Radiographic Measurements of the Affected and Unaffected Feet in Patients with Unilateral Hallux Limitus A Case-Control Pilot Study.

BACKGROUND: Controversy exists regarding the structural and functional causes of hallux limitus, including metatarsus primus elevatus, a long first metatarsal, first-ray hypermobility, the shape of the first metatarsal head, and the presence of hallux interphalangeus. Some articles have reported on the radiographic evaluation of these measurements in feet affected by hallux limitus, but no study has directly compared the affected and unaffected feet in patients with unilateral hallux limitus. This case-control pilot study aimed to establish whether any such differences exist. METHODS: Dorsoplantar and lateral weightbearing radiographs of both feet in 30 patients with unilateral hallux limitus were assessed for grade of disease, lateral intermetatarsal angle, metatarsal protrusion distance, plantar gapping at the first metatarsocuneiform joint, metatarsal head shape, and hallux abductus interphalangeus angle. Data analysis was performed using a statistical software program. RESULTS: Mean radiographic measurements for affected and unaffected feet demonstrated that metatarsus primus elevatus, a short first metatarsal, first-ray hypermobility, a flat metatarsal head shape, and hallux interphalangeus were prevalent in both feet. There was no statistically significant difference between feet for any of the radiographic parameters measured (Mann-Whitney U tests, independent-samples t tests, and Pearson χ(2) tests: P > .05). CONCLUSIONS: No significant differences exist in the presence of the structural risk factors examined between affected and unaffected feet in patients with unilateral hallux limitus. The influence of other intrinsic factors, including footedness and family history, should be investigated further.

The anatomical location of the flexor hallucis brevis as it pertains to implant arthroplasty.

BACKGROUND: Hallux limitus/rigidus is a painful arthritic condition affecting the first metatarsophalangeal joint that can be treated by implant arthroplasty, which, ultimately, may cause loss of the anatomical insertion points of the flexor hallucis brevis muscle. Preparation of the base involves resection of bone, thus compromising the insertion of the flexor hallucis brevis muscle. METHODS: We dissected 54 fresh-frozen cadaveric specimens and quantitatively measured the distalmost insertion point of the medial and lateral heads of the flexor hallucis brevis muscle. These measurements were performed for both heads. The measurements were performed three times by three separate examiners. In addition, taking into consideration the anatomical construct of the articular surface of the base of the proximal phalanx of the hallux, another measurement was performed to note the concavity using 44 of the specimens. Again, these measurements were performed three times by three separate investigators. RESULTS: The mean length from the base of the proximal phalanx to the distalmost insertion of the medial and lateral heads of the flexor hallucis brevis muscle was found to be 7 mm. CONCLUSIONS: This study provides precise anatomical data that can be used by foot and ankle surgeons when considering the use of implant arthroplasty for the treatment of hallux limitus/rigidus and the ability to maintain the insertion point of the flexor hallucis brevis muscle.

Hallux límitus post-quirúrgico. A propósito de un caso / Post surgical hallux limitus. A clinical case

En el presente trabajo se expone un caso clínico de una mujer de 53 años que acude a la Clínica Podológica por presentar artralgia de la Primera Articulación Metatarsofalángica durante la fase propulsiva, de 4 años de evolución. Tras exploración podológica se diagnosticó de Hallux Límitus Funcional caracterizado por una alteración biomecánica de la 1ª AMTF con disminución de la flexión dorsal del Hallux por debajo de los 65º en dinámica con probable etiología quirúrgica por descenso plantar de la primera cabeza metatarsiana. Dicha alteración biomecánica comporta una serie de mecanismos compensatorios al resto del antepié y retropié causados por la insuficiencia estructural y funcional del primer radio. A nivel podológico, se pueden realizar una amplia variedad de tratamientos pero sin lugar a dudas y en cualquier caso, es de relevancia una minuciosa y planificada exploración y valoración del pie junto a toda la Extremidad Inferior del paciente. El objetivo del trabajo es justificar si existe una relación entre Hallux Límitus Funcional y el descenso plantar de la primera cabeza metatarsiana o se contemplan como entidades patológicas independientes y analizar qué tratamientos serían los más indicados. Para ello, se analizó la exploración la patomecánica, el tratamiento del caso clínico estudiado, y se realizó una revisión bibliográfica de la documentación científica relacionada con dichas alteraciones. Tras exhaustivos análisis se concluye que dichas patologías pueden presentar una relación etiológica si durante la fase propulsiva se produce un momento dorsiflexor de la 1ª cabeza metatarsiana como respuesta a las Fuerzas Reactivas del Suelo, limitándose así la flexión dorsal y la activación del Mecanismo Windlass para convertir el pie en una palanca rígida y producir un despegue del primer radio eficiente. Tanto la exploración como la patomecánica del primer radio, son determinantes para el diagnóstico y tratamiento de dichas patalogías, así como conocer las consecuencias que pueden desencadenar en el resto del pie y extremidad inferior, ya que variarán el tratamiento ortopodológico, quirúrgico y físico. En el paciente, las patologías expuestas se atribuyen a una corrección quirúrgica de Hallux Abductus Valgus que ha provocado un descenso plantar de la cabeza metatarsiana (AU)

In this paper, we present a clinical case of a 53 years old woman who comes to the podiatry clinic, suffering from an arthralgia of the 1st metatarsophalangeal joint, during the propulsive stage of gait, for 4 years. After the clinic examination, she was diagnosed as a functional hallux limitus, characterized by a biomechanical alteration of the 1st metatarsophalangeal with a disminution of the dorsal flexion of the hallux below 65º in the dynamic with a probable surgery etiology, because of the descending of the 1st metatarsal head. This biomechanical alteration involves a series of compensatory mechanism for the rest of the forefoot and hindfoot caused by structural and functional failure of the first radio. At a podiatric level, we can executive a wide variety of treatments but, in all cases, we need a planned and through examination and assesment of the foot and lower extremities of the patient. The aim of this paper is to justify whether there is a relationship between Functional Hallux Limitus and the descent of the first metatarsal head, or if they are independent pathological identities and to analyze what kind of treatments are the most suitable. For this purpose, we analyzed the examination, the patomechanics, the treatment and we carried out a bibliographic revision of the scientific documentation related to those alterations. After exhaustive analysis, we conclude that these conditions may have an etiological relationship if during the propulsive phase there is a dorsiflexor moment of the 1st metatarsal head in response to the reactive forces on the ground, thus limiting the dorsal flexion and activating the Windlass Mechanism in order to convert the foot into a rigid lever and produce an efficient launch of the first radio. Both exploration and patomechanics of the first radio are crucial for the diagnosis and treatment for these pathologies, as well as knowing the consequences that can be generated on the rest of the foot and lower limb, as several orthopedic, surgical and physical treatments. The conditions of our patient are attributed to a surgical correction of hallux valgus abductus which led to a lowering of the metatarsal head (AU)

The cheilectomy and its modifications.

Hallux rigidus occurs in 10% of persons aged 20 to 34 years but in as much as 44% of people older than 80 years. Surgical intervention has been suggested for cases of hallux rigidus that have failed using conservative methods. The modified cheilectomy is considered by many the first-line treatment for this disease, given the procedure's inherent ability to eliminate degenerate bone and cartilage and decompress the intra-articular space, while sparing considerable cubic content of bone. Once the cheilectomy has been performed, there remains a sufficient volume of bone to perform a more definitive reconstruction if necessary.

Epidemiological aspects of the surgical correction of structural forefoot pathology.

UNLABELLED: The aim of this study was to associate structural forefoot surgical correction with theories related to the etiology of structural forefoot pathology. All forefoot surgical cases performed at the Inova Fairfax Hospital Ambulatory Surgery Center over a 76-month period (January 2001 through April 2007) were reviewed and classified according to the following surgical categories: hallux abductovalgus, hallux limitus, lesser digital deformity, and combinations of these categories (N = 1684 procedures in 1592 patients). The results suggested that the etiology of lesser digital deformity was associated with the etiology of hallux abductovalgus more so than it was with hallux limitus. In fact, a patient undergoing surgical correction of a hallux abductovalgus deformity displayed 4.63 times greater odds of undergoing surgical correction of a digital deformity, or deformities, compared to a patient undergoing surgical correction of hallux limitus (OR = 4.63, 95% CI 2.81-7.71, P < .0001). Furthermore, medial (second or second and third) toe deformity correction was statistically significantly associated with hallux abductovalgus surgery (OR = 3.34, 95% CI 2.52-4.44, P < .0001), whereas lateral (fifth or fourth and fifth) toe deformity correction was statistically significantly associated with cases that did not involve hallux abductovalgus surgery (OR = 0.27, 95% CI 0.20-0.37, P < .0001). The concept of flexor hallucis longus stabilization is introduced as a possible mechanical explanation for these results. LEVEL OF EVIDENCE: 2.

Total sesamoidectomy for painful hallux rigidus: a medium-term outcome study.

BACKGROUND: The nature of the sesamoid complex in the development of hallux rigidus or limitus (HL) has been poorly characterized and the role of the sesamoids in the surgical management of this condition has not been explored. Previous surgical approaches in younger active patients unsuited to destructive procedures have been limited. MATERIALS AND METHODS: Thirty-three patients (36 procedures) were reviewed between 2 and 4 years following total sesamoidectomy for the management of hallux rigidus/limitus. The American Orthopedic Foot & Ankle Society hallux (AOFAS) clinical rating system was used to compare pre and postoperative scores. The range and quality of motion and transfer metatarsalgia were noted. The three most important patient problems and the degree to which these had been addressed by the surgery and the time to maximal improvement were noted. RESULTS: No significant functional impairment or malalignment were found. There were no instances of pain on metatarsal compression, or of transfer metatarsalgia with or without callus formation. A highly statistically significant improvement in AOFAS scores was found (p < 0.001). CONCLUSION: High levels of clinical improvement and patient satisfaction were found following total sesamoidectomy. No deleterious consequences of sesamoid removal were observed. For symptomatic patients where a joint replacement/fusion is not indicated, total sesamoidectomy was beneficial as an interim procedure, for joints with a moderate (grades 2 to 3) degree of arthrosis.

Dynamic splinting for runner's toe: a case report with gait analysis.

We present a case report of runner's hallux limitus and the effect of dynamic splinting in reducing contracture as measured by gait analysis. After 4 months of treatment with dynamic splinting, the patient regained 45 degrees in active range of motion, and the gait analysis showed significant and beneficial changes.

Length of the sesamoids and their distance from the metatarsophalangeal joint space in feet with incipient hallux limitus.

BACKGROUND: We designed this study to verify whether the sesamoids of the first metatarsal head are longer than normal in feet with incipient hallux limitus, and whether feet with incipient hallux limitus are in a more proximal than normal sesamoid position. METHODS: In a sample of 183 dorsoplantar radiographs under weightbearing conditions (115 of normal feet and 68 of feet with slightly stiff hallux), measurements were made of the length of both the medial and the lateral sesamoids and of the distance between these bones to the distal edge of the first metatarsal head. These variables were compared between the normal and the hallux limitus feet. The relationship between these variables and the hallux dorsiflexion was also studied. RESULTS: We found significant differences between the two types of foot in the medial and lateral sesamoid lengths, but no significant difference in the distance between the sesamoids to the distal edge of the first metatarsal. A poor-to-moderate inverse correlation was found between hallux dorsiflexion and medial sesamoid length and between hallux dorsiflexion and lateral sesamoid length. CONCLUSIONS: The length of the sesamoid bones of the first metatarsal head could be implicated in the development of the hallux limitus deformity.

Radiographic study of the size of the first metatarso-digital segment in feet with incipient hallux limitus.

BACKGROUND: The aim of this study is to confirm whether the absolute and relative lengths of the first metatarso-digital segment is greater than normal in incipient hallux limitus deformity. METHODS: In a sample of 144 dorsoplantar radiographs under weightbearing conditions (94 of normal feet and 50 of feet with a slightly stiff hallux), measurements were made of the relative first metatarsal protrusion, the length and width of the first metatarsal and of the proximal phalanx of the hallux, the length of the distal phalanx of the hallux, and the total length of the hallux. RESULTS: There were significant differences between the two types of feet in the relative first metatarsal protrusion, the width of the first metatarsal, the length and width of the proximal phalanx of the hallux, the length of the distal phalanx, and the total length of the hallux. CONCLUSION: The size of the first metatarso-digital segment could be implicated in the development of hallux limitus deformity.

Finite element modeling of the first ray of the foot: a tool for the design of interventions.

Disorders of the first ray of the foot (defined as the hard and soft tissues of the first metatarsal, the sesamoids, and the phalanges of the great toe) are common, and therapeutic interventions to address these problems range from alterations in footwear to orthopedic surgery. Experimental verification of these procedures is often lacking, and thus, a computational modeling approach could provide a means to explore different interventional strategies. A three-dimensional finite element model of the first ray was developed for this purpose. A hexahedral mesh was constructed from magnetic resonance images of the right foot of a male subject. The soft tissue was assumed to be incompressible and hyperelastic, and the bones were modeled as rigid. Contact with friction between the foot and the floor or footwear was defined, and forces were applied to the base of the first metatarsal. Vertical force was extracted from experimental data, and a posterior force of 0.18 times the vertical force was assumed to represent loading at peak forefoot force in the late-stance phase of walking. The orientation of the model and joint configuration at that instant were obtained by minimizing the difference between model predicted and experimentally measured barefoot plantar pressures. The model were then oriented in a series of postures representative of push-off, and forces and joint moments were decreased to zero simultaneously. The pressure distribution underneath the first ray was obtained for each posture to illustrate changes under three case studies representing hallux limitus, surgical arthrodesis of the first ray, and a footwear intervention. Hallux limitus simulations showed that restriction of metatarsophalangeal joint dorsiflexion was directly related to increase and early occurrence of hallux pressures with severe immobility increasing the hallux pressures by as much as 223%. Modeling arthrodesis illustrated elevated hallux pressures when compared to barefoot and was dependent on fixation angles. One degree change in dorsiflexion and valgus fixation angles introduced approximate changes in peak hallux pressure by 95 and 22 kPa, respectively. Footwear simulations using flat insoles showed that using the given set of materials, reductions of at least 18% and 43% under metatarsal head and hallux, respectively, were possible.

Modified Youngswick procedure for hallux limitus.

Multiple surgical procedures have been described for the correction of hallux limitus deformity. We describe a new modification of the Youngswick procedure for the surgical treatment of hallux limitus. Other procedures for hallux limitus correction are also discussed. This modified Youngswick procedure will provide a new approach to treating hallux limitus secondary to metatarsus primus elevatus when shortening of the first metatarsal is not indicated.