Disorders of the hallux


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Disorders of the Great toe (hallux) are very important as they are very painful, causes many clinical symptoms,and very difficult to treat.The presentation compiled from various important orthopedic textbooks and international journals.

Disorders of the hallux

  1. 1. DR. PRUTHVIRAJ NISTANE Deptt. Of Orthopaedics,Unit II Govt. Medical College and Rajindra Hospital, Patiala
  2. 2. <ul><li>A large proportion of clinical complaints of the foot center on the first metatarsophalangeal (MTP) joint. </li></ul><ul><li>This articulation alone bears one-third of the weight of the forefoot and helps stabilize the longitudinal arch </li></ul>
  3. 4. <ul><li>=Lateral deviation of the proximal phalanx on the 1 st metatarsal head </li></ul><ul><li>Complex deformity of the 1 st ray that frequently is accompanied by deformity & symptoms in lesser toes </li></ul><ul><li>metatarsus primus varus </li></ul><ul><li>hallux valgus </li></ul><ul><li>hallux valgus interphalangeus </li></ul>
  4. 6. <ul><li>Etiology </li></ul><ul><li>Female/male = 2:1 to 15:1 </li></ul><ul><ul><li>Heredity: + FH ~63% </li></ul></ul><ul><li>Essential extrinsic factor = shoe </li></ul>
  5. 7. <ul><li>Etiology </li></ul><ul><li>Intrinsic ANOTOMICAL cause </li></ul><ul><ul><li>Pes planus </li></ul></ul><ul><ul><li>Metatarsus primus varus: juvenile form </li></ul></ul><ul><ul><li>First metatarsal length </li></ul></ul><ul><ul><li>Hypermobility of first ray </li></ul></ul><ul><ul><li>Pronated flatfeet </li></ul></ul><ul><ul><li>Abnormal insertion of the posterior tibial tendon </li></ul></ul>
  6. 8. <ul><ul><li>Amputation of 2 nd toe </li></ul></ul><ul><ul><li>Cystic degeneration of medial capsule MTPJ </li></ul></ul><ul><ul><li>Achilles tendon contracture </li></ul></ul><ul><ul><li>Joint hyperelasticity = Ehlers-Danlos </li></ul></ul>
  7. 9. Anatomy
  8. 11. <ul><li>Pathoanatomy </li></ul><ul><li>Most commonly LATERAL DEVIATION OF GREAT TOE is primary deformity </li></ul><ul><li>Valgus angle of the first metatarsophalangeal joint exceeds 30 to 35 degrees </li></ul><ul><li>Increase in angle between first and second metatarsal (metatarsus primus varus ) at MTMC joint </li></ul><ul><li>Pronation of the great toe </li></ul><ul><li>Subluxation/dislocation of the first metatarsophalangeal joint </li></ul><ul><li>Excessive valgus tilt of the articular surface of the first metatarsal head and proximal phalangeal articular surface </li></ul>
  9. 12. Pathoanatomy
  10. 13. Pathogenesis <ul><li>the abductor hallucis moves plantar ward </li></ul><ul><li>Only restraining medial structure is the medial capsular ligament </li></ul><ul><li>Dorsiflexion of MTP joint </li></ul><ul><li>The adductor hallucis, which is unopposed by the abductor hallucis, pulls the great toe further into valgus </li></ul><ul><li>The flexor hallucis brevis, flexor hallucis longus and extensor hallucis increases the valgus moment, further deforming the first ray. </li></ul><ul><li>the metatarsal head to drift medially from the sesamoids. </li></ul>
  11. 14. Pathophysiology <ul><li>Valgus deviation </li></ul><ul><li>of hallux </li></ul><ul><li>Attenuated </li></ul><ul><li>medial structure </li></ul><ul><li>Varus metatarsal </li></ul><ul><li>head deviation </li></ul><ul><li>Sesamoid </li></ul><ul><li>subluxation </li></ul><ul><li>Hallux pronation </li></ul><ul><li>Lateral contracture </li></ul>
  12. 15. <ul><li>the sesamoid ridge on the plantar surface of the first metatarsal head (the crista) flattens </li></ul><ul><li>With this restraint lost, the fibular sesamoid displaces partially or completely into the first space </li></ul><ul><li>Fibular sesamoid, when pulled proximally by the lateral head of the flexor hallucis brevis, pulls the flexor hallucis longus laterally through the sesamoid apparatus and contributes to recurrent hallux </li></ul><ul><li>valgus.(so, when the deformity is </li></ul><ul><li>severe-excision of the fibular </li></ul><ul><li>sesamoid is added to the </li></ul><ul><li>procedure) </li></ul><ul><li>patient is bearing less weight </li></ul><ul><li>on the first ray and more on the </li></ul><ul><li>lesser metatarsal heads causing </li></ul><ul><li>transfer metatarsalgia, callosities, and stress fractures </li></ul>
  13. 16. first variant , the articular surface of the metatarsal head is offset, resembling a scoop of ice cream sitting at an angle on a cone This has been described as the distal metatarsal articular angle Second variant the articular angle of the base of the proximal phalanx in relation to its longitudinal axis is offset. This has been described as the phalangeal articular angle
  14. 17. Consequences <ul><li>a hammer toe–like deformity of the second toe </li></ul><ul><li>the splaying of the forefoot </li></ul><ul><li>corns often develop </li></ul><ul><li>bursal hypertrophy over the medial eminence of the first metatarsal head (bunion) </li></ul><ul><li>Osteoarthritis </li></ul><ul><li>Callosity </li></ul><ul><li>metatarsalgia. </li></ul><ul><li>The entire forefoot must be evaluated for these multiple components of hallux valgus </li></ul>
  15. 20. <ul><li>History </li></ul><ul><li>Chief complaint: </li></ul><ul><li>Pain  over medial eminence ~70%, at the metatarsophalangeal joint or beneath the lesser metatarsal heads </li></ul><ul><li>Keratosis </li></ul><ul><li>   Associated problems </li></ul><ul><li>   Age & level of activity </li></ul><ul><li>   Occupation </li></ul><ul><li>   Athletic inclinations </li></ul><ul><li>   Shoe wear </li></ul><ul><li>   Reasons for surgery </li></ul>Patient evaluation
  16. 21. <ul><li>Physical examination    </li></ul><ul><li>Vascular / neurologic status </li></ul><ul><li>   ROM of MTP joint </li></ul><ul><li>   Pronation of hallux </li></ul><ul><li>   Callosities under lesser MTHs </li></ul><ul><li>   Hammer / claw toes </li></ul><ul><li>   MTC joint stability </li></ul><ul><li>   Assess hind foot </li></ul>Patient evaluation
  17. 22. X-ray <ul><li>Standard preoperative radiographs should include </li></ul><ul><li>Standing dorsoplantar views </li></ul><ul><li>Standing Lateral views </li></ul><ul><li>Nonstanding lateral oblique view </li></ul><ul><li>Axial sesamoid views </li></ul>
  18. 23. Standing dorsoplantar view Non-standing lateral oblique view Standing lateral view Axial sesamoid view
  19. 24. <ul><li>Evaluation of x-rays </li></ul><ul><li>IMA (normal 8-9  ) </li></ul><ul><li>HVA (normal 15-20  ) </li></ul><ul><li>DMAA (normal 10-15  ) </li></ul><ul><li>PAA (normal 7-10  ) </li></ul><ul><li>OA changes </li></ul><ul><li>Position of sesamoids </li></ul><ul><li>Incongruent or subluxated joint </li></ul>Hallux valgus angle Intermetatarsal angle Distal metatarsal articular angle
  20. 26. <ul><ul><ul><ul><ul><li> Mild Moderate Severe </li></ul></ul></ul></ul></ul><ul><li>Hallux Valgus Angle <20  20  -40  >40  </li></ul><ul><li>Intermetatarsal Angle <11  11  -16  >16  </li></ul><ul><li>Sesamoid Subluxation <50% 50-75% >75% </li></ul>Hallux valgus classification
  21. 28. <ul><li>Give initial trial </li></ul><ul><li>Shoes with wide toe box </li></ul><ul><li>Orthotics </li></ul><ul><ul><li>medial arch support </li></ul></ul><ul><ul><li>hallux valgus splint </li></ul></ul><ul><li>Achilles tendon stretching </li></ul><ul><li>Exercises </li></ul><ul><li>Activity adjustments </li></ul>Non-operative treatment
  22. 30. <ul><li>Painful joint ROM </li></ul><ul><li>Deformity of the joint complex </li></ul><ul><li>Pain or difficulty with footwear </li></ul><ul><li>Inhibition of activity or lifestyle </li></ul><ul><li>for cosmetic reasons alone is seldom indicated except in an adolescent with a significant progressive deformity. Even the mildest symptoms in an adolescent often worsen </li></ul>Indications for surgery
  23. 31. Associated foot disorders - Neuritis / nerve entrapment - Overlapping / underlapping 2 nd digit - Hammer digits - First metatarsocuneiform joint exostosis - Sesamoiditis - Ulceration - Inflammatory conditions ( bursitis , tendinitis ) of 1 st metatarsal head Indications for surgery
  24. 32. <ul><li>Extensive peripheral vascular disease </li></ul><ul><li>Active infection </li></ul><ul><li>Active osteoarthropathy </li></ul><ul><li>Septic arthritis </li></ul><ul><li>Lack of pain or deformity </li></ul><ul><li>Advanced age </li></ul><ul><li>Lack of compliance </li></ul><ul><li>Co-morbidities </li></ul>Contraindications
  25. 33. <ul><li>  Relieve pain </li></ul><ul><li>Correct deformity </li></ul><ul><li>Preserve MTP joint motion </li></ul>Surgical Goals
  26. 34. <ul><li>more than 130 operations recommended for the treatment of hallux valgus, </li></ul><ul><li>most procedures to correct hallux valgus still use one or more of the components described: </li></ul><ul><li>Removal of the exostosis </li></ul><ul><li>dissection of the bursa </li></ul><ul><li>tenotomy and transplantation of the tendons, </li></ul><ul><li>removal of the sesamoids </li></ul><ul><li>partial and complete removal of the head of the first metatarsal </li></ul><ul><li>removal of the proximal end of the proximal phalanx </li></ul><ul><li>together with numerous combinations </li></ul>
  27. 35.     1. Valgus deviation of the great toe    2. Varus deviation of the 1 st metatarsal    3. Pronation of hallux and/or 1 st metatarsal    4. Hallux valgus interphalangeus    5. Arthritis and limitation of motion of the 1 st metatarsophalangeal joint    6. Length of the 1 st metatarsal relative to lesser metatarsals Preoperative evaluation
  28. 36.    7. Excessive mobility or obliquity of the 1 st 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 evaluation
  29. 38. Indications <ul><li>Stress view radiographs - a firm forefoot wrap reduces the intermetatarsal angle to a normal value and decreases the hallux valgus angle </li></ul><ul><li>Middle aged </li></ul><ul><li>Mild to moderate </li></ul><ul><li>a valgus angle at the metatarsophalangeal joint of 15 to 25 degrees </li></ul><ul><li>an intermetatarsal angle of less than 13 degrees, </li></ul><ul><li>valgus of the interphalangeal joint of less than 15 degrees </li></ul><ul><li>no degenerative changes at the metatarsophalangeal joint </li></ul><ul><li>a history of conservative management failure </li></ul>
  30. 39. Modified McBride Bunionectomy <ul><li>L-SHAPED MEDIAL CAPSULAR INCISION </li></ul><ul><li>MEDIAL EMINENCE REMOVAL </li></ul><ul><li>ADDUCTOR TENDON AND LATERAL CAPSULAR RELEASE and reattach to 1 st MT head between heads of 1 st and 2 nd MT </li></ul><ul><li>MEDIAL CAPSULAR IMBRICATION </li></ul>
  31. 40. <ul><li>FIBULAR (LATERAL) SESAMOIDECTOMY - the adductor hallucis and lateral head of the flexor hallucis brevis are released reducing the valgus. </li></ul><ul><li>In addition, the pull of the fibular sesamoid on the flexor hallucis longus through its tendon sheath and pulley system is prevented, reducing another important valgus-producing force on the hallux at the metatarsophalangeal joint </li></ul><ul><li>CLOSURE OF THE INVERTED-L CAPSULOTOMY </li></ul>
  32. 41. <ul><li>Modified McBride bunionectomy </li></ul>DuVries & Mann
  33. 43. <ul><li>Distal Soft tissue handling includes  </li></ul><ul><li>Medial eminence removal </li></ul><ul><li>Adductor tendon and lateral capsular release </li></ul><ul><li>Medial capsular imbrication </li></ul><ul><li>Reduction of MTP joint and sesamoids </li></ul><ul><li>The decision to perform an osteotomy should be made at the time of surgery by passively reducing the intermetatarsal angle. If the first metatarsal does not move laterally, or if it springs back quickly into varus after the laterally directed pressure is released then an osteotomy should be done </li></ul>
  34. 44. A) KELLER RESECTION ARTHROPLASTY <ul><li>INDICATIONS </li></ul><ul><li>moderate-to-severe hallux valgus (30 to 45 degrees) </li></ul><ul><li>mild-to-moderate metatarsus primus varus(intermetatarsal angles of 13 degrees or less) </li></ul><ul><li>pain over the medial eminence </li></ul><ul><li>An incongruous first metatarsophalangeal joint caused by lateral subluxation of the phalanx on the metatarsal head </li></ul><ul><li>severe lateral displacement of the sesamoids, </li></ul><ul><li>Any evidence of degenerative cartilage changes </li></ul>
  35. 45. <ul><li>Resection hemiarthroplasty of the first metatarsophalangeal joint- resect 1/3 of proximal phalanx- mobilizes the hallux, allowing marked correction of valgus </li></ul><ul><li>removal of the medial eminence of the first metatarsal </li></ul><ul><li>fibular sesamoidectomy </li></ul><ul><li>Adductor tenotomy </li></ul><ul><li>lateral displacement of the first metatarsal </li></ul><ul><li>complete lateral dislocation of the sesamoids, marked degenerative changes, and severe pronation of the hallux may benefit </li></ul><ul><li>Complications are more </li></ul>
  36. 46. Resection arthroplasty
  37. 47. B) DISTAL METATARSAL OSTEOTOMY <ul><li>Some studies suggest that VARUS OF THE FIRST METATARSAL WAS THE PRIME OR INITIAL DEFORMITY , and that valgus deviation of the hallux only followed it </li></ul>
  38. 49. Mitchell osteotomy <ul><li>consists of </li></ul><ul><li>(1) Removal of the medial eminence </li></ul><ul><li>(2) An osteotomy of the distal portion of the first metatarsal shaft - DOUBLE OSTEOTOMY OF THE METATARSAL NECK </li></ul><ul><li>(3) Lateral displacement ,planter flexion and angulation of the capital fragment </li></ul><ul><li>(4) Removal of the resulting projection of the first metatarsal </li></ul><ul><li>(5) Medial capsulorrhaphy </li></ul><ul><li>(6) No interanal fixation </li></ul>
  39. 50. <ul><li>Mitchell osteotomy </li></ul>
  40. 51. CHEVRON INTRACAPSULAR OSTEOTOMY <ul><li>Indications </li></ul><ul><li>younger patients (adolescence through the 30s) </li></ul><ul><li>hallux valgus angle of 30 degrees or less </li></ul><ul><li>an intermetatarsal angle of less than 13 degrees . </li></ul><ul><li>ADVANTAGES </li></ul><ul><li>made through cancellous bone </li></ul><ul><li>shortens the metatarsal less </li></ul><ul><li>inherently stable </li></ul><ul><li>Fixation of the osteotomy with one or two Kirschner wires, a cortical screw, or a biodegradable pin adds stability to the osteotomy </li></ul>
  41. 52. <ul><li>Consists of </li></ul><ul><li>(1) medial eminence removal </li></ul><ul><li>(2) a V-shaped intracapsular through the first metatarsal head in trasverse plane </li></ul><ul><li>(3) lateral displacement of the capital fragment </li></ul><ul><li>(4) removal of the resulting projection of the first metatarsal </li></ul><ul><li>(5) medial capsulorrhaphy </li></ul>
  42. 53. <ul><li>Modified Chevron Osteotomy </li></ul><ul><li>simply a more proximal placement of the apex of the osteotomy in the metatarsal head. </li></ul><ul><li>can be used for more severe deformities (up to 35 degrees of hallux valgus and up to 15 degrees of first to second intermetatarsal diversion) </li></ul><ul><li>Johnson Modified Chevron Osteotomy </li></ul><ul><li>changing the length and position of the limbs of the osteotomy in the metatarsal head - short dorsal arm and long plantar arm </li></ul><ul><li>extended the indications for the osteotomy to severe deformities with intermetatarsal angles of 15 or 16 degrees </li></ul><ul><li>a 2.7-mm screw is used for internal fixation </li></ul>
  43. 54. <ul><li>Modified Chevron osteotomy </li></ul>
  44. 55. Metatarsal Osteotomy <ul><li>Johnson modified Chevron osteotomy </li></ul>
  45. 56. C) PROXIMAL FIRST METATARSAL OSTEOTOMY <ul><li>varus of the first metatarsal, whether primary or secondary, contributes to the hallux valgus complex </li></ul><ul><li>correction near the origin of the deformity is reasonable, combined with a soft-tissue procedure at the first metatarsophalangeal joint to correct the valgus of the hallux </li></ul><ul><li>a few degrees' shift of the metatarsal at its base causes marked improvement at the distal end of the metatarsal </li></ul>
  46. 57. Advantages <ul><li>Cancellous bone and broad contact surfaces </li></ul><ul><li>Small changes in position at the osteotomy produce excellent correction at the distal end of the metatarsal where the symptoms are located </li></ul><ul><li>The metatarsal is shortened minimally </li></ul><ul><li>Large angles between the first and second metatarsals can be corrected </li></ul><ul><li>Slightly tilting the distal fragment plantarward reduces load bearing by the second metatarsal, decreasing the chance of transfer metatarsalgia. </li></ul>
  47. 58. Disadvantages <ul><li>  1.    Extensive soft-tissue dissection is required </li></ul><ul><li>   2.    The distal fragment tends to displace dorsally or medially </li></ul><ul><li>3.    The second ray may be overloaded if the fragment displaces or migrates </li></ul><ul><li>   4.    Three incisions are required </li></ul><ul><li>   5.    more difficult </li></ul><ul><li>   6.    more pain, swelling, and immobility </li></ul><ul><li>   7.    Cast immobilization is more frequently needed </li></ul>
  48. 59. Indications <ul><li>A patient without significant degenerative arthritis in the first metatarsophalangeal joint </li></ul><ul><li>hallux valgus of more than 35 degrees </li></ul><ul><li>an intermetatarsal angle of more than 10 degrees </li></ul><ul><li>Severe deformities </li></ul>
  49. 60. Types
  50. 61. Types <ul><li>A) Proximal crescentic osteotomy </li></ul><ul><li>B) Proximal chevron osteotomy- -increased stability at the osteotomy site </li></ul><ul><li>C) Ludloff osteotomy .-- oblique osteotomy of the first metatarsal oriented from dorsoproximal to distal plantar. </li></ul><ul><li>If fixed with lag screw compression is more rigid </li></ul><ul><li>less elevation and shortening </li></ul><ul><li>mechanical stability that allows early ambulation </li></ul><ul><li>simplicity (involving only a single cut in the bone) </li></ul><ul><li>angular correction through bony rotation </li></ul><ul><li>plantar flexion of the first metatarsal </li></ul>
  51. 62. <ul><li>Ludloff osteotomy </li></ul>
  52. 63. <ul><li>D. Scarf osteotomy- -horizontally directed displacement Z- osteotomy made at the diaphyseal level </li></ul><ul><li>“ scarf” refers to a joint made by notching, grooving, or otherwise cutting the ends of two pieces and fastening them together </li></ul><ul><li>versatility: </li></ul><ul><li>lateral displacement of the plantar bone fragment to reduce the intermetatarsal angle </li></ul><ul><li>medial displacement of the capital fragment to correct hallux varus </li></ul><ul><li>plantar displacement to increase the load of the first ray </li></ul><ul><li>elongation or shortening of the first metatarsal. </li></ul><ul><li>The stability of the osteotomy allows early weight bearing </li></ul>
  53. 64. <ul><li>Scarf osteotomy </li></ul>
  54. 65. Identify ???
  55. 66. D) MEDIAL CUNEIFORM OSTEOTOMY <ul><li>Indications </li></ul><ul><li>in adolescents with open proximal metatarsal physes </li></ul><ul><li>especially patients with an abnormally wide intermetatarsal angle </li></ul>
  56. 67. Medial Cuneiform Osteotomy <ul><li>Riedl & Coughlin </li></ul>
  57. 68. E) PROXIMAL PHALANGEAL OSTEOTOMY (AKIN’S) <ul><li>a medially based closing wedge osteotomy at the base of the proximal phalanx, combined with medial eminence removal </li></ul><ul><li>mostly as an adjunctive procedure to the primary bunion repair </li></ul><ul><li>alone rarely is indicated </li></ul><ul><li>limited value if the sesamoid apparatus is subluxed </li></ul><ul><li>does not correct the principal deforming forces of the adductor hallucis and the varus of the first metatarsal, so, is indicated primarily in combination with other procedures , but after which slight residual valgus deformity remains </li></ul>
  58. 69. Indications <ul><li>  1.    Patient older than 55 years </li></ul><ul><li>   2.    Excessive hallux valgus interphalangeus (in patient of any age) </li></ul><ul><li>   3.    Hallux valgus of no more than 25 degrees </li></ul><ul><li>   4.    Intermetatarsal angle of less than 13 degrees </li></ul><ul><li>   5.    Good metatarsophalangeal joint motion </li></ul>
  59. 70. Contraindications <ul><li>1.    Rheumatoid arthritis </li></ul><ul><li>   2.   osteoarthritis at the metatarsophalangeal joint </li></ul><ul><li>   3.    Intermetatarsal angle more than 13 degrees </li></ul><ul><li>   4.    Hallux valgus angle more than 30 degrees </li></ul><ul><li>   5.    Subluxation laterally of the tibial sesamoid more than 50% of its width </li></ul><ul><li>   6.    Open physis of the proximal phalanx (can be performed at neck instead of base) </li></ul>
  60. 71. Proximal Phalangeal Osteotomy <ul><li>Akin procedure </li></ul>
  61. 72. Chevron-Akin Double Osteotomy <ul><li>combination of the chevron and Akin osteotomies to gain greater correction of mild-to-moderate hallux valgus deformities . </li></ul>
  62. 73. F) ARTHRODESIS OF THE FIRST METATARSOPHALANGEAL JOINT <ul><li>Various fixation methods have been described. </li></ul><ul><li>one-quarter tubular plate with one oblique interfragmentary screw </li></ul><ul><li>one-third tubular plate </li></ul><ul><li>two ⅛-inch Steinmann pins placed through the hallux into the first metatarsal </li></ul>
  63. 74. Indication <ul><li>1.    Severe deformity (an intermetatarsal angle >20 to 22 degrees, a hallux valgus angle >45 degrees, and severe pronation of the hallux) </li></ul><ul><li>   2.   with Degenerative arthritis / rheumatoid arthritis </li></ul><ul><li>   3.    motion of the metatarsophalangeal joint is limited and painful </li></ul><ul><li>   4.    Recurrent hallux valgus </li></ul><ul><li>   5.    Hallux valgus caused by muscle imbalance in patients with neuromuscular disorders, such as cerebral palsy, to prevent recurrence </li></ul><ul><li>   6.    Posttraumatic hallux valgus with severe disruption of all medial capsular structures that cannot be adequately reconstructed. </li></ul>
  64. 76. Why to differentiate ??? <ul><li>an increased distal metatarsal articular angle may be the defining characteristic of juvenile hallux valgus </li></ul><ul><li>1.    Pain, either at the metatarsophalangeal joint or beneath the lesser metatarsal heads, may not be the primary complaint in many instances </li></ul><ul><li>   2.Osteotomy of the first metatarsal is almost always necessary </li></ul><ul><li>3.    Varus of the first metatarsal with a widened intermetatarsal angle is almost always present   </li></ul>
  65. 77. <ul><li>4.    Hypermobile flatfoot with pronation of the foot during weight bearing frequently is associated with the deformity </li></ul><ul><li>   5.    Recurrence of the deformity is more frequent </li></ul><ul><li>   6.    Hallux valgus interphalangeus and deformity in articular angles may be prominent </li></ul><ul><li>   7.    The family history frequently </li></ul><ul><li>   8.    Soft-tissue procedures alone are unlikely to result in permanent correction. </li></ul>
  66. 78. Indicaion for surgery <ul><li>Any adolescent 12 to 18 years old </li></ul><ul><li>with cosmetically unattractive hallux valgus deformity </li></ul><ul><li>report to be progressive </li></ul><ul><li>family history is positive for hallux valgus is </li></ul><ul><li>Pain and shoe-fitting problems </li></ul>
  67. 79. Types of surgery <ul><li>lesser deformities  Adductor tenotomy, lateral capsulotomy, medial eminence removal, and medial capsulorrhaphy </li></ul><ul><li>Moderate to severe </li></ul><ul><li>metatarsal physis is fully open  a distal medial opening wedge osteotomy </li></ul><ul><li>metatarsal physis is closed/ near closure  proximal crescentic osteotomy is recommended </li></ul><ul><li>Severe  Peterson and Newman double first metatarsal osteotomies, an opening wedge proximally and a closing wedge distally to correct the abnormal distal metatarsal articular angle and the abnormal intermetatarsal angle </li></ul>
  68. 80. <ul><li>Distal osteotomy </li></ul><ul><li>Mitchell: double cut, step </li></ul><ul><li>Chevron: V shape cut </li></ul><ul><li>Diaphyseal osteotomy </li></ul><ul><li>Scarf osteotomy: Z shape, step cut, translation </li></ul><ul><li>Ludloff: Rotation </li></ul><ul><li>Basal osteotom </li></ul><ul><li>Crescentic </li></ul><ul><li>Basal chevron </li></ul>AVN of 1 st MT head ! Avoid shortening More stable then basal Extensive exposure High corrective power Mild degree Unstable
  69. 82. Hallux Valgus <25  Congruent Joint    Soft tissue procedures Chevron osteotomy   Mitchell osteotomy Incongruent Joint (subluxation)    Distal soft-tissue realignment +    Chevron osteotomy    Mitchell osteotomy Treatment of Hallux Valgus
  70. 83. Hallux Valgus 25  -40  Congruent Joint    Chevron osteotomy + Akin procedure    Mitchell osteotomy Incongruent Joint    Distal soft-tissue realignment + proximal osteotomy    Treatment of Hallux Valgus
  71. 84. Severe Hallux Valgus >40  Congruent Joint    Double osteotomy    Akin + 1 st metatarsal osteotomy    Akin + 1 st cuneiform opening wedge osteotomy Treatment of Hallux Valgus
  72. 85. Severe Hallux Valgus >40  Incongruent Joint    Distal soft-tissue realignment + Proximal osteotomy    First cuneiform opening wedge osteotomy Treatment of Hallux Valgus
  73. 86. Hypermobile 1 st MTC Joint    Distal soft-tissue realignment + fusion 1 st metatarsocuneiform joint Degenerative joint disease    Fusion or Keller procedure or prosthesis Treatment of Hallux Valgus
  74. 87. Post-operative management <ul><li>Immobilization ~2 weeks </li></ul><ul><li>Weight bearing as tolerated or NWB </li></ul>
  75. 88. Post-operative management HV night splint to be worn for 6-8 wks after dressing changes are completed
  76. 89. Complications of surgery <ul><li>Even experience, detailed physical and radiographic evaluations, excellent surgical technique, and careful postoperative care do not guarantee that a complication will not occur </li></ul><ul><li>nonunion </li></ul><ul><li>recurrence of the deformity </li></ul><ul><li>The most troublesome has been metatarsalgia, attributable to dorsiflexion malunion of the distal fragment (use of a Kirschner wire for fixation (instead of sutures) prevented malunion) </li></ul><ul><li>excessive shortening of the metatarsal, </li></ul>
  77. 90. <ul><li>medial eminence pain </li></ul><ul><li>clawed hallux </li></ul><ul><li>transfer keratotic lesions </li></ul><ul><li>development of the opposite deformity, hallux varus </li></ul>
  78. 92. <ul><li>complication of hallux valgus surgery </li></ul><ul><li>BECAUSE  </li></ul><ul><li>(1) complete release of the lateral structures of the metatarsophalangeal joint combined with excessive plication of the medial capsule, which pulls the sesamoids too far medially; </li></ul><ul><li>(2) excessive resection of the medial eminence, leading to loss of medial bony buttress for the proximal phalanx; </li></ul><ul><li>(3) excision of the fibular sesamoid; </li></ul><ul><li>(4) release of the lateral head of the flexor hallucis brevis at its insertion into the fibular sesamoid </li></ul><ul><li>(5) closure of the intermetatarsal angle to neutral or a negative value. </li></ul>
  79. 93. Two types <ul><li>static (supple) </li></ul><ul><li>Uniplanar, and passively correctable </li></ul><ul><li>usually is asymptomatic and mainly is a cosmetic complication </li></ul><ul><li>dynamic (fixed) </li></ul><ul><li>A multiplanar deformity that is fixed, symptomatic, and difficult to correct surgically . </li></ul><ul><li>The term that best describes the deformity is intrinsic minus deformity of the hallux with a varus component. </li></ul><ul><li>This is a true intrinsic-extrinsic muscle imbalance. </li></ul><ul><li>The first metatarsophalangeal joint is hyperextended </li></ul><ul><li>interphalangeal joint is acutely flexed </li></ul>
  80. 94. CORRECTION OF UNIPLANAR (STATIC) HALLUX VARUS <ul><li>Not all patients with acquired hallux varus require operative treatment </li></ul><ul><li>A conservative program of modified shoe wear and taping of the hallux should be attempted </li></ul><ul><li>A medial capsulotomy, placing the sesamoids in their proper location if subluxed medially, and holding the hallux in 10 to 15 degrees of valgus with a K- wire </li></ul><ul><li>Transfer of Extensor Hallucis Longus with Arthrodesis of the Interphalangeal Joint of the Hallux </li></ul>
  81. 95. CORRECTION OF DYNAMIC (MULTIPLANAR) HALLUX VARUS <ul><li>most often either resection arthroplasty (resecting the proximal third of the phalanx) </li></ul><ul><li>or </li></ul><ul><li>arthrodesis of the metatarsophalangeal joint </li></ul><ul><li>along with </li></ul><ul><li>an arthrodesis of the interphalangeal joint or a plantar plate release at the interphalangeal joint with pin fixation </li></ul><ul><li>If all components in the all planes are correctable and passive motion at the metatarsophalangeal joint approaches normal in flexion and extension, soft-tissue repair of the deformity may be successful </li></ul>
  82. 97. <ul><li>adult hallux rigidus most often is caused by degenerative arthritis of the first metatarsophalangeal joint </li></ul><ul><li>in adolescents, hallux rigidus usually results from localized cartilage damage to the first metatarsal head. </li></ul><ul><li>Earliest  lesion in the articular cartilage of the first metatarsal head without any detached subchondral bone, </li></ul><ul><li>Earliest  radiographic finding was a small depression in the dome of the metatarsal head </li></ul><ul><li>Late  limited extension. As the disease worsens, an osteophyte at the dorsal articular margin of the metatarsal head presents a mechanical abutment to extension </li></ul><ul><li>limitation of motion, and pain. </li></ul>
  83. 98. <ul><li>limitation of motion of the metatarsophalangeal joint of the great toe. </li></ul><ul><li>the pathogenesis of hallux rigidus is still not clearly defined, </li></ul><ul><li>its unrelenting destructive course is well appreciated. </li></ul><ul><li>Cartilage damage is believed to initiate the synovitis, which leads to further cartilage destruction, osteophyte proliferation, and subchondral bone destruction. </li></ul><ul><li>may begin in adolescence when a single traumatic event at the metatarsophalangeal joint damages the dorsal articular surface of the metatarsal head. </li></ul><ul><li>Repeated microtrauma also may cause articular cartilage damage. </li></ul><ul><li>Other causes include osteochondritis dissecans of the first metatarsal head secondary to an osteochondral fracture over the dorsal convexity of the joint surface </li></ul>
  84. 100. Non-operative Treatment <ul><li>In most patients, operative correction is required to relieve pain and improve function </li></ul><ul><li>activity modification, shoe adjustments ensuring adequate room for the metatarsophalangeal joint, and stiffening the shoe by inserting either an orthotic device </li></ul><ul><li>NSAIDs </li></ul>
  85. 101. Operative Treatment <ul><li>Cheilectomy  The goal of this procedure is to remove the proliferative bone from around the metatarsal head so as to remove the buttress preventing dorsiflexion of the proximal phalanx on the metatarsal head </li></ul><ul><li>Arthrodesis of the First Metatarsophalangeal Joint </li></ul><ul><li>Resection Arthroplasty (Keller Procedure) </li></ul><ul><li>Extension Osteotomy of the Proximal Phalanx </li></ul>
  86. 103. Scenario #1 <ul><li>Older Patient </li></ul><ul><li>Severe deformity (HV angle > 40) </li></ul><ul><li>Inflammatory disease </li></ul><ul><li>Degenerative Changes </li></ul><ul><li>FUSION ? Keller’s ? Prosthetic arthroplasty </li></ul>
  87. 104. Scenario #2 <ul><li>Young Patient (congenital Hallux Valgus) </li></ul><ul><li>Congruent, Increased DMAA, Increased IMA </li></ul><ul><li>All Extra Articular </li></ul><ul><ul><li>Proximal </li></ul></ul><ul><ul><li>Chevron / Medial closing wedge distally </li></ul></ul><ul><ul><li>Akin </li></ul></ul><ul><ul><li>NO lat release / NO medial tightening </li></ul></ul>
  88. 105. Scenario #3 <ul><li>Middle aged patient / wide forefoot </li></ul><ul><li>Incongruent, Increased IMA, Normal DMAA </li></ul><ul><li>Proximal osteotomy </li></ul><ul><li>Lateral release / Medial tightening (Modified McBride) </li></ul><ul><li>+/- Akin </li></ul>
  89. 106. Scenario #4 <ul><li>The most common one </li></ul><ul><li>Middle aged female </li></ul><ul><li>Not severe, Normal IMA, Slightly incongruent </li></ul><ul><li>Chevron, medial capsular tightening </li></ul><ul><li>+/- Akin </li></ul>