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Director, Foot and Ankle Surgical Residency Program, Regions Hospital, HealthPartners Institute for Education and Research, St. Paul, MN
Staff Surgeon, Foot and Ankle Surgical Residency Program, Regions Hospital, HealthPartners Institute for Education and Research, St. Paul, MN
a r t i c l e i n f o
a b s t r a c t
The lateral hallux stress dorsiexion view is part of our standard workup for midterm hallux limitus (HL)/
hallux rigidus (HR). It provides a functional radiographic examination of the rst metatarsal phalangeal joint.
Midterm HL primarily involves degenerative changes in the upper one third of the metatarsal phalangeal joint
involving formation of bone spurs, dorsal bone impingement, joint space narrowing with cartilage degeneration, and fragmentation of the bone spurs. The lateral hallux stress dorsiexion view provides diagnostic
information not visible on a standard weightbearing lateral view in patients with midterm HL/HR, including
joint space narrowing on the dorsal third of the joint despite intact cartilage through the center one third of
the joint, the extent of maximum rst metatarsal phalangeal joint dorsiexion, and direct visualization of
dorsal bone spur impingement. This functional radiographic examination also appears to provide improved
patient understanding regarding why their joint is stiff and painful. Improved patient understanding of their
condition positively inuences the shared decision making regarding the treatment objectives and options.
The cases of 5 patients with stage II or III HL/HR are presented to depict the utility of this radiographic view,
including objective measurement of maximum rst metatarsal phalangeal joint dorsiexion, conrmation of a
bony block at the end range of dorsiexion, the presence or absence of joint space narrowing at the dorsal
third of the joint, evaluation of the excursion of the sesamoid apparatus, a tool to help the patient understand,
an intraoperative assessment of procedure effectiveness, and a comparison of maximum dorsiexion before
and after surgery.
! 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords:
arthritis
cartilage
degenerative joint disease
hallux rigidus
patient satisfaction
1067-2516/$ - see front matter ! 2014 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2014.07.012
T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18
Fig. 1. The lateral hallux stress dorsiexion view (LAT SD) is performed with the patient in maximum dorsiexion position at the level of the rst metatarsophalangeal joint (MPJ). (A) The
patient is instructed to keep the MPJ on the oor and raise the heel to the point of maximum dorsiexion or pain. (B) The setup for the radiograph is similar to that of a standard
weightbearing lateral radiograph, except that the central beam is focused at the middle of the rst MPJ. The LAT SD view can be used for measurement of maximum forced rst MPJ
dorsiexion. (C) The angle is determined by the bisection of the dorsal and plantar cortices of the proximal and distal thirds of the rst metatarsal versus bisection of the proximal phalanx
of the hallux. (From Taranto MJ, Taranto J, Bryant A, Singer KP. Radiographic investigation of angular and linear measurements including rst metatarsophalangeal joint dorsiexion and
rearfoot to forefoot axis angle. J Foot Ankle Surg 44:190199, 2005.)
preparation, including the procedure duration and available equipment, and postoperative recovery plans.
The lateral hallux stress dorsiexion (LAT SD) view is part of our
standard workup for HL/HR. It provides a functional examination of
the rst MPJ and clinically relevant information not visible on
standard weightbearing foot radiographs in patients with midterm
HL/HR. The LAT SD view is a functional weightbearing radiograph
that provides a view of the joint space narrowing on the dorsal third
of the joint, the extent of the maximum rst MPJ dorsiexion, and
bone on bone impingement that is typically not visible on standard
weightbearing foot radiographs in mid-stage HL/HR (18) (Fig. 1).
This view can also demonstrate the position of the joint in maximum
dorsiexion; thus, it can be used to assess the excursion or lack
of excursion of the sesamoid apparatus. Previous research has
shown the LAT SD angle can be measured reliably, and the method
Fig. 2. Patient 1, with limited rst metatarsophalangeal joint dorsiexion with the upper third joint space maintained. Anteroposterior, lateral, and lateral hallux stress dorsiexion
radiographs of 62-year-old-female with stage II hallux limitus/rigidus. On (A) anteroposterior and (B) lateral radiographs, she had reasonable joint space at the rst metatarsophalangeal
joint, with an elevated and elongated rst metatarsal. (C) Lateral hallux stress dorsiexion view documenting severely restricted dorsiexion with joint space maintained at the upper
third of the joint.
T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18
Fig. 3. Lateral and lateral hallux stress dorsiexion radiographic views. Notice how the standard lateral view does not provide this same information regarding maximum rst metatarsal
phalangeal joint dorsiexion preoperatively (A), at 6 weeks postoperatively (B), or at 4 years postoperatively (C), when compared with the lateral hallux stress dorsiexion view preoperatively (D), at 6 weeks postoperatively (E), and at 4 years postoperatively (F). The patient can see how joint mobility is restricted preoperatively and how joint mobility is improved
after distal metatarsal osteotomy and cheilectomy. The surgeon can measure the amount of dorsiexion preoperatively and postoperativley for objective documentation purposes.
T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18
Fig. 4. Patient 2 demonstrates normal joint space on lateral and lateral hallux stress dorsiexion view, despite joint pain with range of motion. Patient 2 was 58-year-old male with stage II
hallux limitus/rigidus and smooth range of motion yet chronic joint discomfort. A normal joint space was noted on the (A) lateral and (B) anteroposterior radiographs. (C) The lateral hallux
stress dorsiexion view showed maintenance of the joint space at the upper third of the metatarsophalangeal joint indicating at least partially intact cartilage on the upper third of the
metatarsal head. (D) Intraoperative appearance of rst metatarsal cartilage with a central stellate lesion (arrow) but otherwise intact cartilage.
T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18
Fig. 5. Patient 3 is an example of the lateral hallux stress dorsiexion view demonstrating a bony block at the end range of dorsiexion and a lack of joint space at the upper third of the metatarsal
phalangeal joint. Patient 3 was 57-year-old female with stage III hallux limitus/rigidus involving bump pain and pain on range of motion. Standard (A) lateral and (B) anteroposterior views showing
an intact joint space despite clinical evidence of advanced arthritis. (C) Lateral hallux stress dorsiexion view demonstrating a bony block at the end range of dorsiexion and a lack of joint space on
the upper third of the joint. (D) Intraoperative appearance of cartilage with loss of the upper third (arrow), which was predicted from the lateral hallux stress dorsiexion ndings.
Fig. 6. Patient 4 demonstrates frozen sesamoids. In this case, the utility of the lateral hallux stress dorsiexion view for examining excursion of the sesamoid apparatus is shown because
this view is a functional weightbearing examination. Note the lack of movement of the sesamoids (solid arrows) between the (A) lateral and (B) lateral hallux stress dorsiexion radiographs. This depiction of frozen sesamoids should increase the surgeons concern for arthritis of the sesamoid apparatus. This could warrant preoperative and intraoperative
consideration regarding cheilectomy versus fusion. (C) Intraoperative appearance of degenerative joint disease at the sesamoid articulation (dotted arrow) with the metatarsal in this
patient led to the intraoperative decision for planned rst metatarsophalangeal joint fusion.
T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18
Fig. 7. Intraoperative utility of the lateral hallux stress dorsiexion view. A 58-year-old male with stage II hallux limitus/rigidus with dorsal bump pain and pain at the end range of dorsiexion. (A)
Intraoperative relaxed position lateral view demonstrating joint space narrowing and periarticular bone spurs. (B) Intraoperative lateral hallux stress dorsiexion (LAT SD) view demonstrating the
lack of joint space on the dorsal third of the joint. Intraoperative appearance conrmed lack of intact cartilage on the dorsal third of the joint and the patient underwent a cheilectomy. When
performing a cheilectomy, multiple variables are considered including the extent of remaining healthy cartilage, prevention of future dorsal impingement and maintaining enough bone for possible
future arthrodesis procedures. The LAT SD view was useful to evaluate the mechanics of the joint after cheilectomy to conrm that an appropriate amount of dorsal metatarsal bone had been
removed. Intraoperative imaging of the (C) preoperative LAT SD and (D) postoperative LAT SD views can be printed and given to the patient to demonstrate the effectiveness of the procedure.
Table 1
Summary of clinical utility of lateral hallux stress dorsiexion view in hallux limitus/rigidus
Observation on LAT SD view
Refer to
gures cited
None
Figs. 2 to 4
Figs. 5 to 8
None
Fig. 6
None
Fig. 7
Abbreviations: HL, hallux limitus; HR, hallux rigidus; LAT SD, lateral hallux stress dorsiexion; MPJ, metatarsophalangeal joint; ROM, range of motion.
Figs. 2, 3, and 6
Fig. 3
T.J. Boffeli, R.C. Collier / The Journal of Foot & Ankle Surgery xxx (2014) 18
Table 2
Value of the lateral stress dorsiexion view for prediction of intraoperative ndings
Findings on Preoperative AP and
Lateral Radiograph
Prediction of Intraoperative
Findings based on radiographs
Intraoperative Findings
Patient
Example
Abbreviations: AP, anteroposterior; DJD, degenerative joint disease; LAT SD, lateral hallux stress dorsiexion; MPJ, metatarsophalangeal joint.
Fig. 8. The lateral hallux stress dorsiexion view can be a tool for patient understanding of hallux limitus/hallux rigidus. Standard weightbearing anteroposterior and lateral radiographs
will demonstrate ndings the physician can use to help stage hallux limitus/rigidus, including irregular joint space narrowing, attening of the metatarsal head, and dorsal spurring. These
ndings might not resonate in the same manner to the patient. However, we have causally observed that showing the patient a functional weightbearing radiograph such as (A) the lateral
stress dorsiexion view demonstrating bone spur impingement, bone on bone arthritis, and restricted dorsiexion improves the patients understanding of the joint condition. (B)
Note how these ndings cannot be visually demonstrated on the standard lateral view.
view with the postoperative LAT SD view can provide a clear representation of the change in motion after surgical intervention.
Regarding preoperative planning, the LAT SD view seems to provide the most utility in evaluating midterm disease. Accurate staging
is important for appropriate preoperative planning, procedure selection, and patient education. Previous investigators have demonstrated
that early degenerative arthritis of the MPJ occurs at the upper third of
the joint (1417). However, standard weightbearing views cannot
accurately assess joint space narrowing in the upper third of the MPJ
when the central third of the cartilage has remained intact, which is
often the case with midterm HL/HR. The LAT SD view provides
additional insight regarding the condition of the cartilage on the
dorsal third of the MPJ, which is important in the patients with
midterm disease. The more tools the surgeon has to obtain preoperative information about the condition of the cartilage in HL/HR, the
better one can predict the intraoperative ndings, which, in turn,
results in improved preoperative planning, procedure selection, patient education and understanding, and shared decision making. A
summary of the value of the LAT SD for prediction of intraoperative
ndings are listed in Table 2.
The present study was limited by the small population size and
retrospective nature of the study. A prospective study is currently
underway with intent to conrm our observations regarding the
various clinical utilities of the LAT SD view for evaluating midterm HL/
HR. To bring awareness of the utility of the LAT SD view, we reported
the present case series to show that the LAT SD view is a simple test
that provides useful clinical information about multiple factors that
inuence procedure selection and patient understanding of HL/HR.
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