Hallux Rigidus: Cheilectomy With and Without a Dorsiflexion Phalangeal Osteotomy

Indications

Cheilectomy of the first metatarsophalangeal joint (MTPJ) is indicated for painful hallux rigidus with impinging bone spurs. Most frequently indicated for grade I and grade II hallux rigidus, but may also be utilized for grade III.
- Grade I includes mild to moderate osteophyte formation with joint space preservation.
- Grade II includes moderate osteophyte formation with joint space narrowing.
- Grade III includes extensive osteophyte formation with loss of joint space.
A dorsal closing wedge phalangeal osteotomy (Moberg) is indicated.
- When there is loss of cartilage on the remaining aspect of the first metatarsal (MT) head after cheilectomy.
- When dorsiflexion of the first MTPJ remains limited after cheilectomy.
- A dorsal closing wedge osteotomy shifts the phalangeal base to the plantar aspect of the first MT head where the cartilage is usually in better condition and unloads the dorsal aspect of the first MTPJ allowing increased dorsiflexion. It also places the proximal phalanx of the hallux in slight dorsiflexion relative to floor.
In cases of grade III hallux rigidus with extensive cartilage loss, where the patient prefers motion to fusion, a combination of cheilectomy with a dorsal closing wedge osteotomy can be performed.

Indications Controversies

Grade III hallux rigidus can be treated with cheilectomy and associated procedures, fusion, or joint replacement. Fusion is generally recommended as the best procedure for pain relief and correction of accompanying deformity for a stage III hallux rigidus.

Conservative treatment of hallux rigidus involves icing, nonsteroidal antiinflammatory drugs, and cortisone injections for inflammation. Stiff soled, rocker bottom-type footwear to protect the great toe from dorsiflexion and avoidance of activities that require dorsiflexion of the hallux are recommended.

Swelling of the first MTPJ with palpable and often visible osteophytes.
Overlying skin may demonstrate pressure ulcers, bursitis, or hyperkeratosis.
Tenderness to palpation over the dorsal first MTPJ and often over the first web space.
Restricted range of motion (ROM) compared with the unaffected side (normal ROM is 30° of plantar flexion and 90° of dorsiflexion).
Pain with axial loading of the joint, dorsiflexion, and plantar flexion.
May have a Tinel sign to tapping over the dorsal medial first MTPJ and decreased sensation over the dorsomedial hallux.
Rule out gout and other forms of inflammatory arthritis.

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