Hallux Limitus (Surgery) Flashcards
What’s the value for normal
1st MPJ dorsiflexion?
1st MPJ plantarflexion?
Dorsiflexion: 65 degrees
Plantarflexion: 20 degrees
Frequency of Hallux limitus?
1?
In bilateral 2?
Women ratio 3?
- 2nd most common after HV
- 98% of pts had a family history
- 62%
What are the syptoms for Hallux limitus?
1?
2?
3?
4?
5?
- Pain from impingment of dorsal osteophyte
- ROM pain due to irregularity of the articular artilage surface
- Pain from inflammation
- Pain from shoe related pressure on prominant oteophytes
- Pain form irritation of dorsal cutaneous nerves
What are some of the Aiteologies for Hallux limitus?
1?
2?
3?
4?
5?
6?
- Pes Valgus-Hypermobility of 1st ray
- Metatarsus primus elevatus: Hallux equinus
- Long 1st metatarsal/ Short 1st metatarsal
- Varus deformity: Forefoot/ Rearfoot
- Trauma- micro/macro
- Immobalisation
What aresome of the Sytemic Aetiology for Hallux limitus?
1?
2?
3?
4?
5?
- Gouty Arthritis
- Osteoarthritis
- Rheumatoid arthritis
- Neuromuscular disorders
- Iatrogenic causes
Metatarsus Primus Elevatus
Primary MPE
1?
2?
- Secondary to proximal varus deformity
- Hallux equinus subsequently develops to afford medial
Secondary MPE
results from 1?
- retrograde effects of hallux equinus on 1st met head in pes valgus
- Hypermobility 1st ray
How do you differentiate between primary and secondary primus elevatus?
1?
2?
- Evaluation of weight bearing and non weight bearing
- Compare standard lateral to lateral using “forefoot block” test with digits suspended off weight bearing surface
Radiographic measurment for Metatarsus Primus Elevatus
Normally, dorsal cortex of 1st and 2nd metatarsal shaft are 1?
Measure 2?
- Parallel
- Angular divergence between 1st and 2nd metatarsals
Osteochondritis Dissecans
Osteochondral 1?
2 erosion?
Main cause 3?
4?
5 x-rays?
- fracture
- 1st MPJ central and dorsal articular artilage erosion 1st MH
- Cause
- Fragmentation with cleavage lesion
- x-rays may not demonstrate lesion
What are the consequences for progressive osteoarthritis?
Gradual 1.?
2.? Proliferation
3? narrowing
- ? flattening
- ? lesion
6? findings more extensive
- Joint destruction
- Osteophyte
- Joint space narrowing
- Articular surface
- Cystic subchondral
- Intra-operative
Subchondral cyst
Common feature of 1?
Resulting from 2?
Chracateristics 3?
Accompanying features 4?
- OA
- Stress/Pressure
- Multiple and Radiolucent with a surrounding sclerotic margin
- Joint space narrowing and bone sclerosis
- Where is the axis of rotation for hallux?
- What motion does this axis allow for?
- located centrally within the 1st metatarsal head
- Allows for sagittal plane gliding motion of stabalised hallux on rotating metatarsal head
In hallux limitus, where is the axis transferred to 1?
what does this lead to 2?
- Axis of rotation converted to plantar hinge which is at the level of the sesamoidphalangeal ligament
- Leads to dorsal impingment and osteophytic formation
Radiographic Grading
What are the characteristics for Grade I of Hallux limitus?
1?
2?
3?
4?
- Functional limitation of dorsiflexion
- Mild dorsal spurring
- Pain from dorsal hypertrophy
- No structural sesamoid disease
Radiographic Grading
What are the charachteristics of Grade II hallux limitus?
1?
2?
3?
4?
5?
1. Broadening and flattening of 1st met head and base of proximal phalanx
2. Joint space narrowing
3. Structural 1st ray elevatus
4. Osteochondral defect
5. Sesamoid hypertrophy
Radiographic Grading
What are the characteristics of Grade III?
1?
2?
3?
4?
5?
1. Severe loss of joint space
2. Extensive spurring
- Osteochondral defects of
- metatarsal head +/-proximal
- phalanx +/- joint mice
- Extensive sesamoid hypertrophy and loss of joint space
7. Near ankylosis
What are the surgical procedures for Hallux limitus:
- ?
- ?
- ?
- Cheilectomy
- Joint destructive
- Osteotomies
What are the different methods for the joint dstructive surgical procedure for hallux limitus?
1?
2?
3?
1. Keller
- 1st mpj arthrodesis
- Joint implant
What is an stepwise surgical approach for hallux limitus?
- Addresses ?
- Aim to create ?
- soft tissue as well as osseous pathology
2. pain free improved ROM 1st mpj
Some facts about Cheiectomy:
Important 1?
Need to carefully inspetc 2?
Removal of 3?
Abrasion arthroplasty or subcondral drilling to encourage 4?
Good long term success rate with grade 5?
- first step in increasing ROM
- articular cartilage
- loose cartilage
- encourage formation of pseudocartilage
- Grade I and II
More facts about Cheilectomy:
Remove and smooth 1?
Limited application as 2?
Combine with 3?
- first met head and base proximal phalanx
- Sole procedure
- Capsular inter-positional graft
Joint Destructive Procedures:
Keller arthroplasty:
Good procedure for 1?
Arthrodesis of 1st mpj:
Provides predictable 2?
Implant arthroplasty:
Single or two component
- end stage HL deformity
- Stability to 1st mpj and hallux complex
- implants
1st MPJ Arthrodesis
1? treatment
Obliterates 2?
Ideal for stage 3?
Can yield consistently to 4?
- End stage
- motion
- III HL
- good results
What’s does the 1st MPJ arthrodesis procedure involve?
Removal of all 1?
Devices 2?
Fenestrate 3?
to
encourage 4?
- cartilage from 1st metatarsal head and base proximal phalanx
- Sagittal saw, Ronguer/bone curette, Conical reamer system
- subchondral bone with 1.6mm K-wire
- bleeding
What is the alternative fixation technique:
Stable internal fixation
Crossed K-wires
Parallel K-wires
Single A-O screw
Crossed A-O screws
1st MPJ Arthrodesis
After care 1?
Limitations 2?
Complications 3?
- BK cast or post-op shoe for 4-6/52
- No more high heeled footwear
- Delayed healing, Non-union, Improper position
Some facts about joint implants:
Better in 1?
Hemi or double
Complications 2?
Hallux malleus
- Theory than in practice: Lifespan of implants
- Infection, Implant failure, Need for removal
What is the technique involved for Joint implant surgery?
Removal of 1?
Creation of 2?
Selection of 3?
Suturing of 4?
Insertion of 5?
- bone
- Holes
- trial implant
- flexor plate to base prox phalanx
- implant
Moberg osteotomy
1? osteotomy
Cheilectomy 2?
Decompression anddorsiflexion 3?
- phalangeal osteotomy
- 1st MH
- Osteotomy proximal phalanx
Moberg osteotomy
1? skin incision
2? exposed
- Medial
- Capsule inside joint
Moberg Osteotomy
Make 1? first, then 2? why?
Drill holes with 3?
Thread 4?
- proximal osteotomy
- distal osteotomy
- 1.4 mm K-wire
- stainless steel wire
Moberg procedure
After-care:
Post-op sandal 1?
Co-plus wrap 2?
Possible complications:
Avoid 3?
4?
5?
6?
- 4-6/52
- 4/52
- Over tightening wire sutures
- Fracture plantar hinge
- Delayed/non-union
6. AVN base proximal phalanx
1st Metatarsal Osteotomies
Distal osteotomies:
Useful in 1?
Obtain 2?
Youngswick- modification of 3?
Plantarflexory basal osteotomies:
Lambrinudi
Sagittal Z
Waterman
- Mild-moderate metatarsus primus elevatus
- shortening and plantar flexion of capital fragment
- Austin (1982)
Youngswick Osteotomy/Modified Watermann
Modification 1?
2? 1st ray
Fixated with 3?
Ambulatory procedure
Stage 4?
5? loss of joint cartilage
Indications 6? 7?
- Austin osteotomy
- Plantar-flexes and shortens
- screw or Kwire/s
- I or II HL
- < 50%
- Age < 75 years
- Good bone density
Proximal osteotomies:
After care:
Non-weight bearing for 1?
B-K cast
Careful 2?
Less surgery at MPJ level - less surgical scarring around joint
Complications 3?
- 6-8 weeks
- ROM exercises
- Need for nwb
immobilisation
MPE
Delayed/non-union
Reduced ROM 1st mpj
