Welcome to the Podiatry Arena forums, for communication between foot health professionals about podiatry and related topics.
You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members (PM), upload content, view attachments, receive a weekly email update of new discussions, earn CPD points and access many other special features. Registered users do not get displayed the advertisments in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!
If you have any problems with the registration process or your account login, please contact contact us.
Dynamic kinematic and plantar pressure changes following c: a mid-term followup.
Nawoczenski DA, Ketz J, Baumhauer JF. Foot Ankle Int. 2008 Mar;29(3):265-72.
Quote:
BACKGROUND: Hallux rigidus leads to significant loss of first metatarsophalangeal (MTP) joint motion. Cheilectomy surgery aims to increase motion, decrease pain, and facilitate a return to activity. Limited data exist regarding restoration of dynamic kinematics and loading responses following cheilectomy. This prospective study assessed three-dimensional in vivo first MTP joint kinematics and loading characteristics following cheilectomy.
MATERIALS AND METHODS: Twenty patients were evaluated prior to undergoing cheilectomy for hallux rigidus. Fifteen subjects returned for mid-term followup at 1.7 years. Eleven subjects were surveyed at 6 years. Plantar pressure data were acquired during barefoot walking. Comparisons of average pressures were determined for 4 different regions of the foot. Pressure differences were compared within, and between symptomatic and asymptomatic feet. First MTP joint dorsiflexion and abduction were assessed during standing, active motion and gait.
RESULTS: Only four out of 15 patients showed increased lateral metatarsal loading preoperatively. Pressures shifted medially following surgery. Significant increases in dorsiflexion were found for active motion (pre-op = 13.3 +/- 12.7 degrees; post-op = 21.7 +/- 14.7 degrees, p = 0.005) and dorsiflexion during gait (pre-op = 19.3 +/- 12 degrees; post-op = 30.8 +/- 14.8 degrees, p = 0.01). Hallux abduction also increased. During standing, the hallux remained in plantarflexion relative to the first metatarsal.
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.
Re: Gait changes following cheilectomy for hallux rigidus
OK - so someone had to 'study' this, I su'ppose. Seems kind of obvious ? The bony projection is the consequence of abnormal joint function, at least in most cases. Its' removal would have little effect to improve joint mechanics... but now we can at last point to the evidence thanks to three-dimensional in vivo first MTP joint kinematics and loading characteristics following cheilectomy.
(assuming it can withstand the rigour of study critique)
Kind of lightens my heart - I have made the same point for years but some argue a simple cheilectomy can be as effective as an osteotomy....
All the same: this kind of study ( sure it's valuable) has some of the hallmarks of another great study; £1 million was, allegedly, assigned to discover if Falkland penguins tumble when aircraft pass overhead. Great job.
Re: Gait changes following cheilectomy for hallux rigidus
Haven't read the full article, so I don't intend to offer a critique. I'm interested however that dorsiflexion at the MTPJ significantly increased whilst the hallux remained plantarflexed relative to the met head.
I think that one problem with these studies is that the aetiology is not examined. Anecdotally, the vast majority of hallux limitus/rigidus I see seems to be associated with a long 1st met. Cheilectomy or no, this is clearly going to affect gait. This is why I frequently find a shortening osteotomy rewarding provided that the degeneration is not end stage, in which case arthrodesis seems appropriate - as discussed in a recent thread.
However, this is a logitudinal study and is to be applauded for that reason.
Re: Gait changes following cheilectomy for hallux rigidus
G'day all,
I think this article skims the fact that all surgery to the foot is going to alter foot mechanics, especially at the first MTPJ. My thesis was a systematic review and meta-analysis of the surgical procedures for hallux limitus/rigidus. Essentially, chilectomy, like all otehr arthroplasties, will demonstrate an increase in range of motion, and a better quality of life with a reduction in pain at the 1st MTPJ. One paper studdies did demonstrate a change in peak pressures and timing of pressure under the 1st MTPJ.
I do agree with Bill, great to see someone having an attempt at some decnt surgical studies!
-Adrian
The Following User Says Thank You to Adrian Misseri For This Useful Post:
The purpose of this study was to quantify changes in temporal-spatial parameters and multisegmental foot/ankle kinematics in a group of patients with hallux rigidus following cheilectomy. Three-dimensional motion analysis was conducted using a 15-camera Vicon Motion Analysis System on a population of 19 patients who underwent cheilectomy for hallux rigidus. Data were analyzed using the four-segment Milwaukee Foot Model. Preoperative and postoperative tests were compared using paired parametric methods. Results showed significant improvements in walking speed, cadence, stride length, and stance/swing ratio from preoperative to postoperative state. Altered hallux and forefoot positions preoperatively showed shifts towards normal after cheilectomy. Although clinical improvements in pain and passive range of motion were statistically significant, similar improvements in range of motion were not demonstrated during ambulatory testing. The results of this study provide insight into ambulatory improvements following cheilectomy, and suggest further study of the rehabilitation process to improve the recovery of functional range of motion.
Re: Gait changes following cheilectomy for hallux rigidus
"Essentially, chilectomy, like all otehr arthroplasties, will demonstrate an increase in range of motion, and a better quality of life with a reduction in pain at the 1st MTPJ."
Not sure I agree with this.
IF there is increased pain due to a fractured osteophyte then a debridement (I personally don't like the term CHILECTOMY) will help.
Does debridement of the 1st MTPJ give long standing results?
Does debridement of an arthritic ankle, knee or hip give long term results?
No.
The patient will return for a more definitive procedure.
STeve
__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA
Re: Gait changes following cheilectomy for hallux rigidus
Steve et al,
"Essentially, cheilectomy, like all other arthroplasties, will demonstrate an increase in range of motion, and a better quality of life with a reduction in pain at the 1st MTPJ."
On balance I agree with this, of course, there will always be exceptions for a number of reasons.
'Does debridement of the 1st MTPJ give long standing results?
Does debridement of an arthritic ankle, knee or hip give long term results?
No.
The patient will return for a more definitive procedure.'
On balance I disagree with this generalisation.
I do not believe ankle, knee and hip are a fair comparison to an mpt.
I think the difference is that in addition to the intrinsic biomechanical component of the etiology there is the shoe factor.
I have several patients, reviewed after 15 years, who had varying degrees of cheilectomy and Valenti procedures, who are still pleased with the result and have not noticably regressed.
I believe this is due to the fact that the patients tend to be of an age when they are wearing more accomodating shoes. If they continued wearing the more extreme style of shoes, limiting forefoot function, that they wore in the 15-30 year age period I am not so sure that the results would be so pleasing after another 15 years !
Background
Good results are usually reported after arthrodesis of the first metatarso-phalangeal joint, but there is no definite agreement concerning the position that provides the best result.
Methods
We reviewed 35 patients with 39 fusions of the first metatarso-phalangeal joint 8 (2–15) years after surgery. In addition to clinical evaluation we measured the position of the arthrodeses radiographically and clinically, and also the distribution of pressure under the foot using insoles with pressure sensors.
Results
A total of 28 of 39 cases had an AOFAS score of 75 or better (90 best possible). Almost all patients experienced pain relief. Union was observed in 31 out of 39 feet, but the satisfaction rate was not significantly lower in those with pseudarthrosis. There was no strong correlation between the arthrodesis position and patient satisfaction. There was a good correlation (r = 0.8; p < 0.001) between the weight-bearing radiographic extension angle and the height between the plantar surface and the pulp of the hallux and a flat board manually pressed against the sole of the foot. There was significantly increased local pressure under the pulp of the great toe in operated feet.
Conclusions
There is only a weak correlation between position and clinical outcome. A good estimate of the extension angle is made by measuring the height between a flat object placed under the foot and the pulp of the distal phalanx.
INTRODUCTION: Metatarsophalangeal joint osteoarthritis of the great toe (hallux rigidus) is a frequent condition for which numerous surgical techniques have been proposed. The most used ones are cheilectomy and arthrodesis. The objectives of this retrospective study are to present the midterm results of the Valenti procedure and to compare these results with those from other recognized surgical techniques.
MATERIALS AND METHODS: We conducted a retrospective analysis of a continuous group of 32 patients (41 cases) presenting hallux rigidus and treated using the Valenti technique from November 1999 to July 2004. The mean age of these patients at the time of surgery was 57 years. Forty-one percent of these patients also presented a static disorder of the foot. One or several additional procedures were undertaken, at the time of surgery, in 24% of these cases. Patients were assessed using the AOFAS score completed by the walking distance test, the gait test, the tiptoe test and self-evaluation of patient satisfaction. The radiographic work-up before surgery and at follow-up showed the progression of the joint space changes and allowed us to evaluate plantar subluxation at the base of the first phalanx under the metatarsal head.
RESULTS: Twenty-four patients (32 cases) were reviewed and evaluated with a mean follow-up of 5.5 years. Two cases of reflex sympathetic dystrophy were observed as complications. The mean final score was 81 out of 100 from a preoperative score of 47 out of 100. Pain was absent or only occasional in 94% of the cases. Discomfort wearing shoes was absent or moderate in 91% of the cases. Joint range of movement was greater than 30 degrees in 72% of the cases and the toes were stable. Walking distance was unlimited in 79% of the cases. A mean 30% plantar subluxation at the base of the first phalanx was noted at follow-up, with no clinical consequence. The results were comparable irrelevantly of the hallux rigidus grade being treated.
DISCUSSION: The numerous techniques proposed achieve comparable results both in terms of pain relief and functional result but each one has its own limitations. Only arthroplasties with silastic implants and the Keller technique give less satisfactory results. Arthrodesis remains the first-choice treatment for advanced hallux rigidus but failure is possible in case of technical error or malunion. Cheilectomy, a conservative intervention, is ideal for lesions that are not too advanced or remain limited to the dorsal part of the joint; this conservative option presents generally no specific complications. Prosthetic replacement - with, to date, little long-term experience for total arthroplasty - remains controversial because the results deteriorate over time. The Valenti procedure exposes the patient to a possible risk of metatarsophalangeal joint destabilization if the resection is too great, but this does not impair the final functional outcome. CONCLUSION: The arthrectomy described by Valenti is a highly reproducible intervention. We find it to be a good compromise between mobility and stability, providing good results for all hallux rigidus grades and entailing a low complication rate.
Gait changes following cheilectomy for hallux rigidus
Linear Mode
