Session II Hallux Arthritis Mr. V. Dhukaram

Warwick Orthopaedics is a centre of excellence for research, teaching and development of the treatment of musculoskeletal disease. I am delighted to welcome you all for the Warwick Cadaveric Foot and Ankle Surgery course. This course is designed to be practical with no formal lectures. We have put together the educational and product information for you to familiarise prior to the course which would be a valuable adjunct to the course. Vivek DHUKARAM

Cheilectomy First MTPJ Indications: O.A. with pain free mid ROM but positive dorsal impingement, symptomatic dorsal bunion Aim to resect the most affected dorsal articular surface and improve ROM Coughlin reported 92% good results with pain relief and improved ROM in Gr I & II, selected Gr III O.A. Coughlin, Shurnas. Hallux rigidus. Grading and long-term results of operative treatment. JBJS Am 2003 Nov;85-A(11):

Technique Dorsal or medial approach Resect up to 1/3 rd of dorsal articular surface. Over resection will lead to dorsal instability Excise medial, lateral and phalangeal osteophytes Ensure adequate dorsiflexion (80 degrees) If not, require release of FHB from Proximal phalanx Complications Recurrence Incomplete symptom relief

Moberg Osteotomy Dorsal wedge osteotomy of the proximal phalanx increases dorsiflexion at a cost of loss of plantarflexion Combined with cheilectomy for better symptomatic relief Osteotomy technique similar to Akin (preserve the plantar cortex) Success reports similar to cheilectomy without loss of plantarflexion Fixation method: Staple Hunt KJ, Anderson RB Biplanar proximal phalanx closing wedge osteotomy for hallux rigidus. FAI 2012 Dec;33(12):

Keller’s – MTPJ Excision Arthroplasty Indication: Symptomatic hallux valgus and rigidus Problems: De-function hallux, transfer metatarsalgia risk of cock-up toe. So, indications restricted to elderly, immobile patient to improve pain and foot wear compliance or salvage option for previous failed procedures Hamilton modification: Imbrication of dorsal capsule with EHL into the joint space, cheilectomy first MT head Technique: Medial approach Resect proximal 1/3 rd of PP Release FHB to reduce the risk of cockup toe deformity Careful medial capsular repair for better result O'Doherty DP et al. The management of the painful first metatarsophalangeal joint in the older patient: arthrodesis or Keller's arthroplasty. J Bone Jt Surg 1990; 72B:839-42

First MTPJ Fusion Indications: -End stage O.A. -Rheumatoid arthritis -Hallux valgus with O.A. -Deformity secondary to neurological disorder -Salvage for previous failed procedure Technique: Flat cuts of fusion surface – More stable but could result in modest shortening Ball and socket – Preserve length, flexibility in adjusting the position of fusion Ideal fusion position: -5 to 10 degree valgus -Neutral rotation -20 degree dorsiflexion. The dorsiflexion should be adequate for the pulp of hallux to rest on the ground as well as not to overload the hallux. Per-operatively checked against the flat surface holding the ankle in neutral plantigrade position.

Technique Dorsal or Medial approach Remove osteophytes Flat cuts performed using saw Ball & socket using conical reamers guided by centrally placed guide wire Fixation method: Small fragment screws by lag technique, cancellous screws, Staples, headless screws, plate & screws (locking/non-locking depending on bone quality) Conical Reamers

First MTPJ Fusion Complications -Dorsal mal-union resulting in hallux flexus -Plantar mal-union overloading the hallux -Non-union- Less than 5% with better fixations -Secondary O.A. of hallux IPJ DeFrino found restoration of weight-bearing function of first ray following fusion DeFrino PF et al. First metatarsophalangeal arthrodesis:a clinical, pedobarographic and gait analysis study. FAI 2002; 23:

Hallux IPJ fusion Indications: Most common- part of Jones transfer(EHL transfer to MT neck), O.A., Post-trauma, cock up deformity secondary to neurology/iatrogenic Technique: Inverted ‘L’ shaped incision to expose IPJ -EHL divided(transfer to MT) -Resect articular surface -Fixation method:3.5mm screw retrograde drilling with lag technique, headless screw, cancellous screw. Dhukaram et.al Inter-phalangeal joint fusion of the great toe. Foot & Ankle Surg Vol (p )