Comparison of Hallux Rigidus Surgical Treatment Outcomes Between Active Duty and Non Active Duty Populations

ORIGINAL ARTICLES Comparison of Hallux Rigidus Surgical Treatment Outcomes Between Active Duty and Non Active Duty Populations A Retrospective Review Marc D. Jones, DPM* Kerry J. Sweet, DPM Background: Our aim in this study was to compare the long-term outcomes of three different surgical procedures for the treatment of hallux rigidus (ie, cheilectomy, decompressive osteotomy, and arthrodesis) between active duty military and non active duty patients. Methods: A retrospective review of 80 patients (95 feet) undergoing surgical treatment for hallux rigidus was performed. Telephone survey was used to obtain postoperative outcome measures and subjective satisfaction. Additional data recorded and analyzed included age, sex, status of patient (active duty or non active duty), grade of hallux rigidus, surgical procedure performed, date of surgery, time to return to full activity, ability to return to full duty, and follow-up time postoperatively. Results: The decompressive osteotomy group had the highest return-to-duty rate, satisfaction rate, and Maryland Foot Scores of all three surgical groups, although these differences were not statistically significant. Active duty and non active duty patients did not have statistically significant differences in outcomes measures (ie, time to return to full activity, ability to return to full duty, satisfaction, or postoperative Maryland Foot Score) in any of the three surgical groups. Conclusions: Decompressive osteotomy, cheilectomy, and first metatarsophalangeal joint arthrodesis are all reliable and effective procedures for treatment of hallux rigidus in both active duty military and non active duty patients. Active duty military personal have a high rate of returning to their prior military activities after surgical treatment of hallux rigidus. (J Am Podiatr Med Assoc 108(4): 272-279, 2018) Hallux rigidus is a common disorder affecting the first metatarsophalangeal joint (MTPJ), accounting for up to 9.3% of patients visiting a podiatrist. 1 Hallux rigidus is characterized by degenerative changes to the first MTPJ leading to a painful restriction of motion of the joint. The restriction of the joint motion and pain with motion is most pronounced on dorsiflexion rather than plantarflexion. 2,3 There are many proposed causes of hallux rigidus, including anatomical and structural factors such as congenital squaring of the metatarsal head, an elevated first ray, hallux valgus, hypermobility, and pronation. 4-7 Trauma and repetitive loading of *Mann-Grandstaff VA Medical Center, Spokane, WA. Surgery/Podiatry Service, VA Puget Sound Healthcare System, Lakewood, WA. Corresponding author: Marc D. Jones, DPM, Mann-Grandstaff VA Medical Center, 4815 N Assembly, Spokane, WA 99205. (E-mail: marc.jones@va.gov) the joint through high-impact activities such as running and jumping, over a long period, have also been identified as contributing to hallux rigidus. 8,9 Conservative treatment can be effective early on in the disease process, including trials of rigid shoe gear, rocker-bottom shoes, orthotics with modification such as Morton s or reverse Morton s extensions, activity modification, steroid injection, and nonsteroidal anti-inflammatory drugs. 10-12 Once conservative treatment has failed to relieve a patient s symptoms, surgical treatment is most often the option of choice. Many different surgical techniques have been described for treatment hallux rigidus, 13 and are commonly placed into two categories: joint-preserving and joint-destructive procedures. Joint-preserving operations include cheilectomy and first metatarsal and phalangeal osteotomies. Joint-destructive 272 July/August 2018 Vol 108 No 4 Journal of the American Podiatric Medical Association

procedures include excisional with interpositional arthroplasties, arthrodesis, and implant arthroplasty. Generally, joint-preserving surgical treatments are used for early-stage disease and joint-destructive procedure are used for late-stage disease. 14 Although there is significant published literature on surgical treatment options for hallux rigidus, there is little reporting of the outcomes of surgical procedures in athletes or active duty military populations. After our extensive review of the literature, we were unable to find published results on outcomes of surgical management of hallux rigidus in the active duty military population. In light of this, it was the aim of this study to compare the long-term outcomes of three different surgical procedures (ie, cheilectomy, decompressive osteotomy, and arthrodesis) between active duty military and non active duty patients. Methods A retrospective review of patients treated surgically for hallux rigidus by means of electronic medical records between January 2005 and December 2012 was performed. One hundred four patients were identified who had a diagnosis of hallux rigidus and were treated surgically with a first MTPJ arthrodesis, a cheilectomy, or a first metatarsal decompressive osteotomy. These patients were then contacted by means of telephone and given the option to participate in a follow-up survey regarding the outcome of their survey. The patients were first contacted during regular business hours and then a second time in the evening hours if the first attempt was unsuccessful. A minimum of a 12-month followup was an inclusion criterion. Of the 104 patients, 80 were contacted and agreed to and completed the follow-up telephone interview, including the Maryland Foot Score (MFS) and subjective satisfaction questions (Fig. 1). The Maryland Foot Score measures outcomes of foot surgery in terms of functional activities, pain, and appearance of the foot. A high score is 100 and a low score is 0. Exclusion criteria included 1) patients younger than 18 years, 2) patients who underwent additional concurrent surgical procedures, 3) patients with an additional diagnosis of hallux valgus, and 4) a diagnosis of systemic arthropathies. Data recorded included age, sex, active duty status of patient (active duty or non active duty), grade of hallux rigidus, type of surgical procedure performed, date of surgery (DOS), time to return to full activity (RTA), ability to return to full duty (RTD), MFS, subjective satisfaction, and follow-up time. Return to full activity was defined as the time (in weeks) from the DOS to the date when the patient was able to return to all job, recreational, and/or military duties that were required of them without any physical limitations. Return to full duty was defined as the ability (yes/no) to perform all physical activities required to perform their military or civilian job. Satisfaction was defined as those patients who were either completely satisfied with no reservations or completely satisfied with minor reservations at the time of the telephone survey. Grade of hallux rigidus was determined by means of the Drago, Oloff, and Jacobs scoring system (Fig. 2). 6 Each patient was placed in one of three groups based on the surgical procedure that was performed. Surgery that included first MTPJ arthrodesis was completed using fixation consisting of two crossing screws or a compression screw with dorsal plate. The decompressive osteotomy group included a first metatarsal shortening procedure consisting of either a Youngswick procedure or a distal oblique osteotomy procedure that were fixated with either one or two screws. The cheilectomy surgical procedure was performed by removing approximately the dorsal one-fourth to one-third of the first metatarsal head and joint, as well as removing all loose bodies and osteophytes within the joint. All groups of patients were followed with clinical postoperative appointments until healing was complete and the patients were able to return to full activity. The surgical procedure was determined by radiographic and clinical findings and the surgeon s preference. Informed consent was obtained from all the participants, and the research protocol was approved by the institutional review board at Madigan Army Medical Center (protocol number 214065). Results Eighty patients, consisting of 58 men and 22 women, 60 active duty and 20 non active duty, were included in our study. Of these 80 patients, there were 95 feet operated on. The mean age of the patients was 42.4 years (range, 22 78 years). Mean follow-up time was 34.5 months (range, 12 114 months). The cheilectomy group consisted of 26 total feet, with 23 active duty and three non active duty patients. The decompressive osteotomy group consisted of 27 total feet operated on, with 27 active duty and nine non active duty patients. The Journal of the American Podiatric Medical Association Vol 108 No 4 July/August 2018 273

Figure 1. Survey questions posed to patients, including the Maryland Foot Score and subjective satisfaction. (continued on next page) 274 July/August 2018 Vol 108 No 4 Journal of the American Podiatric Medical Association

Figure 1. continued arthrodesis group consisted of 33 total feet, with 20 active duty and 13 non active duty patients. Preoperative grade of hallux rigidus for the cheilectomy group included three (11.5%) grade I, 16 (61.5%) grade II, seven (27.0%) grade III, and zero (0%) grade IV. In the decompressive osteotomy group, 14 (38.9%) were grade I, 20 (55.6%) were grade II, two (5.6%) were grade III, and zero (0%) were grade IV. Within the arthrodesis group, zero (0%) were grade 1, 10 (30.3%) were grade II, 16 (48.5%) were grade III, and seven (21.2%) were grade IV (Table 1). Grade of hallux rigidus was determined by means of the Drago, Oloff, and Jacobs scoring system. 6 A comparison of the outcomes of the patients undergoing a surgical procedure in this study showed a RTD rate of 80.8% (cheilectomy), versus 94.4% (decompressive osteotomy), versus 78.8% (arthrodesis) (P ¼.140). The RTA time was noted to be 12.9 weeks (cheilectomy), versus 19.4 weeks (decompressive osteotomy), versus 20.8 weeks (arthrodesis) (P ¼.002). The mean MFS was 83.1 (cheilectomy), versus 85.2 (decompressive osteotomy), versus 81.3 (arthrodesis) (P ¼.792). The subjective patient satisfaction was noted to be 80.0% (cheilectomy), versus 85.2% (decompressive osteotomy), versus 79.3% (arthrodesis) (P ¼.833) (Table 2). Within the cheilectomy group, the outcomes of the procedures between active duty and non active duty patients were, respectively, as follows: RTD, 78.3% versus 100% (P ¼.512); RTA, 13.3 weeks versus 10.7 weeks (P ¼.182); mean MFS, 80.4 versus 98.0 (P ¼.163); and subjective patient satisfaction with the surgical procedure, 76.3% versus 100.0% (P ¼.482) (Table 3). In the decompressive osteotomy group, the outcomes of the procedures between active duty and non active duty patients were, respectively, as follows: RTD, 92.6% versus 100% (P ¼.557); RTA, 17.0 weeks versus 18.7 weeks (P ¼.830); mean MFS, 83.0 versus 90.6 (P ¼.231); and subjective patient satisfaction with the surgical procedure, 84.3% versus 88.9% (P ¼.798) (Table 4). Among patients in the arthrodesis group, the outcomes of the procedures between active duty and non active duty patients were, respectively, as follows: RTD, 70.0%, versus 92.3% (P ¼.136); RTA, 21.4 weeks versus 20.2 weeks (P ¼.720); mean MFS, 79.5 versus 83.5 (P ¼.5.34); and subjective patient satisfaction with the surgical procedure, 80.0% versus 76.9% (P ¼.615) (Table 5). Overall, five patients in the cheilectomy group were unable to return to duty, with all of these patients being active duty patients. Two of the five underwent fusion before leaving the military and successfully returned to full duty. Of these five patients, three were classified as having grade II disease before surgery and two patients had grade III disease. In the decompressive osteotomy group, the two active duty patients who did not return to duty were grade I before surgery. Within the arthrodesis group, of the six patients unable to return to duty, two were grade II and four were grade III before surgery (Table 6). Five of these patients were active duty and one was non active duty. Journal of the American Podiatric Medical Association Vol 108 No 4 July/August 2018 275

Figure 2. Drago, Oloff, and Jacobs classification system. Discussion In our study, RTA time was the only statistically significant factor (P,.05), with cheilectomy having the quickest RTA at a mean of 12.9 weeks between all patients. This is not surprising, as this procedure does not rely on bone healing associated with an osteotomy or an arthrodesis. The decompressive osteotomy group had the highest RTD rate, satisfaction rate, and Maryland Foot Scores of all of the groups, although these differences were not statistically significant. Within this study, the decompressive osteotomy group was not inferior to the arthrodesis or cheilectomy procedure arms in outcomes measures, which stands in contrast to some of the results of other published studies. Decompressive osteotomies of the first metatarsal have had reported success rates in the literature ranging from 54% to 95%. 1,15-17 Our satisfaction rate of 85.2% falls within this range but is higher than the 73.3% reported by Roukis in a large systematic review. 15 Our satisfaction rate overall for the cheilectomy group was 80.0%, which is lower than rates reported in other published studies. A systematic review of cheilectomies by Roukis that included 23 studies showed a 91% success rate. 18 Coughlin and Shurnas found a 92% success rate among 93 patients with a 10-year follow-up. 14 Newer studies have also reported that there are good outcomes with a cheilectomy procedure in stage III hallux rigidus. 19 Lower satisfaction scores and outcomes are most likely attributable to the active duty patients who were included in this study; these patients have a much higher physical activity demand postoperatively than the general population included in the other studies. Active duty military patients have increased physical demands placed on them on a daily basis, that typically include wearing rucksacks (up to 100 pounds), running, wearing combat boots, deployments, and extensive high-impact activities. Even with these high demands, there was an overall RTD rate of 83.8% in the active duty patients across all three surgical groups. In an exhaustive review of the literature, we found no published outcome studies looking at hallux rigidus surgery in active duty military and scarce published studies looking at athletes. Mulier et al 20 published a study looking at athletes who had a cheilectomy procedure performed, and with a 5-year follow-up, they reported that 10% of the patients were unable to return to their sport because of the procedure and had an RTA of 11.5 weeks. Overall, in our study, with the exception of satisfaction rates in the arthrodesis group, non active duty patients had higher RTD rates, satisfaction rates, and Maryland Foot Scores compared with the active duty patients, although these 276 July/August 2018 Vol 108 No 4 Journal of the American Podiatric Medical Association

Table 1. Preoperative Grade of Hallux Rigidus by Group Surgical Group Grade I Grade II Grade III Grade IV Cheilectomy 3 16 7 0 Decompressive osteotomy 14 20 2 0 Arthrodesis 0 10 16 7 Table 2. Comparison of Outcomes of Each Surgical Group Surgical Group No. of Feet RTD (%) Satisfied (%) Mean Postoperative MFS RTA (weeks) Cheilectomy 26 80.8 80.0 83.1 12.9 Decompressive osteotomy 36 94.4 85.2 85.2 19.4 Arthrodesis 33 78.8 79.3 81.3 20.8 P value.140.833.792.002 a Abbreviations: RTD, return to full duty/activity; MFS, Maryland Foot Score; RTA, return to full activity. a Statistically significant. Table 3. Comparison of Active Duty and Non Active Duty Patient Populations Within the Cheilectomy Group No. of Feet RTD (%) Satisfied (%) Mean Postoperative MFS RTA (weeks) AD 23 78.3 76.3 80.4 13.3 Non-AD 3 100.0 100.0 98.0 10.7 P value.512.482.163.182 Abbreviations: RTD, return to full duty/activity; MFS, Maryland Foot Score; RTA, return to full activity; AD, active duty. Table 4. Comparison of Active Duty and Non Active Duty Patient Populations Within the Decompressive Osteotomy Group No. of Feet RTD (%) Satisfied (%) Mean Postoperative MFS RTA (weeks) AD 27 92.6 84.3 83.0 17.0 Non-AD 9 100.0 88.9 90.6 18.7 P value.557.798.231.830 Abbreviations: RTD, return to full duty/activity; MFS, Maryland Foot Score; RTA, return to full activity; AD, active duty. Table 5. Comparison of Active Duty and Non Active Duty Patient Populations Within the Arthrodesis Group No. of Feet RTD (%) Satisfied (%) Mean Postoperative MFS RTA (weeks) AD 20 70.0 80.0 79.5 21.4 Non-AD 13 92.3 76.9 83.5 20.2 P value.136.615.534.720 Abbreviations: RTD, return to full duty/activity; MFS, Maryland Foot Score; RTA, return to full activity; AD, active duty. Table 6. Number of Patients Unable to Return to Full Activity/Duty Surgical Group Grade I Grade II Grade III Grade IV Cheilectomy 0 3 2 0 Decompressive osteotomy 2 0 0 0 Arthrodesis 0 2 4 0 Journal of the American Podiatric Medical Association Vol 108 No 4 July/August 2018 277

differences were not statistically significant. We had one nonunion in the arthrodesis group (which occurred in a non active duty woman), for a fusion rate of 97%, which is comparable to the published literature showing fusion rates ranging from 92% to 96% in several large studies. 14,21,22 The average age of our patients at the time of surgery was 42.4 years, which is younger than in other studies reported in the literature. Peace and Hamilton 9 reported the mean age of onset as 43 years, with average surgical correction occurring at age 50. Most likely, this is caused by increased wear and tear on the first MTPJ resulting from increased amounts of high-impact activities that the active duty patient experiences on a daily basis. Trégouët, in a study of National Collegiate Athletic Association basketball players, agreed with the theory that a decrease in the range of motion at the first MTPJ was a result of long-term sporting activity. In addition, he supported the premise that repeated cyclic loads below the injury threshold produce a fatigue effect on the joint even without a known traumatic event. 23 This theory would presumably be supported in the active duty military population as well, because of the repetitive nature of their training and deployment environment. The active duty population usually has required daily physical training, marching, and carrying heavy weight (eg, rucksacks) contributing to the repeated cyclical loads to the first MTPJ. This combined with the less frequent contributing factors of macrotrauma and/or microtrauma related to jumping from a significant height out of large vehicles or on rough terrain, kicking in doors, and running with a combat load (.100 pounds) during combat operations can contribute to the early degeneration of the first MTPJ in a portion of our study group. The strengths of this study included a high rate of response to the telephone survey, with 80 of 104 patients (76.9%) contacted and willing to participate in the follow-up survey. As a result, a large sample size of 80 patients, with 95 feet having surgical procedures performed, was able to be obtained. This study also had a mean follow-up time of nearly 3 years (34.5 months) from the DOS to the date of the administration of the phone survey. Limitations of our study include its retrospective nature and the small sample size within the non active duty patient population, especially within the cheilectomy group. Larger prospective studies with preoperative outcome scores are needed to confirm our findings. Conclusions The findings of this study show that a decompressive osteotomy, cheilectomy, and first MTPJ arthrodesis are all reliable and effective procedures for treatment of hallux rigidus in both active duty and non active duty patients. No statistical difference was found between active duty and non active duty patients related to the outcome measures we used in this study. Active duty military personal, just like non active duty patients, can be effectively treated with these three surgical procedures for hallux rigidus and have a high rate of returning to their prior military activities. Financial Disclosure: None reported. Conflict of Interest: None reported. References 1. KILMARTIN TE: Phalangeal osteotomy versus first metatarsal decompression osteotomy for the surgical treatment of hallux rigidus: a prospective study of agematched and condition-matched patients. Foot Ankle Surg 44: 2, 2005. 2. BONNEY G, MACNAB I: Hallux valgus and hallux rigidus: a critical survey of operative result. J Bone Joint Surg Br 34: 366, 1952. 3. SHEREFF MD, BAUMHAUER JF: Hallux rigidus and osteoarthrosis of the first metatarsophalangeal joint. J Bone Joint Surg Am 80: 898, 1998. 4. SCHNIRRING-JUDGE M, HEHEMANN D: The cheilectomy and its modifications. Clin Podiatr Med Surg 28: 305, 2011. 5. LAMBRINUDI P: Metatarsus primus elevates. Proc R Soc Med 31: 1273, 1938. 6. DRAGO JJ, OLOFF L, JACOBS AM: A comprehensive review of hallux limitus. J Foot Surg 23: 213, 1984. 7. HATTRUP SJ, JOHNSON KA: Subjective results of hallux rigidus following treatment with cheilectomy. Clin Orthop Relat Res 226: 182, 1988. 8. O MALLEY MJ, BASRAN HS, GU U, ET AL: Treatment of advanced stages of hallux rigidus with cheilectomy and phalangeal osteotomy. J Bone Joint Surg Am 95: 606, 2013. 9. PEACE RA, HAMILTON GA: End stage hallux rigidus: cheilectomy, implant or arthrodesis? Clin Podiatr Med Surg 29: 341, 2012. 10. COTTERIL JM: Stiffness of the great toe in adolescents. BMJ 1: 158, 1888. 11. DURRANT M, SIEPERT K: Role of soft tissue structures as an etiology of hallux limitus. JAPMA 83: 173, 1993. 12. SHARIFF R, MYERSON MS: The use of osteotomy in the management of hallux rigidus. Foot Ankle Clin 20: 493, 2015. 13. KEISERMAN LS, SAMMARCO VJ, SAMMARCO GJ: Surgical treatment of the hallux rigidus. Foot Ankle Clin 10: 75, 2005. 278 July/August 2018 Vol 108 No 4 Journal of the American Podiatric Medical Association

14. COUGHLIN MJ, SHURNAS PS: Hallux rigidus: grading and long-term results of operative treatment J Bone Joint Surg Am 85: 2072, 2003. 15. ROUKIS TS: Clinical outcomes after isolate periarticular osteotomies of the first metatarsal for hallux rigidus: a systematic review. J Foot Ankle Surg 49: 553, 2010. 16. MALERBA F, MILANI R, SARTORELLI E, ET AL: Distal oblique first metatarsal osteotomy in grade 3 hallux rigidus: a long-term followup. Foot Ankle Int 29: 677, 2008. 17. RONCONI P, MONACHINO P, BALEANU PM, ET AL: Distal oblique osteotomy of the first metatarsal for the correction of hallux limitus and rigidus deformity. J Foot Ankle Surg 39: 154, 2000. 18. ROUKIS TS: The need for surgical revision after isolated cheilectomy for hallux rigidus: a systematic review. J Foot Ankle Surg 49: 465, 2010. 19. CETINKAYA E, YALCINKAYA M, SOKUCU S, ET AL: Cheilectomy as a first line surgical treatment option yields good functional results in grade III hallux rigidus. JAPMA 106: 22, 1988. 20. MULIER T, STEENWERCKX A, THIENPONT E, ET AL: Results after cheilectomy in athletes with hallux rigidus. Foot Ankle Int 20: 232, 1999. 21. GOUCHER NR, COUGHLIN MJ: Hallux metatarsophalangeal joint arthrodesis using dome-shaped reamers and dorsal plate fixation: a prospective study. Foot Ankle Int 27: 869, 2006. 22. ROUKIS TS: Nonunion after arthrodesis of first metatarsal-phalangeal joint: a systematic review. J Foot Ankle Surg 50: 710, 2011. 23. TRÉGOUËT P: An assessment of hallux limitus in university basketball players compared with noncompetitive individuals. JAPMA 104: 468, 2014. Journal of the American Podiatric Medical Association Vol 108 No 4 July/August 2018 279