Rate of Revision Following Cheilectomy Versus Decompressional Osteotomy in Early-Stage Hallux Rigidus

Hallux rigidus, or localized osteoarthritis of the fi rst metatarsophalangeal joint, is a very common pathological condition that is often painful and disabling. This is the most common form of arthritis in the foot and has been estimated to affect up to 1 in 45 adults over the age of 50 (1). A progression of deformity is involved, beginning with mild impaired function, continuing on to increasingly frequent episodes of painful excursion of the joint, with in situ fusion being the end range of the spectrum. The etiology is poorly understood and likely multifactorial. Many causes have been proposed, but some of the more comprehensive and well-accepted literature on this subject was published by Root, Orien, and Weed. They claim that 6 factors are correlated: hypermobility of fi rst ray, metatarsus primus elevatus degenerative joint disease, trauma, excessively long fi rst metatarsal, and immobilization of fi rst ray (2). Other potential etiologies include tight Achilles tendon, pronation, atypical morphology of the fi rst metatarsal head and metabolic conditions (3). Regardless of the underlying deformity, the pathological process is the same: the ability of the fi rst metatarsal head to plantarfl ex in the late stages of gait is compromised. This leads to dorsal jamming against the base of the proximal phalanx and altered joint mechanics. The normal shearing forces for this diarthrodial joint are converted into compressive forces. The result is peri-articular osteophyte formation and chronic infl ammatory fl uid production that precipitates enzymatic degradation of cartilage (4, 5). Numerous conservative modalities for treating this condition have been described in the literature. However, a retrospective analysis of 772 patients performed by Grady et al, demonstrated successful outcomes of non-surgical care alone in 428 patients (55%) (6). This suggests up to 45% of patients will require surgery. Should non-surgical treatment fail at controlling symptoms, an equally extensive list of operations has been advocated. These procedures can be broadly grouped into 2 categories: joint sparing and joint-destructive, with the former typically applied to earlier stages of the deformity and the latter reserved for more advanced cases. A recent study (7) compared the outcomes for 3 common procedures used to treat end-stage disease, metatarsophalangeal joint excisional arthroplasty (8-10), implant arthroplasty (11, 12), or arthrodesis (13-15) and no signifi cant difference between them was encountered, indicating that all 3 are viable options. Many patients will present for treatment prior to developing pronounced arthrosis, and a signifi cant controversy exists regarding what is the most benefi cial surgical approach in these cases. Two frequently employed procedures for early stage hallux rigidus are the cheilectomy and the plantarfl exory decompressional osteotomy. Despite the fact that both procedures have been in use for decades, there is a dearth in the literature of studies to prove their effi cacy, either alone or in comparison to each other. The goal of this study was to compare the rate of revision of the 2 procedures, in an effort to assess which provides superior prolonged outcomes. This would hopefully provide surgeons who treat this deformity a stronger foundation of evidence upon which to conduct surgical planning.