Hallux valgus UG lecture


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Hallux valgus UG lecture

  1. 1. D r Dhananjaya sabat MS, DNB, MNAMS Assistant Professor Orthopedics MAMC & STC, New delhi
  2. 2. INTRODUCTIONLateral deviation of the great toe and medial deviation of the first metatarsalProgressive subluxation of the first metatarsophalangeal (MTP) jointStatic deformity due to valgus angulation of the distal articular surface of the first metatarsal or the proximal phalangeal articular surface.
  3. 3. Pathophysiology No single cause Intrinsic conditions: 1. Metatarsus primus varus: congenital / heriditary ( AD), 2. Pes planus, 3. ligamentous laxity, 4. neromuscular Footwear: 15 times increased incidence female sex 4th-6th decade age Rheumatoid arthritis
  4. 4. AnatomyFour groups that encircle the first MTP joint 1) Extensor hallucis longus and brevis 2) Flexor hallucis longus and brevis 3) Abductor 4) AdductorDeforming 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
  5. 5. Anatomy Plantar Plate 2 seasmoids incorporated into tendons of FHB Plantar Plate formed by tendons of Adductor Hallucis, Abductor Hallucis, FHL and Joint Capsule
  6. 6. Fig 8
  7. 7. Clinical PresentationPAIN over the medial eminence (Bunion). Pressure from footwear is the most frequent cause of this discomfort. Bursal inflammation Irritation of the skin Breakdown of the skin may be noted. Bunion consists of: Bony exostosis / prominence of the metatarsal head Overlying subcutaneous bursa Hyperkeratosis of dermis
  8. 8. Pronated Toe Fig 6
  9. 9. Physical Examination Skin : calluses, areas of redness Sites of pain Magnitude 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 general Gait analysis
  10. 10. Radiographic Examination Weightbearing AP & Lateral Axial (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.
  11. 11. Measure Angles Hallux 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
  12. 12.  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)
  13. 13. SEVERITY OF DEFORMITYCLASSIFICATION MILD MODERATE SEVEREHallux valgus angle < 20° 20° to 40° >40°1-2 intermetatarsal angle 11° or less. 12- 15° 16° or moreSubluxation of the < 50% 50% to 75% > 75%lateral sesamoid, asmeasured on an APradiograph
  14. 14. TREATMENT Non-operative vs. Operative All patients should be treated non-operatively first.Despite conservative measures, some patients eventually need surgical intervention.
  15. 15. TreatmentNON-OPERATIVE Footwear Modification Widen toe box  decrease lateral deviation of great toe  decrease inflammation and pain Decrease heel height  prevent forward slide of the foot Arch support  may negate effects of pes planus
  16. 16. Contracture of the Achilles tendon Stretching exercises Lengthening of the Achilles tendonThermoplastic night splints
  17. 17. TreatmentSURGICAL  Indications:  Persistent PAIN not cosmetic complaints  Progression of deformity  Failure 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.
  18. 18. 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 Lateral Procedures  Tighten lax capsule  Capsular release  advancement, plication or resection  adductor longus release or transfer  Abductor must not be detached  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.
  19. 19. TreatmentSURGICAL: Bony Procedures Distal MT: for IM angle 12-150 Mitchell {step cut} Wilson {Oblique} Chevron Proximal MT: for IM angle > 150. Medial opening wedge, lateral closing wedge, cresentic or dome  Phalangeal: Proximal Phalanx Osteotomy-Akin  Combination osteotomies  Arthrodesis of MCP jt / Keller’s excission for arthritis of MTP jt.  Metatarsocunieform procedures: arthrodesis (Lapidus) for hypermobile first ray
  20. 20. Distal MT OsteotomyMitchell Chevron
  21. 21. Proximal CresentericOsteotomy
  22. 22.  Double Osteotomy Technique
  23. 23. Surgical AlgorhythmHVA 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
  24. 24. ComplicationsSURGERY Recurrent deformity 20-30% Hallux Varus Pronation deformity Pain Neurologic Injury Osteonecrosis Physeal injury/arrest Nonunion/malunion