121 Bulletin• Hospital for Joint Diseases Volume62,Numbers3&4 2005

Abstract

Surgery for the management of hallux rigidus aims to relieve pain and improve function. Arthrodesis, though reliable in terms of pain relief, may encounter some resistance from patients reluctant to have a fusion. Re-sults of other techniques, such as silastic implants, may give poor long-term results. Excisional arthroplasty and cheilectomy are also routinely used. Interposition arthroplasty has been used with some success in other joints. We describe a technique of autologous inter-position arthroplasty using a free ipsilateral gracilis tendon graft for patients with severe hallux rigidus with moderate to high activity levels and who do not wish to undergo fusion.

Surgical management of severe hallux rigidus iscontroversial. Many procedures have been de-scribed, but few yield good long-term results.

Arthrodesis seems togive themost reliable long-termresults.1,2Somepatients,however,areunhappywiththerestrictedmotionandwiththefactthat,iffemale,theymaynotbeabletowearhighheelshoes.3

Other techniqueshavebeendescribed.Excisionar-throplastyisnormallyundertakeninelderlyorsedentarypatients, given the loss of flexion strength of the firstmetatarsophalangeal joint and thepossibilityof trans-fermetatarsalgia inactivepatients.4,5Silastic implants

may produce synovitis, and implant failure has beendescribed.6,7 Cheilectomy has had some success, butresultsarebetterwithlessseverehalluxrigidus.8,9

Interpositionarthroplastyhasbeendescribedinotherjoints with good long-term results, especially in thehand.10-12Inhalluxrigidus,interpositionwiththecapsuleandaportionofflexorhallucisbrevisandextensordigi-torumbrevistendonshasbeendescribed.13,14Coughlindescribedsofttissueinterpositionforhalluxrigidusinagroupofsevenpatients.3Theaimsofthetechniqueareto decompress the joint, provide a stable arthroplasty,retain plantar intrinsic attachment, and preserve digitstrength.3Rangeofmotionisalsoimproved.

Indications and ContraindicationsWeuse this technique to correct severehallux rigidusinactivebiologicallyyoungpatientswithseverehalluxrigidus.

Preoperative PlanningCompletepastmedicalhistoryandphysicalandradio-graphic examinations are necessary. Standard radio-graphs,includinganteroposteriorandlateralweightbear-ingviewsof the forefoot, allow theassessmentof theseverityofdegenerativejointdisease.

TechniqueTheoperationisperformedusingtheanaesthetictech-niqueofchoicewith thepatient supine.Thewholeofthelowerlimbispreparedinthestandardfashionandexsanguinated.A thigh tourniquet is used.A dorsallongitudinal skin incision is used over the first meta-tarsophalangeal(MTP)joint(Fig.1A).Theincisionisdeepened through the skin, subcutaneous tissue, andthroughthemedialaspectoftheextensorhallucislongustendon.ThefirstMTPjointisthenexposed(Fig.1B).

Free Gracilis Interposition Arthroplasty for Severe Hallux Rigidus

David Miller, M.R.C.S., and Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth.)

DavidMiller,M.R.C.S.,andNicolaMaffulli,M.D.,M.S.,Ph.D.,F.R.C.S.(Orth.),areintheDepartmentofTraumaandOrthopaedicSurgery,KeeleUniversitySchoolofMedicine,Hartshill,Stoke-on-Trent,Staffordshire,England.Correspondence: Nicola Maffulli, M.D., M.S., Ph.D.,F.R.C.S.(Orth.),DepartmentofTraumaandOrthopaedicSurgery,KeeleUniversitySchoolofMedicine,NorthStaffordshireHospital,ThornburrowDrive,Hartshill,StokeonTrent,StaffordshireST47QBEngland.

122 Bulletin• Hospital for Joint Diseases Volume62,Numbers3&4 2005

Osteophytesareremoved(Fig.1CandD)anda1.6mmKirschnerwireisinserteddistallyalongthemedullarycanalof theproximalphalanx(Fig.1E).Asmall jointOstek reamer (Hillsborough,Oregon,USA;16,20,or24mmaccordingtothediameterofthefirstmetatarsalheadandbaseoftheproximalphalanx)isthenusedtoproduce a convex surface at the base of the proximalphalanxof thehallux(Fig.1F).TheKirschnerwire isthenremovedandinsertedintothemedullarycanalofthefirstmetatarsalinadistaltoproximaldirection(Fig.1G).Aconcavesurfaceofequalsizeis thenproducedusingthesmalljointreamer(Fig.1H).Thewireisthenremovedandtheareadebrided,takingcaretoleavetheplantarintrinsicligamentsintact. Thetendonofgracilisisharvestedthroughavertical2.5 cm incisionover thepes anserinus (Fig. 2A).Thesartorius fascia is identified and incised between the

gracilisandthesemitendiosusinlinewiththeirfibers.Thesartoriusfasciaisthendissectedoffthesurfaceofthesemitendinosusandthegracilis.Theinsertionofthegracilisonthetibiaisidentified,andaclampisplacedonthedistalendofthetendon.Thetendonisthenpulledwiththeclamptodeliverasmuchofthetendonoutsidethewound. Thetendonisthenpalpatedproximallytomakesurethatthereisnoremainingattachmentsoradhesions.Thetendon stripper is passed in line with the tendon.Thetendon is thendeliveredoutof thewound,strippedofallmuscletissueanddetachedfromitsinsertiononthetibia.15

Thefreegraftisthensuturedusingabsorbablesutureintoaballabout1.5cmindiameter(Fig.2B).This istheninsertedintothefirstmetatarsophalangealjoint,andactsasabiologicalspacer(Fig.2CandD).Thecapsule

Figure 1A,Preoperative:55-year-oldpatientwithseverehalluxrigidus.Onlyminimalpainfuldorsiflexionwaspossiblebothactivelyandpassively.B,Dorsalincisionoverfirstmetatarsophalangealjointandretractionofextensorhallucislongusmedi-ally.C,Dorsalcheilectomy.D,Medialexostosectomy.E,Kirschnerwireinsertedintometatarsalmedullarycanalinadistaltoproximaldirection.F,APowerOstekreamercreatesaconvexproximalsurfacetofirstmetatarsal.G,Kirschnerwireinsertedintoproximalphalanxinaproximaldistaldirection.H,Concavesurfacecreatedonproximalphalanxwithpowerreamers.

ED

CBA

HG

F

123 Bulletin• Hospital for Joint Diseases Volume62,Numbers3&4 2005

Figure 2A,Theharvestedipsilateralgracilistendon.B,Gracilissuturedtoformaball.C,Firstmetatarsophalangealjoint(MTPJ)gapforinsertionofbiologicalspacerwithintactplantarintrinsicligaments.D,Gracilis“ball”inserted.EandF,MovementofMTPJdemonstrated.G,Theskinissuturedusing3-0absorbablesubcuticularsuturematerial.

EDC

BA

GF

issuturedtothegraftandthecapsuleclosed.Theskinisclosedwithabsorbablesuture(Fig.2G).

Postoperative ManagementAt theendof theoperation,acompressivebandage isapplied.Walkingisallowedimmediatelyandthepatientisadvisedtowalkonhisheel.Footelevationisadvisedwhenatrest.

ComplicationsDeepveinthrombosisispreventedbyearlymobilization.Mildtransfermetatarsalgiaandcock-updeformitymaybeencountered.Donorsitemorbidityisalsopossible.

ConclusionsThistechniquecanbeusedforthemanagementofseverehalluxrigidusinactivepatientsandforpatientswhoareconcernedwithmaintainingtheactivemotionofthefirstmetatarsophalangealjoint.

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