A 24-year-old female was under our care for three years. At presentation, she had no past medical history or pertinent family medical history and was not taking any medications. She was referred to our office for treatment of her right great toe, at which point she was 11 months status post a right great toe dorsal cheilectomy performed by an outside physician. She reported making an incomplete recovery with regard to pain and functionality despite three cortisone injections and postoperative physical therapy. She presented with pain at the MTP joint of her right great toe associated with swelling, weakness, limited range of motion, and instability.
Weightbearing anteroposterior, lateral, and oblique radiographs of the patient's right foot taken at her initial visit showed evidence of previous dorsal cheilectomy with no fractures or dislocations (Figures 1 and 2).
Her initial clinical examination was concerning for capsulitis versus osteomyelitis, due to persistent postoperative edema and erythema. An ultrasound-guided aspiration of her right great toe was attempted at her initial visit, but no fluid was aspirated. She was advised to continue physical therapy and wear a postoperative shoe. Following three months of physical therapy, the patient's right great toe pain and symptoms had improved only slightly. Due to her persistent pain and reduced function, T1, T2, and STIR magnetic resonance imaging (MRI) sequences of the right foot were obtained in the sagittal, axial, and true and oblique coronal planes. The imaging, which was obtained 14 months status post dorsal cheilectomy, showed evidence of prior first metatarsal head cheilectomy/osteotomy with contour deformity dorsally and persistent marrow edema thought to be related to postoperative changes. Also noted was 50% surface area loss of the first metatarsal head (Figure 3).
Following review of the MRI, operative treatment described as an allograft spacer versus a fresh allograft transplant was discussed, and the patient ultimately decided to proceed with surgery. Given the surface area loss of the metatarsal head observed on MRI, we believed that OCA transplantation would best restore congruence of the metatarsal head and correct the posterior subluxation of the first MTP joint.
Examination under anesthesia of the first MTP joint demonstrated the patient's range of motion to be limited to 30 degrees of dorsiflexion and 40 degrees of plantarflexion. The contralateral healthy side demonstrated 70 degrees of dorsiflexion and 90 degrees of plantarflexion.
A standard incision was made over the dorsomedial aspect of the first MTP joint (Figure 4). The dorsal nerve was identified and retracted posteriorly. This was followed by a capsulotomy, exposing the MTP joint. Severe adhesions were elevated anteriorly, which were scarred to the exposed medullary bone from the previous cheilectomy. A large osteophyte at the medial aspect of the first metatarsal head that had caused red, swollen, and inflamed skin was identified and excised with a small saw blade. The resection was flushed with the remaining metatarsal neck. A rongeur and a hand rasp were used to smooth the metatarsal, thereby completing the open bunionectomy.
Postbunionectomy, the hallux rigidus correction with implant was performed. Dorsiflexion of the first MTP joint demonstrated articulation of the dorsal aspect of the proximal phalanx with exposed medullary bone on the metatarsal head. This articulation might have deteriorated much of the cartilage to the point where the dorsal half of the metatarsal head was absent, including the articular cartilage, yielding bone-on-bone articulation.
A saw blade was used to gently freshen the soft and osteoporotic bone on the dorsal metatarsal head. Approximately 1 millimeter (mm) was resected from the metatarsal head to obtain fresh medullary bone for healing surface. At least 50% of the dorsal osteochondral aspect of the metatarsal head had been abraded through dorsiflexion, as measured intraoperatively and shown on the preoperative MRI. Cartilage from the proximal phalanx was seen articulating on the bone of the distal metatarsal with Outerbridge classification grade IV chondromalacia on the dorsal aspect.
To address the large osteochondral lesion, a fresh talus allograft was matched with the metatarsal head to create a graft that measured 10 mm in height by 15 mm in length by 15 mm in width. The aspect of the talus that articulates with the navicular matched the metatarsal head exactly. The portion of talonavicular joint cartilage that matched the contour of the metatarsal head measuring 10 x 15 x 15 mm was resected from the talus. The OCA was matched to the metatarsal head for a flush fit and the proximal aspect of the graft was further contoured to match the angle of the abraded metatarsal head. Finally, the graft was positioned on the deficient metatarsal head to test the graft's articulation with the proximal phalanx. Intraoperative tests showed no evidence of proximal phalanx bone-on-bone articulation in either dorsiflexion or plantarflexion with excellent dorsiflexion and cartilage-on-cartilage articulation. Demonstration of the graft with the metatarsal head also showed restored stability, as compared to preoperative MRI findings, which originally revealed joint instability with volar subluxation of the metatarsal head and dorsal subluxation of the proximal phalanx due to the lack of a dorsal metatarsal head (Figure 3).
The metatarsal head was further contoured and affixed to the first metatarsal using a 2.5 x 18 mm screw implant  (Stryker, Kalamazoo, MI). The headless screw, inserted from dorsal to volar, avoided the articular cartilage and provided excellent finishing and compression. Biplanar C-arm fluoroscopy views ensured the appropriate screw length without plantar exposure to prevent the patient from stepping directly on the screw. We then used a pineapple burr to shape the graft to match the contour of the metatarsal head. The dorsal aspect of the graft was secured to the remaining metatarsal with excellent stability (Figure 5). Following the hallux rigidus correction with the implant, dorsiflexion and plantarflexion increased to about 50 and 60 degrees, respectively. This completed the hallux rigidus correction with OCA implantation on the metatarsal head.
To further correct the bunion deformity, the medial capsule was over sewn with a No. 1 Vicryl in a horizontal mattress stitch. Subcutaneous tissue was closed with a 3-0 Vicryl in inverted fashion, and the skin was closed with a 4-0 nylon interrupted horizontal mattress fashion. Xeroform was applied, and a gauze was placed between the first and second toes to keep the great toe in a varus position. Finally, a posterior plaster splint was applied in 90 degrees of ankle dorsiflexion.
The patient returned to our office six days postoperatively with improved range of motion and reduced pain. The patient was advised to weight bear as tolerated and begin a formal postoperative physical therapy program with an emphasis on foot and ankle strengthening and proprioception. She returned to our office five weeks thereafter and reported continued improvement of range of motion. She was advised to discontinue use of crutches and begin walking with a cast shoe. Postoperative radiographs taken at three month follow-up revealed correction of the hallux rigidus and osteochondral lesion with no fractures or dislocations (Figures 6 and 7). She returned to the clinic four months following surgery and reported improved pain and function of the right first MTP joint. Compared to preoperative range of motion, her postoperative dorsiflexion increased by 15 degrees from 30 to 45 degrees and plantarflexion increased by 25 degrees from 45 to 70 degrees. However, at one year following surgery, the patient reported worsening pain and difficulty walking. Her symptoms were suspected to be related to painful hardware, and the 2.5 mm headless screw implant was removed. Over the next nine months, she received additional treatment including a cortisone injection, physical therapy, and home exercises with improvement of symptoms.
At one year and nine months postoperatively, a right foot MRI without contrast was performed to evaluate for graft integrity. The MRI revealed that there was no full-thickness defect or chondral delamination and no evidence of tendon tear or tenosynovitis. At two and a half year follow-up, the patient returned and reported great improvement to her symptoms. She denied swelling, locking/catching, or instability, and physical examination showed excellent strength and range of motion. She was also able to ambulate with ease and was pain-free. At three-year follow-up, the patient was able to run up to two miles without pain and had begun weightlifting. She reported that her right foot symptoms had entirely resolved. Radiographs taken at that time revealed complete resolution of hallux rigidus (Figures 8-10).