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HALLUX RIGIDUS
Decreased/absent 1st MPJ ROM
Normal gait requires 65 to 75 degrees of dorsiflexion at
the 1st MPJ A progressive disorder characterized by decreased ROM and degenerative alteration of the 1st MPJ Secondary to faulty biomechanics or structural pathology
HALLUX RIGIDUS
2nd most common painful affliction of the great toe
joint Affects up to 10% of adults Most commonly seen unilateral May be secondary to osteochondritis dessicans in the adolescent patient
Etiology
This is the nuts and bolts of Hallux Rigidus
Most can diagnose Hallux Rigidus, but true
understanding is properly identifying the cause and offering appropriate treatment options Being able to do so will show the examiner that you have mastery of the condition
can lead to hypermobility Immobility of 1st ray 1st ray elevatus Trauma Arthritis
Drago
Kravitz
pain, no DJD, functional hallux limitus Stage II: Limited motion, pain at end ROM, early DJD, flattening of 1st metatarsal head, small osteophytosis, subchondral eburnation Stage III: Limited motion, pain with ROM, DJD, subchondral cyst formation, asymmetric joint space narrowing, osteophytosis, crepitus Stage IV: Ankylosis
ACFAS Clinical Practice Guideline
rocker bottom sole, stiff sole Graphite plate Injection therapy NSAIDS
Arthroscopy
OATS
Procedure selection did not appear to be related to age All hemi-implants were placed in the base of the proximal
phalanx
Kravette M. A Multicenter Retrospective Review of Outcomes for Arthrodesis, Hemi-Metallic Joint Implant and Resectional Arthroplasty in the Surgical Treatment of End-Stage Hallux Rigidus. J Foot Ankle Surg. 2012; 51: 50-56
Gastrocnemius?
Hypermobility?
Surgical Considerations
Age of patient and longevity of procedure
Activity level of patient Etiology of Hallux Rigidus
Objectives of Talk
Present possible, realistic case scenarios involving
Hallux Rigidus that may be similar to those encountered in the oral portion of the ABPS Certification Exam To reinforce to you that all oral questions may be approached in a similar manner The key to success is being comfortable with the workup
Hallux Rigidus
Should be a familiar topic to all of us
There are many ways to address this problem, which makes
topics
not work?
Grade III Hallux Rigidus Joint space narrowing, subchondral cysts and osteophytosis
Exam Approach
Read yellow card out loud
Ask for any details in history that were not covered
(nature of pain, location, onset, duration, etc.) Ask for PMH, PSH, Medications, Allergies Ask for Family History, Social History, ROS Ask for Vitals if not given Physical Exam: ask in general terms, but may be steered to problem focused
Exam Approach
Labs
Xrays/Imaging
complaining of pain in her great toe for approximately one year. She denies any acute trauma, but relates it started after she began running for exercise. She denies any previous treatment.
contributory Any medications? None Any allergies? NKDA Family/Social History? History of CAD, type 2 diabetes. Patient denies ETOH, tobacco or other drug use. Single, lives alone ROS? Non-contributory
thorough. The examiner will move you along if there are not any other points to obtain Being consistent with your approach will ensure that you are not missing any chances at potential points Being consistent with your approach will also keep your management of the question focused and reproducible
Pain with palpation of the dorsal 1st metatarsal-phalangeal joint Pain at end range of dorsiflexion of 1st MPJ No crepitus
extended and subtalar joint in neutral bilaterally Patient exhibits +5/5 strength 15 degrees of 1st MPJ dorsiflexion with the 1st ray loaded and 35 degrees of 1st MPJ dorsiflexion with the 1st ray unloaded
This may be given to you or you may need to walk
through it
adductus alignment
films
XRAY Exam 1st ray elevatus, no plantar gaping of 1st met-cuneiform joint, small osteophyte
Gastrocnemius equinus
Imaging findings First Ray? We were told ROM of 1st Ray was normal,
DIAGNOSIS
Hallux Rigidus
May or may not need to stage..
Treatment
Consider patient compliance, age, expectations,
Surgical Treatment
Be prepared to mention several options and explain
rational. This may be an area of concentration for obtaining points in the exam.
Try not to get discouraged if your choice is not the one
shown
There are points to be had for knowing surgical
options
osteotomy?
Why would you choose this option? What is your post operative care?
Rational
Joint is well preserved
1st metatarsal is long and elevated Hypermobility is not appreciated clinically or
Post-operative Care
2-3 weeks NWB in splint followed by 2-3 weeks of
In this case
A decompressional osteotomy and a gastrocnemius recession was performed
The Critique
You may be asked to evaluate the post-operative xrays Or at this point things may take a turn.
DVT
Fixation failure Metatarsalgia/overload Know how to handle these complications
uneventful At four months, patient presents complaining of increasing forefoot pain She denies any injury She is not wearing orthoses She is unable to return to exercise type activities
and cause of pain Remember to treat as you would in your office Review post-operative xrays and obtain new films
Does the toe purchase the ground? Is there increased dorsal excursion of the digit? Examiner tells you that the 2nd toe purchases the ground and increased dorsal excursion is not appreciated
shortened
Osteotomies of the First Metatarsal for Hallux Rigidus: A Systemic Review. J Foot Ankle Surg. 2010; 49(6): 553-560
pain in his right big toe since having surgery last year by another doctor in town. He relates that it only started to hurt after the surgery. He relates that some bone spurs were removed from the joint.
NKDA
Social History: Smoker Family History: HTN please proceed to your physical Exam
pain with ROM of 1st MPJ and with palpation of joint Any Crepitus? Mild ROM of 1st MPJ? Decreased Ankle Joint ROM? Within normal limits Any other pertinent physical findings? No, please proceed
evaluate
AP Xray
loss of joint space, normal metatarsal parabola, subchondral sclerosis and cyst formation
Lateral Xray
1st ray elevatus, appears as though dorsal spur has been removed
Surgical Options
Keller? Resect base of PP with interposed capsule
Valenti? Resect base PP, Head First met Cheilectomy?Surrounding spur
Osteotomy?
Arthrodiastasis? Implant? Arthrodesis?
intra-operative findings
Prior surgical intervention had been tried
boot x 1-2 weeks followed by full weightbearing in a walker shoe or boot x 2-3 weeks then progressing to a shoe
Retrospective Analysis of Plate versus Screw Fixation. J Foot Ankle Surg 51: 172-175, 2012
Nonunion of
st 1
MPJ