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Hallux Rigidus and Sesamoid Pathology


KEY FACTS

Hallux Rigidus

  • Hallux rigidus is the most common arthritic condition in the foot.

  • Hallux rigidus tends to be bilateral, although it is often not synchronous.

  • The 1st metatarsophalangeal (MTP) joint generally becomes stiffer and more painful as the arthritis progresses, although progression is inconsistent. Some patients will progress linearly, while others' symptoms will remain consistent over time.

  • Nonoperative treatment is similar to nonoperative treatment for arthritis in any joint with the added component of a stiff insert or shoe to limit 1st MTP motion.

  • Operative treatment depends on how advanced the arthritis is, although symptoms are the best indicator of what treatment is most appropriate. Joint-sparing procedures (cheilectomy, Moberg osteotomy) are generally used for less severe arthritis, and fusion has traditionally been the gold standard for more severe arthritis. Implant arthroplasty with a synthetic implant is not inferior to fusion in early data.

Sesamoid Pathology

  • Sesamoiditis is a poorly understood pathology that can cause significant pain and disability. Treatment consists of offloading or sesamoidectomy for refractory cases.

  • Turf toe injuries can be devastating injuries to the big toe and typically require surgical reconstruction and repair of the plantar tissues of the 1st MTP joint.

A 50-year-old female patient with hallux rigidus symptoms as her primary complaint is shown. She also had some hallux valgus. She had tried shoe modifications without much decrease in her symptoms.

The dorsal osteophyte is seen at the 1st metatarsophalangeal joint in the same patient. The osteophyte was rubbing on her shoe, which made shoewear difficult.

A cheilectomy was performed with a median eminence resection and a combination of a Moberg and Akin osteotomy taking out a dorsomedial wedge to allow for some effective increase in dorsiflexion, while also correcting the bunion to some degree.

The lateral view shows the degree to which the dorsal osteophyte was resected, while also showing the fixation for the phalangeal osteotomy. The patient reported an improvement both in pain and function after surgery.

TERMINOLOGY

  • Osteoarthritis of the 1st metatarsophalangeal (MTP) joint is termed hallux rigidus. Hallux refers to the 1st ray, while the term rigidus is applied since the 1st MTP generally becomes stiff as the disease progresses.

  • The inciting cause is not entirely clear in this pathology, although the arthritis typically affects the dorsal aspect of the joint first.

EPIDEMIOLOGY

  • In 1 epidemiologic study of hallux rigidus, 70% of patients had bilateral disease.

    • Indeed, hallux rigidus is often bilateral, although not always synchronous.

  • 66% of affected individuals were female.

    • An older study had noted hallux rigidus to be much more common in men, although another more recent study had 63% female patients.

  • The mean age at onset was 44 years (range: 14-68 years), and the duration of symptoms prior to treatment was 6 years.

  • 22% of patients recalled some trauma to the hallux; 74% of these patients had unilateral disease.

Etiology

  • This is not entirely clear and may represent a group of pathologies that have a similar endpoint.

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