Abstract
The purpose of this study was to analyze radiographic outcome and patient satisfaction in non-operative care of hallux rigidus. Twenty-two patients representing 24 feet were surveyed and radiographed. Average follow-up was 14.4 years (range, 12–19 years). In 75% (18/24) of the feet, the patients would “still chose not to have surgery” if they had to make the decision again. The pain remained about the same in 22 feet, improved with time in one, and became worse in one. The most common reason given for not having surgery was that the pain was not severe enough. The most common type of self-care was a shoe with an “ample toe box.” More patients benefited from a stiff sole than a soft sole, but the majority of patients did not cite the sole of the shoe as being important. There was measurable loss of cartilage space radiographically over time in 16 of 24 feet, and in eight of the 16 feet, the loss of cartilage space was dramatic. The majority of hallux rigidus patients rated their pain as staying the same over a twelve-year period, despite significant deterioration of joint space noted radiographically.
The study provides data for the hallux rigidus patient who asks, “what happens if I choose not to have surgery?”
INTRODUCTION
Most of the literature concerning hallux rigidus focuses on the operative treatment of this condition. In this study, we were interested in finding out what the outcomes are from non-operative care emphasizing the patient's perspective. The information could be used to gain a better understanding of the natural history of hallux rigidus and to provide data to patients who are considering alternatives to surgical care.
With a minimum follow-up of 12 years, our goals for evaluation of the hallux rigidus patient were fourfold: 1) we wanted to learn what the course of pain was over time; 2) what radiographic changes had occurred; 3) would patients retrospectively still have chosen to avoid surgical care; and 4) what methods of self-care gave the best relief.
METHODS
The records of consecutive patients with hallux rigidus from the senior author's private practice were reviewed. To be included in the study, they were required to meet the following criteria:
Medical record with office notes and radiographs available from at least ten years prior to follow-up contact for this study.
Radiographic evidence of hallux rigidus (loss of first metatarsophalangeal joint space or bone spur of 2 mm or greater on the dorsal or lateral aspect of the first metatarsal head or base of the proximal phalanx); and
Confirmation that no surgical treatment of the affected hallux had been performed.
A questionnaire was sent to all eligible patients. Questions regarding their clinical course were asked and specific information regarding self care, pain and their decision to follow the same nonoperative course was solicited (Appendix A). A phone interview was conducted for some patients who preferred not to participate with the written questionnaire. Twenty patients were recruited to come to the office for a radiograph, and arrangements were made for two patients out of the area to have radiographs made near their home.
Measurements were made on initial and follow-up radiographs to assess changes in bone spur size and cartilage space thickness. Cartilage space thickness was evaluated in terms of minimum thickness at any point of the MP interval and by a method of summing the measurement of joint space 0.5 cm medial and lateral to the central axis (Appendix B).
First MT lengths were measured on the early and late films to check for projectional or magnification differences. Calculations were made to adjust joint space measurements due to differences in radiographic techniques (Appendix B).
Range of motion on follow-up was estimated by active assisted movement relative to the weight-bearing surface of the foot when the patient was seated. In these non-operative patients, range of motion had not been accurately measured with a goniometer at the time of the original diagnosis and was therefore not scrutinized with goniometric measurement in the follow-up examination.
RESULTS
See Appendix C for Patient Data Table
During the period 1977 through 1984, 50 patients qualified for the study as previously defined. Of those 50 patients, 11 were deceased, and 8 were lost to follow-up. Thirty-one patients returned questionnaires and 20 patients (22 feet) additionally returned to the office for radiographs and were personally interviewed and examined by the senior author. Two of the patients who returned questionnaires were radiographed outside our area and were not included in our examinations. The results of this study include the 22 patients (24 feet) who returned questionnaires and were radiographed.
Questionnaire results
Twenty-two patients (24 involved feet) completed questionnaires. Thirteen were men and nine were women. The average age at diagnosis was 53 years (range, 25–71), the average age at follow-up was 68 years (range, 37–86) and the average interval of follow- up was 14.4 years (range, 12–19).
Change in pain over time
Twenty patients with 22 involved feet (92%) said their pain had not substantially changed since the time of their original diagnosis. One patient with 1 involved foot (4%) felt that his pain had become less, and one patient with 1 involved foot (4%) thought his pain had become worse with time.
Affirmation of nonoperative choice
Sixteen of the 22 patients (73%) said they would still choose a nonoperative course if asked to make the decision again; six patients (27%) said they would change and choose surgery. Of the 8 patients for whom surgery had been recommended near the time of their initial diagnosis, five (63%) said they would still choose a nonoperative course if they had to make the decision again, and three (38%) said they would choose surgery.
The foremost reason given (17 patients) for not choosing surgery was that the pain was not severe enough although several other reasons were chosen when solicited (Table 1).
Self-care
The method of self-care most often checked as beneficial was “ample room in toe box of shoe,” and “avoidance of high-heeled shoes” (Table 2). Both stiff-soled shoes and soft-soled shoes were cited as means of relieving discomfort.
Patients’ Reasons for Not Choosing Surgery
Patients could choose more than one reason
Self-Care Methods
Patients could choose more than one reason
RADIOGRAPHIC RESULTS
Joint Evaluation
Twenty-four feet of 22 patients had long term follow-up radiographs (Table 3). There was a measurable loss of cartilage space in 16 feet (67%), and eight (33%) of those had a loss of 2 mm or greater. Those with measurable loss included those with 1 mm or more loss of cartilage space when measured by summation method.
AP and lateral x-rays of a 52-year-old female with hallux rigidus at time of original diagnosis.
Eight feet (67%) had developed lateral metatarsal head spurs not present at the initial diagnosis. Dorsal spurs noted on the initial radiographs had not changed visibly with time, but the lateral spurs seemed to have progressed in those cases that had a significant loss of cartilage space during the follow-up time interval. Fragmentation of spurs was present in eight cases (67%) with late follow-up but in only one case (4%) on the initial radiographs. Spur fragmentation was most common at the base of the proximal phalanx.
The feet that developed lateral head spurs, cartilage space loss, and showed fragmentation of spurs were not coincidental groups.
RESULTS OF EXAMINATION
Range of motion data
Twenty patients with 22 involved feet were examined. Range of motion in the hallux MP joint was greater in flexion than in extension. Extension averaged 9 degrees (0-25) and flexion averaged 15 degrees (0–43) in the 20 feet evaluated (4 feet that were examined with follow-up radiographs did not have follow-up range of motion measurements). Accurate initial range of motion data was not available on these nonoperative cases, and assessment of change in motion over the years could not be made.
DISCUSSION
This study reviews 22 patients who had hallux rigidus cared for non-surgically and were followed an average of 14.4 years. Though only one patient said his pain had worsened since his initial diagnosis, 67% of patients (16/24) with radiographs demonstrated a progressive loss of the cartilage space over time (Figure 1). In the one patient who felt his pain had become worse with time, he had lost no cartilage space.
In our study, most patients found that an ample toe box in the shoe and avoidance of high-heel shoes were important for comfort. Eight of the patients surveyed paid attention to the stiffness or softness of the sole of the shoe, 5 preferring a stiff sole and 3 a soft sole. We mention the potential benefit of a stiff sole to patients but suggest that they try both options.
In 75% of the feet, the patients surveyed affirmed their initial decision to have nonoperative care for their arthritis: If they had to make the decision again, learning from the passage of time, they would make the same decision. This was not influenced by whether or not they were offered surgical treatment at the time of their initial diagnosis. In the non-irritable joint, surgery is not usually recommended unless there are significant bone spurs causing pressure in a shoe. Irritability of the joint is determined with the “forced flexion” test. This test is performed by passively placing the metatarsophalangeal joint in maximum flexion and applying a moderate plantarflexion force. In most patients with active hallux rigidus, this test is quite painful. Forced flexion in our experience is more likely to be painful than forced extension even though range of motion is more restricted in extension than in flexion. Among the 8 patients who were advised to have surgery at the time of their initial office contact, 63% would support their original decision in favor of nonoperative care.
A number of patients have been seen with advanced hallux rigidus, significant loss of joint space, and the presence of a large dorsal metatarsal head spur but without significant pain except with shoe pressure. For these patients, recommendation for the removal of the osteophyte only is made.
CONCLUSION
Long term follow-up of patients with hallux rigidus demonstrated that the pain level remained constant in 92% of cases over an average of 14.4 years. There was no correlation between subjective complaints and radiographic evidence of progression of hallux rigidus as manifested by loss of MTP joint space over time. 75% of patients stated they would make the same choice for nonoperative care if they had to make the decision again.
APPENDIX A: QUESTIONNAIRE FOR PATIENTS WITH ARTHRITIS OF THE GREAT TOE
APPENDIX B: RADIOGRAPHIC MEASUREMENT METHODS
Measurement method for cartilage space analysis
The first MP cartilage space was arithmetically described by adding together the interval between the metatarsal and phalanx on the medial and lateral portions of the joint. The cartilage space was measured 0.5 cm medial and lateral to a point bisecting the joint surface of the proximal phalanx. This “summation” method was devised to reasonably represent the joint space even in those cases that have asymmetry. Some first MP joints have as little as 1 mm of joint space on the medial side of midline and 3.0 mm of space on the opposite side of the central point. In this summation method of measurement, this example would be represented as 4.0 mm, the same as if the joint would have had a space of 2.0 mm on both medial and lateral sides of the joint.
Measurement of osteophytes
The height of the dorsal osteophyte was measured as the distance between the dorsum of the head and the dorsum of the “spur” along a line perpendicular to the longitudinal mid axis line of the metatarsal. This method measures the dorsal but not the proximal extent of these osteophytes. Medial and lateral metatarsal osteophytes were measured on the AP standing radiographs with a method corresponding to that for the dorsal osteophytes.
Adjustment for comparing joint space measurements on x-rays taken at different times
All of the radiographed patients had differences in the measurement of the first MT lengths between early and late studies due to differences in radiographic techniques. To adjust for errors in cartilage space measurement due to differences in radiographs taken at different times, we compared the length of the first metatarsal on the early and late AP radiographs and related the proportionate difference to the summation joint space measurement on the latest radiograph. The metatarsal length difference was 1–5 mm in 19 feet, 6–10 mm in 3 feet and 11–15 mm in 2 feet. There was no consistency with regard to which study, initial or late, had the shorter metatarsal image.
Techniques differ for taking radiographs of the foot: There can be a difference in the distance from x-ray tube to subject and a difference in angle of projection. Currently, for the anterior-posterior standing radiographs of the foot, we use a 20-degree off vertical angle focusing toward the calcaneus. The distance from tube to foot is 91 cm.
APPENDIX C: Patient Data
