Surgical treatment of hallux rigidity

If the mobility in the main joint of the big toe is limited and painful, then this causes a severe impairment in walking. Depending on the cause of painful stiffness during surgery, Brandes and Keller form a mobile joint, or the painful joint becomes motionless. Arthrodesis is also suitable for reducing complaints that arise after surgery for Mauo. The painful joint is operated from a medial-longitudinal incision. After resection of the cartilaginous surfaces, the thumb is brought into a state of extension by 20-25°. Two bone surfaces formed in the form of a roof and attached to each other are well fixed (rice. 8-192). After surgery, external fixation is rarely required. After the wound has healed, the patient can get up and, 3 weeks after the intervention, can begin to walk in shoes with hard soles.

Surgical treatment of concave fifth toe

If the 5th toe turns on the back side, almost lies on the 4th toe and turns steeply upward, then it causes significant complaints. The incorrect position of the finger is corrected by the operation. At the dorso-lateral edge of the V-finger, a skin incision is made in the laterally stretched extensor tendon, which at the level of the proximal joint folds into a transverse fold. The extensor tendon is cut in a Z-shape, then dorsally, by capsulotomy, the proximal joint is relaxed. If necessary, the base of the main phalanx is also resected for this purpose. If the finger can then be brought back to its normal position, then a diamond-shaped flap is cut out from the plantar fold of skin located under the finger, and the skin of the fingertip is sutured to the skin of the sole. Thanks to this skin grafting, the plantar fold under the V toe disappears, resulting in an improved position of the toe. AT

Rice. 8-193. Operation on the fifth toe, backward inward, a) Skin incision on the back of the foot b) extension of the extensor tendon, in) plantar skin excision, G) stitching the skin of the fingertip to the plantar skin

rape on the back of the foot connect the ends displaced in relation to each other extensor tendon knotted seam. After the end of the wound healing, the patient can walk and wear normal shoes a few weeks after the operation. The principle of operation is shown in rice.8-193.

Hammertoe surgery by Holunann

One of pathological conditions toes is the so-called. claw-shaped or hammer-like

Rice. 8-194. Operation by Hohmann with hammer toe. a) skin incision, b) and in) resection of the head of the proximal phalanx

Rice. 8-195. Elongation of the flexor tendon of the big toe with a mallet thumb, a) Pathological position of the finger, b) skin incision, in) flexor tendon lengthening

figurative change of them and painful callus. The mallet finger that causes complaints is being operated on. A longitudinal incision is made above the proximal interphalangeal joint of the finger. After longitudinal splitting of the extensor tendon, the head of the proximal phalanx

rises from the joint and with the help of scissors Liston separated and removed (rice. 8-194). This is followed by suturing of the capsule, extensor tendon and skin. After the wound has healed, the operated finger is kept for several weeks in a redressing bandage, the thickening of the skin disappears on its own. If the proximal joint at the proximal joint cannot be brought out of extension, then the incision is lengthened in the proximal direction, and joint capsule is cut on the dorsal surface of the proximal joint. In exceptional cases, you can remove the entire main phalanx.

Hammer toe is a rare disease, which is a flexion contracture in the terminal joint. To eliminate the deformity, the flexor tendon is lengthened in a Z-shape. This operation can restore the function of the thumb. The tendon lengthens at the level of the main phalanx. The skin incision is made at the medial edge of the main phalanx and continues in the plantar fold, t. gets an L-shape (rice. 8-195).

The articular surfaces of the first metatarsophalangeal joint, as in all joints, are covered with smooth articular cartilage. With arthrosis, gradual damage to the cartilage occurs, it becomes thinner and, ultimately, the bone base of the articular surfaces begins to rub against each other when walking. As a result natural processes bone growths are formed - exostoses, which reduce mobility in the joint. Gradually, the big toe becomes rigid and almost motionless.

Conservative treatment

Treatment is due to the relief of the symptoms of the disease, without eliminating its pathogenetic causes:

Individual orthopedic insoles

Orthoses - abducting splints

individual orthopedic shoes

Physiotherapeutic treatment aimed at relieving pain.

Surgical treatment

Cheilotomy - removal of bone growth that impedes movement in the joint.
This operation is usually recommended for mild to moderate mobility restrictions. It involves the removal of bony exostoses, which allows the finger to move in a greater range.

Shortening the first metatarsal.
This operation allows you to reduce the load on the first metatarsophalangeal joint, thereby reducing pain and stopping the progression degenerative changes in the joint. Usually these mini-operations are performed at the same time on the foot, multi-stage operations.

Arthrodesis

If the damage to the articular surface is significant and there is no way to save the joint and restore mobility, an operation is performed that consists in the complete removal of cartilage in order to fuse the main phalanx of the thumb and the first metacarpal bone. To fix the joint in the desired position, metal screws and plates are used. At the same time, after healing, the thumb cannot move - after all, the joint is no longer there. And the interphalangeal joint of the first toe takes over the partial function of the foot roll.

Taylor deformation

Taylor's deformity or "tailor's foot" - a disease characterized by the deviation of the fifth metatarsal bone outward, varus deformity of the 5th finger with the formation of a painful bump on the outside of the spot.

Same way main reason development of this pathology in modern conditions is heredity, longitudinally - transverse flatfoot. At the same time, the resulting exostosis in the projection of the 5th metatarsophalangeal joint begins to cause inconvenience and pain when wearing everyday shoes. As a result, the growth is covered with hyperkeratosis.

Surgical treatment

Surgical treatment consists in the removal of exostosis from the head of the fifth metatarsal bone, followed by its Z-shaped or L-shaped ostotomy, lateral displacement of the metatarsal bone fragment and fixation with a Herbert titanium screw.

Postoperative period

The healing process usually takes three to six weeks. Immediately after the operation, the load on the legs is allowed in special Baruk postoperative shoes. The load is removed from the front of the foot, the moment of rolling the foot is excluded. Wearing postoperative shoes lasts for 6 weeks after surgery.

In the early postoperative period, antibiotic anti-inflammatory therapy is mandatory. Up to 30 days after the operation, anticoagulation therapy is carried out. On an outpatient basis, after the patient is discharged, special fixing bandages are carried out for up to 3 weeks. Removal after surgical sutures is made on the 14th - 16th day from the moment of operation. After 6 weeks, patients are advised to wear normal everyday shoes with limited foot rollover for up to 2 weeks. 2 months after the operation, it is necessary to make individual insoles for heelless shoes.

“Heels together, toes apart” is a familiar command from a gym teacher or dance teacher. Sometimes its implementation is impossible - the fingers are turned inward and the baby clubfoot. Up to 3 years in the vast majority of cases, the situation does not require aggressive treatment. At an older age, foot adduction creates physical and aesthetic inconvenience for the child.

Foot adduction is often confused with clubfoot. In the frontal projection, the pathologies are visually similar. To make a diagnosis, you should consider the leg in a lateral projection, bending the foot at the joint as much as possible.

Adduction of the forefoot is a violation of the ratio of the musculoskeletal structures that form the Lisfranc joint. It can be congenital - the baby is already born with a diagnosis - and acquired. Without treatment and as they grow older, deformation of the metatarsal bones develops, the distance between the first and other fingers increases.

Dysfunction occurs in 70% of children under 5 years of age. In most cases, it goes away on its own as you get older. Adduction of the anterior section is combined with varus deformity of the legs or O-shaped legs.

Allocate 2 clinical forms foot deformities:

• simple - the Lisfranc joint is affected, changes in the bone structures have not been identified. Functions saved;
• complex - with varus disturbance. The curvature of bone structures, valgus setting of the heel is determined, the motor function is impaired.

The international medical classification ICD 10 assigned the disease code Q66.2 - reduced foot.

Causes and symptoms of foot adduction

The cause of foot adduction is a malformation of the muscles responsible for the physiological installation of the thumb, ligaments of the inner surface - an imbalance between the adductors and abductors of the foot.

Factors contributing to the development of the pathological process:

• genetic predisposition;
• a weakened, poorly physically developed child;
• rickets in history;
• osteoporosis;
• frequent colds and viral diseases;
• inflammatory processes in the joints, ligamentous apparatus of the leg;
• diseases of the peroneal nerve. In this case, the innervation of the foot is disturbed, causing stiffness of the muscles and ligaments.

The symptomatology of the disease is similar to many pathologies of the musculoskeletal structures. The child may complain of pain during movement, fatigue. When wearing shoes, calluses form, a change in gait is observed.

What the doctor will see during the examination:

• the thumb is turned inward, against the background of which the first interphalangeal gap increases;
• the front of the foot is turned inward with outward rotation;
• metatarsal bones deviated from the physiological position;
• the vault is preserved, flat feet are absent;
• heel - valgus deformity;
• dislocations and subluxations of small joints.

How to Treat Sprained Feet in Children

Treatment of adducted feet syndrome in children is long and ends with the cessation of growth - until adulthood. For correction in infants, conservative therapy, gymnastics, massages, wearing specialized shoes, and plastering the sole are indicated. Physiotherapy is widely used, including electrical stimulation and heating with warm paraffin.

If the above methods are ineffective, surgical intervention. Manipulations are carried out at the age of 1-2 years. Further correction of the sphenoid and cuboid bones should be at the age of eight. An orthopedist is engaged in the treatment of flat valgus feet with adduction of the anterior sections.

Massage

Specialized massotherapy when adducting the foot, it is carried out simultaneously with general tonic exercises. medical worker should work with the sole, shins, thigh, lumbar spine.

Massage technique:

1. Loin - stroking, rubbing. The movements are directed towards the lower extremities.
2. Buttocks - kneading, patting.
3. The back of the leg - stroking along the length, then working out each muscle.
4. Foot - stroking, vibration techniques, stretching the Achilles tendon area.
5. Sole - stretching the inside, toning the outside.

Exercises

The exercise therapy complex is selected taking into account the age of the child, the severity of the pathology. At the initial stages, training is carried out on the basis of medical center then at home.

To normalize the setting of the foot, the following are shown:

• classes on the Swedish wall;
• rope climbing;
• walking barefoot on various surfaces - grass, sand, shells on the beach;
• cycling lessons;
• an insole for everyday shoes is begging;
• roller skating;
• dancing, sports physical exercise, in which a clear and staging of the foot is required.

other methods

In a newborn, the position of the foot and components can be corrected with the help of gypsum. The indication for plastering is a deviation of 30 or more degrees from the physiological position.

The gypsum is applied to the foot and part of the lower leg, forming a boot. Changing the position of the leg is carried out once a week or as the size of the foot increases. The duration of the correction is individual, it can be up to 12 weeks.

In such a boot, the child can walk and make movements. After the completion of the plastering stage, wearing orthopedic shoes, specialized insoles - optimally Trives - for the night - splints or plaster splints are shown. Shoes should have a stiff heel, provide pronation and supination of the foot .

With the ineffectiveness of conservative therapy, surgical correction is indicated. The operation is preferably carried out at the age of 8-9 months, since the violation did not affect the spinal column.

During surgery, the ligamentous-articular section of the metatarsus is dissected. The tendons that support the thumb are lengthened. The doctor makes an incision on the outer part of the lower leg. The tendons are removed into the wound and placed in an anatomical position.

The wounds are sutured. A plaster bandage is applied. The duration of wearing a boot after surgery is 1.5 months. After that, they begin to gradually increase the load on the foot. Shown after 2 weeks rehabilitation measures, physiotherapy. At this stage, it is mandatory to wear orthopedic shoes.

At the age of 3 years, surgery involves the reduction of the sphenoid bones. The procedure is carried out in an open way, which allows you to correct the deformation of the foot areas.

Surveillance of patients who have undergone surgical correction is carried out until the age of 15 years.

Possible Complications

Violation of adduction of the foot does not affect the growth, development, physical activity and quality of life of the child. But the legs do not look aesthetically pleasing, there are problems when choosing shoes.

Unlike flat-valgus deformity, the child does not experience problems with movement, there is no clumsiness, frequent falls. Violation of the adduction of the foot does not contribute inflammatory processes in the joints at an early age.

Pediatrician E.O. Komarovsky believes that such violations should be put in order in childhood using corrective devices . But after examination by an orthopedist. The diagnosis must be confirmed by instrumental methods.

But the best prevention, according to the pediatrician, is physical activity, frequent walking barefoot over rough terrain. This will minimize the consequences of birth trauma, genetic predisposition to dysfunction of bone and muscle structures.

In order to prevent stiffness of the first metatarsophalangeal joint (PFJ1), daily development of the range of motion in the joint is necessary. Development of range of motion has importance, to achieve the best postoperative results and allows you to:

• Prevent thumb stiffness;
• Prevent the formation of painful adhesions (scars);
• Accelerate postoperative rehabilitation;
• In the remote period, after 4-6 months, wear model shoes, including high-heeled shoes.

The recovery process directly depends on your desire and attention. If during your rehabilitation you experience difficulties with the exercise, consult your doctor.

First and second week after surgery

Rest and exalted position lower extremities. No exercise is necessary during this period.

Third and fourth weeks

Start with moderate intensity exercise. Grasp the thumb at its base, closer to the metatarsophalangeal joint. Do not confuse the interphalangeal joint (IPJ) with the metatarsophalangeal joint. The interphalangeal joint is located in the middle of the finger, closer to its nail plate. Gently straighten your finger, moving upwards, until you feel resistance and feel slight discomfort. Then hold your finger in this position for ten seconds. Repeat this exercise three times, then bend your finger, moving down, to a similar sensation, repeat the exercise three times, for ten seconds each. This series of exercises should be done three times a day for the second week.

Fifth and sixth weeks

During this period, manual movement development should be increased to about six times a day with gradual increases in strength and intensity.

seventh week

Proceed to a set of exercises, under the influence of a load of mass. This exercise is performed in a standing position, by lifting the heel up, without lifting the fingers from the surface, this exercise allows, under the influence of a load by body weight, to gradually increase the extension volume in the toes. Stand up on your toes for about ten seconds (after the sixth week!!). Start walking uphill to increase toe extension. Walking with a wide stride is also effective - this is an excellent exercise for increasing flexibility in the first metatarsophalangeal joint.

In addition, you can also do the exercises below.

With one hand, grasp the front of the foot, to the base of the big toe. With the other hand, take the thumb at the base, closer to the metatarsophalangeal joint. Stretch the big toe first, as shown in figure A. Then stabilize the forefoot, holding it with your hand, as shown in figure B, with the other hand, pull the big toe up, without twisting, the direction of the forces is indicated by the arrows in the figure, while the foot does not bend (finger to keep straight). Hold your finger in this position for 10 seconds, repeat the exercise three times. Perform a similar exercise, but with the thumb down, keeping the foot straight, as shown in figure B, the direction of the forces is indicated in the picture. Hold your finger in this position for about ten seconds and repeat the exercise three times. These exercises should be performed six times a day.

Big toe pain and bump: what is a stiff toe?

hallux rigidus is the loss of mobility of the metatarsophalangeal joint of the big toe. In fact, this is a pronounced stage of arthrosis of this joint. Loss of mobility of the big toe is very uncomfortable and problematic, since when walking it must be possible to raise the toe up to 40 degrees (dorsal flexion of the metatarsophalangeal joint of the big toe). It affects 2.5% of people over 50 years of age.

What is the hallux rigidus clinic

At first, the patient may complain of pain in the area of ​​the big toe. The symptom is non-specific, it can be a sign of bursitis, osteoarthritis, or the same. In the future, adaptive features appear when walking: restriction of movement in the thumb leads to a change in gait, and pain is also added. On the back surface of the joint, an osteophyte begins to form, which sometimes protrudes quite significantly and this conflicts with shoes. In addition, patients may complain of numbness on the inner surface of the foot, as osteophytes compress cutaneous nerve. More often it develops in people who have disorders in the work of the feet and big toe. For example, with flat feet, as well as with flat-valgus installation of feet.

In a number of patients, Hallux rigidus is observed in relatives, which indicates a hereditary predisposition. In other cases, thumb stiffness is observed in workers of a certain type of work: who have to lower and squat a lot (for example, welders, tilers). Also, one of the reasons may be a finger injury. Or stiffness in the finger is a consequence of diseases such as rheumatoid arthritis and gout.
can determine the cause of your Hallux rigidus and prescribe appropriate treatment.

Classification of rigidity of the 1st metatarsophalangeal joint of the foot

Several different classification schemes have been described for assessing the severity of hallux rigidus. The classification of Coughlin and Shurnas is considered the most relative.
0 degree. The finger deviates by 40-60%. X-ray shows no changes, no pain. Only the rigidity of the joint detected during examination during passive movements.
1 degree. Dorsal flexion no more than 30-40 degrees. Only dorsal osteophyte is revealed. Radiological changes in the joint are minimal. Complaints of mild or occasional pain and stiffness, pain with excessive flexion.
2 degree. The deviation of the finger is not more than 10-30%. Dorsal, lateral, possibly medial osteophytes. There is narrowing of the joint space and periarticular sclerosis on x-ray.

What is the difference between hallux rigidus and hallux limitus

An important distinction needs to be made between the two terms. Rigidus is defined as a pain syndrome due to inflammatory changes in the joint itself, and limitus is due to a change in the tissues themselves (for example, contracture of the calf muscle) or a long and elevated metatarsal bone of the thumb. However, a limited thumb may progress to a rigid thumb over time.

Non-surgical treatments for thumb stiffness

In many cases early treatment may prevent or delay the need for surgery in the future.
Treatment for uncomplicated cases of Hallux rigidus includes:
Shoe selection. Hard-soled boots or shoes may be recommended
orthopedic devices. Morton extensions and support pads can be used to limit the load and change the load characteristics of the joint.

Surgery Hallux rigidus

When conservative therapy does not lead to success, then it comes to surgery. There are quite a few options for operations and the choice of method depends on the specific situation. A task surgical treatment stiffness - reduce pain and improve joint function.

Cheilectomy

Or excision of a part of the head of the metatarsal bone. This is a fairly gentle technique that includes resection<30% дорсальной части головки. Кроме того, удаляются внутрисуставные тела и остеофиты,локализованных на самой плюсневой кости. Удалять более 30% головки не рекомендуется, так как сустав может быть нестабильным вплоть до вывиха проксимальной фаланги. Хейлэктомия — операция выбора на ранних стадиях Hallux rigidus. Это относительно простая операция, которая позволяет относительно быстро вернуться к повседневной жизни. Частота осложнений небольшая (сообщается о 3%). однако хейлэктомия не предотвращает прогрессирования заболевания.

Osteotomy Moberg

This is a dorsal osteotomy of the closing fragment of the proximal phalanx. This operation imitates increased dorsiflexion of the finger. The results of the operation are quite good. Cheilectomy with Moberg osteotomy is recommended in patients with severe cases of rigidity (possibly less than 20 degrees of dorsal flexion).

Arthrodesis of the first metatarsophalangeal joint

Arthrodesis is an operation aimed at completely shutting down the function of a joint, usually in the most functionally advantageous position. Arthrodesis for thumb stiffness is a very widely used technique that is fairly safe and effective. This applies to severe cases of the disease. The operation is performed in an open manner, although percutaneous methods have been reported. There are several methods of internal fixation: plates, screws, pins and staples. The most reliable is the use of a dorsal plate. Arthrodesis has a number of problems: an immobile joint gives the same problems with joint restriction as stiffness, which limits the choice of shoes (especially for women).

Arthroplasty for stiffness

Unlike arthrodesis, which sacrifices movement in the joint to reduce pain, partial or total arthroplasty is an option that relieves pain while maintaining mobility of the metatarsophalangeal joint of the 1st toe. There are techniques for both general articular arthroplasty and hemiarthroplasty (when only one articular surface is replaced with an artificial one. However, the operation is complex and numerous complications have been described, including implant rejection, osteoarthritis in the implant area, infection. The Toefit-implant gives a good result. Plus (Plus Orthopedics AG, Switzerland).

And although the success and benefits of implants for hallux rigidus are described in the literature, there is still a fairly large percentage of complications. In addition, the intensity of symptoms and the degree of functional impairment after treatment are comparable to simpler arthrodesis.

Keller resection

Or interpositional arthroplasty. This was, in fact, one of the first procedures for the treatment of hallux rigidus. The essence of the operation is resection of up to 50% of the base of the proximal phalanx. Although 23% of patients have finger deformity after this operation, the technique occurs in older patients with low physical activity.

Arthrodiastasis of the big toe (Arthrodiastasis)

The operation is based on techniques that relieve the load on the articular surfaces and thereby lead to a decrease in pain (favorable conditions are created for regeneration in the joint). A significant reduction in pain is reported, but the disadvantage of the technique is the need to wear an external fixator for about 3 months.

Arthroscopy

The use of arthroscopy for Hallux rigidus is a new technique that has been introduced recently and is mainly used for grade 1-2 rigidity. Arthroscopic treatment can be performed, as well as cheilectomy through mini-incisions. Arthroscopy is a technically very complex method and requires expensive equipment and additional training of specialists. Complications include damage to the articular cartilage and infection.

Palamarchuk Vyacheslav

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