Reassessing Surgical Options For Recalcitrant Hallux Limitus In An Active Population

Author(s): 
John F. Grady, DPM, FASPS

   Not only does the surgeon remove ossifications, he or she would also remove central defects that are loose and causing trouble. Subchondral drilling of these defects as one would with an osteochondritis dissecans is occasionally necessary. Using power equipment, remove abnormal bone and severely degenerated cartilage in order to allow motion of the phalanx against the metatarsal without any obstruction on the metatarsal.

   One can subsequently remove eccentric and hypertrophied bone from the proximal phalanx with a bone rongeur. Keeping the shape of the proximal phalanx prevents some of the dorsiflexion problems that typical Valenti enthusiasts have encountered.

   An important part of the procedure is to mobilize the sesamoids sharply with a #15 blade. After mobilizing the sesamoids, the toe should dorsiflex 90 degrees. Only then do we begin closure. If the toe does not bend without resistance on the table, then we need to loosen things up more or perform a more aggressive resection dorsally.

Pertinent Post-Op Pearls

For the first two weeks, elevation is key and the patient is not putting the foot below the waist except for a minimal amount of time. After the first two weeks, the patient will engage in an aggressive exercise program for the next six months to two years for passive range of motion, active range of motion and proprioceptive exercises of the first metatarsophalangeal joint. It is important that the patient adhere to this program. Otherwise, one can refer the patient to physical therapy for range of motion improvement.

   Physicians can expect that edema will last for a minimum of six months after the procedure and weakness is a natural result of this procedure as tendons that have not moved for years are not going to have strength for awhile. Mobilization of the joint will give these tendons more responsibility at the time they are deficient in function.

   In addition, the formation of sesamoiditis in sesamoids that have not moved for years is expected and an extraordinarily common result.3 Sesamoiditis still remains an easy problem to treat, particularly with offloading and seems to resolve within approximately six months after surgery. There are those occasions when sesamoiditis is continuing and recurring.

Final Notes

In conclusion, I think we have sometimes unnecessarily limited our scope of surgical procedures to cheilectomy, implants and arthrodesis. The truth is that we should focus more on alternative options of arthroplasty, which are non-implant procedures and have potentially more successful outcomes for the athletic population.

   There are very few athletic patients who have had their athletic careers diminished by the presence of hallux limitus. In our practice, after patients have had this type of arthroplasty, they have shown remarkable improvement and returned to their desired athletic activity. This is true in the majority of cases we have seen.

   Certainly, there is still an indication for arthrodesis and there are indications for implant arthroplasty as well. I just don’t think we should rush from cheilectomy into implant arthroplasty or arthrodesis without considering alternate procedural choices that I have discussed above.

   Dr. Grady is the Director of The Foot and Ankle Institute of Illinois. He is the Chief of the Podiatry Section of the Jesse Brown Veterans Affairs Medical Center and the Director of the Podiatric Surgical Residency Program at the Westside Division of the Veterans Administration Chicago Healthcare System. He is board-certified by the American Board of Podiatric Surgery, the American Board of Podiatric Orthopedics and Primary Podiatric Medicine, and the American Academy of Wound Management. Dr. Grady is a Fellow of the American Society of Podiatric Surgeons and is the Scientific Chairman of the Midwest Podiatry Conference.

Comments

Dr. Grady,

I have used the Valenti Arthroplasty and Keller Interpositional Arthroplasty with good success for
hallux limitus. I agree with you rethinking our approach to Hallux Limitus.

Emanuel Willis,DPM,FACFAS
Scholl's Class of 1986

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