Figure 1. Anteroposterior radiograph of the right foot.
Figure 2. Lateral radiograph of the right foot.
A 64-year-old woman presents with right hallux pain that has persisted for several months. She has had injections into the metatarsophalangeal (MTP) joint with minimal relief. Radiographic examination is performed (Figures 1 and 2).
What is the best surgical option for this patient?
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Hallux rigidus, or arthritis of the MTP joint of the big toe, is the most common arthritic condition of the foot. Patients with the condition may experience difficulty wearing certain shoes as well as pain while walking. Hallux rigidus is more common in women aged >50 years. Conservative treatment consists of nonsteroidal anti-inflammatory drugs and rigid-soled shoes to reduce MTP joint motion. While conservative treatment will help to alleviate symptoms, it will not prevent the progression of arthritis. A number of surgical options exist to prevent arthritis progression; these vary between joint sparing and joint sacrificing. Patients with mild to moderate arthritis often choose a dorsal cheilectomy procedure that involves removing approximately 30% of the dorsal metatarsal head and osteophyte. Cheilectomy increases MTP joint dorsiflexion and is successful in reducing pain in most patients.
A Keller procedure involves resection of the base of the proximal phalanx. Joint resection is often reserved for low-demand elderly patients as the procedure may destabilize the joint and weaken toe push-off strength. MTP joint arthroplasty options may help preserve patient’s motion; these include soft tissue interposition arthroplasty (removal of part of the joint and interposition of a biological spacer) and implant arthroplasty (placement of a silicone or metallic prosthetic implant to replace the joint). Arthroplasty procedures are associated with a slight increase in complication rates compared with joint arthrodesis, the gold standard treatment for severe MTP joint arthritis. Most studies report successful outcomes such as improvement in pain and function after arthrodesis observed in approximately 90% of patients.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).