Abstract
Category:
Midfoot/Forefoot
Introduction/Purpose:
The goal of surgery for hallux limitus is to relieve pain, correct the dorsal joint impingement and improve ROM, especially MTP joint dorsiflexion. Obtaining increased dorsiflexion can be achieved by bone resection (cheilectomy), ostetomy of the proximal phalanx (Moberg), and soft tissue releases (plantar plate release, capsulotomy, ligament recession). In stiff joints of the hand collateral ligament recession is commonly done to improve motion. The purpose of this study was to evaluate the effect of MTPj collateral ligament recession (in addition to cheilectomy) in improving the range of motion achieved during surgery.
Methods:
Twenty consecutive patients undergoing surgical treatment for hallux limitus were studied. A dorsal approach was used and the extensor tendons protected. The dorsal capsule was opened and a cheilectomy was done removing about 25% of the dorsal metatarsal head. The joint was manually distracted and the gap measured with a spacer. Dorsiflexion of the MTP joint was measured. (Historically our goal was to obtain at least 75 degrees of dorsiflexion-more motion achieved by resecting more bone). Recession of the medial and lateral collateral ligaments was then done. Prominent medial or lateral condylar processes were smoothed with a rasp. Dorsiflexion of the MTP joint was again measured. No release of the plantar structures was done. The capsule and skin were closed in standard manner and final motion measured before applying a foot dressing.
Results:
The average introperative MTP joint dorsiflexion ROM obtained by chelectomy alone was 65 degrees (range 45 to 90). This motion was measured related to the plantar surface of the foot. The ROM after cheilectomy and collateral ligament recession was 85 degrees or more in all patients. Collateral ligament recession permitted the joint to be distracted (increased 'joint space') and facilitated the conversion of the MTP joint from a gliding to a hinge joint (the mechanical goal of cheilectomy). Also noted was that less bone needed to be resected from the metatarsal head to obtain the desired correction. After resection of any osteophytes from the dorsal proximal phalanx - this surface needed to rest about 5 mm dorsal to the residual surface (after cheilectomy) of the metatarsal head for optimum recovery of motion. This technique now used in all patients (> 150) with same intraoperative findings.
Conclusion:
For surgical treatment of hallux limitus cheilectomy plus collateral ligament recession resulted in greater intra- operative dorsiflexion of the MTP joint than cheilectomy alone. Less bone resection from the dorsal metatarsal head was also needed to obtain 85+ degrees of intraoperative correction. Intraoperative ROM is the baseline correction and is related to the surgical techniques used. Maintaining ROM after surgery is very dependent on the patient and the intensity of their rehabilitation commitment-so the last clinical follow up ROM did vary from 30 to 90+ degrees.