Hallux rigidus Grading and nonsurgical treatment Jim Barrie
Hallux rigidus Grading and non-surgical treatment Jim Barrie East Lancs Foot and Ankle Service www. foothyperbook. com www. hyperblog. eastlancsfeet. org. uk
Why grade hallux rigidus? • Identify populations by • Natural history • Response to treatment • Risk of adverse effects • Standard tool for research/audit
How? • Clinical features • Imaging • Markers
Options • Coughlin • Roukis • Regnauld
Coughlin grade 0 • Range of dorsiflexion • 40 -60 deg ± 10 -20 deg less than normal side • Clinical • No pain • Stiffness and loss of motion • Radiography • normal
Coughlin grade 1 • Range of dorsiflexion • 30 -40 deg ± 20 -50% less than normal side • Clinical • Mild/occasional pain/stiffness • Pain at extremes of movement • Radiography • Dorsal osteophyte • Minimal loss of space, sclerosis, flattening Roukis: Regnauld: sesamoid changes metatarsus primus elevatus hallux flexus
Coughlin grade 2 • Range of dorsiflexion • 10 -30 deg ± 50 -75% less than normal side • Clinical • Moderate/severe pain/stiffness • Pain just before extremes of motion • Radiography • Osteophytes • Mild/moderate sclerosis/narrowing • Limited to dorsal 25% Roukis: Cysts + loose bodies
Coughlin grade 3 • Range of dorsiflexion • <10 deg ± 75 -100% less than normal side, loss of plantarflexion • Clinical • Constant pain • Pain at extremes of range • Radiography • Substantial narrowing • >25% of joint • Sesamoid involvement
Coughlin grade 4 • Range of dorsiflexion • <10 deg ± 75 -100% less than normal side, loss of plantarflexion • Clinical • Constant pain • Pain at midrange • Radiography • Substantial narrowing • >25% of joint • Sesamoid involvement Roukis/Regnauld: ankylosis Roukis: IPJ/TMTJ OA
Summary - grading • Several similar grading systems • Minimal validation • Which features predict outcome? • Is MPE relevant?
Non-surgical treatment • Natural history • Simple analgesia • Activity alteration • Orthoses/shoe adaptations • Injections
Orthoses/shoe adaptations • Reduce pressure on osteophytes
Reduce pressure
Reduce pressure
Orthoses/shoe adaptations • Reduce pressure on osteophytes • Reduce MTPJ movement
Reduce MTPJ movement
Reduce MTPJ movement
Reduce MTPJ movement
Reduce MTPJ movement
Reduce MTPJ movement
Orthoses/shoe adaptations • Reduce pressure on osteophytes • Reduce MTPJ movement • Increase MTPJ movement
Increase MTPJ movement
Increase MTPJ movement
Increase MTPJ movement
Increase MTPJ movement
How effective is non-surgical care? • Grady (2002) • 772 patients with symptomatic HR • FU 1 -7 y • 428(55%) treated non-surgically
How effective is non-surgical care? • Smith (2000) • 24 patients treated non-surgically • FU 12 -19 y • 75% still wished nonsurgical treatment • Radiographic progression 67%
Injection • Pons et al 2007 • • RCT hyaluronate vs triamcinolone Improvement in both groups No difference in pain at rest Hyaluronate group better to 84 d • Pain walking 20 m • AOFAS pain score • 50% surgery at 1 y
MUA + injection • Solan (2001) • 31 pts MUA + depomedrone/bupovacaine injection • Blinded Xray grading • Minimum 1 y FU Grade 1 2 Surgery 4/12 12/18 Survival 6 m 3 m 3 5/5 2 m
Non-surgical treatment • Benign condition • Simple management • Shoe adaptations • Functional orthoses probably selective • Injections of marginal benefit www. foothyperbook. com www. hyperblog. eastlancsfeet. org. uk
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