Arash Aminian MDMarch 17, 2011

All bunions are not created equal

Complex array of osseous & soft tissue pathology

Lateral deviation of the great toe with medial deviation of the 1st metatarsal

>100 procedures for Hallux Valgus Procedure should address deformity Soft tissue procedure combined with bony

correction most common procedure• Chevron Osteotomy with Silver eminence resection

most common procedure

NWB & WB Gait/shoe wear ROM Hyper mobility 1st ray Adductor tautness Neurovascular Footprints

Painful HV failed palliative measures• Wider shoes• Activity modification• NSAIDS

No inflammatory Non paralytic

• 1st MTP Fusion

PVD Arthritis Neuropathic Pure cosmetic Osteopenia

METATARSALGIA HAMMERTOES CLAWTOES DEVIATED TOES NEUROMAS EQUINUS

AP/Lat & Sesamoid Weight-Bearing IMA < 9 degrees DMAA < 9 degrees HVA < 15 degrees Sesamoid station & metatarsal length Congruity

HVAIMADMAA

High Intra, Inter-observer reliability for HVA, IMA (<5 degree, 95% confidence)

• Measure from the center of MT head to center of MT base

Post-operative measures are less reliable• Anatomy distorted

Functional outcomes failed to correlate with radiographic outcomes (Thordason et al FAI 26:2005)

Plantigrade & painless foot Complex array of pathological bone & soft

tissue deformity must be addressed Each procedure has limitations & indications Multiple options should be available

Congruent Joint Mild deformity

• IMA < 15 degrees, HV < 35 degrees No instability of the 1st Ray

Chevron Osteotomy

Small medial eminence resection• Hallux Varus

Release the capsule through the joint• AVN• Main blood supply to the MT head: Plantar-lateral corner of

the MT head Don’t rely on the capsular plication for deformity

correction

Post-op early motion

CHEVRON

Incongruent Joint Moderate deformity

• IMA 15-20 degrees, HV <40 degrees No instability of the 1st Ray

SCARF OsteotomyModified Chevron

Incongruent Joint Severe deformity

• IMA >20 degrees, HV >40 degrees Instability of the 1st Ray

Lapidus1st MTP fusion

Inflammatory Arthritis Paralytic deformity

1st MTP fusion

Resection of the proximal phalanx Older patient Less demand High risk patients (medical co-morbidities)

AVN Stiffness of the joint Hallux Varus Malunion (Dorsiflexion: transfer

metatarsalgia) Non-union (Lapidus 5%)

Blood supply: Branches of the• 1st dorsal metatarsal artery• 1st Plantar metatarsal artery• Medial plantar artery

Plexus Lateral plantar corner

JBJS 2007:2018-2021.

Do not push a procedure beyond its limits Hypermobile 1st ray=Lapidus DMAA ? Loss of fixation ?

Position of medial sesmoid and axis of 1st MT

JBJS 2009: 1637-1645.