Surgical options for salvage of end-stage hallux rigidus.

When approaching patients with a painful first MTP joint that has failed conservative therapy and first-line surgical treatments (cheilectomy or minor bunion procedures), the surgeon should stratify these patients based upon diagnosis, age, and activity level (Fig. 13). For the young, active patient, an arthrodesis is the gold standard, and the primary predictors of clinical and radiographic success are proper fusion angle alignment and maintenance or restoration of length. The method of fusion site preparation and the choice of fixation have not been found to be significant factors in achieving union, but based on the biomechanical data, we prefer the cup-and-cone method. Young, active patients with hallux rigidus also may be considered candidates for the investigational biologic interpositional arthroplasty procedures. Minimizing the bony resection and interposing soft tissue into the first MTP joint may provide symptomatic relief and maintain or restore motion and strength. Most importantly, this procedure does not seem to burn any bridges. If it fails, these patients can then be revised to an arthrodesis. In the elderly, inactive patient, arthrodesis is a safe and reliable treatment option. The Keller arthroplasty may be preferable, however, because it provides [figure: see text] excellent early symptomatic relief and has a less debilitating postoperative rehabilitation program. After Keller arthroplasty, patients may begin protected weight bearing immediately and after wound healing, may be advanced to weight bearing as tolerated. Whereas after fusion, most authors agree that patients should be nonweight bearing for 4-6 weeks or until there is some evidence of early radiographic union. In an older patient with inadequate upper extremity strength to manage crutches or a front-wheel walker, a first MTP fusion may result in prolonged confinement to a wheelchair. If the patient elects to undergo the Keller procedure, these patients should be counseled preoperatively about the potential complications of transfer metatarsalgia, cock-up deformity of the hallux, and weakness in the push-off phase of gait. The patients between these two extremes fall into a treatment gray zone. The arthrodesis should again be considered the gold standard because it is reliable and durable with time and activity. However, biologic or prosthetic interpositional arthroplasty are exciting investigational treatment options for these patients. If a prosthetic implant is to be used, the double-stemmed, hinged silastic implant with protective titanium grommets, or a metallic hemi-arthroplasty prosthesis, appear to be the two best choices of implant. With the continuous advances in material engineering and tissue engineering, prosthetic and biologic interpositional arthroplasties hold the greatest promise for the painful first MTP joint in the future. These treatment modalities allow restoration of alignment and maintenance of motion, length, and strength, which are fundamental in attaining a good clinical result. When the optimal material is developed (whether it is prosthetic, biologic, or a combination of both), these treatment advantages will be realized without the attendant complications associated with the use of our current implants.