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
