Hallux rigidus
Hallux Rigidus
Summary
This on-demand teaching session offers a detailed exploration of the concept of hallux rigidus, or osteoarthritis of the first MTP joint. The presenter discusses its presentations, etiology, diagnosis with x-rays, classifications, and the difficulties of treatment. He delves into various surgeries including Colectomy, Osteotomies, Proximal Phalangetomy, and C elastic arthroplasty. The session provides an open floor for questions and for discussing specific cases. Medical professionals who attend this session will acquire valuable knowledge about the second most common pathology observed in the forefoot, allowing them to better diagnose and treat conditions of helix rigidus in their patients.
Description
Learning objectives
- Understand the definition, etiology, and symptoms associated with hallux rigidus.
- Identify the types and stages of hallux rigidus through interpretation of X-ray images and patient complaints.
- Examine the different conservative and operative treatment options for hallux rigidus, including their advantages and drawbacks.
- Describe the surgical procedures like Colectomy and osteotomies that can be used in the treatment of hallux rigidus.
- Discuss the expected outcomes and potential complications from these treatments, with a focus on patient satisfaction and quality of life post-surgery.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
So, uh, we are discussing about hallux rigidus. Uh, if you want to ask questions, uh, guys, then you can stop me in, in between, you know, I don't mind at all. Uh, if we make it attractive, like what, what Abdul did, uh, it'll be good, you know, uh, you will gain more. So, uh, hallux rigidus, uh, is essentially, uh, osteoarthritis of the first MTP joint. So, uh, it presents with the painful stiff first MTP joint and the most common underlying etiology is osteoarthritis. Uh, it was first described by guys called Davies and Col in 1887. And, uh, thereafter, core started using the term hex rigidus. So most of the times, uh, when we see hex, we can see osteoarthritis on the x rays in early stages when there is just stiffness of the joint and not much osteoarthritic changes. Uh, some people call it, call it hex limitus as well. So, uh, Abdul talked about, uh, Helix valgus. Uh, the second most common pathology we see in for foot is Helix rigidus. So these two things, uh, are common, uh, in exam, you know, patients are there, uh, longstanding problems. Uh, so they can be come, they can be brought into exam very easily. So causes for hex rius, trauma is the most common cause I know of. So, uh young patients who present you with hex rius usually have football and injuries or uh you know, they remember stabbing their toe. Uh often uh if it is bilateral, it could be familial. The other common causes could be uh inflammatory arthritis, like rheumatoid arthritis. Uh gout very rarely, infection can also lead to damage to the joint and uh arthritis. Uh I forgot to mention that, you know, this uh helix rigidus like unlike uh hell valgus, it has a definite relationship with, you know, shove uh flat foot deformity. Uh But hex, there is no proven relationship with flat foot or say hex vuls or uh a tendon tightness or metatarsal AUC hypermobility uh and occupation. So, uh usual presentation is pain and stiffness. Uh You will see a dorsal uh lump uh which is also called as dorsal bunion. And patients come uh to you saying that I've got a bunion. Uh unless you tell them that it's arthritis, uh this dorsal bump which is caused by osteophytes, it rubs on the shoe and causes nerve irritation. We uh talked about Abdur talked about the dorsomedial branch. Uh So it's important to know that this dorsal medial branch is the middle, most branch of the superficial peroneal nerve and often why people get pain is that the nerve gets pinched between the shoe and the bone. So it would be, I don't know if you can see my mark. It will be here and it will get pinched uh between the skin and the, between the shoe and the bone. So that's why they are getting pain. Or you can say that that's one of the reason why they get pain on the top of the foot. The most common classification uh which is used amongst clinicians. Uh Is this a simple classification which was uh uh put in place by uh and Johnson. Uh and uh essentially, it divides this into mild, moderate and severe. Uh The mild one is uh very little uh uh visibility of osteophytes on the X rays. But essentially a patient presenting with joint stiffness. Uh The moderate or stage two is uh less than 50% joint space narrowing. Uh So essentially some joint space is still visible and uh uh osteophytes uh are there and uh stage three is uh the joint space is gone and there are big osteophytes and a dorsal L. Uh Is there a way to make this uh presentation uh you know, full screen? I think this is the, I mean, ii think there is if you share your screen rather than share the PDF, but I think quite a lot of people said they preferred it this way so that you actually got some people, the sense of some people watching rather than talking to nobody the second classification uh mentioned in literature is by a cuff uh and almost the same, but there's a grade zero in this and grade four in this grade zero is essentially no X ray uh sign of uh Helix Rigidus and grade four is uh uh you know, a more severe grade three. Uh Nobody tries to remember this classification actually. So treatment uh again, it's a common condition. Uh in your registrar training, you have to do uh you know, big toe surgery and registrars often come and say, you know, we have to do 10 numbers or so many numbers of the first surgery. So this is one of the surgeries. Uh I like to take them through uh treatment. Aim for oxy is to physical function and reduce pain. So essentially give patient a painful painfree foot to walk on treatment uh as usual non operative and operative. So early arthritis treatment would be, you know, like knee arthritis, nits. Uh in foot, we can give rocker bottom soles which kind of decrease the movement at the TP joint, the other options uh anywhere in arthritis. Now, uh we you can use PRP injection and I often uh tell patients to try glucosamine uh and uh turmeric, you know, before we jump into any surgery, if we can buy some more time, nothing like it. Uh Operative treatments are divided into joint preserving versus joint sacrificing and then joint sacrificing treatments can be divided into uh joint, you know, motion preserving versus uh stiffness. So, uh one of the common treatments uh we do uh you know, in our uh uh NHS practice or private practice is Colectomy. So, Colectomy involves essentially uh removing the dorsal osteophytes and doing soft tissue release of capsule uh on the dorsum planter and let aspect to get some more movement and removing any debris inside the joint. However, uh you know, uh one has to be careful, uh you can excise up to 25 to 30% of the uh metatarsal head. If you go more, then the joint can sublux sublux. But often I would say there is a, you know, tendency towards excising less rather than more. The aim is obviously to achieve 70 degree dorsiflexion. So you test on table whether you have achieved 70 degree dorsiflexion or not. And if there is anything, any lumpy bit palpable underneath the skin. So, one of the common uh things uh you, which comes to your mind is how do you decide which patient uh will benefit from Colectomy and which patient uh will not? So I'll cover that later on. But essentially uh Colectomy is for patients who present with pain on the top of the foot. So they have more commonly uh arthritis which affects the dorsal one third of the joint rather than global arthritis or metatarsal cymo arthritis. If patient is presenting with plantar pain, then one should be careful uh explaining to the patient that plantar pain may not improve. Uh Nowadays, uh we use uh this minimally invasive surgery. So you put this small little instrument inside uh by making a percutaneous uh cut. And uh you can uh check under X ray that you have uh excised the lump. You can actually check it manually. You know, as you do the surgery more often you can check it manually. You that you have excised the lump. So, uh that's uh that's uh my finger showing where the percutaneous cut is made. And uh once you have excised the lump, you can take the past out. Uh and that helps you POSTOP pain, other treatments uh which are described or uh uh you know, uh often uh not done that commonly are osteotomies of the metatarsal. Uh The mobile osteotomy is the osteotomy of the base of the proximal pharynx. Often when you're doing colectomy. And uh you haven't been able to achieve good range of movement. You can combine it with this dorsally based wedge of the proximal PX to kind of increase the range of movement uh for the patient. Then on the right is the modified Chevron osteotomy, also called young wicks osteotomy. Here, you're taking the wedge out uh to decompress the joint. So you shorten the metatarsal to decompress the joint. Uh while so we more commonly use it in lesser toes to uh decrease the length of the metatarsals for metatarsalgia. Uh it can be used uh for uh Helix as well, but I must say I haven't done this uh since I've been in practice almost uh now 13 years as a consultant. Uh I was going through a review article and uh uh it does mention that uh these osteotomies, uh some of them, they give rise to metatarsalgia essentially because you're shortening the phos metarsal. And uh there is high number of reoperation and poor patient satisfaction uh with ostectomy. So, uh not that commonly practiced in UK at least. OK. So uh we come uh to the joint sacrificing surgeries. Uh uh The, this is uh the first one we discuss is uh operation. This is proximal phalangectomy. And as you see on the X ray, it involves excising almost 3/4 of the proximal pharynx. This is quite uh uh old operation. Uh I must say when I was in training. Uh This is 2003, 4, I do, I do used to see patients with the color osteotomy but as the time has gone on, uh the incidence or the number of uh patients of killer osteotomy have uh decreased, but you still do see uh killers osteotomy uh patients. Uh It was used both for hallux rigidus and valgus. This was the time when you know, uh all arthroplasty surgeons between two hip replacements will do a bunion uh because it was just a small operation and this was this dark time of foot and ankle surgery where litigation rate was, uh, you know, sometimes even more than, more than spines. So, uh, this operation, uh, although it relieves the pain, but it used to le lo uh, leave the big toe quite short and high incidence of, uh, metatarsalgia, floppy toe and cock up toe. Uh, so in last 1012 years, it has significantly gone down. So, another surgery, uh, which is, uh, I would say, you know, uh, commonly not uh not very common but commonly done in UK is uh C elastic arthroplasty. Uh It was uh first uh uh you know, introduced to stabilize uh the joint instability with colors, operation, uh Swansons use them in hands. And uh uh thereafter, some people started using it in feet. The first generation implant uh gave rise to a higher degree of uh wear and tear, uh C elastic sinusitis, lymphadenopathy. And then it came into controversy and there was a period of about, I would say 10 years where not many uh cases were done then um back around 2000. Uh you know, uh there were some series published uh 1996 and 1999 which showed uh less than 10% revision rate at 5 to 9 years with double stem implant. And thereafter, um you know, especially the writing group popularized it and uh II use it uh in selected cases. So, uh this is the paper published uh by Tim Clo from writing. Uh he described the long term outcomes of the elastic implant uh of first MTP joint uh in 100 and eight cases uh with good results. And this is uh a line I have pasted from his paper. Uh This operation offers adequate pain relief, a high patient satisfaction rate and adequate range of motion. Uh Patients option a wide variety of activities and allowing them to wear uh the shoes they like to wear. So this uh pertains to the second generation C elastic. Now, some other companies uh apart from uh uh Swanson's uh have come uh with this implant in the market. Uh this is uh uh another joint sacrificing operation uh which is which uh is called interposition arthroplasty. So you are essentially putting uh some kind of layer between the two uh surfaces of the joint, the base of the proximal phx and metatarsal head. So it was initially started by just using, say that, you know, dorsal capsule or flexor hallucis brevis interposition. Uh And uh it was described by various authors, you know, Hamilton in 1997. Then thereafter, cuff uh cuff actually used uh a roll up of vessels in between the joint uh good results uh published uh nowadays, uh my colleagues, some of them in London use uh uh dermal matrix. So it's kind of a uh dermal allograft and you just voice has gotten on it. I think you might have muted yourself. Am somehow. Oh OK, sorry. So go back to it, uh interpositional arthroplasty. So, uh this is interposition of uh artificial layer or allograft between the two surfaces of the uh MTP joint base of the proximal pins and the metatarsal head. Uh I personally uh have no experience with this but I have seen patients uh post surgery, you know, done by my colleagues in London with good outcomes. Then uh coming to the gold standard of uh uh first MTP joint arthritis, mtp fusion. It is again a joint sacrificing and a joint stiffening operation. It's been widely accepted as a gold standard for severe helix. Uh and it is considered as a safe option which gives you good long term results. Uh It is also indicated in young, a young and active patients as as as a final or endstage procedure. Generally, patients come and ask you uh doctor would I be able to walk uh normally after this operation? And the answer is yes, patients do walk uh normally after this operation and some of them can do uh high impact activities as well. Uh Rate of satisfaction has generally been reported to be more than 80% with this operation. And this is the operation which uh I think uh I like to take my trainees through when they come and work uh with us. So uh the way it's done, uh you saw uh there is a dorsomedial uh cutaneous uh branch of the superficial peroneal nerve. So for most of my, he for most of my first surgery, I use a Universal Medial approach which Abdul discussed a little while ago. So here it is a dorsal approach soon. But essentially you can get the similar exposure from the Universal Medial approach. You prepare the joint, you can use lemur or you can do it without femurs. You take off, take off all the cartilage, you make multiple drill holes to increase the surface area and to bring the stem cells from the marrow and you fix it uh with a leg, a screw and a plate. So most important uh thing with this operation is to put the big toe in right alignment. The most common complication of this operation is to put the big toe in dorsiflex position. So patients come after surgery with their toe pointing uh up or not touching the floor. So, uh here I've drawn uh the long axis of the Phosph Meatal. Uh the book says, uh the toe should be put in about 10 to 15 degrees dorsiflexion with respect to the long axis of phosph Meatal. Often patients uh often uh trainees or doctors, uh you know, when they're learning, they confuse this with 10 to 15 degrees dorsiflexion to the floor. It is not the dorsiflexion to the floor, but it is the dorsiflexion to the long axis of the first metatarsal. So you can see that the first metatarsal long axis is pointing down. So when you put 15 degrees dorsiflexion, the toe will sit pad on the ground. But if you put it 15 degrees dorsiflexion with uh you know, with respect to flow, then the toe would be pointing up. So this is uh how we generally test it on table. You put a, put on a flat surface, you know, either the top of the implant tray or a kidney dish and see that your big toe is touching uh the surface you have put it on. So, uh this is what uh you should see uh with x rays on the table that your toe uh is almost the lowermost toe on your lateral view and it's touching the floor. You can even draw angles to see that, you know, this is the long axis and this is, you know, about 10 degrees, 15 degrees dorsiflex. So this is what I worry about, you know, uh the, the toe uh is not dorsiflexed and this is what I check when my registrar is doing the surgery. So generally, uh most of us have uh now shifted to plate and screw. Uh uh just because of the reliability of fixation and less chances of nonunion. Uh I think the plate and leg screw has decreased the nonunion rates to uh I would say less than 10% or rather less than 5%. I generally tend, tend to tell my patients that there is one in 220 chance of nonunion with the surgery complications. Uh first perfusion. Uh The most common complication, as I mentioned is a mal union. So dorsiflex to other uh complications are uh infection uh nonunion. Uh Generally, we give one dose of antibiotic before the surgery and I mentioned one in 20 chances of nonunion. I give to patients delayed union. I always tell my patients that it can take up to 3 to 6 months for this to heal and the foot will remain swollen for 3 to 6 months. However, they can walk in normal shoes in about six weeks time. Uh because plate is holding the MTP joint, other uh complications are transform metatarsalgia, especially if you're short on the toe. Uh As long as you maintain, do not take much bone off. Uh and you have maintained the length, then it's not a problem. But if you take flat cuts, then sometimes it could be a problem. So uh my talk is more or less finished.