Lecture 46 parekh hr
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Lecture 46 parekh hr
- 1. Hallux Rigidus Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd
- 2. Hallux Rigidus (HR) •1st MTP pain •Stiffness •DF •Proliferative periarticular bone formation •AKA - Hallux Limitus, Dorsal Bunion
- 3. Epidemiology • One in 40 over age 50 (Gould N, 1980) • Occurs bilaterally approximately 50% of the time • Females probably greater than males • Early onset associated with positive family history Boney & MacNab, 1952
- 4. Etiology • Trauma (acute, chronic) • Turf toe • Suggested anatomical abnormalities include: • Flat MT Head • Long/Short 1st MT • Pes Planus • Metatarsus Primus Elevatus (controversial) • Dorsal elevation of 1st MT in relation to lesser MT
- 5. Evaluation •History •Pain & swelling •Physical Exam •Decreased ROM (DF, classically) •Painful ROM •DF- bony impingement •PF- stretch of EHL, capsule, synovium •Bony osteophyte •Dorsal •Dorsolateral- Tinel’s sign (1st WS; DPN)
- 6. Radiographs • AP • Lateral • Oblique
- 7. Grade Pain Decrease ROM (Total°) Radiographs I Occ Mild (<55°) Mild Spur; No/Slight Narrowing II Constant Moderate (40°) Mod Spur; Narrowing III Constant Severe (<20°) Extensive Osteophytes; ±LB; Severe Narrowing Classification
- 8. Conservative Treatment • NSAID’s • Shoe modifications to decrease motion • Stiff sole shoe • Morton’s extension • Steel shank w/ rocker bottom • Taping • Steroid injections
- 9. Proximal Phalangeal Osteotomy • Moberg Procedure • Indications • Adolescents w/ grade I • Older pt’s w/ grade I • If grade II, add cheilectomy • Technique • Osteotomy needs to permit • DF 35° (1st MT) • 15° (bottom of foot)
- 10. Cheilectomy • Indications • Grades I & II (pain relief in 93% of pt’s*) • Lower success for grade III (29%*) • Extent of dorsal MT head excision • Depends on extent of articular damage • ~25% • >30% can lead to subluxation *Geldwart, 1992
- 11. Excisional Arthroplasty •Keller •Indications •Grade III •Older/sedentary •Contraindication •Young/active •Technique •Resection of proximal ⅓ of proximal phalanx
- 12. Soft Tissue Interpositional Arthroplasty • Indication • Grade II and III • Elderly, low demand • Contraindications • Short 1st MT • Metatarsalgia • Technique • Cheilectomy • ~25% proximal phalanx excised w/ transverse osteotomy • EHB + capsule sutured to FHB • Allograft/Xenograft
- 17. Soft Tissue Interpositional Arthroplasty • Results (Parekh) • Satisfaction 90% • Complications • Metatarsalgia • Cockup toe • IP joint stiffness • Decreased flexor strength
- 18. MTP Joint Arthroplasty •Cemented nonconstrained •>50% loosening @ 3.5 yrs •Bony ingrowth •Some short term success •No long term results
- 19. Silicone Implants • Long term failure rates: 57-74% • Complications • Implant failure due to repetitive loading • Silicone synovitis due to foreign body reaction • AVN • Infection • Metatarsalgia • Delayed wound healing • Recurrent deformity • Bony proliferation • Decreased mobility • Fracture • Osteolysis • Recurrent pain
- 20. MTP Arthrodesis •Indications •Painful Grade II •Grade III •Salvage for failed HV •Salvage for H Varus •RA fot •Results •Dorsal plate w/ interfrag screw •93-100% fusion rate
- 21. MTP Arthrodesis • Few contraindications • Requires careful explanation to patient, re: no motion • Multiple reports in literature ranging from 77 to 100% success
- 22. MTP Arthrodesis • First described by Broca in 1852 • 1940 Thompson & McElveney - 15 cases • 1952 McKeever successful in 33 patients -- becomes popular
- 23. MTP Arthrodesis •Severe hallux rigidus •Severe hallux valgus •Rheumatoid arthritis •Salvage (Keller, failed implant) •Post infection •Post traumatic •Neuromuscular disease •Chronic instability
- 24. MTP Arthrodesis •IP joint arthritis •Active infections •Vascular deficiency •Poor skin quality •Significant neuropathy •High heeled shoewear
- 25. MTP Arthrodesis • Technique • Planar coaptation vs. convex-concave • Threaded Steinmann pins • Screw or plate or screw & plate
- 27. Biomechanics - Shortening • 1987, Turan and Lindgren • Planar cuts: 1.0 to 1.5 cm • 1994, Coughlin • Cone shaped reamers: 7.7 mm • Cup shaped reamers: 3.8 mm • 2006, Parekh • No statistical difference 7.1mm v 5.7mm
- 28. Fixation Strength: Biomechanic Studies • 1986, Sykes & Hughes - Planar surfaces with single cancellous screw gave best fixation • 1993, Curtis - Conical surfaces with lag screw was best
- 35. Position • 10-15o DF above the horizontal • 25o from 1st metatarsal axis • 15-20o abduction in the transverse plane - avoid 2nd toe impingement • 0o rotation
- 36. Fusion Rates with Plates • Coughlin & Abdo: 98% fusion with 93% success. • Salis-Soglio & Thomas: 92% • Mankey & Mann: 92% • Coughlin: 100%
- 37. Can We do Better? • Pocket technology • Interfrag through plate
- 38. Can We do Better? • 31.2% nonunion • 6.3% partial union • High nonunion & revision surgery rates • Use w caution
- 39. Results: Reports of union > 90% • 1994, Coughlin: Cup & cone surfaces with mini fragment plate & K-wire • 35 cases with 98% union • 1992, Holmes: Interfragmentary screw added to above with good results
- 40. Complications of Arthrodesis • Malalignment: Varus-valgus, DF-PF, or rotation • Nonunion: 0-7% with plate and interfragmentary screw • IP arthritis increases with less than 20o valgus position
- 41. Complications • IP arthrosis (progression in 6% )* • Decrease in IP joint motion - 22o* • Nonunion • Callus formation • Malposition • Infection • Subsequent plate removal: 7% to 46% *Coughlin, 1994