How To Select The Right Procedure For Hallux Limitus

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Continuing Education Course #115— December 2003

I am very pleased to introduce the latest article, “How To Select The Right Procedure For Hallux Limitus,” in our CE series. This series, brought to you by HMP Communications, consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

Hallux limitus can be a complex condition and each stage has its own diagnostic signs. In this article, Harold Schoenhaus, DPM, describes stages ranging from joint inflammation and jammining of dorsiflexion motion in propulsion to advanced degenerative joint disease. Dr. Schoenhaus, the Chief of Foot and Ankle Surgery at the Graduate Hospital in Philadelphia, also discusses appropriate treatment options for the various stages of this condition.

At the end of this article, you’ll find a nine-question exam. Please mark your responses on the postage-paid postcard and return it to HMP Communications. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Editor-In-Chief
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 62 and successfully answering the questions on pg. 66. Use the postage-paid card provided to submit your answers or log on to www.podiatrytoday.com and respond electronically.
ACCREDITATION: HMP Communications, LLC is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by HMP Communications, LLC are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Dr. Schoenhaus has disclosed that he has no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of his presentation.
GRADING: Answers to the CE exam will be graded by HMP Communications, LLC. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: December 2003.
EXPIRATION DATE: December 31, 2004.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• identify the common causes of hallux limitus;
• describe the diagnostic indicators for the various stages of hallux limitus;
• discuss the merits of performing a Keller with and without an endoprosthesis; and
• discuss surgical procedures for advanced degenerative joint disease.

Sponsored by HMP Communications, LLC.

This intraoperative photo reveals cyst formation of the first metatarsal head.
Note the extensive bony development with spurring about the first metatarsophalangeal joint.
In the above photo, one can see degenerative and erosive changes to the head of the first metatarsal.
Note the extensive spurring on the first metatarsal and proximal phalanx. This patient has high elevatus of the first metatarsal.
In this advanced stage, one should note the uneven lack of joint space and the extensive bony proliferation medially and laterally.
Here is a seated, angled titanium hemi-implant in the proximal phalanx.
66
Author(s): 
By Harold Schoenhaus, DPM

When it comes to hallux limitus, there are several circumstances in which one may see this decreased range of motion of the first metatarsophalangeal joint. You may note a limited range in the direction of dorsiflexion, plantarflexion or both. Depending upon the etiology, you may see the restriction during nonweightbearing, static stance or during the propulsive phase of gait.
The etiology may be secondary to direct macrotrauma to the great toe joint, metabolic conditions such as gouty arthritis or, most commonly, first ray hypermobility associated with abnormal pronation. Hypermobility of the first ray causes an elevation in propulsion that decreases the ability of the hallux to dorsiflex on the first metatarsal. This prevents the necessary 65 degrees of dorsiflexion in propulsion and increases compressive forces across the joint.
The compressive forces, which are repetitive and microtraumatic, lead to inflammatory, degenerative and proliferative changes. These forces affect the bone cartilage and synovium, causing objective and subjective findings. As the process continues, one will see a thinning of cartilage, bone proliferation, hypertrophic changes to the synovium and functional adaptation of the joint. You will usually see exostosis formation dorsally but it may also occur medially and laterally. While hallux limitus is most commonly seen as a sagittal plane deformity, you may also see it with hallux abducto valgus secondary to hyperpronation and first ray hypermobility.
Understanding the four stages of hallux limitus is vital because treatment is often predicated on these stages.

Dealing With Joint Inflammation And Jammed Motion In Dorsiflexion
Stage I. Joint inflammation and jamming of dorsiflexion motion in propulsion are the hallmarks of Stage I. These patients will have a normal, nonweightbearing range of motion and you will not note any X-ray changes.
If the symptoms are associated with direct trauma, prescribing antiinflammatory medication, corticosteroid injections and physical therapy is usually adequate. If the etiology is metabolic in nature, as seen with gout, antiinflammatory medication, injections and uricosuric or xanthine oxidase inhibitors are indicated. When hyperpronation is the cause, add orthotics to the treatment plan.

A Guide To Diagnostic Signs And Treatments For Stage II
Stage II. In this stage, patients begin to show objective clinical signs in addition to the inflammation of Stage I. You will note a dorsal proliferative response that is palpable and evident on X-ray as well. The patient will have a limited range of motion in dorsiflexion due to exostosis formation and one may see some narrowing of the joint space on X-ray. These objective findings are early changes of degenerative joint disease. Hypertrophy of the dorsal capsule develops as it grows over the developing exostosis (dorsal spurring). The contour of the articular surfaces is minimally affected and will allow for relatively normal curvilinear motion.

After exhausting the aforementioned conservative approaches to alleviate discomfort, one can consider surgical intervention. Be sure to explain the goals of surgery clearly to the patient. Reducing pain, removing the offending bone and improving range of motion are the primary goals.
A cheilectomy is the procedure of choice for removing the offending bone. One should begin with a dorsal S-shaped incision in order to avoid postoperative scar contraction. Drilling minor cartilaginous defects through subchondral bone helps promote the proliferation of fibrocartilage. If adjacent soft tissue structures are tight, you may apply a mini fixator for joint distraction and use it for four to six weeks. You can employ manual range of motion in the direction of dorsiflexion and plantarflexion, even with the fixation in place, while still maintaining a distraction force. Early range of motion is essential for maintaining healthy cartilage and allowing for the proliferation of fibrocartilage. Postoperative orthotic control is essential if the underlying cause is first ray hypermobility secondary to pronation.

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