hallux valgus 2008 (pp tshare)

Hallux ValgusHallux Valgus

Hallux valgusHallux valgus

= Lateral deviation of the proximal phalanx on the 1st metatarsal head

Complex deformity of the 1st ray that frequently is accompanied by deformity & symptoms in lesser toes

EtiologyEtiology•Essential extrinsic factor = shoe•Female/male = 2:1 to 15:1

EtiologyEtiology•Intrinsic cause

Heredity: + FH ~63%

Pes planus: pronatn of foot = controversial

Metatarsus primus varus: juvenile form

First metatarsal length: 30% of JHV

Hypermobility of MTC joint: quantitation?

EtiologyEtiology•Intrinsic cause

Miscellaneous factors:

Amputation of 2nd toe

Cystic degeneration of medial capsule MTPJ

Achilles tendon contracture

Joint hyperelasticity = Ehlers-Danlos

AnatomyAnatomy

PathophysiologyPathophysiology

• Valgus deviation of halluxValgus deviation of hallux• Attenuated medial structure Attenuated medial structure • Varus metatarsal head Varus metatarsal head

deviation deviation • Sesamoid subluxation Sesamoid subluxation • Hallux pronation Hallux pronation (HVA >30-35)• Lateral contracture Lateral contracture

PathophysiologyPathophysiology

HistoryHistory   Chief complaint:

pain over medial eminence ~70% keratosis   Associated problems   Age & level of activity   Occupation   Athletic inclinations   Shoe wear   Reasons for surgery

Patient evaluation

Physical examinationPhysical examination   Vascular / neurologic status   ROM of MTP joint   Pronation of hallux   Callosities under lesser MTHs   Hammer / claw toes   MTC joint stability   Assess hind foot

Patient evaluation

Standing dorsoplantar view

Non-standing lateral oblique view

Standing lateral view Axial sesamoid view

Coughlin et al.Angular measurements in the evaluation of hallux valgus deformities.Foot Ankle Int 2002.

IMA (normal <9) [8-9]HVA (normal <15) [15-20]DMAA (normal <10) [10-15]

Hallux valgus angle

Intermetatarsal angle

Distal metatarsal articular

angle

Mild Moderate Severe

Hallux Valgus Angle <20 20-40 >40Intermetatarsal Angle<11 11-16 >16Sesamoid Subluxation <50% 50-75% >75%

Hallux valgus classificationHallux valgus classification

Painful joint ROMPainful joint ROMDeformity of the joint complexDeformity of the joint complexPain or difficulty with footwearPain or difficulty with footwearInhibition of activity or lifestyleInhibition of activity or lifestyle

Indications for surgeryIndications for surgery

Associated foot disordersAssociated foot disorders - Neuritis/nerve entrapment - Overlapping/underlapping 2nd digit - Hammer digits - First metatarsocuneiform joint exostosis - Sesamoiditis - Ulceration - Inflammatory conditions (bursitis, tendinitis)

of 1st metatarsal head

Indications for surgeryIndications for surgery

Extensive peripheral vascular disease Extensive peripheral vascular disease Active infection Active infection Active osteoarthropathy Active osteoarthropathy Septic arthritis Septic arthritis Lack of pain or deformity Lack of pain or deformity Advanced age Advanced age Lack of complianceLack of compliance

ContraindicationsContraindications

MI MI within the previouswithin the previous 6 6 months months Comorbid conditions that place the patieComorbid conditions that place the patie

nt at significant nt at significant CVCV or respiratory risk or respiratory risk

ContraindicationsContraindications

Shoes with wide toe boxShoes with wide toe box

OrthoticsOrthoticsmedial arch supporthallux valgus splint

Achilles tendon stretchingAchilles tendon stretching

Non-operative treatmentNon-operative treatment

 Relieve pain

Correct deformity

Preserve MTP joint motion

Surgical GoalsSurgical Goals

   1. Valgus deviation of the great toe

   2. Varus deviation of the 1st metatarsal

   3. Pronation of hallux and/or 1st metatarsal

   4. Hallux valgus interphalangeus

   5. Arthritis and limitation of motion of the

1st metatarsophalangeal joint

   6. Length of the 1st metatarsal relative to

lesser metatarsals

Preoperative evaluationPreoperative evaluation

   7. Excessive mobility or obliquity of the 1st

metatarsomedial cuneiform joint

   8. The medial eminence (bunion)

   9. The location of the sesamoid apparatus

   10. Intrinsic and extrinsic muscle-tendon

balance and synchrony

Preoperative evaluationPreoperative evaluation

Hallux Valgus <25Hallux Valgus <25Congruent Joint    Chevron osteotomy   Mitchell osteotomyIncongruent Joint    Distal soft-tissue realignment (subluxation)   Chevron osteotomy   Mitchell osteotomy

Modified from Mann RA: Decision making in bunion surgery, ICL 1990.

Treatment of Hallux ValgusTreatment of Hallux Valgus

Hallux Valgus 25Hallux Valgus 25-40-40Congruent Joint    Chevron osteotomy + Akin procedure   Mitchell osteotomyIncongruent Joint    Distal soft-tissue realignment + proximal osteotomy   Mitchell osteotomy

Modified from Mann RA: Decision making in bunion surgery, ICL 1990.

Treatment of Hallux ValgusTreatment of Hallux Valgus

Severe Hallux Valgus >40Severe Hallux Valgus >40Congruent Joint    Double osteotomy   Akin + chevron osteotomy   Akin + 1st metatarsal osteotomy   Akin + 1st cuneiform opening wedge osteotomy

Modified from Mann RA: Decision making in bunion surgery, ICL 1990.

Treatment of Hallux ValgusTreatment of Hallux Valgus

Severe Hallux Valgus >40Severe Hallux Valgus >40Incongruent Joint    Distal soft-tissue realignment + proximal osteotomy   First metatarsal crescentic osteotomy   First cuneiform opening wedge osteotomy

Modified from Mann RA: Decision making in bunion surgery, ICL 1990.

Treatment of Hallux ValgusTreatment of Hallux Valgus

Hypermobile 1Hypermobile 1stst MTC Joint MTC Joint    Distal soft-tissue realignment + fusion 1st metatarsocuneiform joint

Degenerative joint diseaseDegenerative joint disease   Fusion or Keller procedure or prosthesis

Modified from Mann RA: Decision making in bunion surgery, ICL 1990.

Treatment of Hallux ValgusTreatment of Hallux Valgus

DSTPDSTPModified McBride bunionectomy

DuVries & Mann

Metatarsal OsteotomyMetatarsal OsteotomyMitchell osteotomy

Metatarsal OsteotomyMetatarsal OsteotomyModified Chevron osteotomy

Metatarsal OsteotomyMetatarsal OsteotomyJohnson modified Chevron osteotomy

Proximal Metatarsal OsteotomyProximal Metatarsal Osteotomy

Scarf osteotomy

Scarf osteotomyScarf osteotomy

• Z-shaped osteotomy in the transverse plane • Lateral rotation of the distal fragment

Proximal Metatarsal OsteotomyProximal Metatarsal Osteotomy

Ludloff osteotomy

Distal osteotomyDistal osteotomyWilson: oblique cut

Mitchell: double cut, step

Chevron: V shape cut

Diaphyseal osteotomyDiaphyseal osteotomyScarf osteotomy: Z shape, step cut, translation

Ludloff: Rotation

Basal osteotomyBasal osteotomyOpen wedge, close wedge, crescentic

Basal chevron

AVN of 1AVN of 1stst MT head ! MT head !

Avoid shorteningAvoid shorteningMore stable then basalMore stable then basal

Extensive exposureExtensive exposure

High corrective powerHigh corrective power

Mild degreeMild degree

Unstable Unstable

Proximal Phalangeal OsteotomyProximal Phalangeal OsteotomyAkin procedure

Medial Cuneiform OsteotomyMedial Cuneiform OsteotomyRiedl & Coughlin

Resection arthroplastyResection arthroplastyKeller’s procedureKeller’s procedure

Simple resect 1/3 of proximal phalanxDecompress joint and relax tight

lateral structureAllow correction deformity

High recurrence rateLittle improve IMAMetatarsalgiaDifficult salvage of failure procedure

ArthrodesisArthrodesisIndications for fusion in HVArthritis associated with hallux valgusNeuromuscular disease/spasticityInflammatory arthritisSevere deformity with osteoporosisSalvage after failed bunion surgery or failed

arthroplastySalvage after infection (staged

reconstruction)

Post-operative managementPost-operative management

Immobilization ~2 weeks Weight bearing as tolerated or NWB

Post-operative managementPost-operative management

HV night splint to be worn for 6-8 wks after dressing changes are completed