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This longitudinal prospective study of 22 patients (26 feet) aimed to evaluate the effectiveness of percutaneous surgery in the treatment of hallux rigidus, and to assess patient satisfaction with the result of this surgical approach. Pain levels (VAS), quality of life (SF-12) and clinical stage (AOFAS) were scored prior to surgery and 18 months after surgery. Pain relief was noted in all cases, with mean pain scores falling from 7.44 before surgery to 1.69. Perception of quality of life also improved, while AOFAS scores rose from 58.45 to 92.36. These results suggest that percutaneous treatment of hallux rigidus, consisting in capsular release, resection of bony spurs and dorsal wedge osteotomy of the first metatarsophalangeal joint, is effective in terms of both clinical outcome and patient satisfaction, as the scores for both measures were noted to be higher than reported using conventional techniques.
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?
__________________
Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)
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.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
PURPOSE OF THE STUDY In a retrospective study, to evaluate the results of surgical treatment of hallux rigidus on the basis of clinical rating, radiographic findings and visual analogue scale (VAS).
MATERIAL The group included 68 patients, 38 women and 30 men, treated at the orthopaedic ward of the Hospital Ceské Budejovice in the period from April 2004 to June 2007. The average age of the patients was 58.6 years (range, 34 to 79). Right and left feet were affected in 42 and 26 patients, respectively. Follow-up ranged from 3 to 30 months.
METHODS Surgery was undertaken only after all means of conservative treatment had been used. Indications for each type of operation were based on the severity of disorder of the first metatarsophalangeal joint (MTPJ), patient's age, toe's motion restriction and physical stress on the patient's big toe. In patients with moderate degenerative MTPJ disease, in 25 feet, a Moberg dorsal wedge osteotomy of the first proximal phalanx was carried out when plantar flexion was preserved; in 12 feet, a Youngswick sagittal V osteotomy was indicated when both flexion and extension were limited and the first metatarsus was long enough; in 14 cases cheilectomy alone was used. In patients with severe arthritis, the TOEFIT-PLUS modular joint replacement of th first MTPJ was used in seven, the Brandes-Keller resection arthroplasty was carried out in six and arthrodesis of the first MTPJ was performed in four. All patients were examined at 2 and 6 weeks after surgery. Those undergoing osteotomy, arthrodesis or joint replacement were X-rayed after surgery and then at 6 weeks of follow-up.
RESULTS The outcome of treatment was evaluated at 3 to 30 months after surgery by clinical and X-ray examination and using the VAS. The average range of MTPJ motion improved from 5 degrees to 22 degrees in dorsiflexion and from 17.5 degrees to 27 degrees in plantar flexion. Osteotomy or arthrodesis in all patients healed in correct alignment, without loosening or migration of prosthetic components. Based on the VAS (100-point scale), pain assessment was 34 preoperatively and 78 post-operatively; joint motion increased from 51 before to 82 after surgery; and ability for daily activities from 50 to 84. The overall VAS score was 42 before surgery and improved to 83 after surgery. Five patients were dissatisfied; two of them underwent repeat surgery (arthrodesis) with marked improvement and one achieved improvement by shoe modification. The rest of the group reported good or very good outcomes.
DISCUSSION Resection arthroplasty, widely used before, is now performed only in patients exerting minimal physical activity and with severe arthritic disease, because it results in loss of the big toe's supporting funciton. Osteotomies by Moberg or Youngswick procedures involve the use of screws (Barouk). Stable osteosynthesis allows for early post-operative rehabilitation and weight bearing in appropriate modified shoes. Dorsal wedge osteotomy is the method most frequently used in our department to the full satisfaction of our patients.TOEFIT joint replacement is indicated in elderly patients with severe degenerative disease who wish to maintain toe motion and have adequate weight bearing of the treated foot. Emphasis is placed on good post-operative rehabilitation of the joint and on co-operation with the patient.
CONCLUSIONS The hallux rigidus diagnosis covers several grades of degenerative disease of the first MTPJ and therefore its surgical treatment must necessarily involve more than one operative procedure. Even when an appropriate technique is used, the problems may not resolve completely. When the technique to be used is considered, good communication with the patient is necessary, because they should know the principle of treatment and an anticipated outcome of it. Our results show that the surgical treatment of hallux rigidus has good outcome if it is correctly indicated and technically well performed and completed with good post-operative care.
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
Quote:
Background
Arthrodesis of the first MTP joint is an accepted and long established joint destructive procedure for the management of hallux rigidus.
Objectives
This paper presents the results of 29 consecutive first MTP joint arthrodesis procedures for the treatment of hallux rigidus.
Method
The outcomes of 29 (18 female and 11 male) consecutive arthrodesis procedures were analysed with the Foot Health Status Questionnaire (FHSQ), minimal important difference scores, and a patient satisfaction questionnaire.
Results
FHSQ foot pain scores improved for 27 (93%) patients; foot function improved for 23 (79%) patients; shoe scores improved for 18 (62%) patients; foot health improved for 20 (68%) patients; general health improved for 12 (41%) patients; physical activity improved for 21 (72%) patients; social capacity improved for 21 (21%) patients; vigour improved for 15 (51%) patients. FHSQ minimal important difference scores were achieved for foot pain in 25 patients (86%); foot function in 17 patients (58%); and general foot health in 19 (65%) patients. Analysis with the matched pairs Wilcoxon rank sum test (p < 0.05) revealed statistically significant improvement in all FHSQ domains. Female patients appeared to fare better than male patients in all FHSQ categories other than general health and vigour.
Conclusion
Arthrodesis of the first MTP joint can reliably reduce pain relating to hallux rigidus and can improve foot function and allow a return to physical activity.
BACKGROUND: The nature of the sesamoid complex in the development of hallux rigidus or limitus (HL) has been poorly characterized and the role of the sesamoids in the surgical management of this condition has not been explored. Previous surgical approaches in younger active patients unsuited to destructive procedures have been limited.
MATERIALS AND METHODS: Thirty-three patients (36 procedures) were reviewed between 2 and 4 years following total sesamoidectomy for the management of hallux rigidus/limitus. The American Orthopedic Foot & Ankle Society hallux (AOFAS) clinical rating system was used to compare pre and postoperative scores. The range and quality of motion and transfer metatarsalgia were noted. The three most important patient problems and the degree to which these had been addressed by the surgery and the time to maximal improvement were noted.
RESULTS: No significant functional impairment or malalignment were found. There were no instances of pain on metatarsal compression, or of transfer metatarsalgia with or without callus formation. A highly statistically significant improvement in AOFAS scores was found (p < 0.001).
CONCLUSION: High levels of clinical improvement and patient satisfaction were found following total sesamoidectomy. No deleterious consequences of sesamoid removal were observed. For symptomatic patients where a joint replacement/fusion is not indicated, total sesamoidectomy was beneficial as an interim procedure, for joints with a moderate (grades 2 to 3) degree of arthrosis
BACKGROUND: The nature of the sesamoid complex in the development of hallux rigidus or limitus (HL) has been poorly characterized and the role of the sesamoids in the surgical management of this condition has not been explored. Previous surgical approaches in younger active patients unsuited to destructive procedures have been limited.
MATERIALS AND METHODS: Thirty-three patients (36 procedures) were reviewed between 2 and 4 years following total sesamoidectomy for the management of hallux rigidus/limitus. The American Orthopedic Foot & Ankle Society hallux (AOFAS) clinical rating system was used to compare pre and postoperative scores. The range and quality of motion and transfer metatarsalgia were noted. The three most important patient problems and the degree to which these had been addressed by the surgery and the time to maximal improvement were noted.
RESULTS: No significant functional impairment or malalignment were found. There were no instances of pain on metatarsal compression, or of transfer metatarsalgia with or without callus formation. A highly statistically significant improvement in AOFAS scores was found (p < 0.001).
CONCLUSION: High levels of clinical improvement and patient satisfaction were found following total sesamoidectomy. No deleterious consequences of sesamoid removal were observed. For symptomatic patients where a joint replacement/fusion is not indicated, total sesamoidectomy was beneficial as an interim procedure, for joints with a moderate (grades 2 to 3) degree of arthrosis.
Hmmmmmmmmmmmmm.
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.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Hmmmmmmmmmmmmm.
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.
Steve
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?
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Steve,
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.
Regards,
Ryan
Steve,
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.
Regards,
Ryan
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: kevinakirby@comcast.net
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Kevin,
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.
You are performing a double sesamoidectomy for Hallux Rigidus? With no other procedure?
Correct?
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.
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
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.
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.
Quote:
em·pa·thy
n.
1. Identification with and understanding of another's situation, feelings, and motives.
Very glad to hear you are making good progress.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Steve,
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.
Regards,
Ryan
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.
Steve,
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.
Regards,
Ryan
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.
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Kevin,
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.
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.
=================================
Kevin:
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
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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
Steve
Steve:
Who knows, maybe soon you'll be voting Democrat!
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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?
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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?
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Kevin:
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!!!!!!
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Steve,
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.
Regards,
Ryan
Last edited by Ryan McCallum : 13th October 2009 at 02:37 PM.
Reason: Typo
Steve,
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.
Regards,
Ryan
Hello,
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
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?
Steve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Adjunct Professor OCPM
Green Bay, Wisconsin, USA
Surgery for hallux rigidus
Linear Mode
