Surgical options for hallux rigidus: state of the art and review of the literature

Hallux rigidus is a painful condition of the great toe characterized by restriction of the metatarsophalangeal range of motion and progressive osteophyte formation. Many etiologies have been postulated including excessive length of the first ray, trauma, abnormally elevated first metatarsal and a positive family history. However, most cases are likely idiopathic. Plain radiographs are used to grade the severity of hallux rigidus. The more comprehensive grading is represented by Coughlin and Shurnas' system that introduced a four-grade classification. When nonoperative treatment fails to provide relief, surgery should be performed. The goal of surgery is to relieve pain, maintain stability of the first metatarsophalangeal joint and improve function and quality of life. Operative treatments can be divided into joint sparing (e.g., cheilectomy with or without associated osteotomies) versus joint sacrificing (e.g., arthroplasty or arthrodesis). There are a variety of osteotomies available for treatment of hallux rigidus (phalanx and/or metatarsal osteotomies). Newer techniques of interpositional arthroplasty as well as new hemi-arthroplasty designs, including synthetic cartilage implants, offer promising options for preservation of motion. The choice of procedure is based on the condition of the joint, patient's goals and expectations of the surgical outcome, and patient's motivation. This article discusses various procedures along with clinical outcomes and complications. The advantages and disadvantages of each procedure are discussed.