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Hallux Rigidus- Minimally invasive Cheilectomy

    Overview

    Learn the Hallux Rigidus: Minimally invasive Cheilectomy surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Hallux Rigidus: Minimally invasive Cheilectomy surgical procedure.
    A relatively new technique which reduces the post-operative pain ,swelling and visible scarring resulting from debridement of the 1st metatarso-phalangeal joint. Despite these early advantages significant evidence is lacking on any longer term advantage in terms of the outcome of debriding a Hallux Rigidus.
    A minimally invasive cheilectomy should also usually be combined with an MTP joint arthroscopy to lavage from the joint the resulting bone swarf as well as deal with the intra-articular pathology the exists with a degenerate joint.
    Minimally invasive cheilectomy is of use in two overlapping subsets of patients. The first group are those with more generalised (but milder ) arthritic symptoms , where the intervention is part of a more general minimally invasive joint debridement. The second are those who are suffering with exclusively dorsal impingement symptoms , either as part of an advanced but pain-free arthritic joint or an anatomically prominent dorsal aspect to the metatarsal head.

    Indications

    INDICATIONS.
    -Most commonly symptomatic First MTP arthritic change with a dorsal cheilus.
    -On occasion for symptoms of purely dorsal impingement which may occur in the absence of arthritic change.
    -Rarely the technique is also used as a secondary procedure to improve dorsi-flexion and joint range of movement after Hallux Valgus correction surgery that has resulted in significant & symptomatic joint stiffness.
    In my practice it is invariably followed with a 1st MTP joint arthroscopy.
    There is no demonstrated advantage in terms of the longer term outcome using the minimally invasive technique versus an open First MTP debridement.
    That is to say the chance of significant improvement in both cases is in the region of 70-80% (with a 5% chance of early worsening).
    There is in my experience far less pain and swelling if performed arthroscopically which allows in most cases a joint mobilisation program to start by the end of week one and a return to non-manual work within the same time frame. The technique offers not only these early benefits but potentially an easier path to increased dorsiflexion range (compared to joint mobilisation after an open debridement) though this benefit is not proven.
    SYMPTOMS & EXAMINATION.
    In patients with early/mild or moderate 1st MTP arthritic change pain is often activity related. In general it is present during (and for a variable time after) the mechanical stimulus but does not occur at night or at rest to any real extent. Pain will be well localised to the joint and normally deeply felt or dorsally felt. Well localised and consistent plantar pain should alert one to the possibility of symptomatic sesamo-phalangeal arthritis as plantar pain is not a common symptom of more general MTP arthritic change. These are not likely to be adequately treated by a more general joint debridement.
    Swelling and some dorsal deformity may be present to a variable degree. In most cases the nature of the deformity will be a dorsal spur effecting the 1st Metatarsal head . It can also effect the base of the proximal phalanx . On occasion a Hallux Valgus deformity may co-exist. This may be the more relevant way to direct surgical treatment, symptoms dependent, rather than a joint debridement in isolation.
    The patient is likely to display pain at the end of range when the joint is passively moved rather than pain through-out the range, which is more an indication of severe degenerative change.
    If a joint is degenerate enough to produce a cheilus there will always be intra-articular pathology to deal with. If a patient just has isolated impingement pain then an isolated cheilectomy is a reasonable intervention. If joint symptoms are also present then an arthroscopy should subsequently be performed (under the same anaesthetic).
    INVESTIGATION
    X-Ray: A plain X-ray is sometimes sufficient in the level of detail provided to decide on the salvageability of a joint. More often it can be used to rule out the procedure if arthritic change is unexpectedly advanced.
    MRI: As an alternative an MRI is more sensitive in assessing the chondral surfaces (which can be effected without producing plain X-Ray changes). MRI is not however 100% sensitive for chondral involvement and there is no absolute percentage chondral coverage which is recognised as needing to be present for a good outcome after debridement.
    The classification system of Coughlin is probably the most adopted for grading Hallux Rigidus and is worthy of fuller review (see results section). It combines an assessment of range of movement , plain X-ray features , the nature and frequency of pain as well as when during the range of joint movement pain occurs. In this it certainly identifies the aspects of an arthritic joint can that can be measured but lacks a weighting to the relative importance of these features in determining appropriate treatment.
    NON-OPERATIVE OPTIONS
    -Joint injection: This can be a useful intervention in the earliest of arthritic cases, gaining up to 6 months of symptomatic relief . Sloan, Calder & Bendall reported on this in 2001 (Journal Bone Joint Surg 2001. 83(5):706-8)
    -Stiff soled & rocker profile shoes: Examples of which are fit-flops or MBTs.
    -Rigid or semi-rigid functional foot orthotic:
    ALTERNATIVE OPERATIVE OPTIONS
    -Open MTP Debridement +/- Moberg operation: See the OrthOracle technique.
    -First metatarsal osteotomy: (Watermann , shortening Scarf , Youngswick etc): See the OrthOracle technique.
    –Joint replacement (various): See the OrthOracle technique.
    -Joint fusion (various techniques): See the OrthOracle technique.

    Setup

    GA or regional anaesthesia
    Popliteal or intermeattarsal block for post-operative pain relief
    Laminar flow , peri-operative antibiotics and LMW Heparin
    Thigh tourniquet and Flowtron on contra-lateral calf
    Supine position and set-up with calf bolster.

    Operation

    The incision used is placed approximately at the junction of the Metatarsal neck and shaft. It is best placed in the midline and one should avoid the Dorsomedial cutaneous nerve, which also sits here.
    On occasion the Dorso-medial cutaneous nerve can be seen, or palpated, or as in this case both. The incision and portal is better placed dorsal to this structure to minimise the chance of injuring it during the operation.
    When palpating the nerve it will be felt as a “rollable” structure under the index finger. In the eventuality that it sits exactly where the portal should then there is always enough soft tissue laxity to push the nerve (and skin) plantar-wards from its midline location and place the incision where required. The soft tissue distraction needs to be maintained until the portal is fully established.
    The nerve can be caused to dysfunction by direct injury , early post-operative swelling or later onset post-operative scar tissue. If it does often this portal becomes hypersensitive and a “trigger point” to produce sensory symptoms in the distribution of the nerve .

    It is easiest to appreciate the size of the dorsal cheilus by placing the joint into plantarflexion.
    It is useful also to put the MTP joint through its range of movement and note what this is (for comparison with the on-table post-operative range).

    The incision is placed approximately at the junction of the metatarsal head and neck , using a beaver blade. It must avoid the dorso-medial cutaneous nerve.
    If the incision is placed too distally ( and on the head) it will both be prominent in shoe-wear but more immediately may limit the access to the medial aspect of the metatarsal head, making complete clearance of the dorsal cheilus difficult. There needs to be enough of a soft tissue “bridge” ( and as a result soft tissue laxity) between the joints’ dorso-medial aspect and the incision to allow the hand-piece of the Shannon burr to be angled laterally , thus bringing the tip of the burr onto the medial cheilus.

    The incision is made just through the skin and not directly onto the bone. The straight periosteal elevator is then used carefully, and inserted in parallel to the skin cut, to tease a plane of dissection directly onto the metatarsal neck. Even with such a small incision it should be possible to avoid the nerve with this technique.
    A sub-periosteal pocket then needs to be created, extending across the whole dorsal aspect of the joint, both medially and laterally. This should be proceeded to immediately once the periosteal elevator has made contact with bone.
    This step is performed using specific sharp , single use instruments. The initial periosteal elevator (seen here) has a gentle angle of curvature.

    It is easier to create a pocket safely with some tension taken off the soft tissues by dorsiflexing the MTP joint.

    The pocket needs to extend down distal to the cheilus. It may even need to extend to the base of the proximal phalanx if this also is afflicted with a significant prominence.
    There will be some increased resistance noticed getting from the metatarsal neck onto the head as the capsule is stripped off its attachments. The pocket needs to extend across the width of the metatarsal head as well as distal to the cheilus.
    Orientation is best done by regular palpation of the tip of the elevator through the soft tissue envelope , referencing to the bony landmarks. This is also made easier by moving the toe regularly into both dorsiflexion as well as plantarflexion.

    The second periosteal elevator to be used has a much greater curvature and is well designed to clear the far lateral aspect of the joint.

    Again the joint is placed into dorsi-flexion to make following the correct soft tissue plane easier.

    The low speed, high torque MIS burr . The burr chosen for this procedure is known as a Shannon burr.
    The burr , hand-piece and pressure infusing system for irrigation fluid are all specifically designed for the purpose and supplied by OrthoSolutions.
    The cooling irrigation fluid should be run through the system & seen to be visibly doing so before the instrument is introduced.

    For insertion of the burr the MTP joint is placed into dorsiflexion Most of the burring will be done with the joint in this position to lessen the chances of injury to the dorsal soft tissues.
    The burr should run smoothly if it has been placed into an adequate soft tissue pocket. If however it jars initially , catching on the soft tissues , then remove the burr and repeat the steps with the periosteal elevators to improve the dimensions of the pocket.

    It is key that the burring is done in short , controlled bursts . The cutting blades of the burr should always be well beneath the soft-tissue envelope and a continual fluid stream should be cooling the burr. A continual assessment needs to be made about how much bone is being removed . This is easiest done with the toe plantar-flexed as here . Specifically burring is not done with the joint in this position for obvious reasons. Burring is carried out with the toe placed into dorsiflexion.
    One should always be aware of the exact location of the tip of the burr. Throughout the operation the opposite index finger should be continually palpating the bone and burr tip to ensure its appropriate placement. This is not done whilst actively burring.
    Burring should always commence from the most dorsal aspect of the metatarsal head and proceed inferiorly. Whether to start medially or laterally depends on preference and ease of access.

    The position of the MTP joint during burring should be into dorsiflexion . The position of the burr and location of remaining bone should continually referenced by palpating the dorsal aspect of the joint which is easier done by relaxing the MTP joint into a neutral position (whilst not actively burring).

    After a burring bone can be easily expressed through the portal , almost like squeezing toothpaste. A good indication that adequate bone is being removed from the metatarsal head is that the Extensor Hallucis Longus (EHL) tendon becomes far more visible and easily seen ( as demonstrated in this image).
    Once the full cheilus has been removed how much of the metatarsal heads dorsal aspect should be removed is open to debate. Figures of 20% or 30% of the total “height” of the head are quoted frequently. Without X-ray control this can be difficult to judge using a minimally invasive technique (as opposed to an open technique where it is straightforward).
    An increased range on table should be aimed for without destabilising the joint. Full range is not required for a successful outcome nor likely to be achieved.

    An angled rasp is used to remove bony debris/swarf that hasn’t squeezed out easily from the “pocket”.

    Bony debris being removed with the rasp.

    The Cheilus from the metatarsal head is now well cleared (1). The remaining “prominence” at the MTP joint is simply the base of the proximal phalanx(2). On occasion the distal side of the joint can be also be effected by a cheilus. This is more difficult to clear safely because of the closer adherence of the EHL & Extensor Hallucis Brevis (EHBr) tendon to the bone on this side of the joint. If it is to be done then the insertion of the EHBr must be first very carefully subperiosteally elevated sufficiently to allow enough access for the burr without traumatising the tendon.
    A final examination should be made by palpating the dorsal aspect of the joint and ensuring equal resection has occurred across the whole dorsal aspect of the joint. Return to prominent areas. Beware of the dorso-medial aspect of the metatarsal head which can be difficult to access but must also be cleared. The hand-piece will need to be swung fairly lateral to get to this bone and the portal may need to be enlarged slightly to accommodate this particular movement.
    Once adequate clearance has been achieved there should be copious lavage through the medial portal before it is closed. Beware of retaining bone fragments here which will make the surgical scar tender & prominent.
    An MTP arthroscopy should then be performed. The bone debris , if left in the soft tissue envelope , can produce a significant inflammatory reaction. If fragments have displaced into the joint then mechanical symptoms can ensue. If the joint is arthritic then it is highly improbable that intra-articular pathology will not co-exist with the cheilus and the opportunity should be taken to treat this also.

    The starting point pre-cheilectomy , the cheilus most noticeable with the toe angled into plantar-flexion.

    After the procedure the Cheilus should be clearly removed and noticeable increase in range of movement achieved which should be recorded together with the pre-operative range.
    Before closing the incision it is worth lavaging the dorsal “pocket ” thoroughly to lessen the chance of retained bone fragments . These can adhere close to the incision and cause local discomfort in shoewear.

    Another case, with a greater degree of dorsal osteophytosis.
    It is not an issue to remove significant amounts of dorsal bone once used to the technique as the next image demonstrates.

    The appearance after minimally invasive dorsal cheilectomy.

    The plain AP Xray of a patient with mild symptoms & restrictions but a large dorsal Cheilus.
    There appears fairly marked joint space narrowing (but bear in mind that the joint space may simply appear reduced if the X-Ray beam has angled slightly through the large dorsal cheilus)
    An MRI is of use in such cases to assist in determining which joints may be salvageable.

    The plain lateral Xray of a patient with mild symptoms & restrictions but a large dorsal Cheilus.
    This is the lateral view of the previous patient.
    An MRI is of use in such cases to assist in determining which joints may be salvageable.

    The STIR MRI of the same joint.
    A well preserved joint space is visible with minimal & small peri-articular cysts.

    The T2 saggital MRI of the same joint.
    A well preserved joint space is visible with minimal & small per-articular cysts.

    Post Operative

    The protocol is to an extent determined by the condition treated & the associated procedures
    Assuming a straight-forward cheilectomy and ‘scope then reduce the compressive forefoot bandage at 5 days .
    Wounds in all cases are to be kept strictly covered by breathable dressings 24/7 and dry until 2 weeks.
    Sutures removed at this stage. Commonly wounds are slow to heal and a further week of steri-strips to the wound(s) and a regular change of dry dressings is then advised.
    Earlier wound exposure risks superficial infection which can progress to deep infection with rapid speed. Any simple arthroscopic portal erythema noted should be aggressively treated with high dose oral antibiotics and very early clinical review to ensure improvement.
    Beyond 2-3 weeks patients may shower the foot but keep dressings in place whilst in shoe-wear for a further week or two.
    The first two weeks post-op the patient should aim simply to return to comfortable walking. This will be assisted with an appropriately supportive shoe such as a Fit-flop or similar. Range of movement excercises using a theraband may be commenced from between week 1-2 .If these produce an increase in pain then they can be ceased. It is more important that the joint settles to a comfortable state than an increased range of movement is maintained.
    If pain increases or fails to settle post-operatively cease mobilisation excercises ,advise on strict adherence to supportive & shock absorbing shoe-wear (such as Fit Flops) and have a low threshold to inject steroid & Local anaesthetic into the MTP joint under fully sterile conditions.
    If the indication for operation has been arthritis then the time by which a steady state is likely to have been reached is on average 12 weeks and not 6. There is also an associated risk of immediate deterioration , maybe in 5% of patients. Ultimately this may necessitate joint fusion or replacement.
    Shoe-wear choice is highly relevant post-operatively to minimise early symptoms as the foot is recovering . In the majority I advise the wearing of Fit-Flop shoes or similar.
    The Dorsomedial cutaneous nerve to the Hallux is at risk during the operation at the portal used for cheilectomy. It can be caused to dysfunction by either direct injury , early post-operative swelling or later onset post-operative scar tissue. If this occurs the this portal becomes hypersensitive and a “trigger point” to produce sensory symptoms in the distribution of the nerve . Early and aggressive desensitisation should be applied to the scar.

    Recommended Reading

    Arthroscopic surgery of the first Metatarso-phalangeal joint.
    Arthroscopy.1998.14(8):851-855.
    C.N.vanDijk ,K.M.Veenstra, B.C.Nuesch.
    24 consecutive patients with a mixed bag of pathologies.
    In dorsal impingement cases 8 of 12 had a maintained beneficial result at 2 years.
    Hallux rigidus.Grading and long term results of operative treatment
    J Bone Joint Surg 2003.85-A(11): 2072-88
    Coughlin MJ, Shurnas PS
    Outcome of fusion and debridement surgery reported as well as a classification system which has been fairly widely adopted since though is complicated. The grading runs from 0 to 4 and is based on clinical features (the frequency of pain and when it during the arc ot MTP movement) the plain radiographic features of arthritis as well as range of dorsiflexion at the MTP joint (both compared to the normal side as well as in absolute terms).

    Hallux rigidus: Joint preserving alternatives to arthrodesis-a review of the literature.
    World J Orthop. 2014. Jan 18; 59(1):6-13.
    Polzer H et al.
    An excellent full text free access on-line article.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3952696/
    Hallux metatarsophalangeal (MTP) joint arthroscopy for Hallux Rigidus.
    Foot & Ankle Intl .36 (1) ,2015
    K J Hunt.
    Good review article and technique description . Full text at http://journals.sagepub.com/doi/full/10.1177/1071100714559728.

    Reference

    • orthoracle.com

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