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Hallux Limitus/Rigidus surgery

Discussion in 'Foot Surgery' started by nelsandr, Nov 20, 2008.

  1. nelsandr

    nelsandr Member


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    I have a patient that is a dancer that I've seen a few times over the past month. She had previously had a diagnosis of hallux limitus six years ago, so this is no surprise to her. She now has hallux rigidus with less than 10 degrees of passive dorsiflexion in NWB. She also has significant dorsal and lateral osteophyte formation on the 1st MTP. Over the past many years she has functionally learned how to not WB on her 1st as it is painful. We've worked on some mobilization to maintain the continuity of her 1st MTP joint play/arthrokinematics, but this has also been fairly uncomfortable for her with the level of degeneration present. I've contacted a Podiatrist for a consult with the idea that it's probably time to start considering an arthroplasty.
    Prior to her visit I wanted to explore the standard of care to date for this including types of procedure, whether hemi or full, risk factors, satisfaction, etc. so that she might have a better resource going into the appointment. Literature, RCT and citations would be appreciated.

    Thanks in advance for any assistance.

    Andrew Nelson, PT
     
  2. Steve The Footman

    Steve The Footman Active Member

    If there is only 10 degrees of ROM then you might as well say there is 0 degrees. There is a margin of error in the measurement and functionally it makes little difference if it was 10 degrees or 0 degrees but there would be no pain anymore if the joint was totally fused. I think mobilisation is contraindicated in Hallux rigidus as it will be unlikely to be able to get the function back to any significant extent but will cause pain and possibly furthar damage to the joint. If the osteophytes and lipping are the only thing reducing the range of motion and the main joint surfaces are still intact then a Chilectomy might be able to get function back to some degree. I would be surprised if an arthroplasty would get the function back to an extent that she could dance professionally. Most likely just normal activities of daily living without pain.

    Need some of the surgeons to reply with a bit more experience and understanding of the outcomes.
     
  3. a.mcmillan

    a.mcmillan Guest

    Hi Andrew,

    While I cannot offer any clinical advice (4th yr student), I have the following information:

    Maybe intra-articular viscosupplementation could prolong her dancing career? Whether this could be done in addition to chilectomy of the dorso-lateral osteophytes (as suggested by Steve the Footman) I don't know...



    A RCT investigating the efficacy of intra-articular hyaluronan was registered with the Australian New Zealand Clinical Trials Registry in December last year. This trial is being undertaken at La Trobe University, Australia.



    Hope this is of some interest/relevance,

    Andrew
     
  4. Nat

    Nat Active Member

    I've been doing joint resurfacing with the Arthosurface HemiCAP a bit lately. So far my patients love the results. You may want to find someone locally who has experience installing these implants who can advise your patient and see if she's a candidate.

    http://www.arthrosurface.com/index.php/content/view/112/76/

    Oddly enough, most of my referrals for this implant have been from local Physical Therapists, who have been first to recognize hallux limitus in their patients who presented to them with more proximal musculoskeletal complaints.

    Nat
     
  5. drsarbes

    drsarbes Well-Known Member

    Hi Andrew:
    What is your patient's age and health status?
    When you say she is a dancer, is that her profession?
    What kind of dancing?
    Any other arthritic joints?

    Most procedures depend on the answers to the above in addition to radiographic findings.
    Indications and procedure choice are made by the surgeon.

    If you have done all you can do for this patient it's time to refer her out. With all due respect, and please do not take this the wrong way, but the choice of surgical procedure is not yours to make.

    Steve
     
  6. Andrew:

    Once all conservative measures have been exhausted, then surgical consultation is warranted. In general, if the joint still has some good cartilage, the first metatarsal isn't already short with a sub-2nd metatarsal tyloma/intractable plantar keratosis, then some form of shortening osteotomy of the first metatarsal with a cheilectomy works very well for most patients. In effect, this procedure reduces the intra-articular compression force within the 1st metatarsophalangeal joint (MPJ) due to a reduction in the tensile loading force specifically within the medial slip of the central component of the plantar aponeurosis that inserts onto the sesamoids and base of the proximal phalanx of the hallux. A recently published paper on a finite element model of the 1st MPJ showed that changing the stiffness of the plantar fascia was very important in the production of hallux limitus/rigidus deformity (Flavin R, Halpin T et al: A finite-element analysis study of the metatarsophalangeal joint of hallux rigidus. JBJS, 90-B:1334-1340, 2008).

    If the joint is pretty much destroyed, with very little articular cartilage surviving (i.e. bone on bone), then you are left with the choices of either an implant arthroplasty procedure, a joint destructive procedure (i.e. Keller procedure) or a 1st MPJ arthrodesis procedure. In general, the more active the patient, the more I will tend to go to a 1st MPJ arthrodesis procedure since patients can run, dance and play sports quite well with this procedure. However, I know that many podiatric surgeons aren't as fond of 1st MPJ arthrodesis procedures and prefer, instead, hemi or total joint implant arthroplasty procedures, since these procedures preserve range of motion of the joint. Most podiatric surgeons reserve Keller procedures only for end-stage hallux rigidus in patients that would not be good surgical candidates for a 1st MPJ implant arthroplasty or a 1st MPJ arthrodesis.

    Hope this helps.
     
  7. Adrian Misseri

    Adrian Misseri Active Member

    G'Day Andrew,

    I did a systematic review and meta analysis of all non-interpositional arthroplasty procedures and arthrodesis procedures for hallux limitus (unpublish so far due to me lazyness...) and found that overall, good results in terms of cosmesis, pain function and patient satisfaction for all procedures for hallux limitus/rigidus. Of those, the chilectomy seems to be the procedure of choice, as the recovery time is better, it ambulates fairly early, is cosmetic, and not as joint destructive as something like a Keller's arthroplasty. It also advoids complication such as an aquired shourt 1st met/hallux, hallux varus etc. There is also a new interpositinal device on the market which is seeming to be quite good. It's a hemi-artcicular titanium implant called the Biopro, and being metal, it wont degenerate the way a silastic implant will. Of course the suitability will depend on a variety of factiors, including the articular surface on the metatarsal head. As a dancer, she would probably be very much after the arthroplasty option rather than arthrodesis as 1st ray function is paramount in dance. If you include your email I can email you the paper if you'd like?

    Good Luck!
     
  8. drsarbes

    drsarbes Well-Known Member

    "Of those, the chilectomy seems to be the procedure of choice, as the recovery time is better, it ambulates fairly early, is cosmetic, and not as joint destructive as something like a Keller's arthroplasty."

    Hi Adrian:
    I'd like to comment on your last post;
    A ceilectomy is, by definition, less invasive, however, it is normally saved for mild cases with fairly good articular surfaces, painful osteophytes and for younger patients.

    The indications for a ceilectomy, Keller or replacement are different. These procedures should not be viewed as "interchangable" - If you perform a ceilectomy on a joint that needs a replacement you will have a poor outcome.

    Also, since most hallux limitus' are progressive and simple ceilectomies do nothing to prevent further destruction, these are rarely a definitive procedure.

    Kellers resectional arthroplasties, as Dr. Kirby pointed out, are done for hallux rigidus (or at times hallux valgus) on patients where an implant or fusion is contraindicated.

    I think "pooling" all of these procedures together in an outcome study is based on the assumption that
    there is a commonality of the original patholgy and gives the impression that a choice can be made between them.
    I disagree with this.

    Steve
     
  9. Adrian Misseri

    Adrian Misseri Active Member

    G'day Steve,

    Certainly these are different procedures for different indications, no argument there. I was just suggesting that on the limited amount of evidence we have, this seems to be the pattern of results. unfortunately in surgical fields, we have little good quality primary evidence, and even less good quality secondary evidence to suggets on procedure over another. The common throead though was that the joints got better. Unfortunately, sugery is something that is very difficult to do good quality researchon due to the constraits against blinding, placebo, randomisation, control of bias etc. At the end of the day, surgery can be more art than science, and it is the skill, knowledge and experience of the 'artist' in having the best educated attempt at knowing which procedure for which patient for which realistic outcome.
    All respect to the artist!
     
  10. drsarbes

    drsarbes Well-Known Member

    Hi Adrian:
    I agree. Certainly the outcomes of surgery are affected by intangibles that are difficult to measure.
    Experience and skill certainly are factors, but also I would suggest procedure selection, patient compliance, individual healing differences and postoperative care are all factors.

    My point to your original post was that I think it unfair to try to compare the outcomes of Keller arthroplasties, Ceilectomy and hemi or total implants since the indications for surgery vary for these procedures. Naturally the outcomes will be varied. I would relate this to comparing the outcomes of a knee scope for debridement/menisectomy to a total knee replacement.

    Thanks

    Steve
     
  11. Dr. DSW

    Dr. DSW Active Member

    The most important factor in choosing the procedure that is best indicated for this patient is based on the etiology of her hallux limitus/rigidus, and I don't believe that's really been mentioned.

    Dr. Kirby certainly discussed the general importance and differences of the various procedures, but in this particular case it's really a moot point to discuss a cheilectomy vs. a joint implant vs. an arthrodesis vs. a decompression osteotomy without truly knowing the etiology of the condition in THIS particular patient. And with all these cases, the final decision really can not be made until the joint is inspected intra-operatively.

    I don't know of any surgeon that is going to perform a joint destructive procedure such as a Keller, joint implant or arthrodesis if the joint is inspected and found to be healthy in appearance. At that time, it's time to step back, "clean up" the joint and perform a decompression osteotomy to allow the healthy joint to function properly.

    So, as per Dr. Arbes, it's time to refer this patient to the proper professional so she can have a thorough examination and have a surgical procedure that is based on the etiology of her condition, and not just her symptoms.
     
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