Results of Metallic Hemi-Great Toe Implant for Grade III and Early Grade IV Hallux Rigidus

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1 FOOT &ANKLE INTERNATIONAL Copyright 2009 by the American Orthopaedic Foot & Ankle Society DOI: /FAI Results of Metallic Hemi-Great Toe Implant for Grade III and Early Grade IV Hallux Rigidus Kurt F. Konkel, MD; Andrea G. Menger, OTC; Sharon A. Retzlaff, RN Menomonee Falls, WI ABSTRACT Introduction: The authors the short-term and mid-term results of patients with their preoperative status who were surgically treated for advanced Grade III and early Grade IV symptomatic hallux rigidus using the Futura Hemi-Great Toe Implant. Materials and Methods: The authors were able to contact 23 of 33 consecutive patients. They had a detailed evaluation preoperatively and came in for a detailed mid-term evaluation. Some of the patients were able to come in routinely for detailed periodic evaluations. Results: Periodic evaluations showed most patients had a gradual improvement of function over the first 2 years. Patients with early Grade IV disease had a greater propensity to develop early recurrence of their dorsal osteophyte at or before their mid-term followup (average 6 years). In this group of patients, the Futura Hemi-Great Toe Implants lead to 88% good to excellent mid-term results and 88% patient satisfaction over a 6-year average followup. Conclusion: Patients with early Grade IV hallux rigidus tend to develop progressive sesamoid arthritis and recurrent dorsal osteophyte formation more rapidly than advanced Grade III patients. Level of Evidence: IV, Retrospective Case Series Key Words: Futura Implant; Metallic Implant; Hallux Rigidus; Hallux Limitus; Osteoarthritis Great Toe; Dorsal Bunion; Hemi-Toe Implant; Hemi-Great Toe Implant; Great Toe Hemi- Implant Arthroplasty INTRODUCTION Hallux rigidus (HR) is the most common type of osteoarthritis of the foot with an incidence of 2% to 10% of the adult population. 8,21 There remains a question as to the best solution for patients with symptomatic advanced Grade III and early Grade IV osteoarthritis with painful hallux rigidus. 12,18,19,20,21 The shortcomings of debridement with cheilectomy (recurrent arthritis and painful stiffness), Keller resection arthroplasty with or without inter-positional arthroplasty (weakness and instability) and arthrodesis (stiff rigid toe with limited shoe options) gradually became apparent in the senior author s practice. The failure of the Swanson silastic prosthesis in younger more active patients because of rapid wear, breakage and foreign body reaction prevented its continued use and usually resulted in poor bone stock for revision procedures. 30 Metallic hemi-replacement arthroplasties have been used successfully in other joints with little wear or tissue reaction. 1,27 Numerous metallic implants have been available for arthroplasties of the great toe for many years. 3,18,22 Recently two papers have been published with more favorable results in patients with Grade III hallux rigidus. 20,33 The purpose of this paper was to profile the short-term and midterm results of patients with their preoperative status treating advanced Grade III and early Grade IV symptomatic hallux rigidus using the uncemented porous coated Futura hemigreat toe implant. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. However, NEXA(Tornier) paid for the Office Visit, Radiograms and a $20 traveling gratuity for the patient coming in. Corresponding Author: Kurt F. Konkel, MD Advanced Healthcare, Falls Division Orthopaedics N84W16889 Menomonee Ave. Menomonee Falls, WI kkonke@ah.com For information on pricings and availability of reprints, call , x MATERIALS AND METHODS From April 7, 2000 to August 22, 2003, 33 consecutive patients (36 toes) had an insertion of a Futura hemi-great toe implant. Two patients died of unrelated causes, three patients were demented, and five patients (six toes) left the area with no forwarding address or phone number. This left 23 patients (25 toes) included in this study (70% of patients and 70% of the toes). The followup interval was between 54 to 95 months with an average followup of 72 months.

2 654 KONKEL ET AL. Foot & Ankle International/Vol. 30, No. 7/July 2009 Table 1: Implant Fixation X-Ray Grading System Grade O: Grade 1: Grade 2: Grade 3a: Grade 3b: Grade 4a: Grade 4b: Grade 5: Well fixed implant including stem & base of the implant. Absorption of bone around the base of the implant. Absorption and lucency around the base and entire stem of the implant. Absorption, lucency and subsidence of the implant with the stem within the intramedullary canal of the proximal phalanx. Same as Grade 3a plus abutment of the tip of the implant stem against the cortex but with no cortical reaction. Abutment plus cortical hypertrophic reaction at the tip of the implant. Penetration or erosion of the tip of the stem through the cortex. Complete disassociation of the implant in relation to the proximal phalanx and/or first metatarsal head. Fig. 1: Sixty-year-old white female with early Grade IV hallux rigidus. A complete chart review noting complications, pre- and postoperative AOFAS and Koenig scoring was performed before their visit. Preoperative and postoperative radiographs were also reviewed. The changes seen preoperatively were rated using a grading system recommended by Hattrup and Johnson 12 adding a Grade 4 when there were Grade 3 changes plus loss of joint congruity and/or subluxation or bone loss. Postoperatively the radiographs were rated using an implant grading system recommended by Konkel et al. to assess the quality of implant fixation. 19 (Table 1) The amount of recurrent arthritis and dorsal osteophyte formation were also evaluated postoperatively. One patient had bilateral procedures performed at the same time. One patient in this study group returned 4 months after her first great toe implant to have her contralateral great toe replacement arthroplasty done. Preoperatively all patients suffered from hypertrophic arthritis (6 patients had early Grade IV disease (Figure 1) and 17 patients had advanced Grade III disease (Figure 2). There were 6 male patients and 17 female patients. The average age at final followup was 62 years. There were no diabetics. Seven patients were obese (more than 60 lbs overweight) and 16 patients were normal weight for their height. No routine exercises or physical therapy were ordered pre or postoperatively. One patient, a bank executive, sits most of the time but has to wear fashion shoes (low demand). Nineteen patients described their work or leisure activities to require considerable standing, walking, and/or stooping (medium demand). Three patients described their work or leisure requiring a lot of climbing, heavy lifting and walking Fig. 2: Forty-eight-year-old white male with advanced Grade III hallux rigidus. on uneven land or construction sites (high demand). One patient had a previous failed debridement and cheilectomy

3 Foot & Ankle International/Vol. 30, No. 7/July 2009 HEMI-GREAT TOE IMPLANT RESULTS 655 Table 2: Koenig Toe Implant Score 18 Pain (40 Points) [ ] Constant pain with any movement and activities (0 Points) [ ] Pain with walking (10 points) [ ] Pain with walking with some shoes or rapid walking (20 points) [ ] No pain with any activities (40 points) Function (30 Points) [ ] Extremely limited with all walking (0 points) [ ] Moderately limited with all walking (10 points) [ ] Limited only with more vigorous activities (20 points) [ ] No limitations with any activities (30 points) Range of Motion (20 Points) [ ] No or trace motion {<10 Degrees} (0 points) [ ] Mild to moderate motion {10 30 degrees} (10 points) [ ] Full motion {>30 degrees} (20 points) Radiographic Findings (10 Points) + [ ] [ ] Hallux valgus or varus (+ = O points if present; = 2 points absent) [ ] [ ] Joint space narrowed (+ = O points if present; = 2 points absent) [ ] [ ] Osteophytes and/or loose bodies (+ = O points if present; = 2 points absent) [ ] [ ] Sesamoid irregularity (+ = O points if present; = 2 points absent) [ ] [ ] Osteochondral defect (+ = O points if present; = 2 points absent) Summary Total (100 Points) Total Points [] procedure 6 years before on his great toe with a resultant symptomatic early Grade IV hallux rigidus. The patients in this study were evaluated for postoperative complications, transfer metatarsalgia, need for future procedures, X-Ray changes, speed of recovery and satisfaction. The Koenig Score 18 (Table 2) and the AOFAS Forefoot Clinical Scoring 16 systems were used as part of this evaluation for completeness and comparison. The preoperative clinical scores, interval postoperative clinical scores and the final clinical scores were compared. Retrospective clinical scoring has been reported to be inaccurate and was not done. 36 Fig. 3: Futura insertion set with medium (size 30) implant. Set includes: top left, cutting guide; bottom left, burr centering guide; center left, stem broaches; center top, medium implant; center right, trial implants; next right, broach handle; and far right, implant impactor. Surgical procedure The basic surgical approach described by Swanson was used with some modifications. 30,31 All patients were outpatients. Ankle block regional anesthesia was used for all patients. Patients then underwent a debridement and cheilectomy as described by Coughlin typically removing 30% of the metatarsal head dorsally. 4 If a portion of the remaining articular cartilage surface (exceeding 15% of the remaining metatarsal head articular cartilage) was absent, a Futura hemi-toe replacement arthroplasty was inserted (Figure 3). Osteophytes were removed from the dorsal base of the proximal phalanx so that the adjustable Futura cutting jig laid flat and was adjusted to the thickness of cut desired. An oscillating small bone saw was used to make the cut through the cutting slot of the jig. The base of the proximal phalanx was removed taking care not to cut or damage the flexor hallucis longus tendon or sesamoids. Patients with Grade III osteoarthritis and sesamoid articular involvement with a tight joint after debridement and cheilectomy [i.e. less than 3-mm joint gap with moderate (3 pound) longitudinal toe traction (applied using the tips of the surgeons thumb, index and long fingers)] were decompressed by removal of three millimeters more of the base of the proximal phalanx than required for the Futura implant using the adjustable Futura Cutting Jig. Patients with five millimeters or more laxity after debridement and cheilectomy had just enough of the base of the proximal phalanx removed with the adjustable Futura cutting jig for the implant chosen when treating Grade III HR. In patients with a foot size over eleven or treating an early Grade IV HR, an extra 5 to 6 mm of the base of the proximal phalanx was removed. During the trial reduction the joint was tested for stability, impingement or catching. There should be about 5 to 6 mm of joint separation when moderate longitudinal traction was applied to the great toe for Grade III patients and 10 to 12 mm of joint separation for patients

4 656 KONKEL ET AL. Foot & Ankle International/Vol. 30, No. 7/July 2009 with shoe size greater than size 11 or early Grade IV HR. The Futura centering jig was then used to center the Futura broach starting hole in the center of the canal with a power bur. The trial implant was sized using the largest implant that would cover the cut surface, but not overlap the cortical edge of the base of the proximal phalanx (three sizes are available). The appropriate Futura broach was used. The dorsal surface of the broach should be parallel to the transverse axis of the great toe. The final debridement was completed restoring the convex shape of the first metatarsal head and the 30% to 40% cheilectomy was adjusted to optimize ROM and avoid any impingement. Osteophytes on the sesamoids were removed as needed to limit catching and impingement. Synovectomy was avoided since it was felt this would result in increased joint stiffness. The chosen implant was impacted into the proximal phalanx with the impacting tool until the base of the implant contacted the cancellous surface of the proximal phalanx. A power burr was used to create a slight concavity to the cheilectomy base on the dorsal surface of the first metatarsal head. Bone wax was compressed into the concave defect to cover the cancellous dorsal cheilectomy site filling in the concavity just created allowing for a thicker layer of bone wax which was used to discourage scarring of the dorsal capsule on the first metatarsal head during early wound healing as recommended by Coughlin. 3 The tissues were closed in layers. A soft dressing and postoperative shoe were used initially until the skin sutures were removed and primary wound healing assured. Postoperative care The first postoperative visit was in eleven to fifteen days. At that time the sutures were usually removed. An open toed postoperative shoe was applied. The patients were next seen 6 to 8 weeks postoperatively. The patients were also encouraged to stop using the opentoed shoe. Oxford shoes with anatomic toe boxes and Roller-bottom (rocker-bottom) soles were suggested to be used until all the swelling and tenderness in the great toe had resolved. At followup visits over the first twelve months the patients were encouraged to resume normal walking patterns emphasizing normal stride lengths and using the great toe for push off. RESULTS There were no infections, hospitalizations or anesthetic complications in this study group. All wounds healed primarily with the sutures removed at 11 to 20 days. Opentoed postoperative shoes were discontinued 29 (range, 8 to 49) days from surgery. The patients returned to wearing all types of shoes at 9 (range, 1 to 20) weeks postoperatively. The patients returned to work on light duty from 1 to 112 days (average 31 days) and returned to work full duty from 2 days (bank executive) to 4 months from the date of surgery. Most patients returned to full duty within 2 months. There was no lucency about the stem of the implants and there was no measurable subsidence of the implants at final evaluation. There were lucencies at the bases of the implants in all but one patient (one toe). This patient had no observable lucency around his implant 64 months after implantation. There were two cases of mild transfer metatarsalgia and two mild clawing of the great toe (one with early Grade IV HR and one with advanced Grade III HR) with an inability to get the great toe onto the floor when standing barefoot and no visible push off during normal barefoot walking. The ROM, AOFAS Clinical Score and Koenig Clinical Scoring were evaluated and the results after 6 years average followup were summarized (Table 3). At last followup, 72 (range, 54 to 95) months postoperatively pain was: 1) absent in 19 patients, 2) mild and occasional in three patients, and 3) moderate and daily in one patient. There were four patients with pain: 1) one with early Grade IV HR. At 84 months after implantation there was increasing osteoarthritis of first MT head and sesamoids, 40 degrees of Total ROM of the first MTPJ and a AOFAS score of 49, 2) another with advanced Grade III HR. At 73 months after implantation he had moderately severe recurrent dorsal osteophyte (RDO) and some subsidence of the implant into the first MT head, -5 degrees of plantarflexion, mild plantar first MT head pain, 15 mm of floating of his great toe and weak push-off when walking. His AOFAS score was 75, 3) A third with advanced Grade III HR. At 55 months after implantation she had a mild RDO and dorsiflexion of 60 degrees and mild occasional aching of her first MT Head and 4) A final one with advanced Grade III HR. He was a heavy construction worker with subsidence of the implant into the first metatarsal head, mild transfer metatarsalgia and Table 3: Pre-/Postoperative (avg, 72 months)/percentage of Improvement Preoperative Postoperative (avg, 72 months) % Improvement Plantar flexion 1 Deg. ( 15 to 15) 13 Deg. ( 20 to 30) 92% Dorsiflexion 16 Deg. (5 to 50) 60 Deg. (20 to 85) 73% Total ROM 17 Deg. (10 55) 72 Deg. (15 115) 76% AOFAS Score 19 (17 to 50) 89 (40 100) 79% Koenig Score 16 (8 to 42) 86 (17 to 96) 81%

5 Foot & Ankle International/Vol. 30, No. 7/July 2009 HEMI-GREAT TOE IMPLANT RESULTS 657 Fig. 4: Amount of recurrent dorsal osteophyte seen on the lateral radiograph from 5 to 7 years postop. a severe recurrence of his dorsal osteophyte. He was offered either an inter-positional arthroplasty or fusion but chooses to live with it as long as the severe constant pain he had before surgery does not return. There were five floating toes when standing barefoot from 5 mm to 15 mm. At final followup there was a 68% incidence of recurrent dorsal osteophytes (RDO). The recurrence was: severe in three, moderate in four, mild in 10 and with no observable recurrence in 8 (Figure 4). After reviewing the patients affected with RDO it was apparent that as the preoperative Grade of HR worsened the speed of recurrence and its intensity increased especially when this was coupled with more vigorous use that could not be avoided. The results were progressive changes affecting the first MT head and sesamoids. As the sesamoids bind down onto the first MT head, the first MTPJ acted more like an eccentric hinge joint resulting in greater pressure on the dorsal surface of the first MT head with subsidence of the implant into the first MT head and a shelf-like RDO blocking extension (Figure 5). There were three unsatisfied patients. One worked as a heavy construction worker with pain, severe RDO, transfer metatarsalgia and a poor result. He would not do it again. His AOFAS score was 40. Another worked for a marketing firm and needed to wear designer shoes all day. She had only 40 degrees total ROM of her great toe and aching in her first MTPJ. She had a poor result and would not do it again. Her AOFAS score was 49. The third worked as a factory machinist on his feet all day with climbing and stooping. He had mild plantar first MTPJ aching, 5 degrees of flexion, 15 mm of floating, some subsidence of the implant into the first MT head, and 55 degrees of total ROM of the first Fig. 5: Progressive DJD of sesamoids with gradual subsidence of the Futura implant into the first MT head, especially dorsally. MTPJ. He has a fair result and would not do it again. His AOFAS score was 75. The overall results were: Excellent 64%, Very Good 20%, Good 4%, Fair 4%, Poor 8%. Therefore 88% of patients considered their results good to excellent and 12% considered their results fair to poor. The overall satisfaction rate mirrored the clinical results with 88% satisfied and would do it again and 12% dissatisfied and would not have the procedure done gain. DISCUSSION Remedies suggested when HR becomes symptomatic include: 1.) Morton s shank shoe extension with rocker bottom shaped soles with or without non-steroidal antiinflammatory medications, 31 2.) Injection and manipulation, 32 3.) Resection arthroplasty (Keller procedure) 14, 4.) Cheilectomy with or without debridement, synovectomy and Moberg s osteotomy, 8,25 5.) Hemi-great toe replacement arthroplasty, 19,20,22,34,35,37 6.) Total Toe replacement arthroplasty, 10,15,17,18,28 7.) Arthrodesis 6,25 and 8.) Soft tissue interpositional arthroplasty. 2,4,5 In the principal author s experience, few patients have chosen Morton s shoe modifications unless they have serious unrelated health problems and are unable to undergo surgery. Injection with manipulation gives only short-term relief. Injection and manipulation are only recommended for

6 658 KONKEL ET AL. Foot & Ankle International/Vol. 30, No. 7/July 2009 selected patients with Grade I and Grade II symptomatic HR. 12,32 Active patients do not like the weakness and instability of the great toe after Keller resection arthroplasties or interpositional arthroplasties. 5,14 Cheilectomy with or without debridement and synovectomy is currently recommended as the treatment of choice in most patients especially over 60 years of age with Grade II or early Grade III disease. 8,24,25 The resection of a large amount of the dorsal metatarsal surface with a closing wedge osteotomy of the proximal phalanx (Moberg procedure) has been recommended to improve the longevity of the procedure and dorsiflexion range of motion (ROM) of the first MTPJ. 13 Total Toe replacement arthroplasties of the first MTPJ are being developed in the U.S.A. and Europe to potentially overcome the shortfalls of currently established procedures. The Total Toe implants suffer from early loosening and failure. They are presently considered experimental. 10,15,17,18,28 Arthrodesis has been used successfully with excellent results in selected patients and is advocated by some surgeons as a primary procedure for advanced Grade III and Grade IV disease 4 and as a salvage when other procedures have failed. 23,26 Young, active and/or female patients are hesitant to accept arthrodesis of the great toe with its fixed position and limited shoe options as their primary form of treatment. 6 Patients with poor bone stock and/or other severe medical problems can have difficultly achieving a successful arthrodesis. Silastic great toe implants have been advocated since ,34,35 Those implants have resulted in a high rate of complications and failures with poor resultant bone stock for salvage procedures. 30 Metallic hemi-replacement arthroplasties have been used successfully in other joints with little wear or tissue reaction. 1,27 Numerous metallic implants have been available for arthroplasties of the great toe for many years. 3,18,22 Konkel et al. reviewed the mid-term results of the titanium version of the Swanson hemi-toe design documenting progressive subsidence and lucency about the implant leading to his precautionary conclusions. 19 Ghalambor et al. found microscopic metallic wear and tissue response in failed titanium great toe implants. 9 Raikin et al. recently published an article comparing arthrodesis to a Bio Pro metallic hemiarthroplasty. Grade I and Grade II Hallux Rigidus were excluded leaving Grade III and Grade IV patients included in the study. Using the Bio Pro implant they had a 24% revision rate because of aseptic loosening and subsidence of the implant. 29 They concluded that arthrodesis was more predictable than the Bio Pro metallic hemi-arthroplasty for alleviating symptoms and restoring function in patients with severe osteoarthritis of the first metatarsophalangeal joint. 29 In drawing their conclusions they modified the AOFAS hallux MP scoring system to a 90 point scale but used the full 100 point scale when evaluating the implant group. 29 When reviewing the results of the Swanson titanium implant paper with the Bio Pro paper both implant designs suffered from aseptic loosening and subsidence with similar negative recommendations. 19,29 Recently two papers have been published with more favorable results in patients with Grade III hallux rigidus using a cemented Trihedron hemi-implant in the first paper with an average 5-1/2-year followup and a porous coated uncemented Futura hemi-implant in the other paper with an average 8 year followup. 20,33 These are the first articles to use an implant documenting no aseptic loosening or subsidence. At last followup the average AOFAS hallux MP score was 88.2 for the Trihedron implant paper and 83 for the Futura implant paper. 20,33 This is equal to or better than the arthrodesis results in Raikin et al. s paper when the results are adjusted to the same AOFAS hallux MP 100 point scale. 20,29,33 The ideal treatment, for these patients, has yet to be determined. 11,38 The surgical treatment of the first MTPJ is quite complex with 3 integrated joint surfaces working together. The two great toe sesamoids are often involved in the disease process. Therefore the sesamoids should be included in the surgical plans to optimize the results and minimize long term problems and failures. No implant on the market today takes the sesamoids into consideration. Some surgeons remove the lateral great toe sesamoid as part of their implant arthroplasty to prevent impingement against the prosthesis. 10 Konkel et al. reported that the Futura hemi-great toe implant had been used successfully with only mild lucency at the bases of the implants and no clinically visible subsidence on radiographs after 8 year average followup. 20 The main limitation of the article was the lack of detailed preoperative and sequential postoperative evaluation. The purpose of this study was to provide a more detailed preoperative and postoperative evaluation with larger mid-term patient numbers. After analyzing the initial data the authors decided to evaluate the patients results more closely. Four things became Graph. 1: Patient (MT) results measuring plantarflexion, dorsiflexion, total ROM, AOFAS clinical score and Koenig clinical score from preop to 6-years postop.

7 Foot & Ankle International/Vol. 30, No. 7/July 2009 HEMI-GREAT TOE IMPLANT RESULTS 659 and more room for bone wax is important to discourage scarring of the dorsal capsule and/or early dorsal osteophyte formation and 4) Patients that have an early severe recurrence of their dorsal osteophyte with a poor result can be salvaged to a satisfactory result, when the implant is in good position and firmly fixed into the proximal phalanx, by a second debridement and dorsal concave cheilectomy. By implementing the above first three changes over the past 2 years the authors have noticed a faster initial recovery in most patients. It will take years to know if the incidence of RDO will change in amount and/or severity as followup time increases. Graph. 2: Patients overall results measuring plantarflexion, dorsiflexion, total ROM, AOFAS score and Koenig score from preop to an average of 6 years postop. CONCLUSION Treating patients with advanced Grade III and early Grade IV HR using debridement, cheilectomy and insertion of a Futura hemi-great toe implant can be expected to result in an 88% good to excellent result based on this study. The 12% fair to poor results may be significantly reduced with the recommended changes in the surgical procedure and more careful patient selection. REFERENCES Graph. 3: Combined results of dissatisfied patients. apparent: 1) Although some patients will achieve dorsiflexion greater than seventy degrees (Graph 1), patients with occupations or avocations that require routinely sixty or more degrees of dorsi-flexion should be done only after a detailed discussion with the patient regarding the expected end results. (Graph 2) Probably an interpositional arthroplasty would be a better fit for those patients. If that rule were followed in this series the three unsatisfied patients would have had interpositional arthroplasties (Graph 3), 2) After analyzing our patients with subsidence into the first MT Head and severe RDO it was observed that they also had advancing sesamoid arthritis. It was felt by the authors that this effectively tethered the joint lowering the center of rotation plantar-ward causing progressive jamming of the implant into the first MT head dorsally. It was also felt by the authors that patients with larger feet needed more play in the joint to allow freer motion of the implant on the first MT Head. Therefore patients with feet greater than size eleven and or patients with early Grade IV HR should be put in a little looser as indicated in the described operative procedure. Konkel et al. s paper recommended a tighter insertion of the implant into the first MTPJ and no consideration regarding the size of the foot 20, 3) Creating a mild concavity on the dorsal surface of the cheilectomy base so that there is no impingement of the Futura implant from 90 to 100 degrees of dorsiflexion 1. Amstutz, HC; Sparling, EA; Grigoris, P: Surface and Hemi- Surface Replacement Arthroplasty. Seminars in Arthroplasty, 9(3): , Berlet, GC; Hyer, CF; Lee, TH; et al. Interpositional Arthroplasty of the First MTP Joint Using a Regenerative Tissue Matrix for the Treatment of Advanced Hallux Rigidus. Foot Ankle Int., 29(1): 10 21, Chen, DS; Wertheimer, S: The Keller arthroplasty with use of the Dow Corning titanium hemi-implant. J. Foot Surg., 30: , Coughlin, MJ; Shurnas, PJ: Hallux Rigidus: Grading and Long- Term Results of Operative Treatment, J Bone Joint Surg., 85-A: , Coughlin, MJ; Shurnas, PJ: Soft-Tissue Arthroplasty for Hallux Rigidus. Foot Ankle Int., 24(9): , DeFrino, PF; Brodsky, JW; Polio, FE; Crenshaw, SJ; Beischer, AD: First Metatarsophalangeal Arthrodesis: A Clinical, Pedobarographic and Gait Analysis Study. Foot Ankle Int., 23(6): , Dobbs, BM: Hemi-Implants in Foot Surgery. Clinics in Podiatry, 1(1): 79 87, Feltham, GT; Hanks, SE; Marcus, RE: Age-Based Outcomes of Cheilectomy for the Treatment of Hallux Rigidus. Foot Ankle Int., 22: , Ghalambor, N; Cho, DR; Galdring, SR; Nihai, A; Trepman, E: Microscopic Metallic Wear and Tissue Response in Failed Titanium Hallux Metatarsophalangeal Implants: Two Cases. Foot Ankle Int., 23(2): , Gibson, JNA; Thomson, CE: Arthrodesis or Total Replacement Arthroplasty for Hallux Rigidus: A Randomized Controlled Trial. Foot Ankle Int., 26(9): , Gould, N: Hallux Rigidus: Cheilotomy or Implant?. Foot Ankle, 1(6): , Hattrup, SJ; Johnson, KA: Subjective Results of Hallux Rigidus Following Treatment with Cheilectomy. Clin. Othop., 226: , Hollis, MH: Hallux Rigidus. emedicine., orthoped/topic125.htm, 2004.

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