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Surgery for hallux rigidus

Discussion in 'Foot Surgery' started by NewsBot, Jun 23, 2008.

  1. NewsBot

    NewsBot The Admin that posts the news.


    Members do not see these Ads. Sign Up.
    Evaluation of the treatment of hallux rigidus by percutaneous surgery.
    Mesa-Ramos M, Mesa-Ramos F, Carpintero P.
    Acta Orthop Belg. 2008 Apr;74(2):222-6.
  2. Adrian Misseri

    Adrian Misseri Active Member

    I also found similar results in my thesis, and found statistical significant results. Any suggestions best journal to put a systematic review of the literature lookng at surgical outcomes for surgery on hallux limitus/rigidus?
  3. falconegian

    falconegian Active Member

    What is your experience after 18 months. I think that follow up is too short. After 4 yrs I think that the results would be worse!
  4. Admin2

    Admin2 Administrator Staff Member

  5. drsarbes

    drsarbes Well-Known Member

    I think the term is too broad. Hallux Rigidus takes into account a lot of variables that have a direct effect on treatment choice and prognosis.

    For instance; an otherwise healthy (podiatric) individual with a history of trauma with resultant traumatic arthritis and dorsal spur with limited ROM but without crepitation will do much better with a local debridement then a patient with a biomechanical predisposition to Hallux Rigidus, pain, crepitation and a long and dorsally mobile first ray.

    The second patient will have (at best) short term partial relief and will be back for a fusion or replacement.

    Or a patient with gouty arthritis. A local debridement where a true hallux rigidus exists (no ROM) is not going to have much relief by simply removing a few spurs.

  6. NewsBot

    NewsBot The Admin that posts the news.

    Indications for and methods of hallux rigidus treatment.
    Filip L, Stehlík J, Musil D, Sadovský P.
    Acta Chir Orthop Traumatol Cech. 2008 Jun;75(3):173-9.
  7. NewsBot

    NewsBot The Admin that posts the news.

    First MTP joint arthrodesis for the treatment of hallux rigidus: Results of 29 consecutive cases using the foot health status questionnaire validated measurement tool
    A.J. Maher and S.A. Metcalfe
    The Foot; Volume 18, Issue 3, September 2008, Pages 123-130
  8. NewsBot

    NewsBot The Admin that posts the news.

    Total sesamoidectomy for painful hallux rigidus: a medium-term outcome study.

    Tagoe M, Brown HA, Rees SM.
    Foot Ankle Int. 2009 Jul;30(7):640-6.
  9. NewsBot

    NewsBot The Admin that posts the news.

    Total sesamoidectomy for painful hallux rigidus: a medium-term outcome study.
    Tagoe M, Brown HA, Rees SM.
    Foot Ankle Int. 2009 Jul;30(7):640-6.

  10. drsarbes

    drsarbes Well-Known Member

    So what's next? Removal of the patella for Arthritic knees?

    Perhaps someone more informed than I can explain this study and it's outcome.

  11. Steve:

    From a biomechanical standpoint, it makes sense that by removing the sesamoids you are also removing the dorsal 1st metatarsophalangeal (MPJ) compression forces caused by the plantar fascia, abductor hallucis, flexor hallucis brevis, and adductor hallucis muscles.

    I lectured last year at the Podiatry Institute Seminar in San Diego on "Surgical Biomechanics of Hallux Limitus and Hallux Rigidus". One of the research studies I talked about was a finite element study done in JBJS where they modeled the 1st MPJ and found that the plantar fascia was responsible for most of the compression forces at the dorsal 1st MPJ (Flavin R, Halpin T et al: A finite-element analysis study of the metatarsophalangeal joint of hallux rigidus. JBJS, 90-B:1334-1340, 2008). I would tend to worry about transfer metatarsalgia and any new symptoms that could be caused by the increased pronation of the foot as a result of sesamoid excision. However, it is an interesting idea and considering the results from the 2-4 year followup, maybe it is a better surgical alternative than the Keller bunionectomy?

    Hope your Achilles tendon is mending well. Has your empathy increased for your surgical patients now?:drinks
  12. Ryan McCallum

    Ryan McCallum Active Member

    The lead author is my surgical tutor. We perform the sesamoidectomy quite frequently.
    If you have any specific questions, I'd happily do my best to try and answer them for you.
  13. Ryan:

    How is the hallux purchase post-surgically? Also, are patients pain-free post surgically or do they still experience 1st MPJ pain with ambulation? I would appreciate a pdf copy of the paper to my e-mail, if you could be so kind:
  14. Ryan McCallum

    Ryan McCallum Active Member

    I don't actually have a pdf copy of the article at the minute but I'll try to get one and if I can't, I'll happily post a paper copy to you.

    Generally hallux purchase is good. We try and get our patients mobilising the 1st MTPJ as early as possible and aggressively as possible post operatively. Quite often, when patients are not so compliant with this, the hallux does not purchase the ground or purchase power is reduced but this normally responds well to a manipulation under anaesthesia.
    There has been some criticism that sesamoid removal will lead to hallux malleolus however there were no instances reported in the study and I think I have only seen it once following this procedure. Granted, I do not see all of our follow ups but I am not sure there have been any other cases.

    As for pain post operatively, I have seen patients reporting 100% relief of pain and unfortunately, some worse off (very few thankfully!). The vast majority do well and I suppose this comes down to patient selection. We make it very clear to these patients that this is not a definitive procedure and that at some stage in the future, they will need a more destructive procedure. I think in cases were we have had less than satisfactory outcomes, we have maybe 'pushed the limits' where patients were not keen on joint fusion (even if we have advised them that this is most appropriate) and were too young for joint replacement. I suppose a benefit of this is that removal of the sesamoids does not limit choice where these patients do require further surgery.

    I must say, I have only been working in the unit since this paper was submitted for publication so my experiences are not from those patients reported on in the paper.

    In my limited experience, I think it is an effective procedure but certainly has limitations.

    I hope this helps and if there is anything else, I'll try to answer the best I can.

  15. drsarbes

    drsarbes Well-Known Member

    Hi Ryan:
    Very interesting.

    My question is this: Am I missing something here?

    You are performing a double sesamoidectomy for Hallux Rigidus? With no other procedure?
    In other words...a patient with NO MOTION in the 1st MTPJ with pain on attempted motion, you are merely excising the Tibial and Fibular sesamoids and getting good results?

    I must admit, I have not heard of this.


    Hi Kevin:

    Achilles is healing. 22 days, 2 hours and 29 minutes post op, but who's counting??????

    Empathetic? Very good question.
    I wouldn't say more empathetic but I do have a new appreciation for what some "symptoms" actually feel like.
    It has been enlightening as far as the day to day challenges of being disabled.

    Thanks for asking, I appreciate that.

  16. Steve:

    Having a new appreciation for what some symptoms actually feel like and being enlightened as far as the day to day challenges of being disabled is, by definition, having increased empathy.

    Very glad to hear you are making good progress.:drinks
  17. Ryan McCallum

    Ryan McCallum Active Member

    No; you are not missing anything. I completely agree with you.

    Like I said, I have only joined the team as a trainee after this paper was submitted for publication so I have nothing to do with this paper.

    I am not quite sure how the actual name of this paper was derived, but for hallux rigidus, I have not seen this performed. I see this procedure fit for cases on hallux limitus only.

    We always remove all osteophytes in conjunction with excision of both sesamoids and usually consent patients for a 'sesamoidectomy with joint remodelling'.

    I will check on Monday morning why 'hallux rigidus' was used in the title.

    I'm sorry, I did actually mean to put in my last post that I was not exactly sure why the title eluded to hallux rigidus when we don't (as far as I am aware) perform a sesamoidectomy for hallux rigidus, but rather hallux limitus.
  18. Ryan:

    Thanks for this information. Do the surgeons who do the sesamoidectomis for hallux limitus ever consider doing just a shortening osteotomy of the first metatarsal neck along with a cheilectomy for hallux limitus since this is the most commonly performed procedure for this condition here in the States. I have found shortening osteotomy with cheilectomy to be an excellent procedure for most patients and tends to make them asymptomatic within 4 - 6 weeks following surgery, being able to walk all day without pain. I can understand the biomechanics of the sesamoidectomy, but I would rather not lose the sesamoids since they are important stabilizers of the first MPJ and hallux interphalangeal joint unless it was absolutely necessary.
  19. Ryan McCallum

    Ryan McCallum Active Member

    I am not entirely sure if there are others performing a sesamoidectomy for hallux limitus here in the UK. There are none that I know of. Other members may wish to contribute here??

    A shortening osteotomy of the 1st metatarsal is the procedure of choice in our center in cases where the 1st metatarsal is long. Where it is of 'normal' length or short, we choose the sesamoidectomy. Do you find many cases of transfer metatarsalgia after shortening the 1st metatarsal?

    Something I forgot to include in an earlier post was that the sesamoidectomy is contraindicated in cases of early or mild OA and the motion at the 1st MTPJ is well preserve for the reason you stated, in that the sesamoids are important in stabilising the joint and there is significant risk of hallux malleolus if they are removed. We refrain from performing a true Cheilectomy in conjunction with sesamoid excision but rather try and restore the original joint profile by simply removing osteophytes and I think this at least contributes to maintaining a 'stable' joint. I could be wrong with that assumption.

    I cannot seem to find an electronic copy of the paper so will sort out a paper copy this week and post it across for you.

  20. Griff

    Griff Moderator

    Hi chaps,

    Electronic copy attached for you both


    Attached Files:

  21. drsarbes

    drsarbes Well-Known Member

    Thanks for the clarification.

    IMHO; if you have a hallux "limitus" and a long 1st metatarsal on an active patient under 55 then the debridement (with or without sesamoidectomy) should not be considered a definitive procedure.

    I agree with Kevin that a procedure to focus on the underling biomechanical etiology (in this case a long 1st metatarsal) would have a greater chance of rendering long term relief.

    This is very interesting take on the difficult condition of hallux limitus which we see so frequently. I just have never excised a sesamoid in conjunction with hallux limitus/rigidus procedures unless the sesamoids were so arthritic that the sesamoid/metatarsal joint was arthrodesed. Maybe I should take another look at this.

    I'll read and digest the study you supplied us with. Thank you.

    Side bar:

    EMPATHY: I always (right or wrong) related the word EMPATHY with "feeling" rather than understanding. Like the difference between "feeling" you should do something or "thinking" you should do something.

    Minor point, I agree. But I DO "understand" some situations better - if this fits the definition of EMPATHY then yes, I'm more empathetic. It just sounds "liberal" to me!!!!!!! haha

  22. Ian:

    You da man!!
  23. Steve:

    Who knows, maybe soon you'll be voting Democrat!;):drinks
  24. Ryan:

    I have seen a few cases of sub-2nd metatarsal callouses/pain after 1st metatarsal shortening osteotomies, but generally not. 1st metatarsal shortening osteotomy with cheilectomy for hallux limitus is one of the surgeries I like doing the most since it is very predictable and very successful in relieving the joint pain with minimal risk of other problems. During surgery, before and after I make my initial shortening cuts, I load the 1st metatarsal head plantarly and then see how much resistance to hallux dorsiflexion is noted before and after (I use a horizontal "L" cut, like a Reverdin-Laird bunionectomy). I will occasionally remove slightly more bone from the vertical cuts at the distal metatarsal if the resistance is too high to full dorsiflexion to put more "slack" in the medial band of the plantar fascia. A few of the podiatrists here in Sacramento also take the thin slice of bone from the osteotomy and then put it in the horizontal part of the osteotomy to try and plantarflex the 1st metatarsal also. Both modifications seem to work well.

    Hope this helps.
  25. drsarbes

    drsarbes Well-Known Member

    "Who knows, maybe soon you'll be voting Democrat!"
    Right after I start performing McBride Bunionectomies!!!!!

  26. I don't agree with the notion that the 1st metatarsal shortening osteotomy must be reserved only for those cases where there is a radiographically "long first metatarsal". My goal with this surgery for hallux limitus is to decrease the dorsal 1st MPJ compression force whether the first metatarsal is normal length or long. The shortening osteotomy will effectively reduce the tensile force in the medial band of the central component of the plantar aponeurosis which attaches to the sesamoids which will, in turn, decrease the 1st MPJ dorsal compression force during weightbearing activities. Precise shortening osteotomies of the first metatarsal neck with screw fixation is an excellent surgery with routinely good to excellent results with a minimum of post-surgical sequellae.
  27. drsarbes

    drsarbes Well-Known Member

    If you have a normal met parabola and wish to decompress the 1st MTPJ it's more practical to perform a phalangeal osteotomy.

    I was waiting for a comment on my McBride Bunion quip - I got nothing!!!!!!

  28. Ryan McCallum

    Ryan McCallum Active Member

    I do appreciate the principle behind a phalangeal osteotomy and I know a few of my colleagues work with surgeons who favour the Kessel Bonny to decompress the 1st MTPJ. What I never quite understood or was convinced about was does this procedure actually decompress the joint? I'm hoping I don't get shot down for asking that!

    The reason I ask is that when I have thought bout this procedure, I always imagined that after the osteotomy is performed and is being fixated, I always would have thought that the distal portion would close up against the proximal fragment rather than the other way around? If that was the case, the joint would not be decompressed. I am not sure what I have said makes sense there?

    I kind of assumed that this procedure worked because it resulted in the hallux being effectively dorsiflexed thus allowing a 'rocker effect'. In addition to this, it would maximise the time in which the base of the proximal phalanx would articulate with the remaining articular cartilage of the 1st metatarsal head. I could be way off here! Where I work, we pretty much never do this procedure so I have only actually seen it once so please forgive my ignorance!!

    Thanks Steve and Kevin for this discussion, I am finding it very helpful.

    Last edited: Oct 13, 2009
  29. Lee

    Lee Active Member


    I've performed Kessel Bonney's for hallux limitus and had good results, but (as Steve has said) I've always cautioned patients, as part of the consent process, that it is unlikely to be a definative procedure and is potentially buying time prior to further surgery at a later date (as I would for most joint preserving surgeries of joints with signs of OA). I also agree with you Ryan, the 'decompression' element of the phalangeal osteotomy is probably a myth and most likely puts the hallux into a slightly dorsiflexed position, reducing total time of compression of the dorsal aspects of the joint surfaces for each step taken.

    If you want to see some being performed, feel free to PM me and arrange a visit - there's probably going to be some on the list at some point. I know I've got a few metatarsal osteotomies booked too if you're interested.

    For further info, here's a paper that's worth looking at (I haven't read it recently, but I think I recall the authors conceeding some methodological issues based on poor results from metatarsal osteotomies) -

    Kilmartin TE. Phalangeal osteotomy versus first metatarsal osteotomy for the treatment of hallux rigidus. J Foot Ankle Surgery .2005. 44(1):2-12

    Have a good one,
  30. drsarbes

    drsarbes Well-Known Member

    Hi Ryan:

    I'm glad you brought this up.

    My post was eluding to the fact that if you wish to shorten the ray (the hallux included in that anatomic segment) a phalangeal shortening rather than a metatarsal shortening could be carried out if the patient has a normal metatarsal parabola. It certainly heals quicker and you are not shortening an otherwise normal metatarsal.

    I personally do not perform these anymore (either met or phalangeal) with the thought of decompressing the MTPJ. The simple reason is because my results were not predictable or long lasting. Perhaps it was my patient selection. On the other hand, if merely shortening a metatarsal increased joint ROM then every patient undergoing a metatarsal osteotomy for hallux varus would have wonderful ROM.

    There are so many subcategories of hallux limitus/rigidus I have a hard time with any study that groups them all together.

    One illustration of this is a patient who has a more or less acute onset of pain in an otherwise advanced hallux rigidus (regardless of the cause); one that has been present for decades. This patient will do well with a simple debridement (pain most likely from a fractured osteophyte) in contrast to a younger patient with a less a deteriorated joint on xray, a history of more chronic, insidious pain, even better motion but pain on ROM - this patient needs more than a simple debridement for long term relief.

    If you attempt a shortening osteotomy on the first patient, or an implant, or a fusion, I think you are over treating them. This patient will most likely get good results from anything you do as long as the joint is cleaned or replaced or fused, but, is a fusion or osteotomy or implant the best treatment when they would do just as well with a simple debridement?

    To group these two patients together in a study that cookbook's surgical procedures merely based on a Dx of "hallux rigidus" is, in my opinion, of little value to us out here on the front line.

    What think you?

  31. Ryan McCallum

    Ryan McCallum Active Member

    Hi Steve,
    Thanks for that. What you have written about the two different presentations makes perfect sense. I suppose that variation makes decision making a bit more challenging. (Or maybe that comes with greater experience?)

    Being the trainee in our team, I list the patients for whatever procedures the consultant frequently does (not what I want to see) and I think if I started listing for procedures he doesn't like to do, I'd find myself spending the next month's worth of theatre sessions doing heel pain clinics or something!

    Having said that, as part of my training, I have to visit other centers and will hopefully get an opportunity to see what other surgeons here in the UK do and quiz them as to why. What are your favoured procedures for hallux limitus/rigidus?
    I suppose at the end of the day, choice of procedure will inevitably reflect what you find gives most consistent results.

    cheers for the offer. I have my rotations timetabled for the next 18months and when I have my pod surgery sessions, I'll take you up on that.
    Out of interest, do you favour Kessel Bonny and decompressive osteotomies as your joint preserving procedures? Have you had many instances of transfer pain following shortening of the 1st ray (I am assuming that you meant decompressive osteotomies when you mentioned met procedures?).

    As for the title of the study, I did ask. Apparently the advisory board that reviewed the paper had suggested changing the title to rigidus rather than limitus.

  32. Lee

    Lee Active Member

    Hello Ryan,

    I'm sure we can sort something out - shouldn't be a problem. I generally favour Kessel Bonney's unless the 1st met's long or elevated, in which case it's a 1st met osteotomy. I've previously done procedures as Kevin has described for long 1st metatarsals with no elevatus (including the ?modified Youngswick? to decompress and plantarflex the metatarsal head) and I've had some great results with a plantarflexing (sagittal) scarf for those with elevatus.

    In terms of rates of transfer metatarsalgia, so far (touch wood) the incidence has been minimal post op with the osteotomies - maybe I'm doing well with my pretty strict criteria for met vs phalanx osteotomy, or maybe I've been lucky (most likely). I try not to over-shorten the met and use intra-operative fluoroscopy for all the procedures. We'll see how the long term results go - I'll probably be less optimistic in a few years, but time will tell.

  33. Ryan McCallum

    Ryan McCallum Active Member

    Thanks, Lee.

    I don't actually see that much elevatus to be honest. In fact, I am yet to see a case where this has influenced the choice of procedure (excluding a number of cases where this has been as a result of previous hallux valgus surgery).

    Having said that, I don't know if I am just missing it, not appreciating its importance it or a mixture of both!

    I have always thought of metatarsus elevatus being as a result of the pathology due to platar soft tissue contracture or spasm as rather than as an aetiological factor. For that reason, it never really comes into my mind with surgical planning.
    Would be interested to hear what you or others thought on this.

    This thread has definitely made me think more about what I assumed I had a reasonable understanding of!! Thanks for the input.

  34. Lee

    Lee Active Member

    No worries,

    Hopefully, I haven't given the impression that I'm seeing loads of elevatus and doing loads of plantarflexing osteotomies? They're not all that common (I just seem to be getting a few through the door at the moment - like buses, etc...). You could be right about many cases of elevatus being contributed to by plantar soft tissue contracture.

    Have a good day,
  35. drsarbes

    drsarbes Well-Known Member

    Hi Ryan:

    Next time you have a patient with 1st MTPJ pain but fairly good motion NWB, load the first ray and see what you get. My prediction is that you will see more met/elevatus.

    It's good to hear that you are getting good results with the shortening osteotomies. I soured on the procedures when I was getting patients returning years later (or sooner) with continued and progressive arthritis. Perhaps I was expecting too much.

  36. Lee

    Lee Active Member

    I can appreciate why Steve. I must say that I'm not one for over selling the procedure to the patients - I always give them advice on the fact that they will still have OA in the joint post surgery and that this may progress potentially leading to another surgery (usually after going through conservative care as needed). Patients keep telling me I'm a pessimist - I tell them I'm a realist! :D
  37. drsarbes

    drsarbes Well-Known Member

    Or a real pessimist!

    Either way it's a difficult pathology to treat. Orthopods have no problem doing 3 or 4 knee scopes then a joint replacement then a joint replacement-replacement. Perhaps I just need an attitude adjustment rather than a different surgical procedure.

  38. Thurman

    Thurman Welcome New Poster

    Hi Ryan, I may have a few questions for you!! I've downloaded the PDF that was kindly attached for a bit of bed time reading!! I'll be in touch.

    Im currently looking at MPE / evidence based HR/HL treatment/surgery and ultimately a treatment pathway as a "nice project"

  39. janq

    janq Member

    Have any of you performed shaving of sesamoid instead of sesmoidectomy? What were your results?
  40. admin

    admin Administrator Staff Member

    Prospective Assessment of Dorsal Cheilectomy for Hallux Rigidus Using a Patient-reported Outcome Score.
    Harrison T, Fawzy E, Dinah F, Palmer S.
    J Foot Ankle Surg. 2010 Mar 19. [Epub ahead of print]

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