CHAPTER 7

LONGTERM FOLLOW-UP OF THE GREEN.WATERMANN OSTEOTOMY FOR HALLUX LIMITUS

Jasom Dickerson, D.P.M.Ricbard Green, D.P.M.Donald Greem, D.P.M.

INTRODUCTION

Hallux limitus rigidus is a well-known entity tophysicians treating the foot and ankle. There arenumerous approaches to the surgical treatment ofhallux limitus ranging from the simple soft tissuerelease, and cheilectomyl-' to the joint destructiveprocedures.8-1' Between these extremes are variousphalangeal and metatarsal osteotomies utilized forhallux limitus.B,e''"' (Table 1) Choosing the mostappropriate surgical approach, wiih such a widearray of procedures having various indications,contraindications, advantages and disadvantages,can be a challenging task.

In 7987, Bernbach and McGlamryr5 suggesteda step-wise surgical approach to hallux limitus.This began with a cheilectomy, progressed to aVatermann-type or Austin-type procedure, then toa plantar-declinatory wedge osteotomy, and finallyan implant. The following year, Bernbach'6 addedan additional procedure to this step-urise approach:the Green-Vatermann procedure. Laakman pre-sented a preliminary repofi on this procedure withvery positive results in 19963 The purpose of thispapef is to present a retrospective analysis of thelong-term efficacy of the Green-\Tatermann proce-dure for hallux limitus.

MATERIALS AND METHODS

Letters were sent to all eighty patients who had theGreen-\Watermann procedures for painful hallux lim-itus/rigidus performed by authors DG and RGbetween 7990 and 1999. Thirty-two patientsresponded to the subjective questionnaire regardingpreoperative and postoperative pain and level offunction, complications, need for further surgery, andoverall patient satisfaction.(Table 2) The medicalrecords and radiographs of the 32 patients represent-ing 40 Green-\X/atermann procedures were reviewed.

Tatrle I

TIALLTIX LIMITUS RIGIDUSSUMMARY OF PROCEDT]RES

L Joint DestructiveA. Resectional arthroplasty

1. Resect proximal phalanx base (Keller)2. Resect metatarsal head (Mayo, Heuter,

Stone)B. Implant arthroplasty

1, Silastic (hemi or total)2. Metallic (hemi or total)

C. Arthrodesis 1 First MTPJ (McKeever)II. Joint Preserwing

A. Proximal phalangeal1. Basilar dorsal wedge osteotomy

(Kessel & Bonney)2. Regnauld enclavement3. Sagittal-Z osteotomy

B. First metatarsal1. Long diaphyseal osteotomy2. Green-\Tatermann osteotorny3. Shortening, Offset, long-arm chevron

osteotomy (Youngswick/ Selnar)4. Plantarflexory wedge osteotomy5. Sagittal-Z osteotomy6. Double osteotomy

C. Cheilectomy7. Valenti modification

D. First metatarsal -cuneiform arthrodesis(Lapidus)

Using the preoperative radiographs, the first metatar-sophalangeal joints were graded according to themodified Drago, Oloff, and Jacobs and Regnauldscale','a as grade I, grade II, grade III, or grade N(Table ,. One patient (3o/o) had halluxlimitus/rigidus grade I that showed no radiographic

38 CHAPTER 7

Table 2

SUBJECTTVE PATIENT SURVEYPATIENT SURVEY

PRIOR TO SURGERY:Which big toe joint was operated on? Right Left_ Both_On a scale of 1 to 10 (10 being worst), what was your level of pain before surgery?Did the pain in your big toe joint limit you from daily activities? Yes_ NoDid the pain limit you from sports activities? Yes_ NoDid the pain limit you from wearing cefiain shoes? Yes_ No_Describe the stiffness you experienced before surgery: Very Stiff

-

Not very stiffNo Stiffness at all

FOLLOWING SURGERY:PainDid your surgery relieve the pain in your big toe joint? Yes_ No_Do you experience any pain now in your big toe joint with normal daily activities?No Pain Mild, occasional pain_ Moderate, dally pain Severe pain3, Do you experience any stiffness now in your big toe joint? Yes_ No4. Are you able to participate in sports activities without pain? Yes_ No5. Do you have any painful calluses on the ball of your foot? Yes_ No

Function1. Are you satisfied with the amount of motion in your big toe joint? Yes- NoThe amount of motion in my big toe joint following surgery has:

Increased greatly- Increased somewhat- No change DecreasedDoes your big toe joint limit your normal daily activities?

No limitations_ Some limitations_ Severe limitationsDoes your big toe joint restrict the type of shoes you can wear?

No restrictions_ Restricted to wide shoes/sneakers_ Restricted to many types\fhat sports activities/hobbies are you involved in that require increased physical d mands?

(\flalking, running, golf, bowling, etc.

Compkcations'Were there any complications following your surgery? Yes- No- If Yes, what were they?How long were you wearing a surgical shoe? 2weeks- Jweeks- 4weeks- Over 4 wks-Have you required additional surgery on your big toe joint? Yes- No-Are you pleased with the appearance of your big toe joint? Yes- No-Do you have any swelling of the big toe joint? None- Slight Constant-Did you have any rype ol physical therapy after surgery Yes- No

-Oaerall impressionChief complaints satisfactorily resolved: (Please check one)Very strongly agree (90o/o or more improved)

-

Strongly agree (700k improved)Agree (50% improYed)-Disagree (less than 500/o improved )-Strongly disagree (minimal improvement, worse)_

Oaerall Satisfaction:Very Pleased (would highly recommend)Pleased (would recommend) _Displeased (would not recommend)

CHAPTER 7 39

Table 3

Grade of Hallux LimitusGrade I

Grade II

Grade IIIGrade IV

CharacteristicsFunctional LimitusNo radiographic changes

Joint adaptationProliferative and destructive joint changes

Joint deterioration and arthritisAnkylosis

PREOPERATTVE GRADING SCALE FOR IIALLIIX LIMITUS/RIGIDUS

Number of Feet1

70

32

Based on the modified Drago, Oloff, Jacobs, and Regnauld system.

changes, but had a functional limitus. Thirty-twojoints (80%o) had joint adaptation and proliferativeand destructive joint changes noted as grade ILSeven (-180/4, as a grade iil, demonstrated jointdeterioration and arthritis. No joints were graded IVwith ankfosis. Twenty-four of the thiqr-two patientsrepresenting twenty-eight Green-Vatermann proce-dures were returned for clinical evaluation.

Of the thirry-two patients who responded tothe subjective questionnaires, 17 were males and15 were females. The average age at the time ofsurgery was 55 years (range 41. to 69 years). Theaverage length of follow-up was 4 years (range 1 to10 years). Eight patients had bilateral surgery for a

total of 40 Green-\Tatermann procedures per-formed. There were twenty-five procedures on theright foot and fifteen on the left foot.

SURGICAL TECHNIQUE

The surgical technique used in the Green-\Tatermann procedure has been previouslypublished by Bernbach'6 in 19BB and by Feldman"in7992. Gig.1) The procedure begins with a standardbunion approach with anatomic dissection in layersdown to the first metatarsophalangeal joint capsule.A capsulotomy of choice is then performed (usuallya dorsomedial linear capsulotomy), and the capsuleis reflected to allow exposure of the first metatarsalhead. An attempt is made to preserve the dorsalmetatarsophalangeal joint plica if possible. A dorsalcheilectomy or generous resection of the firstmetatarsal prominence is performed, which oftenrequires sacrifice of the dorsal plica to resect thewhole dorsal shelf of bone. (Fig. 2) Resection of an

Figure 1. The modified Watermann procedure shortens and plantardeclinates the metatarsal head. An appropriate portion of bone is

removed dorsally to allow the desired shortening. The angle of theplantar cut determines the ratio of shodening to plantar declination.

Figure 2. Resection of the dorsal exostosis (cheilectomy) is usuallyrequired

40 CHAPTER 7

Figure lA. Appearance of the first metatarsal head prior to remodelingof the dorsal exostosis. Exuberant bone proliferation is noted.

Figure JC. Remodelling of the medial erlinence nith a power sau,-.

appropriate amount of medial eminence is then per-formed. (Fig. 3A)

Next, a through-and-through osteotomy ismade from medial to lateral in the lower two-thirdsof the metatarsal head and neck. The osteotomy ismade from the plantar cofiex just proximal to theattachment of the plantar plica and exlends dorsallyand distally into the metatarsal head. (Fig. 38) Theamount that the osteotomy is angled from theweight-bearing surface will determine the ratio ofmetatarsal shortening to plantar-declination. Astandard 45-degree angle will give a 1:1 ratio. Amore parallel angle will give greater shorteningrelative to plantar transposition, while a moreverlical angle will give greater plantar transpositionrelative to metatarsal shortening.lT The saw bladecan then be detached from the power equipmentand left in the planlar osteotomy to assist in accurateplacement of the dorsal osteotomies. (Fig. 3C)

Figure 38. Remoclelling and resection of the dorsal exostosis with apowel sa[r.

F'igure 4. The medial eminence is resected ifneeded. The PASA correction can be achievedvia a trapezoidal dorsal wedge. The capital frag-ment can be transposed laterally if necessary.

A rectangular or trapazoidal section of bone inthe dorsal one-third of the metatarsai head isresected, maintaining a perpendicular relationship tothe weight-bearing surface. The width of the rectan-gular section of bone will determine the amount ofshortening. The distal osteotomy is performed first,and is usually made parallel to the proximalafiicular set angle (PASA) of the first metatarsal headin order to correct the angle to zero to eight degrees.The inferior aspect of the osteotomy should intersectthe distal aspect of the plantar osteotomy utilizing

/T

CHAPTER 7 4t

the plantar saw blade as a guide. The proximalosteotomy is performed next, and can be made per-pendicular to the long axis of the first metatarsal.This creates a dorsal trapezordal-shaped wedge ofbone with a wider base medial. (FiS. 4) If no PASA

correction is desired, one can also perform thedistal osteotomy perpendicular to the longitudinalaxis of the first metatarsal creating a dorsalrectangular-shaped wedge of bone. (Fig. 5)

The section of bone is removed to allowshortening, and the capital fragment is slid proxi-mally and declinated along the plantar slope ofbone. (Fig. 5) Lateral transposition of the capitalfragment can also be performed at this time if a

relative reduction of the intermetatarsal angle isdesired. Reciprical planing may be necessary toinsure a flush fit of the bone edges.

Fig iA. Disection of the plantar tissues in preparation for the plantararm of the osteotomy. Note the preseffation of the plantar attachmentof the capsular tissue.

Fig 6A. Execution of the dorsal osteotomy resulting in removal of a

segment of bone to shorten the first metatarsal, Removal of a trape-zoidal section of bone will al1ow simultaneous correction of the PASA.

Fkation of the osteotomy site is then accom-plished with either a 0.062" threaded K-wire or a 4.0

mm AO cancellous screw. (Fig. 7) The fixation is

usually proximal-dorsal to distal-plantar insuring thetlxation is not exposed at the plantar articulatingsurface. The capitai fragment is then inspected forstabiliry, and if necessary, a second threaded K-wireis placed. The K-wire is cut flush with the metatarsal

cofiex dorsally and adequately countersunk as

necessary to prevent dorsal impingement. (Fig. 8)

Standard layered closure of the soft tissues is thenachieved with adjunctive capsulorrhaphy done as

determined intra-operatively by the surgeon. PASA

correction, lateral transposition of the capitalfragment, and/or lateral release of the metatarsol-phalageal joint are not usually required, but may benecessary if a dorsal medial bunion is associated

with the hallux limitus.

Fig 58. Erecution of the plantar arm of tl're osteotomy. The saw blacle

is left in place to help guide execution of the dorsal osteotomY

Fig 68, F'irst metatarsal osteotomy completed. The distal capital frag-ment will shoden and plantarflex based upon thts osteotomy.

42 CHAPTER 7

Fig 7A, Appearance following translocation of the first metatarsal headNote good apposition of the osteotomy surfaces.

Fig 8A, Postoperative lateral radiograph showing plantar flexion of thecapital fragment and flration with a single Kirschner wire from dorsalprorimal to plantar distal.

Fig 78. Flxzrtion of the osteotom), $,ith Kirschner wire

Fig 88. Direction and placement of a cancellolrs screw lbr fkation ofthe osteotomy. Note the direction and location are the same as forKirschner-wire firation.

POSTOPERA ITVE MANAGEMENT

The patient is discharged in a rigid surgical shoe,and aliowed to bear weight as tolerated. Often a

betadine soaked gauze bandage is applied postop-eratively as a betadine cast. Passive range of motionexercises are begun no later than postoperative daythree, and then gradually and progressivelyincreased until full motion is achieved. Physicaltherapy is often prescribed beginning 2 to 3 weekspostoperatively consisting of active and passivemnge of motion exercises. The rigid surgical shoe isusually worn for 3 weeks while the metaphysealosteotomy is healing.Fig 8C. Postoperative lateral

'$(l.aterman Osteotomy withfr-ration of the osteotomy.

radiograph shou.'ing fixation of a Green-a cancellous screw pror.iding enhanced

CHAPTER 7 43

SUBJECTIVE RESULTS

On a scale of 1-10 (10 being the worst) patientsreported an a-verage pain rating of 8 preoperatively(range 4 to1,0). A11 patients reported pain and stiff-ness in the first metatarsophalangeal joint beforesurgery. Sixty-two percent of the patients reportedlimitations with daily activities. Twenty-eightpatients (BB%) had limitations with spofis, and 24patients (75o/o) had limitations in shoe gear.

Thifty patients (94%o) repofied that surgery hadsignificantly reiieved the pain in the great toe joint.No patients admitted to worsening pain. Elevenpatients (34o/A had no pain, eighteen (560/A hadmild, occasional pain; three (9%) had moderatepain: and no patients had severe pain. Twenty-fivepatients (7Aolo1 were able to participate in sportingactivities which included walking, running, tennis,bowling, squash, basketball, golf, hockey, weight-lifting, aerobics, biking, and skiing. None of thepatients reported the development of painfulcalluses following surgery. Although slx patientsOBVA developed pain sub 2nd metatarsal head, allwere relieved with orthotics and padding. Onepatient complained of pain sub 1st metatarsaldirectly in the sesamoid areabilateraly.

A11 patients reported satisfaction with theappearance of their great toe joint followingsurgery, and 24 patients (750/o) reported a markedincrease in their first metatarsophalangeal jointralrge of motion. Five patients (.75o/o) reported adecrease in first metatarsophalangeal range ofmotion following surgery and three patients (9%o)

related no change in first metatarsophalangeal jointrange of motion. Only eight patients(2570) reportedthat their great toe joint still limited them fromsome daily activities, and sixteen patients (50%)

related limitations to the type of shoes they canwear. This was repofted mostly by the femalepatients, who were not able to wear high heals.None of the patients related any complications fol-lowing surgery, such as infection, wounddehiscence, or dislocation. Surgical shoes wereworn for 2 to 4 weeks, and passive range-of-motion exercises were performed by all of thepatients, ranging from immediately followingsurgery to 2 weeks. A11 patients had postoperativeorthotics. Nine patients related slight occasionalswelling. None related continual swelling.

The results were then calculated using the mod-ified American Othopedic Foot and Ankle SocietyRating System for Hallux Metatarsophalangeal-Interphalangeal Scale.'5 An average score of 83(range, 38-100) was obtained. (Table 4) Twenty pro-cedures were rated as having excellent results, fifteenas good, none as fair, and five as poor.(Table 5)

Table 4

MODIFIED AMERICAII ORTHOPEDICFOOT AI\[D ANIIE SOCIETY RAIING

SYSTEM FOR TIALLTIXMETATARS OPHAIA,NGEAL S CALE

Pain (40 points)None 40Mild, occasional 30Moderate, daily 20Severe 0

Function (40 points)Activity limitationsNo limitations 10Some limitations of daily activities includingrecreational and leisure activities (shopping,employment requirements) 5

Severe limitation of dailyand recreational activities 0

Footwear requirementsNo restrictionsRestricted to sneakers, wide shoesRestricted to many types

Range of motionCompletely satisfiedNonpainful, limited motionPainful, restricted motion

CallusesNone or present and nonpainfulPainful

SwellingNoneSlightConstant

Aiignment/cosmesis (10 points)Good, pleasedFairPoor, unhappy

Success of surgery (10 points) Percent/100

Total nurnber of patients surueyed = J2; total namber ofprocedures = 40; auerage score 83 /100 (range 38 to 100).

1050

10

50

50

5

30

10

50

44 CI{APTER 7

ResultExcellentGoodFairPoor

Score90-L000/o

70-B9o/o

5o-59oto

<5oo/o

Number ofProcedures

2015

0

5

Table 5

RESULTS OF SUBJECTTVE SURVEY

patients had non-tender tyloma formation beneaththe second metalarcaT. One patient reportedsesamoid pain following surgery on both feet.

The attending physicians generally recorded a

limitation of motion of the first metatarsolpha-langeal joint preoperatively, but did notconsistently record the range of motion in degrees.Only postoperative degrees of range of motionwere recorded. The ayerage degree of dorsiflexionat follow-up was 58 degrees (range 44 to 85degrees). The average degree of plantarflexionmotion was 9 degrees (range 5 to Z0 degrees).

Radiographic studies at the time of follow-upincluded dorsoplantar and lateral views. Themetatarsal protrusion distance (MPD) pre-operatively, ranged from 5mm to -5mm with anaverage of -.27mm. Negative numbers arerecorded when the first metatarsal is shofier thanthe second. Postoperatively the MPD averaged -427mm (range 0 to (-11) mm) with an a.verageshofiening of the first metatarsai of 4mm (range 0to (-7) mm).

Nthough the first metatarsal is often elevatedabove the second metatarsal on the laleralradiograph, it is the change in the elevation fromthe base to the metatarsal head that is of greatersignificance. Camasta described the variability insuperimposition of the first and the secondmetatarsals on the lateral radiograph withpositional changes in the x-ray machine tube-head.'6 Seiberg described a reproducible method ofevaluating radiographic elevatus by using standardreference points.27 The Seiberg index (S.I.), com-pares the difference between the cortices of the 1st

and2nd metatarsals at 1.5cm distal to the metatar-socuneiform joint and at the surgical neck of the1st metatarsal.(Fig. 9) The distance in mms of theproximal measurement is subtracted from the dis-tance in mms of the distal measurement to give theindex. The S.I. is positive, with a metatarsus primuselevatus. Preoperatively the S.L was positive for allpatients except two patients whose index was zero(neither elevated/declinated). The average preop-erative S.I. was 2.7 (range 0 to 4).

Postoperatively the capital fragment plantartransposition was measured by using a modifiedS.I. (the difference between the dorsal cofiex ofthe 1st metatarsal proximal and distal to theosteotomy site). All osteotomies obtained plan-tarflexion of the caprtal fragment of 1mm to 2mmwith an alrerage of 7.25mm. Negligible changes

Based on the modified American Ortbopedic Foat and AnkleSociety Rating Systeru. for Hallux Metatarsophalangeal Scale

Twenty-two parients 6BVA felt that their chiefcomplaints were >90 percent resolved. Six (18%)felt that they were >700/o improved. One (30/A felt>500/o rmproved. Three (190/o) indicated no improve-ment. No patient felt they were made worse fromthe procedure. Thus 88% of the patients were morethan 700/o improved, and 900/o of the patients wereimproved by at" leasl 500/o. Twenty-nine patients(90o/o) said they would undergo the same proce-dure again. Three patients (90/o) had reservationsabout their surgery.

OBJECTTVE RESULTS

Twenty-four out of 32 patients (28 procedures)agreed to a follow-up examination and a long termupdated radiographic evaluation. The patients werealso evaluated regarding appearance, edema, scar,

neurological status, deformity, dorsiflexion andplantarflexion range of motion measurements, andpain on range of motion and palpation. The meanfollow-up time was 4 years (range 1 to 10 years).Average age at the time of follow-up was 55 yearsold (range 45 to 6Z years). There were 19procedures on the right foot and 9 procedures onthe left foot.

Two patients had some pain upon palpationand range of motion. No patients had persistentperiarticular edema. None of the patients hadhypertrophic scars. One patient had an asympto-matic recurrence as noted by palpable prominentdorsal exostosis. One patienthad a palpable K-wirefixation dorsally, but it was not painful. Six patientsresponded positively with tenderness to palpationplantar to the second metatarsal head. Two of the

CHAPTER 7 45

were noted in the intermetatarsal angle, sesamoidposition, and the base of the proximal phalanx inrelationship to the head of the metatarsal. Therewas a small amount of reduction in the halluxabductus angle.

COMPLICATIONS

Three patients felt their symptoms had not improvedpostoperatively. Two patients were available forfollow-up examination. The first patient was a 54-year-old nurse who had surgery five years prior forgrade II hallux limitus bilaterally. Postoperatively,her symptoms seemed to be resolved for 7 or 2

years. She then began to have sub 1st metatarsalpain and pain with range of motion worse withplantarflexion. Orthotic devices helped, but did noteliminate the pain. She was unable to ambulatewithout shoes/orthotic devices. She had a very thinplantar pad beneath the first metatarsal and aprominent tibial sesamoid bilaterally. She was ableto speed walk with her shoes and orthotic devicesand feels she is not worse than she was pre-operatively. Tibial sesamoiditis and progression ofher degenerative joint pain may require furthersurgery, which will probably include a Kellerprocedure and/or removal of the tibial sesamoid.

The second patient is a 47-year-old femalewho works for the FBI. She underwent a Green-\Tatermann procedure three years prior for grade IIhallux limitus. Postoperatively she continued tohave joint pain and stiffness that seemed to be

improving with physical therapy. Five months post-operatively she had a comminuted fracture of her5th metatarsal base requiring 3 months in a shortleg cast. Currently she has 35 degrees of dorsiflex-ion but no plantarflexion. She has pain with endrange of motion. She denies sub 1st or 2ndmetatarsal pain. She continues to work as a fieldofficer, but notices increased pain after long dayson her feet. The inability to continue with physicaltherapy and cast immobilization for J months mayhave considerably added to her joint stiffness.Currently she states the pain has not stopped herfrom working. Eventually she may require a jointdestructive procedure.

The third patient is a 42-year-old female whounderwent bilateral Green-\Tatermann osteotomiesfor grade I and grade II hallux limitus 4 years prior.This patient was not available for follow-up exami-nation. Her questionnaire indicates her pain is in herentire forefoot. She also answered yes when askedif the pain in her first metatarsal joint had decreased.She does feel that she has joint stiffness and islimited in her shoe gear. Her 6-week postoperativex-rays show well-healed, well-aligned osteotomieswith no degenerative changes of significance.

DISCUSSION

Root et. al indicate that 65 to 75 degrees of dorsi-flexory motion is necessary at the first MPJ for normalambulation." Hallux limitus is the restriction ofmotion at the first metatarsophalangeal joint (MTPJ)

Functional hallux limitus is the condition in whichthe limitation of hallux dorsiflexion is only presentupon weightbearing. In a structural hallux limitus,the restriction of motion is present on both weighrbearing and non-weightbearing. The condition inwhich there is no range of motion at the first metatar-sophalangeal joint is referred to as hallux rigidus.

Numerous authors3l2'18,20'28-3a have proposedanatomic abnormalities of the foot as the primarycause of this condition, suggesting pes planus,forefoot pronation, metatarsal elevation, and anabnormally long 1st ray, hallux and/or metatarsal.(Table 6) Davies-Colley33 originally described it as

hallux flexus in 1887 suggesting an abnormallylong hallux as an etiology. Cotterill, several monthslater designated the term of hallux rigidus.35

Cochrane in 1927, felt that hallux rigidus, wassecondary to shortened and contracted plantar firstmetatarsophalangeal joint structures.36 In 1954,

Figure !, Seiberg Index is a sagittal measurement of the relationship ofthe first metatarsal to the second metatarsal. The perpendicular dis-tance from the dorsum of the second metatarsal to the dorsum of thefirst metatarsal shaft is measured at the first metatarsal neck and 1.5 cmfrom the first metatarsal base. The proximal measurement is subtractedfrom the distal measurement to give the Seiberg Index.

46 CHAPTER 7

Table 6

ETIOLOGIC FACTORSOF IIALLI.IX LIMITUS

Configuration of the head of the first metatarsal(round, square)

Hypermobility of the first rayAbnormal prontation of the subtalar joint

Immobility of the first rayDJD at the Lisfranc:s articulationCongenital coalition between the first metatarsal

and first cuneiform or between the navicularand calcaneus

Long first metatarsalOverloading of the first metatarsalMetatarsus primus elevatus

CongenitalAcquiredIatrogenic

DJD of the first metatarsophalangeal jointTrauma

Acute gross injuryChronic microtrauma

Occupation/activitiesDegenerative yoint disease.

Hicks3' discussed the inter-relationship of theplantar aponeurosis and its effect on extension ofthe toes at the metatarsophalangealjoint, includingthe hallux. Durrant and Siepert3a believed, that softtissue structures: flexor hallucis brevis andsesamoid apparatus, medial plantar fascial siip; andscarring of the joint capsule, were all capable oflimiting motion of the 1st MTPJ.

Lambrinudi3' reported on dorsal elevation ofthe first metatarsal head as an anatomic abnormal-ity. He used the term "metatarsus primus elevatus"to describe an abnormal elevation of the first ray as

a cause of hallux rigidus. Meyer et a1.37 reported onthe elevation of the first metatarsal in a group of720 randomly selected foot radiographs. Thediagnosis of hallux limitus was made in 22 of the720 patients. The mean elevation of the firstmetatarsal above the 2nd at the metatarsal neckwas 5.9 mm for the group as a whole. Theyconcluded that approximately 7.0 mm of first rayelevation is a consistent radiographic finding in-patients with and without hallux rigidus. Hofton et

al.'e found similar results with an avetage of neadySmm of metatarsus elevatus as

^ normal finding in

patients with hallux rigidus as well as in normalsubjects. Meyer felt that metatarsus elevatus wasparamount in the pathogenesis of hallux rigidus,while Horton considered it a secondary phenome-non rather than a pimary cause.'e'37 Root, Orien,and \7eed" felt that acquired hallux limitus can

develop from abnormal subtalar joint pronationwhich allows for hypermobility of the first ray andmetatarsus elevatus.

Kinematic analysis of the first metatarsoh-palangeal join in patients who have hallux rigidusreveals a decrease in the total arc of motion, withrelatively normal plantar flexion but markedlyrestricted dorsiflexion. Motion analysis revealsinstant centers of rotation that ate displaced andlocated eccentrically about the metatarsal head.38'3e

Roukis et a1.30 quantitatively demonsttated thatmotion of the first metatarsophalangeal joint is

influenced by the position of the first ray. First

metatarsophalangeal joint dorsiflexion decreased

79o/o as the first tay was moved from the weight-bearing resting position to 4 mm dorsiflexed, anddecreased 34.7o/o as the first ray was moved from theweightbearing resting position to B mm dorsiflexed.

The increased motion of the first metatarsopha-

langeal joint when subjects are non-weight-bearinghas been attributed to unrestricted plantar flexion ofthe first metatarsal, which allows the transverse axis

to remain within the center of the head of the first

metatarsal. This mechanism allows the hallux toglide and rotate without impaction on the firstmetatarsal [g2d.:s'+o

Plantar declination of the caprtal fragment inconjunction with shortening produces a bettermechanical environment for hallux range ofmotion and weightbearing. The author believesthat the most impofiant structural change is theshortening of the metatarsal to allow a "slack in theline." This will effectively relax the plantar struc-tures for increase fange of motion.e'74'1'6'18'22'23'2a3a

The Green-Watermann procedure obtains sur-

gical correction by three mechanisms: shofieningthe first metala;rsal, plantar transposition of the firstmetatarsal head, and a dorsal cheilectomy. In thosecases that may require it, correction of PASA andlat-eral transposition of the capital fragment is

available, The procedure requires five osteotomiesand allows the first metatarsal capital fragment to bemoved in four different directions.'7

CHAPTER 7 47

The subjective results showed a decrease in the

patient's mean level of pain. The largest difference

was afi increase in the patient's mean overallsatisfaction when comparing preoperative and post-

operative assessments. Twenry-nine patients (90%o)

said they would highly recommend the surgery topatients with similar symptoms. Patients also

experienced a mearr increase in their level ofactivity, an improved appearance of the foot, less

limitation in the style of shoes that could be

tolerated, and an increase in the amount of motionat the big toe joint. It is interesting to note that

patients achieved a more substantial decrease in the

level of pain rather than in the amount of firstmetatarsophaTangeal joint range of motion.

Objective biomechanical results showed ade-

quate range of motion of the first metatar-

sophalangeal joint. Although no preoperativecomparisons could be made, patients felt a signiii-cant increase in range of motion. There was a

significant decrease in the level of pain with tange ofmotion, which may have contributed to the sensation

of an increased range of motion.The mean metatarsal protrusion distance was

decreased postoperatively as was expectedindicating that the metatarsal was indeed shortened.

The mean Seiberg sagittal plane displacement was

recorded to be 7.25 millimeters of declination. One

needs to appreciate that, due to the declination ofthe metatarsal, ordinarily any capital fragmentshortening will concomitantly elevate it as well. The

angulation of the plantar osteotony will mitigate this

elevation to some extent or may even plantardecli-

nate the capltal fragment. However, six of our

thifiy-two patients complained of sub znd metalarsal

pain (relieved with ofihotic devices). Of note, four

of the six patients had a Seiberg index of 3 or

greater. Placing the plantar arm closer to the vertical

plane (allowing for more plantar transposition), may

alleviate this problem. One patient (two feet) had

increased sesamoid pain. The Seiberg Index was -5

and -3 respectively. Placing the plantar arm closer to

the horizontal plane (allowing less plantar transposi-

tion) may have prevented this problem.The disadvantages of the Green-Vatermann

osteotomy include the precision necessary in per-

forming the procedure, the requirement of fine

instftimentation, and the inherent instability of the

design. All patients in the study had uneventfulhealing with no delayed healing or nonunions'

CONCLUSION

The Green--Watermann procedure has shown to be

an effective treatment of haliux limitus as a iointpreservation procedure. It addresses the elevated first

metatarsal and shortens to allow for decreased

tension in the soft tissue structures. Vith presefl/ation

of the first metatarsophalangeal joint, this procedure

also allows for maintenance of a propulsive gait post-

operatively. Even in many grade III hallux limitus

cases, good results have been gained. of course

good funtional control postoperatively in an orthotic

device have helped to neutraiize the pathologic

forces causing the elevated 1st ray. The procedure is

not intended to reverse the athritis that has aTready

occurred. The patients are made aware that, in the

future, joint destructive procedures may be required

as the aging process continues. The good functional

results are giving patients a stable joint withsignificant reduction in symptoms and years of a

more active lifesryle.

48 CHAPTER 7

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