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The Journal of Bone and Joint Surgery (American) 85:2072-2088 (2003)
© 2003 The Journal of Bone and Joint Surgery, Inc.

Hallux Rigidus

Grading and Long-Term Results of Operative Treatment

Michael J. Coughlin, MD1 and Paul S. Shurnas, MD2

1 901 North Curtis Road, Suite 503, Boise, ID 83706. E-mail address: footmd{at}aol.com
2 Regional Orthopaedic Health Care, No. 3 Medical Plaza, Mountain Home, AR 72653

Investigation performed at St. Alphonsus Regional Medical Center, Boise, Idaho

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: There have been few long-term studies documenting the outcome of surgical treatment of hallux rigidus. The purposes of this report were to evaluate the long-term results of the operative treatment of hallux rigidus over a nineteen-year period in one surgeon's practice and to assess a clinical grading system for use in the treatment of hallux rigidus.

Methods: All patients in whom degenerative hallux rigidus had been treated with cheilectomy or metatarsophalangeal joint arthrodesis between 1981 and 1999 and who were alive at the time of this review were identified and invited to return for a follow-up evaluation. At this follow-up evaluation, the hallux rigidus was graded with a new five-grade clinical and radiographic system. Outcomes were assessed by comparison of preoperative and postoperative pain and AOFAS (American Orthopaedic Foot and Ankle Society) scores and ranges of motion. These outcomes were then correlated with the preoperative grade and the radiographic appearance at the time of follow-up.

Results: One hundred and ten of 114 patients with a diagnosis of hallux rigidus returned for the final evaluation. Eighty patients (ninety-three feet) had undergone a cheilectomy, and thirty patients (thirty-four feet) had had an arthrodesis. The mean duration of follow-up was 9.6 years after the cheilectomies and 6.7 years after the arthrodeses. There was significant improvement in dorsiflexion and total motion following the cheilectomies (p = 0.0001) and significant improvement in postoperative pain and AOFAS scores in both treatment groups (p = 0.0001).

A good or excellent outcome based on patient self-assessment, the pain score, and the AOFAS score did not correlate with the radiographic appearance of the joint at the time of final follow-up. Dorsiflexion stress radiographs demonstrated correction of the elevation of the first ray to nearly zero. There was no association between hallux rigidus and hypermobility of the first ray, functional hallux limitus, or metatarsus primus elevatus.

Conclusions: Ninety-seven percent (107) of the 110 patients had a good or excellent subjective result, and 92% (eighty-six) of the ninety-three cheilectomy procedures were successful in terms of pain relief and function. Cheilectomy was used with predictable success to treat Grade-1 and 2 and selected Grade-3 cases. Patients with Grade-4 hallux rigidus or Grade-3 hallux rigidus with <50% of the metatarsal head cartilage remaining at the time of surgery should be treated with arthrodesis.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.


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Related articles in JBJS:

Hallux Rigidus. Surgical Techniques (Cheilectomy and Arthrodesis)
Michael J. Coughlin and Paul S. Shurnas
JBJS 2004 86: 119-130. [Abstract] [Full Text]  

Hallux Rigidus: Grading and Long-Term Results of Operative Treatment
Brad S. Webb, Rob Amiot, Sean Wilson, Michael Nute, Michael J. Coughlin, and Paul S. Shurnas
JBJS 2005 87: 462-463. [Extract] [Full Text]  



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Letters to the Editor:

Read all Letters to the Editor

Metatarsus Primus Elevatus and Hallux Rigidus
Brad S Webb, et al.
JBJS Online, 26 Jul 2004 [Full text]
Drs. Coughlin and Shurnas respond:
Michael J. Coughlin M.D., et al.
JBJS Online, 4 Aug 2004 [Full text]