Fig. 8.6 Hallux limitus. There is a callus with preulcerative changes on the plantar medial aspect of the great toe.

requires regular debridement and footwear modification. The natural history for hallux interphalangeal joint lesions is for the preulcerative condition to progress to a full-thickness ulcer and eventually to amputation. Correlation between elevated plantar pressure and a lesion beneath the hallux can be demonstrated qualitatively using a Harris footprint mat, or quantified using an electronic gait platform or in-shoe measuring device. Location of the peak plantar pressure corresponds with the location of the callus or ulcer. All too often, the initial treatment for this condition totally ignores the pathomech-anical aetiology and focuses on the wound. Although local wound care and off-loading of the foot may result in healing of the ulcer, this outcome is short lived. The ulcer inevitably recurs and becomes a chronic non-healing wound. The obvious risk, for a diabetic patient, is wound infection, extension of infection to bone and eventual amputation of the hallux.

Surgical treatment for hallux interphalangeal joint ulcers is directed at increasing the dorsiflectory range of motion of the hallux. Some authors advocate hallux interphalangeal joint arthroplasty and report an overall success rate of 91%, with only minor complications. Most authors however, advocate a procedure, to increase dorsiflectory range of motion, at the level of the 1 st metatarsophalangeal joint. Keller arthroplasty is the procedure most often cited for surgical correction of recalcitrant interphalangeal joint ulceration of the hallux in adults. Downs reported successful results of this procedure in a series of patients ranging in age from 30 to 65 years. Postoperatively all ulcers healed promptly with no recurrence at follow-up after 2-5 years. Dannels reported similar results in a series of Native American Indians with diabetes, with an age range of 39-58 years.

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