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Hallux rigidus Grading and non-surgical treatment

Hallux rigidus Grading and non-surgical treatment

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Hallux rigidus Grading and non-surgical treatment

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  1. Hallux rigidusGrading and non-surgical treatment Jim Barrie East Lancs Foot and Ankle Service www.foothyperbook.com www.hyperblog.eastlancsfeet.org.uk

  2. Why grade hallux rigidus? • Identify populations by • Natural history • Response to treatment • Risk of adverse effects • Standard tool for research/audit

  3. How? • Clinical features • Imaging • Markers

  4. Options • Coughlin • Roukis • Regnauld

  5. Coughlin grade 0 • Range of dorsiflexion • 40-60deg ± 10-20deg less than normal side • Clinical • No pain • Stiffness and loss of motion • Radiography • normal

  6. Coughlin grade 1 Roukis: metatarsus primus elevatus hallux flexus Regnauld: sesamoid changes • Range of dorsiflexion • 30-40deg ± 20-50% less than normal side • Clinical • Mild/occasional pain/stiffness • Pain at extremes of movement • Radiography • Dorsal osteophyte • Minimal loss of space, sclerosis, flattening

  7. Coughlin grade 2 • Range of dorsiflexion • 10-30deg ± 50-75% less than normal side • Clinical • Moderate/severe pain/stiffness • Pain just before extremes of motion • Radiography • Osteophytes • Mild/moderate sclerosis/narrowing • Limited to dorsal 25% Roukis: Cysts + loose bodies

  8. Coughlin grade 3 • Range of dorsiflexion • <10deg ± 75-100% less than normal side, loss of plantarflexion • Clinical • Constant pain • Pain at extremes of range • Radiography • Substantial narrowing • >25% of joint • Sesamoid involvement

  9. Coughlin grade 4 • Range of dorsiflexion • <10deg ± 75-100% less than normal side, loss of plantarflexion • Clinical • Constant pain • Pain at midrange • Radiography • Substantial narrowing • >25% of joint • Sesamoid involvement Roukis/Regnauld: ankylosis Roukis: IPJ/TMTJ OA

  10. Summary - grading • Several similar grading systems • Minimal validation • Which features predict outcome? • Is MPE relevant?

  11. Non-surgical treatment • Natural history • Simple analgesia • Activity alteration • Orthoses/shoe adaptations • Injections

  12. Orthoses/shoe adaptations • Reduce pressure on osteophytes

  13. Reduce pressure

  14. Reduce pressure

  15. Orthoses/shoe adaptations • Reduce pressure on osteophytes • Reduce MTPJ movement

  16. Reduce MTPJ movement

  17. Reduce MTPJ movement

  18. Reduce MTPJ movement

  19. Reduce MTPJ movement

  20. Reduce MTPJ movement

  21. Orthoses/shoe adaptations • Reduce pressure on osteophytes • Reduce MTPJ movement • Increase MTPJ movement

  22. Increase MTPJ movement

  23. Increase MTPJ movement

  24. Increase MTPJ movement

  25. Increase MTPJ movement

  26. How effective is non-surgical care? • Grady (2002) • 772 patients with symptomatic HR • FU 1-7y • 428(55%) treated non-surgically

  27. How effective is non-surgical care? • Smith (2000) • 24 patients treated non-surgically • FU 12-19y • 75% still wished non-surgical treatment • Radiographic progression 67%

  28. Injection • Pons et al 2007 • RCT hyaluronate vs triamcinolone • Improvement in both groups • No difference in pain at rest • Hyaluronate group better to 84d • Pain walking 20m • AOFAS pain score • 50% surgery at 1y

  29. MUA + injection • Solan (2001) • 31 pts MUA + depomedrone/bupovacaine injection • Blinded Xray grading • Minimum 1y FU

  30. Non-surgical treatment • Benign condition • Simple management • Shoe adaptations • Functional orthoses probably selective • Injections of marginal benefit www.foothyperbook.com www.hyperblog.eastlancsfeet.org.uk