Thomas J Chang, DPM reviews the current literature for the treatment options available for Hallux rigidus. Dr Chang also discusses which procedures are currently supported and which have fallen out of favor.
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Thomas Chang, DPM
Redwood Orthopaedic Surgery Associates
Santa Rosa, CA
Clinical Professor and Past Chairman,
Department of Podiatric Surgery
California College of Podiatric Medicine
San Francisco, CA
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Dr. Harold Schoenhaus: -- important talk and Tom Chang is back with us and he’s going to be talking on hallux rigidus. Please welcome, Tom.
Dr. Tom Chang: Thank you, Harold. 5:30, no, 6:10 on a Friday night in Las Vegas and this is where you are. Thank you for being here. Okay, so we’ll just try to focus on what I think is important. We all see hallux limitus-rigidus probably one of the more difficult things. I much rather do and take care of patients with hindfoot fractures, flatfeet and cavus feet. I just feel like it’s not as predictable in my hands dealing with these patients over the years with limitus and rigidus. Podiatry as a profession has kind of evolved with a lot of different kind of creative ways to treat this surgically and I think our colleagues in orthopedic world have kind of focused on kind of one or two procedures as either a joint salvage or joint distractive and it’s kind of the premise of how they operate on this. But I think it’s just important to talk about what’s out there, things that we have learned and ways that we can maybe move forward. Anyway, so these are it’s either my disclosures as I’m required to give and objectives here which we’ll talk about over the next several minutes. There’s definite etiologies besides all these kind of mechanical things. We know that you can have traumatic changes in the joint from injury and inflammatory and arthritic issues from trauma and fractures into the joint. But mechanically, we see these kind of unstable areas where the joints just doesn’t move well over time and there’s stiffening of those sesamoids that can’t glide any further and we have limitation and pain and stiffness which we know has been classified by many different authors but in general as most categories are, the earlier stages if they fail conservative options are more joint salvage options and then we move on to more joint destructive as we get further advanced. But as we are better about salvage and trying to restore movement, we find that you can try some of these joint salvage approaches for even more disease joints as in stage 3 and 4. There’s a whole slew of described procedures. I wrote the McGlamry limitus chapter years ago and there’s several hundred procedures describe for limitus, as well as valgus, hallux valgus. A lot of them are kind of variations of the same theme. The general premise is to consider kind of a decompression to that area either from the proximal or distal side and then possibly some type of a rotational cartilage or realigning procedure but trying to align the first ray into a functional position that is more in line with the lesser metatarsals, stabilizing the medial column. Those are all kind of the general principles which we all understand. We’ve done this for years. We use similar principles for hallux valgus and decompression as well and realigning that along the medial column. But all these procedures that we’ve learned back in school and residency, we still do. I still do osteotomies and can talk about that. But the use of osteotomies never was really widely accepted by orthopedic colleagues in their training and what they feel has been reported as efficacious in treating this problem. So this is Haddad, Steve Haddad in 2000 saying that these theories that we all base our treatments on, met primus elevatus, excessive met length have never been proven. So that’s something that we all kind of operated from anecdotally but never show that really to be indicated or those need to be treated in successfully treating hallux rigidus-limitus. I know a lot of the orthopedic colleagues that I have grown up with back in the Bay Area, Roger Mann, Glenn Pfeffer, those guys that were there when I started, have been told by many patients of both of ours that they never take postop laterals. They just never take laterals. When I get films from their offices for bunion procedures, any type of procedures, there’s no laterals for forefoot work. So, they truly don’t believe that that elevated ray makes a difference in what they choose to do, so it’s kind of interesting. In ’01, a year later, there was some description on looking at the cortexes and the structural or radiologic elevatus and maybe surmising that that plays a role which we believe and treat as a profession in podiatry. Coughlin and his group in foot and ankle mentioned a few years later in JBJS that hallux rigidus is not associated with any of these things that we believe it to be, elevatus mobility, the first ray, long first met, gastroc tightness and normal foot posture. Anyways, it just felt like it was just some type of random finding without any correlation to things about mechanically that we know and believe to be true, which is kind of crazy.
But he felt like that upwards to 5 to 6 millimeters of elevatus was well within normal limits. This is a JBJS in 2004. But we see this. We see the mechanical position of that first ray. We see it from a structural kind of a developmental position as well as we see it from surgical malpositions. We know that that first MPJ just doesn’t move better with that position and we also know that there’s transfer metatarsalgia. So we just haven’t proved that well until more recently but here we go. Here’s another case where clearly that does play a role in that position and the overall function. So Roukis, who has really kind of taken on this topic as one of his passions in life, talked about really trying to surmise if met primus elevatus was true or not. So he reviewed all the literature. He looked at, I think, many, many articles and then he found that there is clearly a correlation that met primus elevatus does exist in hallux rigidus and it’s greater and not found other common entity. So that was a nice kind of a way to look at it. Foot and Ankle International also believe that years later and saying that met primus elevatus now greater than 5 millimeters is a reliable predictor of hallux rigidus-limitus and those problems that we know about. So I think we’ve all understand that. As we do that and we think about the elevation and position and maybe the length when we treat these patients as a profession, we’ve learned and I think grown up with doing osteotomies. I trained in Atlanta. We did a lot of Green-Watermanns, decompressions. We’ve done a lot of [indecipherable] [06:45]. We resected wedges while using access guide and try to plantarflex and shorten things that mechanically would change the length and the structural sagittal plane position of the first metatarsal. That makes sense logically. These are some of the things that we do. Here obviously is just a diagram of showing that. Don Green who is part of the Green-Watermann evolution have talked about for years that when he sees these patients years later, they all feel that the range of motion is better on questionnaires. The preop and postop range of motion is better because they really have less pain, fragmentation or hypertrophy, bone is removed. There’s less tension in the joint. If you measure them, they definitely don’t really have increased range of motion but they all perceive that they do. So it’s more that their pain is better and we’ve kind of decompressed the joint. But in 2010, Roukis set out to see if there really was a benefit to doing these osteotomies that we all do and maybe not everyone, but now I think we kind of evolved in learning and growing up with treating hallux rigidus-limitus with osteotomies as per se in the earlier stages. He looked at many articles and followed different criteria. We've kind of retrospected studies where we kind of neglect it because they just weren’t really great research based and he looked at really level 1 and level 2. So out of all those, he only found like maybe four out of hundreds of those that satisfy the criteria. But he looked at these studies and try to summarize all the collective data and he found that with osteotomies that the mean dorsiflexion that they found increased with like 10 degrees. Out of all those, about 25% of these patients were really not that happy postsurgery and the complications were about 30%. Okay. That includes possibly a revision, maybe to another procedure, maybe metatarsalgia that was operative or even nonoperative, with mechanical support or just off waiting that. But clearly, those were findings that were not present beforehand and reported at 30% with osteotomies in this high level one and two EBM studies. If you look at cheilectomy with the same criteria for screening the articles, looking at the quantity of the articles and accumulating the data, the data is here. The mean dorsiflexion is about 9 degrees versus 10 degrees. The surgical revision was about 10% and 75% of the patients or 77 were happy, so that means there’s maybe 23 that were not, 23%. That may lead to closely the 30% of complications that reported in the osteotomy group. So the bottom line is, there’s really not much different support wise in terms of the literature out there in orthopedic and podiatric literature that really tells you that osteotomies are so much more successful or better than a cheilectomy. And Weil has talked about that for years even though he has osteotomies in his name, a really well done cheilectomy really makes a big difference and that maybe cheilectomy is modified with Moberg distally or another aggressive or lengthy type of modification distally at the proximal phalanx, but it’s just increasing the joint space and not necessarily doing an osteotomy with shortening and fixation at the first metatarsal.
The orthopedic colleagues for years have said, listen, if you’re going to save the joint, you think the joint is worth salvaging, cheilectomies are really the only procedure that you really need. There’s nothing shown that these osteotomies that everyone is doing really makes a difference. It’s a matter of perspective in my opinion on how you’re trained and how your perspective. This is a side of my brother’s. He sent this to me, saying that “Would you ever eat at this restaurant if you saw those on the road,” and we eat a lot. We have something going with our food. But anyways, he goes, “If you ate at this restaurant, you probably would get a fortune cookie that says something like this.” Anyways, he said, “But if you take a step back like you’ve taught me for years and you just look more broad at the whole picture, you may find that it’s a really great restaurant,” and that is something that you may choose to try. So the bottom line is I’m not telling you that you should not do osteotomies, distal osteotomies. I’ve done hundreds of them. I trained doing them in Atlanta, I do them at the school when I taught there. I still do them but I’m not really sure sometimes why I do them. The literature doesn’t necessarily support me doing them versus cheilectomy. I’ve done lot more cheilectomy in the last three or four years now than I have in the past 20 years. I just think that there’s something to be said for that. There’s probably less complications. There’s no bone healing issues. There’s no fixation issues and patients are on the most part pretty comfortable to how they have done with previous osteotomies, with cheilectomies. I’ve actually done them more even on long first metatarsals where I felt like I need to shorten them in the past and anecdotally, I can tell you that I really don’t think there’s a much difference in the model, maybe take a third of the metatarsal head off and clean out the joint well and that really is just more anecdotal. Now, there are situations where you have some significant elevatus, not just the distal kind of met elevatus you see on the first ray on the lateral view, but more structural, maybe from the malalign surgery or something more along the medial column proximal, while that motion comes sometimes out of the naviculocuneiform joint and more proximal medial contributions. So those are things to think about. When you need to have significant structural changes for these cases, then I would do osteotomies there because I feel like realigning the medial column make sense and not just fairly just bringing down the first met head. Now these are just some examples. In those cases, it’s been described that you can have longitudinal rotational osteotomies. This is a kind of a scarf type which is an option 90 degrees rotated, dorsal to plantar and you can rotate that and titrate that down. It’s very easy to do. You can position that where you want, temporary fixate it, check the alignment and then you can change it if you want to because the through and through osteotomy, you can also do this for cavus or elevate them versus elevated first met where you plantarflex it. So that works well. This is just an example where that’s rotated and elevated and malpositioned. We just cut it through and through and rotate that plantarly. Here’s an example of just the MIS procedure that went awry. Elevation is pretty significant in those cases. I did osteotomy, rotated down, sagittal plane with screws and that seemed to be much more functional. So those make sense to me. The large structural deviation many times postsurgery with malpostioned and/or more proximal types of structural elevatus. But sometimes when you rotate that down and you do a rotational for these large osteotomies, you also rotate the cartilage, the functional cartilage and do a more plantar position, right? So that makes sense that you may lose some functional cartilage that you may use. So there are people that do double osteotomies, proximal rotations and then Watermann distally because of the cartilage position. So that’s something you could consider where you just do some type of sagittal plane revered and/or a Watermann or something there to dorsiflex the head. Now you have more functional position of the hallux and you have more cartilage oriented and a good position. Double osteotomies make a sense, they make sense. The other thing I would say is that in these osteotomy approaches, soft tissues are important to consider. This is something that I wrote about maybe in 1996 when I was at the school. There were times where people are doing EPS pretty regularly at that time and they found that when they did EPS, that patient has better first MPJ range of motion, right? So that was maybe reporting may remember that. Obviously, wasn’t the reason to do EPS but that that was just an ancillary finding. So the reason for that is because the medial band and the fascia obviously attaches to the distal flexor plates and the [indecipherable] [15:03] that are attached from that plate or that distal band of the fascia into the MPJs.
So if you release that band there, then you have less adhesions or less tension along that first MPJ or even any of the MPJs plantarly and that’s what we found through EPS. That’s what we used to do on some of these resistant cases. So like when you do these procedures, hallux limitus-rigidus cases and you free up the soft tissue, you do a cheilectomy, you may do an osteotomy, you get an increase of motion as you go from one step to the other. If you’re still not fully satisfied after you’ve done your osteotomy, you feel like you’ve reached your soft tissues, you could consider releasing the plantar medial band of that soft tissue right behind the MPJ. This is just example of the medial band obviously dorsiflexed the toe. You know that from their tension. The only other structure you worry about is the long flexor to the toe but we looked at this in cadavers at CCPM and we found that you’re pretty clearly away from the FHL in a deeper layer so the superficial band is that medial band that we used to just making incision and make a stab incision, where you find that maybe you get maybe 10 degrees greater range of motion, just because of soft tissue tension in the plantar fascial areas. So that’s something that you may consider as just another contribution to these areas and that’s just kind of a diagram of that. The other standard for hallux rigidus clearly is where you have stage 3, stage 4 and you resort maybe to an arthrodesis. Arthrodesis, they are much more widely accepted now. There’s really not much that you can’t do functionally with an arthrodesis except for wear high heels, up to maybe an inch you can wear but nothing greater. You have to really educate your patients on that but it seems to be very functional. There are professional soccer players in Europe that have a big toe joint fusion that are paid crazy amounts of money. They’re fully functional. And so patients in your practice can hike and walk and play golf and do all that. So they need to know that they can run. The only thing that’s important is just a position. We used to try to dorsiflex it more nowadays. I think it’s important to load the foot, assimilate weightbearing, make sure that the pulp of the hallux is kind of gently touching the ground. You could elevate it slightly but you don’t really want to clear view when you fully load the foot. You don’t want that. You want the hallux just to be touching the ground, it has some dorsiflexion available to the IPJ and you have some compensation there. You also have compensation through proximal joints along the medial column. You have three other joints back there. That can also move in the sagittal plane, you’re fairly functional with that. Emily Cook and her colleagues did a met analysis of other options of first MP implant for rigidus-limitus, hemi as well as totals. They actually found many citations here, it’s just like a met analysis, 3,049 procedures in general. In general, patients are 95% satisfied. That’s pretty remarkable. It’s impressive. We all do first MP implants. We know that they still are an option. What frustrates me sometimes they go to ACFS and I hear dogmatic statements made that we shouldn’t be doing any first MPJ implants. That’s just crazy because when you look at residency training log through ABPS and the communication with ABPS officer, they tell me that when they have a hallux rigidus or hallux limitus diagnosis code, lot of those procedures that residents are still doing around the country are first MP implants. I think that they play a role and I think in the right patient they obviously have high satisfaction rates. Paul Kim out of Georgetown did a study where he looked at multi-centered, these are the ACFS sponsored research project and looked at just outcomes for arthrodesis, hemijoint implants and the resection arthroplasty, essentially Kellers for hallux limitus and hallux rigidus. This is just a panel here. You may have seen article, there are three main used to be study groups and they pretty much have similar patients and postop followup. Importantly, there really was no main difference in terms of demographics between the groups and there was really no significant difference in the reported outcomes in terms of patient’s satisfaction. They’re all happy. Joint pain was better with any of those procedures. If you look at the scores, pre and postsurgery, they are very similar with ACFS and AOFAS, that’s great to see all of this have similar outcomes. But what’s interesting is that the complication rate was lower in arthrodesis. There was this more stability on the medial column, maybe less lateral transfer metatarsalgia, those type of things, less reactive bony growth. That’s interesting to know. I think in the general scheme of it, similar outcomes, the complications were lower in that patient with arthrodesis. That’s something that is widely accepted as a very viable option. It’s also been introduced in the last five, 10 years that we have interposition arthroplasty options.
You can use tendons and capsules, just as a separator or space were there. Allografts have been used, cadavers, menisci have been used and described. There’s discussion this morning on resurfacing techniques. Dr. Schoenhaus authored a few papers back in 2009 on an acellular matrix to recover the met head and that’s been actually very favorable in terms of the early outcomes and reports and there’s metallic HemiCAPS that are out there as well that can be used for that. This is an article that Schoenhaus and Brigido authored back in 2009 in clinics. There are options for joint salvage kind of trying to find a nice interface between the sesamoid metatarsal apparatus is something to think about. I think another exciting next evolution of treatment will be coming soon. It’s used widely around the world, in Europe and Canada but not yet in the U.S. I think soon you’ll see that. I think a speaker this morning spoke about it as well. It’s just a synthetic cartilage implant that is really just design to go ahead and give a little bit of separation moved the proximal phalangeal impaction away from the met head and essentially just mimics cartilage polymer but in terms of the speed of the surgery, in terms of having patient outcomes of two years, they found that utilizing these cartilage implants, this pain decrease or the improved function and range of motion all increase. It’s really something that’s exciting as an option. You really don’t burning bridges if the patients end up having more joint problems in the future then they can always have a revision to a fusion or something else with minimal bone resection on the initial surgery. Something that you look for with these synthetic cartilage implants in the next several months. Conclusions from Roukis’s paper in 2012, it just show that the literature supports these general options for hallux rigidus currently, cheilectomy with some modifications distally, interpositional arthroplasties and arthrodesis. That’s what we’ve described already. If you use implants, probably the hemis are better because they have less bone resection and you can revise them easier. Undecided are other resurfacing and allogenic interpositional arthroplasties and things are not really supported are osteotomies and also two component implants. It’s just something to think about and take home with you. Okay, in summary, we clearly need better studies to support how we approach this. I think if you still do osteotomies in your hands that work well there’s some biomechanical reasons that make sense but the literature doesn’t always support that over just doing a cheilectomy for the same problem. The met primus hallux valgus seems to be a reliable indicator so just think about that as something that has been shown now to be more prevalent in hallux rigidus and something that you can use to use the guided diagnosis and you could choose to treat that but a cheilectomy is really as the first sign approach that we find predictable as well as arthrodesis for more advanced stages. Thank you for your time and I appreciate my invitation here this weekend and enjoy the weekend. Thank you.