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Hallux valgus

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  • 1. *Hallux valgus By Dr upender satelli Pg ms(ortho) Gandhi medical college
  • 2. *introduction *Hueter defined the deformity as an abduction contracture in which the great toe is turned away from the mid-line of the body. * The adjective valgus implies a static deformity and should not be used interchangeably with abductus which refers to movement caused by muscle function *Bunion is another term commonly used *It is a poor term because it is ambiguous. *For some it will mean inflammation of the bursa overlying the metatarsophalangeal joint * for others it will refer to the bony medial eminence Lateral deviation of the great toe and medial deviation of the first metatarsal Progressive subluxation of the first metatarsophalangeal (MTP) joint
  • 3. *hereditary *Hypermobile 1st MTC *Metatarsus Primus Varus *Hyperpronated 1st Ray *Medial slanted 1st MTC *Pronation of hind foot *Pes planus *Achillis contracture *Generalised Joint laxity *Neeuromuscular disorders cp ,stroke *Shoe wearing pointed *Etiology
  • 4. pathology The most consistent and important soft tissue pathology is probably attenuation of the medial ligamentocapsular tissue of the first metatarsophalangeal joint (MTPJ)
  • 5. • Weakening of tissues on medial side 1st MTP, erosion of ridge on metatarsal head between sesamoids proximal phalynx ➔ valgus, metatarsal head ➔ varus • groove appears on medial side of articular cartilage from lack of normal pressure ➔ apparent prominence of medial exostosis • excessive pressure of shoes over prominence ➔ medial bursa • medial soft tissue attenuation ➔ metatarsal head move medial and medial sesamoid lie under eroded ridge, lateral sesamoid in1st metatarsal space *pathogenesis
  • 6. • Tendons of EHL, FHL ➔ lateral ➔ adductors • Adductor hallucis, lateral head FHB contribute to valgus • Abductor hallucis, medial head FHB lose abduction moment • Muscle imbalance ➔ dorsiflexion/pronation of 1st toe • Decreased plantar pressure under 1st ray ➔ insufficiency of 1st ray ➔ overload of lesser ray • 2nd toe may claw ➔ eventually 2nd MTP dislocate
  • 7. normal Hallux valgus
  • 8. severity of the acquired hallux valgus is characterized by the following three values: 1.Angle of hallux valgus: the angle observed between the axis of the first metatarsal and base phalanx. (HV) 2.Intermetatarsal angle: the angle measured between the axis of the first and second metatarsals. 3,Lateral displacement of the medial sesamoid in percent *severity
  • 9. * *Asymptomatic *Pain- The primary symptom of hallux valgus is PAIN over the medial eminence. *Pressure from footwear is the most frequent cause of this discomfort. *deformity *Tenderness *Aesthetic *Look for presence of: *neurologic disorder *ligamentous laxity Sources of Pain in Hallux Valgus • Medial Eminence • 2nd Toe • Metatarsosesamoid Articulation • Dorsomedial Cutaneous Nerve • Transfer Metatarsalgia
  • 10. PHYSICAL EXAM *Skin *calluses, areas of redness *Sites of pain *Motion of 1st MTP joint-increased or decreased *Mobility and structure of foot in general *Gait analysis *The patient sitting and standing * accentuated with weightbearing *Pes planus deformity *Contracture of the Achilles tendon *Magnitude of the Hallux Valgus deformity *Pronation of the great toe
  • 11. *Passive and active range of motion of the MTP joint is measured *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 of more than 9 mm represents hypermobility
  • 12. Radiographic Examination Weightbearing AP/Lateral non weightbearing oblique view and axial views (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.
  • 13. *Radiologically 15 9 10 • intermetatarsal angle > 10° -Intersection of 1st and 2ndMT normally < 9 degrees increased with metatarsus primus varus distal metatarsal articular angle > 9°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. hallux valgus angle > 15°- Intersection of longitudinal axis of 1st MT and proximal phalanx.
  • 14. * *Hallux valgus angle of less than 20° *First-second intermetatarsal angle of 11° or less. *Subluxation of the lateral sesamoid, as measured on an AP radiograph, is less than 50%.
  • 15. * *Hallux valgus angle of 20° to 40° *First-second intermetatarsal angle of less than 16° . *50% to 75% Subluxation of the lateral Sesamoid.
  • 16. * *Hallux Valgus angle of more than 40° *First-second intermetatarsal angle of 16° or more *More than 75% subluxation of the lateral sesamoid.
  • 17. *Treatment *Non-operative vs. Operative *All patients should be treated non- operatively first. *Important to decide who wants the treatment--parents or the patient. *Pain more important than cosmesis.
  • 18. Nonoperative *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 Contracture of the Achilles tendon *Stretching exercises *Lengthening of the Achilles tendon
  • 19. Surgical treatment *Indications: *Persistent symptoms 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
  • 20. • Valgus deviation of the great toe (hallux valgus) • Varus deviation of the first metatarsal • Pronation of the hallux, first metatarsal, or both • Hallux valgus interphalangeus • Arthritis and limitation of motion of the first metatarsophalangeal joint • Length of the first metatarsal relative to lesser metatarsals • Excessive mobility or obliquity of the first metatarsomedial cuneiform joint • The medial eminence (bunion) • The location of the sesamoid apparatus • Intrinsic and extrinsic muscle-tendon balance and synchrony Any procedure chosen must take into account the following structural components
  • 21. Congruent joint Chevron osteotomy Mitchel osteotomy Incongruent joint Distal soft-tissue realignment (subluxation) Chevron osteotomy Mitchell osteotomy *Hallux valgus < 25 Hallux valgus > 25-40 Congruent joint Incongruent joint  Chevron osteotomy with Akinprocedure  Mitchell osteotomy Distal soft-tissue realignment with proximal osteotomy Mitchell osteotomy
  • 22. Congruent joint *Double osteotomy *Akin and chevron osteotomy *Akin and first metatarsal osteotomy *Akin and first cuneiform opening wedge osteotomy Incongruent joint *Distal soft-tissue realignment with proximal osteotomy *First metatarsal crescentic osteotomy *First cuneiform opening wedge osteotomy *Severe hallux valgus >40
  • 23. *Distal soft tissue procedures
  • 24. Distal soft tissue reconstruction Silver popularized it by performing medial capsulorrhaphy, a medial exostectomy, and a lateral capsular and adductor release. McBride, who advocated removal of the lateral sesamoid and transfer of the adductor tendon to the lateral aspect of the first metatarsal head.
  • 25. Distal soft tissue reconstruction Medial and lateral procedures *If done in the presence of a congruent joint can create a non-congruous articulation. *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.
  • 26. 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
  • 27. *Medial side procedure recommended *Be aware of cutaneous branch of medial plantar nerve.
  • 28. *Lateral procedure *Can be more difficult than medial procedure *Neurovascular risk
  • 29. * *modified procedure includes * release of adductor hallucis, transverse metatarsal ligament, and lateral capsule combined w/ excision of medial eminence and plication of the capsule medially; - *this procedure was modified to retain the lateral sesamoid, which helps to prevent hallux varus (which as common w/ original Mcbride bunionectomy); - * as this procedure attempts to re-align the MTP joint, it is best performed on an incongruent joint;
  • 30. Indications: - incongruent joint; - MP joint deformity of < 30 deg and IMA deformity < 15 deg; - if the IMA is < 15 deg, then a proximal metatarsal osteotomy will be required; - if intermetatarsal angle is > 15 deg, then basilar osteotomy is performed prior to soft tissue procedure; - Contraindications: - include vascular impairment or advanced MTP degenerative joint disease; - should not be performed w/ a congruent joint; - because the majority of the extrameduallary blood supply to the metatarsal head is derived from vessels entering the lateral periosteum and joint capsule, is contra-indicated w/ concomitant distal osteotomy procedures such as Chevron and the Mitchell;
  • 31. combines soft tissue release and removal of the medial eminence with resection of the proximal end of the proximal phalanx; - Indications: - advanced hallux valgus or hallux rigidus deformity w/ significant arthrosis, a - for housebound ambulator - for recalcitrant non healing ulcers of the IP joint of great toe, by decompressing the toe and allowing more extension at the MP joint; - Contra-indications: - this procedure results in loss of stability of the 1st MT joint (and loss of the Windlass mech) and therefore should not be performed in young active individuals; - contraindicated in patients with short first metatarsals or metatarsalgia, in patients with an excessively long 2nd metatarsal; *Keller procedure
  • 32. thru medial approach skin, subQ tissue, and joint capsule are opened; - capsular tissue is then stripped from - medial eminence is excised in line w/ medial aspect of metatarsal shaft; - proximal 1/3 of the proximal phalanx is excised; - it is essential that the FHB attachment to the distal fragment is preserved - note that resection of >50% of the proximal phalanx is @ "cock up" dorsiflexion deformity, where as resection of < 33% of the proximal phalanx is @ w/ severe loss of motion; - to avoid the "cock up" dorsiflexion deformity, consider suturing the flexor hallucis longus to the sesamoid pad, or by suturing the sesamoid pad to the remaining proximal phalanx; - draw in any redundant structures into the joint w/ a purse string suture; - alignment maintained bmooth 5/64 inch Steinmann pin across the MP joint; - the bony surfaces must be help apart by the Steinman pin; - pin is left in place for 4 weeks; -
  • 33. Bony Procedures *Most will require osteotomy *Combine with DSTP *Types *Phalangeal osteotomy *Distal MT osteotomy *Proximal MT osteotomy *Combination osteotomies *Metatarsocunieform procedures
  • 34. *Phalangeal osteotomy
  • 35. Akin osteotomy Correction of a hallux valgus deformity with a medial eminence resection and medial capsular reefing, combined with a medial closing-wedge phalangeal osteotomy *Used primarily for Hallux Valgus Interphalangeus deformity. *Can combine with 1st MT osteotomies for greater correction in congruent joint.
  • 36. *Distal metatarsal osteotomies *Done for IM angle 12-15 degrees *Numerous types *Mitchell {step cut osteotomy} *Wilson *Chevron
  • 37. *Wilson osteotomy *Oblique osteotomy *Allows the MT head to slide proximally and medially. *Large cancellous area for healing. *May shorten 1st MT, transfer weight to lateral MT heads--metatarsalgia results.
  • 38. A dorsomedialincision a dorsaland plantar skin flap is created, with care being taken to avoid the cutaneous nerves. A distally based flap is then created from the medial joint capsule in order to expose the medial eminence and is removed in line with the medial aspect of the metatarsal shaft. Transverse osteotomy is through the metatarsal neck, just proximal to the level of sesamoids Lateral 3mm of metatarsal cortex is left uncut. The lateral cortex is then cut proximal to the first cut which creates a step off in the distal fragment. The distal fragment is tdisplaced laterally by the width of step off and is placed into a slight degree of plantar *Mitchell osteotomy *Step cut osteotomy
  • 39. * *°accepted widely for the correction of mild * and moderate hallux valgus deformities * Correction is less than the Mitchell. * Reduces risk of dorsal displacement * A midside incision is made over the first MTP joint * An inverted L or lenticular medial capsulotomy * The medial eminence is excised * the V-osteotomy is planned and performed with care taken to ensure thateach cut is made precisely to give stability, which is the essence of the procedure * K wire drilled medial to lateral through the first metatarsal head, * aiming at the head of the fourth metatarsal and inclined 208 plantarly * transposed laterally
  • 40. *Proximal metatarsal osteotomies
  • 41. *Proximal crescentic osteotomy *Dorsal longitudinal incision *moderate to severe HV @ WITH metatarsus primary varus *Unique to this is the use of a crescentic sawblade, direct the convex aspect ofthe blade proximally. *(EHL) tendon and dorsomedial sensory nerve to the hallux must be protected. *The osteotomy is 1 cm distal to the first TMT joint, and the screw used for fixation is started 1 cm distal to the osteotomy - usual complication is dorsiflexion malunion
  • 42. proximalChevron osteotomy *Longitudinal medial midaxial incision. *The medial dorsal and plantarsensory nerves and EHL tendon must be protected. *Approx 2 cm distal to the first TMTjoint, we mark the apex of the osteotomy *limbs of the osteotomy are marked at 60° to one another,extending from the apex proximally. *we pull the proximalfragment medially with a towel clamp while translating the distal fragment laterally . * In addition, an opening wedge effect is created to optimizecorrection of the 1–2 IMA. distal fragment is slightly plantarflexed relative to proximal fragment, leaving a slight gap on the plantar aspect to be bone grafted with bone resected from the medial prominence
  • 43. *Opening wedge osteotomy *longitudinal midaxial medial approach. *The dorsal and plantar sensory nerves andthe EHL tendon must be protected. *Minimal periosteal stripping is required. * oblique osteotomy is performed using perpendicular to the metatarsal. osteotomy, starting 1.5–2.0 cm distal to the medial aspect of the first TMT joint and directing proximally and laterally *Lateral cortex should not disrupted The plate is then secured with two screws distal and two proximal to the osteotomy.
  • 44. *Ludloff osteotomy medial longitudinal midline incision. *dorsal and plantar sensory nerves and the EHL tendon must be protected. * starting at the dorsalaspect of the proximal metatarsal, essentially at the first TMT joint. *The blade must rest on the medial and not dorsal aspect of the metatarsal *. Elevating the saw few degrees so that the blade is directed approx.10° plantarward limits the risk of dorsiflexing distal fragment. *identifying thedesired osteotomy exit point on the plantar cortex prior to starting the osteotomy *Only the dorsal two thirds of the osteotomy are completed with the initial cut. compression screw isthen placed across and perpendicular to the completed *We use a towel clip to pull the proximal fragment medially and rotate the distal fragment about the screw to correct the 1–2 IMA
  • 45. *A second screw is placed from plantar to dorsal, again perpendicular to the osteotomy . *The medial prominences of the distal and proximal fragments are shaved at the proximal and distal aspects of the osteotomy, respectively
  • 46. *Mau osteotomy *proximal oblique orientation is opposite to that of the Ludloff osteotomy, with proximalplantar and distal dorsal exit points *Because of the plane of the osteotomy, have greater initial stability with weight-bearing when compared to the Ludloff. *Sagittal saw is placed parallel to the weight- bearing surface of the foot and the osteotomy is completed from proximal- plantar to distal-dorsal. *Fixation is with two cannulated screws placed from dorsal to plantar, perpendicular to the osteotomy
  • 47. *Scarf osteotomy *Medial longitudinal incision *Diaphyseal z shaped osteotomy *Lateral translation of distal fragment With bonecuts rotation can also done Moderate to severe hallux valgus deformity 2 screws dorsal to plantar 1 lag screw 1 positional Medial eminence is resected Care of dorsal and plantar nerves and EHL tendon Complication unique – troughing impaction of 2 frgaments loss of metatarsal height
  • 48. *Closed wedge osteotomy *dorsal incision, using the interval between the extensor hallucis brevis and longus. * long oblique osteotomy, with a laterally based wedge and a more proximal medial apex The osteotomy *should not violate the medial cortex; instead the medial cortical apex serves as a hinge *the proximal cut first followed by the distal cut * After removing the laterally based wedge of resected bone, the osteotomy is closed *while avoiding dorsiflexion of the distal fragment. *use two 2 screws from medial to lateral perpendicularto the osteotomy
  • 49. *Hallux valgus interphalangeus *valgus at the IP joint of big toe *associated with a congenital anomaly of the distal phalanx *X-ray : wedge-shaped Epiphysis *Management *osteotomy of the proximal phalanx *fusion of the IP joint after growth has finished
  • 50. Hypermobility of the first ray has been considered to be one of the causative factors of hallux valgus. 1,41 An average of 4.2º of motion has been reported to be present in the normal first metatarsocuneiform joint.42 Clinical signs of first ray hypermobility have traditionally included the presence of a dorsal bunion, callus beneath the second metatarsal head and arthritis of the first and second metatarsocuneiform joint. Radiographically cortical hypertrophy along the medial border of the second metatarsal shaft has been thought to be diagnostic of first ray hypermobility. In one recent study hypermobility of the first ray was assessed by increased thickness of the medial cortex at the midshaft of the second metatarsal on x-ray.42
  • 51. Complications - 10-55% Recurrence Hallux Varus AVN Nonunions Malunions
  • 52. Up to 16% Usually can be reduced by choosing appropriate surgery for deformity Patient Factors: Generalized diseases - RA, gout, hypothyroid Hereditary, poor compliance, footwear, Neurologic - DM, NMD, CP, Parkinsons Adolescent, generalized joint laxity, joint contractures, arthritis