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Bilateral hallux rigidus

Posted by Marie on 4/30/03 at 21:02 (117485)

Dr. Z

I tried orthotics with a morton's extension like you suggested and it didn't seem to help much. I then went to several orthopedic surgeons and podiatrists who said they would do a cheilectomy, but if after they went in, if the joint looked worse, they would fuse the toes. This is something that is very scary for me. I was a very active person. Don't I have any other options? How about prolotherapy? Can you exercise on an eliptical trainer or treadmill after fusion? My friend had her toes fused and has nothing good to say about the results. She told me this was only a temporary fix and that other body parts started to hurt her more. Right now, I have severe pain where my leg fits into my hip joint and a very tight plantar fascia. Could this be due to spurs in my toes? Also, the doctors have told me that if I don't do something soon, then an arthrodesis is my only choice. Any suggestions? Thanks a bunch! Marie

Re: Bilateral hallux rigidus

Ed Davis, DPM on 4/30/03 at 21:58 (117492)

Marie:

Doctors who suggest arthrodesis (fusion) of the big toe joint need to find a place in a natural history museum in the vicinity of the dinosaurs. ;)

There are four stages of hallux rigidus, the staging being based on severity of the problem. Stage 1 may be treated via cheilectomy -- it assumes that removal of bone from the top of the first metatarsal head will free up motion at the joint and that the cartilage in the joint is not in bad shape.

Stage 4 is end stage hallux rigidus where the caritilage is in such bad shape that the joint is not salvagable, leaving two options fusion (not a good idea) or an implant ( the Futura Generation 2 silastic hinged implant is primo!:))

Now, stop and think for a minute -- cheilectomy vs. fusion?? That is NEVER a choice as you are either in stage 1 or stage 4. What happens if you are in stage 2 or stage 3?

Here is a basic choice grid:
Stage 1 -- do physical therapy, orthotic with kinetic wedge or surgical cheilectomy.
Early Stage 2 -- similar choices to stage one but more likely to do chielectomy.
Late Stage 2, early Stage 3 -- decompressional osteotomy of metatarsal head.
Late stage 3 -- decompressional osteotomy of first metatarsal head combined with metallic hemi-implant (Biopro or Wright Medical).
Stage 4 -- fusion or silastic hinged implant (Futura Generation 2 hinged).

One dilemna is that some surgeons do not have specific experience with all the above and as such their limited armanetarium leads to a restriction of choices. See a doctor who knows the full spectrum of treatment choices.
Ed

Re: Futura biomedical

Ed Davis, DPM on 4/30/03 at 22:05 (117493)

A link:
futurabiomedical.com/productsLGTMain.htm
ed

Re: Futura biomedical -try again

Ed Davis, DPM on 4/30/03 at 22:06 (117495)

http://www.futurabiomedical.com/productsLGTMain.htm

Re: Futura biomedical -try again

Ed Davis, DPM on 4/30/03 at 22:07 (117496)

http://www.futurabiomedical.com/products/LGTMain.htm

Re: Futura biomedical -try again, Dr. Lawrence

Ed Davis, DPM on 4/30/03 at 22:12 (117497)

For some reason, I cannot get the link to open by left clicking on it but when I right click, then click, 'open in new window' the link does come up.

Dr. Lawrence of San Diego is a genius. He has designed both this implant and several hemi-implants. He is my 'guru' when it comes to hallux rigidus and would be the one that would operate on my foot if I needed to have the procedure done.
Ed

Re: Bilateral hallux rigidus

Dr. Z on 5/01/03 at 05:58 (117513)

Great summary Dr. Ed

I would also consider the Valenti procedure depending on the stage.
I would place this is the cheilectomy group. It is where the doctor removes a V shaped piece of bone from the first met head and base of the proximal phalanx.

Experience is important with hallux limitus treatment. I also like the biopro implant.
Fusion is a last resort but does give an excellence relief of pain
but the post recovery period is very long with non-weight bearing.

Sounds like a second opinion for in needed to make sure your surgical choices are completely explored

Re: Bilateral hallux rigidus

Dr. David S. Wander on 5/01/03 at 07:43 (117518)

In addition to the choices described by Dr. Davis and Dr. Z, there are procedures to address the deformity, depending on the stage of the deformity. I have seen many patients over the years that would have minimal benefits from a cheilectomy (simple clean up of the joint) and are not at end stage hallux rigidus, therefore do not need a fusion or implant. Many times the rigidus is caused by an elevated metatarsal, long metatarsal, long phalanx (toe bone), etc., and correcting this problem can 'decompress' the joint and allow more normal range of motion while perserving the joint and cartilage. There are many osteotomies (surgical fracture and realignment of the bone) that address this deformity and I've had many happy patients over the years that were not severe enough for a fusion or implant.

Although I usually agree 100% with Dr. Davis, I do not agree that performing a fusion is procedure that went out with the dinosaurs. Many studies have shown that very active younger patients may do better with a fusion (with the toe fused at about 15 degrees. Silastic type implants are excellent and basically function as a joint spacer without reproducing the mechanics of a true joint. Two piece articulating metal implants have still not proven themselves over the long term and hemi metal implants are regaining popularity. I wouldn't consider any of these procedures as going out with the dinosaurs, each procedure has it's indication for the right patient, by the right surgeon.

Re: Bilateral hallux rigidus

Richard, C.Ped on 5/01/03 at 09:16 (117533)

Hi Marie,
I have come across different ways of making a Morton's extension. I have seen it made with very soft material, thus defeating the purpose of limiting the motion of the joint. I use a turf toe material that is pretty rigid in which I add slight rocker in order to 'roll off' while walking.

Is the toe on yours flexible?
Richard

Re: Bilateral hallux rigidus

Ed Davis, DPM on 5/01/03 at 16:43 (117574)

David:

You have made many excellent points. First MTP joint fusions have not gone out with the dinosaurs but I was really referring to the docs who believe that it is either a cheilectomy or fusion, basically ignoring all the other options and associated biomechanical issues. :)
Ed

Re: Bilateral hallux rigidus

Ed Davis, DPM on 5/01/03 at 16:46 (117575)

Dr. Z:
Good point. I would probably categorize the Valenti as a late stage 2, early stage 3 procedure with the other osteotomies. I think that you, Dr. Wander and I are making similar points in that there are numerous options which work and that doctors who are experienced with as many options as possible can offer patients the best choices.
Ed