Study Examines Combination Of Procedures For Hallux Rigidus

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Here one can see a mini-arthrotomy ankle fusion with Therics beta tricalcium sulfate as the bone graft. (Photo courtesy of Luis Leal, DPM)
A new study suggests that surgeons may want to consider a combination of hemi-implant arthroplasty and decompressional osteotomy when treating patients with hallux rigidus.
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By Brian McCurdy, Senior Editor

Can a combination of two procedures yield positive results for patients with hallux rigidus? A recent study, presented as an abstract at the annual meeting of the American College of Foot and Ankle Surgeons (ACFAS), notes increased function and decreased pain in patients who underwent a combination of a hemi-implant arthroplasty with a decompressional osteotomy.
As part of the study, 11 patients with hallux rigidus underwent the combination of surgical procedures. Patients had either grade III or IV hallux rigidus, less than 20 degrees of first metatarsophalangeal joint (MPJ) dorsiflexion, and a first and second intermetatarsal angle of less than 14 degrees. Of the eight patients available for follow-up, six patients received the Waterman-Green osteotomy and K2 hemi-implant (KMI), one received the Waterman-Green osteotomy with the Great Toe Hemi Implant (Biopro), and one underwent the Austin-Youngswick osteotomy and received a K2 hemi-implant.
Patients who underwent the combination procedure experienced a significant decrease in pain and increase in function, according to the study. Eighty-seven percent of the patients (or seven out of the eight patients) rated their surgical results as good, very good or excellent. One patient reported a fair result.
Robby Amiot, DPM, a co-author of the study, says a 13-month follow-up revealed that the patients’ average American Orthopedic Foot and Ankle Society (AOFAS) Hallux MPJ/IPJ score increased by 31.7 points. He adds that the total range of first MPJ motion increased by an average of 20.1 degrees after the surgery and notes that patients’ average dorsiflexion increased 19.2 degrees after the surgery.

Dr. Amiot says the combination treatment has promising results and believes its long-term results will prove to be better than performing only a hemi-implant arthroplasty or a first MPJ fusion. Dr. Amiot is currently working on a long-term prospective study to examine the effects of the therapy.
“We feel maintaining motion of the first MPJ is extremely important for a patient to have a normal gait pattern,” says Dr. Amiot. “It is our belief that a decompressional osteotomy of the first metatarsal will not only plantarflex the metatarsal head but will also decompress the first MPJ.”
He notes the decompression will permit a greater post-op range of motion as opposed to performing only a hemi-implant arthroplasty.
Dr. Amiot compares the decompressional osteotomy to distraction arthrodiastasis of the first MPJ, saying each procedure permits greater joint space, easier range of motion and results in less pain.

What About Potential Complications?
As Dr. Amiot points out, a few patients experienced “minor” post-op complications. However, with the exception of one patient, Dr. Amiot says the complications did not affect the surgical outcome. He says the rate of complications in the study is equivalent to the complication rates reported in other hallux limitus/rigidus studies.
Among the complications was a delayed union in a patient, who was noncompliant and a smoker, and wound up achieving clinical and radiographic union after conservative measures. Another patient with a stress fracture healed with conservative treatment, notes Dr. Amiot.
One patient experienced deep vein thrombosis but later rated his result as excellent and wants to have the procedure performed on his contralateral foot, according to Dr. Amiot.

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