Modern principles of hallux rigidus treatmenT

Introduction: pain in the area of the first toe caused by osteoarthritis of the first metatarsophalangeal joint (I MTP) is one of the most common pathologies of the human foot. In this pathology, painfulness is caused by arthritic changes in the joint, movements in the joint become painful, and joint mobility decreases [1]. T he above is a clinical manifestation of hallux rigidus disease. When diagnosing this pathology, radiologic examination reveals narrowing of the articular gap of the first metatarsophalangeal joint and the presence of dorsal osteophytes of I MTP [3]. Patients with hallux rigidus are quite often encountered in the clinical practice of a physician. The etiology of hallux rigidus encompasses a variety of factors, and there are many approaches to the treatment of this disease. To date, the choice of treatment is based on a combined assessment of clinical and radiologic findings. The aim of this article is to review the current knowledge on the treatment of hallux rigidus.

Research objective: to determine the modern principles of conservative and surgical treatment of the first metatarsophalangeal joint disease hallux rigidus.

Materials and methods: A systematic literature search was conducted in relevant databases with the search terms “hallux rigidus”. The depth of the search was 24 years. The number of articles used for this paper was 42. A systematic review of research papers on the treatment of hallux rigidus was conducted according to the preferred reporting elements for systematic reviews and meta-analyses (PRISMA).

Results: There are many treatment options for hallux rigidus in the current literature. Treatment of hallux rigidus can be divided into conservative and surgical treatment. Surgical treatment is usually divided into surgery that preserves the I MTP and surgery that does not preserve the I MTP. Treatment tactics depend on the severity of hallux rigidus, the clinical picture and the patient's complaints. For I-II degrees of first metatarsophalangeal joint damage, methods such as cheillectomy combined with or without Moberg surgery, shortening chevron osteotomy should be used. In the case of III degree hallux rigidus, there is experience with treatment by endoprosthesis of the I MTP, but this method of treatment has insufficient positive results and leads to difficulties in subsequent surgical interventions. This technique requires further observation and more in-depth clinical studies. Therefore, arthrodesis of the first metatarsophalangeal joint remains the "gold standard" for the treatment of patients with advanced hallux rigidus. However, other methods have emerged with comparable clinical results that allow preservation of joint motion, but there are not enough reliable results from long-term studies.

1. Hamid K.S., Parekh S.G. Clinical Presentation and Management of Hallux Rigidus. Foot Ankle Clin. 2015 Sep;20(3):391-9. Epub 2015 Jul 2. DOI: 10.1016/j.fcl.2015.04.002

2. Lam A., Chan J.J., Surace M.F., Vulcano E. Hallux rigidus: How do I approach it? World J Orthop. 2017 May 18;8(5):364-371. DOI: 10.5312/wjo.v8.i5.364.

3. Massimi, S., Caravelli, S., Fuiano, M. et al. Management of highgrade hallux rigidus: a narrative review of the literature. Musculoskelet Surg 104, 237–243 (2020). doi: 10.1007/s12306-020-00646-y.

4. Grady J.F., Axe T.M., Zager E.J., Sheldon L.A. A retrospective analysis of 772 patients with hallux limitus. J Am Podiatr Med Assoc. 2002 Feb;92(2):102-8. doi: 10.7547/87507315-92-2-102.

5. Waizy,H. Hallux rigidus. Oper Orthop Traumatol 33, 463-464 (2021).Doi:10.1007/s00064-021-00749-0

6. Fletcher A.N., Patel V., Cerrato R. Minimally Invasive Cheilectomy for Hallux Rigidus. Foot Ankle Clin. 2024 Sep;29(3):471-484. Epub 2024 Mar 21. doi: 10.1016/j.fcl.2024.01.003

7. Razik A., Sott A.H. Cheilectomy for Hallux Rigidus. Foot Ankle Clin. 2016 Sep;21(3):451-7. Epub 2016 May 24. doi: 10.1016/j.fcl.2016.04.006

8. Anderson M.R., Ho B.S., Baumhauer J.F. Republication of "Current Concepts Review: Hallux Rigidus". Foot Ankle Orthop. 2023 Jul 25;8(3):24730114231188123. doi: 10.1177/24730114231188123.

9. Miettinen M., Rämö L., Lähdeoja T., Sirola T., Sandelin H., Ponkilainen V., Repo J.P. 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. BMJ Open. 2021 Aug 27;11(8):e049298. doi: 10.1136/bmjopen-2021-049298.

10. Vasso, M., Del Regno, C., D’Amelio, A. et al. A modified Austin/chevron osteotomy for treatment of hallux valgus and hallux rigidus. J Orthopaed Traumatol 17, 89–93 (2016). Doi: 10.1007/s10195-015-0366-7

11. Airapetov G.A., Vorotnikov A.A. Modernapproaches to the treatment of hallux rigidus. Journal of Clinical Practice. 2021; 2(12): 103-109 DOI:10.17816/clinpract65062

12. Coughlin M.J., Shurnas P.S. Hallux rigidus. Grading and long-term results of operative treatment. J Bone Joint Surg Am. 2003 Nov;85(11):2072-88. DOI:10.2106/00004623-200502000-00045

13. Solan M.C., Calder J.D., Bendall S.P. Manipulation and injection for hallux rigidus. Is it worthwhile? J Bone Joint Surg Br. 2001 Jul;83(5):706-8. doi: 10.1302/0301-620x.83b5.11425.

14. Pons M., Alvarez F., Solana J., Viladot R., Varela L. Sodium hyaluronate in the treatment of hallux rigidus. A single-blind, randomized study. Foot Ankle Int. 2007 Jan;28(1):38-42. doi: 10.3113/FAI.2007.0007.

15. Givissis P.K., Symeonidis P.D., Kitridis D.M. et al. Minimal resection interposition arthroplasty of the first metatarsophalangeal joint. Foot (Edinb). 2017; 32:1–7. doi: 10.1016/j.foot.2017.03.004

16. Kline A.J., Hasselman C.T. Metatarsal head resurfacing for advanced hallux rigidus. Foot Ankle Int. 2013 May;34(5):716-25. Epub 2013 Feb 13. doi: 10.1177/1071100713478930.

17. Gibson J.N., Thomson C.E. Arthrodesis or total replacement arthroplasty for hallux rigidus: a randomized controlled trial. Foot Ankle Int. 2005 Sep;26(9):680-90. doi: 10.1177/107110070502600904.

18. Raikin, Steven M. MD; Ahmad, Jamal M.D.; Pour, Aidin Eslam MD; Abidi, Nicholas MD. Comparison of Arthrodesis and Metallic Hemiarthroplasty of the Hallux Metatarsophalangeal Joint. The Journal of Bone & Joint Surgery 89(9):p 1979-1985, September 2007. DOI: 10.2106/JBJS.F.01385

19. Lawrence B.R., Thuen E. A retrospective review of the primus first MTP joint double-stemmed silicone implant. Foot Ankle Spec. 2013 Apr;6(2):94-100. Epub 2013 Jan 4. doi: 10.1177/1938640012470715.

20. Pulavarti R.S., McVie J.L., Tulloch C.J. First metatarsophalangeal joint replacement using the bio-action great toe implant: intermediate results. Foot Ankle Int. 2005 Dec;26(12):1033-7. doi: 10.1177/107110070502601206.

21. Nagy M.T., Walker C.R., Sirikonda S.P. Second-Generation Ceramic First Metatarsophalangeal Joint Replacement for Hallux Rigidus. Foot Ankle Int. 2014 Jul;35(7):690-8. doi: 10.1177/1071100714536539.

22. Dawson-Bowling S., Adimonye A., Cohen A., Cottam H., Ritchie J., Fordyce M. MOJE ceramic metatarsophalangeal arthroplasty: disappointing clinical results at two to eight years. Foot Ankle Int. 2012 Jul;33(7):560-4. doi: 10.3113/FAI.2012.0560.

23. Baker M.I., Walsh S.P., Schwartz Z., Boyan B.D. A review of polyvinyl alcohol and its uses in cartilage and orthopedic applications. J Biomed Mater Res B Appl Biomater. 2012 Jul;100(5):1451-7. Epub 2012 Apr 19. doi: 10.1002/jbm.b.32694.

24. Goucher N.R., Coughlin M.J. Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study. Foot Ankle Int. 2006 Nov;27(11):869-76. doi: 10.1177/107110070602701101.

25. Younger, Alastair & Baumhauer, Judith. Polyvinyl Alcohol Hydrogel Hemiarthroplasty of the Great Toe. Techniques in Foot & Ankle Surgery. 2013; 12(3): 164-169. DOI:10.1097/BTF.0b013e3182a2b350

26. Baumhauer J.F., Singh D., Glazebrook M., Blundell C., De Vries G., Le I.L., Nielsen D., Pedersen M.E., Sakellariou A., Solan M., Wansbrough G., Younger A.S., Daniels T.; for and on behalf of the CARTIVA Motion Study Group. Prospective, Randomized, Multicentered Clinical Trial Assessing Safety and Efficacy of a Synthetic Cartilage Implant Versus First Metatarsophalangeal Arthrodesis in Advanced Hallux Rigidus. Foot Ankle Int. 2016 May;37(5):457-69. Epub 2016 Feb 27. doi: 10.1177/1071100716635560.

27. Goldberg A., Singh D., Glazebrook M., Blundell C.M., De Vries G., Le ILD, Nielsen D., Pedersen M.E., Sakellariou A., Solan M., Younger A.S.E., Daniels T.R, Baumhauer JF; Cartiva MOTION Study Group. Association Between Patient Factors and Outcome of Synthetic Cartilage Implant Hemiarthroplasty vs First Metatarsophalangeal Joint Arthrodesis in Advanced Hallux Rigidus. Foot Ankle Int. 2017 Nov;38(11):1199-1206. Epub 2017 Aug 18. doi: 10.1177/1071100717723334.

28. Daniels T.R., Younger A.S., Penner M.J., Wing K.J., Miniaci-Coxhead S.L., Pinsker E., Glazebrook M. Midterm Outcomes of Polyvinyl Alcohol Hydrogel Hemiarthroplasty of the First Metatarsophalangeal Joint in Advanced Hallux Rigidus. Foot Ankle Int. 2017 Mar;38(3):243-247. Epub 2016 Dec 7. doi: 10.1177/1071100716679979.

29. Jeffrey E Johnson, Jeremy J McCormick. Modified oblique Keller capsular interposition arthroplasty (MOKCIA) for treatment of late-stage hallux rigidus. Foot Ankle Int. 2014 Apr;35(4):415-22. doi: 10.1177/1071100714523590

30. Schenk S, Meizer R, Kramer R, Aigner N, Landsiedl F, Steinboeck G. Resection arthroplasty with and without capsular interposition for treatment of severe hallux rigidus. Int Orthop. 2009;33(1):145–50. doi: 10.1007/s00264-007-0457-z.

31. Clews C.N., Kingsford A.C., Samaras D.J. Autogenous capsular interpositional arthroplasty surgery for painful hallux rigidus: assessing changes in range of motion and postoperative foot health. J Foot Ankle Surg. 2015; 54(1):29–36. doi: 10.1053/j.jfas.2014.09.004.

32. Kennedy JG, Chow FY, Dines J, Gardner M, Bohne WH. Outcomes after interposition arthroplasty for treatment of hallux rigidus. Clin Orthop Relat Res. 2006; 445:210–5. doi: 10.1097/01.blo.0000201166.82690.23.

33. Deland J.T., Williams B.R. Surgical management of hallux rigidus. J Am Acad Orthop Surg. 2012; 20:347–358. doi: 10.5435/JAAOS-20-06-347.

34. Migues A., Slullitel G. Joint-preserving procedure for moderate hallux rigidus. Foot Ankle Clin. 2012; 17:459–471. doi: 10.1016/j.fcl.2012.06.006

35. Bobrov D. S., Slinyakov L. YU., Chenskii A.D., M.I. Matvienko, M. YU. Kholodaev, N. D. Khurtsilava. Deformiruyushchii osteoartroz pervogo plyusnefalangovogo sustava, ili rigidnyi 1 palets stopy: klinika, diagnostika i lechenie (Analiticheskii obzor literatury). Kafedra travmatologii i ortopedii – 2014; 3(11), 4-12. – eLIBRARY ID: 24343035, EDN UMSEBT

36. Colò G., Fusini F., Samaila E.M., Rava A., Felli L., AlessioMazzola M., Magnan B. The efficacy of shoe modifications and foot orthoses in treating patients with hallux rigidus: a comprehensive review of literature. Acta Biomed. 2020 Dec 30;91(14-S):e2020016. doi: 10.23750/abm.v91i14-S.10969.

37. Alshehri A.S., Alzahrani F.A., Alqahtani L.S., Alhadlaq K.H., Alshabraqi H.A., Aljaafri Z.A. Outcomes of Operative Versus Nonoperative Management for Hallux Rigidus: A Tertiary Care Center Experience. Cureus. 2023 Oct 13;15(10):e46991. doi: 10.7759/cureus.46991.

38. Kim P.H., Chen X., Hillstrom H., Ellis S.J., Baxter J.R., Deland J.T. Moberg Osteotomy Shifts Contact Pressure Plantarly in the First Metatarsophalangeal Joint in a Biomechanical Model. Foot Ankle Int. 2016 Jan;37(1):96-101. Epub 2015 Sep 18. doi: 10.1177/1071100715603513.

39. Kim J., Rajan L., Fuller R.M., Mizher R., Cororaton A.D., Kumar P., An T.W., Deland J.T., Ellis S.J. A Patient-Reported Outcome-Based Comparison of Cheilectomy With and Without Proximal Phalangeal Dorsiflexion Osteotomy for Hallux Rigidus. Foot Ankle Spec. 2024 Feb;17(1):67-77. Epub 2023 Jan 10. doi: 10.1177/19386400221147775.

40. Ilchenko D.V., Korolev A.V., Kardanov A.A. Long-term functional results of first metatarsophalangeal joint arthrodesis for hallux rigidus Genij Ortopedii 2020; 1(26): 30-36. DOI 10.18019/1028-4427-2020-26-1-30-36

41. Кавалерский Г. М., Ченский А. Д., Сорокин А. А., Прохорова М. Ю. Эндопротезирование первого плюснефалангового сустава при Hallux rigidus Кафедра травматологии и ортопедии. – 2014; 1(9): 7-9. – http:jkto.ru/id-3/id-2/1-9-2014-/hallux-rigidus.html. [Kavalerskii G. M., Chenskii A. D., Sorokin A. A., Prokhorova M. YU. Ehndoprotezirovanie pervogo plyusnefalangovogo sustava

42. pri Hallux rigidus Kafedra travmatologii i ortopedii. – 2014; 1(9): 7-9. – http: jkto.ru/id-3/id-2/1-9-2014-/hallux-rigidus.html]

43. Il'chenko D.V., Il'in D.O., Kardanov A.A., Achkasov E.E., Korolev A.V. Kompleksnyj podhod k konservativnomu lecheniju pacientov s osteoartrozom pervogo pljusnefalangovogo sustava. Nauchno-prakticheskaja revmatologija. 2021;59(4):463–470. doi: 10.47360/1995-4484-2021-463-470