SLR - November 2013 - Lonny Nodelman
Reference: J Bone Joint Surg Am. 2013 Apr 3; 95(7): 606-10.
Reviewed by: Lonny Nodelman, DPM
Residency Program: Cambridge Health Alliance
Podiatric Relevance: Surgical treatment of symptomatic end-stage hallux rigidus classically involves some form of joint-destructive procedure. This retrospective study investigated a novel treatment approach combining a standard cheilectomy with a Moberg-type dorsiflexory wedge osteotomy of the proximal phalanx of the hallux, both of which were typically being reserved for mild to moderate degrees of hallux rigidus. The authors of this study hypothesized that acceptable patient outcomes could be achieved with this approach and that preservation of 1st MPJ structure could allow for a more straightforward revision in the future if necessary.
Methods: Between October 2000 to June 2007, 81 patients (81 feet) underwent unilateral primary cheilectomy of the 1st metatarsophalangeal joint (MTPJ) with concomitant Moberg-type osteotomy of the proximal phalanx of the hallux. This combined procedure was recommended to patients who were less than 70 years of age and possessed less than 20 degrees of dorsiflexory motion of the 1st MPJ. Radiographically, this corresponded to a Grade-III deformity according to the Hattrup and Johnson classification for hallux rigidus. If patients possessed little or no motion of the 1st MTPJ they were encouraged to undergo an arthrodesis-type procedure. The operative technique consisted of a standard dorsomedial skin incision overlying the 1st MTPJ with a subsequent capsulotomy to allow exposure of the metatarsal head and proximal phalangeal base. A dorsal cheilectomy was undertaken whereby the dorsal third portion of the metatarsal head was resected. Next, a dorsiflexory wedge osteotomy of the proximal phalanx was performed and fixated utilizing a single two millimeter stainless steel screw. The patients were allowed to bear weight immediately in the postoperative period and were transitioned to regular shoes at three weeks post-op. Outcome measures included both pre- and postoperative AOFAS scores and 1st MTPJ dorsiflexory range of motion measurements.
Results: The subjects in this study had end-stage hallux rigidus deformity with an average age of 55 years with a mean duration of follow of 4.3 years. There was a significant mean difference of 27 degrees of 1st MTPJ range of motion compared preoperatively versus postoperatively at the latest follow-up visit. The mean AOFAS score improved significantly from 67.2 points preoperatively to 88.7 points postoperatively. Eighty-five-point-two percent of patients were satisfied with their procedure and 14.8 percent were not. As expected, radiographically, there was a measurable decreased in the length of the proximal phalanx with a corresponding decrease in the 1st MTPJ width postoperatively. All osteotomies healed without non-union or mal-union.Four-point-nine percent of the included patients in this study subsequently underwent arthrodesis of the 1st MTPJ.
Conclusions: This is a novel study with findings that support the use of a combined cheilectomy with a proximal phalangeal dorsiflexory ostetomy for the treatment of advanced stage hallux rigidus deformity in the short-term period. The average duration of follow-up was only 4.3 years, and with expected joint deterioration into the intermediate and long-term period, propagation of these results is uncertain. This study supports a novel treatment option for podiatric patients with end-stage hallux ridigus that possesses little morbidity compared to other available procedures. Advantages include maintenance of joint motion, a relatively benign postoperative recovery, and preservation of joint structure that allows for later revision. The conversion to an arthrodesis should be relatively straightforward since this investigated procedure allows for preservation of osseous structure of the 1st MTPJ.