What is new about hallux rigidus?

Hallux rigidus (HR) represents one of the most frequent forefoot disorders, together with hallux valgus and lateral toe deformities, being the most frequent degenerative process in the foot and ankle.This publication is the result of the collaboration of colleagues of the Spanish Society of Medicine and Foot and Ankle Surgery (Sociedad Española de Medicina y Cirugía del Pie y Tobillo, SEMCPT) and the Argentinean Society of Medicine and Foot and Leg Surgery (Sociedad Argentina de Medicina y Cirugía de Pie y Pierna, SAMCPP). It is an honor for us to have this work edited in the Journal of the Foot & Ankle, a journal with a marked Latin identity. We really thank Alexandre Leme Godoy-Santos, Chairman of the Editorial Board, for his help and contribution. This update topic has been coordinated by R. Viladot Pericé and A. Viladot Voegeli, together with M. Herrera and M. Núñez-Samper.Considering the interest and the extent of this topic and, according to the coordinators, we have divided the publication into two parts. The first one describes general aspects (definition, etiology, classification, treatment algorithm, etc.) and the conservative treatment of HR, whereas the second one addresses the different surgical techniques described to treat this disease.The aim of this work is to review our knowledge on HR and to perform an update on the innovations that have emerged during the last years.

Concept, etiology, and pathomechanics of hallux rigidus

There is a continuous anatomical, functional and pathomechanical roadmap from functional hallux limitus to hallux rigidus. Although many etiologies for hallux rigidus have been studied it is very probable that it has a primary origin with less-than-ideal movement when we are born. Upon a restricted range of motion, symptoms may arise depending on the amount of work and how compensatory mechanisms work around the first metatarsophalangeal joint. Changes occurring at the joint that allow the transition from a sliding movement mechanism (physiological) to a rolling mechanism (pathological) may trigger anatomical and functional changes resulting in pain and dysfunction. Any surgical technique that is able to restore the sliding mechanism to the first metatarsophalangeal joint will have a positive impact on pain and function in a patient with a symptomatic functional hallux limitus/rigidus. Level of Evidence V; Therapeutic Study; Expert opinion.

Hallux rigidus: clinical examination, radiology, and classification

The severity of hallux rigidus depends on the degree of joint involvement, from local pain to stress fractures of other bones of the foot due to hyper-support. Radiology is mandatory to have an accurate diagnosis and gives us a parameter of joint injury. We use the Coughlin and Shurnas classification as the gold standard for treatment. Level of Evidence IV.

Evaluation of the clinical-radiographic results of patients undergoing arthroscopic metatarsal-phalangeal arthrodesis of the hallux

Introduction: Hallux rigidus (HR) is a frequent pathological condition of the foot, responsible for marked functional impairment. Metatarsal-phalangeal arthrodesis is an excellent treatment alternative for advanced stages of the disease, usually performed as an open surgery. Forefoot arthroscopy had its greatest development in the last decade, with a progressive expansion of indications, yielding encouraging results. Objective: To present the clinical and radiographic results of patients undergoing arthroscopic metatarsal-phalangeal arthrodesis of the hallux, depicting the technique and reporting complications. Methods: This study involves a series of cases, we operated 9 patients (10 feet), all with advanced HR (grades 3 and 4 - Coughlin-Shurnas). The patients underwent an arthroscopic procedure through two dorsal portals, small joints instruments. We assessed the results using the AOFAS functional score and the visual analogue pain scale. The radiographic parameters we used to analyze were the metatarsal-phalangeal angulation in the anteroposterior (pre- and postoperative) and lateral (post-operative) views, and we measured the radius shortening. Conclusion: Arthroscopic metatarsal-phalangeal arthrodesis is an excellent treatment option in advanced stages of hallux rigidus, with minimal disruption and providing excellent results, in addition to a low incidence of complications. Level of Evidence IV; Therapeutic Studies; Case Series

Conservative treatment of hallux rigidus: narrative review of scientific evidence

This study proposes an update on conservative treatment of hallux rigidus based on scientific evidence. This is a narrative review of 19 articles that analyzed conservative treatment of hallux rigidus in its different modalities. Conservative treatment is effective in approximately half of the patients with hallux rigidus, and footwear modifications, use of insoles, and hyaluronic acid injections are the most effective treatments, according to evidence-based medicine. Level of Evidence III; Therapeutic Studies; Systematic Review of Level III Studies.

Metatarsophalangeal arthrodesis of the hallux using a minimally invasive technique

Objective: To evaluate the outcomes of the metatarsophalangeal arthrodesis (MTPA) of the hallux using a percutaneous technique. Methods: The MTPA of the hallux was performed in a total of 27 feet: 20 patients diagnosed with hallux rigidus and 7 with rheumatoid arthritis. The mean postoperative follow-up time was 30.7 months. The results were evaluated using the visual analogue scale (VAS) for pain, the American Orthopaedic Foot & Ankle Society (AOFAS) forefoot score, and regards to union rate. Results: All 27 patients were operated percutaneously and noticed relief of the pain, with a mean increase of 50.9 points in AOFAS scores and a mean decrease of 7.4 points in the VAS. The mean union time was 10 weeks. There were no cases of nonunion. Conclusion: Percutaneous first MTP arthrodesis proved effective for treating hallux rigidus and degenerative rheumatic pathologies. Level of Evidence IV; Therapeutic Studies; Cases Series.

Proposed treatment algorithm for hallux rigidus

This study performs a literature review on the treatment of hallux rigidus and proposes a treatment algorithm.This literature systematic review expanded a similar study conducted in 2014 by the authors and analyzed the levels of recommendation according to scientific evidence.Most articles found in the search present scarce evidence (level IV or case series), we only found 8 articles with an at least moderate level of recommendation (B); of these, only one article had a level of evidence I.Conservative treatment is effective with the implementation of footwear modifications, use of insoles, and infiltrations with hyaluronic acid. Cheilectomy, either isolated or combined with Moberg osteotomy, shows good outcomes in stage III, or moderate, although its outcomes worsen after 5 years. Metatarsophalangeal joint (MTPJ) arthrodesis is still the gold standard in stage IV, or advanced. In recent years, the technique of interposition arthroplasty has re-emerged, especially with the use of a synthetic cartilage implant (Cartiva®), with outcomes at least similar to those of MTPJ arthrodesis in comparative studies. Level of Evidence III; Therapeutic Studies; Systematic Review of Level III Studies.