Hallux Limitus

• Hallux Rigidus refers to stiffness of the big toe.
• Chandler Ligas DPM, AACFAS, presents information on the condition.

Agenda

• Topics discussed include the definition, etiology, staging/grading, salvage procedures, and destruction procedures for Hallux Rigidus.

Definitions

• Arthrosis of the First Metatarsophalangeal Joint (MPJ) was originally defined in 1881 by Nicholadoni.
• Hallux Limitus is a term for limited Range of Motion with Pain.
• Hallux Rigidus is the end stage of the condition, presenting virtually no motion at all.

Functional Analysis

• During the propulsive phase of gait, natural plantarflexion of the first metatarsal is observed.
• Normal MPJ has 65 degrees of dorsiflexion.
• Normal MPJ has 20 degrees of plantar flexion.
• Dorsiflexion allows for the movement of the proximal phalanx and hallux.
• The Sessamoid apparatus is pulled slightly distal within the FHB tendon, engaging the Windlass Mechanism.

Epidemiology

• The first MTP joint is the most common arthritic site in the foot.
• Hallux Rigidus frequently presents bilaterally.
• Over half of patients report a family history of the pathology.

Etiology

• Traumatic Articular Fracture, OCD, and other traumatic injuries are common contributors.
• Biomechanical factors include Excessive Subtalar Joint Pronation, Dorsiflexed First Ray, Long First Ray, Metatarsal Shape, First Ray Insufficiency, etc.

Risk Factors

• Knee osteoarthritis and hallux valgus are independent risk factors.
• episodes of gout are independent risk factors.
• A family history of hallux rigidus is consitent with bilateral hallux rigidu.
• Unilateral hallux rigidus can occur in patients with a history of trauma.
• There is a higher prevalence of hallux rigidus in older adults (≥50 years).
• Females have a higher frequency of hallux rigidus.
• Increased height "the greater the height of the patient, the greater the development of hallux rigidus".

Clinical Symptoms

• Structural Hallux Limitus main complaint is pain.
• Structural Hallux Limitus results in a limited range of motion.
• Structural Hallux Limitus causes palpable dorsal osteophytes/bone spurs.
• Functional Hallux Limitus results in passive range of motion that may be normal.
• Patients with Functional Hallux Limitus complain of joint stiffness with ambulation.
• Weightbearing results in a limited range of motion in patients with Functional Hallux Limitus

Staging/Grading - Regnauld

• Grade I: Functional Hallux Limitus.
• Grade II: Joint adaptation with flattening of the first metatarsal head and pain at the end range of motion.
• Grade III: Arthrosis with flattening of the first metatarsal head, osteophytes, asymmetric joint space narrowing, and erosions.

Staging/Grading - Coughlin/Surnas

• Grade 0: Dorsiflexion 40-60°, normal radiography, with no pain present.
• Grade 1: Dorsiflexion 30-40°, dorsal osteophytes, minimal/no other joint changes.
• Grade 2: Dorsiflexion 10-30°, sclerosis/joint narrowing, and osteophytes are mild to moderate.
• Grade 3: Dorsiflexion <10°, severe radiographic changes, moderate to severe pain at extremities.
• Grade 4: Characterized by Stiff joint, severe changes with osteochondritis dissecans and loose bodies.

Staging/Grading - Roukis

• Grade 1: Metatarsus primus elevates, minimal dorsal exostosis, periarticular subchondral sclerosis, and minimal flattening of the metatarsal head.
• Grade 2: Moderate dorsal exostosis, flattening metatarsal head, sesamoid hypertrophy, and minimal joint space narrowing.
• Grade 3: Severe dorsal exostosis, focal joint space narrowing, cyst formation, and loose bodies.
• Grade 4: Excessive exostosis of the metatarsal head and proximal phalanx base with absent joint space and ankylosis

Staging/Grading

• Grade 0: 40°-60° (20% loss of normal motion),Normal Radiographic Findings, No pain. Only stiffness and loss of motion with clinical findings.
• Grade1: 30°-40° (20%-60% loss of normal motion), Minimal joint space narrowing, periarticular sclerosis and flattening of the metatarsal head, Mild or occasional pain and stiffness at the extremes of movements with clinical findings.
• Grade 2: 10°-30° (50%-75% loss of normal motion), Dorsal, lateral, possibly medial osteophytes with flattened appearance to the metatarsal head; less than one-fourth of the dorsal joint space is involved on the lateral radiograph; mild to moderate joint space narrowing and sclerosis; sesamoids not involved, Moderate to severe pain and stiffness. Pain occurs just before maximum dorsiflexion and maximum plantarflexion.
• Grade 3: ≤10° (75%-100% loss of normal motion). Loss of plantarflexion as well (often ≤10°), Same as in grade 2 but with substantial narrowing, cystic changes, more than one-fourth of the dorsal joint space is involved on the lateral radiograph, sesamoids enlarged, cystic, and/or irregular, Constant pain and substantial stiffness at the extremes of range of motion but not at midrange.
• Grade 4: Same as in grade 3 , Same as in grade 3, Same as in grade 3 but with hindrance of passive motion.

Grade 1 Functional Limitus

• Hallux Equinus/flexus
• Plantar subluxation proximal phalanx
• Metatarsus primus elevates.
• Joint dorsiflexion may be normal with non-weightbearing but ground reactive forces elevate the first metatarsal and yield limitation
• No degenerative joint changes

Grade II Stage of Joint Adaptation

• Flattening of the First Metatarsal Head
• Possible Osteochondral defect
• Cartilage Fibrillation and Erosion
• Pain on end ROM
• Passive ROM may be limited.
• Subchondral eburnation

Grade III Stage of Established Arthrosis

• Severe Flattening of the First Metatarsal head
• Osteophytosis, particularly dorsally
• Degeneration of Articular Cartilage
• Crepitus
• Subchondral Cysts

Grade IV Stage of Ankylosis

• Obliteration of the Joint Space
• Exuberant osteophytosis with loose bodies
• < 10 degrees of Range of Motion
• Total Ankylosis is common.

Conservative Therapy

• 50% of Hallux Limitus Patients met with Satisfactory results when using conservative care
• RICE Therapy
• Stiff Soled Shoe or Rocker Bottom Shoe
• Orthotics with Morton Extension.
• Steroid Injections

Surgical Management

• Joint Sparing: Cheilectomy, Youngswick, Waterman and Lambrinudi
• Joint Destructive consists of 1st MPJ Arthrodesis, Keller, Mayo, Valenti and Arthroplasty.

Goals of Surgical Intervention

• It should decrease pain.
• It should improve Activities of Daily Living and Function.
• Pain not improved with conservative management should seek surgical intervention.
• Cosmetic appearance, and patients with manageable pain should not seek surgical internvetions.

Remember Basic Principles

• Glissane's Principles, complete removal all cartilage, fibrous tissue, and any other material, close apposition of fusion sites, optimal position for fusion, and maintain position until fusion.
• Anatomic Dissection Principles, Dissection through differing skin, subcutaneous tissue, periosteum and bone to safely achieve surgical target tissue and Ability to minimize disruption to accelerate recovery.

Considerations for Salvage

• Severity of Deformity
• Metatarsalgia
• Desire / Need for Motion
• Muscle Tendon Balance
• Joint Status (DJD)
• Complication Potential
• Patient Age

Cheilectomy

• The point is to remove dorsal osteophytes.
• Indications include Adequate joint space, Dorsal osteophytes, Stage I or II, Dedicated bump pain, and No deformity.

Cheilectomy Technique

• Historically resected the dorsal 1/3 of the metatarsal head.
• Remove dorsal osteophyte and any damaged tissue.
• Removal of osteophyte from base of proximal phalanx.
• Repair of articular cartilage can be done through Marrow Stimulation or Cartilage Replacement

MIS Cheilectomy

• Introduce the burr through the incision and begin to resect the bone spur.
• Rotate the burr from lateral to medial, avoid migration over the spur.
• Important to introduce burr into the spur and not on top of the spur

Cheilectomy Complications

• Overaggressive resection Joint Instability;
• Arthrofibrosis;
• Continual Pain and MIS burr
• EHL laceration

Waterman

• First Described in 1927
• Goals = Bring Plantar Cartilage Dorsal
• Dorsal Osteophytes Stage II
• Dorsal Cartilage Eburnation

Waterman Technique

• Spurring is removed.
• Osteotomy created to remove a trapezoidal wedge.
• The size of the wedge determines the amount of dorsiflexion needed. Important to not violate sesamoids

Waterman Modification

• Modified Oblique Waterman;
• Waterman Green

Waterman Green Technique

• Apex of osteotomy 1/3 to 12 from the dorsal osteophyte;
• Plantar arm performed extends proximal to sesamoid apparatus;
• the first Dorsal arm perpendicular to long axis of metatarsal;
• a more Acute angle of the apex equals shortening and The more vertical = plantarflexion

Youngswick Indications

• Stage II and III Hallux Limitus
• Specific Patient Preference Goal to shorten and plantarflex
• The capital fragment Long first metatarsal and metatarsus elevatus

Youngswick Technique

• Osteotomy performed with the dorsal and plantar arms angled approximately 90' to one another.
• The plantar cut is made first, since it dictates direction of correction.
• The dorsal distal cut is made next, followed by the proximal dorsal cut.

Other Joint Sparing Procedures

• Indicated for functional hallux limitus where first metatarsal elevatus is thought to be primary cause Plantar flexor wedge osteotomy of the base of the first metatarsal
• Kessel and Bonney, Used to dorsiflex the hallux to decrease the need of first MPJ; range of motion for clearance and Dorsiflexory wedge osteotomy of the proximal phalanx of the hallux

Complications General

• With any osteotomy malunion, nonunion.
• Fragmentation of the capital fragment Avascular necrosis

Complications Specific

• Waterman- Avascular Necrosis, Sesamoid Disruption/Arthritis.
• Lambrinudi- First Metatarsal Elevatus

Joint Destructive Procedures

• Destructive procedures include Arthrodesis, Keller, Mayo, Valenti and Arthroplasty.

First Metatarsophalangeal Joint Arthrodesis

• Gold Standard for Stage III and IV Hallux Rigidus/Limitus
• Painful/Symptomatic First MPJ

First MPJ Arthrodesis Technique

• Anatomical Dissection and Removal of spurs/cartilage/chondral bone
• Goal is to shorten the leg as little as possible.
• Goal is to get down to subchondral bone (healthy bleeding cancellous bone).
• One can perform Hand instrumentation, Reaming or planar cuts and break the subchondral Bone, or use Fenestrating vs. Fishscaling.

First MPJ Arthrodesis Positioning

• Intraoperative Position is Paramount Sagittal plane- 0-10 degrees dorsiflexed
• Coronal Plane- Nail plate in same position as other toes
• Transverse plane- Even with the second digit 10-15 degrees of valgus In regards to 1st Metatarsal Axis
• Neutral Rotation Dorsal Plate and 2 Crossing K-wires

Optimal Fusion Postion

• Align the Pulp of toe just off WB surface in alignment with the second digit.
• Ensure Nail faces straight up.

First MPJ Arthrodesis Fixation

• Crossing Screws
• Dorsal Plate and 1 Crossing Screw Staples
• Dorsal Plate and 2 Crossing K-wires

Roukis et al 2011

• Did a Systematic Review of 2,656 joints Nonunion incidence was 5.4% (153 of 2,818)
• Symptomatic nonunion occurring in 32.7% (50 ) Overall incidence of malunion was 6.1% (39 of 640)
• Dorsal malunion accounting for 87.1% (34 of 39) The overall incidence of hardware removal was 8.5% (69 of 817)

Keller Arthroplasty

• Stage III or IV Hallux Limitus/RigidusReserved for Elderly patients with low physical demands
• Involves removal of the proximal 1/3 of the proximal phalanx of the hallux Typically the hallux will be pinned to help hold position
• Capsular repair acts as an interpositional graft as well.

Keller Arthroplasty Complications

• Loss of intrinsic muscular attachment– lack of hallux purchase– cock up hallux– flail hallux
• Over-resection of Proximal Phalanx– Flail Hallux– Cosmetic appearance
• Under-Resection of Proximal Phalanx– Continual pain and restricted range of motion

Mayo Arthroplasty

• Indicated: Stage III and IV hallux limitus Care is taken not to cut the flexor tendon.
• Transverse cut is made to remove all articular cartilage from the head of the metatarsal.
• Typically 0.5 1 cm of bone is resected.
• All soft tissue attachments are freed after resection and ensured hallux moves freely

Valenti

• Described in 1976 as a V Resection of the metatarsophalangeal joint Goal is to preserve first ray length
• Indicated Stage II and III hallux limitus in elderly patients
• dorsal osteotomy with 30° angulation to the long axis of metatarsal, 45° to the long axis of proximal phalanx, obtaining the final dorsal flexion of approximately 90°

Arthroplasty

• Indicated in destructive joints and with patients with stages 2 -4.
• Involves an autogenous flap capsule/periosteum
• Involves EHB Tendon allograft or acellular dermal matrix

Arthroplasty Complications

• Metatarsalgia Most Common
• loss of ground contact/ Great toe weakness/ decreased push off power and callous formation and
• Interposition arthoplasty- viable option for treatment of moderate to severe hallux rigidus. - A systematic review and meta-analysis Foot Ankle Surg 2019 Oct

Hemi Arthroplasty

• Indicated Stage II III Involves removing of the proximal phalanx base and implanting metallic implant Aggressive cheilectomy is also performed

Metatarsal Head Resurfacing

• Indicated Stage II III Involves aggressive cheilectomy and implanting a metallic implant
• Should also release all soft tissue over the head of the metatarsal to allow for adequate range of motion

Hemi Arthroplasty Data

• Mean preoperative and postoperative AOFAS scores were 39.76 and 90.40 points Improvement of 50.65 points
• The phalanx and the metatarsal head saw equal subjective improvements
• Range of motion increased to 42.95 degrees 5 Year Survivorship 87%
• Common complications include Revision surgery and moderate-severe metatarsalgia

Head Resurfacing Trials

• 59 trials from January 2005 to December 2009 subset tracked for 10 years with 73.6% follow up rate (32 implants)
• Implants removed from one pt who was happy with outcome
• Repeat surgery done on the other foot
• 93.7% survival rate
• This is a good option to treat Hallux limitis

Implant Arthroplasty

• Total Toe Implant Indicated with a score of Stage II-IV
• Should have no other present Should have no other deformities present or be present to ensure accurate data collection
• Used to Replace the proxima phalanx and head of the metatarsal head

Total Toe Arthoplasty

• Mean AOFAS score was a 40.6 improvement
• Range was 32.5 degrees
• Data shows, the Hemi-arthoplatyy is better than Total due to several outcomes such as reduced need of replacement.
• This suggests its better for stability purposes.
• Some complications include Meatatarsalgia along with infection.

Hinged Implant Athroplasty

• Most commonly designed by Swanson
• 1/4 - 1/3 of the proximal phalanx.