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Hallux limitus/rigidus are conditions that have some
overlap. A non-functioning 1st MPJ leads to compensation. The foot will become apropulsive eliminating the ability to toe-off
in gait. The foot will invert subconsciously to avoid bending the joint thus preventing pain. Often this will lead to other
problems - metatarsalgia, stress fractures, neuritis and even ankle sprains.
There is a radiographic classification
system which in my experience is not very helpful especially with an athletic individual. Stage II hallux limitus has minimal
joint changes and usually warrants a cheilectomy or 1st MPJ scope by rule.
With over 500 cases of Stage II hallux
limitus, we have seen joints with no cartilage to speak of. In some cases cartilage transplant, drilling, and/or arthrodiastasis
are an option if and only if the area of grade IV chondromalacia is less then 30% of the joint. Otherwise those methods will
yield less then a year of relief.
Ironically, there is movement towards hemi-arthroplasty. Biopro is the primary implant
choice. With over a 1000 surgical cases of grade II-IV hallux limitus, rarely do we ever see severe chondromalacia of the
1st proximal phalanx base, it is always the 1st metatarsal head that is degraded and the worst.
Joint implants for
the 1st MPJ are flawed by design, simply because the biomechanics of the 1st MPJ are so complex. The joint has both distraction
and compression during gait cycle, which sets the implant up for failure. Range of motion post surgery is always less then
normal making it no better then before surgery.
As far as Keller procedures (removal of the proximal phalanx base),
it really is reserved for the elderly. There are so many side effects to this procedure that it should be reserved for the
least mobile patient. In general the elderly.
Essentially, 1st MPJ fusion is the best alternative for a severely arthritic
1st MPJ. Fusion reduces the pain while it does not provide any motion; however, it does allow the foot to toe-off and become
propulsive. In an athlete or in my experience with a soldier, they can run again.
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