Hallux Limitus and Rigidus

ajkim1's version from 2015-05-08 11:54


Question Answer
Hallux LimitusProximal phalangeal base is plantarly sublimed upon the first MT. Hallux has limited dorsiflexion motion at the MTPJ during propulsion
Precursor to hallux rigidusHallux limitus
Hallux equinusPlantarflexed hallux, metatarsus primus elevatus
Cause of hallux equinusFHB sesamoid complex causes hallux to be plantar flexed
Hallux rigidusAnkylosis of the 1st MTPJ secondary to repetitive trauma during dorsiflexion
How is there less pain during the limitus to rigid transition?Joint loses more motion so it becomes less painful. If we auto fuse then the pain is gone
Will removing the bump relieve hallux rigidus pain?No blocking of joint movement so it'll move around more and hurt
Most common cause of hallux limitusTrauma
Other causes of hallux limitusLong, short, dorsiflexed 1st MT
What happens to joint space in hallux limitusDecreases and articular surface flattens
When is final decision made on hallux limitus treatment?Intra-op
What part of the bone gets very hardSubchondral bone
How much cartilage must be intact to preserve joint?50%
Next step if x-rays turn out negativeCAM boot or fiberglass cast, ibuprofen and rest, NWB crutches 3-4, then x-ray again
Next step if x-rays turn out negative twice after conservative treatmentAdvanced imaging
Pathobiomechanics of hallux limutusRestricted first ray plantar flexion, first MTPJ sagittal plane subluxation, bony adaption, 1st MTPJ DJD
How does uncompensated FF varus contribute to hallux limitus?Medial column is trying to get to the ground, MTPJ will sublux if hallux can't dorsiflex
What sesamoid pathology is associated with hallux limitus?Osteopenic sesamoid due to NWB, hypertrophy of sesamoids, proximal migration of sesamoids (FHB, primary destabilizer of hallux, in spasm)
What does pain and crepitus indicate?Cartilage loss
What does pain with no crepitus indicate?Inflamed joint (synovitis), still a lot of cartilage left
Where does hallux limitus pain come from?Neuritis of proper digital branch of the dorsal cutaneous nerve (sharp pain), pericuboid pain on lateral side because people are trying to offload IPJ
How do shoes look with hallux limitus?Lateral heel is worn out, bottom of shoe worn out at hallux IPJ, worn out under 2nd MT head
Biomechanics behind the dorsiflexed first rayTA overfiring becomes supinator of the foot and lifts up the first ray
Hallux limitus radiologyDorsal osteophytes, 1st MTPJ DJD with flattening and narrowing, subchondral cysts and sclerosis
What must be done if you excise the sesamoids?Fuse IPJ, maybe also MTPJ
_______ hallux limitus exists when the 1st MTPJ DF ROM is reduced when the FF loadsFunctional
_______ hallux limitus exists when 1st MTPJ ROM is reduced with the FF loaded and unloadedStructural
Which type of hallux limitus responds better to orthotic control?Functional
Non-surgical management with orthoses1st ray cut-out, heel lift, kinetic wedge
Essential non-surgical management for hallux limitus?ROM exercises


Question Answer
Indications for joint preservation proceduresThe need to reduce osseous deformities and remove loose bodies, having enough viable cartilage to salvage the articulation
Curettage and drillingK-wire to make holes, subchondral bone is very hard but go down 5-10 mm to form fibrocartilage
OATSTake bone plug (with cartilage) from talus and put into 1st MTPJ, surgery will recreate the joint space, best if there's a small focal defect vs. a big surface area
Chilectomy dorsal procedureTaking dorsal bump off top to increase ROM, sew up, put bone wax on bleeding bump and to prevent bone from adhering to capsule
KellerResect base of phalanx
WatermannAfter curettage and drill and then chilectomy, V cut in bone breaks plantar cortex and drops MT head down, axis of rotation changes and ischemic cartilage is on top, taking wedge out will drop and rotate, affected cartilage moves up dorsal from plantar and there's more for toe to ride on
When are joint destructive procedures indicated?Joint is beyond repair with minimal to no articular cartilage available for salvage
ArthrodiastasisStretching out the joint 10mm by putting on rail for 2 weeks, maybe cartilage will regenerate if there's enough space for it
_______ and _______ will dictate the type of joint destructive procedure performedAge and functional demands


Question Answer
Joint destructive proceduresKeller, Capsular arthroplasty, Valenti, Arthrodesis (McKeever, Coughlin), Implant (interpositional, total joint replacement)
Joint preservation proceduresCurettage and drilling, OATS, Chilectomy, Waterman
Ideal candidate for KellerDM or minimal ambulatory individual, not for young people
McKeeverTake out cartilage from 1st MT and proximal phalanx, fuse with screws
Optimum positioning for 1st MTPJ arthrodesis15-25 degrees DF, 10-15 degrees ABD (or parallel to lesser digits), no frontal plane deviation
Implant propertiesInert, not biodegradable, duration, nonirritating
Interpositional implantsOne component, act as "spacers"
Where are semi implants placed?Phalangeal side or MT head side
Total joint replacement2 component implants, either semi constrained (sagittal motion) or nonconstrained (more than one plane)