55: Surg Management of Hallux Limitus- Frush Flashcards
normal 1st MPJ motion
normal dosiflexion = 65-70 degrees
only 25-30 degrees attainable w/o 1st ray plantarflexion
etiology hallux limitus
- Dorsiflexed 1st metatarsal
- Trauma
- Pronation decreasing pull of peroneus longus
- Long 1st met/ Short 2nd met
- Generalized arthridities (ie gout)
- Iatrogenic/ previous surgery
ACFAS classification hallux limitus
-
STAGE 1: Functional Limitus
- hallux equinus/flexus
- plantar subluxation proximal phalanx
- metatarsus primus elevatus
- jt dorsiflexion may be normal with NWB but ground reactive forces elevate the 1st met and yield limitation
- no DJD radiographically
- hyperextesnion of hallucial IPJ
- pronatory architecture
-
STAGE 2: Joint adaptation
- flattening of the 1st me thead
- osteochondral defect/lesion
- cartialge fibrillation and erosion
- Pain end ROM
- passive ROM limited
- small dorsal exostosis
- subchondral ebumation
- periarticular lipping of proximal pphalanx, the first met head, and individual sesamoids
-
STAGE 3: Established Arthrosis
- severe flattenign of 1st met head
- osteophytosis, dorsally
- asymmetric narrowing jt space
- DJD
- erosions, excoriations
- crepitus
- subchondral cysts
- pain on full ROM
- assoc with inflmmatory jt flares
- STAGE 4: Ankylosis
- obliteration jt space
- exuberant osteophytosis with loose bodies w/o jt space or capsule
- less than 10 degrees ROM
- deformity and/or malalignment
- total ankylosis
- inflammatory jt flares
- local pain secondary to skin irritation or bursiits caused by underlying osteophystosis
joint reconstruction based on orthopedic deformity
joint destructive procedure choice based on pt
list non-jt destructive procedures
- Exostectomy
- Cheilectomy “clean up”
- remove dorsal exostosis off the 1st met head
- used prior to cartilage destruction
- needs early ROM, may recur
- Cheilectomy “clean up”
- Proximal phalanx osteotmy
- Kessel bonney
- resection of dorsally based wedge of bone from base proximal phalanx
- Regnauld “mexican hat”
- shortening osteotomy of proximal phalanx
- Kessel bonney
- 1st metatarsal osteotomy
- Watermann
- dorsal wedge trapezoid osteotomy out of 1st met head
- Watermann-Green
- piece bone removed from dorsal half of met head with second cut angulated to protect sesamoids
- Youngswick
- austin/chevron osteotomy with two parallel cuts dorsally
- allows lateral transposition
- Dorsal V
- chevron cut made dorsal to plantar through met neck
- Sagital Z
- sagittal z through met shaft with proximal arm exiting meditally and distal arm exiting laterally
- can lengthen or shorthen
- Lambrinudi (not jt destructive)
- plantarflexory base osteotomy to correct metatarsus primus elevatus
- Oblique sagittal base osteotomy
- cut through metatarsal base
- Watermann
- Arthrodiastasis
- stretch periarticular soft tissue structures in staged process
distraction protocol for arthrodiastasis
- Intra-operative distraction of up to 5mm
- Uses min-rail ex fix
- Joint left static for 5 to 7 days allowing adaptation
- Distraction 0.5mm/day for a maximum of 14 days
- Joint left static for 14 days
- Physical Therapy
- Total of 8 to 12 mm
joint destructive surgical options
- arthroplasty
- keller
- resection proximal 1/3 of proximal phalanx
- hemi or total implant
- keller
- arthrodesis
what should be removed in keller pt with HAV and hallux limitus?
Keller = Resection of the proximal 1/3 of the proximal phalanx
HAV –> Remove medial eminence
Hallux limitus –> Do cheilectomy as well
indications for keller resectional arthroplasty
- Geriatric bunion
- Retrograde buckling
- Get up 5.5 degrees correction if not rigid
- Retrograde buckling
- Osteoporosis/Cystic changes
- End stage hallux limitus/rigidus
- Hallux Varus with unsalvageable joint
- Neuropathy
- Bunion deformity in patient you don’t want to use hardware
- Ulcer under hallux IPJ due to hallux limitus
contraindications for keller
- Salvageable first MPJ
- Active individual
- Especially athlete or dancer
- Spastic neuromuscular disease
- Need 1st MPJ stability
complications for a keller
- Floating toe/Flail hallux (b/c lost FHB)
- Lesser metatarsalgia
- Hallux malleus or cock up deformity
- Lesser met stress fracture
- Retraction of Sesamoids
- Ankylosis of the joint
post-op keller
WB in postop shoe 2-3 wks
remove k wire if used after 2-4 wks
advantages and disadvantages of keller procedure
- (+) Eliminates joint pain
- (+) Minimal postop disability
- (+) Early return to regular shoegear
- (+) Relatively easy to perform with minimal dissection required
- (+) Can be performed in presence of 1st ray malalignment
- (-) Creates shortened hallux
- (-)Loss of 1st MPJ function and/or stability
- (-) Increased incidence of central metatarsalgia
- (-) Salvage procedures can be difficult due to loss of bone
criteria for implant arthroplasty
- End stage hallux limitus or rigidus
- Failed Keller arthroplasty
- Adequate bone stock to accept stem of implant
- No active infection
- No allergy to implant material
- Normal alignment of 1st MPJ
- Unless 2nd procedure planned realign met
two different types of impants
- Hemi
- Base of proximal phalanx replaced
- Total
- Base of proximal phalanx and 1st met head removed
- One component (one piece spans entire jt)
- Two component (two different pieces)
when should you piston an implant?
- Necessary for silicone
- Disperses forces better
- Prolongs implant life
- Try to avoid with metal implant
- Will cause bone resorption and loosening of implant
steps for a 1st met head implant
- insert guide pin perpendicular to surface
- insert taper post and decompress the jt
- mapping out the jt surfce
- reaming for inlay socket
- remoe excess bone
- tamp inlay in place
what implant acts as dynamic spacer?
total flexible hinge implant
- Made of silicone
- Has stems for proximal phalanx and 1st met with central hinge
- Can face hinge dorsally or plantarly
what are grommets?
- Thin titanium shield that fits over stem
- Protects silicone from
- Shearing forces
- Sharp bone edges
which type of implant allows greater postop ROM
two compenent system
(replaces base of proximal phalanx and 1st met head)
contraindications ofr 1st MPJ arthrodesis
IPJ arthritis
Patient with severe osteoporosis
Patient whose job requires a lot of squatting (ex – roofer)
best procedure for younger or hightly active pts
1st MPJ arthrodesis
comparitive postop care
- Cheilectomy, Keller, Implants
- WB in postop shoe until sutures out, then regular shoegear to tolerance
- Distal 1st met osteotomies
- WB in postop shoe 4-6 weeks, then supportive shoegear
- Proximal 1st met osteotomies
- NWB 6-8 weeks
- 1st MPJ fusion
- WB in removable fracture walker for 6-8 weeks
Early ROM is key to successful outcome, usually started as soon as skin incision healed enough to allow
cheilectomy
kessel bonney
regnauld
watermann
watermann-green
youngswick
dorsal V
saggital Z
lambrinudi
oblique sagittal base osteotomy
keller resectional arthroplasty
