55: Surg Management of Hallux Limitus- Frush

Question 1

normal 1st MPJ motion

Answer 1

normal dosiflexion = 65-70 degrees

only 25-30 degrees attainable w/o 1st ray plantarflexion

Question 2

etiology hallux limitus

Answer 2

• Dorsiflexed 1st metatarsal
• Trauma
• Pronation decreasing pull of peroneus longus
• Long 1st met/ Short 2nd met
• Generalized arthridities (ie gout)
• Iatrogenic/ previous surgery

Question 3

ACFAS classification hallux limitus

Answer 3

• 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

Question 4

joint reconstruction based on orthopedic deformity

Answer 4

Question 5

joint destructive procedure choice based on pt

Answer 5

Question 6

list non-jt destructive procedures

Answer 6

• Exostectomy
  
  • Cheilectomy “clean up”
    
    • remove dorsal exostosis off the 1st met head
    • used prior to cartilage destruction
    • needs early ROM, may recur
• Proximal phalanx osteotmy
  
  • Kessel bonney
    
    • resection of dorsally based wedge of bone from base proximal phalanx
  • Regnauld “mexican hat”
    
    • shortening osteotomy of proximal phalanx
• 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
• Arthrodiastasis
  
  • stretch periarticular soft tissue structures in staged process

Question 7

distraction protocol for arthrodiastasis

Answer 7

• 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

Question 8

joint destructive surgical options

Answer 8

• arthroplasty
  
  • keller
    
    • resection proximal 1/3 of proximal phalanx
  • hemi or total implant
• arthrodesis

Question 9

what should be removed in keller pt with HAV and hallux limitus?

Answer 9

Keller = Resection of the proximal 1/3 of the proximal phalanx

HAV –> Remove medial eminence

Hallux limitus –> Do cheilectomy as well

Question 10

indications for keller resectional arthroplasty

Answer 10

• 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
  
  • Bunion deformity in patient you don’t want to use hardware
  • Ulcer under hallux IPJ due to hallux limitus

Question 11

contraindications for keller

Answer 11

• Salvageable first MPJ
• Active individual
  
  • Especially athlete or dancer
• Spastic neuromuscular disease
  
  • Need 1st MPJ stability

Question 12

complications for a keller

Answer 12

• 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

Question 13

post-op keller

Answer 13

WB in postop shoe 2-3 wks

remove k wire if used after 2-4 wks

Question 14

advantages and disadvantages of keller procedure

Answer 14

• (+) 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

Question 15

criteria for implant arthroplasty

Answer 15

• 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

Question 16

two different types of impants

Answer 16

• 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)

Question 17

when should you piston an implant?

Answer 17

• Necessary for silicone
  
  • Disperses forces better
  • Prolongs implant life
• Try to avoid with metal implant
  
  • Will cause bone resorption and loosening of implant

Question 18

steps for a 1st met head implant

Answer 18

1. insert guide pin perpendicular to surface
2. insert taper post and decompress the jt
3. mapping out the jt surfce
4. reaming for inlay socket
5. remoe excess bone
6. tamp inlay in place

Question 19

what implant acts as dynamic spacer?

Answer 19

total flexible hinge implant

• Made of silicone
• Has stems for proximal phalanx and 1st met with central hinge
• Can face hinge dorsally or plantarly

Question 20

what are grommets?

Answer 20

• Thin titanium shield that fits over stem
• Protects silicone from
  
  • Shearing forces
  • Sharp bone edges

Question 21

which type of implant allows greater postop ROM

Answer 21

two compenent system

(replaces base of proximal phalanx and 1st met head)

Question 22

contraindications ofr 1st MPJ arthrodesis

Answer 22

IPJ arthritis

Patient with severe osteoporosis

Patient whose job requires a lot of squatting (ex – roofer)

Question 23

best procedure for younger or hightly active pts

Answer 23

1st MPJ arthrodesis

Question 24

comparitive postop care

Answer 24

• 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

Question 25

Answer 25

cheilectomy

Question 26

Answer 26

kessel bonney

Question 27

Answer 27

regnauld

Question 28

Answer 28

watermann

Question 29

Answer 29

watermann-green

Question 30

Answer 30

youngswick

Question 31

Answer 31

dorsal V

Question 32

Answer 32

saggital Z

Question 33

Answer 33

lambrinudi

Question 34

Answer 34

oblique sagittal base osteotomy

Question 35

Answer 35

keller resectional arthroplasty