Slideshow: Addressing the Subchondral Bone Complex and First Ray Alignment in End-Stage Hallux Rigidus

Figure 1. A 44-year-old male patient presented with a painful and stiff right great toe joint. His pain level, when seen by his local podiatrist in June 2020, was 9/10 on a visual analog scale. Nearly 2 years of conservative care, which included wider shoes/padding and orthotic management, yielded no improvement. He sought surgical management for this problem. Accordingly, his local podiatrist ordered an MRI without contrast of the area. Physical exam findings at that visit in 2022 included dermatological, vascular, and neurological findings all within normal limits. Musculoskeletal findings included hypermobility at the first metatarsocuneiform joint and painful end-range dorsiflexion at the right first MTPJ in the with less than 5 degrees dorsiflexion upon weight-bearing. Previous right foot X-ray findings included a long and elevated first metatarsal with a large osteochondral defect of the central metatarsal head with eburnation and dorsal spurring consistent with moderate-to-severe primary osteoarthritis of the great toe joint.

Figure 2. A 44-year-old male patient presented with a painful and stiff right great toe joint. His pain level, when seen by his local podiatrist in June 2020, was 9/10 on a visual analog scale. Nearly 2 years of conservative care, which included wider shoes/padding and orthotic management, yielded no improvement. He sought surgical management for this problem. Accordingly, his local podiatrist ordered an MRI without contrast of the area. Physical exam findings at that visit in 2022 included dermatological, vascular, and neurological findings all within normal limits. Musculoskeletal findings included hypermobility at the first metatarsocuneiform joint and painful end-range dorsiflexion at the right first MTPJ in the with less than 5 degrees dorsiflexion upon weight-bearing. Previous right foot X-ray findings included a long and elevated first metatarsal with a large osteochondral defect of the central metatarsal head with eburnation and dorsal spurring consistent with moderate-to-severe primary osteoarthritis of the great toe joint.

Figure 3. The MRI without contrast showed severe osteoarthritic changes of the first MTPJ of the right foot with osteophytic lipping and stage III chondral wear and subchondral stress response.

Figure 4. The MRI without contrast showed severe osteoarthritic changes of the first MTPJ of the right foot with osteophytic lipping and stage III chondral wear and subchondral stress response.

Figure 5. The MRI without contrast showed severe osteoarthritic changes of the first MTPJ of the right foot with osteophytic lipping and stage III chondral wear and subchondral stress response.

Figure 6. Here is the foot one week postop. The patient was strictly non-weight-bearing for 2 weeks postop then converted to partial weight-bearing for 4–6 weeks and full weight-bearing after 6–8 weeks (after fusion was apparent on plain film radiographs).

Figure 7. Here is the foot one week postop. The patient was strictly non-weight-bearing for 2 weeks postop then converted to partial weight-bearing for 4–6 weeks and full weight-bearing after 6–8 weeks (after fusion was apparent on plain film radiographs).

Figure 8. Twelve-week X-rays revealed continued full consolidation of his first metatarsal-internal cuneiform arthrodesis, which allowed shortening and plantarflexing of the first ray. Joint space was increased in the first MTPJ with adequate bone removal noted. There was no implant subsidence or ectopic bone formation, the implant was stationary, and no movement evident. The patient was very pleased with the procedure and had very minimal swelling of his right foot at 12 weeks postop with a pain level is 2/10.

Figure 9. Twelve-week X-rays revealed continued full consolidation of his first metatarsal-internal cuneiform arthrodesis, which allowed shortening and plantarflexing of the first ray. Joint space was increased in the first MTPJ with adequate bone removal noted. There was no implant subsidence or ectopic bone formation, the implant was stationary, and no movement evident. The patient was very pleased with the procedure and had very minimal swelling of his right foot at 12 weeks postop with a pain level is 2/10.

Figure 10. At 4 months postop we performed hardware removal (two 3.0-mm partially threaded cannulated cancellous screws) due to localized pain of the right midfoot only. Resolution of right midfoot pain occurred status post 2 weeks of the hardware removal.

Figure 11. At 4 months postop we performed hardware removal (two 3.0-mm partially threaded cannulated cancellous screws) due to localized pain of the right midfoot only. Resolution of right midfoot pain occurred status post 2 weeks of the hardware removal.

Figure 12. At 4 months postop we performed hardware removal (two 3.0-mm partially threaded cannulated cancellous screws) due to localized pain of the right midfoot only. Resolution of right midfoot pain occurred status post 2 weeks of the hardware removal.

Figure 13. At 4 months postop we performed hardware removal (two 3.0-mm partially threaded cannulated cancellous screws) due to localized pain of the right midfoot only. Resolution of right midfoot pain occurred status post 2 weeks of the hardware removal.

Figure 14. Here is a comparison of the foot at 8 months postop following the implantation of S-Core (Subchondral Solutions).

Figure 15. Here is a comparison of the foot at 8 months postop following the implantation of S-Core (Subchondral Solutions).