Elsevier

The Foot

Volume 30, March 2017, Pages 32-37
The Foot

Patient reported outcomes six months following surgical treatment of end stage hallux rigidus in a community based podiatric surgery service

https://doi.org/10.1016/j.foot.2017.01.007Get rights and content

Highlights

  • Hallux rigidus is a common complaint which may have a deleterious impact on a patient’s health related quality of life.

  • Arthrodesis, implant arthroplasty and Keller’s arthroplasty are the mainstay of surgical treatment.

  • Little has been reported about the impact of such treatment with respect to health related quality of life.

  • All three procedures can have a positive impact on quality of life, particularly in relation to pain and mobility.

  • All three procedures demonstrate good levels of patient satisfaction.

Abstract

Introduction

End stage hallux rigidus can be treated surgically by arthrodesis, excisional arthroplasty and implant arthroplasty. Evaluation of these techniques has focused on clinical indicators such as radiographic, complications and subjective examination. Little attention has been given to health related quality of life and the use of patient reported outcome measures is still infrequent.

Method

An evaluation was undertaken in a community based podiatric surgery service. utilising the PASCOM-10 online database. Patient reported outcomes were captured on the day of surgery and six months’ post operation in the form of the Manchester Oxford Foot Questionnaire (MOXFQ) and the PASCOM PSQ-10 patient satisfaction questionnaire.

Results

Between 1st November 2011 and 31st October 2014, there were 157 admissions for treatment of end-stage hallux rigidus; 61 implant arthroplasties, 53 Keller’s arthroplasties and 43 arthrodeses. The age range was 45–89, 72% female. MOXFQ scores improved across all domains for all procedures, the score change exceeded the minimal clinically important change threshold of 13 points and large effect sizes were achieved (range 1.10–3.179). Patient satisfaction was good for all procedures with mean PSQ-10 scores of 81.89 for arthrodesis; 82.36 for implants and 81.89 for Keller’s. Few serious complications were encountered though the overall incidence of complications was high for the implant group.

Conclusion

This evaluation found all three procedures are clinically effective with high levels of patient satisfaction and improved quality of life. Although the implant arthroplasty is associated with a higher incidence of complications, this is not reflected in the outcomes achieved.

Introduction

Hallux rigidus is a common painful complaint which may have a deleterious impact on a patient’s health related quality of life (HRQOL) [1]. As the disease progresses to its more severe form patients who remain symptomatic may request surgical intervention. Painful end stage or severe hallux rigidus has been treated surgically for over 100 years and much has been published about the results of surgical intervention [2]. Many procedures have been described for the management of hallux rigidus such as cheilectomy, osteotomy and joint resurfacing. The options for severe disease can be grouped into three categories; arthrodesis, excisional arthroplasty and joint replacement by means of an implant arthroplasty [3]. To date evaluation of these techniques has largely focused on clinical indicators such as radiographic findings, complications and subjective examination of joint range of motion or other clinical features [4].

Relatively little attention has been given to HRQOL following hallux rigidus surgery and indeed the use of patient reported outcome measures is still not a routine feature of published foot and ankle surgery research [5]. This study utilised PASCOM-10 (www.pascom-10.com) to facilitate an evaluation of the surgical treatment of end stage hallux rigidus by means of Keller’s arthroplasty, implant arthroplasty or 1st MTP joint arthrodesis in a long established community based English NHS podiatric surgery service. End points for the evaluation were clinical and patient reported outcomes at six months following surgery.

The podiatric audit of surgery and clinical outcome measures (PASCOM-10) is a web-based audit and service evaluation instrument owned by the College of Podiatry (London, UK), provided as a service to its members [6]. PASCOM-10 captures patient data relating to their episode of care including; surgical data, outcomes, satisfaction and complications all of which can subsequently be reviewed via automated reports. The system was first conceived by Tollafield in 1994 [7] and the project went through several iterations before becoming an online tool in 2010, rebranded as PASCOM-10.

PASCOM-10 benefits from the inclusion of The Manchester Oxford Foot Questionnaire (MOXFQ) which has become a popular choice in the UK because it has been through a thorough development process including a relevant patient group, addressing concerns around construct validity [8]. The instrument has been through additional testing for responsiveness, minimal clinically important differences and comparison with previously well accepted instruments [8], [9], [10]. The PSQ-10 questionnaire also included in PASCOM-10 has been widely used to evaluate satisfaction with podiatric surgery and has been shown to be both reliable and repeatable but has not as yet been tested for validity [7], [11].

Section snippets

Method

The study design was a retrospective service evaluation utilising existing surgical audit data generated by and extracted from the PASCOM-10 online database. PASCOM-10 has an in built reporting package which is able to identify all patients relevant to the study. The system was fully implemented by the department in November 2011 with formal governance approval for its use. PASCOM-10 data collection begins when a patient is listed for surgical treatment and all consenting patients then

Results

Between 01/11/2011 and 31/10/2014, there were a total of 2221 admissions for podiatric surgery. Of these 157 admissions were for the treatment of end stage hallux rigidus. Table 1 below provides further demographic detail. Several patients in each group attended for surgery to both feet during the study period. The surgical procedures of interest were sometimes performed alongside other procedures (Table 2), all of which have the potential to influence outcomes. The Keller’s arthroplasty was

Discussion

The choice of surgical procedure for end stage hallux rigidus is often a difficult one and the decision must be made in partnership with the patient taking account of her expectations, activity levels, lifestyle and shoe choice. McNeil et al. in summarising the findings of their review were able to make grade B recommendations in support of arthrodesis but found insufficient evidence to support the use of either implant arthroplasty or Keller’s arthroplasty [16]. Several other studies have all

Declaration of interest

The author is a member of the PASCOM-10 working party, a clinician lead group which actively works on behalf of the College of Podiatry (London, UK) to develop and promote PASCOM-10. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

I would like to thank Mr. Matt Rothwell for his early support and guidance in developing this manuscript.

References (32)

  • T. Neogi et al.

    Epidemiology of osteoarthritis

    Rheum Dis Clin N Am

    (2013)
  • A.J. Maher et al.

    First MTP joint arthrodesis for the treatment of hallux rigidus; Results of 29 consecutive cases using the foot health status questionnaire validated measurement tool

    Foot

    (2008)
  • T. Harrison et al.

    Prospective assessment of dorsal cheilectomy for hallux rigidus using a patient-reported outcome score

    J Foot Ankle Surg

    (2010)
  • M.F. Gilheany et al.

    Hallux valgus and hallux rigidus: a comparison of impact on health-related quality of life in patients presenting to foot surgeons in Australia

    J Foot Ankle Res

    (2008)
  • P.S. Shurnas et al.

    Arthritic conditions of the foot

  • M.J. Coughlin et al.

    Hallux rigidus. Grading and long-term results of operative treatment

    J Bone Jt Surg

    (2003)
  • Cited by (10)

    • Keller's arthroplasty for hallux rigidus: A systematic review

      2022, Foot and Ankle Surgery
      Citation Excerpt :

      Moreover, 2 studies [11,23] indicated to have included only severe or end-stage hallux rigidus, without specifying a classification system (Table 1). The original KA was performed in 10 articles for a total of 424 halluces (73%) [10,13,14,17,19,21,23–26]. The original KA consists in the resection of approximately one-third of the proximal phalange of the hallux and of the first metatarsal head medial eminence; then the joint capsule is closed without any interposition.

    • Hallux rigidus – Osteoarthritis of the first MTP-joint. Surgical and patient-reported results from Swefoot

      2021, Foot and Ankle Surgery
      Citation Excerpt :

      No international consensus on surgical treatment of HR exists today. The different procedures can be divided into joint-preserving and joint-sacrificing techniques [3,12–17]. The joint-preserving procedures include dorsal cheilectomy and different types of proximal phalangeal- and first metatarsal osteotomies [12,14,18–22].

    View all citing articles on Scopus
    View full text