Hallux Rigidus Grade Does Not Correlate With Foot and Ankle Ability Measure Score

Hallux Rigidus: Update on Conservative Management

Hallux rigidus is a degenerative arthritic condition affecting the first metatarsophalangeal joint. Prevalence in patients aged 50 years and above is estimated at 20% to 30%, with a portion being symptomatic. Conservative treatment's efficacy is linked to initial pain levels; though shoe modifications and insoles are commonly recommended, their true effectiveness lacks strong evidence. Injection therapy, including corticosteroids and hyaluronic acid, demonstrates varied outcomes, with about 50% of patients undergoing surgery within 1 to 2 years. The condition's etiology remains elusive, but recent biomechanical hypotheses hold promise.

Quantification of First Metatarsal Joint Surface Interactions in Hallux Rigidus Using Distance and Coverage Mapping: A Case-Control Study

BACKGROUND

Weightbearing cone-beam computed tomography (WBCT) has proven useful for analysis of structural changes of the foot and ankle when compared to conventional radiographs. WBCT allows for extraction of distance and coverage mapping metrics, which may provide novel insight into hallux rigidus (HR). This study retrospectively assessed HR joint space using distance and coverage mapping in a case-control study.

METHODS

WBCT images of the foot and ankle for 20 symptomatic HR and 20 control patients were obtained. Three-dimensional models were created and analyzed using a custom semiautomatic measurement algorithm. Distance and coverage mapping metrics for the first metatarsophalangeal and metatarsosesamoid joints were extracted from the models and compared between cohorts. Relationships between these metrics and visual analog scale (VAS) scores, a patient-reported outcome of pain, were assessed in HR patients.

RESULTS

Overall first metatarsophalangeal joint space narrowing was noted in HR patients when compared to controls by an average of 11.8% (P = .02). However, no significant changes in the overall coverage of the joint were noted. Decreased joint space width and increased surface-to-surface coverage were only and particularly observed at the plantar medial quadrant of the first metatarsal head in HR patients relative to controls. VAS score was significantly but weakly correlated with dorsolateral quadrant coverage (R2 = 0.26, P = .03).

CONCLUSION

Distance and coverage mapping serve as a complementary option to current techniques of quantifying HR changes. These metrics can expand the scope of future work investigating joint articulation changes in HR.

Assessment and Management of Atraumatic First Metatarsophalangeal Joint Pain

Nontraumatic pain in the first metatarsophalangeal joint is frequent and can be debilitating. The metatarsophalangeal joint complex comprises four articulating surfaces including the first metatarsal, the proximal phalanx, and tibial and fibular sesamoids, which are all contained within a synovial capsule. The most common causes of pain are hallux valgus and hallux rigidus. However, other diagnoses, such as functional hallux limitus, sesamoiditis, gout, and inflammatory autoimmune arthritis, need to be considered as well. A systematic approach is key to accurately diagnose the source of pain, which can sometimes be the result of more than one condition. The most important clinical information to obtain is a focused history, meticulous clinical examination based on understanding the precise anatomy and biomechanics of the first metatarsophalangeal joint, and analysis of the relevant imaging. Each pathology has a different treatment algorithm, as such, understanding the pathoanatomy and biomechanics is important in forming an effective treatment plan.

Relationship Between Preoperative PROMIS Scores and Postoperative Outcomes in Hallux Rigidus Patients Undergoing Cheilectomy

BACKGROUND

Previous studies have demonstrated that preoperative patient-reported outcome measures are associated with postoperative outcomes in foot and ankle surgery, and also in specific procedures such as bunionectomy, flatfoot reconstruction, and total ankle replacement. The primary purpose of this study was to determine if preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) physical function, pain interference, pain intensity, and depression scores were associated with the ability of patients undergoing cheilectomy for hallux rigidus to achieve a minimal clinically important difference (MCID) of improvement.

METHODS

This retrospective study included preoperative and ≥2-year postoperative PROMIS physical function, pain interference, pain intensity, and depression scores for 125 feet in 118 patients undergoing cheilectomy collected from an institutional review board (IRB)-approved foot and ankle registry database. MCIDs were established using distribution-based methods to determine clinical significance of improvements in PROMIS scores. Receiver operating characteristic (ROC) curves and area under the curve analyses were used to determine which preoperative PROMIS scores were associated with patients meeting the MCID.

RESULTS

ROC analysis found statistically significant areas under the curve (AUCs) for the physical function domain (AUC 0.71), pain intensity (AUC 0.70), and depression (AUC 0.79) PROMIS domains. Subsequent analyses were unable to identify clinically useful 95% sensitivity and specificity preoperative thresholds, with the exception of the 95% sensitivity PROMIS physical function threshold. A preoperative physical function score of greater than 53.2 resulted in a 63% probability of achieving the MCID. The pain interference PROMIS domain did not demonstrate a statistically significant AUC.

CONCLUSION

Preoperative PROMIS physical function, pain interference, pain intensity, and depression scores are minimally associated with preoperative to 2-year postoperative improvement in patients undergoing cheilectomy. It may be difficult to determine which patients improve from a cheilectomy based on the severity of symptoms they exhibit preoperatively.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Complications of Hallux Rigidus Surgery

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.

First metatarsophalangeal joint arthrodesis/fusion: a systematic review of modern fixation techniques

Background

First metatarsophalangeal joint arthrodesis is commonly performed for symptomatic end-stage hallux rigidus. It has been postulated to produce good results in the literature. Various fixation techniques offer differences in union rates, complications and functional outcomes, stirring debates about which produces the best outcomes for patients. Therefore, this review aims to synthesise and compare the outcomes of modern fixation techniques used for first metatarsophalangeal joint (FMPJ) arthrodesis.

Methods

The electronic database searched were PubMed, CINAHL, Cochrane Library, and Google Scholar. The critical appraisal skills programme tool for cohort study was used. The interventions consisted of screw(s), plate(s), and staple(s). Studies comprising outdated fixation techniques such as suture, metallic wire, external fixation, Rush rods or Steinmann pins were excluded. Participants were adults over 18 years, undergoing FMPJ arthrodesis in the UK. Studies with the population consisting primarily of revision cases, patients with rheumatoid arthritis or diabetes were excluded.

Results

Seven UK studies included 277 feet and a 95.7% overall union rate at a mean union time of 83.5 days. Staples had the highest union rate of 98.2% at mean union time of 84 days, followed by plates (95.2%, 92 days), and finally screws (94.9%, 71 days). The overall complication incidence is 5.8%. All of the fixation techniques produced good functional outcomes postoperatively.

Conclusions

Whilst staple techniques showed the highest union rate, plating techniques are preferable over screws or staples for better results across several outcome measures, including reduced complication incidence, stability, early ambulation, and good functional outcome. The Manchester-Oxford Foot Questionnaire and EuroQol-5Dimensional are recommended as measurement tools to assess functional outcomes following FMPJ arthrodesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00540-9.

Physical Function and Pain Interference Levels of Hallux Rigidus Patients Before and After Synthetic Cartilage Implant vs Arthrodesis Surgery

BACKGROUND

Hallux rigidus is a common and painful degenerative condition of the great toe limiting a patient's physical function and quality of life. The purpose of this study was to investigate pre- and postoperative physical function (PF) and pain interference (PI) levels of patients undergoing synthetic cartilage implant hemiarthroplasty (SCI) vs arthrodesis (AD) for treatment of hallux rigidus using the Patient-Reported Outcomes Measurement Information System (PROMIS).

METHODS

PROMIS PF and PI t scores were analyzed for patients who underwent either SCI or AD. Postoperative final PROMIS t scores were obtained via phone survey. Linear mixed model analysis was used to assess differences in PF and PI at each follow-up point. Final follow-up scores were analyzed using independent sample t tests.

RESULTS

Total 181 (59 SCI, 122 AD) operatively managed patients were included for analysis of PROMIS scores. Final phone survey was performed at a minimum of 14 (mean 33, range, 14-59) months postoperatively, with 101 patients (40 SCI, 61 AD) successfully contacted. The mean final follow-up was significantly different for SCI and AD: 27 vs 38 months, respectively (P < .01). The mean age of the SCI cohort was lower than the AD cohort (57.5 vs 61.5 years old, P = .01). Average PF t scores were higher in the SCI cohort at baseline (47.1 and 43.9, respectively, P = .01) and at final follow-up (51.4 vs 45.9, respectively, P < .01). A main effect of superior improvement in PF was noted in the SCI group (+4.3) vs the AD group (+2) across time intervals (P < .01). PI t scores were similar between the 2 procedures across time points.

CONCLUSION

The SCI cohort reported slightly superior PF t scores preoperatively and at most follow-up time points compared with the arthrodesis group. No differences were found for PI or complication rates between the 2 treatment groups during this study time frame.

LEVEL OF EVIDENCE

Level IV, case series.

Treatment of hallux rigidus (HARD trial): study protocol of a prospective, randomised, controlled trial of arthrodesis versus watchful waiting in the treatment of a painful osteoarthritic first metatarsophalangeal joint

INTRODUCTION

Hallux rigidus is a common problem of pain and stiffness of the first metatarsophalangeal joint (MTPJ) caused mainly by degenerative osteoarthritis. Several operative techniques have been introduced for the treatment of this condition without high-quality evidence comparing surgical to non-surgical care. In this trial, the most common surgical procedure, arthrodesis, will be compared with watchful waiting in the management of hallux rigidus.

METHODS AND ANALYSIS

Ninety patients (40 years or older) with symptomatic first MTPJ osteoarthritis will be randomised to arthrodesis or watchful waiting in a ratio of 1:1. The primary outcome will be pain during walking, assessed using the 0-10 Numerical Rating Scale (NRS) at 1 year after randomisation. The secondary outcomes will be pain at rest (NRS), physical function (Manchester-Oxford Foot Questionnaire), patient satisfaction in terms of the patient-acceptable symptom state, health-related quality of life (EQ-5D-5L), activity level (The Foot and Ankle Ability Measure Sports subscale), use of analgesics or orthoses and the rate of complications. Our null hypothesis is that there will be no difference equal to or greater than the minimal important difference of the primary outcome measure between arthrodesis and watchful waiting. Our primary analysis follows an intention-to-treat principle.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Ethics Committee of Helsinki and Uusimaa Hospital District, Finland. Written informed consent will be obtained from all the participants. We will disseminate the findings of this study through peer-reviewed publications and conference presentations.

PROTOCOL VERSION

21 June 2021 V.2.0.

TRIAL REGISTRATION NUMBER

NCT04590313.

Prevalence of Hallux Rigidus in Patients With End-Stage Ankle Arthritis

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.

Youngswick osteotomy for treatment of moderate hallux rigidus: Thirteen years without arthrodesis

PURPOSE

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.

METHODS

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).

RESULTS

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.

CONCLUSION

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.

LEVEL OF EVIDENCE

III.

Comparing First Metatarsophalangeal Joint Flexibility in Hallux Rigidus Patients Pre- and Postcheilectomy Using a Novel Flexibility Device

Background

Hallux rigidus (HR) is a common pathology of the first metatarsophalangeal (MTP) joint causing pain and stiffness. However, severity of symptoms and radiographic findings are not always concordant. A novel flexibility device, which measures the mobility of the MTP joint through its arc of motion, has been validated. This study compares flexibility in patients before and after cheilectomy (with or without proximal phalanx osteotomy) for HR.

Methods

This is a single-center study of adult patients with HR who were indicated for cheilectomy or cheilectomy and Moberg (dorsiflexion closing wedge) osteotomy of the proximal phalanx based on symptoms and radiographs from 2013 to 2015. Pre- and postoperatively, patients underwent testing with a validated flexibility protocol to generate flexibility curves. Parameters included early and late flexibility, laxity torque, and laxity angle. Patients completed Foot and Ankle Outcomes Scores (FAOS) pre- and postoperatively. Twelve operative patients underwent preoperative testing, with 9 completing postoperative testing (mean age, 53.0 years; 67% female; mean 2.8-year follow-up).

Results

Patients had significant improvements in early sitting and standing flexibility, sitting and standing laxity angles, standing laxity torque, and both sitting and standing maximum dorsiflexion after surgery (all P < .05). While preoperative early flexibility, laxity angle, and maximum dorsiflexion all differed significantly between patients and controls (P < .015), postoperative early flexibility was similar to controls (P > .279). FAOS scores for pain, symptoms, sport, and quality improved significantly after surgery.

Conclusion

Surgical treatment with cheilectomy was associated with significant improvements in nearly all flexibility parameters for sitting and standing positions. However, most postoperative flexibility parameters did not improve to the level of normal controls. Regardless, patients still experienced significant improvements in outcomes. This study demonstrated that surgical correction is associated with significant biomechanical and clinical results. The flexibility device can be used in further studies to assess outcomes after other HR procedures.

Level of Evidence

Level II, prospective comparative study.

Assessment of Various Measurement Methods to Assess First Metatarsal Elevation in Hallux Rigidus

Background:

While metatarsus primus elevatus (MPE) has been implicated in the development of hallux rigidus, previous studies have presented conflicting findings regarding the relationship between MPE and arthritis. This may be due to the variety of definitions for MPE and the radiographic measurement techniques that are used to assess it. Additionally, previous studies have only assessed elevation of the first metatarsal with respect to the floor or the second metatarsal, and not with respect to the proximal phalanx. The aim of this study was to examine the reliability of new radiographic measurements that consider the elevation of the first metatarsal in relation to the proximal phalanx, rather than in relation to the second metatarsal as previously described, to assess for MPE. In addition, we aimed to determine whether the elevation of the first metatarsal was significantly different in patients with hallux rigidus than in a control population.

Methods:

A retrospective chart review was conducted from prospectively collected registry data at the investigators’ institution to identify patients with hallux rigidus (n = 65). A size-matched control cohort of patients without evidence for first metatarsophalangeal (MTP) joint arthritis was identified (n = 65). Patients with a previous history of foot surgery, rheumatoid arthritis, or hallux valgus were excluded. Five blinded raters of varying levels of training, including 2 research assistants, 1 senior orthopedic resident, 1 foot and ankle fellowship-trained orthopedic surgeon, and 1 attending musculoskeletal fellowship-trained radiologist, evaluated 7 radiographic measurements for their reliability in assessing for MPE in hallux rigidus and control groups. Four of the 7 were newly designed measurements that include the relationship of the first MTP joint. Inter- and intrarater reliability were calculated using intraclass correlation coefficients (ICCs) and categorized by Landis and Koch reliability thresholds. The measurements between the hallux rigidus and control populations were compared using an independent t test.

Results:

Six of the 7 radiographic measurements were found to have substantial to almost perfect interrater reliability (ICC, 0.800-0.953) between all levels of training, except for the proximal phalanx–first metatarsal angle, which showed moderate reliability (ICC, 0.527). Substantial to almost perfect intrarater reliability (ICC, 0.710-0.982) was demonstrated by the measurements performed by research assistants. All 7 of the measurements taken by the musculoskeletal fellowship-trained radiologist demonstrated significant differences in first metatarsal elevation between the hallux rigidus and control populations, with the hallux rigidus group showing increased elevation (P < .001-.019).

Conclusion:

This study confirmed the reliability of 7 radiographic measurements used to assess for MPE, including 3 previously established and 4 newly described measurements. Observers across all levels of training were able to demonstrate reliable measurements. In addition, the measurements were used to show that patients with hallux rigidus were more likely to have MPE compared with patients without radiographic evidence for first MTP arthritis. These measurements could be used in future work to examine how the presence of MPE relates to the etiology and progression of hallux rigidus, and how it affects the results of operative treatment.

Level of Evidence:

Level III, retrospective comparative study.

Patient-Perceived Recovery and Outcomes After Silastic Implant Arthroplasty

In some chronic musculoskeletal conditions, patients with persistent pain and disability have still achieved recovery through behavioral adaptations (readjustment) or cognitive coping (redefinition). Although the pendulum shift from physician-reported clinical indicators to patient-reported outcomes measures (PROMs) has recently focused on quantifying residual pain and disability to determine recovery (resolution), whether patients are capable of coping with any ongoing deficits and achieving other forms of recovery has not been considered. We performed a retrospective case series to assess patient-perceived recovery and outcomes after silastic implant arthroplasty for hallux rigidus. From July 2006 to July 2016, 28 patients at a single institution were enrolled. PROMs were prospectively obtained and compared between patients considering themselves recovered without or with residual deficits (recovered-resolved, recovered-not resolved) and those not recovered. Holistic satisfaction, procedure-specific satisfaction, complications, reoperations, and failure rates were recorded. Overall, 50.0% perceived themselves as recovered-resolved, 43% as recovered-not resolved, and 7% as not recovered. The mean modified Foot Function Index was 17.26, the verbal analog scale for pain score was 2.03, and implant survivorship 100% at a median of 67 (interquartile range 28.4 to 103.5) months. Although only 50% of patients reported complete symptom resolution, satisfaction was high, and most perceived themselves as recovered, suggesting recovery in hallux rigidus might not always be predicated by the complete resolution of all symptomatology. Although PROMs relying on pain inference and functional disability will continue to be utilized with increasing frequency, foot and ankle surgeons should be cognizant of their inherent limitations in assessing other forms of recovery.