55 - Treatment of Hallux Limitus Flashcards
1
Q
Overview of history
A
- 1887 - First described by Davies-Colley
- 1888 - Cotterill coined the term Hallux rigidus
- Usually classified by pain with ROM of 1st MPJ and limitation of ROM of 1st MPJ
2
Q
1st MPJ motion
A
- Normal dorisflexion is 65-70 degrees
- Only 25-30 degrees attainable without 1st ray plantarflexion
- If you can’t plantarflex, it leads to jamming which leads to pathology of the joint (jamming, arthritis, bone spurs)
3
Q
Etiology
A
- Dorsiflexed 1st metatarsal
- Trauma (MOST COMMON)
- Pronation decreasing pull of peroneus longus
- Long 1st met or short 2nd met
- Generalized arthridities (i.e, gout, RA, etc.)
- Iatrogenic (previous surgery leading to the 1st ray sticking up in the air)
4
Q
ACFAS Classification (2003)
A
- Stage I: Stage of functional limitus
- Stage II: Stage of joint adaptation
- Stage III: Stage of established arthrosis
- Stage IV: Stage of ankylosis
5
Q
Stage I
A
Stage of functional limitus
- Hallux equinus with plantar subluxation of proximal phalanx and metatarsus primus elevatus
- Joint dorsiflexion may be within normal with NWB, but ground reactive forces elevate the first metatarsal and yield limitation
- No degenerative joint changes noted radiographically
- Hyperextension of the hallux IPJ
- Pronatory architecture of foot is present
6
Q
Stage II
A
Stage of joint adaptation
- Flattening of the first metatarsal head
- Osteochondral defect/lesion
- Cartilage fibrillation and erosion
- Pain on END ROM, passive ROM may be limited
- Small dorsal exostosis
- Subchondral eburnation
- Periarticular lipping of the proximal phalanx, the first metatarsal head and the individual sesamoids
7
Q
Stage III
A
Stage of established arthrosis
- Severe flattening of the first metatarsal head
- Osteophytosis, particularly dorsally
- Asymmetric narrowing of the joint space
- Degeneration of articular cartilage
- Erosions and excoriations, crepitus (popping) of joint during ROM
- Subchondral cysts
- Pain throughout FULL ROM and associated inflammatory joint flares
8
Q
Stage IV
A
Stage of ankylosis
- Obliteration of joint space
- Exuberant osteophytosis with loose bodies within the joint space or capsule
-
9
Q
Treatment recommendation for Stage I and II
A
- Since there will be no or very little joint and cartilage damage, the idea is to save the joint as much as you can – NO joint destructive procedures are recommended here
- Either clean up any burring that is occurring or treat any underlying etiology (pronation)
10
Q
Treatment recommendation for Stage III and IV
A
- Since the joint is pretty much shot at this point, the idea is to do a joint destructive procedure
- Either some sort of arthrodesis or a joint implant is recommended – Age plays a factor
11
Q
Non-joint destructive procedures
A
Exostectomy o Cheilectomy (MOST COMMON)
Proximal phalanx osteotmy
o Kessel bonney
o Regnauld
1st metatarsal osteotomy o Watermann, Watermann-Green o Youngswick o Dorsal V, Sagital Z o Lambrinudi
Arthrodiastasis
12
Q
Cheilectomy (MOST COMMON)
A
- Joint “clean up” procedure
- Remove dorsal exostosis off the 1st met head (shave off bone to prevent jamming)
o May need to remove excess bone off base of proximal phalanx as well
o Can be primary procedure or used with all other procedures - Look at condition of cartilage
o Used as primary procedure for early disease, prior to large amount of cartilage destruction – If done on patient with extensive cartilage defect, may increase pain
o For small defect, use K wire do osteochondral drilling – Helps create fibrocartilage - This is not going to be your last procedure, it will just get you by until you need a more definitive procedure like an arthrodesis
13
Q
Complications of Cheilectomy
A
- Adhesions (scar tissue)
o Early ROM is key to prevent this
o Some suggest bone wax or electrocautery to prevent bleeding bone and adhesions - Recurrence
o At some point, limitation of movement, exostosis, and joint destruction will likely progress
14
Q
Cartilage grafting or patching
A
- Emerging treatment option
o Cartilage graft or cartilage patch
o These have cartilage cells, it needs to be rehydrated before insertion into the joint
o Can take fresh-frozen talus bone, then being placed in the joint - Not done a lot because the simple arthrodesis is effective, not necessarily needed
15
Q
Kessel Bonney
A
- Older procedure, not done much anymore
- Resection of a dorsally based wedge of bone from the base of the proximal phalanx
- Plantarflexory motion is redirected
- Will increase hyperextension deformity of hallux if already present
- No degenerative changes present
- Does not relax capsular structures address primary deformity
- Effective for a stage 1 or stage 2 hallux limitus
- Hallux will be sticking up in the air a little bit
16
Q
Regnauld
A
- Also known as the “Mexican Hat” procedure
- Shortening osteotomy of proximal phalanx
- Creates a peg and hole effect
- Technically difficult to perform and fixate
- Thought to create more joint space by decompressing it
- You take off a wedge of bone all the way around the bone – the thought behind this procedure is that if you have an excessively long phalanx, you are somewhat shortening the phalanx
- Hard to say how effective it actually is because not a lot of people are doing this
17
Q
Watermann
A
- Most of the procedures that are currently done focus on the metatarsal head, not the phalanx, such as this procedure
- Dorsal wedge osteotomy out of 1st metatarsal head
- Originally described as a trapezoidal piece of bone removed from met head
- Works by reorienting the cartilage and decompressing the joint
- Difficult to fixate
18
Q
Complications of Watermann
A
- May violate the sesamoids and cause pain and arthritis
- Lesser metatarsalgia
19
Q
Watermann-Green
A
- Piece of bone removed from dorsal half of met head and has a second
cut that is angulated to protect sesamoids - Plantarflexes met head and decompresses the joint by shortening the metatarsal
- More stable and easier to fixate than traditional Waterman osteotomy
- PROTECTS SESAMOIDS
20
Q
Youngswick
A
- MOST COMMON
- Austin (chevron) osteotomy with two parallel cuts dorsally
- Shortens metatarsal, plantarflexes metatarsal
- Allows lateral transposition if needed
- Stable and easy to fixate – don’t have to try to not
violate the sesamoid apparatus, you can go in at a
safer angle
21
Q
Dorsal V
A
- Chevron cut made dorsal to plantar through metatarsal neck
- Plantarflexes metatarsal head
- Can be difficult to fixate and does not offer decompression
- NOT taking a wedge of bone out, just making a cut from dorsal to plantar
and sliding the metatarsal head down
22
Q
Sagittal Z
A
- Sagittal Z through met shaft with proximal arm exiting medially and distal arm exiting laterally
- Can be used to lengthen or shorten
- If shortening, should take out equal amounts of bone from either arm
- Also allows for plantarflexion, so have to be careful not to trough the bone
- Not common
23
Q
Lambrinudi
A
- Plantarflexory base osteotomy to correct metatarsus primus elevatus - Used for structural elevatus - Requires non-weightbearing - More difficult to perform
24
Q
Oblique sagittal base osteotomy
A
- Goes through both cortises
- Allows for plantarflexion and shortening if necessary
- Can take out a wedge if IM needs to be corrected
- Not as stable as other 2 base procedures
25
Arthrodiastasis
- Last non-joint destructive procedure we will talk about
- Initially used in hip in Verona, Italy
- Stretch periarticular soft-tissue structures in staged process, mini rail is used
- Need to discuss this with your patients – might not be okay with external fixation
26
Distraction protocol
- Intra-operative distraction of up to 5mm
- 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 for a total of total of 8 to 12 mm
- Physical Therapy
27
Joint destructive procedures
- Arthroplasty (Keller, Hemi or total implant)
| - Arthrodesis
28
Keller resectional arthroplasty
- Resection of the proximal 1/3 of the proximal phalanx
- HAV – Remove medial eminence
- Hallux limitus – Do cheilectomy as well
- You will be losing flexor hallucis brevis***
- Things will be out of balance, so you can potentially end up with a hammer toe on the hallux
- Typically done for elderly patients who are not as active because you lose FHB and end up with a hammer toe
29
Indications of Keller
- Geriatric bunion (Retrograde buckling, Get up 5.5 degrees correction if not rigid)
- Osteoporosis/Cystic changes
- End stage hallux limitus/rigidus
- Hallux Varus with unsalvageable joint
- ***Neuropathy***
30
Neuropathy as an indication for a Keller
***Neuropathy***
o Bunion deformity in patient you don’t want to use hardware
o Ulcer under hallux IPJ due to hallux limitus (biomechanical etiology of ulcer)
o NEUROPATHY is usually the reason she ends up doing a Keller
31
Contraindications of Keller
- Salvageable first MPJ
- Active individual (Especially athlete or dancer, You are losing the flexor hallucis brevis, so you will lose some of the push-off power and possibly altered gait)
- Spastic neuromuscular disease (Need 1st MPJ stability)
32
Complications of Keller
- Floating toe/Flail hallux
- Lesser metatarsalgia
- Hallux malleus or cock up deformity
- Lesser met stress fracture (due to the FHB be gone and the 1st metatarsal head being weaker – more pressure on the lesser metatarsals)
- Retraction of sesamoids
- Ankylosis of the joint
33
Modifications to Keller
- Reattaching the flexors
- Leaving a plantar “shelf” where the flexors are still attached
- Capsular interposition (flaps or purse-stringing)
- May use K wire to stabilize the toe
34
Keller and capsule interposition
- The capsule is typically thin in elderly patients
| - You might not have a lot of capsule available in order to do this
35
Post-op course for Keller
- WB in postop shoe 2-3 weeks
| - Remove K wire if used after 2-4 weeks
36
Advantages of Keller
- Eliminates joint pain
- Minimal postop disability
- Early return to regular shoe gear
- Relatively easy to perform with minimal dissection required
- ***Can be performed in presence of 1st ray malalignment
37
Disadvantages of Keller
- 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
38
Now we are moving on to implants
FYI
39
Criteria for implant arthroplasty
- End stage hallux limitus or rigidus
- Failed Keller arthroplasty
- Adequate bone stock to accept implant stem, no active infection, no allergy to implant material
- Normal alignment of 1st MPJ (NO BUNION CAN BE PRESENT) unless 2nd procedure planned realign metatarsal
40
Types of implants
Hemi
o Base of proximal phalanx replaced
Total
o Base of proximal phalanx and 1st met head removed
o One component
o Two component
41
Implant materials
Silicone
o Very popular in the 80’s, but found to break down over time
Metal
o Cobalt chromium – strong and corrosion resistant, but contains nickel
o Titanium – Integrates well with bone and light weight, but not as durable
42
Implant types
- 1st generation: Silicone – hemi and total
- 2nd generation: Improved silicone – hemi and total with grommets
- 3rd generation: Metallic – hemi and total that are press fit
- 4th generation: Metallic – hemi and total with threaded stem
43
Technique considerations
Sterilization and handling of implant
o Try to handle as minimally as possible
o Contamination is a concern
o Static charge (silicone) is a concern
Modification of implant
o Modifications can weaken implant – not recommended
o Can shorten stem if needed
44
Technique considerations considered
- Size of the implant (use smallest for best motion)
- Pistoning of the implant
- Necessary for silicon – disperses forces better and prolongs implant life
- Try to avoid with metal implant – will cause bone resorption and loosening of implant
45
Keller with implant
- Remove base of proximal phalanx (about the same thickness as implant)
- If for hallux limitus, do cheilectomy
- Check size of implant
- Drill or tamp hole in base of proximal phalanx for implant stem
- Insert the implant
46
1st metatarsal head resurfacing
- Can be used for 1st or 2nd met head
- One component system
- 2 component system – stem and cap separate
47
1st metatarsal head implant procedure
- Insert guide pin perpendicular to surface
- Insert taper post and decompress the joint
- Map out the joint surface
- Ream for inlay socket
- Remove excess one
- Tamp inlay in place
- This way you have a nice smooth surface on the head of the metatarsal and you have not destroyed any tendons in the process (like you do when doing a phalanx procedure)
- You do unfortunately get some bone loss with this, so if it does fail that can be a problem
48
Total flexible hinge implant
- Made of silicone
- Has stems for proximal phalanx and 1st met with central hinge – can face hinge dorsally or plantarly
- Acts as a dynamic spacer – get some motion but not as much as hemi or 2 component systems and stabilizes joint
49
Grommets
- Thin titanium shield that fits over stem
| - Protects silicone from shearing forces and sharp bone edges
50
Total implants – Two component systems
- Replaces base of proximal phalanx and 1st met head
- Allows for greater postop range of motion than 1 component system
- Difficult to salvage if failure because you are taking out a lot of bon on either side of the joint, so if it fails you will need to do an arthrodesis with bone graft to regain some of that length
51
Post-op course with implants
- Postop shoe until skin heals (usually 2 weeks)
- Early range of motion for hemi and 2 component systems (start at 1-2 weeks, needs to be passive)
- May need continued compression for up to 4 weeks (Coban or Ace wrap)
52
1st MPJ arthrodesis
- Joint DESTRUCTIVE procedure
- End stage procedure
- Generally better procedure for younger or highly active patients compared to arthroplasty
- Fixated with 2 crossing screws or locking plate
53
Contraindications of 1st MPJ arthrodesis
- IPJ arthritis
- Patient with severe osteoporosis
- Patient whose job requires a lot of squatting (i.e. – roofer)
- Best option for a young, healthy, active person
54
Diagram of arthrodesis
- Transverse and sagittal plane views of hallux fusion position temporarily fixated with a k wire
- Dorsal/transverse plane view shows temporary wire fixation across the first MPJ fusion site for primary arthrodesis – Note that the hallux is not touching the second toe
- Sagittal plane view from medial shows temporary wire fixation across the fusion site
- Note that the hallux is elevated 5-10 mm from the supporting surface – this is due to the thickness of the hallux sesamoids
55
Post-op 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
***In non-destructive procedures, EARLY ROM is key to successful outcome, usually started as soon as skin incision healed enough to allow motion
56
STUDY – Hallux limitus outcomes
- A multicenter retrospective review of outcomes for arthrodesis, hemi-metallic joint, and resectional arthroplasty in the surgical treatment of end-stage hallux rigidus
- Kim PJ, Hatch D, DiDomenico LA, Lee MS, Kaczander B, Count G, Kravette M, Level 3 study
- Purpose: Multicenter, retrospective, comparative study examining the long-term outcomes of arthrodesis, hemi-metallic joint implants, and resectional arthroplasty in patients with end-stage hallux rigidus
57
Methods for study
Inclusion criteria
- Minimum 1 year follow up
- Had arthrodesis, hemi-implant arthroplasty, or resectional arthroplasty
- Stage 3 or 4 hallux rigidus (Coughlin and Shurnas Classification)
Exclusion criteria - seronegative or seropositive arthropathy
58
Measurement for study
```
First meatarsophalangeal joint and first ray scoring scale (ACFAS)
o Pain (30 points)
o Functional capacity (15 points)
o Appearance (5 points)
```
```
Modified Hallux Metarsophalangeal-Interphangeal scale (AOFAS)
o Pain (40 points)
o Function (40 points)
o Alignment/cosmesis (20 points)
```
59
Results of study
General
o BMI was selected to be lower –may be why implant did almost as good as arthrodesis
Complications with arthrodesis
o Metatarsalgia was most common
o Non-union and malalignment were next most common
o Revision, IPJ pain and delayed union were less common
Complications with implant
o Bony overgrowth to joint was most common
o Radiolucency around implant, migration of implant and dorsal drift of hallux were next
o Metatarsalgia, cystic changes, first ray elevation, subsidence of implant, sub-first metatarsal pain and revision were less common
60
Limitations to study
o Had no preop scores to compare to postop since it was retrospective
o Surgical technique not standard
o May have procedure bias
61
"You can look through the case study on your own"
- HPI: 46 year old male, right 1st MPJ pain for past 2 years, likes to run but pain has been preventing it
- PMH: kidney stones, chronic back pain, PSH: right 2nd hammertoe repair
- Meds: advil, subtuex, Lexapro
- SHx: denies tobacco, alcohol or drug use
- ROS: denies arthridities, psoriasis, tingling, numbness
- PE
o NVSI
o 10 degrees total ROM
o Pain at end ROM
o No crepitus
o Pain with palpation of dorsal boney prominence
- Assessment
o Hallux limitus
