Hallux ValgusD r Dhananjaya sabat MS, DNB,

MNAMS

Assistant Professor OrthopedicsMAMC & STC, New delhi

INTRODUCTIONLateral deviation of the great toe and

medial deviation of the first metatarsal

Progressive subluxation of the first metatarsophalangeal (MTP) joint

Static deformity due to valgus angulation of the distal articular surface of the first metatarsal or the proximal phalangeal articular surface.

PathophysiologyNo single causeIntrinsic conditions: 1. Metatarsus primus varus:

congenital / heriditary ( AD), 2. Pes planus, 3. ligamentous laxity, 4. neromuscular

Footwear: 15 times increased incidencefemale sex4th-6th decade ageRheumatoid arthritis

AnatomyFour groups that encircle the first

MTP joint 1) Extensor hallucis longus and brevis2) Flexor hallucis longus and brevis3) Abductor4) Adductor

Deforming Musculature1. Abductor Hallucis

-Inserts in the plantar aspect of the proximal phalanx-Can draw the phalanx medial and push metatarsal

head lateral2. Adductor Hallucis

-2 origins-common tendon to plantar aspect of proximal

phalanx and lateral aspect of plantar plate/sesamoid complex

AnatomyPlantar Plate

2 seasmoids incorporated into tendons of FHB

Plantar Plate formed by tendons of Adductor Hallucis, Abductor Hallucis, FHL and Joint Capsule

Fig 8

Clinical PresentationPAIN over the medial eminence (Bunion).

Pressure from footwear is the most frequent cause of this discomfort.

Bursal inflammationIrritation of the skinBreakdown of the skin may be noted.

Bunion consists of:Bony exostosis / prominence of the metatarsal headOverlying subcutaneous bursaHyperkeratosis of dermis

Pronated Toe Fig 6

Physical ExaminationSkin : calluses, areas of rednessSites of painMagnitude of the hallux valgus deformity Pronation of the great toe Motion of 1st MTP joint- increased or decreased, Pain

or crepitus, or both, with motion of the MTP joint Metatarsocuneiform joint for hypermobility

Examiner grasps the first metatarsal with the thumb and index finger and pushes it in a plantar lateral-to-dorsomedial direction; mobility > 9 mm represents hypermobility

Pes planus deformity , Contracture of the Achilles tendon

Mobility and structure of foot in generalGait analysis

Radiographic ExaminationWeightbearing AP & LateralAxial (Sesamoid)Assess for bone and joint deformity

Length and shape of 1st MT

Congruent vs. Incongruent joint

Osteoarthrosis

Forefoot alignment is evaluated for metatarsus

Adductus

Hindfoot is Inspected for Pes Planus or Pes Cavus.

Measure AnglesHallux Valgus angle: Intersection of longitudinal axis of 1st MT and proximal phalanx. Normal < 150

Intermetatarsal angleIntersection of 1st and 2nd MT. Normal < 90 ; increased with metatarsus primus varus

Distal Metatarsal Articular Angle (DMMA)

Defines the relationship of the distal articular surface of the 1st MT to the longitudinal axis. Quantities the magnitude of lateral slope of articular surface.

With subluxation, the articular surface deviates laterally in relationship to the 1st Metatarsal. Usually < 60 .

Proximal Phalangeal Articular Angle (PPAA)

CLASSIFICATION MILD MODERATE SEVERE

Hallux valgus angle < 20° 20° to 40° >40°

1-2 intermetatarsal angle

11° or less.

12- 15° 16° or more

Subluxation of the lateral sesamoid, as measured on an AP radiograph

< 50% 50% to 75%

> 75%

SEVERITY OF

DEFORMITY

TREATMENTNon-operative vs. Operative

All patients should be treated non-operatively first.

Despite conservative measures, some patients eventually need surgical intervention.

TreatmentNON-OPERATIVE

Footwear ModificationWiden toe box

decrease lateral deviation of great toedecrease inflammation and pain

Decrease heel heightprevent forward slide of the foot

Arch supportmay negate effects of pes planus

Contracture of the Achilles tendon Stretching exercises Lengthening of the Achilles tendon Thermoplastic night splints

TreatmentSURGICAL

Indications: Persistent PAIN not cosmetic complaintsProgression of deformityFailure of non-operative treatment

Goals:Correct all pathologic elements and yet

maintain a biomechanically functional forefoot

Usually will not result in a foot with normal appearance

Combine soft tissue procedures with bony procedures in almost all cases.

TreatmentSURGICAL: SOFT TISSUE PROCEDURE

Distal Soft-Tissue ReconstructionMedial and lateral procedures Hallux Valgus angle <30 degrees IMA < 15 degrees High rate of recurrence if done without bony procedure Medial and lateral procedures at the same time

contraindicated.

Medial Procedures Tighten lax capsule advancement, plication or

resection Abductor must not be detached

Lateral Procedures Capsular release adductor longus release or

transfer Division of transverse MT

ligament risk NV bundle

•Medial side procedure recommended•Be aware of cutaneous branch of medial plantar nerve.• Lateral procedure more difficult.•Neurovascular risk.

TreatmentSURGICAL: Bony ProceduresDistal MT: for IM angle 12-150

Mitchell {step cut}Wilson {Oblique}ChevronProximal MT: for IM angle >

150. Medial opening wedge, lateral closing wedge, cresentic or dome

Phalangeal: Proximal Phalanx Osteotomy-AkinCombination osteotomies Arthrodesis of MCP jt / Keller’s excission for arthritis of MTP jt.Metatarsocunieform procedures: arthrodesis (Lapidus) for

hypermobile first ray

Distal MT OsteotomyMitchell Chevron

Proximal Cresenteric Osteotomy

Double Osteotomy Technique

Surgical Algorhythm HVA IMA Procedure

< 40° < 13° to 15° modified McBride or distal chevron osteotomy

< 40 ° > 13° to 15° modified McBride and proximal osteotomy

>40° > 20° modified McBride and proximal osteotomy or arthrodesis

ComplicationsSURGERYRecurrent deformity 20-30%Hallux VarusPronation deformityPainNeurologic InjuryOsteonecrosisPhyseal injury/arrestNonunion/malunion