Hemi-Implant Arthroplasty with Decompression and Plantarflexion Autograft Osteotomy of the First Metatarsal Head for Hallux Limitus William Montross DPM FACFAS, Austin Brown DPM, Luc Bibeau DPM, Ankurpreet Gill DPM

Statement of Purpose Results References Literature Review 1. Roukis, Thomas S. “Metatarsus Primus Elevatus in Hallux Rigidus.” Hallux limitus is often treated with hemi-implant 4 patients that underwent surgery for hallux limitus Analysis and Discussion After failure of conservative care for hallux limitus and In our cohort of patients, we were able to Journal of the American Podiatric Medical Association, vol. 95, no. 3, arthroplasty to preserve range of motion while treating the rigidus, surgical gold standard for treatment is were reviewed. Mean follow up for the cohort was 2005, pp. 221–228 successfully implement a decompression and 2. Jones, Mackenzie T., et al. “Assessment of Various Measurement arthritic first metatarsal-phalangeal joint. While this arthrodesis of the great toe joint.3 Despite this, patients 20.5 months (± 7.2). At final follow up, 2 patients had procedure may treat the pain inducing element of hallux complete resolution of pain, 1 patient had continued plantarflexion osteotomy of the first metatarsal Methods to Assess First Metatarsal Elevation in Hallux Rigidus.” Foot often elect to preserve range of motion in attempts to & Ankle Orthopaedics, vol. 4, no. 3, 2019, pp. 1-9 limitus, the inherent anatomical causative factor often pain, and 1 patient did not report whether they had head with radiographic evidence of a significant salvage the joint to avoid first ray stiffness and freedom correction and complete pain relief in 2 of 4 3. Galois, Laurent, et al. “Surgical Options for Hallux Rigidus: State of remains unaddressed. Many believe that an elevated first of shoe gear selection.4 Hemi-implant arthroplasty residual pain or not. The mean first metatarsal the Art and Review of the Literature.” European Journal of patients. Due to the prevalence of implant failures Orthopaedic Surgery & Traumatology, vol. 30, no. 1, 2019, pp. 57–65 ray contributes to dorsal jamming and progression of remains an attractive option for these patients due to midpoint uncoverage angle measured 55.1°(± 8.5) arthritis to the great toe joint.1 Our study presents a novel pre-operatively and 32.4°(± 6.4) post-operatively. The reported in the literature, we believe the adjunctive 4. Konkel, Kurt F., et al. “Results of Metallic Hemi-Great Toe Implant for numerous advantages, including minimal bone Grade III and Early Grade IV Hallux Rigidus.” Foot & Ankle approach to addressing the patient’s pain with proximal mean pre- to post-operative difference of 22.7° (p- procedure is necessary as a preventative maneuver resection, excellent pain reduction outcomes, and that addresses potential causes of implant failure. International, vol. 30, no. 7, 2009, pp. 653–660. phalanx hemi-implant arthroplasty but also performing an preservation of range of motion.5 This is ideal for value 0.0097 ((95% CI: -37.0572 to -8.3428)) was 5. Vogler, Harold, and Ryan B. Rigby. “Techniques in Hemiarthroplasty of Decompression osteotomies have shown promising the First Metatarsophalangeal Joint.” The Journal of Foot and Ankle autograft osteotomy at the metatarsal head to achieve patients with stage II and III hallux limitus, as short term statistically significant. plantarflexion and decompression. long-term results when implemented for hallux Surgery, vol. 55, no. 3, 2016, pp. 650–654 outcomes remain excellent even when articular rigidus while significantly improving range of 6. Kissel, Charles G., et al. “A Prospective Investigation of the Biopro® degeneration is prominent on up to 78% of the motion.8,9 Authors have also found that the use of Hemi-Arthroplasty for the First Metatarsophalangeal Joint.” The Figure 1 metatarsal head.6 Long term outcomes continue to Figure 3 Journal of Foot and Ankle Surgery, vol. 47, no. 6, 2008, pp. 505–509 decompression osteotomies for hallux rigidus 7. Raikin, Steven M., and Jamal Ahmad. “Comparison of Arthrodesis prove inferior to arthrodesis as implant failure and results in dramatically reduced surgical revision and Metallic Hemiarthroplasty of the Hallux Metatarsophalangeal complications remain prevalent, signifying the need for rates.10 First ray elevatus is considered a woeful Joint.” Journal of Bone and Joint Surgery, vol. 90, 2008, pp. 171–180 advances in implant design or the implementation of prognosticating factor in the development and 8. Slullitel, Gastón, et al. “Youngswick Osteotomy for Treatment of adjunctive procedures to protect the implant.7 Some Moderate Hallux Rigidus: Thirteen Years without Arthrodesis.” Foot progression of hallux rigidus yet remains and Ankle Surgery, vol. 26, no. 8, 2020, pp. 890–894 authors suggest that plantar deviation of the center of unaddressed with a lone hemi-implant 9. Kilmartin, Timothy Edward. “Phalangeal Osteotomy versus First rotation at the great toe joint causes osteophyte arthroplasty.11 Ronconi et al performed the only Metatarsal Decompression Osteotomy for the Surgical Treatment of formation and progressive arthritis that contributes to other known study of 21 patients that underwent a Hallux Rigidus: A Prospective Study of Age-Matched and Condition- implant failure.4 Others suggest that decompressing the Matched Patients.” The Journal of Foot and Ankle Surgery, vol. 44, hemi-arthroplasty utilizing an oblique osteotomy of no. 1, 2005, pp. 2–12 joint with a shortening metatarsal osteotomy can Methods and Procedures the first metatarsal head with the rationale that 10. Cullen, Benjamin, et al. “Rate of Revision After Cheilectomy Versus optimize implant survivability by reducing contact reducing shear forces could result in improved Decompression Osteotomy in Early-Stage Hallux Rigidus.” The Journal A retrospective review was performed for 4 patients that 5 pressure. We addressed these concerns with the clinical and radiographic outcomes.12 76.1% of their of Foot and Ankle Surgery, vol. 56, no. 3, 2017, pp. 586–588 underwent surgery for stage II and III hallux limitus and an adjunctive osteotomy in hopes of providing long term 11. Usuelli, Federico, et al. “Radiographic Considerations of Hallux Valgus patients were satisfied with the procedure and a versus Hallux Rigidus.” Foot & Ankle International, vol. 32, no. 8, elevated first ray with a minimum follow up of 12 months. pain relief and implant integrity. The procedure performed involved the resection of the statistically significant improvement in AOFAS 2011, pp. 782–788 Figure 4 12. Ronconi, Paolo, et al. “Hemiarthroplasty and Distal Oblique First proximal phalanx base with insertion of a smooth metallic scores was found, but radiographic measures yielded unsatisfactory results. Given the paucity of Metatarsal Osteotomy for Hallux Rigidus.” Foot & Ankle International, phalangeal endoprosthesis. An L-shaped osteotomy was Figure 2 vol. 32, no. 2, 2011, pp. 148–152 then performed at the metatarsal neck with an additional literature evaluating the use of implant protective bone cut to remove a wedge from the dorsal arm (Figure adjunctive procedures, further studies are 1). This wedge was then transplanted to the plantar arm warranted to determine their long-term impact. In of the osteotomy to achieve both plantarflexion and conclusion, we believe our approach to addressing hallux limitus with hemi-implant arthroplasty Conflicts of Interest shortening of the 1st metatarsal neck (Figure 2). The first Ankurpreet Gill: None to disclose metatarsal midpoint uncoverage angle was assessed pre- combined with a distal metatarsal osteotomy Luc Bbeau: None to disclose operatively (Figure 3) and post-operatively (Figure 4) to provides adequate plantarflexion and Austin Brown: None to disclose decompression to the first metatarsal phalangeal William Montross: Speaker for Integra, last official engagement was 2 years ago. determine the degree of plantarflexion correction, and Received former royalty on Integra movement implant. The phalangeal patients were assessed clinically for residual pain at final joint that could improve implant survivability and component of movement implant is used in the procedure described in this follow up.2 long-term patient outcomes. study