try not to get discouraged if your choice is not the one

There are points to be had for knowing surgical


Surgical Treatment Options

They may ask you: What should be done and why?
They may ask you: What was done and why?

My Choice: Decompressional 1st Metatarsal Osteotomy and Gastrocnemius Recession

How would you do it? How would you fixate the

Why would you choose this option? What is your post operative care?

Joint is well preserved
1st metatarsal is long and elevated Hypermobility is not appreciated clinically or

radiographically Gastrocnemius equinus

Post-operative Care
2-3 weeks NWB in splint followed by 2-3 weeks of

protected WB in a boot or surgical shoe

No consensus is given for combination of procedures

In this case
A decompressional osteotomy and a gastrocnemius recession was performed

The Critique
You may be asked to evaluate the post-operative xrays Or at this point things may take a turn.

Things May Take a Turn.

Infection/osteomyelits Dehissence

Fixation failure Metatarsalgia/overload Know how to handle these complications

The examiner tells you:

First three months of post operative period were

uneventful At four months, patient presents complaining of increasing forefoot pain She denies any injury She is not wearing orthoses She is unable to return to exercise type activities

Why does she have forefoot pain?

Perform post operative physical to determine location

and cause of pain Remember to treat as you would in your office Review post-operative xrays and obtain new films

Examiner Tells You:

Pain is located sub 2nd metatarsal head 1st MPJ ROM is supple and WNL 2nd digit is contracted now and partially reducible
What else do we need to know? Stability of 2nd MPJ.

Does the toe purchase the ground? Is there increased dorsal excursion of the digit? Examiner tells you that the 2nd toe purchases the ground and increased dorsal excursion is not appreciated

Why Does She Have Pain?

Because the 1st metatarsal was excessively


Post Operative Xrays

1st ray was long, sesamoids are anatomic, joint appears decompressed

What would you do doctor?

What are conservative options? Be

specific(functional orthoses with metatarsal pad, 2nd metatarsal head cutout)

Well, that didnt provided the patient any relief Do you have a surgical remedy?

A 2nd Metatarsal Osteotomy and PIPJ Arthrodesis

Would You Consider a Plantar Plate Repair?

Not in this case, because the digit was clinically stable

What could be done to verify that there was not a

tear in the capsule? An arthrogram or MRI.

Periarticular Osteotomies of 1st Metatarsal for Hallux Rigidus

22.6% underwent surgical revision

Roukis T, Clinical Outcomes after Isolated Periarticular

Osteotomies of the First Metatarsal for Hallux Rigidus: A Systemic Review. J Foot Ankle Surg. 2010; 49(6): 553-560

Oral Exam Question #2

A 39 year old male presents complaining of increasing

pain in his right big toe since having surgery last year by another doctor in town. He relates that it only started to hurt after the surgery. He relates that some bone spurs were removed from the joint.

Oral Exam Question # 2

PSH: Foot Surgery Medications: Lisinopril

Social History: Smoker Family History: HTN please proceed to your physical Exam

Oral Exam Question #2

Integument? Unremarkable
Neurovascular? Intact Orthopedic? Be specific

Oral Exam Question 2

Nature and location of pain? Deep aching type

pain with ROM of 1st MPJ and with palpation of joint Any Crepitus? Mild ROM of 1st MPJ? Decreased Ankle Joint ROM? Within normal limits Any other pertinent physical findings? No, please proceed

Oral Exam Question 2

May I see the xrays of the foot?
These are the only two available. Please


AP Xray
loss of joint space, normal metatarsal parabola, subchondral sclerosis and cyst formation

Lateral Xray
1st ray elevatus, appears as though dorsal spur has been removed

What is Your Treatment Plan?

An Orthotic device with a Mortons Extension or a

rocker bottom shoe

He is wearing orthotics Please Proceed

Surgical Options
Keller? Resect base of PP with interposed capsule
Valenti? Resect base PP, Head First met Cheilectomy?Surrounding spur

Arthrodiastasis? Implant? Arthrodesis?

Please Offer a Surgical Treatment Plan for the Patient.

Base upon age, etiology, clinical, radiograghic and

intra-operative findings
Prior surgical intervention had been tried

You are told.

Intra-operatively, you find that 50% of the dorsal 1st

metatarsal cartilage is denuded or eroded

An Arthrodesis was Done

Please Explain the Surgical Technique

Dorsal medial incision
Curettage of Joint because of congruency and length Two point fixation How else could you have prepped the joint? What other procedures could be considered?

How Would You Position the Hallux?

Traditional = 10 to 15 degrees dorsiflexed to floor and

15-25 degrees of abduction (parallel to 2nd digit)

Position of Function = On the ground

Hallux is meant to bear weight and off load the metatarsals..

What is Your Post Operative Protocol

WB vs. NWB
Dayton, A., McCall, A. 100% radiographic fusion rate

at 6 weeks with immediate weightbearing, JFAS, 2004

DeDomenico, protected partial weightbearing in cast

boot x 1-2 weeks followed by full weightbearing in a walker shoe or boot x 2-3 weeks then progressing to a shoe

Be Ready for the Complication

Nonunion rate for arthrodesis of 1st MPJ is 2-13%
Hemi-implant arthroplasty has an osseous overgrowth

rate of 28.8% and lucency about the implant rate of 19.2%

Resectional arthroplasty shows a floating hallux in

30.9% of cases and lesser metatarsalgia in 14.5% of cases

Fusion Rates of 1st MPJ Arthrodesis

Single screw fixation = 71%
Crossed Screw fixation = 90% Dorsal plate fixation = 100% Dorsal plate and plantar screw = 93%
Dening J, Arthrodesis of the First Metatarsophalangeal Joint: A

Retrospective Analysis of Plate versus Screw Fixation. J Foot Ankle Surg 51: 172-175, 2012

Nonunion of

st 1


Please Evaluate the Xray

Orientation of distal screw is quite shallow, joint space gapping, radiolucency around screw threads