Hallux Limitus/Hallux Rigidus Role of the Sesamoid Apparatus

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MP Arthrodesis
- Unraveling The Myths Craig A. Camasta, DPM
Atlanta, Georgia, USA
Hallux Limitus
ƒ “Dorsal” Bunion
ƒ Spasm of Short Flexor
ƒ Immobility of Sesamoids
ƒ DJD of 1st MPJ
Hallus Limitus
ƒ Plantar Tyloma
– Hallux IP Joint
ƒ Transfer Metatarsalgia
– 2nd MP Joint
1st MPJ Axis of Motion
ƒ Normal Function
– Central in Metatarsal Head
– Changes With Position of Joint (Cam)
– Sagittal Plane Gliding
1st MPJ Axis of Motion
ƒ Sesamoid Immobility
– Plantar Shift of Axis
– Fixed Position
– Hinge Motion (Fulcrum)
Sesamoid Immobility
ƒ Plantar Axis (S-P Ligament)
ƒ Dorsal Impingement & DJD
ƒ Plantar Cartilage Spared
ƒ Crista Furrowing
Hallux Equinus
ƒ Gripping of the Proximal Phalanx
ƒ Provide Medial Stability
ƒ Spasm of Short Flexors
Hallux Equinus
ƒ Functional Fusion of MPJ
ƒ Straight-line Dorsal Cortices
ƒ Long Medial Column
ƒ Apparent Met Primus Elevatus
Hallux Equinus or
Metatarsus Primus Elevatus ?
Varus (any level…)
Hallux Equinus - Secondary Elevatus
Sesamoid Hypertrophy & Osteopenia
ƒ Chronic Traction
ƒ Reactive BoneProliferation
ƒ Correlates to Degree
of MPJ DJD
ƒ Predictor of Salvageability
Relative Joint Surface Area
ƒ Normal Surface Area
– M-P Joint
– M-S Joint
60%
40%
ƒ Hallux Limitus Æ Rigidus
– M-P Joint
– M-S Joint
40%
60%
Sesamoid Hypertrophy…
Hallux Limitus / Rigidus – Surgical Tx
ƒ Elimination of Motion
– Fusion
ƒ Restore Motion
– Resection Arthroplasty
+ / - Implant
– Cheilectomy/Osteotomy
ƒ Alter Joint Position
– Osteotomy
61F Painful Hallux Rigidus…
Cheilectomy + Osteotomy…
Indications for 1st MP Fusion
ƒ Hallux Rigidus – no joint space, sesamoid fusion
ƒ Hallux Valgus with DJD
ƒ Chronic / Recurring Gout
ƒ Failed Prior Surgery (cheilectomy, implant, etc)
ƒ Hallux Varus (resistant to flexible reduction)
ƒ Hallux Equinus (spasm of FHB, sesamoid
retraction)
ƒ Neurologic Deformity
ƒ Complex Forefoot Deformities
1st MP Joint Range Of Motion
ƒ 65-75 Degrees “Required” For
Normal Gait…
ƒ Based on Disability Rating
Available ROM…
ƒ NORMAL GAIT
ƒ Less than 10 Degrees…
(Hetherington, et al.)
Controversies With 1st MP Fusion
ƒ I need 65 degrees of motion… No you don’t !!!
ƒ You have a painful stiff joint in a bad position… we will
give you a painfree stiff joint in a more functional
position…
ƒ Can I wear high heel shoes? -- you will be able to wear
anything after surgery that you can wear now, it just won’t
hurt to wear them…
ƒ Can I run and exercise? You will be able to do everything
that you do now, it just won’t hurt to do it…
1st MP Joint Fusion
ƒ 1st MPJ Fusion
– Motion = Pain
– Metatarsal-Sesamoid Joint
– Adjacent Joint DJD
– Position, Position, Position…
1st MP Fusion
Position of Fusion
Position of Fusion…
ƒ Dorsal – Hallux Parallel to Corrected 2nd Toe
ƒ Lateral – Hallux Parallel to Ground
(just barely touching ground)
ƒ Foot Maximally Pronated
(Simulates Late Midstance)
Sagittal Angle of Fusion ???
ƒ Different in Every Foot…
ƒ Hallux Proximal Phalanx Parallel to Ground
ƒ As Soon As Heel-Off Æ Hallux IPJ Purchase
1st MP Fusion
Post-Op Year 4 Fusion
1st MP Fusion PO Year 7
Hallux Valgus / Rigidus
Fusion - Metatarsal/Phalanx/Sesamoids
Fusion – Metatarsal/Phalanx/Sesamoids…
Ultimate Bunion Procedure…
Salvage Procedure…
ƒ Failed Hallux Limitus /
Valgus Surgery
– Cheilectomy
– Osteotomy
– Implant
ƒ AVN…
ƒ Complex Forefoot
Derangement
Hallux Valgus Æ Varus Æ Fusion
Failed Implant - POW 8 Graft + LP
Severe HAV, Obese, Ni Allergy
Pre & POM 3 (FWB)
(SM) Post Op Year 1
Locking Screws / Plates + Bone Graft
Complex Forefoot Derangement
ƒ Forefoot Effect on Rearfoot
ƒ Spastic FHB Tendon
ƒ Volkman’s Ischemic
Contracture post
Compartment Syndrome
Post Traumatic Compartment
Syndrome – Hallux Equinus
Range of Motion Examination
Post-Op 1st MP Fusion
Metatarsus Primus Elevatus ?
1st MP Fusion / Pan Met Head Resection
Pre-Op
and
Post-Op Year 4
62 Female HAV/HR
Pre and Post
POM 6
B/L 1st MP Fusion
52 Male Prior Osteotomy/Cheilectomy
1st MP Fusion…
Gait (left foot)
Toe-Raise (left foot)
45 M B/L Hallux Limitus + GOUT
Post B/L 1st MP Fusion
Gait Post B/L Fusion
(NG) 60F Painful B/L Hallux Rigidus
Hallux Equinus / Rigidus
Post Op B/L 1st MP Fusion
Gait Barefoot – B/L 1st MP Fusion
Gait Shod – B/L 1st MP Fusion
(AW) POM 9 Mitchell – Nerve Entrapment
(AW) POY 3 - 1st MP Fusion…
Nightmare…
Pre & Post Gait
1st MP Fusion - Summary
ƒ Normal Gait Requires NO MOTION
ƒ NEUTRAL Position of Fusion
ƒ Remember the SESAMOIDS
ƒ WB to Tolerance
ƒ Primary & Salvage Procedure…