[Indications for and methods of hallux rigidus treatment].

PURPOSE OF THE STUDY: In a retrospective study, to evaluate the results of surgical treatment of hallux rigidus on the basis of clinical rating, radiographic findings and visual analogue scale (VAS).

MATERIAL: The group included 68 patients, 38 women and 30 men, treated at the orthopaedic ward of the Hospital Ceské Budejovice in the period from April 2004 to June 2007. The average age of the patients was 58.6 years (range, 34 to 79). Right and left feet were affected in 42 and 26 patients, respectively. Follow-up ranged from 3 to 30 months.

METHODS: Surgery was undertaken only after all means of conservative treatment had been used. Indications for each type of operation were based on the severity of disorder of the first metatarsophalangeal joint (MTPJ), patient's age, toe's motion restriction and physical stress on the patient's big toe. In patients with moderate degenerative MTPJ disease, in 25 feet, a Moberg dorsal wedge osteotomy of the first proximal phalanx was carried out when plantar flexion was preserved; in 12 feet, a Youngswick sagittal V osteotomy was indicated when both flexion and extension were limited and the first metatarsus was long enough; in 14 cases cheilectomy alone was used. In patients with severe arthritis, the TOEFIT-PLUS modular joint replacement of th first MTPJ was used in seven, the Brandes-Keller resection arthroplasty was carried out in six and arthrodesis of the first MTPJ was performed in four. All patients were examined at 2 and 6 weeks after surgery. Those undergoing osteotomy, arthrodesis or joint replacement were X-rayed after surgery and then at 6 weeks of follow-up.

RESULTS: The outcome of treatment was evaluated at 3 to 30 months after surgery by clinical and X-ray examination and using the VAS. The average range of MTPJ motion improved from 5 degrees to 22 degrees in dorsiflexion and from 17.5 degrees to 27 degrees in plantar flexion. Osteotomy or arthrodesis in all patients healed in correct alignment, without loosening or migration of prosthetic components. Based on the VAS (100-point scale), pain assessment was 34 preoperatively and 78 post-operatively; joint motion increased from 51 before to 82 after surgery; and ability for daily activities from 50 to 84. The overall VAS score was 42 before surgery and improved to 83 after surgery. Five patients were dissatisfied; two of them underwent repeat surgery (arthrodesis) with marked improvement and one achieved improvement by shoe modification. The rest of the group reported good or very good outcomes.

DISCUSSION: Resection arthroplasty, widely used before, is now performed only in patients exerting minimal physical activity and with severe arthritic disease, because it results in loss of the big toe's supporting function. Osteotomies by Moberg or Youngswick procedures involve the use of screws (Barouk). Stable osteosynthesis allows for early post-operative rehabilitation and weight bearing in appropriate modified shoes. Dorsal wedge osteotomy is the method most frequently used in our department to the full satisfaction of our patients.TOEFIT joint replacement is indicated in elderly patients with severe degenerative disease who wish to maintain toe motion and have adequate weight bearing of the treated foot. Emphasis is placed on good post-operative rehabilitation of the joint and on co-operation with the patient.

CONCLUSIONS: The hallux rigidus diagnosis covers several grades of degenerative disease of the first MTPJ and therefore its surgical treatment must necessarily involve more than one operative procedure. Even when an appropriate technique is used, the problems may not resolve completely. When the technique to be used is considered, good communication with the patient is necessary, because they should know the principle of treatment and an anticipated outcome of it. Our results show that the surgical treatment of hallux rigidus has good outcome if it is correctly indicated and technically well performed and completed with good post-operative care.