In 1927, Cochrane noted that elastic resistance to dorsiflexion of the hallux was retained after the cheilectomy or dorsiflexion osteotomy of the metatarsal head and speculated that the shortening and tightness of the soft tissues below the first metatarsophalangeal joint would be the etiology of hallux rigidus. He devised a novel surgery in which the plantar tissues were divided using a plantar approach and reported good results in 12 patients with the disappearance of elastic resistance during dorsiflexion and with no recurrence. Although he identified the etiology of hallux rigidus and developed a revolutionary surgery that directly addressed the etiology, this approach has not yet been seen in current surgeries. Therefore, we hypothesized that current surgeries for hallux rigidus lack rationality regarding etiology and aimed to critically review joint-preserving surgeries based on etiology. First, we summarized the literature on proposed causes and explained how the condition progresses from shortened, tightened plantar soft tissues. We then reviewed joint-preserving surgeries in terms of etiology and treatment efficacy and finally mentioned the arthroscopic Cochrane procedure as a promising option.

Hallux rigidus (HR) is a prevalent arthritic condition in the foot. Cheilectomy is a common joint-preserving procedure for HR, involving the removal of prominent osteophytes to relieve impingement of the 1st MTPJ. This study aims to identify factors associated with the failure of cheilectomy in the treatment of HR. A retrospective review of a prospectively collected database from 2007 to 2021 identified all cheilectomy cases. The minimum follow-up was 2 years. Preoperative demographic data, patient-reported outcome measures (PROMs) and foot radiographs were collected. PROMs were reassessed in postoperative reviews, and cases were categorized as successes or failures. Failure was defined by meeting at least one of the following criteria at the latest review: 1) Visual analog pain score (VAS) more than or equal to 4, 2) undergoing subsequent revision procedures, or 3) reporting poor or terrible satisfaction with the surgery. The analysis involved 66 patients, with 19 failure and 47 success cases. Both groups showed similar age, BMI, and gender profiles. Preoperative radiographic parameters were comparable between groups. However, preoperative VAS was significantly higher in the failure group: 7.16 vs 5.23 (p = .0029). Logistic regression confirmed preoperative VAS as a predictor of nonresponse (p = .023). Receiver Operating Characteristic analysis established an optimal cut-off VAS score of 7.0. Patients with a preoperative VAS score of more than 7 had an odds ratio of 5.11 (p = .0055) for failure. A higher preoperative VAS score is significantly associated with cheilectomy failure in HR treatment, suggesting a cutoff score of 7.0.

Minimally invasive cheilectomy is becoming a more prominent surgical approach in the management of mild to moderate hallux rigidus. This systematic review aims to analyze and present the current literature on patient-reported outcomes following minimally invasive (MIS) cheilectomy for mild to moderate hallux rigidus.

PubMed, Cochrane Central Register of Controlled Trials, and Scopus databases were searched in April 2024. Inclusion criteria consisted of articles evaluating patients undergoing cheilectomy through an MIS approach either using fluoroscopy or arthroscopy, studies that reported patient-reported outcomes, and studies written in English. The primary outcome measure was scored patient-reported outcomes. The secondary outcome measures included complications, secondary surgeries, surgical techniques, return to activity, patient satisfaction, and grades of hallux rigidus.

Eight studies met the inclusion criteria, and a total of 296 patients were evaluated. Overall, 36 of 296 (12.2%) underwent arthroscopy with a shaver, 130 of 296 (43.9%) underwent an MIS percutaneous approach with burr, and 130 of 296 (43.9%) had a combination of both techniques. The mean reported range of motion (dorsiflexion) improved from 32.4 degrees (range, 6.3-50.0 degrees) to 61.2 degrees (range, 47.6-89.6 degrees). All studies that reported patient outcomes scores demonstrated improved outcomes regardless of surgical technique. Overall combined reported complication rate was 18 of 296 (6.1%), with the most common complication being dorsomedial cutaneous nerve problems, affecting 6 of 296 patients (2.0%).

Minimally invasive cheilectomy results in positive patient outcomes, patient satisfaction, preserves range of motion, and has low complication rates for the treatment of mild to moderate hallux rigidus.

Hallux rigidus can present a difficult problem to both competitive and elite athletic populations. Once an appropriate diagnostic workup has been performed, nonoperative management strategies, including anti-inflammatory medications, injection therapies, shoewear modifications, and orthotic devices, represent the mainstay conservative management options. Surgical management can be considered where an athlete's athletic performance is limited. A joint-sparing cheilectomy can provide a predictable return to sport at the most elite levels. The addition of a proximal phalangeal osteotomy can be considered when necessary. Arthroplasty or arthrodesis techniques can be used for persistent symptoms or progressive disease, but with less predictable outcomes.

Cheilectomy, a joint-conserving procedure, is often a first-line choice for treating early stages of hallux rigidus. Recent evidence has revealed its efficacy in treating more advanced stages. However, when degeneration is profound, first metatarsophalangeal (MTP) fusion remains the most appropriate strategy. Nevertheless, it is common for surgeons to proceed initially with cheilectomy, reserving joint fusion for subsequent considerations if cheilectomy fails. This article will explore the relationship between the 2 procedures and evaluate the research surrounding the effect of prior cheilectomy on first MTP joint arthrodesis.

Dorsal cheilectomy refers to a surgical resection of the dorsal osteophyte from the first metatarsal head. It is most often performed in patients with hallux rigidus, who have little to no midrange pain of the first metatarsophalangeal joint. The procedure is simple, quick, and maintains range of motion. Additional advantages of this procedure include low morbidity, quicker postoperative recovery, avoidance of costly implants, and the fact that the procedure does not inhibit future conversion to an arthrodesis. These proposed advantages have led some authors to advocate for the use of a cheilectomy, even in patients with more extensive disease.

Minimally invasive dorsal cheilectomy (MIDC) has become a popular alternative to an open approach for treating Hallux Rigidus (HR). To reduce some of the complications related to the MIDC approach, a first metatarsophalangeal (MTP) joint arthroscopy can be performed in addition to address the intra-articular pathology associated with Hallux Rigidus. This study aims to examine the effectiveness of MIDC with first MTP arthroscopy in patients with HR with a minimum 1-year follow-up.

This was a multicenter retrospective review for adult patients with Coughlin and Shurnass Grade 0-3 who were treated with MIDC and first MTP arthroscopy between 3/1/2020 and 8/1/2022, with at least one year of follow-up data. Demographic information, first MTP range of motion (ROM), visual analog scale (VAS), Manchester-Oxford Foot Questionnaire (MOXFQ), and EQ-5D-5 L scores were collected. Continuous data was expressed as a mean and standard deviation, categorical data was expressed as a percentage. Wilcoxon Rank Sum test was used to compare continuous variables. All P < 0.05 was considered significant.

A total of 31 patients were included in the study. Average follow-up time was 16.5 months (range: 12 to 26.2). There was 1 (3.2%) undersurface EHL tendon tear, 2 (6.5%) conversions to an MTP fusion, and 1 (3.2%) revision cheilectomy and capsular release for MTP joint contracture. There was a significant improvement in patient's ROM in dorsiflexion (50 vs 89.6 degrees, P = 0.002), postoperative VAS pain scores (6.4 vs 2.1, P < 0.001), MOXFQ pain scores (58.1 vs 30.7, P = 0.001), MOXFQ Walking/Standing scores (56.6 vs 20.6, P = 0.001), MOXFQ Social Interaction scores (47.3 vs 19.36, P = 0.002), and MOXFQ Index scores (54.7 vs 22.4, P < 0.001).

We found that MIDC with first MTP arthroscopy was effective at improving patient-reported outcomes at one year with low complication and revision rates. These results suggest that MIDC with first MTP arthroscopy is an effective treatment for early-stage HR.

IV.

Cheilectomy of the 1st metatarsophalangeal joint (MTPJ) is one of the most common procedures for the management of hallux rigidus. However, there is no consensus regarding outcomes following minimally invasive dorsal cheilectomy (MIDC) for the management of hallux rigidus.

To evaluate outcomes following MIDC for the management of hallux rigidus.

During November 2023, the PubMed, EMBASE and Cochrane Library databases were systematically reviewed to identify clinical studies examining outcomes following MIDC for the management of hallux rigidus.

Six studies were included. In total, 348 patients (370 feet) underwent MIDC for hallux rigidus at a weighted mean follow-up of 37.9 ± 16.5 months. The distribution of patients by Coughlin and Shurna's classification was recorded in 4 studies as follows: I (58 patients, 27.1%), II (112 patients, 52.3%), III (44 patients, 20.6%). Three studies performed an additional 1st MTPJ arthroscopy and debridement following MIDC. Retained intra-articular bone debris was observed in 100% of patients in 1 study. The weighted mean American orthopedic foot and ankle society score improved from a preoperative score of 68.9 ± 3.2 to a postoperative score of 87.1. The complication rate was 8.4%, the most common of which was persistent joint pain and stiffness. Thirty-two failures (8.7%) were observed. Thirty-three secondary procedures (8.9%) were performed at a weighted mean time of 8.6 ± 3.2 months following the index procedure.

This systematic review demonstrated improvements in subjective clinical outcomes together with a moderate complication rate following MIDC for the management of hallux rigidus at short-term follow-up. A moderate re-operation rate at short-term follow-up was recorded. The marked heterogeneity between included studies and paucity of high quality comparative studies limits the generation of any robust conclusions.

First metatarsophalangeal (MTP) arthrodesis is a common surgical intervention for addressing MTP pain and deformity. Despite great interest on the topic of return to sport (RTS) after first MTP arthrodesis in the literature, no systematic review exists on this topic. The purpose of this systematic review is to investigate RTS after first MTP arthrodesis.

This study is a systematic review using PubMed, Web of Science, CINAHL, and MEDLINE from database inception until May 10, 2023. Search algorithm used was (MTPJ OR MTP OR "hallux rigidus" OR cheilectomy OR metatarsal OR metatarsophalangeal) AND (arthrodesis OR fusion) AND sport. Inclusion criteria were surgical intervention of first MTP arthrodesis and outcomes related to sport.

Ten articles were included out of 249 articles initially retrieved. Patients (n = 450) had a frequency weighted mean (FWM) age of 58.6 ± 5.1 years with a FWM follow-up time of 32.1 ± 18.9 months. A total of 153 patients (reported in 34.0% of patients) had a FWM postoperative Foot and Ankle Ability Measure Sport score of 70.4 ± 21.8 at final follow-up. For sporting activities reported by multiple studies (running, yoga, golf, hiking, tennis, elliptical, and biking), about 9.8% to 28.1% of patients (n = 69 reports) stated that sporting activity difficulty decreased, 67.2% to 87.5% of patients (n = 340 reports) stated that sporting activity remained the same, and 1.8% to 8.5% of patients (n = 23 reports) stated that sporting activity difficulty increased after first MTP arthrodesis depending on the sporting activity. One article reported RTS time of 11.7 ± 5.1 weeks after first MTP arthrodesis (n = 39).

RTS after first MTP arthrodesis is highly variable depending on patient and sport. Numerous different sporting activities have high rates of RTS after first MTP arthrodesis, with a majority of patients reporting similar or increased ability to perform sporting activities after surgery.

Arthritis of the first metatarsophalangeal (MTP) joint, hallux rigid, is a common and disabling source of foot pain in the adult population. Hallux rigidus is characterized by diseased cartilage and large, periarticular osteophytes that result in a stiff, painful joint. Activity modification, sensible shoes, orthotics, anti-inflammatory medications and occasional intra-articular steroid injections can be attempted to alleviate the discomfort associated with hallux rigidus. A number of surgical options exist for the treatment of recalcitrant hallux rigidus. Cheilectomy is a useful treatment for dorsal impingement pain seen in mild hallux rigidus. A new polyvinyl alcohol hemi-arthroplasty implant has shown promising early and midterm results in the treatment of advanced hallux rigidus; however, arthrodesis of the first MTP joint remains the gold standard treatment for advanced hallux rigidus because of unpredictable outcomes after early-generation joint replacement implants.

Patients with hallux rigidus who do not experience significant pain relief after cheilectomy often require a conversion to metatarsophalangeal (MTP) fusion. However, it is unclear whether the previous cheilectomy affects outcomes of the subsequent fusion. The aim of this study was to compare patient-reported outcomes and complications in patients undergoing MTP fusion for hallux rigidus between patients with a history of cheilectomy and those undergoing a fusion as a primary procedure.

This retrospective cohort study included patients who underwent MTP fusion who had preoperative and minimum 1-year postoperative Patient Reported Outcomes Measurement Information System (PROMIS) scores. Patients were divided into a "primary MTP fusion" cohort and a "prior cheilectomy" cohort based on their history of a previous cheilectomy. Preoperative, postoperative, and improvement in PROMIS scores, along with rates of complications including nonunion, infection, interphalangeal (IP) joint pain, and removal of hardware were compared between groups.

The prior cheilectomy group had significantly lower preoperative physical function scores than the primary MTP fusion group (P < .05). Postoperatively, the prior cheilectomy group had worse physical function (P < .017) and global physical health (P < .017) scores. However, there were no significant differences in pre- to postoperative change in PROMIS scores. There were no significant differences in rates of nonunion (P = .99), infection (P = .99), or hardware removal (P = .99). More patients in the prior cheilectomy group had IP joint pain (P = .034).

This study found that a prior cheilectomy may not affect serious complication rates of a subsequent fusion, but it may be associated with worse baseline function. Overall, our results suggest that a prior failed cheilectomy does not influence the amount of improvement in function and pain from MTP fusion.

Level III, retrospective cohort study.

Hallux rigidus can be treated with a variety of surgical procedures, including joint preserving techniques, arthrodesis, and arthroplasty. The most commonly reported complications for joint preserving techniques consist of progression of arthritis, continued pain, and transfer metatarsalgia. Although good outcomes have been reported for arthrodesis overall, careful attention must be paid to technique and positioning of the toe to avoid nonunion or malunion. Arthroplasty preserves motion but in the case of failure can present the additional challenge of bone loss. In these scenarios, the authors recommend distraction bone block arthrodesis with structural autograft.

Mixed results for functional outcomes and long-term fixation have been reported for first metatarsophalangeal arthroplasty. This prospective study was designed to evaluate the migration of the BioPro metatarsophalangeal-1 (MTP-1) joint hemiprosthesis with Roentgen stereophotogrammetric analysis (RSA). Migration patterns of the prosthesis, prosthesis-induced erosion of the metatarsal bone, and clinical outcomes were evaluated sequentially to 5 years postoperation (PO).

Eleven female patients received the BioPro-1 hemiprosthesis. Prosthesis translation and metatarsal erosion were measured with RSA at immediately PO, 6 weeks, and 3, 6, 12, 36, and 60 months postoperatively. Clinical assessment was done by patient questionnaires.

RSA data of 9 patients were available for analysis. Median (range) number of markers used in RSA analysis, condition number, and mean error of markers around the prosthesis were 4 (3-7), 320 (208-862), and 0.13 (0.02-0.28), respectively. Progressive subsidence was seen up to 3 years PO (mean 2.1 mm, SE 0.32). Progressive metatarsal erosion was found from 1 year PO (mean 0.49 mm, SE 0.15). Pain, function, and quality scores improved after surgery and did not deteriorate at later follow-up moments.

Model-based RSA of the BioPro-1 prosthesis shows nonstabilizing medial and distal translation and metatarsal erosion. Despite the measured migration and erosion, clinical outcomes improved and remained similar up to 5 years postoperation.

Level II, prospective analysis of MTP-1 hemiprosthesis.

Hallux rigidus is the most common arthritic pathology of the foot. This review article discusses the pathophysiology and common clinical presentation of hallux rigidus. Furthermore, we discuss multiple classification systems that categorize the arthritic process and guide management. Surgical interventions include cheilectomy, Moberg osteotomy, synthetic cartilage implants, interpositional arthroplasty, and arthrodesis. The common complications are reviewed, and the rates of these complications highlighted. Surgical options for hallux rigidus globally have successful outcomes with low rates of complications when done on appropriate patients.

Arthritis of the foot is a significant cause of pain and disability. The prevalence of foot arthritis in adults aged ≥50 has been reported to be 17%. Of those, 25% are estimated to be radiographic arthritis of the first metatarsophalangeal joint. The purposes of this study were to (1) identify the prevalence of radiographic hallux rigidus (HR) in a population of patients with end-stage ankle arthritis relative to that reported in the general population and (2) identify associations between the presence of HR and demographic and clinical factors. A total of 870 feet in 809 subjects with end-stage ankle arthritis who underwent primary total ankle arthroplasty between November 2006 and November 2017 were included. Feet were stratified by patient age: <40, 40 to 59, 60 to 79, and ≥80 years. Etiology of ankle arthritis was classified as inflammatory, post-traumatic, primary, and other. The prevalence of HR in the study group was 72.9%. The prevalence of HR was slightly higher in patients with inflammatory arthritis (odds ratio 1.31, 95% confidence interval 0.73 to 2.32) and primary arthritis (odds ratio 1.18, 95% confidence interval 0.86 to 1.63). The prevalence of HR increased with age (p = .01). In conclusion, the prevalence of radiographic HR in a population with end-stage ankle arthritis was significantly higher relative to patients without documented comorbidities in the foot and ankle. Increasing age was associated with a higher prevalence of the disease.

Osteochondral fresh allograft transfer of the first metatarsal can be an accepted surgical management option for early stages of hallux limitus. This study consisted of evaluating clinical outcomes with patients who underwent this procedure. Thirteen (N=13) patients were included in this study, 10 (76.9%) were female and 3 (23.1%) were male. The mean age was 52.2 (range, 27-61) years and the mean body mass index was 25.3 (range, 33.8-19.4) kg/m². Intraoperative evaluation of osteochondral defects of the first metatarsal demonstrated a mean diameter size of 8.2 mm. Ten (76.9%) patients had a concomitant cheilectomy procedure performed. The mean follow-up was 41.0 (range, 3.5-89.1) months. American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale questionnaire and patient satisfaction survey were completed. The mean AOFAS Hallux Metatarsophalangeal-Interphalangeal score, which was determined postoperatively, was 71.2 (range, 55-85) of 100. Four (30.8%) patients with overall scores below 60 (range, 55-59) reported moderate daily pain at the first metatarsophalangeal joint. Mean AOFAS pain score was 26.9 (range, 20-30) of 40. Mean AOFAS function score was 30.8 (range, 24-35) of 45. Mean AOFAS alignment score was 13.4 (range, 8-15) of 15. There was statistical significance in mean AOFAS total score when comparing hallux limitus grade 1 versus grade 2, as well as when comparing grade 1 versus grade 3, p < .05. There was no significance in mean AOFAS total score when comparing number of plugs used, body mass index, and size of defect. However, an overall improvement in preoperative symptoms and patient satisfaction was documented and therefore osteochondral fresh allograft transfer can be considered a reasonable option in treating defects found at the first metatarsal head.

The surgical treatment of moderate-advanced hallux rigidus is controversial. Cheilectomy is widely used but has recurrence rates of up to 30%. Dorsal oblique metatarsal osteotomy (DOO) has also shown good results, however, there is no study comparing outcomes of the DOO against cheilectomy.

This was a retrospective propensity score matched study based on registry data from a single tertiary institution. Between 2007 and 2017, all patients who had undergone dorsal cheilectomy or DOO for hallux rigidus were included. Patients with previous foot surgery, revision surgeries, and concomitant surgical procedures were excluded. Clinical outcomes, complication rates, revision rates and patient satisfaction were assessed at 2 years postoperatively.

There were 44 patients (34 cheilectomy, 10 DOO). After propensity score matching, 17 cheilectomy and all 10 DOO cases were selected for comparison. Patients in both groups had a significant improvement in visual analogue pain scores (VAS) and AOFAS 1st toe scores 2-years post-operatively (P<0.001) with high levels of post-operative satisfaction (85.1%). Overall there were no statistically significant differences in post-operative scores, improvement in scores, complication rates, revision rates, and levels of patient satisfaction between groups.

Both the DOO and cheilectomy give similarly good outcomes for moderate-advanced hallux rigidus. Further studies are needed to elucidate differences in indications for each procedure.

For hallux rigidus, dorsal cheilectomy remains a treatment option even with advances in interposition techniques and devices. Cheilectomy aims to alleviate dorsal impingement and improve pain and function as well as range of motion. Cryopreserved umbilical cord allograft, with properties to mitigate inflammation and scar formation, has theoretical benefit for improving outcomes following cheilectomy. In this first prospective randomized and blinded cheilectomy study reported, we aimed to compare outcomes between cheilectomy alone and cheilectomy with umbilical cord allograft.

Patients were randomized to cheilectomy alone (CA) or cheilectomy with cryopreserved umbilical cord (ie, amniotic membrane-umbilical cord [AM-UC]). Patients were evaluated with American Orthopaedic Foot & Ankle Society (AOFAS), Foot Function Index (FFI), and visual analog scale (VAS) pain outcomes collected preoperatively and at 6 months and 1 year postoperatively. In addition, radiographic range of motion data were collected using stress radiographs. Fifty-one patients (26 AM-UC, 25 CA) completed the study, with 5 bilateral surgeries in the AM-UC group and 2 in the CA group, totaling 31 and 27 feet, respectively.

The AM-UC group had statistically significant improved AOFAS and FFI scores at 1 year compared with the CA group, but there was no difference at 6 months. There was no significant difference between groups for VAS-pain scores at any time point, but overall VAS-pain improved in both groups from preoperative values. There was no significant difference in range of motion (total arc) between groups and changes in range of motion (total arc) in both groups from preoperative to 1 year postoperative were small.

We present the results of the first randomized and blinded prospective study of cheilectomy surgery patients. When appropriately selected, cheilectomy remains a good option for patients with symptomatic hallux rigidus. Cryopreserved umbilical cord is a potential adjuvant to cheilectomy, with 1-year results showing improvements in functional outcome scores.

Level II, prospective comparative study.

The purpose of this study was to evaluate the need for first metatarsophalangeal joint (MTPJ) arthrodesis as a measure of the Youngswick osteotomy survival, or any other secondary procedures in the long term follow up in patients with stage II and III hallux rigidus.

We retrospectively evaluated 61 patients with stage II and III hallux rigidus who had undergone Youngswick osteotomy and analyzed their outcomes in the long term using first metatarsophalangeal arthrodesis as an end point. The candidates for inclusion underwent clinical and radiographic evaluation, including the Foot and Ankle Outcome Score (FAOS).

Mean follow-up time was 54.8 months. All patients had improved their FAOS, with all achieving postoperative scores >75 points at the final follow up (P<0.05). Although 49 % (P<0.05) of the patients depicted worsening of the radiological aspect of the MTPJ, over the long time, no patient needed a first MTPJ arthrodesis.

Our results show satisfying long-term outcomes with regard to function, pain relief, and patient satisfaction of the Youngswick osteotomy in grade II as well as grade III hallux rigidus that sustained over the follow up period; even in patients followed up for over 13 years.

III.

In 2016, the US Food and Drug Administration (FDA) approved the use of a polyvinyl alcohol (PVA) hydrogel implant for the surgical management of hallux rigidus. Though recent studies have evaluated the safety and efficacy of the implant, no study has compared outcomes following PVA implantation with those following traditional joint-preserving procedures for hallux rigidus, such as cheilectomy with Moberg osteotomy. The purpose of this study was to compare clinical and patient-reported outcomes for patients undergoing cheilectomy and Moberg osteotomy, with or without PVA implant, at a single multisurgeon academic center. Our hypothesis was that the addition of the PVA implant would result in superior clinical and patient-reported outcomes.

In total, 166 patients were identified who underwent cheilectomy and Moberg osteotomy with (PVACM; n = 72) or without (CM; n = 94) a PVA implant between January 2016 and December 2018 by 1 of 8 foot and ankle fellowship-trained orthopedic surgeons at our institution. Of these patients, 60 PVACM and 73 CM patients had both baseline and minimum 1-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. The average time to survey follow-up was 14.5 months for PVACM patients and 15.6 months for CM patients. Retrospective chart review was performed to assess the incidence of postoperative complications and reoperations, with an average clinical follow-up of 27.7 (range, 16.0-46.4) months for PVACM patients and 36.6 (range, 18.6-47.8) months for CM patients.

Both PVACM and CM cohorts demonstrated significant improvement in the PROMIS Physical Function, Pain Interference, Pain Intensity, and Global Physical Health domains when comparing preoperative and postoperative scores within each group (P < .01). When comparing scores between the PVACM and CM cohorts, preoperative scores were similar, while CM patients demonstrated significantly higher postoperative Physical Function (51.8 ± 8.7 vs 48.8 ± 8.0; P = .04) and significantly lower Pain Intensity (39.9 ± 8.3 vs 43.4 ± 8.7; P = .02) scores. The pre- to postoperative change in Physical Function was also significantly greater for CM patients (7.1 ± 8.5 vs 3.6 ± 6.2; P = .011). In the PVACM group, there were 3 revisions (5%), 1 reimplantation, 1 conversion to arthrodesis, and 1 revision to correct hyperdorsiflexion. In the CM group, there was 1 revision (1.4%), a conversion to arthrodesis (P = .21). Other postoperative complications included persistent pain (7 out of 60 PVACM patients [11.7%] and 8 out of 73 CM patients [11.0%]; P = .90) and infection in 3 PVACM patients (5%) and no CM patients (P = .05).

Though our results generally support the safety and utility of the PVA implant as previously established by the clinical trial, at 1 to 2 years of follow-up, CM without a PVA implant may provide equivalent or better relief compared with a PVACM procedure, while avoiding potential risks associated with the implant.

Level III, retrospective comparative study.

Hallux rigidus is a common arthritic condition that has been addressed surgically with a range of techniques, from an isolated cheilectomy to first metatarsophalangeal (MTP) joint fusion. Recently, hemiarthroplasty with polyvinyl alcohol (PVA) hydrogel implant has been used as an alternative treatment to relieve pain while preserving motion of the first MTP joint. We retrospectively reviewed patient-reported outcome scores and clinical outcomes for patients treated for hallux rigidus with PVA hydrogel implant at an academic, multisurgeon center.

A total of 103 patients who underwent first MTP hemiarthroplasty with PVA hydrogel implant between January 2017 and October 2018 were retrospectively reviewed (average, 26.2 months). Eight surgeons were represented. Baseline Patient-Reported Outcomes Measurement Information System (PROMIS) scores for the Physical Function, Pain Interference, Pain Intensity, Global Physical Health, Global Mental Health, and Depression domains were collected prospectively and compared with PROMIS scores collected at a minimum of 1 year postoperatively (average, 13.9 months). Seventy-three patients had both preoperative and postoperative scores. Ten of these patients had undergone a prior procedure of the first MTP, and 52 underwent concurrent Moberg osteotomy at the time of PVA hydrogel implantation.

For patients with baseline and postoperative PROMIS scores, significant pre- to postoperative improvement was detected for the Physical Function, Pain Interference, Pain Intensity, and Global Physical Health domains (P < .05). Patients who had undergone a prior procedure of the first MTP had significantly higher postoperative Pain Intensity scores compared with those who did not undergo a prior procedure. Patients undergoing concurrent Moberg osteotomy had significantly lower postoperative Pain Interference and Pain Intensity scores compared with those who did not undergo a Moberg. Two patients underwent revision procedures in the first 2 years postoperatively, one with revision hemiarthroplasty and one with conversion to arthrodesis.

On average across our entire cohort, physical function and pain scores improved significantly pre- to postoperatively; however, postoperative pain scores were significantly higher for patients who had undergone a prior procedure of the first MTP and significantly lower for patients who underwent concurrent Moberg osteotomy. The implant displayed excellent survivorship in the first 2 years postoperatively, with only 2 revision procedures.

Level III, comparative series.

Several operative interventions are available to alleviate pain in hallux rigidus, and the optimal operative technique is still a topic of debate among surgeons. Three of these are arthrodesis, cheilectomy, and Keller's arthroplasty. Currently, it is unclear which intervention yields the best long-term result. The aim of this study was to assess which of these interventions performed best in terms of patient-reported outcome, pain scores, and disease recurrence at long-term follow-up.

These data are the follow-up to the initial study published in 2006. In the original study, 73 patients (n = 89 toes) with symptomatic hallux rigidus were recruited and underwent first metatarsophalangeal joint arthrodesis (n = 33 toes), cheilectomy (n = 28 toes), or Keller's arthroplasty (n = 28 toes). Outcome measures were AOFAS hallux metatarsophalangeal-interphalangeal (HMI) score, and pain was assessed with a visual analog scale (VAS) at a mean follow-up period of 7 years. Patients of the original study were identified and invited to participate in the current study. Data were collected in the form of AOFAS-HMI score, VAS pain score, Manchester-Oxford Foot Questionnaire (MOXFQ), and Forgotten Joint Score (FJS-12). In addition, a clinical examination was performed and radiographs were obtained. Data were available for 37 patients (45 toes), with a mean follow-up period over 22 years.

AOFAS-HMI and VAS pain score improved during follow-up only in arthrodesis patients. Furthermore, no statistically significant differences in clinical and patient-reported outcome were detected between groups based on AOFAS-HMI, VAS pain, MOXFQ, or FJS-12. However, clinically important differences in patient-reported outcomes and pain scores were detected, favoring arthrodesis. Radiographic disease progression was more evident after cheilectomy compared with Keller's arthroplasty.

Arthrodesis, cheilectomy, and Keller's arthroplasty are 3 sucessful operative interventions to treat symptomatic hallux rigidus. Because clinically important differences were detected and symptoms still diminish many years after surgery, a slight preference was evident for arthrodesis.

Level III, comparative study.

This study aimed to evaluate the clinical and radiological outcome after cheilectomy and proximal phalangeal biplanar osteotomy for patients with mild and advanced stages of hallux rigidus.

A total of 105 feet (grades 0-4) were treated with cheilectomy and a Moberg-Akin osteotomy of the proximal phalanx. All patients were clinically assessed preoperatively and followed up for 12 months by range of motion, visual analog scale (VAS) pain score, American Orthopaedic Foot & Ankle Society (AOFAS) score, Short Form 36 (SF-36) score, and weightbearing radiographs.

This operative procedure resulted in a statistically significant positive effect on mobility of the first metatarsophalangeal joint (P = .001), VAS pain score (P < .001), AOFAS score (P < .001), and SF-36 score (P < .001).

Cheilectomy and biplanar osteotomy of the proximal phalanx was an effective procedure for hallux rigidus with a positive effect on clinical and radiological outcome.

IV, case series.

Dorsal cheilectomy of the first metatarsophalangeal joint is an accepted treatment to alleviate dorsal impingement, pain, and reduced dorsiflexion in hallux rigidus. Traditionally performed via an open incision, this procedure has more recently been performed using minimally invasive techniques despite limited supportive published evidence.

From December 2012 through December 2017, a retrospective analysis of all cheilectomies performed in our institution was done. The surgical technique was recorded along with any subsequent procedures performed for either persistent or recurrent pain, and complications were also noted. A comparison between open and minimally invasive outcomes was performed. In total, 171 cheilectomies were performed during this period. There were 38 open and 133 minimally invasive procedures.

At a mean 3-year follow-up, the reoperation rates of the 2 groups were different with only 1 (2.6%) of the open group requiring a fusion, while 17 (12.8%) of the minimally invasive surgical (MIS) group required further surgery (relative risk, 4.86; P = .059). In the open group, there was 1 (2.6%) complication, compared with 15 (11.3%) in the minimally invasive group (relative risk, 4.29; P = .076).

While patients may opt for MIS cheilectomy with a proposed faster recovery time and better cosmesis, they should be counseled about the risks and benefits of both methods, and that the technique of MIS cheilectomy utilized in this study appears to have an increased relative risk of requiring a further procedure.

Level III, retrospective comparative series.

Hallux rigidus is the most common arthritic condition in the foot. First metatarsophalangeal joint cheilectomy produces satisfactory results in retrospective studies with reported good to excellent results in up to 97% and pain relief and function in 92%. The results of cheilectomy for higher grades of hallux rigidus are less favorable. The purpose of this study was to evaluate the long-term functional results and survivorship of cheilectomy for treatment of hallux rigidus.

This was a retrospective, questionnaire-based study investigating the long-term results of cheilectomy for treatment of hallux rigidus. The preoperative arthritic grade was graded retrospectively according to the Hattrup and Johnson (H&J) grading system. A questionnaire was administered via email or telephone that included questions regarding pain recurrence following surgery, current functional status, and satisfaction with the operation. Kaplan-Meier survival analysis was performed to estimate survival time between arthritic grades. We reviewed 165 patients (169 feet) with an average follow-up of 6.6 (5.0-10.9) years.

The overall survival rate (painless at the time of last follow-up) was 70.4% (119 feet), with no significant difference between the 3 H&J arthritic grades. Most of the recurrences (28 feet, 75%) were at the first 2 years following the surgery. Nine feet (5.3%) had a second procedure at a mean postoperative time of 3.6 (range, 1.6-7.4) years. Of the 169 feet, 117 (69.3%) reported being satisfied or very satisfied and 127 (75.1%) indicated they would repeat the operation under the same circumstances.

Our study supports the use of cheilectomy for treatment of hallux rigidus (grade 1-3 Coughlin and Shurnas) as a reliable procedure with favorable results. At long-term follow-up, patients who underwent cheilectomy had a low revision rate and a moderately low rate of pain recurrence.

Level IV, retrospective case-series.

Arthrodesis of the first metatarsophalangeal (MTP) joint has been shown to be effective in alleviating pain and correcting deformity in hallux rigidus. However, outcomes in specific sports and physical activities remain unclear. The aim of this study was to assess sports and physical activities in young patients following first MTP joint arthrodesis and to compare these results with clinical outcomes.

Patients between ages 18 and 55 years who underwent MTP arthrodesis were identified by review of a prospective registry. Fifty of 73 eligible patients (68%) were reached for follow-up at a mean of 5.1 (range, 2.2-10.2) years with a mean age at surgery of 49.7 (range, 23-55) years. Physical activity was evaluated with a previously developed sports-specific, patient-administered questionnaire. Clinical outcomes were evaluated with the Foot and Ankle Outcome Score (FAOS).

Patients participated in 22 different sports and physical activities. The most common were walking, biking, weightlifting, swimming, running, and golf. Compared to preoperatively, patients rated 27.4% of activities as less difficult, 51.2% as the same, and 21.4% as more difficult. Patients returned to 44.6% of preoperative physical activities in less than 6 months and reached their maximal level of participation in 88.6% of physical activities. Ninety-six percent of patients (48/50) were satisfied with the procedure regarding return to sports and physical activities. Improvements in the FAOS Symptoms subscore were associated with increased postoperative running and walking duration, and improvements in FAOS Pain subscores were associated with greater patient satisfaction.

Patients were able to participate in a wide variety of sports and physical activities postoperatively. Some patients reported increased difficulty, but were nonetheless satisfied with the procedure regarding physical activity participation. These findings suggest that first MTP joint arthrodesis is a reasonable option in young, active patients, and may be used to guide postoperative expectations.

Level IV, retrospective case series.

Few studies reporting long-term results of surgical treatment of hallux rigidus have been published. The aim of this study is to assess the clinical outcome of Valenti procedures in a series of patients with hallux limitus/rigidus with a minimum 10-year follow-up time. We retrospectively evaluated 38 patients (40 feet) who underwent a Valenti procedure with a mean follow-up of 132 ± 19.6 (range 114 to 184) months. All patients were clinically reassessed on the basis of the evaluation of pain (visual analogue scale), function (American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale Assessment and Foot & Ankle Disability Index), and subjective satisfaction. The scores before and after treatment, obtained from clinical recordings and clinical evaluation during the last follow-up visits, were compared. We found significant improvement of the mean values of the visual analogue score (p < .0001), Foot & Ankle Disability Index (p < .0001), and American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale Assessment (p < .0001) during the latest follow-up visits. The results suggest that the Valenti technique represents a safe, reproducible surgical procedure that allows satisfying long-term results. The few reported complications were essentially the progressive worsening of the joint stiffness, but no sesamoiditis, metatarsal overload, secondary surgeries, or failures were documented.

Following failure of conservative treatment, a dorsal cheilectomy can be performed for patients in early stages of hallux rigidus by a traditional open approach or by a minimally invasive technique. We report our clinical outcomes following minimally invasive dorsal cheilectomy (MIDC).

Eighty-nine patients (98 feet) with symptomatic hallux rigidus treated between 2011 and 2016 were included in this study. The average age was 54 years. Manchester-Oxford Foot Questionnaire (MOxFQ) scores and visual analog scale (VAS) pain scores were collected. The mean follow-up was 50 months.

The average VAS score improved from 8.0 preoperatively to 3 postoperatively. The mean MOxFQ summary index score decreased from 58.6 preoperatively to 30.5 postoperatively. All 3 MOxFQ domains also improved. Swelling took an average of 5.3 weeks to settle. There were 2 wound infections and 2 delayed wound healings. Two patients had transient nerve paraesthesia, while 2 patients had permanent numbness in the dorsomedial cutaneous nerve distribution. Twelve patients (12%) underwent reoperation, of which 7 had a first metatarsophalangeal joint arthrodesis for ongoing pain, 4 had repeat cheilectomy for residual impingement, and 1 had an open removal of loose bone.

Our results suggest that MIDC resulted in improvement in patient-reported outcome measures and was a safe technique with minimal complications. The complications were similar to open cheilectomy. There was an associated learning curve as 5 of our reoperations were due to incomplete cheilectomy. Coughlin grade 1 did well with MIDC as with open cheilectomy as none went onto an arthrodesis. However, 10% (7/65) of our grade 2 and 3 cases went on to an arthrodesis.

Level IV, retrospective case series.

Focal damage to articular cartilage, also called an osteochondral defect (OCD), can be a cause of pain and decreased range of motion. Recent advancements have led to transplantation techniques using particulated juvenile articular cartilage allograft. This technique has been applied to the first metatarsal head to a very limited degree, with no published results to our knowledge. The aim of this study was to review the clinical results of patients who underwent particulated juvenile cartilage allograft implantation for first metatarsal head OCDs.

We performed a retrospective consecutive case series study. Nine patients, at an average age of 41 years, were treated for symptomatic focal osteochondral defects of the first metatarsal head with particulate cartilage grafting from 2010 to 2016. Patients were contacted by phone to assess interest in returning to the office for follow-up, where weightbearing radiographs of the foot were obtained and a foot examination was performed.

At an average follow-up of 3.3 years, 7 of 9 patients reported no pain with recreational activities and no patient required further operations. This patient cohort was physically active, with 6 of 9 listing running as a regular activity. The average overall American Orthopaedic Foot & Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale questionnaire score was 85 (maximum 100), AOFAS pain 35.6 (maximum 40), and AOFAS function 40.1 (maximum 45). Patient satisfaction surveys correlated with the AOFAS scores and revealed that 7 of 9 patients were very satisfied with their results, 1 was satisfied, and 1 patient was very dissatisfied.

Particulated juvenile cartilage allograft transplantation is a promising treatment option for symptomatic first metatarsophalangeal focal articular cartilage lesions. Further study is needed to demonstrate which lesions respond better to this type of cartilage graft versus traditional marrow-stimulating procedures.

Level IV, retrospective case series.

Foot osteoarthritis (OA) is a common problem in older adults yet is under-researched compared to knee or hand OA. Most existing studies focus on the first metatarsophalangeal joint, with evidence relating to midfoot OA being particularly sparse. Symptomatic radiographic foot OA affects 17% of adults aged 50 years and over. The first metatarsophalangeal joint is most commonly affected, followed by the second cuneometatarsal and talonavicular joints. Epidemiological studies suggest the existence of distinct first metatarsophalangeal joint and polyarticular phenotypes, which have differing clinical and risk factor profiles. There are few randomized controlled trials in foot OA. Existing trials provide some evidence of the effectiveness for pain relief of physical therapy, rocker-sole shoes, foot orthoses and surgical interventions in first metatarsophalangeal joint OA and prefabricated orthoses in midfoot OA. Prospective epidemiological studies and randomized trials are needed to establish the incidence, progression and prognosis of foot OA and determine the effectiveness of both commonly used and more novel interventions.

Hallux rigidus can be treated using several different methods and the best treatment option depends on the severity of degenerative changes of the metatarsophalangeal (MTP) joint. However, the ideal operative option for advanced hallux rigidus remains debatable. This prospective study was performed to evaluate the intermediate-term clinical outcomes of distal metatarsal osteotomy used as a joint-preserving method for the treatment of advanced hallux rigidus.

Forty-two cases (39 patients) were followed for more than 3 years after distal metatarsal dorsiflexion osteotomy for advanced hallux rigidus of grade III-IV. Clinical evaluations included the American Orthopaedic Foot & Ankle Society (AOFAS) scores, Foot and Ankle Ability Measure (FAAM) scores, and patient subjective satisfaction scores. Range of motion (ROM) of great toe, complications, reoperation rates, width of the MTP joint space, and times to union were evaluated.

Mean AOFAS hallux and mean FAAM scores significantly improved from 56.4 and 61.2 points preoperatively to 87.6 and 88.7 points at final follow-up, respectively ( P < .001). Grade III and IV groups had significantly different AOFAS and FAAM scores at final follow-up. Mean dorsiflexion of great toe significantly improved from 14.8° preoperatively to 35.5° at final follow-up ( P < .001). Mean patient satisfaction score at final follow-up was 92.8 points. There were 4 cases (9.5%) of subsequent fusion and 2 cases (4.8%) of transfer metatarsalgia.

Distal metatarsal dorsiflexion osteotomy using bio-compression screws appears to be an effective operative option for grade III advanced hallux rigidus with viable cartilage on >50% of the first metatarsal articular surface, as it restored joint motion, provided reliable pain relief, and did not require implant removal. However, based on the unsatisfactory clinical results and the high rate of reoperation observed, the authors cannot recommend this operative method for the treatment of end-stage (grade IV) hallux rigidus.

Level IV, prospective case series.

An estimated 40% of the US population have foot problems.Of all patients aged over 50 years, 2.5% report degenerative arthritis of the first metatarsophalangeal (MTP) joint, termed 'hallux rigidus'. First MTP osteoarthritis is the most common arthritic condition in the foot.Progression of great toe arthritis is associated with pain and loss of motion. Non-surgical intervention begins with shoe modifications and orthotics designed to limit MTP motion.In patients with mild arthritis, operative procedures focus on removing excess osteophytes (cheilectomy) to prevent dorsal impingement with or without a concomitant osteotomy (Moberg) to improve or shift range of motion into a less painful arc.In patients with more advanced arthritis, operative management has centred on arthrodesis of the first MTP joint.A recent Level 1 study shows excellent function and pain relief with a small hydrogel hemi-implant into the metatarsal headMultiple joint-sparing procedures such as joint arthroplasty or resurfacing have been described with inconsistent results. Cite this article: EFORT Open Rev 2017;2:13-20. DOI: 10.1302/2058-5241.2.160031.

Arthroscopic approaches to subtalar, double, and triple arthrodesis allow relative preservation of the soft tissue envelope compared with traditional open approaches. The surgical technique involving the use of a 4.5-mm 30° arthroscope via sinus tarsi portals is described. All 3 joints of the triple joint can be prepared for fusion with motorized burrs. Rigid fixation is achieved with cannulated screws. High union rates and low complication rates have been reported.

Surgical treatment of moderate hallux rigidus remains controversial and the optimal surgical technique has yet to be defined. Decompressive metatarsal osteotomy is one of the procedures available; however, one of the potential drawbacks is the effect of the metatarsal shortening. We evaluated the global effect of the decompressive metatarsal osteotomy, accounting for the metatarsal index. We retrospectively evaluated 78 patients with stage II and III hallux rigidus who had undergone Youngswick osteotomy and analyzed their outcomes according to the metatarsal index. The candidates for inclusion underwent clinical and radiographic evaluation, including the visual analog scale foot and ankle score, first metatarsophalangeal joint range of motion, and first metatarsal protrusion distance to define the metatarsal index. Also, shortening of the first metatarsal was measured postoperatively, and the occurrence of metatarsalgia was considered a postoperative complication. The mean follow-up period was 53 ± 17 months. The groups stratified according to the metatarsal index (index plus, index plus minus, and index minus) presented with similar results (p > .05). The average preoperative visual analog scale foot and ankle score of 56.4 ± 13.8 points improved significantly to 84.1 ± 5.5 points postoperatively (p < .0001). Also, the mean preoperative dorsiflexion of 20.4° ± 1.5° improved to 37.3° ± 1.6° postoperatively (p < .0001). Of the 78 patients, 97% would recommend the procedure to a family member or friend. Four patients (6%) experienced postoperative metatarsal pain. We found consistent results with this procedure. The reported functional score and dorsiflexion improvement provide evidence that good outcomes and high levels of patient satisfaction can be achieved, regardless of the metatarsal length.

The reliability of range of motion (ROM) measurements has not been established for the hallux metatarsophalangeal (MTP) joint in patients with hallux rigidus. The aim of the present study was to prospectively assess the clinical versus radiographic difference in ROM of the arthritic hallux MTP joint.

One hundred consecutive patients who presented with any grade of hallux rigidus were included in this prospective study to determine the hallux MTP range of motion. Clinical range of motion using a goniometer and radiographic range of motion on dynamic x-rays was recorded.

The mean difference between clinical and radiographic dorsiflexion was 13 degrees (P < .001). For all measurements, clinical dorsiflexion was equal to or less than radiographically measured dorsiflexion. The difference was significantly greater in patients with a clinical dorsiflexion of less than 30 degrees than in patients with 30 degrees or more. Radiographic measurement of hallux dorsiflexion had an excellent intra- and interobserver reliability.

We describe a reliable, reproducible, and straightforward method of measuring hallux MTP ROM that improved upon measuring clinical ROM.

Level II, prospective comparative study.

Forty-seven patients (50 feet) underwent surgical intervention for symptomatic hallux rigidus from February 1998 to April 1999. Thirty-eight patients (41 feet) returned at 1 year for a follow-up evaluation. Of these 38 patients, 20 (21 feet) returned for the 15-year follow-up evaluation. Subjective evaluations were performed using the modified American Orthopaedic Foot and Ankle Surgery hallux metatarsophalangeal-interphalangeal 100-point scale. Long-term postoperative objective physical examination and radiographic analysis were performed. These data were compared with the preoperative and short-term follow-up data. The subjective evaluation showed a statistically significant differing over the long term, with a mean increase of 27.6 points. The results of the physical examination and radiographic measurements were mixed. The long-term dorsal range of motion was not significant across surgery type. Radiographically, the procedure types resulted in similar changes, suggesting that neither joint preservation nor joint destructive procedures were more stable over time. Plantar transposition of the capital fragment, offsetting the longitudinal shortening of the first metatarsal, was not significant, confirming the short-term findings. For this patient population, the long-term results of surgical intervention for hallux rigidus, regardless of procedure type, provided subjective patient improvement but no statistically significant increase in first metatarsophalangeal joint function or dorsal range of motion.

Existing techniques for operative treatment of hallux rigidus commonly combine skeletal and soft tissue interventions to obtain long-lasting relief of pain. To date, operative treatments include implant arthroplasty, cheilectomy, various osteotomies, nonimplant arthroplasty, and arthrodesis. We assessed a technique that respects the anatomy and joint function and used a shortening osteotomy of the head of the first metatarsal.

We evaluated a series of 40 consecutive patients affected by grade II and III hallux rigidus, aged 32 to 79 years, who had undergone surgery from January 2010 to January 2014. All patients were evaluated clinically and radiographically, preoperatively and postoperatively, and underwent a final follow-up at a mean of 35.4 (range = 12-51) months. For the clinical evaluation, the American Orthopaedic Foot & Ankle Society (AOFAS) clinical rating scale for the hallux metatarsophalangeal-interphalangeal joints was used.

A patient survey revealed excellent and good overall satisfaction in 90% of the sample. Postoperative results included a significant increase (P < .001) in the median global AOFAS score, from 39 (range = 25-60) to 84 (range = 78-94).

The technique of a shortening osteotomy of the first metatarsal head appeared to be useful for the correction of stiffness, pain relief, and an improvement in range of motion. Other advantages were that it preserved the integrity of the metatarsophalangeal joint and led to a rapid functional recovery.

Level IV, retrospective case series.

Cheilectomy is the surgical resection of 20% to 30% of the dorsal metatarsal head and proximal phalanx. The present retrospective study evaluated the long-term efficacy of aggressive cheilectomy to address degenerative joint disease of the first metatarsophalangeal joint. To our knowledge, this is the second longest duration study to date to evaluate the long-term efficacy of the cheilectomy procedure, with a mean follow-up period of 7.14 years (range 39 weeks to 14.87 years). The mean patient age was 55.71 ± 9.51 years, and 37 (65%) of the patients were female. Age, sex, foot type, and preoperative radiographic parameters of hallux rigidus were also evaluated and correlated. The mean percentage of success with this operation was 87.69%. Of the 58 patients, 51 (87.93%) experienced no limitations in their daily activities. Only 2 patients (3.33%) subsequently required subsequent arthrodesis. The results of the present study suggest that cheilectomy offers long-term satisfaction for patients with hallux rigidus and is an acceptable alternative to the joint destructive procedure of first metatarsophalangeal arthrodesis.

Diabetic foot ulceration of the plantar hallux is a challenging condition and can require partial hallux amputation when complicated by infection. Lower extremity biomechanics play an important role in the development of hallux ulcers, and hallux rigidus (HR) could influence the outcomes after partial hallux amputation. We hypothesized that radiographic evidence of HR in patients with diabetes would be associated with greater ulcer recurrence and reamputation rates after partial hallux amputation. We performed a retrospective review of all patients with diabetes who had undergone a partial hallux amputation from January 2005 to December 2012. The subjects were divided into 2 cohorts according to the presence or absence of HR identified on preoperative radiographs. Baseline characteristics and outcomes were compared using a 2-sample Student's t test for continuous variables, and categorical variables were compared using the chi-square test for homogeneity and Fisher's exact test. A total of 52 patients were included, with 16 (31%) positive for radiographic evidence of HR at partial hallux amputation. Differences in the patient demographics and comorbidities were not significant between 2 cohorts with and without HR or reamputation. Reamputation was required in 5 subjects (31%) with HR and 2 (6%) without HR (p = .023). The average follow-up duration was 126 ± 89 weeks. Our results have demonstrated that the reamputation rate after partial hallux amputation is significantly greater in patients with than in those without radiographic evidence of HR. Surgeons should evaluate patients for HR when planning partial hallux amputation and use adjuvant methods of offloading when HR is evident to prevent recurrent ulceration and reamputation.

Cheilectomy consists of excision of the dorsal exostosis and part of the metatarsal head. It is typically performed for patients in the earlier stages of hallux rigidus presenting with dorsal pain and dorsiflexion stiffness in the absence of through-range symptoms, rest pain, and plantar pain and with negative result on grind test. If joint motion-preserving surgery is appropriate, then cheilectomy is generally considered to be the first-line surgical choice. In addition to the standard open technique, minimally invasive surgery in the form of either percutaneous or arthroscopic surgery is available. The indications, surgical techniques, and outcomes are discussed.

The purpose of this study was to evaluate prospectively the results of the dorsal wedge phalangeal osteotomy for treating moderate hallux rigidus.

The prospective study included 42 consecutive feet in 40 active patients, with an average age of 55.1 (range, 41-65) years. Clinical evaluation included American Orthopaedic Foot and Ankle Society (AOFAS) score, pain visual analog scale, range of motion, and subjective patient satisfaction. Radiographic evaluation was performed, including linear and angular measurements. The average follow-up was 2.7 (range, 2-3.8) years.

The preoperative and postoperative mean AOFAS scores were 51.7 and 88.8, respectively (P = .001), and for pain VAS were 7.6 and 1.9, respectively (P = .001). Good and excellent results at final follow-up were seen in 34 feet. All patients returned to their previous activities. Satisfaction with surgery was good or excellent in 39 patients. The average passive metatarsophalangeal (MTP) dorsiflexion improved from 20.3 to 55.7 degrees (P = .001). The average MTP joint space improved from 2.2 to 2.3 degrees (P = .001). The radiographic measurements were unchanged, except anatomic angles related to phalangeal dorsiflexion. The average width of the bone wedge was 3.5 (range, 2.2-5.0) mm, and significant correlation was found with final AOFAS score (P = .006) and pain VAS (P = .001). There were 2 revisions for screw irritation.

Phalangeal osteotomy was a reliable and reproducible treatment for moderate hallux rigidus in active patients, with substantial improvement in AOFAS score and MTP dorsiflexion and decreased pain.

Level IV, prospective case series.

Functional hallux rigidus is a clinical condition in which the mobility of the first metatarsophalangeal joint is normal under non-weight-bearing conditions, but its dorsiflexion is blocked when first metatarsal is made to support weight. In mechanical terms, functional hallux rigidus implies a pattern of interfacial contact through rolling, whereas in a normal joint contact by gliding is established. Patients with functional hallux rigidus should only be operated on if the pain or disability makes it necessary. Gastrocnemius release is a beneficial procedure in most patients.

Cheilectomy is commonly performed for osteoarthritis of the first metatarsophalangeal joint and generally has a successful outcome and high rate of patient satisfaction over the short to medium term. Despite the relatively good results achieved in most cases, a proportion of patients have ongoing pain after cheilectomy. This article outlines the potential causes of ongoing pain, including progression of osteoarthritis, neuralgic symptoms, and transfer metatarsalgia. Management strategies for treating the ongoing symptoms are discussed.

Arthritis of the foot can be a difficult problem. It is initially managed with antiinflammatory medications and footwear modifications or bracing. However, a significant percentage of people with arthritis of the foot go on to require surgical intervention, which is most commonly arthrodesis.