Hallux Rigidus .pdf

HALLUX RIGIDUS 1 Jarrod Smith, DPM, FACFAS Assistant Professor Normal 1st MTPJ ROM Ginglymoarthrodial joint Ginglymus joint à Hinge joint A) Rolling motion for the first 20-30° of hallux dorsiflexion Arthrodial joint à Sliding B) First ray plantarflexion changes the motion to a sliding motion for th...

HALLUX RIGIDUS 1 Jarrod Smith, DPM, FACFAS Assistant Professor Normal 1st MTPJ ROM Ginglymoarthrodial joint Ginglymus joint à Hinge joint A) Rolling motion for the first 20-30° of hallux dorsiflexion Arthrodial joint à Sliding B) First ray plantarflexion changes the motion to a sliding motion for the remainder of propulsion C) Compression occurs at end range of motion Normal ROM = 65 – 75° Normal 1st MTPJ ROM 1st metatarsal head is shaped like a cam which aids: Rolling II. Sliding III. Sliding IV. Compression I. Normal 1st MTPJ ROM Normal 1st MTPJ ROM Requirements First ray plantarflexion STJ supination Normal parabola (2nd met longer than 1st) Normal intrinsic/extrinsic muscle function Normal sesamoid function Intact proximal phalangeal base (Windlass) Intact plantar aponeurosis (Windlass) Medial Column Stabilization Plantarflexion of the 1st ray is dependent on the pull of the peroneus longus tendon Medial Column Stabilization Plantarflexion of the 1st ray is dependent on the pull of the peroneus longus tendon The wedge-shape of the middle and lateral cuneiforms result in a key stone effect within the medial cuneiform and cuboid Medial Column Stabilization Plantarflexion of the 1st ray is dependent on the pull of the peroneus longus tendon The wedge-shape of the middle and lateral cuneiforms result in a key stone effect within the medial cuneiform and cuboid This stabilizes the lesser tarsus and allows the first ray to plantarflex First Ray Plantarflexion This stabilizes the lesser tarsus and allows the first ray to plantarflex Hallux Rigidus Definition - A progressive disorder of the first MTP joint, characterized by a diminished ROM and degenerative alterations of the joint. Hallux Rigidus Definition - A progressive disorder of the first MTP joint, characterized by a diminished ROM and degenerative alterations of the joint. If any of the requirements for normal 1st MTPJ ROM is not met, the result is usually first ray elevation Hallux Rigidus Elevation of the first metatarsal (metatarsus primus elevatus) causes the proximal phalanx of the hallux to sublux plantarly (hallux equinus/flexus). Because some movement is generally available the term hallux limitus is used. Only 25-30° are possible without 1st ray plantarflexion. Hallux Rigidus Windlass mechanism Heel lift with ankle plantarflexion will dorsiflex the 1st MTPJ Tightening of the plantar fascia Raises the arch Resists elongation of the foot Shortens the foot Assists in resupinating the subtalar joint Hallux Rigidus Windlass mechanism function is blocked by any force the drives the first ray up The first ray is prevented from plantarflexing The hallux cannot dorsiflex Plantar fascia tension still increases, however, this results in increased 1st MTPJ compression Hallux Rigidus Etiologies of hallux limitus/rigidus: Functional (biomechanical) causes Pronation 1st ray hypermobility Weak peroneus longus All lead to first ray dorsiflexion and subsequent “jamming” of the dorsal aspect of the MTP joint Hallux Rigidus Etiologies of hallux limitus/rigidus: Functional (biomechanical) causes High heels Increasing heel height reduces 1st MTPJ dorsiflexion A 1-inch heel reduce dorsiflexion by 20° Each additional inch decreases dorsiflexion by 14° A 2-inch heel will decrease 1st MTPJ ROM by 34° meaning you will need 100° of dorsiflexion if we need 65° to propel forward Hallux Rigidus Etiologies of hallux limitus/rigidus: Structural causes Immobilization of the 1st ray (in dorsiflexion) Congenital metatarsus primus elevatus Congenital long first metatarsal/short 2nd metatarsal Arthritis of the 1st TMTJ (decreased ROM) Rigid flatfoot deformity Hallux Rigidus Etiologies of hallux limitus/rigidus: Iatrogenic à Previous surgery Unintentional first ray elevation with HAV correction This is why you most likely will never intentionally dorsiflex the first metatarsal head with HAV correction Hallux Rigidus Etiologies of hallux limitus/rigidus: Trauma TMTJ arthritis MTPJ arthritis Turf-toe Malunion of a 1st metatarsal fracture (healed in elevatus) Systemic arthridities (gout, RA) Hallux Rigidus Common clinical findings: Pain Limited motion at the 1st MTPJ Dorsal bump on the 1st metatarsal head Dorsal bunion Hypermobility of the hallux IPJ Plantar callus at the IPJ Metatarsus primus elevatus Metatarsalgia à lateral dumping Hallux Rigidus Radiographic findings: Dorsal osteophytic formation 1st metatarsal head (flag sign) Base of the proximal phalanx Metatarsus primus elevates Hallux equinus 1st MTP joint space narrowing Flattening of the 1st metatarsal head Subchondral sclerosis Pronatory changes in the foot Functional vs Structural Functional hallux limitus (flexible) Decreased hallux dorsiflexion only when the forefoot is loaded Responds well to orthotic management (functional orthosis) Raise the arch up, allow the 1st ray to plantarflex, thus unblocking the windlass mechanism, and allowing hallux dorsiflexion Functional hallux limitus can develop into a structural hallux rigidus Functional vs Structural Structural hallux rigidus (fixed) Decreased hallux dorsiflexion with the forefoot loaded and unloaded Orthotics have limited utility Hallux Rigidus Treatment Options: Conservative treatment Functional Treatment Orthotic management Physical therapy PL strengthening Joint mobilization Adjunct Treatment à limited utility without functional treatment NSAIDs Injections Orthotic Management Goals of treatment Increased ROM of the 1st MTPJ by correcting the biomechanics Plantarflex the first metatarsal Raise the arch = increase metatarsal declination Reverse Morton’s extension Decrease the ROM of a painful 1st MTPJ = mimic a fusion Dorsiflex the hallux Morton’s extension Orthotic Casting Start with subtalar joint in neutral position Lock the midtarsal joint by applying a dorsiflexory force to the 4/5th met heads Hold the STJ in neutral with the midtarsal joint locked with one hand & plantarflex the first ray with the other Plantarflexing the first ray to remove supinatus/forefoot varus is critical to first ray function Reverse Morton’s Extension Allows the first ray to plantarflex more (if able) Increases ROM of the 1st MTPJ Morton’s Extension Dorsiflexes the hallux Decreases ROM of the 1st MTPJ Hallux Rigidus Surgical Treatment Options: Joint salvage procedures Joint destructive procedures Goal is to keep what remains of the joint and get it to function better Usually, can be revised to a joint destructive procedure Not considered definitive Destroys the joint Considered definitive, however, not all are Before we can get into surgery…we must classify!!! Drago, Oloff, & Jacobs Classification Drago, Oloff, & Jacobs Classification Stage I: Functional Limitus Limited dorsiflexion with weightbearing but normal ROM with non-weight-bearing Little/no degenerative changes Biomechanical derangement (pronation) 1st ray insufficiency Metatarsus primus elevatus Hallux equinus Hyperextension hallux IPJ Treatment: Joint-Salvage procedure Drago, Oloff, & Jacobs Classification Stage I: Functional Limitus Limited dorsiflexion with weightbearing but normal ROM with non-weight-bearing Little/no degenerative changes Biomechanical derangement (pronation) 1st ray insufficiency Metatarsus primus elevatus Hallux equinus Hyperextension hallux IPJ Treatment: Joint-Salvage procedure Drago, Oloff, & Jacobs Classification Stage 2: Adaptation Flattening of the first metatarsal head Osteochondral defect Pain on end ROM Limited passive ROM Small dorsal exostosis Subchondral sclerosis Periarticular lipping of the first metatarsal head, proximal phalanx, & sesamoids Treatment: Joint-Salvage procedure Drago, Oloff, & Jacobs Classification Stage 2: Adaptation Flattening of the first metatarsal head Osteochondral defect Pain on end ROM Limited passive ROM Small dorsal exostosis Subchondral sclerosis Periarticular lipping of the first metatarsal head, proximal phalanx, & sesamoids Treatment: Joint-Salvage procedure Drago, Oloff, & Jacobs Classification Stage 3: Deterioration Severe flattening of the first metatarsal head Dorsal osteophytosis Asymmetric joint space narrowing Degeneration of articular cartilage Crepitus Subchondral cystic formation Pain on full ROM Treatment: Joint-Salvage or Joint-Destructive procedure Drago, Oloff, & Jacobs Classification Stage 3: Deterioration Severe flattening of the first metatarsal head Dorsal osteophytosis Asymmetric joint space narrowing Degeneration of articular cartilage Crepitus Subchondral cystic formation Pain on full ROM Treatment: Joint-Salvage or Joint-Destructive procedure Drago, Oloff, & Jacobs Classification Stage 4: Anklylosis Obliteration of joint space Exuberant dorsal osteophytosis w/ loose bodies < 10° ROM Degeneration of articular cartilage Deformity/Malalignment Total ankylosis may occur Treatment: Joint-Destructive procedure Drago, Oloff, & Jacobs Classification Stage 4: Anklylosis Obliteration of joint space Exuberant dorsal osteophytosis w/ loose bodies < 10° ROM Degeneration of articular cartilage Deformity/Malalignment Total ankylosis may occur Treatment: Joint-Destructive procedure Treatment Algorithm HALLUX RIGIDUS 2 Jarrod Smith, DPM, FACFAS Assistant Professor Hallux Rigidus Surgical Treatment Options: Joint salvage procedures Cheilectomy Decompression osteotomy Youngswick - distal metatarsal osteotomy Kessel & Bonney- phalangeal osteotomy Arthrodiastasis Chrondroplasty à rarely used in isolation Cheilectomy Joint clean up procedure Removal of osteophytosis from the metatarsal head and proximal phalanx Can be the primary procedure Often used with other procedures Can be coupled with chondroplasty if a chondral defect is present This procedure can increase patient’s symptoms if joint is deteriorated Drilling of subchondral bone stimulates bleeding à fibrocartilaginous ingrowth Cheilectomy increases joint movement à increased movement of an arthritic joint = pain Should be presented to patients as a “stop gap” procedure If it ends up being definitive treatment, then “yay” Needing to progress to a fusion shouldn’t be shocking CHEILECTOMY CHEILECTOMY Youngswick Decompression osteotomy of the metatarsal head Austin osteotomy with an extra parallel cut dorsally Allows for shortening and plantarflexion Most useful with long 1st metatarsals (same length as 2nd or longer) & mild elevatus YOUNGSWICK Youngswick Decompression Osteotomy Kessel & Bonney Decompression osteotomy of the proximal phalanx Changes the posture of the hallux Indicated for adolescents early on then indications expanded to adults May make revision fusion more difficult due to creating a secondary deformity In order to properly align the hallux, you have to plantarflex the hallux more than you would without the secondary deformity. This leads to a prominent plantar phalangeal base KESSEL & BONNEY Arthrodiastasis External fixation with a mini-rail Stretches periarticular soft-tissue structure Gives cartilage a “rest” Hypothesized that cartilage is nourished via disuse osteopenia of the subchondral plate ARTHRODIASTASIS Chondroplasty Addresses cartilage erosions that are often present Rarely done in isolation à biomechanical causes are not addressed The subchondral plate is penetrated, usually with a k-wire, to allow bleeding Clotted blood then forms fibrocartilage CHONDROPLASTY Hallux Rigidus Surgical Treatment Options: Joint destructive procedures Resection arthroplasty Interpositional implant arthroplasty Valenti Keller Hemi-implants Silastic implants Cartiva Total joint replacement 1st MTPJ arthrodesis Lapidus??? Valenti Resection Arthroplasty “V” cut in the sagittal plan removing the majority of the MTPJ Some consider this a joint salvage procedure à I disagree Revision to a fusion would be very difficult Indications same as a Keller Low functional requirements VALENTI Keller Resection Arthroplasty Resection of the base of the proximal phalanx What is required for “normal” 1st MTPJ ROM? Normal 1st MTPJ ROM Requirements 1st ray plantarflexion STJ supination Normal parabola (2nd met longer than 1st) Normal intrinsic/extrinsic muscle function Normal sesamoid function Intact proximal phalangeal base (Windlass) Intact plantar aponeurosis (Windlass) Normal 1st MTPJ ROM Requirements 1st ray plantarflexion STJ supination Normal parabola (2nd met longer than 1st) Normal intrinsic/extrinsic muscle function Normal sesamoid function Intact proximal phalangeal base (Windlass) Intact plantar aponeurosis (Windlass) Keller Resection Arthroplasty Resection of the base of the proximal phalanx What is required for “normal” 1st MTPJ ROM? Only indicated in patients with low functional requirements Most common complication is central metatarsalgia Why? KELLER 1st MTPJ Implant Arthroplasty Require bone resection for implantation Sub 2nd metatarsalgia is a very common complication Large discrepancy in the modulus of elasticity of cartilage vs cobalt chromium How does an implant address the biomechanical pathology that caused the rigidus? Makes revision to a fusion more difficult 1ST MTPJ IMPLANT SYNTHETIC CARTILAGE IMPLANT Synthetic Cartilage Graft 1st implant to mimic the modulus of elasticity of cartilage Subsidence is very common Sinking of the implant into the metaphyseal bone Happens quite rapidly (3 weeks post-op) Specific Revision System 1st MTPJ Fusion The “gold standard” for hallux rigidus surgical treatment Definitive Positioning is critical for proper function post-operatively Too dorsiflexed = hallux malleus Too plantarflexed = hallux IPJ pain/arthrosis Joint is painful when it moves = can’t hurt if it doesn’t move However, malposition will create other problems 1st MTPJ Fusion Positioning is critical for proper function post-operatively Literature suggests 15° abducted and 15° dorsiflexed Plating systems are developed with these angles This also assumes everyone’s anatomy is the same My recommendation is to load the foot intraoperatively Seeking the plantar hallux to barely touch or be just above the loading plate 1st MTPJ Fusion Positioning is critical for proper function post-operatively Literature suggests 15° abducted and 15° dorsiflexed Plating systems are developed with these angles This also assumes everyone’s anatomy is the same My recommendation is to load the foot intraoperatively Seeking the plantar hallux to barely touch or be just above the loading plate 1ST MTPJ FUSION Lapidus Realigns a structurally pathologic 1st metatarsal Shortens the first ray thus “decompresses” the joint Need a very clean 1st MTPJ Patients do NOT like double fusions (1st MTPJ and 1st TMTJ) LAPIDUS Case # 1 71-year-old female presents for treatment of her right foot pain PMH Obesity PE Pulses are palpable Sensorium is intact 1st MTPJ has no ROM with forefoot loaded/40° when unloaded 1st MTPJ is painful at the dorsal aspect on palpation Mild crepitus Pain on palpation of the midfoot with mild edema Case # 1 Pathology? Stage? Case # 1 Pathology? 1st MTPJ arthrosis Mild elevatus Pronatory changes Horizontal calcaneal inclination angle NC arthrosis w/ sag Stage? Late stage 3 Treatment options? Case # 1 Treatment options? 1st MTPJ fusion NC fusion Gastroc recession Patient doesn’t want surgery Orthotics Stretching regimen Case # 2 66-year-old female presents for treatment of her right big toe joint pain PMH Prior bunion surgery on the right 2 years ago Podiatrist who performed the original surgery is recommending fusion Here for 2nd opinion PE Pulses are palpable Sensorium is intact 1st MTPJ has no ROM with forefoot loaded/50° when unloaded Joint is painful at the dorsal aspect on palpation No crepitus Case # 2 Pathology? Stage? Case # 2 Pathology? Stage? Functional limitus NC sag 2 Treatment options? Case # 2 Treatment options? Orthotics Next step = Cheilectomy Case # 3 63-year-old female presents for treatment of her left big toe joint pain PMH Smoker – ½ PPD x 20 years – Current smoker Otherwise, unremarkable PE Pulses are palpable Sensorium is intact Left 1st MTPJ has 15° of motion loaded and unloaded Joint is painful throughout ROM w/ crepitus Case # 3 Pathology? Stage? Case # 3 Pathology? Stage? 1st MTPJ arthrosis Structural rigidus 3 Treatment? Case # 3 Case # 3 Questions Copyright Notice This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws.