Should Fusion Become the Surgical Standard for Hallux Rigidus?

Hallux rigidus is a multifaceted and often-debated condition when it comes to surgical intervention. Podiatry Today had the opportunity to converse with Alan A. MacGill, DPM, FACFAS, about his thoughts on the question of, "Is fusion the only answer?"

Q: What role do you feel fusion truly plays in the treatment of hallux rigidus? Do you feel it is over- or under-utilized?

A:

Dr. MacGill stresses that first MTPJ arthrodesis for hallux rigidus is indeed a very important option for both the patient and the surgeon, as it affords predictable pain relief, position maintenance, and may provide longevity compared to other methods.

“This may be the reason why surgeons are quick to offer fusion to their patients and (is) therefore overutilized, in my opinion,” he says. “Not every patient needs an arthrodesis, nor does every patient want an arthrodesis. This is why it's important for surgeons to know what other options are available.”

 
Q: In what circumstances do you feel fusion may not actually be the best answer?

A:

“The typical patient I have found resistant to arthrodesis is the active and fashionable female in the 35 to 55-year-old age group,” he answers. “They are usually concerned with limitations in certain shoe gear and the inability to participate in certain activities like yoga and pilates. I also feel that the elderly patient with severe joint disease, osteopenia, and limited functional demand may not need an arthrodesis to meet their goals of walking with less pain.”  

Q: Are there key radiographic or clinical findings surgeons should hone in on when determining the applicability of fusion for a patient with hallux limitus?

A:

Dr. MacGill, the Director of the Foot and Ankle Surgery Residency at HCA Florida-Northwest Hospital, says that too often, he sees failed first MTPJ implants that were utilized in patients with metatarsus elevatus. While identifying this deformity is vital, he also stresses that surgeons should pay attention to metatarsal protrusion.

“From a clinical standpoint, the surgeon must be cognizant of the hindfoot position and a triceps surae contracture that may influence the biomechanics of the first ray,” he adds. 

Q: Overall, what else would you like attendees to know about this topic?

A:

Dr. MacGill says that surgeons have many good surgical options to address hallux rigidus and should not feel pigeon-holed into cheilectomy or arthrodesis.

“The success of a procedure boils down to the patient selection and your technical execution,” he explains. “Discussing and managing expectations will help you find the best procedure for your patient.”