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Hallux Rigidus- Youngswick osteotomy

    Overview

    Learn the Hallux Rigidus: Youngswick osteotomy surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Hallux Rigidus: Youngswick osteotomy surgical procedure.
    The aetiology of hallux rigidus is multi-factorial. Causes include trauma, osteochondritis dissecans, inflammatory arthropathy and iatrogenic injury. A proportion of cases are thought to be related to metatarsus primus elevatus. This was first noted by Lambrinudi In 1938 who described impingement pain and progressive degenerative change result from a mechanical malalignment of the 1st metatarso-phalangeal joint, with an eccentrically located centre of rotation of the 1st metatarsal head. Patients will frequently present with a reasonable range of movement in the non-loaded foot at the 1st MTP joint but a notable restriction in movement in the loaded foot, sometimes called a “functional hallux limitus”. Radiographic findings in metatarsus elevatus, are of a variable degree of degenerative change within the joint, and on the lateral weight bearing view, the proximal phalanx lies in a flexed position relative to the metatarsal head, and the 1st metatarsal is elevated relative to the lesser metatarsals. Patients may present with a dorsal prominent at the 1st metatarsal head which is out of proportion to the small or absent dorsal osteophyte.
    Austin first described a distal shortening planterising osteotomy for the treatment of metatarsus primus elevatus in 1962. Youngswick modified the Austin technique to allow a plantarisation and proximalisation of the 1st metatarsal head, which he described in 1982. A number of other distal metatarsal osteotomies including the Watermann-Green osteotomy, the V-osteotomy and Weil’s osteotomies have been described to address the problem.
    Bryant in 2004 treated 23 feet with mild to moderate hallux limitus with 2 years of follow-up and found that the Youngswick osteotomy produced a significant increase in the range of movement and dorsiflexion in the 1st MTP joint in patients with mild to moderate hallux limitus. They found that pressure measurement showed peak pressure beneath the hallux of the 1st metatarsal remained unchanged. However, peak pressure was significantly increased through the 2nd metatarsal and reduced in the 5th metatarsal, the concluded that post-operatively the foot functioned in a less inverted and more physiological pattern, and that the procedure was associated with a high patient satisfaction.
    Lemar in 2006 provided a mechanical comparison of the Youngswick versus the modified Weil’s osteotomy and sagittal V osteotomy and noted that the Weil’s and Youngswick osteotomies were mechanically more stable than the sagittal V osteotomy when loaded to failure.
    In a journal of foot and ankle surgery 2016, Slullitel looked at 78 patients who had undergone a Youngswick osteotomy for stage 2/3 hallux rigidus and assessed the 1st metatarsal length as being longer, equal or shorter than the 2nd metatarsal pre-operatively. They recorded high patient satisfaction. 97% of patients would recommend the procedure to family members. There was no difference between the groups in relation to transfer metatarsalgia or complication rates. They concluded that the procedure had high satisfaction rates, independent of 1st metatarsal length.
    Villadot In ‘the foot’ 2017, reported the study involving 50 patients, 25 who underwent a Youngswick Austin osteotomy versus distal oblique osteotomy, they found that both the Youngswick osteotomy and distal oblique osteotomy are both safe, stable with good to excellent clinical results and low complication rate. Slightly higher patient satisfaction not statistically significant in the oblique osteotomy group.
    The Youngswick plantarising shortening 1st metatarsal osteotomy is a useful surgical adjunct for management of hallux rigidus in mild to moderate hallux rigidus, especially useful in those patients with a metatarsus elevatus and a well preserved range of movement in the unloaded foot compared to the loaded foot.

    References:
    Modifications of the Austin Bunionectomy for treatment of metatarsus primus elevatus associated with hallux limitus. J Foot Surg. 1982 Summer;21(2):114-6. Youngswick FD.

    Metatarsus Primus Elevatus. Proc R Soc Med. 1938 Sep;31(11):1273. Lambrinudi C.
    J Am Podiatr Assoc. 2004 Jan-Feb;94(1):22-30. Plantar pressure and joint motion after Youngswick procedure for hallux limitus.
    Bryant AR, Tinley P, Cole JH.

    J Foot Ankle Surg. 2016 Nov-Dec;55(6):1143-1147. Joint Preserving Procedure for Modrate Hallux Rigidus: Does the Metatarsal Index Really Matter?
    Slullitel G, Lopez V, Seletti M, Calvi JP, Bartolucci C, Pinton G.

    Youngswick-Austin versus distal oblique osteotomy for the treatment of Hallux Rigidus. Foot(Edinburgh). 2107 Aug;32:53-58.
    Viladot A, Sodano L, Marcellini L, Zamperetti M, Hernandez ES, Perice RV.

    Indications

    INDICATIONS:
    modified Youngswick procedure is indicated in patients with symptomatic hallux rigidus who have failed non-operative treatment, with Grade 1-2 degenerative radiographic change within the 1st MTP joint (One study: Alerba FAI 2008 reported good results of shortening, plantarising osteotomy in patients with Grade 3 hallux rigidus). Other commonly performed procedures for grade 1-2 degenerative change include cheilectomy, Mobergs’ osteotomy and even 1st mtpj fusion.
    Whilst a cheilectomy is very successful in patients with large dorsal osteophytes, it is less helpful in those cases where the dorsal osteophyte is small or absent. There is a subgroup of hallux rigidus patients in whom there is associated metatarsus elevatus, in these cases there is often a marked discrepancy in the range of dorsiflexion in the dorsiflexed compared to the unloaded foot, a cheilectomy is usually insufficient to allow adequate dorsiflexion or abolish impingement in the loaded foot. Whilst a moberg is useful in re-aligning the toe and in effect can change the vector of the arc of movement of the 1st mtpj dorsally, it will not remove the dorsal impingement. In these circumstances, a Youngswick osteotomy, which allows decompression of the joint and alters the centre of rotation of the MTPJ might be a preferable option.
    SYMPTOMS & EXAMINATION
    Patients with a hallux rigidus/functional limitus often complain of a dorsal prominence over the 1st metatarsal head and can complain of dorsal type impingement pain produced by dorsiflexion of the hallux on the metatarsal. Pain in the mid-range of movement on the grind test is likely to indicate more extensive degenerative change within the joint.
    Pain as a result of pressure on the plantar aspect of the 1st metatarsal head, is likely to indicate metatarso-sesamoid pathology, which may be a relative contraindication to joint preserving surgery. Range of movement in the 1st metatarso-phalangeal joint should be assessed with the foot in an unloaded and simulated loaded position, discrepancy between the range of movement in the 1st MTP joint noted. A significant discrepancy would indicate a degree of “functional” hallux limitus.
    IMAGING
    Weight bearing AP and lateral views should be performed. Relevant findings of the AP radiographs include osteophytes, joint narrowing, sclerosis and subchondral cystic change. The relative lengths of the 1st metatarsal compared to the lesser metatarsals should be assessed, as well as any degree of hallux valgus, though hallux valgus, hallux interphalangeus, lesser toe deformity, midfoot arthritis. On the lateral weight bearing views, the presence of a dorsal osteophyte, metatarsus elevatus can and the relative plantar flexion of the hallux at the 1st metatarsophalangeal joint are all relevant findings. The metatarso-sesamoid joint should be inspected as well as any incongruity in the 1st TMT joint.
    MRI scan can be useful to assess the degree of chondral damage and the integrity of the rest of the joint surface. If there is widespread articular damage, or severe metatarso-sesamoid arthropathy, then a fusion or arthroplasty might be more appropriate. In a functional limitus a small area of chondropathy is frequently seen in a focal part of the dorsal one third of the metatarsal head
    ALTERNATIVE OPERATIVE TREATMENT
    Joint preserving treatments include cheilectomy and mobergs’ osteotomy. Cheilectomy is the procedure of choice in mild to moderate arthritis with a large dorsal osteophyte and no elevation of the 1st metatarsal. The moberg in circumstances where plantar flexion of the 1st mtpj is relatively well preserved but dorsiflexion is very restricted.
    Joint sacrificing surgeries include 1st MTP joint fusion or arthroplasty.
    NON-OPERATIVE MANAGEMENT
    Physiotherapy treatment should be directed towards stretching the tight gastrocnemius and plantar fascia to reduce the load through the 1st metatarsal head in association with 1st mtpj active an passive range of movement exercises and intrinsic foot exercises. Orthotic management can be helpful in reducing the load through the joint. In those with moderate to severe degenerative change, a stiff orthotic aimed at reducing the range of movement through the 1st mtpj. Firm soled shoes with a forefoot rocker can help with reduce movement through the joint through the second and 3rd rockers which can help with symptomatic control. In patients with a functional hallux limitus with a good range of movement in the unloaded foot, an insole with an arch support, an excavation under the first metatarsal head and posting under the hallux to allow the 1st metatarsal head to drop and the proximal phalanx to dorsiflex can be helpful in certain patients.
    CONTRAINDICATIONS
    Relative contra-indications to joint preserving surgery/ modified Youngswick osteotomy include inflammatory arthropathy, widespread degenerative change, gross stiffness, pre-existing transfer metatarsalgia, sesamoid pathology.

    Setup

    The patient is positioned supine on the table, surgery can be performed under general or regional block.
    A local anaesthetic ankle block is applied pre-operatively. The ankle is draped and an ankle or thigh tourniquet is applied. The medial longitudinal incision is marked.

    Operation – 1

    The skin incision has been marked. The patient has been prepped and draped and ankle block inserted. The skin is marked for a medial incision in the inter-nervous plane to approach the 1st metatarsal.

    An incision is developed through the skin and then subcutaneous tissue, taking care to avoid traumatising the skin edges.

    The skin incision is taken below the subcutaneous fat and this is carefully dissected off the underlying capsule, with adequate traction, there is often a well defined plane, and this is developed to identify the dorsomedial nerve which is protected. A small pocket is developed plantarly, superficial to the capsule to reduce the risk of damage to the plantar hallucial nerve when the capsule is repaired.

    The capsule is incised horizontally down to bone and this elevated off the medial eminence from the distal diaphysis to the proximal phalanx. Ensure that the incision is not made too plantarly, as this will put the plantar vessels at risk which will compromise the blood supply to the metatarsal head and can result in avascular change here.

    The capsule is carefully elevated to provide a dorsal flap and expose the dorsal margin of the 1st metatarsal head. Dissecting the capsule off the bone will ensure a well preserved flap to provide a solid capsular repair during closure.

    The capsule has been elevated off the dorsal aspect of the 1st metatarsal and the articular surface of the 1st metatarsal head is exposed and inspected carefully for evidence of chondral damage and dorsal osteophyte. Chondral flaps can be debrided. More extensive plantar cartilage damage or metatarso-sesamoid arthritis should be noted, as they may affect the outcome.

    The plantar capsule is carefully elevated off the 1st metatarsal head. The elevation of the capsule should be taken very slowly over the plantar aspect. The neurovascular bundle should be identified and preserved. The thick white capsule is elevated off. An area of yellow fat is exposed which contains the neurovascular bundle. The dissection should then progress more dorsally proximal to the neurovascular bundle on to the plantar aspect of the diaphysis of the 1st metatarsal to expose a sub-periosteal pocket into which the plantar limb of the osteotomy is directed.
    The plantar neurovascular leash is at risk here and should be carefully protected, as if damaged may devascularise the metatarsal head after osteotomy.

    The horizontal limb of the osteotomy is progressed, the alignment of the cut here is too horizontal. The plantar limb of the osteotomy should exit proximal to the neurovascular bundle. The angulation of the plantar limb should be a minimum of 45 degrees, making this steeper will allow increased depression of the head. Centering the apex of the osteotomy dorsally, will allow more flexibility in the inclination of the plantar limb. If the plantar limb still passes close to the plantar neurovascular bundle, the apex of the osteotomy can be made moved more proximally.

    The alignment of the plantar limb of the osteotomy here is more vertical, which will allow good plantar flexion. The osteotomy is progressed through the medial cortex proximally to distally and exits the plantar aspect of the 1st metatarsal through the previously developed pocket with good retraction of the soft tissues. The osteotomy is then taken back through the distal(lateral) cortex and completed at the distal aspect leaving the dorsal limb of the osteotomy intact. Advancing the saw in a methodical way, cutting first the medial and then the lateral cortex, and making sure that the cortices are breached before advancing the saw along the osteotomy line, produces two flat congruent cut edges and helps prevent an incomplete osteotomy. Re-cutting an incomplete osteotomy often leads to incongruent edges and poor reduction of the dorsal and plantar surfaces.. The dorsal portion of the metaphysis of the 1st metatarsal, at this stage is still intact.

    The dorsal cortex is then osteotomised parallel to the articular surface, using a reciprocating saw or as in the photograph here, an oscillating saw. The plantar fragment is at risk of notching with the saw, which can act as a stress-riser so care should be taken to cut the dorsal cortex only.
    At this stage in essence a dorsally placed chevron osteotomy, with a long plantar limb has been performed.

    A parallel resection of bone is then performed proximal to this. The bone bridge between the 1st and 2nd dorsal osteotomies will determine the degree of shortening and therefore plantarisation of the capital fragment with a larger rectangle of bone producing more shortening and plantarisation.
    As this is a powerful osteotomy, it is advisable to start off with a small sliver of bone and remove further small slivers sequentially to prevent excessive shortening and to help fine tune the correction.

    The resected rectangle of bone is removed from the dorsal distal osteotomy site using small forceps. Soft tissue attachments may need to be released laterally.

    The osteotomy site is then reduced with axial pressure so that the osteotomy slides proximally and plantarly and the distal and proximal aspects of the dorsal osteotomy are opposed. This provides a stable reduction and dorsiflexion and plantar flexion of the 1st metatarsophalangeal joint should be assessed with the foot loaded. If insufficient range of movement has been achieved, a further resection of bone may be required at this stage (This can be assessed by observing the foot in a loaded position, if the proximal phalanx is still hinging and impinging , as opposed to rotating on the 1st metatarsal head).
    A 2mm drill is angled distally, the entry point should be proximal enough to allow resection of any prominent step in the bone at the distal osteotomy. A decent bridge of bone between the drills’ entry point and the osteotomy should be allowed to minimise the risk of this hole fracturing through into the osteotomy as the screw is driven home.

    The depth gauge determines the length of the screw. 4mm should be subtracted from this to ensure that the screw tip is not protrudent to the articular surface.

    A 1.1mm guide wire is passed down the drill hole and the step drill is selected.

    The step drill is passed over the guide wire and used down until the shoulder engages the proximal cortex, to allow effective seating of the head of the screw.

    An Ortho Solutions metascrew 3mm is then passed over the guide wire and into the pre-drilled hole and advanced. The alignment of the screw in a proximal to distal direction is advantageous as it produces axial compression, can be placed more proximally, in theory, provides more rotational stability than a vertical screw and a larger volume of distal bone for fixation.

    The screw is passed until the head is completely buried and not prominent dorsally. The osteotomy should be tested for stability and the plantar aspect of the joint inspected to ensure that the screw is not protruding intra-articularly.

    With adequate plantarisation there is usually a step of bone on the proximal side of the osteotomy and this can be excised in association with any remaining dorsal osteophyte at the 1st metatarsal head.
    Positioning the screw 6-7 mm proximally to the osteotomy, as opposed to right next to it will allow sufficient resection of the dorsal prominence distally .

    The dorsal osteophyte and prominent dorsal bone is trimmed carefully using an oscillating saw until there are no prominent edges and the proximal phalanx glides smoothly over the dorsum of the 1st metatarsal head.

    The joint is thorough irrigated to remove bone debris.

    The medial capsule is closed using 1-0 Vicryl, phalanx being held in a neutral position. Care to avoid the dorsomedial nerve and the plantar hallucal nerve. The MTP joint should be plantar flexed and dorsiflexed to ensure that there is a smooth range of movement.

    Subcutaneous tissue is closed with 2-0 Vicryl, again care to protect the dorsal and plantar nerves.

    Skin is closed with an absorbable fine subcuticular suture and the author’s preference is to use a dermal glue.

    The range of movement is assessed with the foot unloaded, which is equal to the pre-operative range of movement.

    Operation – 2

    Range of movement is assessed with the foot loaded and the hallux is now able to dorsiflex beyond 60 degrees.

    A Mann dressing is applied on top of simple adhesive dressings.

    Pre operative weight bearing AP radiograph, note good preservation of joint space.

    Lateral pre-operative radiograph, note prominent dorsal 1st metatarsal head with minimal osteophyte.

    Lateral post-operative weight-bearing radiograph, patient not loading fully through 1st ray, however dorsal prominence improved.

    post-operative AP radiograph, joint space remains well preserved, subtle shortening of 1st ray.

    Post Operative

    Elevation – The patient is advised to elevate the foot regularly for the first 2 weeks post-operatively.
    Analgesia – Regular analgesia is advised for 72 hours, and the taken as necessary..
    Mobilise fully weight bearing in a post-surgical heel wedge sandal for 6 weeks whilst the osteotomy unites.
    Range of movement – early range of movement is encouraged. The patient should work with a physiotherapist to actively and passively mobilise the 1st MTP joint.
    Stitches are removed at 2 weeks post-operatively. The foot can then be bathed and the scars should be massaged.

    Recommended Reading

    J Am Podiatr Assoc. 2004 Jan-Feb;94(1):22-30. Plantar pressure and joint motion after Youngswick procedure for hallux limitus.
    Bryant AR, Tinley P, Cole JH.
    Bryant et al 2004 showed that range of movement in the 1st MTP joint returned to within normal limits following youngswick osteotomy. Peak pressures reduced from the 4th and 5th rays. The amount of plantar flexion was minimally not significantly reduced. Pressure below the 1st metatarsal head does not seem to change after surgery. The foot function took 18 months to stabilise.
    The functional post-operative recovery continues even after full clinical and radiographic recovery. They noted an increased load through the 2nd metatarsal head post-operatively, which was not clinically evident.

    J Foot Ankle Surg. 2016 Nov-Dec;55(6):1143-1147. Joint Preserving Procedure for Modrate Hallux Rigidus: Does the Metatarsal Index Really Matter?
    Slullitel G, Lopez V, Seletti M, Calvi JP, Bartolucci C, Pinton G.
    Slullitel in the journal of foot and ankle surgery 2016 reported excellent results in 78 modified Youngswick procedures with high levels of patient satisfaction and outcome was noted related to the relative length of the 1st metatarsal.

    Youngswick-Austin versus distal oblique osteotomy for the treatment of Hallux Rigidus. Foot(Edinburgh). 2107 Aug;32:53-58.
    Viladot A, Sodano L, Marcellini L, Zamperetti M, Hernandez ES, Perice RV.
    Viladot reported good results in both oblique osteotomies and Youngswick osteotomies in 50 patients and recommended the procedures as safe and allows immediate weight bearing with rapid recovery to function, good to excellent clinical results and a low complication rate.

    The Use of Osteotomy in the Management of Hallux Rigidus. Foot Ankle Clin. 2105 Sep;20(3):493-502
    Shariff R, Myerson MS.
    Myerson in foot and ankle clinics 2015 noticed that with the Youngswick osteotomy as the angle of the osteotomy as acute, the degree of plantar displacement can be achieved as restricted and this needs to be assessed prior to performing the osteotomy.


    Reference

    • orthoracle.com

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