Christopher Bromley, DPM discusses the clinical and radiographil presentation of hallux limitus, its staging, as well as the current common treatments. He also reports new conservative and surgical options that can be used to treat hallux limitus.
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TAPE STARTS – [00:00]
We’ll talk about current trends for Hallux Limitus.
Disclosures, I do quite a bit of speaking for a number of companies. If you hear me talk about today -- alright so the goal today is to understand the condition that is near and dear to our heart probably the second most common thing we see besides plantar fasciitis, hallux limitus is typically a reduced range of motion of obviously first MTP, also referred to as a dorsal bunion arthritic great toe, typically results from either trauma or elevatus or supinatus of the first ray.
Typical clinical presentation, obviously patients will come in, they don’t have a typical medial bunion deformity hallux valgus. They will limitation in range of motion and pain. There will be typically pain with ambulation, increasing with activity, sports shoes. They may also in the late stage III or IV, they may also have sesamoid pain, more common in women than men typically, people over 50, although it’s becoming more common in people under 50. And about 60% is found bilaterally. If it’s a direct result of trauma, typically you’ll have a compression injury to the first metatarsal as we’ve described turf toe, you’ll have an osteochondral defect and that osteochondral defect as it's typically doesn’t heal well will lead to pain in the joint.
Indirectly, if a patient has a flexible flatfoot or forefoot supinatus, you’ll end up with TMT hypermobility and that leads to jamming on a weightbearing and toe off. Clinical evaluation is important, obviously getting a good history and getting an idea from the patient what their expectations are, somebody may be very sedentary or somebody may also be a ballroom dancer.
Good exam, gate exam look at the biomechanics to figure out what other factors, what their vascular and neurologic status is and then get a good medical history. As I mentioned this morning, I had a case where we were doing a lapidus and the woman forgot to mention to us that she had failed every clinical trial for osteopenia. Also evaluate obviously their medications and supplements, particularly nowadays if people are taking fish oil and if you’re planning surgery you want to make sure you take them off.
Radiographic exam, this is an important slide, so obviously typical presentation here for probably a stage II. Obviously, we see a collapse of the joint here and you’re going to get some periarticular sclerosis. This is the view that we don’t take often enough, a sesamoid axial, it’s a tough for you to take in the late stage II or III or even IV, but I what I do tell patients when we are talking about planning, if they’ve got pain due to the dorsal spur or the first MTP if we replace the joiner or fuse it, that pain will typically go away. If they have any sesamoid involvement in this late II or III or IV, whether I’m replacing or refusing, if they’ve got sesamoid involvement, I’d typically tell them that pain is not going to go away, important to make sure you manage their expectations.
So this is a good graphic. It just shows you a normal, normal range of motion of the first MTP and then we go through the four stages of hallux limitus. So we’ve got in the in the early stage I you can see you may have an osteophyte, may have some pain and range of motion, and obviously the treatment is obviously -- we will get into treatment as far as managing it conservatively. Stage II as you can see significant decrease in the range of motion loss, you’ll see a flattening of the metatarsal, you’ll also start to see a periarticular sclerosis and osteophytes growing off the dorsal first met as well as the base of the proximal phalanx, and you’ll monitor severe pain at range of motion.
The III’s, you’ll see less than 10 range of motion, you are going see severe narrowing of the joint, lots of bone formation around, and then you’ll start to see the sesamoid start to change here. And obviously stage IV, there is a little range of motion, we’ve almost fusion going on across the joint, and these are the patients who typically will either live with it or go into a fusion. So treatment alternatives, one of the things that we obviously specialize in is as experts in looking at what their shoe gear is about, what the biomechanics are, and what some of the firstline treatment are. I don’t know about you, but one of the things that’s been very frustrating for me is the fact there was so many shoe companies that have gone to a really flexible shoe without a really good last. I always tell patients I pick up their shoes and I start flexing them like look your foot is designed to bend here, it is not designed to bend in the middle. I don’t care if you like these shoes, they’re light, they’re not doing any good. I spend hours every day referring patients to better shoes, not just for orthotics, but also to get into a good shoe with good structure, because the trend now with these really flexible, loose kind of stuff, it's really not going to working and even if you put a great orthotic and it’s still not going to work because the shoe doesn’t hold the foot on the orthotic. I respect all the orthotic lectures that were given today, but we should probably have a primer on what good shoes is.
As far as pain management, we still do a fair amount of topical. I work with a couple of good topical compounding companies and one of the things about topical compounds is you have to remember to tell the patient it only works if you apply it, and you need to apply frequently three to four times a day for three minutes. The reason it’s three minutes, I tell them three times a day for three minutes, so they remember it
And I tell them that if you just rub on a topical compound, it's going do nothing other than use up the compound. you’ve got a massage the skin structures enough so that the blood flow is enough into the structure to grab the compound and pull it in. if you don’t apply three to four times a day and you don’t apply for three to four minutes, you’re not going to get better.
I’m not a big injection guy. I think the only time I ever use a cortisone injection is for gout, but if we do have a patient who has hallux limitus and you need something to help get them over the hump until their orthotics are here or until you going to plan a surgical intervention, I tend to use the injections barely. I use very little oral NSAIDs. As we talked about in the workshop today, I do more boswellia [phonetic] talking to patients about into a low-inflammatory diet. Some of the new modalities in the office, if you’ve been here before you’ve heard me speak about low-level laser we do a fair amount of that, it's helpful. Low-level laser is good for inflammation, but it’s not going to do much for the deformity. it's just to help to manage the symptoms. Obviously other things, physical therapy, topical steroid with iontophoresis is helpful, but again it just going to manage the symptoms, it's going to buy them some time.
Beyond conservative care obviously, accurate staging you’ve only got I, II, III or IV and what is your goal. If the patient has a very active lifestyle and you’d like to preserve the range of motion and the purchase of it you want to make sure that you give them the options that will work well for their lifestyle. I’m not a big fan of staging it, I think earlier in my career well we all would just do a cheilectomy and maybe down the road, we’ll be doing something else, but I think with some of the better procedures that we will talk about I tend to talk to patients about early intervention, we start conservatively with orthotics, better shoes, and if they fail with that, then we talk to them about what our treatment options are.
If they move on to an arthrodesis, we typically talk about stabilizing the medial column and looking at fixing the deformity because even if you put a good resurfacing -- there’s a couple great companies that make a product resurfacing. Even if you fix that, if you got an elevated first ray, it's a wonderful joint, you may have put in beautifully, but it’s not can work because it’s going to fail just like their joint did.
So what’s new, the alternatives that we have beyond the compounding and laser, we are doing a lot with the biologics. As a part of our bunion surgery, we do and I’ll show you some slides on osteochondral repair where when I was trained in residency we had a K-wire and we could drill it in and maybe we get some subchondral drilling. I’ll show you why that’s not a great option, but the osteochondral repair, kits that we have from the ankle we use that particular device and then we combine that with an allograft as a part of our procedure.
We also use that a lot when we are going bunions. If we’re doing a bunion, whether it’s a proximal or distal osteotomy, if we have an osteochondral defect there we want to address it. So we typically will fix that first and then perform the osteotomy and then before we close, we’ll put the allograft down over that to see that cartilage. For patients who have late stage II’s or III’s, our typical choice is to do a resurfacing, either on the base of the phalanx or the metatarsal head. I’m not a big proximal phalanx guy, I think there are easier to put in, but typically when I look at a stage II or stage III, most of the damage is going to be on the metatarsal head. It's usually sparing of the proximal phalanx. It's not when you get to the end of stage III or IV where you see the base of the proximal phalanx cartilage go. So for late III’s that are painful in the sesamoid or at IV, my typical choice will be to do, in an older patient who is very sedentary to go with a standard Keller Procedure. If there are younger patient that are active, we’ll do a fusion, so we’ll show you some of those.
Intra-articular options obviously, there are still people who like cortisone injections obviously, the relief is going to be temporary. These injections are out-of-pocket, they don’t particularly last very long. I’ve done stem cell, PRP and biologic injections, they are not very helpful. They typically don’t last and the reason they don’t is because we haven’t fixed the deformity. This is showing you some of the flow in membrane. This is an example of using an allograft repair. So in a typical bunion surgery, we’ll wrap it around the metatarsal. If we got an osteochondral defect, we’ll actually do, I’ll show you the nano effects. So first choice for stage I or early stage II is to do cheilectomy, this will work if you’ve got a dorsal spur, but if you got an osteochondral defect you’ve got to do a repair there or it's still going to hurt that’s where we get into using that the nano effects, which is a tool.
Basically, what we are going is when we do these repair, if you just nick at the surface, you’re not can do anything. What you’ve got to do is get down 7 to 9 mm to the subchondral bone to create the bleeding. Once you get the bleeding, there you’ll get the repair. So basically this is a tool we use in the ankle, it's a reusable handle and a peg, these are disposable and there’s a pin. So what you do is you just kind of tap this in, you make a little grid pattern and then you use the thumb to pull the pinout. It's a really, really, nice device, it's very inexpensive. The reason it works for the osteochondral repair is what you’re trying to do is get down to the subchondral bone to get some bleeding. The downside of using a K-wire, the K-wire is small, the problem is when you spin the K-wire in, the friction of the K-wire going through the cortical and then subchondral bone is it spins the trabecular pattern together and it basically seals it off, and there’s also heat from the friction. So the advantage of a nano fracture is it's going to go straight in straight out 7 to 9 mm, so that tends to work a little bit better.
So this is an example of what you might see in a stage I or II whether you’re doing a cheilectomy and you can see this big defect in the center that’s obviously the source of the patient’s pain because it’s bone-on-bone. So what you want to do here is you want to address this. So we go ahead and do the procedure, we make a little grid pattern and then we do all the work that we need, you want to get all the dorsal bone off, you also want to remember to clean off the base of the phalanx, so you’ve get a nice joint that moves and then before we close, we put the graft over.
So again classic Keller is still used, I actually had a patient a few weeks ago who had a Keller done by another provider. She’s on in years, she’s very sedentary, I’m not a big base implant, I’m more of the hemi first metatarsal for stage II and III’s, total for the late stage III, and fusion for the IVs. So again Keller I don’t need to spend time with you guys. The advantage of the hemi base for some people is it’s very easy to put in, but as I said the downside is it doesn’t really address the osteochondral defect and also doesn’t work particularly well that’s why we do that sesamoid axial view. You can see some of these cases before and after, let’s what they look like. This is an implant a hemi implant, which I have about 15 years’ worth of experience is this one here on the top. The advantage of them is that they’re very stable because they’re screwed in with a titanium peg, they do replicate the normal mechanism of the first MTP, they don’t disrupt the sesamoids and they do work particularly well.
The downside of some of the other ones is they just slide in, they’re not as stable, they tend to move a little bit, but we will go over some cases. This is an example of what the one product looks like, it is very stable. Of all the ones I put in over the last 15 years, the two or three that I have ever taken out. They’re little bit challenging to takeout, which shows you how stable they are. In order to get them out, you actually got to put an osteotome between the bone and rock it back and forth. It’s a two-piece implant and there is a Morse taper that keeps the chrome piece in place. You’ve got to break that taper to release the cap and then you can put the instrumentation in and back that screw up, but I’ll tell you of the three that I’ve taken out there in there pretty tight. Very easy to perform, not difficult, again it’s the right patient selection is really important and good dissection, so we’ll go through the case. This is what it looks like on the lower, you can see that the curvature here. There a there’s a 0.35 and a 0.45 as I’ve gone on in years I tend to use more of the 0.45 than anything else.
I’m showing you some range of motion postoperatively. There’s some other implants on the market. I’ve tried these as well, they’re little tricky to put in because you’ve got to cut all this out. One of the reasons I don’t particularly like this one is if I cut all this out to put this implant in, if I’ve got to take this implant out, I haven’t left myself with much to work with. If I take it out, I’m going to end up with a toe that sitting up in the air and it’s also difficult to rebuild as a fusion.
As I said in an earlier in the lecture, we use biologics when we do these. Postop protocol is early range of motion, every time they take the ice pack off, they’re going to do ranging motion up and down. We typically take them out of a surgical shoe within about a week and we take the dressing off and we start getting them to move it. I tell them they’ve got about 12 weeks to move this particular toe and if you don’t move in 12 weeks, it's not going to move.
For the late stage III or those that have sesamoid involvement, we typically tend to either do a total or fusion. This is an example of a fusion plate, there are lots of great ones out there. Most of them are locking plates, I do with my first MTP fusions always use a compression screw and you want to do the typical joint prep to get where you need to be.
This is an interesting lady. She she’s a librarian at Vassar College, which is right around the corner from me. She has like purple hair, a very interesting lady. She came in with the spontaneous varus on both great toes without any prior surgery. i think it’s related to -- we know you can see we can have a good outcome for her.
First MTP arthroplasty, we’ve got good total toe implants to work with this is called a Toe Motion System. So it’s basically like what I showed you before except there is a phalangeal component. It's a little more challenging to put this in if you’ve never put them in. This is pretty easy. Both these components have been used for years in the shoulder. My good friend Russ Warren at HHS has a quite a bit of experience in the shoulder with these and some pretty high profile athletes. This is what that looks like on the DP and the lateral. These are again typically late stage III and the deciding factor for me is if I’m doing fusion or a replacement is sesamoid. If they got any sesamoid involvement and they’ve got sesamoid pain, I’m going to fuse it. If the sesamoids are okay and it hasn’t been too many years since it got that way and I’ve got some joint to work with, but you could see this is good positioning. We’ve maintained the length, here we don’t have a lot of shortening and we have good alignment.
If you look at this x-ray, you can see there’s not a lot of margin for error in the phalanx. When you put these in, you’ve got to be dead center and remember that the proximal phalanx comes up plantarly, you want to make sure you don’t come out through the plantar cortex. This is one of those using the mini C-arm is pretty helpful. Here’s a good x-ray showing you how much range of motion you can get out of that implant.
This is a case that a patient had the metatarsal component put in. The problem with this particular case was the surgeon didn’t do a really good job cleaning off the phalanx. So even though they did a decent job putting this in because they didn’t clean out around here that bone is trying to grow over that implant, so that’s going to reduce your outcome. So what we did is we just converted that patient to a total. When this particular implant was put in, we didn’t have a total, so now we’ve got a total where we can convert them. So typical dissection for these are very long incision, so that you get good exposure, and the way that the set works you basically put a guidewire in and take a picture to make sure you’re right where you want to be and then you tap and screw in this phalangeal component and then you press in the poly. I will tell you that when I do these, they tell you drill right through the cartilage, what I do now is I almost Kellerise [phonetic] the base. I take a sagittal saw and I take the base of the cartilage like maybe 2 mm right off. So I’ve got the reason being is I want a nice flat surface to work with and I also want to be able to decompress. They make a 1 mm and 2 mm spacer, which is nice, but even with the one if you don’t decompress here, you’re going to end up with a really tight joint. So by Kellersing the base before I put that in, it tends to work better.
You can see here where we put that in, we've got some good positioning. This is a nonunion for a fusion that patients very unhappy with, we converted them to a total, I tend to stay away from this.
Every now and then, I’ll have patients come who were referred to me for, “I didn’t like my first MTP fusion, I hate it, I don’t like the fact that my toe doesn’t move, can you convert me to a total joint.” And I've tried it initially when the total toe came out and I’ll tell you I never really loved the results. The patients were okay, but if the patient’s been fused for a while, even if I put a nice implant in there and do a beautiful job, it’s not going to move because they’ve lost all their intrinsics, the toe is not moving but it was worth a try.
Again, here is a case where implant positioning was good, but didn’t do a good resection off the phalanx. So again we convert that into a total. Here’s a patient just a 68-year-old. This is one of the nurses I used to work with at Vassar. One of the key when you do this procedure is the guidewire placement. So you want to be parallel to the long axis and then you want to be sort of perpendicular to passa. What I typically do is I only put this guidewire in 2 mm or 3 mm and I get an idea where I am because this is a big pin, if you put this pin in all the way which is supposed to go way back to here and you don’t like it. When you go to take it out to reposition it to improve, it's going to go right in the same hole, so I put in 2 mm or 3 mm and take a picture, take a lateral and a DP to get an idea of where you want to be, you want to be sort of perpendicular to passa right down the middle.
This is positioning for the phalanx same thing, remember what I said that the proximal phalanx tends to come up plantarly, so you want to be right in here. This is one of the earlier cases and this is a good example and this picture of why, what I want to do now is -- so that I can decompress this better as I basically take out almost that much bone off maybe 2 mm or 3 mm and square it off. It makes it much easier to use and much easier to get implant in, and it really decompress it and that’s what it looks like if it’s done correctly.
Again, there are lots of different options out there. There’s still colleagues of mine that they are using the silastic implants. There are a couple of different companies out there. They’re all good implant, you just had to figure out what works best for you. Multiple options, obviously if you’ve got an osteochondral defect and you want to do a cheilectomy for stage I great. If you got II with just metatarsal disease, you can re-surface. If you got a late III, you can do a total and if you got a late stage III with sesamoid or stage IV, then we go ahead and fuse. So that sort of wraps up to fixer to fuse. I’ll tell you more often than not, I’m the guy the try to replace the joint as supposed to fusing it, but that’s up to personal choice.
So you guys have been a great audience. Do you have any questions? No, good all right well thank you very much for your attention and for hanging out, and I look forward to seeing you on Sunday.
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