hallux rigidus-daniel greenan
DESCRIPTION
ComprehensiveTRANSCRIPT
Daniel E. Greenan, DPM, FACFAS
HALLUX RIGIDUS Decreased/absent 1st MPJ ROM Normal gait requires 65 to 75 degrees of dorsiflexion at
the 1st MPJ A progressive disorder characterized by decreased ROM and degenerative alteration of the 1st MPJ Secondary to faulty biomechanics or structural pathology
HALLUX RIGIDUS 2nd most common painful affliction of the great toe
joint Affects up to 10% of adults Most commonly seen unilateral May be secondary to osteochondritis dessicans in the adolescent patient
Etiology This is the nuts and bolts of Hallux Rigidus Most can diagnose Hallux Rigidus, but true
understanding is properly identifying the cause and offering appropriate treatment options Being able to do so will show the examiner that you have mastery of the condition
Etiology of Hallux Rigidus Long 1st metatarsal (structural) Hypermobile 1st ray (functional). Faulty biomechanics
can lead to hypermobility Immobility of 1st ray 1st ray elevatus Trauma Arthritis
Physical Exam subtleties End range of 1st MPJ dorsiflexion is usually abrupt Look for interphalangeal joint hyperextension Less pain with ankylosis
Plantar hallux hyperkeratosis Transfer metatarsalgia
Classification Systems of Hallux Rigidus Regnauld Hanft Roukis/Jacobs
Drago Kravitz
General Staging of Hallux Rigidus: Stage I: Limited motion with weightbearing, mild
pain, no DJD, functional hallux limitus Stage II: Limited motion, pain at end ROM, early DJD, flattening of 1st metatarsal head, small osteophytosis, subchondral eburnation Stage III: Limited motion, pain with ROM, DJD, subchondral cyst formation, asymmetric joint space narrowing, osteophytosis, crepitus Stage IV: Ankylosis ACFAS Clinical Practice Guideline
Conservative Options for Hallux Rigidus Orthoses : Mortons Extension, 1st ray cut out Shoe modifications or shoe quality: metatarsal bar,
rocker bottom sole, stiff sole Graphite plate Injection therapy NSAIDS
Surgical Options (joint specific/joint preserving) Cheilectomy Osteotomies Arthrodiastasis
Arthroscopy OATS
Surgical Options (joint specific/joint destructive) Arthroplasty Implant Arthrodesis
Comparison of Arthrodesis, Implant and resectional arthroplasty Similar long-term (average 3 years) patient satisfaction
scores for treatment of end stage Hallux Rigidus.
Procedure selection did not appear to be related to age All hemi-implants were placed in the base of the proximal
phalanx
Kim PJ, Hatch D, DiDomenico LA, Lee MS, Kaczander B, Count G,
Kravette M. A Multicenter Retrospective Review of Outcomes for Arthrodesis, Hemi-Metallic Joint Implant and Resectional Arthroplasty in the Surgical Treatment of End-Stage Hallux Rigidus. J Foot Ankle Surg. 2012; 51: 50-56
Surgical Options (global considerations) Ankle joint ROM? Mobility of 1st Ray?
Gastrocnemius?Hypermobility?
Do you need to consider other surgical procedures to
address any faulty biomechanics? Gastrocnemius recession or Lapidus Arthrodesis?
Surgical Considerations Age of patient and longevity of procedure Activity level of patient Etiology of Hallux Rigidus
Degree of joint degeneration Biomechanical findings Patient expectations Surgeon experience
Daniel E. Greenan, DPM Slide #15 in your syllabus
Objectives of Talk Present possible, realistic case scenarios involving
Hallux Rigidus that may be similar to those encountered in the oral portion of the ABPS Certification Exam To reinforce to you that all oral questions may be approached in a similar manner The key to success is being comfortable with the workup
Hallux Rigidus Should be a familiar topic to all of us There are many ways to address this problem, which makes
for a great exam question Be confident in your approach Difficult to find a consensus: (AGE AND ETIOLOGY) Remember that an exam question usually involves several
topics
While studying for Hallux Rigidus: Think big picture Is it functional or structural? What are the potential complications?
What is plan B if the initial treatment/procedure does
not work?
Grade I Hallux Rigidus Functional limitation of motion
Grade II Hallux Rigidus Joint adaptation
Grade III Hallux Rigidus Joint space narrowing, subchondral cysts and osteophytosis
Grade IV Hallux Rigidus Ankylosis of Joint
The History Card Flip it over and read it out loud All information present and not present is key Have your system in place and stay consistent
Exam Approach Read yellow card out loud Ask for any details in history that were not covered
(nature of pain, location, onset, duration, etc.) Ask for PMH, PSH, Medications, Allergies Ask for Family History, Social History, ROS Ask for Vitals if not given Physical Exam: ask in general terms, but may be steered to problem focused
Exam Approach Labs Xrays/Imaging
Stay consistent even though the examiner will
often move you along
Oral Exam Question # 1 A 42 year old, otherwise healthy female presents
complaining of pain in her great toe for approximately one year. She denies any acute trauma, but relates it started after she began running for exercise. She denies any previous treatment.
Oral Exam Question #1A 42 year old, otherwise healthy, female presents complaining of pain in her great toe for approximately one year. She denies any trauma, but relates that it started after she began running for exercise. She denies any previous treatment.
Where do we go from here? We are told she is healthy
Oral Exam Question #1 Any other pertinent findings in the history? Non
contributory Any medications? None Any allergies? NKDA Family/Social History? History of CAD, type 2 diabetes. Patient denies ETOH, tobacco or other drug use. Single, lives alone ROS? Non-contributory
Oral Exam Question #1 Still have got to ask. Get the points for being
thorough. The examiner will move you along if there are not any other points to obtain Being consistent with your approach will ensure that you are not missing any chances at potential points Being consistent with your approach will also keep your management of the question focused and reproducible
Oral Exam Question #1: PHYSICAL EXAM FINDINGS Integument is intact. Pedal pulses are +2/4 bilateral Intact neurological sensation. Achilles tendon and patellar
tendon reflexes are +2/4 bilateral right foot
Pain with palpation of the dorsal 1st metatarsal-phalangeal joint Pain at end range of dorsiflexion of 1st MPJ No crepitus
Oral Exam Question #1: Physical Exam Findings 1st ray range of motion is WNL Ankle joint dorsiflexion is decreased with the knee
extended and subtalar joint in neutral bilaterally Patient exhibits +5/5 strength 15 degrees of 1st MPJ dorsiflexion with the 1st ray loaded and 35 degrees of 1st MPJ dorsiflexion with the 1st ray unloaded This may be given to you or you may need to walk
through it
Oral Exam Question #1: WHAT IS NEXT? Ask what the foot looks like.. You may be handed a Photo or given a description
Foot appears to have a global Metatarsus
adductus alignment
Oral Exam Question #1: What is Next? Xrays Have a systematic, reproducible approach to reading
films
Oral Exam Question #1
Ask for foot and ankle films
XRAY Exam 1st ray elevatus, no plantar gaping of 1st met-cuneiform joint, small osteophyte
What else may be needed? Labs? Joint Fluid analysis? Other imaging?
Examiner will either give it to you or say non-
contributory or not available
Consider what you know 42 year old healthy female Painful 1st MPJ Decreased ROM of 1st MPJ
Gastrocnemius equinus Imaging findings First Ray? We were told ROM of 1st Ray was normal,
but what else needs to be considered?
DIAGNOSIS
Hallux RigidusMay or may not need to stage..
Treatment Consider patient compliance, age, expectations,
biomechanical findings, xrays (joint integrity, 1st metatarsal length)
Dont Forget Conservative Care Even though this is a surgical board question be
prepared to give conservative care options Ask if conservative care has been exhausted If they move you along, go to your surgical options
Surgical Treatment Be prepared to mention several options and explain
rational. This may be an area of concentration for obtaining points in the exam. Try not to get discouraged if your choice is not the one
shown There are points to be had for knowing surgical
options
Surgical Treatment Options They may ask you: What should be done and why? They may ask you: What was done and why?
My Choice: Decompressional 1st Metatarsal Osteotomy and Gastrocnemius Recession How would you do it? How would you fixate the
osteotomy? Why would you choose this option? What is your post operative care?
Rational Joint is well preserved 1st metatarsal is long and elevated Hypermobility is not appreciated clinically or
radiographically Gastrocnemius equinus
Post-operative Care 2-3 weeks NWB in splint followed by 2-3 weeks of
protected WB in a boot or surgical shoe No consensus is given for combination of procedures
In this caseA decompressional osteotomy and a gastrocnemius recession was performed
The Critique You may be asked to evaluate the post-operative xrays Or at this point things may take a turn.
Things May Take a Turn. Nonunion Infection/osteomyelits Dehissence
DVT Fixation failure Metatarsalgia/overload Know how to handle these complications
The examiner tells you: First three months of post operative period were
uneventful At four months, patient presents complaining of increasing forefoot pain She denies any injury She is not wearing orthoses She is unable to return to exercise type activities
Why does she have forefoot pain? Perform post operative physical to determine location
and cause of pain Remember to treat as you would in your office Review post-operative xrays and obtain new films
Examiner Tells You: Pain is located sub 2nd metatarsal head 1st MPJ ROM is supple and WNL 2nd digit is contracted now and partially reducible What else do we need to know? Stability of 2nd MPJ.
Does the toe purchase the ground? Is there increased dorsal excursion of the digit? Examiner tells you that the 2nd toe purchases the ground and increased dorsal excursion is not appreciated
Why Does She Have Pain? Because the 1st metatarsal was excessively
shortened
Post Operative Xrays1st ray was long, sesamoids are anatomic, joint appears decompressed
What would you do doctor? What are conservative options? Be
specific(functional orthoses with metatarsal pad, 2nd metatarsal head cutout) Well, that didnt provided the patient any relief Do you have a surgical remedy?
A 2nd Metatarsal Osteotomy and PIPJ Arthrodesis
Would You Consider a Plantar Plate Repair? Not in this case, because the digit was clinically stable
What could be done to verify that there was not a
tear in the capsule? An arthrogram or MRI.
Periarticular Osteotomies of 1st Metatarsal for Hallux Rigidus 22.6% underwent surgical revision
Roukis T, Clinical Outcomes after Isolated Periarticular
Osteotomies of the First Metatarsal for Hallux Rigidus: A Systemic Review. J Foot Ankle Surg. 2010; 49(6): 553-560
Oral Exam Question #2 A 39 year old male presents complaining of increasing
pain in his right big toe since having surgery last year by another doctor in town. He relates that it only started to hurt after the surgery. He relates that some bone spurs were removed from the joint.
Oral Exam Question # 2 PMH: HTN PSH: Foot Surgery Medications: Lisinopril
NKDA Social History: Smoker Family History: HTN please proceed to your physical Exam
Oral Exam Question #2 Integument? Unremarkable Neurovascular? Intact Orthopedic? Be specific
Oral Exam Question 2 Nature and location of pain? Deep aching type
pain with ROM of 1st MPJ and with palpation of joint Any Crepitus? Mild ROM of 1st MPJ? Decreased Ankle Joint ROM? Within normal limits Any other pertinent physical findings? No, please proceed
Oral Exam Question 2 May I see the xrays of the foot? These are the only two available. Please
evaluate
AP Xrayloss of joint space, normal metatarsal parabola, subchondral sclerosis and cyst formation
Lateral Xray1st ray elevatus, appears as though dorsal spur has been removed
What is Your Treatment Plan? An Orthotic device with a Mortons Extension or a
rocker bottom shoe He is wearing orthotics Please Proceed
Surgical Options Keller? Resect base of PP with interposed capsule Valenti? Resect base PP, Head First met Cheilectomy?Surrounding spur
Osteotomy? Arthrodiastasis? Implant? Arthrodesis?
Please Offer a Surgical Treatment Plan for the Patient. Base upon age, etiology, clinical, radiograghic and
intra-operative findings Prior surgical intervention had been tried
You are told. Intra-operatively, you find that 50% of the dorsal 1st
metatarsal cartilage is denuded or eroded
An Arthrodesis was Done
Please Explain the Surgical Technique Dorsal medial incision Curettage of Joint because of congruency and length Two point fixation How else could you have prepped the joint? What other procedures could be considered?
How Would You Position the Hallux? Traditional = 10 to 15 degrees dorsiflexed to floor and
15-25 degrees of abduction (parallel to 2nd digit) Position of Function = On the ground
Hallux is meant to bear weight and off load the metatarsals..
What is Your Post Operative Protocol WB vs. NWB Dayton, A., McCall, A. 100% radiographic fusion rate
at 6 weeks with immediate weightbearing, JFAS, 2004 DeDomenico, protected partial weightbearing in cast
boot x 1-2 weeks followed by full weightbearing in a walker shoe or boot x 2-3 weeks then progressing to a shoe
Be Ready for the Complication Nonunion rate for arthrodesis of 1st MPJ is 2-13% Hemi-implant arthroplasty has an osseous overgrowth
rate of 28.8% and lucency about the implant rate of 19.2% Resectional arthroplasty shows a floating hallux in
30.9% of cases and lesser metatarsalgia in 14.5% of cases
Fusion Rates of 1st MPJ Arthrodesis Single screw fixation = 71% Crossed Screw fixation = 90% Dorsal plate fixation = 100% Dorsal plate and plantar screw = 93% Dening J, Arthrodesis of the First Metatarsophalangeal Joint: A
Retrospective Analysis of Plate versus Screw Fixation. J Foot Ankle Surg 51: 172-175, 2012
Nonunion of
st 1
MPJ
Please Evaluate the XrayOrientation of distal screw is quite shallow, joint space gapping, radiolucency around screw threads