BIOMECHANICS OF HALLUX RIGIDUS

Transcription

BIOMECHANICS OF HALLUX RIGIDUS:
Myths and Misconceptions
Douglas H. Richie, Jr., D.P.M.
Clinical Associate Professor,
Department of Applied Biomechanics,
California School of Podiatric Medicine
Seal Beach Podiatry Group Inc
drichiejr@aol.com
Hallux Limitus and Hallux Rigidus:
Exploring the Myths and Misconceptions
Douglas H. Richie, Jr. D.P.M.
Seal Beach, California
DRichieJr@aol.com
Associate Professor of Podiatric Medicine,
Western University of Health Sciences
Adjunct Associate Professor of Clinical Biomechanics,
California School of Podiatric Medicine, Oakland CA
Douglas H. Richie, Jr. D.P.M.
Seal Beach, California
DRichieJr@aol.com
Doug Richie D.P.M.
gratefully acknowledges the
support and friendship of
Paris Orthotics
Associate Professor of Podiatric Medicine,
Western University of Health Sciences
Adjunct Associate Professor of Clinical Biomechanics,
California School of Podiatric Medicine, Oakland CA
For lecture notes:
www.richiebrace.com
www.RichieBrace.com
LIMITATION OF RANGE OF MOTION OF THE 1ST MTPJ
Hallux Flexus : Davies-Colley (1887)
Hallux Rigidus: Cotterill (1887)
Hallux limitus: Hiss (1931)
Functional Hallux Limitus: Laird (1972)
MYTHS AND MISCONCEPTIONS
ABOUT HALLUX RIGIDUS
Normal range of motion of the 1st MTPJ
Question #1
1. A minimum of 60 degrees of dorsiflexion of the
hallux on the 1st Met is required for normal gait
(True or False?)
Reports of clinical measurements
of ROM of 1st MTP:
65-110 Degrees Dorsiflexion
(Buell, Hopson, Joseph, Mann, Shereff)
Reports of ROM during gait:
50-90 degrees Dorsiflexion
(Buell, Hopson, Johnson, Milne, Sammarco)
Clinical assessment of ROM of the 1st MTPJ
“Relationship Between Clinical Measurements and Motion of the First
Metatarsophalangeal Joint During Gait” Nawoczenski et al. JBJS 81-A,
pp 370-376, March, 1999.
Electromagnetic tracking to determine 3-D motion of the
hallux relative to the 1st Metatarsal
33 subjects
Four Clinical Tests for ROM of 1st MPJ
compared to actual ROM of 1st MPJ
during gait
Clinical Tests
Active ROM-weight bearing
Passive ROM- weight bearing
Passive ROM-non weight bearing
Heel Rise test
Results
Walking ROM dorsiflexion:
42 degrees
Heel Rise ROM dorsiflexion:
58 degrees
Passive ROM non-wt bear:
57 degrees
Passive ROM dorsiflexion:
37 degrees
Active ROM dorsiflexion wt.bear:
* 44 degrees
“Measurement of the active range of
motion with the subject weight bearing
may be a more appropriate choice for a
clinical test because the mean value for
dorsiflexion more closely matched that
during gait.”
“Relationship Between Clinical Measurements and Motion of the First
Metatarsophalangeal Joint During Gait”
Nawoczenski et al. JBJS 81-A, pp 370-376, March, 1999.
Biomechanics of Hallux Rigidus
Key Point #1:
Patients do not use all of the range of motion available in their
pedal joints during gait. Measuring total range of motion of
the 1st MTP does not predict how much motion the patient
actually needs or uses during gait.
Research Method
Subject criteria:
o
6 people
o 2 males
o 4 females
o 12 feet
o No foot pain or any limited motion at the first
mtpj
o Treadmill running and walking
Preliminary Results - Walking
SUBJECT
MAX
MIN
DIFFERENCE
EP-R
176.54
153.11
23.43
EP-L
166.78
140.03
26.75
MA-R
174.18
147.45
26.73
MA-L
176.67
138.46
38.21
JJ-R
175.99
140.73
35.26
JJ-L
179.44
134.35
45.09
JL-R
176.72
149.19
27.53
JL-L
162.42
132.46
29.96
TS-R
169.89
137.69
32.2
TS-L
167.56
121.11
46.45
ZY-R
175.3
134.11
41.19
ZY-L
176.72
136.69
40.03
AVERAGE
34.4025
Preliminary Results - Running
SUBJECT
MAX
MIN
DIFFERENCE
EP-R
170.45
156.87
13.58
EP-L
174.15
143.28
30.87
MA-R
174.86
147.6
27.26
MA-L
175.75
149.07
26.68
JJ-R
172.52
152.94
19.58
JJ-L
175.38
144.83
30.55
JL-R
177.22
155.48
21.74
JL-L
174.85
151.16
23.69
TS-R
172.86
140.83
32.03
TS-L
168.02
138.5
29.52
ZY-R
171.75
136.63
35.12
ZY-L
173.08
141.49
31.59
AVERAGE
26.8508
Statistical Significance
o Standard Deviation
o Walking = 7.7575
o Running = 6.1785
o Ttest p-value = 0.002358
Walking
Running
When running , compared to walking:
- the ankle flexors (Triceps, FDL, FHL) fire earlier
-ground reaction forces in FF peak earlier
-Early, greater contraction of FHL limits dorsiflexion of the
1st MTP
When running the Flexor Digitorum Longus and the
Flexor hallucis longus fire earlier and resist
DORSIFLXION of the digits to a greater degree than
during walking.
The flexor hallucis longus can be a natural
splint to resist dorsiflexion of the 1st MTP.
Hallux Rigidus: Role of Soft Tissue Constraints
-plantar aponeurosis
-flexor hallucis longus
Sectioning of the plantar fascia results in an increased
dorsiflexion of the 1st MTP by 9.8 degrees.
Harton FM, Weiskopf SA, Goecker RM. Sectioning the plantar fascia. Effect on first
metatarsophalangeal joint motion. J Am Podiatr Med Assoc 2002;92:532-6.
Key Point #4:
Dorsiflexion of the 1st MTP is restricted by tension in the
soft tissues around the joint: Plantar aponeurosis, FHL
tendon, FHB and other sesamoid anchors. Procedures
which improve hallux rigidus do so by decompressing the
joint, which relaxes tension on these structures.
Classification of Grades of Disease of Hallux Rigidus
Role of Metatarsus Primus Elevatus
First Ray Hypermobility
The term “hypermobility” was
first used to describe the
mechanical function of the
first ray in 1935 by Dudley J.
Morton, Professor of
Anatomy, Columbia
University, in his classic
treatise, “The Human Foot”,
on the evolution, physiology,
and functional disorders of
the foot
Root et al Extensively Discussed First Ray
Hypermobility in 1977
“Hypermobility is any motion occurring at
a joint in response to forces which are
interacting at a joint at a time when the
joint should be stable under such forces”
“Hypermobility of the first ray is a state of
abnormal 1st ray instability that occurs
while the forefoot is bearing weight”
How do we measure
“hypermobility” of the First Ray?
Measuring “First Ray Mobility”
Examiner may use an estimated amount of
manual force on first metatarsal head to
measure “first ray mobility”
Root ML, Orien WP, Weed JH, RJ Hughes: Biomechanical Examination of the Foot,
Volume 1. Clinical Biomechanics Corporation, Los Angeles, 1971.
2 mm
Plane of
left thumbnail
Plane of
right thumbnail
Position of Ankle Can Affect First Ray Mobility
Plantarflex: Increase mobility
Dorsiflex: Decrease mobility
Grebing, BR; Coughlin, MJ: The effect of ankle position on the exam
for first ray mobility. Foot Ankle Int. 25:467– 475.
Devices which measure First Ray ROM
Glasoe, WM; Grebing, BR; Beck, S; Coughlin, MJ; Saltzman, CL: A comparison
of device measures of dorsal first ray mobility. Foot Ankle Int. 26:957– 961.
Kim, JY; Keun Hwang, S; Tai Lee, K;Won Young, K; Seon Jung, J: A simpler
device for measuring the mobility of the first ray of the foot. Foot Ankle Int.
29:213 – 218.
Klaue, K; Hansen, ST; Masquelet, AC: Clinical, quantitative assessment of first
tarsometatarsal mobility in the sagittal plane and its relation to hallux valgus
deformity. Foot Ankle Int. 15:9– 13.
Glasoe and coworkers have done considerable research on
developing a special apparatus that applies a precise amount of
loading force on the first metatarsal head to determine the
amount of “first ray mobility”
Glasoe WM, Yack HJ, Saltzman CL: The reliability and validity of a first ray measurement device. Foot
Ankle Int. 21:240-246, 2000.
Glasoe WM, Allen MK, Saltzman CL, et al: Comparison of two methods used to assess first ray
mobility. Foot Ankle Int. 23:248-252, 2002.
Glasoe WM, Allen MK, Ludewig PM, Saltzman CL: Dorsal mobility and first ray stiffness in patients
with diabetes mellitus. Foot Ankle Int. 25:550-555, 2004.
Pronation of the subtalar joint does not appear to be
linked to “hypermobility” of the 1st ray, or to reduced
range of motion of the 1st MTP.
Hypermobile First Ray?
82 Asyx Adults
Dorsiflexion ROM of 1st Ray measured
with “mobility device” as described By
Glassoe et al.
3 subgroups defined: hypomobile,
normal and hypermobile
Plantar pressures and hindfoot
kinematics measured during walking
Cornwall MW, McPoil TG, Fishco WD, et al: The influence of first ray mobility on forefoot
plantar pressure and hindfoot kinematics during walking. Foot and Ankle Int27:539-547, 2006.
RESULTS
“Based on the findings of this study, it appears that a
person with a hypomobile first ray does not demonstrate
increased plantar pressure or force under the first
metatarsal head or diminished hindfoot eversion during
walking. Conversely, the foot with a hypermobile first
ray does not show increased pressure and force under
the second metatarsal head along with increased
hindfoot eversion during walking.”
“Hypomobile” First Ray had significantly more hindfoot
eversion compared to the “normals” and “hypermobile”
first rays
Cornwall MW, McPoil TG, Fishco WD, et al: The influence of first ray mobility on forefoot
plantar pressure and hindfoot kinematics during walking. Foot and Ankle Int27:539-547, 2006.
Is Metatarsus Primus Elevatus equivalent
to Hypermobility of the First Ray?
Coughlin MJ, Shurnas PS: Hallux Rigidus: Demographics, Etiology, and Radiographic
Assessment. Foot & Ankle International/Vol. 24, No. 10/October 2003, pp 731-743.
Hallux rigidus was NOT associated with:
MPE First ray hypermobility
Increased first metatarsal length
Achilles or gastrocnemius tendon tightness
Abnormal foot posture
Hallux rigidus WAS associated with:
hallux valgus interphalangeus
female gender
and a positive family history in bilateral cases.
In most cases the problem was bilateral, the exceptions
being when there was trauma involved. If trauma had
occurred, then the problem was unilateral.
Mechanical Restriction of ROM of the 1st MTPJ
Elevate First Metatarsal 4mm dorsal:
Decrease ROM 19%
Elevate First Metatarsal 8mm dorsal:
Decrease ROM 35%
Roukis TS, Scherer PR, Anderson CF: Position of the first ray and motion of the
first metatarsophalangeal joint. JAPMA 86: 538, 1996
“The present study determined that a statistical
difference exists for each of the radiographic measurements
performed n the halux valgus, plantar fasciitis, and Morton’s
neuroma patient populations compared with the hallux
rigidus populations.”
“Despite these findings, the role that distal first
metatarsal plantar-displacement osteotomy plays in the
surgical management of hallux rigidus is questioned based
on several studies that have failed to show any reduction in
the metatarsus primus elevatus or hallux equinus angles
postoperatively and the positive subjective and objective
findings obtained after other simpler procedures.”
Roukis TS: Metatarsus primus elevatus in hallux rigidus: Fact or
fiction? JAPMA 95: 221, 2005
Horton, G; Park, Y; Myerson, M: Role of metatarsus primus elevatus in the
pathogenesis of hallux rigidus. Foot Ankle Int. 20:777 –780, 1999.
“There did not seem to be any direct or linear relation between the amount of elevation of the first ray
and the grade of hallux rigidus. It seems more likely that elevation of the first metatarsal in patients
with advanced hallux rigidus is a secondary phenomenon rather than a primary cause. This is
evidenced by the fact that patients with grade I or grade I1 hallux rigidus had a mean elevation of 7.3
and 7.4 mm, respectively, whereas those with advanced hallux rigidus had a mean elevation of 9.2 mm.”
Coughlin MJ, Shurnas PS: Hallux Rigidus: Demographics, Etiology, and Radiographic Assessment. Foot
& Ankle International/Vol. 24, No. 10/October 2003, pp 731-743.
“Based on the results of this
study, there were 10 cases of up
to 10 mm of MPE identified.
However, it appeared that MPE
was a secondary change as there
was a correlation with advancing
grade of hallux rigidus. We
believe that elevatus is a
secondary change resulting from
an arthritic MTP joint and that
the first ray elevation associated
with radiographically advanced
hallux rigidus is analogous to
metatarsus primus varus in
hallux valgus; as the bunion
deformity progresses so does the
1–2 intermetatarsal angle, and
similarly as hallux rigidus
progresses so does the first ray
elevation.”
“However, treating elevatus with osteotomies appears to
treat a secondary rather than a primary problem, and these
osteotomies have been associated with difficult salvage
procedures when they fail.”
STUDIES SHOW NO IMPROVEMENT OF
METATARSUS PRIMUS ELEVATUS OR HALLUX
EQUINUS MEASUREMENTS AFTER DISTAL FIRST
METATARSAL HEAD OSTEOTOMIES
Laakmann G, Green RM, Green DR: “The modified Waterman procedure: A
preliminary Retrospective Study” in Reconstructive Surgery of the Foot and
Leg: Update ’95, ed by CA Camasta, p 128, The Podiatry Institute, Tucker, BA,
1995.
Dickerson JB, Green R, Gren DR: Long-term follow-up of the GreenWaterman osteotomy for hallux limitus. JAPMA 92: 543, 2002.
Roukis TS, Jacobs PM, Dawson DM, ET AL: A prospective comparison of
clinical, radiographic, and intraoperative features of hallux rigidus: short-term
follow-up and analysis. J Foot Ankle Surg 41: 158, 2002.
Key Point #2:
Metatarsus Primus Elevatus is the RESULT of, not the CAUSE
of Hallux Rigidus
Key Point #3:
Osteotomies, intended to plantarflex the first metatarsal will
not achieve that end result as long as motion is still available
in the joints of the First Ray
What does the science reveal?
Attempts to plantarflex the First Ray via Osteotomy will not
lead to overall plantarflexion
Explanation: Other joints will compensate and increase
motion to balance the foot
Question #5
5. A standard lateral weight bearing x-ray depicts the
alignment of the osseous structures of the foot
during the midstance period of gait (True or False?)
Standard Lateral X-Ray Positioning
Angle and Base of Gait?
Static Stance
Intrinsics and Extrinsics
Inactive
Midstance in Gait: Single Support
RELAXED STANCE
1. Extrinsic foot muscles inactive
2. Arch integrity maintained solely
by plantar fascia
Basmajian, 1963
Huang, 1993
Reeser, 1983
Static Stance
• No windlass
• No plantar intrinsics
• No peroneus longus
FIGURE 1-96 This figure shows the foot in final propulsion. The hallux is
dorsiflexed 75° from the 1st metatarsal as heel lift elevated the base of the
1st ray 48° and the 1st ray plantarflexed in relation to the rest of the foot by
10°. The transverse axis of motion of the 1st metatarsophalangeal joint
(T.A.) has shifted to allow the proximal phalanx of the hallux to gllide to
the dorsum of the 1st metatarsal head.
Dynamic Gait
In terminal stance:
• Foot inverts
• 1st ray plantar flexes below 2-5
Due to:
Peroneus longus
Plantar intrinsics
Windlass
Dynamic Gait
1st Ray
plantarflexes
below 2-5
Inverting Foot
Removing First Ray Elevatus
On lateral wt. Bearing radiograph:
Hallux Dorsiflexion Stress
Coughlin
Chinese Finger Trap
Bouche
What happens when you surgically ReAlign the First Ray via osteotomy?
• 6 cadaver specimens
• Plantar flexion motion of 1st Ray in closed chain
measured: Hallux plantar grade & windlass
activated
• Comparison of MPV condition vs corrected
• In MPV: no signif. PF of 1st Ray with DF of
hallux
• In rectus alignment, PF of 1st Ray increased 4˚
with DF of Hallux
Rush SM. Christensen JC, Johnson CH: Biomechanics of the First Ray. Part II:
Metatarsus Primus Varus as a Case of Hypermobility. Jour Foot & Ankle Surg
39: 68, 2000.
“The ability of the foot to engage the
windlass mechanism is dependant on a fully
corrected first ray which realigns the
metatarsal with the sesamoid apparatus and
hallux.”
“We were able to show in a cadaver model
that functional stability can be increased by
26% with deformity correction without an
arthrodesis procedure.”
Rush SM. Christensen JC, Johnson CH: Biomechanics of the First Ray. Part II:
Metatarsus Primus Varus as a Case of Hypermobility. Jour Foot & Ankle Surg
39: 68, 2000.
What does the science reveal?
Restoration of alignment of the First Ray in the
transverse plane will significantly improve
stiffness and reduce hypermobility.
What happens when you surgically
Re-Align the First Ray via fusion?
Outcomes of Surgical Procedures
Level of Evidence
Level I: high quality prospective randomized clinical trial
Level II: prospective comparative study
Level III: retrospective case control study
Level IV: case series
Level V: expert opinion
Grades of Recommendation
Grade A treatment options are supported by strong evidence
(consistent with Level I or II studies)
Grade B treatment options are supported by fair evidence
(consistent with Level III or IV studies)
Grade C treatment options are supported by either conflicting
or poor quality evidence (consistent with Level IV studies)
Grade I when insufficient evidence exists to make a recommendation
Yee G. Lau J. Current concepts Review: Hallux Rigidus. Foot Ankle Int. 29(6);
637-646, 2008.
PROCEDURE
Non-Operative
(Foot orthoses, footwear
Modification, corticosteroid,
Sodium hyaluronate)
GRADE of
RECOMMENDATION
B
Cheilectomy
Grade I and II
Grade III
B
I
Prox. Phal. Osteotomy
I
1st Met Osteotomy
C
Keller Arthroplasty
B
Interpositional Arthroplasty
I
Arthrodesis
B
Silastic Implant
C
Two Piece Metal
Not recommended
Hemi Arthroplasty
C
(with reservations)
Deborah A. Nawoczenski, P.T., Ph.D.1; John Ketz, M.D.2; Judith F. Baumhauer, M.D. Dynamic Kinematic
and Plantar Pressure Changes Following Cheilectomy for Hallux Rigidus: A Mid-Term Followup. Foot &
Ankle International/Vol. 29, No. 3/March 2008
During gait, however, the amount of dorsiflexion relative to abduction changed
between pre-op and postoperative testing. Expressing this kinematic coupling
relationship as a ratio, the preoperative ratio of dorsiflexion to abduction was
1.17:1, suggesting that for every 1.17 degree of hallux dorsiflexion, approximately 1
degree of abduction occurred during gait. Following surgery, this ratio increased to
1.7:1, indicating a greater amount of hallux dorsiflexion, relative to abduction
during gait. This change in kinematic coupling may be considered a favorable
outcome, as first MTP dorsiflexion, rather than off-axis abduction, is the desired
motion during terminal stance/push off of gait. These findings may help to explain
the satisfactory outcomes following cheilectomy surgery, in spite of motion
restrictions.”
J Foot Ankle Surg. 2010 Nov-Dec;49(6):553-60.
Clinical outcomes after isolated periarticular osteotomies of
the first metatarsal for hallux rigidus: a systematic review.
Roukis TS.
Abstract
The author undertook a systematic review of electronic databases and other relevant
sources to identify material relating to the clinical outcomes and need for surgical revision
after isolated periarticular osteotomy of the first metatarsal for hallux rigidus. Information
from peer-reviewed journals, as well as from non-peer-reviewed publications, abstracts
and posters, and unpublished works, was also considered. In an effort to procure the
highest quality studies available, studies were eligible for inclusion only if they involved
consecutively enrolled patients undergoing isolated periarticular osteotomy of the first
metatarsal for hallux rigidus, involved a prospective study design, included some form of
objective and subjective data analysis, evaluated patients at a mean follow-up ≥12
months' duration, and included details of complications requiring surgical intervention.
Four studies involving 93 isolated periarticular osteotomies of the first metatarsal followed
up for a weighted mean of 18.6 months were identified that met the inclusion criteria.
Clinical outcomes after isolated periarticular osteotomies of the first
metatarsal for hallux rigidus: a systematic review.
Roukis TS.
Peak dorsiflexion range of motion of the first
metatarsophalangeal joint for the entire cohort of 93 patients
increased 10.4°. The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal
Scoring Scale for the entire cohort of 93 patients increased 39 points from a weighted mean of 47.2 preoperatively to 86.2
For the two studies that included it, complete
satisfaction or satisfaction with reservations was reported in
only 55/75 (73.3%) patients, with the remainder being
dissatisfied. A total of 21 (22.6%) procedures underwent
surgical revision in the form of hardware removal (n = 8), lesser metatarsal surgery for intractable postoperative
postoperatively.
metatarsalgia (n = 7), no mention of revision procedure (n = 3), Keller resection arthroplasty (n = 2), and treatment of infection
with revision of non-union (n = 1). Two studies specified the grade of hallux rigidus that underwent revision surgery after isolated
periarticular osteotomy of the first metatarsal as follows: grade I, 16.7% (n = 3/18) and grade II, 30.5% (n = 18/59).
Roukis TS.
Finally, a total of 30.5% (n = 18/59) of patients
developed postoperative metatarsalgia or stress
fracture. Additional prospective studies involving validated subjective and objective outcome
measurement tools with computerized gait analysis and long-term follow-up after isolated periarticular
osteotomy of the first metatarsal for the various grades of hallux rigidus, as well as with comparison
Based on the
high incidence of complications until these studies can
be completed, routine use of isolated periarticular
osteotomy of the first metatarsal for hallux rigidus
should be performed with caution or not at all.
with isolated cheilectomy and Valenti arthroplasty, would be beneficial.
J Foot Ankle Surg. 2010 Nov-Dec;49(6):546-52. Epub 2010 Sep 15.
Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield
better functional results? A systematic review of the literature.
Brewster M.
Abstract
As first metatarsophalangeal joint arthrodesis is generally considered to be a successful procedure for the treatment of hallux
rigidus, many surgeons question the usefulness of total joint replacement. In an effort to elucidate the clinical evidence, we
undertook a systematic review of the literature comparing the functional outcomes of arthrodesis and joint replacement in first
metatarsophalangeal surgery. Using multiple search engines and medical subject headings, 10 articles were eligible for inclusion: 5
featured arthrodesis and 5 featured total joint replacement. The American Orthopaedic Foot and Ankle Society-Hallux
metatarsophalangeal-interphalangeal score was used in all articles. The mean age at operation was 53 years for joint replacement
patients and 55 for those undergoing joint arthrodesis. Most patients in all studies were female. There was a significant increase
The median postoperative score for joint
replacement was 83/100 (range 74-95) and 82/100 (range 78-89) for
arthrodesis. The median revision rate in joint replacements was 7% (range
0%-10%) and 0% (range 0%-12%) for arthrodesis. This systematic review
reveals that arthrodesis achieves better functional outcomes than total
joint replacement. The operative techniques and prostheses for joint replacements are however still in an early stage
from pre- to postoperative scores in both procedures.
of development and advances still need to be achieved to produce a more successful and anatomical prosthesis that could be
functionally superior to an arthrodesis.
COMPENSATION FOR A PAINFUL 1ST MTP
Alteration in gait by weight shifting
laterally and “toeing off” over the lesser
metatarsal (fourth and fifth) heads
externally rotating at the hip during
swing phase of gait to allow for complete
toe clearance. Ankle push-off power is
reduced
VanGheluwe, B; Dananberg, HJ; Hagman, F; Vanstaen, K: Effects of hallux limitus on plantar foot pressure and
kinematics during walking. J. Am. Podiatr. Med. Assoc. 96:428 – 436, 2006.
Brodsky, JW; Baum, BS; Pollo, FE; Mehta, H: Prospective Gait Analysis in Patients with First Metatarophalangeal Joint
Arthrodesis for Hallux Rigidus. Foot Ankle Int. 28:162 – 165, 2007.
Mulier, T; Steenwerckx, A; Thienpont, E; et al.: Results after cheilectomy in athletes with hallux rigidus. Foot Ankle.
20:232 – 237, 1999.
Nawoczenski, DA: Nonoperative and operative intervention for hallux rigidus. J Orthop. Sports Phys. Ther. 29:727 –
735, 1999
Hallux Rigidus
Maher AJ, Metcalfe SA. First MTP joint arthrodesis for the treatment of
hallux rigidus : Results of 29 consecutive cases using the foot health status
questionnaire validated measurement tool. The Foot 18: 123-130, 2008.
“Concerns exist within the literature that fusion of the first
MTP joint may be detrimental to foot function and normal
gait. However, in this series foot function as judged by the
FHSQ scores improved significantly supporting the
argument that fusion actually stabilizes the first MTP joint
restoring weight bearing under the joint and in doing so
allows the restoration of hallux propulsion.”
Studies of gait after fusion of 1st MTPJ
Brodsky JW, Baum BS, Pollo FE, Hehta H, et al. Prospective gait analysis in
patients with first metatarsophalangeal joint arthrodesis for hellux rigidus.
Foot Ankle Int 2007: 28(2): 162-5.
DeFrino PF, Brodsky JW, Pollo FE, Crenshaw SJ, Beischer AD, et al. First
metatarsophalangeal arthrodesis: a clinical, pedobarographic and gait
analysis study. Foot Ankle Int 2002: 23(6): 496-502.
Vol. 23(3): 496-502, 2002
Summary:
-Normal peak pressures across hallux over shorter duration.
-Weight-bearing role of 1st ray reestablished.
-Force & pressure in lesser toes increased.
-Shorter step-length when pushing-off involved side.
-Reduction of ankle PF angle at toe-off.
-Decreased ankle PF moment & ankle power at toe-off.
-No change in hip or knee angle at toe-off.
Altered gait patterns in hallux rigidus
-Are the changes due to restricted ROM of the 1st MTP?
-Or, are the changes due to pain?
Therefore, should the goal of surgery be
restoration of ROM of the 1st MTP?
Or……
Elimination of pain at the 1st MTP?
The best surgical outcomes for hallux rigidus
do not increase ROM of the 1st MTP…
….they eliminate pain
What are the best
surgical options for
the Active Patient?
Grade 1 and 2: Cheilectomy
Grade 3 and 4: Arthrodesis
Hallux Rigidus in the Running Athlete
Rationale for Cheilectomy
- Literature supports the favorable outcomes in all patient populations
- Relative low risk, and minimal disability
- Will reduce pain and may improve ROM
- Downside: Probably not a lifetime correction for the runner
Deborah A. Nawoczenski, P.T., Ph.D.1; John Ketz, M.D.2; Judith F. Baumhauer, M.D. Dynamic Kinematic and Plantar
Pressure Changes Following Cheilectomy for Hallux Rigidus: A Mid-Term Followup. Foot & Ankle International/Vol. 29,
No. 3/March 2008
Conclusion: Cheilectomy was effective in maintaining balanced
plantar loading. First MTP motion increased
but dorsiflexion was still less than normative values. The magnitude
of dorsiflexion relative to abduction favorably improved during gait.
These findings suggest that kinematics continue to be altered and
may lead to further degenerative joint changes. Exploration of
alternative surgical techniques is warranted.
Hallux Rigidus in the Running Athlete:
Downside of Distal 1st Metatarsal Osteotomies
- Success is based upon
decompression of the 1st MTP,
not plantarflexion
- The more decompression, the
more shortening
- The more shortening, the greater
the risk of transfer metatarsalgia
- Greater peak forefoot pressures in
running will accentuate metatarsalgia
Downside of Implant Arthroplasty
- Current understanding of the mechanics of
the 1st MTP in walking is limited
- Current understanding of the
mechanics of the 1st MTP in running is
non-existent
- Speculate that compressive forces and
shear forces are magnified in running
- Little good options available when implant
fails
Do prosthetic implants for the 1st MTP function
allow the coupled motion of the 1st MTP?
- dorsiflexion-abduction
-plantarflexion-inversion
First Ray
• First Ray dorsiflexion preceeds MTJ
supination about longt. axis.
• First Ray dorsiflexes and inverts.
Kelso SF, Richie DH, Cohen IR, Weed JH and Root M: Direction
and range of motion of the first ray. JAPMA 72: 600, 1982
First Ray
Average total ROM
= 12.38 mm
Total frontal
plane motion
Sagittal
= 8.23º
Ratio = 0.77º
Frontal
Kelso SF, Richie DH, Cohen IR, Weed JH and Root M: Direction and
range of motion of the first ray. JAPMA 72: 600, 1982
8º
Rationale for Arthrodesis
- In Grade 3 and 4 the ROM of the 1st MTP has already been lost
- The athlete has been running with little ROM for years
- The disability of hallux rigidus is the PAIN, not loss of ROM
- Goal of surgery is to eliminate PAIN, not restore ROM
Current Understanding of
Hypermobility of the First Ray
Why is the science so contradictory?
We do not know how to measure this condition
We do not understand the role of this condition in
common pathologies:
Hallux valgus, hallux rigidus, adult acquired flatfoot
Metatarsus Primus Elevatus
What are the final recommendations?
To reduce hypermobility:
Restore transverse plane alignment of the 1st metatarsal
over the sesamoids
To improve alignment of the medial arch: Fuse the 1st TMT (Lapidus)
Key Point #5:
Foot orthotic interventions which decrease tension on the
plantar aponeurosis can be expected to improve range of
motion and decompress the 1st MTP.
What are the essential and “nonessential” joints of the First Ray?
Question #8
8. The majority of sagittal plane motion of the 1st Ray
takes place at the 1st Met Medial Cuneiform joint
(rather than Med.Cun.-Navicular Joint)
(True or False)
Which joint in the First Ray
Segment provides the most
motion?
1st Met-Medial Cuneiform
Navicular-Cuneiform
Medial view of first ray dissected free of skin and muscle
attachments. Method of sagittal plane measurement is
demonstrated showing calipers on pin in medial cuneiform
and “Devil’s Level” on platform on 1st metatarsal.
First Ray
• First Ray dorsiflexion preceeds MTJ
supination about longt. axis.
• First Ray dorsiflexes and inverts.
Kelso SF, Richie DH, Cohen IR, Weed JH and Root M: Direction
and range of motion of the first ray. JAPMA 72: 600, 1982
First Ray
Average total ROM
= 12.38 mm
Total frontal
plane motion
Sagittal
= 8.23º
Ratio = 0.77º
Frontal
Kelso SF, Richie DH, Cohen IR, Weed JH and Root M: Direction and
range of motion of the first ray. JAPMA 72: 600, 1982
What happens when you fuse one
of the joints of the First Ray?
Results of Fusion of Joints of the First Ray
Fusion of the First Ray
Summary
Out of 17 specimens, only 5 demonstrated significant reduction
of motion by fusing either the 1st TMT or the Nav Cun joints.
The 1st TMT fusion had the largest restriction of motion.
Summary
Three specimens demonstrated mild reduction
of motion, with either fusion showing similar results.
Summary
The nine remaining specimens showed no significant
reduction of motion of the First Ray, either by fusing
the 1st TMT or the Nav Cun joints.
Summary
When there was a significant reduction of overall motion of
the First Ray, it was the 1st TMT fusion which appeared to
have the largest influence.
However, this only occurred in 1/3 of the cases.
Summary
Out of 17 specimens, only 5 demonstrated significant reduction of motion by fusing either the
1st Met-Cun or the Nav Cun joints. The 1st Met-Cun fusion had the largest restriction of
motion.
Three specimens demonstrated mild reduction of motion, with either fusion showing similar
results.
The nine remaining specimens showed no significant reduction of motion of the First Ray,
either by fusing the 1st Met-Cun or the Nav Cun joints.
When there was a significant reduction of overall motion of the First Ray, it was the 1st MetCun fusion which appeared to have the largest influence. However, this only occurred in 1/3
of the cases.
Current Understanding of
Hypermobility of the First Ray
Why is the science so contradictory?
We do not know how to measure this condition
We do not understand the role of this condition in
common pathologies:
Hallux valgus, hallux rigidus, adult acquired flatfoot
Metatarsus Primus Elevatus
What are the final recommendations?
To reduce hypermobility:
Restore transverse plane alignment of the 1st metatarsal
over the sesamoids
To improve alignment of the medial arch: Fuse the 1st TMT (Lapidus)
Key Point #1:
Patients do not use all of the range of motion available in their
pedal joints during gait. Measuring total range of motion of
the 1st MTP does not predict how much motion the patient
actually needs or uses during gait.
Key Point #2:
Metatarsus Primus Elevatus is the RESULT of, not the CAUSE
of Hallux Rigidus
Key Point #3:
Osteotomies, intended to plantarflex the first metatarsal will
not achieve that end result as long as motion is still available
in the joints of the First Ray
Key Point #4:
Dorsiflexion of the 1st MTP is restricted by tension in the
soft tissues around the joint: Plantar aponeurosis, FHL
tendon, FHB and other sesamoid anchors. Procedures
which improve hallux rigidus do so by decompressing the
joint, which relaxes tension on these structures.
Key Point #5:
Foot orthotic interventions which decrease tension on the
plantar aponeurosis can be expected to improve range of
motion and decompress the 1st MTP.
The Twisted Plate Theory of Foot Stability
Key Point: With the foot resting on the ground, everting the hindfoot will
increase ground reaction forces (plantar pressure) against the First
metatarsal head.
Applying a 6 degree medial (varus) wedge across the forefoot will increase
ground reaction forces (plantar pressure) against the First metatarsal head.
A Cotton osteotomy or plantar flexion osteotomy anywhere along the First
Ray will increase ground reaction forces (plantar pressure) against the First
metatarsal head.
The Twisted Plate Theory of Foot Stability
Essential Key Point!
Any measure which increases plantar pressure at the 1st metatarsal will
deliver dorsiflexion moment, resulting in dorsiflexion motion across the key
joints of the First Ray. As long as there is motion available in the N-C and
Med Cun-1st Met joints, any surgical procedure which increases pressure
against the plantar surface of the first metatarsal will cause an immediate
dorsiflexion of the first ray back to its original state of equilibrium.
In the lateral column, increased plantar pressure under 4th and 5th
metatarsals does not cause dorsiflexion motion of the Calc-Cuboid or
Cuboid-4th and 5th mets because these joints are inherently stable.
reduced
20:232 – 237, 1999.
735, 1999
Vol. 23(3): 496-502, 2002
Summary:
Or……
BEFORE
AFTER
Functional Hallux Limitus
Enhance 1st MPJ Motion:
Kinetic Wedge
1st Met Cutout
Cluffy Wedge
KINETIC WEDGE
1ST MET CUT OUT
CLUFFY WEDGE
Hallux Rigitus /
Sesamoid Injuries
Block 1st MPJ Motion:
Plate Insole
Plate Midsole
Orthotic Foot Plate Extension
Outcomes of Surgical Procedures
Level of Evidence
Level I: high quality prospective randomized clinical trial
Level II: prospective comparative study
Level III: retrospective case control study
Level IV: case series
Level V: expert opinion
Grades of Recommendation
Grade A treatment options are supported by strong evidence
(consistent with Level I or II studies)
Grade B treatment options are supported by fair evidence
(consistent with Level III or IV studies)
Grade C treatment options are supported by either conflicting
or poor quality evidence (consistent with Level IV studies)
Grade I when insufficient evidence exists to make a recommendation
Yee G. Lau J. Current concepts Review: Hallux Rigidus. Foot Ankle Int. 29(6);
637-646, 2008.
PROCEDURE
Non-Operative
(Foot orthoses, footwear
Modification, corticosteroid,
Sodium hyaluronate)
GRADE of
RECOMMENDATION
B
Cheilectomy
Grade I and II
Grade III
B
I
Prox. Phal. Osteotomy
I
1st Met Osteotomy
C
Keller Arthroplasty
B
Interpositional Arthroplasty
I
Arthrodesis
B
Silastic Implant
C
Two Piece Metal
Not recommended
Hemi Arthroplasty
C
(with reservations)
Deborah A. Nawoczenski, P.T., Ph.D.1; John Ketz, M.D.2; Judith F. Baumhauer, M.D. Dynamic Kinematic
and Plantar Pressure Changes Following Cheilectomy for Hallux Rigidus: A Mid-Term Followup. Foot &
Ankle International/Vol. 29, No. 3/March 2008
During gait, however, the amount of dorsiflexion relative to abduction changed
between pre-op and postoperative testing. Expressing this kinematic coupling
relationship as a ratio, the preoperative ratio of dorsiflexion to abduction was
1.17:1, suggesting that for every 1.17 degree of hallux dorsiflexion, approximately 1
degree of abduction occurred during gait. Following surgery, this ratio increased to
1.7:1, indicating a greater amount of hallux dorsiflexion, relative to abduction
during gait. This change in kinematic coupling may be considered a favorable
outcome, as first MTP dorsiflexion, rather than off-axis abduction, is the desired
motion during terminal stance/push off of gait. These findings may help to explain
the satisfactory outcomes following cheilectomy surgery, in spite of motion
restrictions.”
Clinical outcomes after isolated periarticular osteotomies of
the first metatarsal for hallux rigidus: a systematic review.
Roukis TS.
Abstract
The author undertook a systematic review of electronic databases and other relevant
sources to identify material relating to the clinical outcomes and need for surgical revision
after isolated periarticular osteotomy of the first metatarsal for hallux rigidus. Information
from peer-reviewed journals, as well as from non-peer-reviewed publications, abstracts
and posters, and unpublished works, was also considered. In an effort to procure the
highest quality studies available, studies were eligible for inclusion only if they involved
consecutively enrolled patients undergoing isolated periarticular osteotomy of the first
metatarsal for hallux rigidus, involved a prospective study design, included some form of
objective and subjective data analysis, evaluated patients at a mean follow-up ≥12
months' duration, and included details of complications requiring surgical intervention.
Four studies involving 93 isolated periarticular osteotomies of the first metatarsal followed
up for a weighted mean of 18.6 months were identified that met the inclusion criteria.
Roukis TS.
Peak dorsiflexion range of motion of the first
metatarsophalangeal joint for the entire cohort of 93 patients
increased 10.4°. The American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal
Scoring Scale for the entire cohort of 93 patients increased 39 points from a weighted mean of 47.2 preoperatively to 86.2
For the two studies that included it, complete
satisfaction or satisfaction with reservations was reported in
only 55/75 (73.3%) patients, with the remainder being
dissatisfied. A total of 21 (22.6%) procedures underwent
surgical revision in the form of hardware removal (n = 8), lesser metatarsal surgery for intractable postoperative
postoperatively.
metatarsalgia (n = 7), no mention of revision procedure (n = 3), Keller resection arthroplasty (n = 2), and treatment of infection
with revision of non-union (n = 1). Two studies specified the grade of hallux rigidus that underwent revision surgery after isolated
periarticular osteotomy of the first metatarsal as follows: grade I, 16.7% (n = 3/18) and grade II, 30.5% (n = 18/59).
Roukis TS.
Finally, a total of 30.5% (n = 18/59) of patients
developed postoperative metatarsalgia or stress
fracture. Additional prospective studies involving validated subjective and objective outcome
measurement tools with computerized gait analysis and long-term follow-up after isolated periarticular
osteotomy of the first metatarsal for the various grades of hallux rigidus, as well as with comparison
Based on the
high incidence of complications until these studies can
be completed, routine use of isolated periarticular
osteotomy of the first metatarsal for hallux rigidus
should be performed with caution or not at all.
with isolated cheilectomy and Valenti arthroplasty, would be beneficial.
J Foot Ankle Surg. 2010 Nov-Dec;49(6):546-52. Epub 2010 Sep 15.
Does total joint replacement or arthrodesis of the first metatarsophalangeal joint yield
better functional results? A systematic review of the literature.
Brewster M.
Abstract
As first metatarsophalangeal joint arthrodesis is generally considered to be a successful procedure for the treatment of hallux
rigidus, many surgeons question the usefulness of total joint replacement. In an effort to elucidate the clinical evidence, we
undertook a systematic review of the literature comparing the functional outcomes of arthrodesis and joint replacement in first
metatarsophalangeal surgery. Using multiple search engines and medical subject headings, 10 articles were eligible for inclusion: 5
featured arthrodesis and 5 featured total joint replacement. The American Orthopaedic Foot and Ankle Society-Hallux
metatarsophalangeal-interphalangeal score was used in all articles. The mean age at operation was 53 years for joint replacement
patients and 55 for those undergoing joint arthrodesis. Most patients in all studies were female. There was a significant increase
The median postoperative score for joint
replacement was 83/100 (range 74-95) and 82/100 (range 78-89) for
arthrodesis. The median revision rate in joint replacements was 7% (range
0%-10%) and 0% (range 0%-12%) for arthrodesis. This systematic review
reveals that arthrodesis achieves better functional outcomes than total
joint replacement. The operative techniques and prostheses for joint replacements are however still in an early stage
from pre- to postoperative scores in both procedures.
of development and advances still need to be achieved to produce a more successful and anatomical prosthesis that could be
functionally superior to an arthrodesis.
reduced
20:232 – 237, 1999.
735, 1999
Vol. 23(3): 496-502, 2002
Summary:
Or……
1ST MTPJ ARTHRODESIS
PRE-OP
POST-OP
POST-OP FUNCTION
6 Yrs S/P 1st MTPJ Fusion Right
Hallux Rigidus
Maher AJ, Metcalfe SA. First MTP joint arthrodesis for the treatment of
hallux rigidus : Results of 29 consecutive cases using the foot health status
questionnaire validated measurement tool. The Foot 18: 123-130, 2008.
“Concerns exist within the literature that fusion of the first
MTP joint may be detrimental to foot function and normal
gait. However, in this series foot function as judged by the
FHSQ scores improved significantly supporting the
argument that fusion actually stabilizes the first MTP joint
restoring weight bearing under the joint and in doing so
allows the restoration of hallux propulsion.”
Studies of gait after fusion of 1st MTPJ
Brodsky JW, Baum BS, Pollo FE, Hehta H, et al. Prospective gait analysis in
patients with first metatarsophalangeal joint arthrodesis for hellux rigidus.
Foot Ankle Int 2007: 28(2): 162-5.
DeFrino PF, Brodsky JW, Pollo FE, Crenshaw SJ, Beischer AD, et al. First
metatarsophalangeal arthrodesis: a clinical, pedobarographic and gait
analysis study. Foot Ankle Int 2002: 23(6): 496-502.
What are the best
surgical options for
the Active Patient?
Grade 1 and 2: Cheilectomy
Grade 3 and 4: Arthrodesis
Deborah A. Nawoczenski, P.T., Ph.D.1; John Ketz, M.D.2; Judith F. Baumhauer, M.D. Dynamic Kinematic and Plantar
Pressure Changes Following Cheilectomy for Hallux Rigidus: A Mid-Term Followup. Foot & Ankle International/Vol. 29,
No. 3/March 2008
Conclusion: Cheilectomy was effective in maintaining balanced
plantar loading. First MTP motion increased
but dorsiflexion was still less than normative values. The magnitude
of dorsiflexion relative to abduction favorably improved during gait.
These findings suggest that kinematics continue to be altered and
may lead to further degenerative joint changes. Exploration of
alternative surgical techniques is warranted.
Hallux Rigidus in the Running Athlete:
Downside of Distal 1st Metatarsal Osteotomies
- Success is based upon
decompression of the 1st MTP,
not plantarflexion
- The more decompression, the
more shortening
- The more shortening, the greater
the risk of transfer metatarsalgia
- Greater peak forefoot pressures in
running will accentuate metatarsalgia
Downside of Implant Arthroplasty
- Current understanding of the mechanics of
the 1st MTP in walking is limited
- Current understanding of the
mechanics of the 1st MTP in running is
non-existent
- Speculate that compressive forces and
shear forces are magnified in running
- Little good options available when implant
fails
Do prosthetic implants for the 1st MTP function
allow the coupled motion of the 1st MTP?
- dorsiflexion-abduction
-plantarflexion-inversion
Rationale for Arthrodesis
- In Grade 3 and 4 the ROM of the 1st MTP has already been lost
- The athlete has been running with little ROM for years
- The disability of hallux rigidus is the PAIN, not loss of ROM
- Goal of surgery is to eliminate PAIN, not restore ROM
Advantages of Locking Plate for 1st MTP Arthrodesis
Locking plates are more stable than non-locking plates
DeTora M, Kraus K. Mechanical testing of 3.5 mm locking and nonlocking bone plates. Vet Comp Orthop Traumatol. 2008; 21(4):318-22
Locking Plates: Advantages
- Locking plates do not rely on plate/bone compression and precise plate contouring
is not critical.
- Therefore, in contrast to the use of conventional plating, one can implant locked
plating without compressing the periosteum.
- Unicortical fixation helps preserve the blood supply and reduces screw-induced
stress in bone.
- With conventional plating, the bone is pre-stressed.
- With locked plating, the plate and not the bone is pre-stressed.
Advantages of Screw Fixation for 1st MTP Arthrodesis
- Less expensive
- Less likely to require
removal of hardware
- Easier to “customize”
the alignment of fusion
Disadvantages of Screw Fixation for 1st MTP Arthrodesis
- Technically more
difficult
- Less contact across the
arthrodesis interface
- Theoretically less stable
than plate compression
Conical Reamers: Improved technique for 1st MTP Arthrodesis
- The reamers remove the articular cartilage and subchondral bone,
which is critical to healing.
- The reamers also create a machined fit with the hallux in variable
positions.
- The favorable joint debridement and congruent “machined” fit of the
arthrodesis interface improves arthrodesis rates as much as the type of fixation
one employs.
Goucher NR, Coughlin MJ. Hallux metatarsophalangeal joint arthrodesis using dome-shaped
reamers and dorsal plate fixation: a prospective study. Foot Ankle Int. 2006; 27(11):869-76.
CONCLUSION
40 degrees of dorsiflexion (extension) of the 1st
MTP is adequate for normal walking gait and…
30 degrees dorsiflexion may be adequate for running
Locking Plates: Description
- Locking plates and screws consist of threaded screw heads
and plate holes that allow one to insert the screw into the
plate itself, thereby facilitating a form of cortical purchase.
- The penetration of the screw through the near cortex to
the plate serves as the second cortex.
- One can achieve further stability via bicortical screw
purchase but this is not a requirement.
Locking Plates: Principles
- Each screw forms a fixed right angle and this eliminates the potential
for toggle.
- Multiple fixed, right angle anchors provide excellent fixation.
- Therefore, locking plates function similarly to external fixation by not
requiring friction between the plate and bone to provide stabilization.
- Locking plates have a shorter distance between the plate and bone
construct than an external fixator does, thus making locking plates
more stable.
Negative Aspects of Conventional Plating:
- Bicortical screw fixation required
- Potential for irritation of sesamoid apparatus
- Bicortical fixation along the plantar surface of the proximal
phalanx could cause pressure pain and/or flexor hallucis
brevis and longus tendonitis
Locking Plates for 1st MTP
Arthrodesis: Advantages
- New first MPJ specific plates are prepositioned to ensure accurate alignment (the
single most crucial component other than
stabilization)
- Furthermore, the new plates allow polyaxial
locking, providing multi-axial, fixed angle
constructs.
- This is especially important for first MPJ
arthrodesis due to architecture of the first MPJ
and the irregular surface shapes.
- Not only is the surgeon able to place the
screws at an angle of 15 degrees to the plate
with each hole but the plate itself also allows
for polyaxial loading
Disadvantages of Locking Plate for 1st MTP Arthrodesis
- Theoretically, locking plates use the same principles as external fixators
and do not require compression against the bone for stability
- However, for 1st MTP arthrodesis, a “hybrid” technique is often employed
where the plate is compressed into the dorsal surface of the bone.
- Once one applies a locking plate to a bone and compresses the plate
in a traditional fashion, the favorable aspect of preserving the periosteal
blood supply is lost.
Disadvantages of Plate Fixation for 1st MTP Arthrodesis
In addition, the rigid stability afforded by locking plates
and the compromise of the periosteal blood supply beneath
the plate is a detriment to bone healing based on current
understanding of bone and fracture healing with plate
fixation.
Ganesh VK, Ramakrishna K, Ghista DN. Biomechanics of bonefracture fixation by stiffness-graded plates in comparison with stainlesssteel plates. Biomed Eng Online. 2005; 4:46.
Disadvantages of Locking Plates
Alternatively, application of a locking plate that is not directly
compressed to the bone results in a dorsally prominent implant
that is likely to irritate the soft tissues clinically. This type of
application is less problematic in subcutaneous plating of the
distal tibia or femur, but often results in hardware irritation
over the first MPJ
Conventional Plating of 1st MTP Arthrodesis
Furthermore, there is abundant evidence to suggest
dorsal plate fixation using conventional implants
affords predictable arthrodesis rates and high
patient satisfaction
Kumar S, Pradhan R, Rosenfeld PF. First metatarsophalangeal
arthrodesis using a dorsal plate and a compression screw. Foot Ankle Int.
2010; 31(9):797-801.
Berlet GC, Hyer CF, Glover JP. A retrospective review of immediate
weightbearing after first metatarsophalangeal joint arthrodesis. Foot
Ankle Spec. 2008; 1(1):24-8
LOCKING PLATES vs CONVENTIONAL PLATES:
PROVEN ADVANTAGE?
- There is little evidence to suggest locking plates are any better or even
comparable to traditional plates with respect to MPJ arthrodesis.
- A study presented at the American Academy of Orthopaedic Surgeons
showed that there was a higher nonunion rate with locking plates for
MPJ arthrodesis
Hunt KJ, Ellington K, Anderson RB, et al. Locked versus non-locked plate fixation for hallux MTP
arthrodesis. Presented at the 25th Annual Summer Meeting of the American Orthopaedic Foot and
Ankle Society, July 15-18, 2009. Vancouver, British Columbia.
POSITIVE OUTCOMES OF 1st MTP
ARTHRODESIS WITH SCREW FIXATION
The forces acting across the MPJ during healing are primarily bending
and, to a lesser magnitude, shear. Historically, transarticular screw
fixation has shown very favorable arthrodesis rates dating back 30
years
Wassink, S, VAn Den Oever M. Arthrodesis of the
first metatarsophalangeal joint using a single
screw: retrospective analysis of 109 feet. J Foot
Ankle Surg. 2009; 48(6):653-61.
Brodsky JW, Passmore RN, Pollo FE, Shabat S.
Functional outcome of arthrodesis of the first
metatarsophalangeal joint using parallel screw
fixation. Foot Ankle Int. 2005; 26(2):140-6.
J Am Podiatr Med Assoc. 2005 May-Jun;95(3):221-8. Metatarsus primus elevatus in hallux
rigidus: fact or fiction? Roukis TS.
Abstract
Two hundred seventy-five lateral weightbearing radiographs of isolated pathology were
reviewed and stratified into hallux rigidus (n = 100), hallux valgus (n = 75), plantar fasciitis
(n = 50), and Morton's neuroma (n = 50) groups. The patient population consisted of healthy
individuals with no history of foot trauma or surgery. The first to second metatarsal head
elevation, Seiberg index, first to second sagittal intermetatarsal angle, first to fifth
metatarsal head distance, and hallux equinus angle were measured in each population.
Statistically significant differences were found between the hallux valgus, plantar fasciitis,
and Morton's neuroma populations and the hallux rigidus population, which showed
greater elevation of the first metatarsal relative to the second for each radiographic
measurement technique. In the hallux rigidus population, there was a statistically significant
difference between grade II and grades I and III regarding the first to fifth metatarsal head
distance (greater in grade II) and the hallux equinus angle (lower in grade II). A review of
the literature and comparison with historical controls reveals that metatarsus primus
elevatus exists in hallux rigidus and is greater than that found in hallux valgus, plantar
fasciitis, and Morton's neuroma groups.
First Ray Elevatus: Cause or Effect of Hallux Rigidus?
Meyer, J.O., Nishon, L.R., Weiss, L., and Docks, G.: Metatarsus primus elevatus and the
etiology of hallux rigidus. J. Foot Surg., 26:237-241, 1987.
The authors concluded that approximately 7.0 mm of first ray elevation is a
consistent radiographic finding in patients with and without hallux rigidus. In
addition, they discouraged basing surgical correction of the presumed deformity
on radiographic elevatus. It should be noted, however, that they believed that
metatarsus primus elevatus was paramount in the pathogenesis of hallux rigidus.
Do lateral weight bearing radiographs accurately depict
the functional position of the first ray during gait?
Question #5
5. A standard lateral weight bearing x-ray depicts the
alignment of the osseous structures of the foot
during the midstance period of gait (True or False?)
Standard Lateral X-Ray Positioning
Angle and Base of Gait?
Static Stance
Intrinsics and Extrinsics
Inactive
Midstance in Gait: Single Support
Static Stance
• No windlass
• No plantar intrinsics
• No peroneus longus
FIGURE 1-96 This figure shows the foot in final propulsion. The hallux is
dorsiflexed 75° from the 1st metatarsal as heel lift elevated the base of the
1st ray 48° and the 1st ray plantarflexed in relation to the rest of the foot
by 10°. The transverse axis of motion of the 1st metatarsophalangeal joint
(T.A.) has shifted to allow the proximal phalanx of the hallux to gllide to
the dorsum of the 1st metatarsal head.
What are these procedures?
Cheilectomy
Arthrodesis
CONCLUSION
Active range of motion of the 1st MTP while
standing is the best indicator of true range of
motion used by the patient during gait
The FDL can also become a pathologic
force across the 1st MTP.
Screw vs Plate Fixation for 1st MTP Arthrodesis: Cost Comparison
There is evidence showing dorsal plate fixation to be significantly more
expensive. Further buttressing this argument is that there was no
significant difference in fusion rates between screw fixation and more
expensive plate fixation.
Hyer, CF, Glover JP, Berlet GC, Lee TH. Cost comparison of crossed
screws versus dorsal plate construct for first metatarsophalangeal joint
arthrodesis. J Foot Ankle Surg. 2008; 47(1):13-8.

BIOMECHANICS OF HALLUX RIGIDUS

Transcription

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