A Novel Case Using Human Pericardium Allograft as a Biologic Spacer in Hallux Rigidus
Hallux rigidus is degenerative arthritis affecting the first metatarsophalangeal joint (MTPJ) that can result in pain, stiffness, and limited dorsiflexion. It is the most common arthritic condition of the foot and can significantly impair gait and quality of life.1 Patients with this condition often complain of difficulty with activities such as squatting or walking uphill.2 Pain is typically most notable during toe-off in gait and there is often dorsal osteophyte formation on the first metatarsal head, which may cause shoe irritation.2 The etiology of hallux rigidus is multifactorial and includes genetic predisposition, trauma, and anatomic abnormalities such as a long or elevated first metatarsal.2,3 It is common in adults aged 30–60 and has no strong gender predilection.2 Radiographically, one can usually see joint space narrowing, dorsal osteophyte formation, subchondral sclerosis, and flattening of the metatarsal head.4 Grading systems such as that from Coughlin and Shurnas help to determine the severity of the condition and can guide treatment.5
Conservative treatment options may include shoe modification, orthotics (possibly using a Morton’s extension), corticosteroid injection, and physical therapy.6 Surgical options depend on the condition’s severity and include cheilectomy, Moberg osteotomy, interpositional arthroplasty, Keller resection, and first MTPJ arthrodesis.7,8
The pericardium is a membrane that forms a protective, sac-like enclosure around the heart and the origins of the great vessels, serving both mechanical and protective roles.9,10 It is composed of 2 layers: an outer fibrous layer known as the parietal pericardium, and an inner serous layer that lies in direct contact with the heart muscle, also referred to as the epicardium.10 The parietal pericardium is rich in collagen and contains glycoproteins and glycosaminoglycans—such as hyaluronic acid—suspended in a loose, gel-like matrix. This matrix functions as a storage site for various signaling molecules, including growth factors and cytokines.10,11 Structurally, the tissue is primarily made up of Type I collagen interwoven with elastic fibers like fibrillin and elastin.10 When used as an allograft, pericardial tissue retains its original structural integrity and biochemical characteristics even after decellularization.9 SteriGraft Pericardium (BoneBank Allografts) is one such lyophilized allograft, derived from human pericardial tissue. It is processed using a proprietary decellularization method called GraftCleanse and sterilized through gamma irradiation to ensure safety and suitability for surgical applications.
PalinGen XPlus Hydromembrane (Amnio Technology) is chemically cross-linked with extracellular matrix fibers to give it strength, shape, and slower resorption in vivo.12 These amniotic allografts contain collagen types I, III, IV, V, and VII, cytokines, hyaluronic acid, fibronectin, laminin, fibrinogen, amino acids, proteoglycans, tissue inhibitors of metalloproteinases (TIMPs), extracellular matrix proteins, and mesenchymal stem cells.13 Amniotic allografts also include key growth factors such as fibroblast growth factor (FGF), epidermal growth factor (EGF), platelet-derived growth factor (PDGF), vascular endothelial growth factor (VEGF), and transforming growth factor beta (TGF-β).13
Interpostional arthroplasty of the first metatarsophalangeal joint is a surgical procedure designed to alleviate pain and preserve joint motion in patients with moderate-to-severe hallux rigidus. This technique involves resecting the damaged joint surface and placing a synthetic or biologic interlay to maintain the joint space and mobility.14 Interpostional arthroplasty is especially considered in cases where there is significant joint degeneration but some range of motion remains and the patient desires to preserve joint mobility for functional or lifestyle reasons.15 Surgeons have used various materials for interpositional spaces including autogenous tissues such as the patient’s joint capsule or tendons (either via graft or transfer), allogenic grafts using decellurized matrices, and synthetic materials like polyvinyl alcohol hydrogels.14,15 A systematic review by Emmons and colleagues reported that most patients experienced improvement with this procedure and in a retrospective study by Aynardi and team 89.5% of patients rated their outcomes as excellent or good.16,17 In this case presentation, we highlight a case of an interpositional arthroplasty for hallux rigidus with the novel use of a pericardium allograft.
Key Clinical Details
A 63-year-old female initially presented with a past medical history of pes planus. She also related a history of bilateral trauma-induced hallux rigidus secondary to a violent assault occurring nearly 4 years prior, which also left the patient with a traumatic brain injury. She had known allergies to beta-lactam antimicrobials, baclofen, dextropropoxyphene, and gabapentin. There was no pertinent surgical or social history other than former tobacco use and being employed in a physically demanding profession. Physical examination demonstrated intact neurovascular status, no gross deformity of the foot besides pes planus and hallux rigidus bilaterally, and noting that the patient ambulated without ambulatory aids.
The patient complained of pain in the first metatarsophalangeal joints of both feet that worsened with activity, especially during the toe-off phase of gait. Patient described the pain as deep, aching, and occasionally sharp. She demonstrated limited dorsiflexion of the metatarsophalangeal joint, less than 10 degrees on the right foot and less than 20 degrees on the left foot, with crepitus throughout the range of motion. There was a palpable osteophyte dorsally on the right first metatarsal head and pain was elicitable with forced dorsiflexion on the right.
Radiographs of both feet demonstrated joint space narrowing at the first metatarsophalangeal joints, dorsal osteophyte formation (right more prominent than left), subchondral sclerosis and cysts, and flattening of the metatarsal head, all bilaterally. There were also loose bodies within the right first metatarsophalangeal joint. We assessed the right first metatarsophalangeal joint as grade 3 and the left first metatarsophalangeal joint as grade 2 based on the Coughlin and Shurnas classification.
The patient had tried and not seen success with conservative therapies including footwear modifications with stiff-soled and rocker bottoms, custom orthotic inserts, activity modifications, physical therapy, pharmacologic treatments including orals and topicals, and corticosteroid injections. After discussing the treatment options available, including continued conservative care and surgical intervention, the patient elected to pursue surgical management. The risks and benefits of surgical intervention were explained in detail and we discussed the various surgical treatments available including cheilectomy, Moberg osteotomy, interpositional arthroplasty, Keller resection arthroplasty, implant arthroplasty, and arthrodesis. The decision was reached to proceed with an interpositional arthroplasty to attempt to preserve motion in the joint.
The patient underwent the interpositional arthroplasty using a pericardium allograft on both first metatarsophalangeal joints 3 weeks apart, starting with the right foot. For both surgeries positioning was in the supine position. Local anesthesia was attained, and we achieved hemostasis with a pneumatic tourniquet on the ankle and anatomic dissection. A linear longitudinal dorsal incision over the first metatarsophalangeal joint extended from midway on the first metatarsal to the hallux interphalangeal joint. Using blunt and sharp dissection, we carried the incision down to bone. Using a McGlamry elevator, we then freed up and exposed the head of the first metatarsal completely. A Kirschner wire driven centrally into the first metatarsal became a guide for the reamer. We then rounded and smoothed the head of the first metatarsal using a series of reamer sizes, larger to smaller.
A Kirschner wire again became a guide for the reamer, but this time driven centrally into the proximal phalanx. The rounding and smoothing of the base of the hallux proximal phalanx also took place using a series of reamer sizes, now, smaller to larger. A rongeur assisted with removal of any bony irregularities of the first metatarsal head or of the base of the hallux proximal phalanx before smoothing with a rasp. Using a 2.5 mm drill, we then created a hole from dorsal to plantar through the neck of the first metatarsal.
We then removed the pericardium allograft from soaking in saline. Using size 1 polyglactin 910 suture, we tied each corner of the pericardium with a surgeon’s knot, leaving a 6-cm tail on each. We then placed the percaridal allograft interpositionally into the first MTPJ, covering the head of the first metatarsal completely. Using a suture passer, we routed the tails from the plantar two corners of the graft through the hole in the neck of the first metatarsal from plantar to dorsal.
We tied each plantar corner suture with a dorsal corner suture in a crisscross fashion, securing the pericardial allograft in place. Reapproximation of deep tissues was with 3-0 polyglactin 910 suture. We then implanted the amniotic allograft hydromembrane overtop the deep tissues. After meticulous layered closure of the incision, we dressed the foot with impregnated nonadherent gauze under dry gauze, cast padding, and a compression wrap. Discharge was to home that same day, with full weight-bearing status in a protective postoperative shoe.
Following both surgeries, the patient managed pain using only over-the-counter acetaminophen. She experienced rapid and successful recoveries without complication and has been able to enjoy activities again that she previously could not due to loss of function and pain.
Final Discussion
For this case, we selected human pericardium for its mechanical durability, tensile strength, and dense collagen matrix which allows it to act as a stable, long-lasting interpositional layer capable of withstanding compressive and shear forces within the first metatasophalangeal joint. We added amniotic allograft for its biologically active properties to promote angiogenesis and fibroblast activity. This helped modulate inflammation, reduce adhesion formation, and support regenerative tissue growth around the pseudojoint. The net result is that the pericardium preserved joint space and motion and the amniotic allograft provided the biologic environment for healing and capsule reinforcement.
The outcome of this case report supports the use of interpositional arthroplasty in the surgical management of hallux rigidus and highlights the novel use of pericardium allograft in this surgical procedure. The patient made an excellent recovery from both surgical procedures and has since returned to all of the activities she previously enjoyed but had been limited from due to her condition.
It is important to note that this case was performed at the Southern Arizona Veteran Affairs Health Care System, therefore cost and reimbursement were not factors in determining treatment. All products used are all reimbursable through Medicare and private insurance and have their own designated HCPCS codes. The cost-to-benefit ratio would need to be assessed on an individual provider and patient basis. All pricing of the wound care products used in this case are available to the public through the Department of Veteran Affairs Federal Supply Schedule. Providers should consult their specific Local Coverage Determinations and insurance coverage policies for coverage information that applies to their patients.
Dr. Evensen is a podiatrist in the Department of Veteran Affairs at the Southern Arizona Veteran Affairs Healthcare System in Tucson, AZ.
Dr. Davis is a first-year resident in the Department of Veteran Affairs at the Southern Arizona Veteran Affairs Healthcare System in Tucson, AZ.
Dr. Jolley is a podiatrist in the Department of Veteran Affairs at the Southern Arizona Veteran Affairs Healthcare System in Tucson, AZ.
Disclosures
The authors of this article declare no conflict of interest. The companies involved had no role in the design of the study; in the collection, analyses, or interpretation of date; in the writing of the manuscript, or in the decision to publish the results.
Acknowledgements
This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, and Office of Research and Development. The authors gratefully acknowledge the Southern Arizona VA Health Care System which provided facilities and materials for this research.
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