Ryan Fitzgerald, DPM defines the entities known as hallux limitis and hallux rigidus. Dr Fitzgerald describes a couple of the classification systems reported in the literature and also reviews the various surgical solutions available for each of the stages. The lecture ends with some case reports illustrating the surgical principles previously described.
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Ryan Fitzgerald, DPM
PRESENT RI Associate Editor
Clinical Assistant Professor of Surgery
USC GHS Center for Amputation Prevention
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Ryan Fitzgerald none
Harold: Fitzgerald has been one of our young guns who is a prolific writer, excellent speaker, and really is making a name for himself on the lecture circuit. He is involved with Hess Orthopedics & Sports Medicine. He’s a graduate from the Barry School in Miami. Ryan is going to be talking to us on hallux limitus-igidus. Please welcome Ryan Fitzgerald.
Ryan Fitzgerald: I want to thank Harold for those kind words. They’re hard to live up to but I’ll do my best. I also apologize in advance. I just flew in about an hour and a half ago. I got camped in Charlotte Airport last night, so that was pretty fantastic. We’re going to be talking about the hallux limitus-rigidus kind of conundrum. It’s one of those interesting things that it’s something we know a lot about. Consequently, we know relatively little about it. We think we know it but there’s a lot to it. It’s almost too simple, really. We have to break it apart and think about the component pieces to really get a good understanding of what we’re dealing with. Let me see if I can get it to advance. Nope. Allen, can we get it to advance? There we go. Okay. We all know that hallux limitus-rigidus is essentially a progressive condition at the first metatarsophalangeal joint, a degenerative change. And as a consequence to this, the findings are what you would expect. Spur formation, pain, inflammation, difficulty with motion and movement and these are largely the pain complaints that we see. It can be a structural deformity or it can be something that’s more positional. And that’s something to consider as we’re thinking about what we’re going to do to fix it. Commonly, it’s associated with foot types that are inherent. So there is a genetic component and it’s, again, something to be mindful of as you’re considering the surgical options. Certainly, overuse is an option as well, particularly in the context of once you’re down the road of degenerative change, that can snowball out of control. Some basic definitions. We all know that the normal range of motion at the first metatarsophalangeal joint is about 50 to 65 degrees, depending on who you read. Hallux limitus is essentially something less than that, to a degree. Once you get into less than about 20% range of motion, that’s when you start having the rigidus component. Often, we think of this as sort of one block term, but it’s really helpful to break them into their two-component parts, the limitus part and then the rigidus part. The limitus part can be functional or structural. So it’s either position of the foot as a consequence of the architecture of the bones or it’s more the biomechanics and how the foot is attaching to the ground as you’re going to the gait cycle. These are important factors to consider when you’re determining what you’re going to do to fix it, whether it’s something you can address with an orthotic, whether you need to do surgery, and then what surgery you need to do. Once you get into a rigidus situation, it’s really more of a structural problem not likely to be well received with conservative care alone. The functional and it’s like what we talked about, is essentially a decreased hallux dorsiflexion which is positional when the foot is loaded. In nonweightbearing, you have appropriate range of motion. But once the foot is down in the weightbearing position, you don’t have the appropriate dorsiflexion. The structural limit is a decreased range of motion in both positions essentially weightbearing or none. And it’s important to do both a nonweightbearing and weightbearing exam when you’re evaluating these patients. And we’ll talk about that as well. The etiology is really first metatarsal based. If you look at this list, most of everything is associated with the first ray. Certainly, the first metatarsal being either dorsiflexed, or too long, is a common issue and we see a lot around in our radiographs. If you have a too short first metatarsal, that can actually cause you to have a limitus as well which is an interesting sort of variation. Certainly, any trauma to the medial column can cause this. Secondary arthritis due to inflammatory conditions like rheumatoid arthritis, things like that can certainly cause it. Then the iatrogenic causes the bunion gone bad. I just took the oral boards about two or three weeks ago now. One of the questions for the oral exam was a dorsiflexed first ray and subsequent transfer lesions in the hallux limitus. It’s definitely something that you see and is a little more complicated than we would expect which is why we’re talking about it today. Again, the bottom line is there’s something jamming up the first metatarsophalangeal joint. You have to think that through. The clinical findings. Bursitis, pain, all the things you would expect. You can sometimes see that the EHLs and spasm. Often, there’s a palpable dorsal osteophyte, or dorsal medial osteophyte, and then a plantar callus with evidence of transfer to the hallux. You’re not getting that dorsiflexion. In patients with neuropathy, you often see that there’s an ulcer in allocation sub-IPJ.
That’s something to think about as well. Hypermobility or plantarflexed first ray can also be noted. You can get this metatarsalgia, you get lateral dumping, that the weight gets transferred off from the first met as the patients tried to accommodate for this pain by walking on the outside of their feet. There are a couple of classification systems. And like one of the previous speakers said, I don’t really like classification systems. I think that a lot of times they’re overly complex and they’re out there for people to get their names out there. But there are some fairly good ones for hallux limitus. Two that I particularly like are Oloff and Jacobson, and the Regnauld classification. These are a bit broken down based on the degree of deformity, grade 1, 2, 3. You can see that as you progress from 1 down to 3, there’s increasing degenerative change. That’s kind of the key point. That’s the benefit of a classification system is that it helps you see where you’re going. There was a more recent edition in 2003, Coughlin modified and added more to the Regnauld classification by breaking it down and adding ideas about what one should do for each stage. In grade 0, you can see, these are the findings. Basically, it’s a normal finding. Range of motion, a little bit of pain, but it’s pretty normal radiographically. There’s not a lot of clinical findings apart from that. You can see that there’s really no surgical options for that person. That’s somebody you want to try to treat conservatively. Then as you progress across 1, 2, 3 and 4, the severity of the deformity becomes increasingly significant, and then as a consequence of that, the required surgical procedure. You can see in grade 2, we’re starting to talk cheilectomies, which I’m not a fan of, and there’s a lot of support, doing something a little bit more. But decompression osteotomies are a big thing in sort of level 2. Then as you get into level 3, you start thinking, well, the joint space itself is pretty compromised, the cartilage is going to be compromised, we need to start thinking in terms of joint-sparing procedures versus more joint-destructive procedures like implant arthroplasty or fusion. Then ultimately, once you get to grade 4, you’re pretty much hosed in terms of the quality of the cartilage. You’re talking something destructive. This is a good article to read interestingly enough. It’s a useful system. It’s one that actually I’m able to really apply in my practice. I encourage you to take a look at that. Essentially, it is as you would expect that, over time, it is a slowly progressive deformity. As the time progresses, you can see that you go from a relatively normal and stable joint, progressing ultimately to significant periarticular spurring and join space collapse. Interestingly, note the flattening of the metatarsal head. That’s an important marker. It’s one of the findings that I use in my practice to determine, am I going to try to save the joint or not? Because what I found is as the joint flattens out, as the head flattens out, the quality of the cartilage is increasingly poor. It’s going to be very difficult to make that a functional joint without doing something to the cartilage, either chondroplasty, a little micro-OATS, or ultimately implant arthroplasty. This is just breaking that classification system down again. You can see a grade 0. The joint space is pretty appropriate. You do have a little bit of decreased loss of motion, maybe 10 to 20%. It’s more painful but not radiographically so. These are people that you can usually treat with some conservative care, try to get them into an orthotic that allows for more range of motion with a dancer’s pad or something. That’s a good way to go with the grade 0’s. Grade 1, you’re starting to see more changes about the metatarsophalangeal joint. As a consequence of this, the surgical options become more appropriate. This is a joint that you can usually salvage. Occasionally, they’ll have some scuffs or tears in the cartilage itself, but the joint space itself can be maintained, particularly if you can decompress it. These are people that I think of in terms decompression osteotomies in conjunction with orthotics and some other conservative care items. They generally show about 20 to 30% range of motion loss. Grade 3, you can really start to see this flattening of the metatarsal head as well as the spurring. Once you have that degree of structural deformity, you have to start thinking in terms of more aggressive corrections. Because even if you decompress that joint, you still got an abnormally-shaped head, you know the cartilage is going to be compromised to a degree, and you need to be able to address that as wee. Again, here, you start seeing significantly decreasing range of motion. Then ultimately, the flattened appearance would start to get those periarticular spurring. A cheilectomy alone is not going to do it. Sometimes, a decompression osteotomy with chondroplasty possibly depending on what it looks like. But oftentimes, I’ll go to the OR consented to do a series of things and we’ll see what it looks like because you actually need to look at the cartilage to know what you’re going to do. If the cartilage is shut, you could do resurfacing with an Arthrosurface or some sort of cap implant. They’re a variety on the market. Essentially, it has one as well. We’ll talk about those moving forward. Grade 3, you start to notice significant joint space narrowing and some more spurring, and it starts becoming sort of variations on the theme, increasing deformity, joint space narrowing, more spurring, less range of motion.
That’s essentially how it goes. The greater the deformity, the more correction you’re going to need. These are patients who are certainly going to get some sort of decompression but also something to address the level of the cartilage either at the base of the phalanx or on the metatarsal head. Then ultimately grade 4. This is not a joint that you’re likely to be able to salvage in any substantial way. You can make it move or you can make it rigid. But either way, it’s going to be not what they were born with any sense of the imagination. This is somebody that I would talk about, a fusion versus an implant arthroplasty, and I’ll give you my criteria for when I do one or the other. But it’s important to know, when you get this far, you have to have that realistic conversation. You’re not going to be able to decompress that it’s going to work. Interestingly, there are a few articles out there. I’m talking about Laporta’s article about the arthrodiastasis. For some of those grade 1 hallux limitus-rigidus, there are some articles out there to be discussed, putting in little mini external fixator on their destructing out the ankle joint or the first metatarsophalangeal joint. I’ve actually done it a few times and we’ve had some pretty good results. I was kind of skeptical frankly, and I didn’t think it was going to work. But the patient series that we have, again very small series, but they’ve been really happy. We had them range motion and stretched it out. So far so good, they’re doing okay. When we start talking conservative and surgical management, we all know what these things are. It’s not rocket science. It’s not nearly as complicated as fixing the things that other people are talking about today. We’re either replacing the joint with something else. We’re putting something in between or fusing it so it doesn’t move. I tell my patients that arthritis is just bones grinding on bones. To make it feel better, you have to stabilize it so that it doesn’t move. That’s what we’re talking surgically. The basic nonsurgical stuff is essentially the same nonsurgical stuff for anything else. Anti-inflammatories, mobilization, orthotics to a degree, and you have to think about what you’re hoping to accomplish. Is it reasonable to expect that they’re going to feel better or not? Occasionally, it is valuable to delay surgery. Sometimes, there are social constraints, but you have to remember that this is a progressive deformity. In the context of that, it’s going to get worse. A decompression osteotomy early on may ultimately be far less aggressive than fusing it in a year or two. You have to have that as those kind of conversations with the patients, sometimes a little bit more is the right answer. In terms of surgical concepts, you have to remove the boney block. You want to reorient the articular surface and essentially shorten the first ray to allow there to be motion in that decompression to create a functional joint, and then also functional medial column which will allow for weight transfer that will reduce the risk of transfer lesions and other compensatory problems. You can see from this to that. This is something you’re going to be able to salvage, this is clearly not. For each one, you’re going to have a very different paradigm. In terms of joint procedures that are preserving, there’s a significant list and I’m not going to go through all of them. But, they’re available in any textbook. The reality is you do some and you don’t do others. A lot of it depends on where you were trained and what your residency attendance do and what you become comfortable with. My combination is usually I do some Youngswick-Austin or I’ll do some sort of midfoot thing. A cotton if it’s too long or too short. Then a lot of combination procedures. The other thing you have to be aware of is the potential for proximal set angle problems. There’s rotation of the head. Oftentimes, you’ll have to do a shortening procedure and then also some sort of procedure for that as well, a Reverdin of some sort. In terms of joint destructive procedures, things like a Valenti, a Keller, implant arthroplasty and ultimately fusion. There are a variety of ways to do these and a variety of techniques. There are some that are better than others and that’s beyond the scope of this lecture, ultimately, but just to know that they exist. When you’re taking your boards, when you having to answer questions, know that this is the list of destructive procedures. Again, in my practice, I do a few Kellers. I don’t like them as much. I figured if you’re going to do a Keller, you could do something else. I do a fair number of implants not because I really like them but more an issue of the patients themselves. Then fusion is, I think, underutilized. It’s a really great procedure, you can get it to work. There are a variety of ways to do it, either with plate screws, SP-Fix, combination of those things. Here’s my paradigm for what I do. The literature supports this after a review. Certainly in the grade 1 and 2, conservative care modalities are appropriate. It’s necessary to make sure that you progress through all those options. As you start progressing down, however, you can see that the nature becomes more significant in terms of cheilectomy versus osteotomy versus some sort of adjunctive soft tissue. That it’s a more aggressive osteotomy which is mostly when you’re kidding yourself that you think you’re going to get some more motion. And it works for a little while and you end up doing one of the more definitive procedures. When I get down into 3’s and 4’s, implant arthroplasty versus arthrodesis is my go-to procedures. Largely based on what I can get the patient to commit to.
I don’t want to fuse somebody who’s not going to listen because a painful nonunion is going to be far worse than the arthritis that they have the hallux limitus or rigidus. It’s important to really consider those options, consider the degree of the deformity and then what are you going to do? You see this on the x-ray, and the patient says it hurts when my big toe goes up. You’re faced with a series of choices. You knock the bump off, is that going to be enough? Is it enough to just bring this bone back a little bit? I mean take off the base of the phalanx. You have a lot of choices and a lot of options and many of the products out in the [indecipherable] [15:25] encourage you to visit with them, they all have products for this. It’s a big, a lot of options. But you have to consider the degree of deformity and age of the patient, what are the realistic functional outcomes? Then, are they going to be compliant? Because you don’t want to fuse somebody who’s not going to listen. Then consider the postop course. You also have to consider your salvage options. The options of what are you going to do if what you do fails, what’s the next step? If you fuse it and they get a nonunion, then what? If you put an implant and it doesn’t work, then what? Just be thinking in terms of that. In this case, would we do an implant, do we do a fusion? These are the options. Then the postoperative care, yeah, it’s a calculated risk. You have to think of what you’re going to do. They’re procedure-specific. Obviously, there are some things you want to really get them doing a range of motion quickly on. That would be the joint preserving procedures. Other things, you want them to leave it alone. You don’t want them to touch, you don’t want any weight on it until there’s radiographic signs of healing and those would be more of the arthrodesis type procedures. Now, interestingly, there’s a couple of articles about NSAIDs. I’ll share this with you, I’m running out of time, but this is important. Generally speaking for implant arthroplasties, I do use NSAIDs unless there’s a contraindication, largely because I want to limit the amount of inflammation while they start range of motion. With one caveat, you have to be careful. These patients do get complications and can be fairly significant. I had a lady who had no previous history, had had a hallux limitus on the one side, we did an implant on the one side. She loved it, she wanted to come back for a second on the other side. We had done everything the same the one side that we did at the second side. On postop day three, she presented to the ER unconscious. She had been found on the floor of her bathroom. They checked their H&H and her blood count was 9 and 24 something. She had a bleeding ulcer from the Toradol that I gave her. I operated on Tuesday, she had taken Wednesday day time doses and then fell at Wednesday night. She had about four Toradol tablets, 40 milligrams. No history. She had been taking ibuprofen like aspirin and things like that, had been eating it like candy for months prior the surgery. No previous history, but it does come to get you. She was admitted, transfused, we got her sorted out, she’s fine, but the risk is there. You have to take it seriously. It’s not always going to be somebody who says oh, I have a problem and you don’t give it, you have to be aware of that potential. Yes and no on the NSAIDs. I do like it, it does work, but there is a risk. I also like physical therapy for these, particularly the ones you want to get them moving forward. Here are just a few pictures. We’re running out of time and Harold is going to yank me off the stage here, but this is just the Ascension implant for a metatarsophalangeal joint resurfacing. Again, there’s arthrodesis. I like arthrodesis because if you can get it to heal and it’s in the right position, it’s going to be very, very functional. Patients have very little complains with this generally speaking. I get more complains on the implants, but frankly the people who want implants wanted implants anyway. We talked about doing the fusion then we sort of go back to the implant. Largely, because they’re unwilling to commit to the recovery. This is a 42-year-old female, I’ll just show you, she had a functional limit. It was only when she was weightbearing, but it was enough that she wanted to have something done. She had a small bunion. You can see, what is that, 13 degrees or so? We ended up just doing a decompression osteotomy on her. Just brought it back a little bit, got her some more range of motion, no big deal, she did great. This guy is a 51-year-old policeman. He had a more significant deformity as you can see here. And he would be one that I would really push towards a fusion and I think it’d be more functional for him in the long run, but he’s a policeman, he doesn’t want to stay off his feet. He wanted to have a surgery, one and done, back to work in a couple of weeks. He opted for an implant, which we did. This is the Ascension Movement total toe. And it’s a neat system because it comes in one big tray but it’s a phalangeal site, a metatarsal site or both. You have the options to do one, the other or sort of everything in between. He got a total because he had degenerative changes on both sides of the cartilage. But you can see here, it’s positioning, you kind of see how it kind of coughs up and resurfaces. He’s got a great range of motion, happy as a clam. Then this patient was a 52-year-old lady with a history of RA. She had previous surgery. Another physician had fused her IPJ for mallet toe that she had developed and she had started getting increasing degenerative changes here. This was her primary complaint but she had a lot of pain under the metatarsal heads as well, not surprising from her hammertoe. Ultimately, we decided to do a modified Hoffman-Clayton and took her back, fused the big toe, and then also took out the met heads and did the toes as well.
And so you can see this is her after the fact. She got a great result with her fusion. She was very, very happy. That’s her foot now. You can see it’s sort of all the right position and she’s walking in her regular shoe, no problem. In conclusion, you really have to think of this as sort of a multifactorial component deformity. It’s not just that the joint is jammed but there a couple of reasons that it may be jammed and you have to really address or you’re going to be sorry, it’s not going to work for you. Particularly if you have a elevated of the first metatarsal. If I could leave you with anything, if the first med is elevated and you don’t address it, you’re going to have problems no matter what you do unless you fuse it and even then, it can be problem. You have to consider the options, the degree of deformity and then ultimately progress accordingly in terms of your surgical plan and you have to be ready for any complications and manage them early and aggressive. There are specific complication specific to individual procedures, nonunion, malunion, perfusions, synovitis for implants, things like that. Just be aware of them. Just be ready to deal with them as needs be. Are there any questions? All right.