In my opinion, hallux limitus results ultimately
come down to a return to biomechanics basics of
1st ray function. For instance, in this case,
presumably, the Lapidus procedure was performed
to address an excessively hypermobile 1st ray
and resultant high IM angle (corroborate via
review of original plain films). If not, then I
question its performance in a predominate hallux
limitus case. Pre-op films are helpful in
establishing the extent of deformity and its
planar dominance.
Given Root's theory of planar dominance, I
suspect many surgeons underestimate that the 1st
metatarsal still deviates in more than just 1
plane. As such, when 1st ray hypermobility
exists, there is always some component of
metatarsus primus elevatus that co-exists with
bunion deformities. The multi-planar 1st
metatarsal shifting with time may be under
appreciated by many foot surgeons. Yet, its the
mpe component that creates 1st MTP ROM
limitation. It's why, in conjunction with 1st
metatarsal shortening that occurs from osteotomy
procedures, we often try to orient them in such
a way to create a plantar flexion component.
If this is not addressed, the residual mpe
creates a functional HL and is responsible for
those resultant compressive, structural changes
incurred about the 1st MTP. In this case, if the
Lapidus was not bi-correctionally oriented to
induce a 1st ray plantar flexion component, as I
suspect, then what one is now left with is
persistent mpe. A lateral projection would
confirm this, especially when compared to the
pre-op images, neither of which were provided,
and which I respectfully suggest Dr. Aldrich
review.
The hemi-implant may have been successful in
reducing some of the 1st MTP arthralgia
resulting from those compression forces and
articular surface damage, but the persistent
limitation of joint motion will remain no matter
what conservative measures are incorporated. In
a healthy 45 year old, this is likely
insufficient to maintain an active lifestyle. In
addition, I suspect the plantar lateral hallux
pain may already represent post operative
compensatory hallux extensus which results from
the combined loss of 1st ray motion from the MCJ
fusion, and persistent ROM limitation at the 1st
MTP.
You're likely going to need to address the
residual mpe, either by revising the Lapidus, or
incorporating a plantarflexory 1st metatarsal
osteotomy ala Youngswick, and/or basal phalanx
osteotomy ala Kessel-Bonney to restore 1st MTP
dorsiflexion. PT and other conservative measures
simply won't address significant, structural,
residual mpe and persistent HL.
With any of these surgical scenarios, extensive
PT, by a licensed therapist, not just the
patient, is generally required. While I usually
don't Rx PT for the majority of my hallux valgus
corrections, instead have my patients perform
self passive and eventually active 1st MTP
exercises, I universally incorporate more
aggressive PT for all of my hallux limitus
cases. This post-op component is specifically
addressed with HL patients pre-operatively to
ensure they are prepared to adhere to that
protocol because 1st MTP ROM restoration
DIRECTLY equates to maximum functional results
for those patients. Hope this helps.
Barry Mullen, DPM, Hackettstown, NJ,
yazy630@aol.com
