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Hallux Rigidus

The first MTP joint plays an important functional role during the gait cycle as it carries approximately 119% of body’s weight with each step.


Trauma is considered to be one of the main causes of unilateral hallux rigidus and the family history, female gender and hallux valgus interphalangeus are associated with bilateral involvement. Other associated conditions are repetitive stress, inflammatory and metabolic conditions, long first metatarsal and metatarsus adductus.

Clinical Presentation

Patients may present with pain, altered gait pattern, difficulty in wearing certain types of shoes due to limited dorsiflexion.


Painful and restricted movements at the extreme of dorsiflexion indicate dorsal osteophytes however pain during the midrange motion indicates more diffuse level of arthritis.

There may also be associated pathologies including hallux valgus, flatfoot or lesser toe deformities.

Clinical Assessment

There is usually a localised, palpable and tender dorsomedial osteophyte and reduction and pain in the range of motion.


A reliable and reproducible method of measuring the range of motion was described by Vulcano et al. with the use of dynamic x-rays. There was a significant difference reported between clinical ROM and radiographic ROM. Standard weight-bearing plain radiographs AP, lateral and oblique are obtained to assess the joint.


Conservative Treatment

Non-operative treatment is usually attempted first.


The modalities include analgesia, shoe-modifications, activity modification, physiotherapy and intra-articular injections (Steroids, PRP, Hyaluronic acid).

Grady et al. reported a 55% success rate with these modalities (orthotics, injections and shoe modifications) in a retrospective review of 772 patients.

Solan et al. reported the outcomes of MUA and injection for hallux rigidus and their results showed that patients with grade I hallux rigidus experienced pain relief for 6 months and one third required surgery; grade II patients had pain relief for 3 months and two-thirds required surgery; grade III patients had only minimal benefit and all of them required surgery.

PRP injections have also been shown to reduce stiffness and pain, however, the current evidence is scarce to support their use.

Pons et al. compared steroids and hyaluronic acid injections in a prospective RCT and reported no difference in rest pain, however, in hyaluronic acid group gait pain improved at 28 and 56 days.

Morton type orthotic extension, navicular pads and rocker-bottom soles alter the load pattern and may help the symptoms. Shoes with high toe box can help taking some pressure off the joint.

Physiotherapy and gait training in early stages may help improving the ROM.

Surgical Treatment

When conservative measures fail, surgical options include cheilectomy with or without Moberg osteotomy, interpositional arthroplasty, replacement arthroplasty and arthrodesis.

The choice of procedure is based on the condition of the joint, patient’s expectations and surgeon’s experience. The aims of surgery are to improve pain, function and quality of life and to maintain stability of joint.


Cheilectomy is the treatment of choice for early stage OA. It involves resection of approximately 30% of the dorsal metatarsal head and excision of osteophytes. It has been shown to improve the dorsiflexion, gait pattern and increase the peak push-off power of the ankle.


An ideal patient for cheilectomy is someone with primarily dorsal symptoms of impingement, large dorsal osteophytes and less than 50% joint space narrowing.

Coughlin et al. reported the longest follow-up study with a mean follow-up of 9.6 years on 89 patients treated with cheilectomy, 97% good to excellent results and 92% improvement in pain and function.

Nawoczenski et al. a 91% satisfaction rate and an average postoperative VAS score of 1.7 in a prospective study on 11 patients with an average follow-up of 6.2 years. In another prospective study on 20 patients with grade I to III hallux rigidus, the same authors reported a 12° improvement in dorsiflexion after cheilectomy.

Smith et al. prospectively evaluated 17 patients with stage I and stage II hallux rigidus after cheilectomy and found an average improvement of 16.7° in functional first MTP range of motion with gait analysis.

Bussewitz et al. reported a success rate of 98.5% in 197 patients after cheilectomy with a mean follow up of 3.2 years.

Nicolosi et al. reported 87% pain relief and 95% patient satisfaction in 58 patients with a mean follow up of 7 years.

Cetinkaya et al. reported the outcomes of cheilectomy in grade III hallux rigidus for 22 patients and showed an improvement in VAS from 89 to 29 with no revisions in their series.

Easley et al. reported a 31% recurrence of dorsal osteophytes in a retrospective study on 75 patients. However, 43% patients had mid-range pain suggesting that the predominant symptoms in these patients might be the result of progression of arthritis.

Cheilectomy with Moberg Osteotomy

Dorsal closing wedge osteotomy of the proximal phalanx increases the dorsiflexion and facilitates the third rocker of the gait cycle and hence reduces the stress on the arthritic joint. It is performed in conjunction with cheilectomy in early stages.

Waizy et al. compared the outcomes of cheilectomy alone versus cheilectomy and Moberg osteotomy in a study on 60 patients. Patients who had cheilectomy with Moberg osteotomy reported higher satisfaction rates.

O’Malley et al. reported the outcomes of cheilectomy and Moberg osteotomy in 81 patients with grade III OA with a mean follow up of 4.3 years. They reported significant improvement in dorsiflexion and AOFAS scores with 85% patient satisfaction and 4.9% patients requiring subsequent arthrodesis.

Smith et al. reported 99% satisfaction rate in a retrospective review on 17 patients with grade I and II hallux rigidus at 2.5 years follow-up after cheilectomy and no complications or revision surgery.

Moberg osteotomy alone has also been tried and Perez-Anzer et al. have reported good results in 42 patients with grade II and III OA, with improved AOFAS and VAS scores.

Despite the good results, conversion to arthrodesis after Moberg osteotomy may pose some difficulty due to an extended shape of proximal phalanx.


Arthrodesis is considered a ‘gold-standard’ for severe and end-stage hallux rigidus. It has been shown to improve pain, propulsion, function and stability during gait.

There are multiple techniques for arthrodesis. The joint can be prepared with flat cuts or with conical reamers. Flat cuts are more technically demanding and have an increased risk of shortening the first ray along with higher risks of nonunion. While conical reamers require specialised instrumentation, they allow more freedom to change first MTP alignment while maintaining bony contact.


Fixation can be achieved with crossed lag screws or a lag screw with a dorsal plate.


Biomechanical testing has shown that a lag screw with a dorsal plate offers the most stable construct, although at the expense of increased cost.

Goucher and Coughlin reported on 50 patients prospectively after first MTP arthrodesis using conical reamers and fixation with a lag screw and dorsal plate. Patients had a 96% satisfaction rate, 92% union rate and 4% revision rate at average 1.3-year follow-up.

Doty et al. used a similar technique in 49 patients with minimum one-year follow-up and reported 89% good to excellent results with 98% union rate.

Bennett and Sabetta prospectively evaluated 200 patients treated with a dorsal plate with one-year follow-up and reported a 99% union rate and a 1% revision rate.

Brodsky et al. examined sports participation in 53 patients at average 3.7-year follow-up and found that patients were able to return to hiking 92% of the time, golf 80% of the time, tennis 75% of the time and jogging 75% of the time.

Politi et al. compared the strengths of five commonly used techniques and found the most stable technique to be to be a combination of an oblique lag screw and dorsal plate. The weakest technique was the dorsal plate alone with K-wire fixation.

Hyer et al. compared the cost and results of two crossed screws and dorsal plating, and showed that two cross screws provided simple and less costly option with no statistically significant differences in time to fusion, subsequent revision and metalwork problems.



Options for MTPJ arthroplasty include silastic implants, all-metal implants and synthetic cartilage implants.

Metallic implants attempted to replicate total hip and total knee designs in the first MTP joint. There are some reports of moderate patient satisfaction and pain improvement, however, these implants have been associated with early and high failure rates due to osteolysis and subsidence.


Pulavarti reported a revision rate of 5.5% and implant subsidence rate of 33% at average 3.9-year follow-up in a prospective study of 32 patients.

Gibson and Thomson reported on 63 patients in an RCT comparing arthrodesis to arthroplasty and found that 49% of patients had radiographic loosening at one year with a 15% revision rate at two years in arthroplasty group.

Ceramic implants have been reported to have similarly poor results. Nagy et al. reported 68% implant survival at 9 years for 31 second-generation ceramic implants in a retrospective study. Dawson-Bowling reported a 26% re-operation rate at 8 years with 52% of implant loosening in a retrospective study of 32 cases.

Hemi-arthroplasty involves a metallic implant of either the proximal phalanx or the metatarsal head. Townley et al. reported on a retrospective series of 279 patients with 8-months to 33-year follow-up of a metal hemiarthroplasty of the proximal phalanx and found good to excellent results in 95% of patients. However, other studies could not replicate these results and reported poor outcomes.

Konkel et al. reported subsidence and radiolucencies in all ten patients retrospectively reviewed at 37 to 105 months after a proximal phalanx hemi-arthroplasty.


Raikin et al. retrospectively reviewed 21 metatarsal head hemiarthroplasties at average 6.6-year follow-up and found a revision rate of 24% with decreased satisfaction, AOFAS scores and higher VAS pain scores compared with a cohort of 27 arthrodesis patients.

Gheorghiu et al. observed a marked decrease in patient satisfaction and ROM in patients undergoing hemiarthroplasty compared to arthrodesis with a mean follow up of 4 years. In contrast another study by Voskuiji et al. reported better satisfaction rates in patients undergoing hemiarthroplasty.

The reported complications include loosening, change in angulation, subsidence, stiffness and ongoing pain. These reports of higher complication rates, unpredictable long-term results and poor survival have lead to their cautious use among surgeons. In addition, failure of arthroplasty is difficult to manage due to significant bone loss.

Silastic implants have a better outlook but in selected patients. An ideal patient is over 55 years of age with relatively lower physical demands and neutral alignment of the big toe. In a suitably selected patient these implants have been shown to provide good clinical and functional results with longer survival rates.

For silastic implants, Clough et al. reported satisfactory functional outcomes and high patient satisfaction in 83 patients (108 feet) with mean age of 55 years at the time of surgery and a mean follow up of 8.3 years with the use of double-stem implants. These results provide a more-encouraging account compared to the available reports of metallic implants in terms of symptomatic and functional improvements and fewer complications.

A systematic review included all 28 studies published on silastic implants and included 2354 feet in 1884 patients (1968 to 2003). The review included 8 studies with first generation single stem implants and 20 studies with 2nd generation double stem implants and showed an overall failure rate of 5.3% (11% single vs 3.6% double stem) at a mean follow up of 85 months. There was a mean improvement of 76% in pain and 84% patient satisfaction. Radiological changes were reported in 14.7% cases.

Interpositional Arthroplasty

It is a joint sparing option that aims to maintain joint motion in patients with severe hallux rigidus. Keller resection arthroplasty was one of the initial procedures in this regard that involves resection of up to 50% of the base of the proximal phalanx. However, the procedure may potentially destabilize the first MTP joint leading to transfer metatarsalgia, excessive shortening of the toe, cock-up deformity, clawing of the IP joint, and high rates of revision. It has therefore been proposed to reserve the Keller resection in patients with severe hallux rigidus who are over the age of 70, and functionally have low physical demands.

Schneider et al. reported a 90% stable first MTP joint in 78 patients (87 toes) who underwent Keller resection with 23 years of follow-up, 5% revision rate, 23% (19 toes) patients with a cock-up deformity, however, only one patient required revision.

In view of the potential complications of Keller’s resection, multiple modifications have been developed, including a limited resection, addition of a cheilectomy, and a placement of a spacer (joint capsule, extensor hallucis brevis, tendon autograft, tendon allograft, synthetic matrix) with an aim to preserve the bone stock, maintain or increase joint motion, stability and length.

Aynardi et al. retrospectively reviewed 133 patients who underwent interpositional arthroplasty with either autograft or synthetic soft tissue with 90% patients reporting good to excellent outcomes at a mean follow-up of 62.2 months, an overall failure rate of 3.8%, an infection rate of 1.5% and transfer metatarsalgia in 23% patients.

Schenk et al. compared the outcomes of Keller’s resection and interpositonal arthroplasty. They did not find any significant difference between the clinical and radiological outcomes of the two procedures in a short-term follow-up study of 1.26 years.

Mackey et al. compared interpositional arthroplasty with arthrodesis and reported equivalent clinical outcomes. However, interpositional arthroplasty reported an additional benefit of motion preserving motion and a more physiologic pattern of plantar pressure during gait cycle.

Berlet et al. described the use of a regenerative tissue matrix (RTM) as an allograft interpositional spacer for the treating advanced hallux rigidus. It is a biologically engineered allograft consisting of collagen and extracellular protein matrices. In their early report, 9 patients underwent the procedure with no failure at 10 month follow-up. At 5-year follow-up, none of the patients had subsequent fusion or additional procedures performed and all were satisfied with the procedure.

In a multicentre prospective randomised trial of 202 patients a 8-mm to 10-mm synthetic cartilage implant (Cartiva) placed in the first MT head and compared with a first MTP arthrodesis at two-year follow-up.


Baumhauer et al. reported equivalent reduction in VAS pain scores and improvement in FAAM sports functional scores with the synthetic implant and first MTP arthrodesis. Synthetic cartilage patients had an average of 4° of improvement in dorsiflexion and a revision rate of 9.2% to arthrodesis.


While longer survivorship analysis is planned, this implant offers encouraging results. Additionally, because the implant removes only 8 to10 mm of bone surrounding the metatarsal head, revision to arthrodesis is less challenging with minimal loss of length of the first metatarsal.​




Conservative treatment for hallux rigidus is the first line and may provide symptomatic benefit in about 50% for an interim period.


Surgical treatment is indicated once the conservative measures fail and is individualised for each patient depending on their physical demands and expectations.

For mild to moderate degenerated changes cheilectomy (+/- Cartiva) provides consistent results but are interim procedures.


For severe cases, fusion remains the ‘gold standard’ and provides consistent results to improve pain and function. 


Arthroplasty (Silastic) has a reasonable role in selected patients and provides good results.


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