Summary

Hallux Rigidus is osteoarthritis of the First Metatarsophalangeal (MTP) joint. It is the most common arthritic condition of the foot (1 in 40 people >50). Unlike Hallux Valgus (Bunions), which is a deformity, Hallux Rigidus is a "wear and tear" condition characterized by the formation of large Dorsal Osteophytes (bone spurs) which physically block dorsiflexion. This results in a painful, stiff toe that hurts with every step (push-off). Treatment is staged: early disease (dorsal impingement) is treated with Cheilectomy (shaving the spur), while advanced disease is treated with Arthrodesis (Fusion), which provides reliable, permanent pain relief. [1,2,3]

Key Facts

• The "Dorsal Bunion": Patients often complain of a "bunion on top of the toe". This is the dorsal osteophyte.
• Stiff vs Crooked: Hallux Rigidus = Straight and Stiff. Hallux Valgus = Crooked and Mobile. Rarely do they coexist severely.
• The Fusion Fear: Patients are terrified of "fusion" ("Will I limp?"). The answer is no. A fused big toe allows normal walking, jogging, and even hiking. It only limits high heels and sprinting.

Clinical Pearls

"Check the ROM": In early stages, plantarflexion is preserved, but dorsiflexion is blocked by the spur. In late stages, the joint is rigid in all directions.

"Carbon Plate": A stiff carbon-fiber insert (Morton's extension) in the shoe acts as a splint, stopping the toe from bending during push-off. This is the #1 non-surgical fix.

"Cartiva Failure": Synthetic cartilage implants (polyvinyl alcohol) were popular but have high failure rates (subsidence/pain) leading to difficult revision fusions. Be cautious.

                 STIFF BIG TOE
                       ↓
             X-RAY: JOINT SPACE?
            ┌──────────┴──────────┐
        PRESERVED               DESTROYED
    (Grades 1-2)              (Grades 3-4)
         ↓                         ↓
    CONSERVATIVE              CONSERVATIVE
   (Stiff Sole)              (Stiff Sole)
         ↓                         ↓
      FAILED?                   FAILED?
         ↓                         ↓
    CHEILECTOMY                FUSION
  (Remove spur)              (Arthrodesis)

Protocol

• Shoe Modification: Wide toe box (accommodates the bump). Rocker bottom sole.
• Orthotics: Carbon fiber Morton's Extension plate. (Stiffens the sole under the big toe to prevent bending).
• Injections: Corticosteroid. Relief is often temporary (3 months).

1. Cheilectomy

• Indication: Grade 1-2 (Dorsal impingement dominant).
• Procedure: Remove the dorsal 30% of the metatarsal head (the spur + some head).
• Outcome: Improves motion (dorsiflexion). Relieves pain.
• Risk: Progression to arthritis later (does not stop the disease).

2. Arthrodesis (Fusion)

• Indication: Grade 3-4 (End stage). Failed Cheilectomy.
• The Gold Standard.
• Technique:
  • Joint surfaces prepared to bleeding bone (cup and cone reamers).
  • Fixation: Plate and screws vs Crossed screws.
  • Position:
    • Valgus: 10-15 degrees (away from other toes).
    • Dorsiflexion: 10-15 degrees (allows toe-off).
• Outcome: 95% satisfaction. Permanent pain relief.

3. Arthroplasty (Implant)

• Hemi-cap / Cartiva: Metallic or synthetic resurfacing.
• Evidence: controversial. Higher failure rates than fusion.
• Interposition: Using capsule/tissue (Keller procedure). Used in low-demand elderly to preserve some flop.

Fusion vs Replacement

• Gibson et al (RCT): Compared Arthrodesis vs Arthroplasty. Fusion had better functional outcomes, less pain, and fewer revisions. Fusion remains the Gold Standard.

Cheilectomy Success

• Coughlin et al: Reported 97% satisfaction in Grade 1-2 patients treated with Cheilectomy, with long-term durability.

The Condition

Your big toe joint is rusty. A bone spur has grown on top, acting like a doorstop preventing the toe from bending up.

The Fix

• Mild: We shave off the "doorstop" (Cheilectomy). This buys you 5-10 years.
• Severe: We fuse the joint.
  • "Will I walk funny?" No. You walk normally. You just can't wear 4-inch heels.
  • "Will I run?" Yes.
  • "Does it hurt?" Once healed, it is painless forever.

Q1: What is the optimal position for 1st MTP Fusion? A:

• Valgus: 10-15 degrees (Match the 2nd toe, do not impinge).
• Dorsiflexion: 10-15 degrees relative to floor (Allows clearance during toe-off).
• Rotation: Neutral.

Q2: What is a Cheilectomy? A: Removal of the dorsal osteophyte and the dorsal 1/3 of the metatarsal head to relieve impingement and improve dorsiflexion in early Hallux Rigidus.

Q3: What is the Keller Procedure? A: Resection Arthroplasty (removing the base of the proximal phalanx). It leaves a floppy toe (cock-up deformity risk) and unstable push-off. Reserved for low-demand, sedentary elderly patients.

Q4: Describe the radiographic appearance of Hallux Rigidus. A: Narrowing of joint space, subchondral sclerosis, and prominent dorsal osteophytes (seen best on lateral view). Squaring of the metatarsal head.

(End of Topic)