A Plantarflexory-Shortening Osteotomy for Hallux Rigidus: A

A Plantarflexory-Shortening Osteotomy for
Hallux Rigidus: A Retrospective Analysis
Richard Demer, DPM, FACFAS, 1 Keith Goss, DPM/;t Hiedi Noel Postowski, DPM, 2 and Nancy Parsley, DPM2 This retrospective study reportea the olinical and radiographic finoings of a plantarflexory-shortening first metatafSQ! osteotomy for treatment of haJlf,ix rigidus. Twenty-six patients (33 faet) were evaltleteci with fi/ mean 34.4 months follow-up (range, 18-65 months). Assessment consisted of clinlc.f:'! mSI;lSufl5ments of total range of first metatarsophalangeal joint motion and radiographic mf!KI$urem€lnts
of first metatarso­
phalangeal JoInt space, Including plantarflexion and shortening of the first metatarsal. patients wenr waluated pO/rtOPBratlYefy using the Amerlc9n Orthopedic Foot ana Ankle Society's HsJlux Metatarso· phalangeaf.lnterphafangeal Scoring System. The mean preopet<lUve first metatarsophalangeal jOint total . mnge of motion was 33.S· (5°-60~), and postoperatlve~y increased to 72,1° (50-100°), fl mean increase
of 38.0· at follow-up (range, :?5°-50') ~ < .001). This range of motion was ob$erved despite a lack of
significant Improvement in radiographic joint space measurements, (preoperative mee.1 1.26; postoper·
ative mean 1.82). Postoperative radiographs Siso demonstnrtad 1-4 mm of pfantarllexion of the first
metatarsal head. ena a mean 1mm shortening of the first metatarsal. At last follow-up. 85% (22126) of
patients t<lted their result as vel)' good to excellem, 8% (2126) reported a good result, 4% (1126) ill fair
result, and 4% (1125) 8 poor result. The mean postopl'trstive rating scale score was 78.11100. No patient
required revls/onal surgery for hallux rigidus, Four patients had postoperative lesser mstfJtsrsalgia. 3 of
which were self-limiting, and 01')8 that resolved following surge"j. The resl,Jlt'$ of thls stl.Joy show the
pJantarfleXory-shOrtaning fifl'!t mstata.rssJ to be an effsctive sUli1iC~J treatment fOr ha/lvx rfgldus with
roprodr.Jciblt; deformlty correction end patient satisfaction. (The Journai of Foot &. Ankle Surgery 44(5):
377·389,2005)
e.
Key words: hallux rigldus. osteotomy, decompression, plantar flexion
Hallux rigidus can be defined as a limitation of dcrr,;;;­
flexion of the base of the proximal phalanx on the head of
the first metatarsal. First reported by Davis-Colley (1) in
1887 as "hallux flexus;' this clinical entity was described a<;
flex.ion of tb~ proximal phalanx with a~sociated swelling
and stiffness to the first metatarsophalangeal Joint (MPJ).
Cotterill (2) coined the term "hallUX rigidus" to describe the
same entity. adding pain and limited ballux dorsi flexion to
thE; pathological picture. Regnauld later prcsi:.nted hallux
rigidus as chronic osteoarthritis of the fint MPJ that pro­
gressed throtl~ 4 predictable stages a~ detennined by clin­
ical and radiographic assessment (3).
Although many competing theories have been propO$Cd
for the etiology of hallux rigidus. it appears thll[ there is a
functional, biomecn..'lnlcal abnormality of the first ;\WJ
Acldrc." oorresponcteocc I(l: Richard· DCn1I!:f. DPM. FACFAS, l'1Z1
Fillaneinl Loop. Lal::c Ridg~. VA 22192. E-mail: Richd87@>~ol.,"m
Iprivstf pr~ctice. Northern Vtrt;inii Podistrlc Surgical Rc~ictcnc)' !r~;n·
ing committee member. 1.ake Ridge, VA
'Rc;<idcnc, lNOVA l"airfax HoSpilnJ Podiatric R~,idency·l'roRr3rn
CO!,yrighl <0 2005 by ti'le Amm"sn Col1~ of Foot and :\nkle S\lT~rm,
I067.2S 1610514405-0007$30.0010
ooi:to. 10531.jfa<;. 2005,07.010
(4-6), The proposed causes for hallux rigidus inclUde hy.
permobility of the first ray, immobilization of the first ra),.
a long first metatarsal, metatarsus primus elevatus. degen­
erative joint disease. trauma. abnonnal first metatarsal head
morphology, exce,ssive length of the hal)\l1<, plana! domi­
nance, first metatarsal-cuneifonn ,jOint morphology, ~e­
striclcd sesamoid migration, neoplasm, joint 5epsi~, and
iatrogenic causes (4-8). Indeed. any condition that limits
the ability of the first metatarsal to plantarflex in the late
stance phase of g:dt has lxen implicated in causing reo
st~icte<l first MPl range of motion ane! subseqllont joint
destruction (7).
Regardless of the etiology, the primary pathology is the
same: the first metatarsal head becoUles elevated, prevent­
ing the normal dorsal motion of the proximal phalanx upon
the fiTst metatarsal head, In this position, the ground reactive
force upon the hallux in late stance Is altered frOI'il a gliding
motion to a comprest."" force (direct impact) upon the
contiguous. surface of the first meta.tarsal head. In a hea.lthy
diaTHlfOdial joint, a shear force from gJiding cartilage allOWS
_ redl'rocal movement of the articular surface" with minimal
friction (9), In contrast, compressive forces within a joint
have been ~hown to produce penarticull\f,'osteophyte pro­
duction and destruction of cartilage (10). In this manner, the
VOi..UME 44, NUMBER 5. SEPTEMBER/OCT06ER 2005
371
FIGURE:3 Lateral radiograph showing the at<!p-off Ol'ltween ths
rmtallil~al
FIGURE 1 Preop",,,,tlv9 dorsopl'.lntar radiographs of Ii! patlsnt wit/':
hallUl\ Rlgld!)s, AJ The distal point Of the first metatarsal. 8) Tha distal
point of the sacand metatarsaL C) Joint width measured in mililme­
ter$,
'lead an::! shaft.
minimization of ~hear forces and increased compression is
often associated with an incre2sed vol\lme of synovi!!l fluid.,
which crcate.~ joint effusion ami ~welling, Accordingly, a
biom:;chanicaJ fault leads to a chronic stare of inflammatory
fluid production. (:rccipit(lting enzymatic degradation of the
cartilage (11, 12),
The literature describes a broad range of conservative
modalities and surglC<l! procedures for the treatment of thi~
disease proce~s (13-41). The proposed surgical procedures
ean be categorized as either joint-preserving or joint-de­
structive, Selection of the appropdate surgical procedure i 5
based upon clinical and radiographic asse~sment of the
degree of joint destrucrion and a detennination of the stage
or severity of the (\lsta~e, To date, however. th~('e is no
consen$US as 10 the appropriate surgical algorithm for the.
treatment of hallux rigidus. Fl.lrthennore, the common sur­
gical options of resectional Mthroplasty and first MPJ arth­
rodesis are not designed to correct or restOre the normal
blomechanical function of the first MPJ,
The biome-chanical principles of plantarfIcxioT) and de­
compre~sion are necessary components fot an osteotomy for
this condition, in order to create an optimal environment for
the function and survivl'J of the cam lagc.. The purpose of
this paper i.s to present the clinical and radiographic rc,ult~
of a plantarftexOl)'-"hortening osteotomy for effective treat­
ment of $tage~ .2 and 3 hallux rigid us. This procedure was
de~;igned to addre~s the goals of first metatarsal plantarflcx­
ion and decompression as well as to eflllb[c early weight
bearing and jOint TD"IgC cf motion.
Materials and Methods
nGURE 2 Pl'l!loperatlvs lateral view. A) Metatarsus primus eleva­
tus engls or Meary's method (45). El) Metatarsal declination ant;Jle
formed frQm the bisection of the first metatarsal and a line Irom t~fl
ca.lcanaal tuberocity and 1M head of 1M tiltt-. r.'Ietatar~al extended,
378
THE JOURNAL OF FOOT & ANKLE SURGERY
111is was a retro~pectivc review of 26 patients (33 feet)
treated ,....ith a plantarflexory-shortening mteotomy hy the
Senior z.uthor over a period of 3.3 years. Candidates for the
operatior. met the following inclusion (:ritcria: 1) clinical
PATIENT QUESTIONNAIRE 1) How much pain did you have before and after surgery';
none m.ild, occasional moderate, daily severe, always present 2) How would you describe the function of your foot before and after surgery" no activity limitations limited recreational activities limited daily activities severe limitation of all activities l) How would you de$cribe the type offoohvear you were able to wear before and after surgery'!
fashionable shoe, no inserts
comfort footvtcar with insert
modified shoe or brace
4) How would you rate the overall appearance of your foot after surgery?
excellent
very good
good
fair
poor
5) How would you rate the results of your surgery? (Consider relief of pair., funct10n and
appearance of your foot)
excellent
very good
good
fair
poor
6) If you are still expereincing pain, please describe.
FIGUFIE 4 Pali<!lnt
loss of range of motion of the first MPJ, defined as less than
55 ~ of hallux dorsiflexion. and 2) radiographic changes to
the first :Ml'J consistent with hallux ngidus. Utilizing the
4-stage c1as!':ifioation system of Drago, Oloff, & Jacob$,
these patients were classified as either having stage 2 or 3
hallux figidus (42). For inclusion in this study. all cases
were required to have a minimum follow-up of 18 months.
Patients were not excluded on the basis of age, smoking
history. history of trauma. medical diagnosis, or previous
surgical treatment for hallux rigidus,
Candidates for inclusion into thi, study underwent clini­
cal evaluation preoperatively. and the clinical data recorded
in the patients' medical records were rer:o~pectively re­
vieWed. All clinical me..~surementt; were taken at the initial
examination and at fullow up, Paticnt~ were re~alled a;
diffe.."etlt points in their postoperative cottr5e. The reSl!lts
queGtio~naire,
were calculated utilizifig i:,eir data from the 13$t postoper­
ative visit. AJI patients were included in the study, which
accounted for the variance in length of time of final follow­
up, The clioical examination included total range of motion
(,fROM) of the first .MPJ, as well as net plMtartiex-ion and
dorsiflexion of the hallux relative to its neutral position,
Neutral position of the hallux was defined as the position of
:]-,e first MPJ with the foot in stance and the hallux patallel
to [he weight-be,lling surface, First MPJ ROM was deter­
mined Clinically Witl1 the foot unloaded and loaded with
plantar pressure to the forefoot. Measurements were per­
forn:ed by placing one arm of a tractQgraph parallel to the
Ion Iilitudinal bisection of the first metatarsal, and the second
~ parallel to the hallux. The hallux was maximll11y dor­
sitlexed and planUlrflcxed und the endpoints of motion were
then recorded. The single exclusionary criterion was anky-
VOLUME 44, NUMBEFI 5, S=~TEM8ER/OCT08ER 2005
319
HALLUX METATARSOPHALANGEAL-INTERPHALANGEAL SCALE (45) Pain (40 points)
None
Mild, occasional
Moderate, daiJy
Severe, almost always present
40
30
20
0
Function (45 points)
Activity limitations
No limitations
No limitations of daily activities, limitation
ofrecreational activities
Limited daily and recreational activities
Severe limitation of daily and recreational
activities
Footwear requirements
Fashionable, no inserts
Comfort fooMear, shoe insert
Modified shoes or brace
MTPJ range of motion (dorsiflexion plus plantarflexion)
Nonnal or mild restriction (75° or more)
Moderate restriction (30-74<'»
Severe restriction (less than 30°)
IPJ range ormotion (pJantarflexion)
No restriction
Severe restriction (less tha.'1 10°)
IvtTP1-IPl stability (aU planes)
Stable
Oefinitley unstable or able to dislocate
Callus related to hallux MTPJ·IPJ
No callus or asymptomatic caHus
Callus, synptomatic
Alignment (15 points)
Good, hallux well aligned
Fair, hallux mal alignment, no syrntoms
Poor, symptomatic malalignment
10
7
4
0
10
5
0
10
5
0
5
0
5
0
5
0
15
8
0
FIGURe 5 AOFAS Hallu~ Metatarsophalan9sal a'ld Interphalangeal Cl1nlcal Rating $cal!l (46).
losis of the fi'CSt MP!. or isolated ankylosis of the sesamQjd~
to the first metatarsal head. While it was not possible to
make an accurate evaluation of this preoperatively, no pa­
tient included in this study demonstrated ankylo~is of the
sesamoid;:; to the first metatarsal head on the basis of intra­
operative inspectic)n.
Radiographic examination W<lS performed preoperatively,
380
THE: JOU!=lNAL OF FOOT &. ANKI.E SURGERY
immediately postoperatively. and at the time of each pa­
last follow up. Standard anteroposterior (AP) and
lateral weight-bearing fQvi radiographs were obtained pre­
operatively (Figs 1 and 2) MeAsurements obtained from AP
radiographs included: J) joint width. 2) first metatllJ'$al
protrusion distance. 3) metatarsal length, and 4) metatarsal
par<lbola (43). The joint width. measured in millimeters,
tient'~
A
FIGUFlEi 6 CA) Tha first cut of 1M osteotomy I, domal to plat'ltar. Just proxiMal th'il se$~mojd apparatus, Md perpendicular to the first
metatarsal ~haft and its declination. (S) The capital fragment Is rmeted distally after inserting a Q,062-inch Kirshner wire parallel 10 the long
axis of the first metalal'$al. (C) A tram,ven:I& osteot¢my Is mliloe 3--4mm. superior to the plantar aspect. The amount of plantarflexioo Is
detem'1lned wl!h this cut. The Ileoond dOn:l~ to plantar cut Is made maetlng tha plantar transverse cut. in order to shortsll the first metatarsal
and creat& a plantar shelf. Articular deviatiQn eaf! be corrected by removing more bone madially, Ti'ls amount of ~hOl1ening is datetmlned with
this cut. (D) Completed osteotomy with ralocatlon Of ths metata~1 head. Note the piantarfiexiOf"l and lateral displacem&nt Of the head of the
first me!lItsr$al.
was determined as the distance in mm from the midpoint of
the bisection of the medial and lateral aspects of the first
metatarsal head and the midpoint of the bisection of the base
of the proximal phalanx (Fig 1). 111is was perfonned pre­
operative, immediately postoperatively. and at the last fol­
low-up visit.
The metatarsal protrusion distance was calculated by
measuring. in millimeters, the ab~olute length of the first
and ~econd rnetatars<tls and subtracting one from the other
(Fig I). The length was detmni!'led from the intersection of
the interrnetatmal angle to the distal most aspect of the first
:md second metatarsaJ heads (44). The length of the lirst
metatar.sal was then subtracted from the second metatarsal
length. A positive value: indicated the: ~ecQnd metatarsal was
longer than the lirst metatarSal and il negative value indi­
cated that the first was longer than the second.
Anterior-posterior x-rays were also utillzed to determine
tlle length relationship to the other metatarsals (metacarsal
parabola). The length of each DletatarsaI was measured. and
subtracted from the (onge.~t metatarsal, resulting in a. value
of length in millimeters. Each value was then given a
numerical value (1-5) with the longest metatarsal given the
number I and the shone,st metatltrsaJ given the number 5.
The metatarsal parabola was calculated for each dor$Qpl~t'l-
tar radiograph that provided a data point for all patients
within the study on their preoperative. immediate poSloper­
l\tive, and fin\ll x-rays,
Mea;;uremcnt~ obtained from the lateral radiographs in­
cluded: I) metatarsus pri::!i.iS c.levatus (45), 2) length of !he first
metatarsal, 3) first metat;m;aJ declination angle, and 4) position
of the first metatarsal head relative to the position of the lesser
metatarsal heads (first md.atarsa{ planlrui'lex.ion), 'The met.atar"
sus pM mus elevat1.IS angle, or talar, firSt metatarsal angle wa.<;
calculated according to Meary's method (45) (Fig 2). The
longitudinal axis of the talus WID; determined by measuring the
bisection of the talar neck and body. The longitudinal axi~ of
the first metatarsal was also mea.M·ed lIsing the dorsal and
plantar asp~t~ at the proximal and distal melaphyseal-diaph.
yseal junct1Ons. 111e angle was created as these tWD lines
intmected, A negative value resulted in a planLtrflexed nrst
metatarsal, where the tim metatarsal bisection was below the
talus bisection. and Vice versa.
The first metatarsal declination angle was determined,
using [he lateral radiograph. by the angle formed (rom the
bisection of the fi,st me'atarsal and a horizontal line created
rcpre~entinj!; the floor (Fig 2). Thjs last line was created
from a point on tbe tuberosity of the os calcis and the,
inferior llSPCct of the: fifth metatarsal head. As this line was
VOLUME 44. NUMBER 5. SEPTEMBER/OCTOBER 2005
381
t>~
ment in millimeters, of the metatarsal head in relation to
the shaft of the first metatarsal (Fig 3). This measurement
WAs made from a point at the distal-mo~t point <;forsally of
the shaft of the metatarsal, just proximal to the ost~or­
omy. and a point on the distal fragment. just distal to the
o,teoton1Y· This n;Jmoer \Va~ unable to be calctl !ate~1 on
(he final x-ray~ due \0 remodeling of the head of the first
metatarsal. Evidence of seS,lmoid defonnity, the shape of
the first metatarsal head. osteophyte formation. IOQse
boeies. subchondral sclerosis, and evidence of nonunion
were also noted and recorded from both the AP and
latera! radiographs.
A patient questionnaire was completed postoperatively
by all patients in the: study (Fig 4), F..very patient was given
a questionnaire at each interval during their can-back pro­
:::ess. Only the quest.ionna.lrc from the last call back was
utiiizcd for this study, The American Orthopedic Foot &.
AnkJe Socie:y's (AOFAS) Hallux Metatarsophalangeal and
Intel?halange.al Clink..! Rating system was I,ltiliuc to eval­
\late changE~ in function, appearance. symptoms, and over­
all patient satisfaction (46) (Fig 5).
Following duta collection. statistical analysis was per­
fonned 10 <:alclllat.. the mean total ROM. dorsiflexion, plan­
tMfiexion. and radiographic pammeters. The change be·
(ween the preoperath~ and postoperative values for
dependent variables was presented a, meatls with a 95%
confidence interval. However, the paired data were not
nonnally distributed and, therefore. the analyses were car­
rite out use,~ a Wilcoxon Signed Ranle t test. a nO:1paramet·
ric version of a paired 1 test.
Surgical Tecrnique
All procedures were perfomled tmder local block with
intravenous sedatiQn and an ankle pneumatic tourniquet.
After exposing the distal aspe.:;t of the first met..:l.t3rsaJ
through a dorsomedial inciS.ion. the metatll.r~al head was
remodeled and all reactiVE seft tissues and loose bodies
were removed.
A don;al to plantar osteotomy was then performed at the
level of the nle·Ultan<al neck. The fim cut wa.~ made just
proximal to I.he sesamoid apparatus and the proximal ex,tent
of the plantar articular crutiJage or the first metatarsal,
FIGURE 7 (,4) Oo~oplantar vi~w of the flxated osteotomy. Note j"
Figure 3 (same patient) th~ final screw fixation and tl1e stable plar:tar
$11611. (B) I.ong-term (36 month) foll¢w-up of e<lrn9 patlenl :a$ In
Figurl3 3. Note th13 remodeling ct ~h~ fir.;;t metatarsal head.
Screw ha$ been removed.
""6
carried distalward, an intersection wa~ created with the
declination of the first metatarsal.
A calculation "'as also n111dc only from the immediate
postoperative x-ray for the amount of plantar displace-
382
THE JOURNAL OF FOOT & ANKLE SliRGERY
a~
well as perpendicular 10 the first metatarsal in the transverse
and ~agittal planes (Fig 6), A 0.062 K-wire was placed from
dorsal to plantar into the central a'\pect of the capital frag­
:nem. This wire act~ as a toggling device to distract the
osteotomy in order to visualize the cancellous bone of the
capit..'tl fragment (Fig 6).
Once the capital fragment had tleen di~tr.flcted and rotated
10 expose the i!HCr1or ll.!;pc:ct. (\ second osteotomy was per­
formed perpendicular to the fiT~t osteotomy. and approxi·
mately 3-4 rnm superior tl) the plantar aspect of the capital
TABLE 1 Patient data (cllrlleal evaluation)
..,..
Calf!
Age
Sid",
Motion in Deg'eas
FlU
Months
"
Poot
Pre
Pr~
TROM
49
~
~
<l
e
1\
7
8
9
10
11
12
13
53
70
35
55
54
48
44
26
eo
.119
45
48
14
51
15
55
Hi
38
R
R
L
R
l
L
R
I­
R
A
t.
R
L
R
R
R
I.
l
R
I.
Z5
40
5
15
40
:lO
40
90
10[)
30
70
50
85
65
90
50
70
60
25
50
10
3D
25
35
35
15
60
21
19
10
,0
22
20
48
35
2':
.i0
L
A
I.
5
10
10
5
5
5
5
10
18
16
20
7D
.5
10
25
20
60
50
3C
50
5
5
50
;0
.20
.5
10
5
5
20
10
35
20
40
10
19
46
10
10
46
:33
.26
-;0
50
Ie
50
5
10
;00
85
70
50
80
10
20
25
75
60
5
5
10
10
10
20
;0
20
40
R
R
L
R
eo
60
65
26
40
70
55
R
eo
HI
~O
5
10
65
55
20
45
49
is
20
30
25
52
10
70
70
L
L
.25
26
35
25
BO
R
40
39
<10
65
40
52
24
60
60
0
5
L
10
45
37
50
51
70
Post
F'lantarllexiOl"l
10
R
17
20
21
22
23
75
45
Pre
20
30
30
30
30
18
19
55
90
50
Post
Oorsiflexion
25
50
50
70
5
15
5
10
10
10
15
20
10
5
18
26
26
45
34
42
22
39
31}
30
40
45
65
10
55
10
45
;;
40
65
5
30
5
60
45
50
10
10
25
25
46
47
so
70
70
70
i5
75
45
65
40
50
eo
15
45
40
30
~D
90
fragment (Fig 6). This cuI is perpendicular to the 0,062
K-\\'ire (or parallel to the weight-bearing surface), The
placement of this osteotomy determines the net plantitrflexion created_ An osteotomy made more dorsal from the
plantar cortex will result in increased plantarflcxion of the
first metatarsal head. This second os!Cotomy extend~ into
the capital fragment a distance of 2-4 rom_ The capital
fragmtnt was relocated to its original po~ition and the
K-wire was removed. A third osteotomy was performed
from dorsal to plantar, distal and parallel (0 the first ostcot·
omy and extended plal1tatly to the level of the second
osteotomy (Fig 6), Removal of the rectangle of bone created
an "l" configuration ofthe capital fragment. Caution should
he taken in making this third osteotomy a~ excessive ~hortening can occur jf the osteotomy performed is too distal to
the first osteotomy,
The plantar portion of the shaft of the metatarsal was
then f'asped to prom<lte bone healing when affixed to the
shelf of the capital fragment. The capital fragm~nt was
:10
37
27
40
4S
25
47
eo
25
30
20
35
55
10
15
10
45
47
5
!ran~lated proximally and plantarly beneath the- first
metatar:o;al shaft_ If a high lntermetatarsal angle is present,
a lateral translation of the capital fragment can also be
performed, The osteotol\l}' was fixated with one 4,0 canr.ulated screw placed from dorsal-proximal to plantardistal (Figs :3 and 7). Finally, the first MP] was ~'isLlalized
to confirm the screw did not violate the joint surface_
Intraoperative 1)uoroscopy was also employed to cOl'lfhm
that ali screw threads crossed the osteotomy site,
'Postoperatively, patients Were placed in a surgical shoe
and were instructed to be noo-weight bearing for 3-5
days, Patients were then allowed to walk without an
assistive device in a sllrglcai shoe with a 1/4 inch Plasti­
lOte (Apex, Inc" TeaneCk, NJ) first ray cutout. If able,
patients were allowed to return to an athletic shoe in
approximately 4 weeks pending radiographic evidetice ()f
consolidation, Physloal1nerapy including active and pa~si\'E~ rangc of motion exerc.ises began once sutures were
removed,
VOLUME 44, NUMBER 5, SEPTEMBE:RlQCiOaeA 2005
383
-
,AEltE2 Clinie.al fating (100 points
Q$S!
Gender
P'eoperativ<!)
po1jsibl~)
Po~tQperatiYE1
TASLE ~ Antl'!tior-postt!riQr radiographie findings:
preoperative
S')bwctiv~
Results
(11_
Cat;1e
MetatsrMli
Millimeters
Side
Parab"lll.
2
M
F
:;I
M
SO
~xc",neMt
69
97
very good
6<1
95
(;ll(e~lIent
70
85
very gOQd
very gOOd
very good
excellent
excellelit
excellent
Wiry gOOd
fl'Jir, fair
18
4
F
6{)
5
F
6
'I'
M
57
64
1'2
47
59
8
9
10
11·
12
M
F
M
F
14
F
M
F
F'
13
15
M
16·
17
M
18
19
20
21
F
F
F
F
F
23
49
95
100
80
82
72
39
64, 75
80
95
62
5'1
30
30,23
37
54
90
62
67
2,
95
100
61
good
excellent
excellerl
very gOOd
100
exceliMt
39
95,100
95
192
vt:Jry good
3
4
70
24'
M
25
2tS
F
F
39
35. 35
69
90
90.90
87
exceilent
excelfent
gMO
49
85
good
'Indicate", bilateral procedure witi' l;IifferE'!'lces be!wet'l" the:: !eet
(rignt foot, left foet)
"<-
The plamamexofy-shonening osteotomy was performed
on 26 patients and 33 feet. including 19 right fccun,i 14 left
feet, with 7 bilateral procedures (Table I) The patien:
population consisted of 17 female and 9 male patients with
an average age of 48.6 year;; (range. 26-70 years) TIle
mean follow-up time was 34.4 months (range. 18-65
months). Six patients were followed for an average of 19. I
t1')onth~. and 20 patients were fol1owed for an average of
39.4 months Six patients reported a history of trauma to the
fir.~t MPJ, and I patient (2 feet) had a pre\!iou.~ joint de­
bridement procedure. Reiters syndrome, lupus, and gOUt
were db.gnosea individually in 3~eparate patienlS. Immop·
eraliYely, 2 additional patiems were found to nave gOll~y
tophi.
Evaluation ~t 181>t fOJlo\\i-UP revealed 85% (22/26) of
patients reporting a very good to excellent result. and S%
(2126) a good result (Ta.blc 2), One patient (4%) had a lo~~
of hallux purcha~e and rnted result a~ fair. One patient rated
the result as poor and relared rio reduction in pain from the
preoperative level. Postoperalively, 13 of 26 p9tj(;nt~ re­
ported complete relief of pain, and II reponed Infrequent
~pisodM of "minimal" discomfort, ofr.en in association with
384
THE JOU~NA1. OF FOOT & ANKLE SURGERY
~
L
R
L
R
13
14
15
16
R
R
L
L
R
2.5
1
:2
2
1
0.5
0.5
1
1.S
L
1.5
R
2
L
0
2
9
i
1Q
3
0
, ~2, 3. 4,5
"0
2. 1.3,4,5
3
S
5
3
:(,1.3.4.5
R
l,
'2
19
L
R
A
0
:;l
1.5
1
0
-1
1
20
~
0.5
2~
L
2"-
Ii
:2
1.5
L
1.5
R
R
:2
1.5
25
26
2,3, 1.4,5
2.3,1.4. ;:;
2,3. 1.4. S
2, 1,3,4. .5
1='2. 3, ~. 6
0
17
1B
21
22.
Results
1
0
L
~2
2,1,3. 4 ,5
2. i, 3, .I., 5
iI
R
.,
1,2.3,4,5
2
0.5
, .5
I
a
5
-2
R
L
L
2.1,3,4,5
2. 1,3,4.5
2,1, 3..~, 5
2,1,3, I.. 1>
1 "'2. :;, ~. 5
2,1. J.~. 5
1 =2, 3. 4, 5
2,1,3,4,5
05
6
t;;)(oell~rr!
F
3
::,
L
R
10
F
Distance
1.5
2
0.5
5
11
2~
Space
!:'{
eX<;0ilMt
23
.,rotrusiOn
11
very gODd
pOOr
exceoJ!en\
W!l"!
Joint
1=2,3,4,5
2,1,3.4,5
2,1,3. '.5
2.1,3,4. is
2. 1, 3, 4. 5
2. 1, 3, 4. :;
1=:2.3,4. 5
1.2.3,4, 5
1.2,3,1•. 5
2. 1, 3, 4.1)
3
2. 1.3.', 5
5
-2
2,3. 1. 4,5
1,2.3. 'T. 5
-2
1.2.3.4.5
excessive weight,bearing activity. The average AOFAS
score postoperatively was 78, l/J 00 (Table 2). Twenty-five
patients returned to a running-type shoe a1 4 weeks with
return to full activity in 2-6 months, with I patient requir,
ing additional surgical treatment (gastrocnemius rece~~ion)
and st:bsequent p<Jstpoilcment of return to functional ~hoe
gear
Postoperative TROM was significantly improved follow­
ing the surgical procedure (Table I}. The improvement in
TROM was statistically .~ignificant at immediate po~!Oper­
ative evaluation and at last follow-up (P < .001) M.ean
TRO;\1 increased from 333" (range, 5"-60Q ) preoperatlvely
to 72.1' (range, 50°-100") postoperatively, representing an
average increase of 217%. The greatest increase in TROM
was 60' (2 p:ni!!!nts), The smallest increase in TROM WI!.$
25 7 (3 patients). The greatest pl'nion of increased TROM
occurred in the direction of dor~jMexion. rdative to the
T,ASLE 4 Ant~riQr-PQsterior radfogrephle finding!!: immedIate
ponQperatlva
CAlia
Sjde
Millimetats
Join!
SpaC(;
1
2
F!
R
l
R
a
~
10
11
12
13
14
15
17
18
19
20
21
S
10
9
10
11
2.3. 1.4,5
2,3, 1,4, 5
2, 3. 1,4.5
2,3, 1,4, 5
2, , =3,4,5
2,1 =-'? 4,5
A
J
4
L
4
A
R
L
R
L
R
A
R
L
L
R
2.5
2.5
'1
2, 1 =3, '" 5
2. 3, 1. 4, :;
2
2,1,3,4. S
6
2,3, 1. 4, 5
A
L
R
L
L
R
R
A
5,5
e
3.5
4
10
14
1S
13
S
2
<1
2
>l
4
2./5
6
2
10
4
7
9
10
2
4
"4
10
3.5
8
9
2,3.1=4,5
2, S, 1=4,5
2,3,4,1,5
2, 3. 4, 1, 5
2, 3, 1. 4, 5
2, 3, 1. 4, 5
2,3,1,4,5
2, ;'3.1,4,5
2, S, 1, 4, !;i
M!IIi~ters
!'retrusion
Space
Distanee
1
R
1
2
R
0
9
8
L
1
11
R
L
;<
13
2
2
,1
-<
5
10
2.5
:3
<1
5
L
6
R
I..
7
S
9
10
11
12
13
14
15
R
:3
:3
14
6
0
3
2, 3, 1. 4, 5
L
0
4
L
2
10
2,3.1,4,5
2, 3, 1,4,5
R
2.5
1
2.5
8
2, 3, 1,4,5
20
R
21
~
14
17
R
L
L
L
2.5
.2
2.5
2
2
a
2,1,3,4.5
/)
2.3,1.4,5
22
R
;:
7
2, 3, 1,4, 5
23
L
2
24
R
2
2.5
25
26
l
R
R
(5
2.3,1,4.5
:>
1~
4.
10
25
L
R
2,;3,1,4,5
2,3,1.4.5
3
3
2, 1,3.4.5
26
1'\
:3
:3
2.3, 1,4,5
neutral postion of the hallux. PlantarilexiQn range of motion
increa.~ed an average of 50 _10".
Radiograpttic eVllluaticn consisted of anteri0pO$ferior
(AP) and lateral radiographs evaluated preoperatively (TabJe 3), immediately postoperatively (Table 4) and at longterm fOllow-up (Table 5), On preoperntl,'c AP radiographs,
only 5 patients had a first metatatliallonger than the second
metatarsal. The first and second metatarsals were of equal
length in 6 patients. Four patients had a first metatarsal that
was 9horter than the third.
The preoperative joilJt space distance ranged from 0 to
2.5 mm (mean, 1.26 mm: SD :!:: 0.613) (Table 3). Immediatcly postoperatively. the joint space was increased from 2
to 5..5 mm (mean, 3.21 mm); SD :!: 0.829) (Table 4).
Howeve·r,at foHow-up the joint space ranged from 0 to 2.5
mm (mean, 1.82 rom; SD :t 0.808) (Table 5). Despite the
lo~s of nl'$t MPJ joint space omervcd at the last follow-up,
there was no correlation to the first :MPJ TROM. III fact.
2, 3, 1",4,5
2, 1, $, 4, 5
14
S
L
1. 4, 5
2,3, 1,4,5
2,3,1,4,5
2, 3. 1, 4, S
2, 1~3,4,5
2, 1, :1, ~,5
2, I, :), 4. 5
2.5
16
HI
4
2, S,
R
L
R
L
R
A
R
L
1S
:3
2
2
2
:>
~
Metatarsal
JOint
.'3
24
lat1t follow-up
Parabola
2.1""3,4,5
2, :l, 1,4,5
2.3,1,4,5
2, 3, 1, 4. 5
2.3. ;,41,5
a, 3,1.4,5
3
2,5
3
22
23
-
Sld~
"rotrrJsiOl'l
Dilltance
i.
l
16
:<
Case
Antllri(lr~pa!l.terior md;ogr~pha:
Metatsrs;;!1
Parabola
3
4
3
L
7
S
lABU;;5
'<.:1
1.5
7
S
'5
6
~Q
10
5
8
7
2, 3. 1,4, 5
2.3,1,4,5
2,3.1 ... 4 ,5
2,3,4, 1.5
2,3,4.1.5
2l .3, 1, 4, 5
z~
1 ::=3, 4,5
2, S, 1.4,5
2.3,1, 4,5
2=3,1., 4, 5
2,3.1,4,5
2,3.1,4.5
5
2,1,3,4,5
3.5
12
2.3,1, 11.5
2,3,1.a,S
2.3,1,4,5
2.3, 1.4,5
2,3,1,4,5
5
:3
2, 1,3.4,5
7
5
12
2, 1, 3, 4,5
there was no loss of first :MPJ TRO.:\:t in any patient po,t­
operatively to the point that the TROM was rhe same or Ics,~
than the preoperative range of motion.
Tn each case. the first metatarsal was shortened by the
procedure, with it greater negative first metatarsal protrusion
distance on AP radiographs (Tables 3, 4 and 5). The average
shortening ~,as 6.1 mm (range, 2-12 mm), At last followup, the majority of the patient.<: (20126) e;{hibited a metatar·
sal length pattern of 2, 3. 1. 4. 5 (Table 5). There was no
correlation between the runount Qf shortening and postoperative complications, Specifically, patients with the great.
est degree of first metatarsal shortening were not more or
less likely to complain of metatarsalgia symptoms.
Review of the preoperative lateral radiographs demon­
~trated that 23 of 26 patients demonstrated elevation of the
fir~t metatarsal relative to the bi~cetion of the talu!'. (Table
6). First metatarsus elcvatus values were a.~ high as 2i~
preqJer3tively, Postoperatively. tile greate-<;t net change in
VOLUME 44. NCMBER 5, SEPTEMBER/OCTOBER 2005
385
-
T"Ah.E 8 Lateral radlogl'2phs: preoperative
Ca16
Side
" &
Mrillmll'!ter:;
Oegr~s
TABLE 7 Laternl radiographic fll'ldlngs, Immediate
poa\:operative
•
Case
MPE+
Declination
Length
15
20
22
60
57
5
25
27
71
75
2
21
51;1
22
68
4
R
10
10
13
S
B
58
L
-6
7
2i
R
R
14
<I
23
20
lA
L
R
S
15
20
18
59
69
54
66
62
-9
e
21
49
9
10
19
49
11
-4
25
64
15
B
15
15
15
23
16
SO
12
511
MPE'
~
;:
4
5
a
9
10
11
R
R
L
!1
L
L
12
R
13
R
14
1S
16
11
18
19
20
~1
22
23
:N
25
26
L
l
R
L
R
L
R
L
t.
R
!=l
!1
L
R
L
R
F1
-4
4
,
~
5
13
5
1
3
5
3
FI
R
L
R
S
7
8
l
I­
R
L
R
Declil'1ai:lo~
55
26
-9
0
0
-iO
~5
53
58
25
70
23
20
65
1
2
20
29
55
2.5
57
~
28
ISS
5.2
2.5
:3
-5
22
25
R
R
5
20
-21
2B
L
-·16
30
13
R
R
-10
2
2Q
48
61
14
L
L
63
'5
A
0
-Jtl
-20
-7
-10
2
21
65
67
5a
L
16
R
L
:3
2
2
.2
25
L.
69
Plantarflexiont
:;
FI
22
20
Ls~9th
-16
-3
-10
0
-10
28
56
62
59
A4
48
54
50
4
<1
:3.5
2
3
50
46
:3
:3
3
32
57
2
25
20
20
0
20
25
2
25
59
66
55
58
5a
10
20
55
30
28
65
30
4
3.5
3
2
15
22
25
~
25
54
17
18
19
2
26
67
20
R
L
L
FI
10
19
27
115
65
21
R
0
2
64
R
-7
19
24
16
5B
I,.
sa
2.$
22
20
23
59
64
59
22
23
24
3
1.5
2
3
:3
H
8
20
54
.s
-2
23
26
26
R
2
0
53
58
2.5
25
L
R
26
57
S
27
12
4
12
7
60
58
'MPE = !"I1~tatarus prlml,ls elalltltus. A negative value m!lflr'l!l "
plant~rfl8x!'?d first metatarsal (talar bisection superior to metatarsal
bisection).
plantarf!cxed position of the first metatarsal was 28' 03 0
elevated to 15 0 plantarflexed) (Tables 7 and S). In all ca$es.
th~ first metatarsal w;;.s pJantarly displaced from its Qriginal
position when compared with m¢i!.surements of preoperati ve
films. A range of 1-4 mm (mean of 2.67 mm) of plantar
translation of the head of the first metatarsal was noted. This
aSSe8sme·l'lt was performoo exclusively on the radiographs
of the first postoperati....e viSit as significant remade ling
masked a.ny future change in first metatarsal head position
(Table 7).
A single intraoperative complication OCCI.l1re.d during mis
study. in which a fracture developed between the screw hole
and the osteotomy during SCrew placement. This was rdated
to jl1.a.de.qUAte c.ountersinldng f,lr the sen-v.'. Rigid intema)
fixation was accomplished and nQ further complications
386
1
?
MIIJlmetar'S
O~rees
Side
THE JOURNAL OF FOOT & ANKLE SURGERY
51
2
-MPE '" met.ataf9uS primus eleva:tu$. tPlantartle:<:lon ". ~mouMt or plantar displacame'1t of the metatarsal head. dC'.veloped in this case. Hardware was removed \n 44% of
patier.t~. These plItients related an incrca.<;e in first MPI
ROi\·1 following removal of the hardware. All S<.:tcws were
removed due to painfUl prominence of the ~crew head. None
of these Screw heads was prominent due to loo;;ening. Once
low-profile 4.0mm cannulated screws were used fOT the·
performance of the procedure. there were no furthe.r com·
plaints of painful prominence lUld nO patient required screw
removal.
The rate of pos.toperative complications was 15% (5133),
and 80% (4/5) of these were self-limited or resolved .vim
conservative treatment modalities, Four paricl'lts (15%) re­
ported lesser metatarsalgia with pilin beneath the second
metatarsal. Three of the cases were treated with conserva­
tive measures, consisting ()f inJections and accommodative
rA.l..E8
Lateral radiographS! last fohow-up
03~
Side
Degra,*,
MPr;:+
1
2
R
A
L
.:;
11
4
l
L
R
L
5
Millimeters
Deelfnation
Length
54
10
20
-i5
26
53
-8
-8
27
61
27
25
69
-10
5
22
62
54
~
15
-10
29
R
0
54
56
R
L
-12
64
50
~8
28
25
25
59
5
16
5;:
L
11
R
R
-16
-16
3()
26
43
28
52
48
L
0
14
L
-10
15
11
-20
6
7
8
9
10
R
11
12
13
L
R
l
R
l
16
17
18
-15
2
-15
-10
3
3D
30
20
63
5-t
5?
20
57
23
61
54
51
0
L
R
L
-s
23
23
25
1
9
30
20
21
-2
22
R
R
1
22
53
53
61
2
2.1
57
L
1()
R
R
A
0
23
'M r:>1::
46
45
46
0
19
25
26
20
32
2
20
21
22
24
20
20
47
62
59
59
= m!!t!ltarsus primus elevatus,
padding, with complete resQlution of symptoms. The fourth
patient noted pain 6 months postoperatively and. despite
conservative lUell.sures. ultimately underwent a second
metatarsal osteotomy, which resulted in complete resolution
of symptom1O.
One patient (4%) reporteJ sesamoid pain.. which also
resQlved with orthotic accommodation, 111m were no cases
of avascular necrosis, delayed union, or nonunion No pa­
tient was found to have MPJ or hallux inteq>halanJ<:eaJ iojnt
instability (if plantar callosities at their follow up ;isit.· One
patient was dissatisfied with the appearance of the position
of the hallux due to poor purchase of the toe.
Discussion
!-I-allux rigidus affects 1 in 45 people over 50 years of age.
and the first l\1PJ is the third lllost common joint to develop
progres~ive osteoarthritis in the adult (47). Many surgical
procedures have been described to correct this problem.
However. no single procedure has proven superior in treat­
ing the; moderate to severe Wlll:eS of this deformity.
111e plantarBcxory-shoTteni;g osteotomy described here
has been shown (0 be efficacious in the active -patiel'lt who
demoo,lrates a strucroral de.fonnity of the first MPJ with
advanced radiograph!.c findings of <)sleoarthtitis. The natllTe
of the osteotomy allo·wl1 for shortening, plantarfie)tion, and
transliuion of the first metatarsal. In addi.tion, this osteotomy
is de,~igned to allow mobilization of plantar joint ~tructtlres,
a key principle in the surgical correction of hallux rigidus
(33) Shortening of the fir!;! metatar~al enables relaxation of
the long flexors, extc;l,ors. and capsular !;tructures, Which
aids in deccmpression of Ihe first :MPI It is also a stab1e
osteotomy that maintains the ruticular angulation of lhe first
).1PJ The ver,atility of this procedure is evident in its ability
to allow multipJanar correction for metatarsus primus eleva.
tus. elongation of the first metatarsal, and InetataMUS primus
adducros. while preserving joint function.
This procedure was performed succeSsfully ~n patients
with varying degrees of joint destflJctlon, ranging from mild
osceoph),tic lipping to stage 3 hallux rigidus (42). All pa­
tients in this study noted mal'ked improvement in their range
of moti,on and a reduction and/or elimination of firM MPJ
p~.in, which was maintained at last follow-up. Furthermore,
the increase in fir~t MPJ RO\1 at last follow-up was com­
pared favorably ~o the rzsuhs docum.en\~d for O(ner joint
decompression osteotomies (48 -50). There was an average
33,30 improvement in first MPJ dorsitlexion ROM and an
incre..tse of 38.6' of TRaM in this study. In comparison, a
study by Laakmann et OIL which evaluated 26 fcet following
a Watermllnn-Green 0~teotomy. demonstrated mean in­
crease in dorsiflexion ROM of only 6" (49). In a !timilar
study comparing 3 different osteotomies for hallux rigidus.
increa.<;e~ in first ;\·tPJROM ranged from 0.2" t,) 8° (50). In
a study by Roukis ot aI, first MPJ ROM "was consistently
Jes~ than 10 degrees" in a population including patients that
had a decompression o$teotol)1Y (48). Clearly. the critical
Rttribute of this procedure relative to other reports for hallux
rigic1us it:; the dramatic increl\~e in range of motion to the
first :YiP], as well a~ the preservation of the increase at latest
fo!low-\Ip. It is difficult to say exactly why there was such
a ~ig11lfica!l1 i!lcrea~e 1(\ the postoperative range of motion
from thi, procedure. The ability to shorten the first meta­
tarsal independent of the amount of plantarffexion of the
rnetats;"al head may be ')'.'!~ of tile most important factors.
Maintaining the relative alignment of the ~e9amoids and the
proximai phalanx without angular changes to the head of the
firs! mctatar(;al may also playa role in the improved rangE:
of motion.
One limjtation of this J)TOcedure is ankylosis of (h~ first
MP] or isolated ar,kylo~is of the sesamoids to the first
metatarsal. In this siruBti,)n. a jQiTlt-destnJctive prOCed\lre
VOLUME 44, NUMel:R 5, S~PT:;;MeER!OCT08E:R 2005
381
S:IC~ as fir~t MPJ artnrodesis may be preferable, The poten­
tta! compllcatl?" of !cs:~er metatarsalgia exists with any
p~:edure that 1~ performed on the first ray, Despite careful
clI~al and radlOgraphic surveillance of our patjent popu­
1a.tJ.(\t1, we were unable to predict which patients would
develop lesser metatarsalgia. Indeed, those patients with the
g:reltest shortening and planr.arfiexion did nOt report symp­
tom of ,!t1etatarsalgia, The authors believe that the purely
trampQsttlOnal nature of the osteotomy (no angulational
conponent). allows the firs! metatar~aHo·sesamoid rela­
tiQl1sl1ip to remain unchanged, therefore mimmizing meta­
tarsalgia symptoms, ­
Eu.mination of the re.~ults of this new procedure should
be umpered with some of the limitations of this ~tudy. The
Jlla11n.er of data collecti On and the measurements taken frore
ead patient create a potential for variability. It is also
difficult to tl'Uly ascertain the resulrs of each patient's ~ub­
jective symptoms, and therefore, the qut'$tionnaire has its
inheJ'ent limications, Lastly. the specific nature of a retro­
spective study design has its Own Haws. Despite these
issues, we are confident that this procedure is efficacious for
the treatment of hallux rigidus,
<;)
sincal';Qo of hallu~ llmitu~ ~nd hallux rtgidu,. Low~r E,lremitv
1:5.5-66,199.1,
.
Charnley], Sympt'sium OIi BiomCoChnni"'~. I.ondon, [rlMitllt~ (If Me­
chanical
IO.
Ensine~ring.
J 969,
S.!t~r
RB. RenellcnR of mURCu.loske!<:tal tisslle!; to diSOrders and inju­
ries, ch 3. II'): Texl","k at Di,tort/us Qn.1lnjllri~.~ of rhe MIi.~,:,,'{)skel.
"UrI Syt!~m, 2nd e(!, pp 30-34, Willi~ms Bnd Wilkin~, 5nltimorc,
1984,
11 I\kegc" \VH, Chu CR. Bu~b~e w. Articular cartilage: morpnlJio8Y.
phy~,ology, and [tInction. In Diar.II(>tis of Bo,,, ,>rid Jolm DisorJ"'r;t.
pp 793-815. edil~d by D Resnick WB Saunders, New York. 2002.
~ 2. Has,setbacher P. Jo~nJ ph:ysloJogy. In: Rhf!urnilt()lo,~y. pp ! :;" I-{t
edited hy JH Khpl'~' Wld PA Dieppc. Mosby, London. ]994,
13, C3\'Qlo D, Cavillaro D. Amngton 1... Tho Wst~rmllIln o~lo')(Omy f,or
hall~I):
limitus, JAMA 69;52-57, 1979,
14. KiMel CG, Mistretti RP, Unrne BJ. ChcilCoCtQm~. chondropleMy. and
sagittal "Z" ostcol(\my, aprelimilUlt}' repol'! on an JllternaHvc j(T;nt
prc~crv~lion sppn,:\~h!;:) halJ\l~ limitu~,
J foot Ankle Surg
34:~ ll­
31B, 1995.
15. Selner AJ. Bogdan R, 5elner MD. Bunch EK. Math¢ws RL Riley J.
TricorrectiQlHI! osteotomy for the oorrection of late ~ta"c halJll~ limi­
tuslrl1<idvs, J Am Pooiatt Mod Ass.x 87:414-424, 1997.
1.6, Vicga<; GV, RCCon$lf\lction ()f hallux limirus deformity lI~;Mg a fir<;!.
1'Y>I!IJtarsg' '-'giual Z .,stc(,!I)ll'Iy, J Foot Ankle SUf« ~7: 204-211. 1995.
17. Feldman KA. 'The Green-Waterman l'1"'<'~durc, ~eometric 3I1alyr,i'l1l1d
prc.ope1'~t'Vt r3dio~r~p~ic ccmplate tedmiqllc . .I Foot Surg 31; 182­
185, [992,
Conclusion
The early re~ults of this retrospective study are encour­
aging, particularly the high subjective patient ratings. De­
spite the radiographic loss of joint space, the findings of
increased motion and elimination of pain are consi!'tent
among the patients in this study, and demonstrate the value
of this procedure in the preservation of pain·free joint range
of motion even in the late·r stages of hallux rigidus.
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