Contemporary Approaches to Stage II and III Hallux Rigidus: The Role of Metallic Hemiarthroplasty of the Proximal Phalanx
Section snippets
Material and methods
Thirty-seven patients (15 men and 22 women; 42 HMP joints) were treated by the senior author (WST) with metallic proximal phalangeal hemiarthroplasty for symptomatic hallux rigidus between September 1995 and October 2004. The average age was 52.9 years, with a range of 38 to 71 years. The indications were severe symptoms with grade III radiographic changes, or grade II changes with an intraoperative finding of absence of articular cartilage on greater than 50% of the metatarsal head.
Surgical technique
The HMP joint was exposed through a dorsal skin incision. The dorsal approach allows easy access to medial, dorsal, and lateral osteophytes and easier implant insertion. Care is taken to avoid injury to the dorsomedial cutaneous nerve. The capsule is incised longitudinally in line with the skin incision 2 mm to 3 mm medial to the extensor hallucis tendon. Careful subperiosteal sharp dissection is performed medially, dorsally, and laterally on the metatarsal head and base of the proximal phalanx
Postoperative management
Immediate weight bearing to tolerance is permitted in a postoperative shoe. Patients are encouraged to progress rapidly to a soft slipper or dorsally cutout athletic shoe. The progression to normal ambulation and the use of standard foot gear is limited only by the persistence of swelling and discomfort. Following complete convalescence, no restrictions are placed on reasonable activities.
The FFI is used to measure the impact of foot pathology on function in terms of pain, disability, and
Clinical outcome
Twenty-eight patients with 32 hemiarthroplasties completed pre- and postoperative modified FFI and patient satisfaction questionnaires (Fig. 6). Twenty-three patients with 25 implants returned for a final clinical evaluation. Preoperative and postoperative radiographs in all patients were reviewed to identify malalignment, loosening, or implant migration. Recurrent marginal osteophytes also were assessed.
No major postoperative complications occurred that were related to the procedure. One
Discussion
This case review demonstrates acceptable outcomes following a metallic proximal phalangeal hemiarthroplasty. FFI scores were improved significantly, and high rates of patient satisfaction were noted.
Technical errors likely contributed to radiographic loosening that was noted in two patients (three implants). At one point it was presumed that inserting the implant in a plantarflexed position (ie, dorsiflexing the toe on the implant) would improve postoperative dorsiflexion. This was not
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