Abstract
Research Type:
Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies
Introduction/Purpose:
Hallux rigidus, a degenerative condition of the first metatarsophalangeal joint, causes joint stiffness and pain. Although non-surgical treatments such as orthotics, physical therapy, platelet-rich plasma, and corticosteroid injections are initially employed, they are effective in only 55% of patients. For those unresponsive to conservative management, cheilectomy is a common surgical intervention. Various approaches include Open Cheilectomy, Minimally Invasive Dorsal Cheilectomy (MIDC), and MIDC with subsequent first-MTP arthroscopy (MIDC-scope). Despite the prevalence of cheilectomy for treating hallux rigidus, the impact of different surgical approaches on parameters of postoperative pain, range of motion (ROM), and patient-reported outcomes (PROMS) remains underexplored. This study evaluated postoperative outcomes to determine whether the type of cheilectomy significantly impacts these key parameters, providing insights into optimizing surgical strategies for hallux rigidus management.
Methods:
A retrospective review was performed on 31 patients (23 female, 8 males; 13 lefts, 18 right feet) who underwent cheilectomy performed by a single surgeon at tertiary orthopaedic centers in Boston, MA between December 2019 and July 2024. Among them, 8 patients underwent an open cheilectomy, 10 underwent MIDC-scope cheilectomy, and 13 underwent MIDC cheilectomy. Pre- and postoperative measures include ROM (active AROM and passive PROM), Visual Analog Scale (VAS) pain scores, PROMS (Pain Intensity (PI), Pain Interference (PIF), Physical Function (PF), Depression Score, Mental Score), and complications including extensor hallucis longus (EHL) tendon lacerations. Welch’s ANOVA and Welch’s t-tests were utilized to compare pre- and postoperative outcomes due to a sizeable proportion of independently missing data, which precluded the use of paired t-tests. Covariance correlations between patient demographics, preoperative measures, and postoperative findings were also analyzed. Results are presented as mean values with significance set at p < 0.05.
Results:
VAS pain scores decreased significantly postoperatively in all groups (MIDC: 3.85, MIDC-scope: 5.21, Open: 4.12; p < 0.01, Welch's T-Test). While most PROMs showed no significant improvement (p > 0.17), PI pain scores in the MIDC-scope group decreased by 11.37 (p < 0.05, Welch's T-Test). The open group demonstrated lower mean postoperative PI scores compared to MIDC/MIDC-scopegroups (p < 0.025, ANOVA). Notably, older patients showed increased postoperative PI scores (r(31)=0.61, p < 10^-4) and less reduction in VAS scores (r(31)=-0.64, p < 10^-4).
Finally, postoperative complications include one EHL tendon laceration (recognized and treated intraoperatively) and two superficial infections in the MIDC-scope group, and six minor wound complications equally distributed amongst the MIDC, MIDC-scope, and Open groups, all in female patients.
Conclusion:
Minimally invasive surgery (MIS) cheilectomy approaches have been demonstrated to be a safe and effective treatment for hallux rigidus, with significant postoperative improvements in VAS and PI pain scores. MIS meets the improvement in VAS scores seen in Open Cheilectomies and outperforms them in pain intensity scores. Further longitudinal research is necessary to best understand how this technique compares to other available treatment options and to explore cost analyses between approaches. Additionally, future studies should further investigate the minimal pain improvement post-cheilectomy in older patients to determine age-stratified surgical strategies for optimal hallux rigidus management.
