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I recently attended a Danenberg presentation which was both highly informative and interesting. At this conference there were a couple of topics that challenged my understanding of treating different conditions.
1. Dr Danenberg advocated the use of 1st ray cut outs and Reverse Mortons extensions in cases of Hallux Rigidus and Limitus. Traditionally I have used Mortons extensions with those pts who have less than 35 deg of pain free motion. My thinking was that you couldnt get blood from a stone, so if the Motion was not physically present then trying to enhance it was futile, and you couldnt reverse O/A changes which were the result of chronic 1st MPJ disfunction issues.
I beleive the point made by Dr Danenberg (and I hope I am not misrepresenting his views) was that if you promoted proper 1st MPJ function then over time boney remodelling could take place to allow (if not normal) functional 1st MPJ motion. Dr Danenberg also highlighted the fact that to date there is no evidenced based outcome studies supporting either treatment rational which is pretty ordinary for our proffession considering we treat it on such a regular basis.
2. Of perhaps most concern (and I know its been discussed here previously) is the ascertion that many Podiatrists (myself included) are perhaps doing more harm than good by some putting patients in2 rigid custom orthotics that may weaken the intrinsic musculature of the feet (please refrain from using PTTD and Rigid F/F Varus as exceptions Cuase I already know they are exceptions).
I look forward to hearing your views, especially on the 1st point.
2. Of perhaps most concern (and I know its been discussed here previously) is the ascertion that many Podiatrists (myself included) are perhaps doing more harm than good by some putting patients in2 rigid custom orthotics that may weaken the intrinsic musculature of the feet (please refrain from using PTTD and Rigid F/F Varus as exceptions Cuase I already know they are exceptions).
__________________ Craig Payne
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The real issue with the management of hallux limitus and rigidus is that essentially we as podiatrists are trying to make an osseous pathology more comfortable for a patinet. However we achieve this, provided it causes no other harm to the patient and leaves a patient in a satisfied state, is alright. I use both first ray cut outs and first ray extensions with my patients with hallux limitus and rigidus with good results for both, basing each case's amount of motion, exostosis development, possiblility of pain free motion, X-ray results and other foot mechanics. I make very clear to my patients though that we care just trying to relieve symptoms of what is a bony deformity, and the only real way to correct a bony deformity such as this, especailly with the arthropathy and exostosis development, is via surgery. Both arthroplasty and arthrodesis generally yield satisfactory results, and there is a now an implant on the markey which is also showing promising results (BioPro, look it up, very interesting). As soon as I publish my thesis (when I eventually get around to it), there will be a piece of secondary evidence for the surgical approach for hallux limitus and rigidus management. (As far as my searches have demonstrated, and unless one has been published in the last 12 months, no systematic reviews or meta analysis studies exist looking at arthroplasty and arthrodesis of purely hallux limitus/rigidus (or prove me wrong :))).
As you pointed out, Dannenberg pointed out the lack of evidence for either management techniques. I agree, there is a huge gap in the amout of well constructed, well designed, methodoligically sound, primary evidence to prove a lot of what we practice in podiatric biomechanics. With this in mind, we have to make the best decision based on the availiable evidence, our own understanding and presentation of each case.
Essentially, judge each case individually, and consult the current idea, concepts and literature to HELP you make the best clinical decision, not TELL you what to do.
Cheers!
__________________
Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)
Mr T
Here's a pic of a Hallux Rigidus I replaced recently. The piece floating was a fractured osteophyte from the dorso-lateral aspect of the phalangeal base.
I submit that there is no way on God's green Earth anyone is going to get more ROM in this joint from the "outside"
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Mr T
Here's a pic of a Hallux Rigidus I replaced recently. The piece floating was a fractured osteophyte from the dorso-lateral aspect of the phalangeal base.
I submit that there is no way on God's green Earth anyone is going to get more ROM in this joint from the "outside"
Steve
Good one, Steve. I sure don't see how a custom foot orthosis is going to remodel that one either......even if it does have a Kinetic Wedge.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Many thanks for your replies thus far. In fairness to Dr Danenberg, when I raised the possibility of a similiar osseous block occuring due to a 'floating' fragment, he conceded that trying to facilitate gtr ROM at the joint would not be possible.
Ok, lets put all this into practice. I have a 40 y/o female patient who presented with hallux rigidus. She has about 10 degrees of available motion, and her main complaint is not pain through the joint, but rather a painful corn under the proximal phalanx of her hallux. This lesion can be excrutiatingly painful, and debridement provides only a months relief (and Im very proud of how zaelously I attack corns). The patient has a Mortons foot, with a significantly shorter 1st ray. Hallux Rigidus is bilateral, but the HD is presnt only on 1 side. I have not yet taken xrays of the joint (should I?)
Now if I was to employ a Mortons extension under her Hallux, I would increase the GRF under the proximal phalanx and therefore presumably increase the frequency at which her corn returns. Could I place and apperture in the course of the extension to accomodate the corn?
Or could I have the mortons extension angled at about 10 deg d/f (to act as a rocker), similiarly to how Dr Kirby Fuses the Hallux at about 15 deg.
Alternatively, I could use a 1st ray c/o coupled with a reverse mortons ext to Plant flex the 1st ray and despite the dorsal lipping on the MPJ, attempt to facilitate the 15 deg (at a minimum) of Dorsi Flexion, and reduce the GRF under the Proximal Phalanx and therefore reduce frequenc of which the corn returns.
What say you?
Thankyou all for your time and expertise. As a new grad trying to get the best outcome for his pts, its sometimes tricky when you cannot draw on clinical experience to guide the 50/50's.
Kevin I have a great respect for your opinions and the advice that you offer up on this forum, but the not so subtle dig via the kinetic wedge jibe may not encourage Dr Danenberg to enter the fray and explain his side of the argument. As i said at the beginning of this thread I hope that I am not misrepresenting any of Dr Danenbergs views, so if I have have said something that sounds like rubbish the buck stopps with me. As a clinician Im very grateful to Dr Daneberg for publishing outcome studies so they can be taken apart on forums like this and discussed. It all helps with my understanding of lower limb biomechanics, even if I sometimes may not entirely agree with every thing he his saying.
Studying biomechanical theories at uni, it was clear that Dr Danenberg and yourself have contributed much to our understanding of lower limb biomechanics. It would be wonderful if we could organise a great debate, with 4 or 5 prominent thinkers in the field respectfully bashing out their ideas. I raised the idea with Dr Danenberg and he was not completely averse to it.
MrT
Last edited by trophikas : 13th May 2008 at 04:54 PM.
Mr T
Here's a pic of a Hallux Rigidus I replaced recently. The piece floating was a fractured osteophyte from the dorso-lateral aspect of the phalangeal base.
I submit that there is no way on God's green Earth anyone is going to get more ROM in this joint from the "outside"
Steve
Gday Steve
Great pic and point duly noted. Did the osteophyte present on xray? Was the imiging the main thing that giuded your surgical intervention or was it the initial failure of conservative management to relieve symptoms? Would a mortons extension blocking D/Flex of the 1st have provided symptomatic relief.
Great pic and point duly noted. Did the osteophyte present on xray? Was the imiging the main thing that giuded your surgical intervention or was it the initial failure of conservative management to relieve symptoms? Would a mortons extension blocking D/Flex of the 1st have provided symptomatic relief.
MrT
Hi:
I find it fairly common for patients with long standing Hallux Rigidus/Limitus that give a history of acute onset of increased pain to have a fractured osteophyte.
These are almost always on the phalangeal base and mostly dorso-lateral. They are easily seen on radiograph if you are looking for them.
These patient have pain on motion as you would expect, but if you palpate the dorsomedial aspect of the base they will jump off the exam table.
If the joint is gone and I see a fracture I normally don't do much in the way of conservative treatment.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Kevin I have a great respect for your opinions and the advice that you offer up on this forum, but the not so subtle dig via the kinetic wedge jibe may not encourage Dr Danenberg to enter the fray and explain his side of the argument.
On the contrary, Howard and I go a long ways back and he is not one to back down just because I made a tongue-in-cheek comment about his Kinetic Wedge. In fact, I would estimate that Howard is more likely to "enter the fray" because of my bad joke.....just so that he can set me straight.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Hi MrT:
Just as a follow up on your question
"Did the osteophyte present on xray?"
I had this x-ray on my computer. This isn't the same patient as in the surgical photo, but it's pretty typical.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Hallux Rigidus Orthosis
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