2. INTRODUCTION
The term “Hallux Valgus” was introduced by Carl
Hueterto define static subluxation of first MTP joint
with lateral deviation of great toe and medial deviation
of first metacarpal.
It is a complex deformity of first ray characterized by
lateral deviation of the great toe accompanied by
deformity and symptoms in the lesser toes
3.
Bunion: Derived from latin word “BUNIO” meaning
Turnip.
It has been used to denote any enlargement /deformity of
the MTP joint(Hallux Valgus; enlarged bursa; ganglion;
gouty arthropathy etc).
8. This windlass mechanism is responsible for:
Depression of 1st Metatarsal Head
Weight transfer to hallux.
In HV
this mech is disrupted
Transfer of weight laterally
*Surgery must minimize disruption of the windlass.
10. PATHO ANATOMY
Increased metatarsophalangeal angle
-plantar shift of abd.hallucis
-unopposed action of add.hallucis pulls greater toe
to further valgus
-medial capsular stuctures stretched and
attenuated
-medial shift of metatarsal head
13. DEMOGRAPHICS
Age of Onset: dependent on patient’s understanding, symptoms,
magnitude and family history: hence variation b/w various
studies.
Coughlin: 4% in 1st decade; 20% in adoloscent age.
65% in 3rd to 5th decade
Early age of onset more the severity
14. DEMOGRAPHICS
Gender: 2:1 to 7:1 female preponderance.
Constricting footwear
Bilaterality: 84% have b/l disease, 20% require b/l
surgery
Frequency: 2% to 4%.
15. ETIOLOGY
Extrinsic
Intrinsic
Heredity- 60% to 90%
Pes Planus
Footwear
Occupation
Hypermobility of Metatarsocuneiform joint
Ligamentous laxity
Achilles Contracture
Neuromuscular disorders
Systemic conditions like RA
Misc factors: 2nd toe amputation; Cystic degnera
of medial capsule
17. CLINICAL ASSESMENT
With the patient standing and sitting Foot is examined
for
Pes planus
Contracture of achilles tendon
Magnitude of Hallux valgus
Any pronation of great toe
Active & passive movements of MP joint
Metatarso cuneiform joint hypermobility
18.
Deformities of lesser toes
Metatarsalgia of other MT joints
Corns, calluses, warts, interdigital neuromas,
plantar keratosis
Neurovascular status of the limb.
20. RADIOGRAPHIC MEASUREMENTS
Hallux Valgus Angle: On AP wt bearing radiograph axes
are drawn on the 1st Metatarsal and Proximal phalynx
equidistant from medial and lateral cortices.
Normal
<15
Mild
<20
Moderate
20-40
Severe
>40
28. SURGICAL TREATMENT-AIMS
Correction of the IMT and HV angles
Creation of a congruent 1st MTPJ with sesamoid
realignment
Resection of the medial eminence is done parallel
to and flush with the MT shaft
Retention of function and ROM of the 1st MTPJ
Maintenance of normal weight bearing mechanics
31.
This procedure attempts to re-align the MTP joint, it
is best performed on an incongruent joint
Mild Deformity with incongruent joint
Mc Bride’s Procedure
36. 2. COMBINED SOFT TISSUE AND BONY
PROCEDURE
Keller’s Resection Arthroplasty
Resection of 1/3 rd of the proximal phalanx of great
toe – decompresses the joint and relaxes the tight
lateral structures
Bunionectomy
Release of adductor tendon.
37.
38.
D/A- High rates of recurrence, reduces the function
of the 1st ray, transfer metatarsalgia, & decreased
ROM of the 1st MTP joint
Should only be considered in elderly patients with
low functional demands
Mod.to severe Hallux Valgus (HV 30-45)
Mild to moderate Metatarsus primum varus (IMT
angle <13degree)
40. OSTEOTOMIES OF THE 1ST METATARSAL
Principles:
Technically easier to undertake & reproducible
Osteotomy should be stable so that re-displacement
does not occur
Length of the 1st metatarsal should be maintained to
prevent the development of transfer lesions &
metatarsalgia. Dorsiflexion with resultant elevation of
the MT head should be avoided
41. CONTD……….
The metatarsal blood supply should be preserved in
order to avoid AVN of MT head.
Long-term outcome should show a low recurrence
rate of the deformity
43. 1ST METATARSAL DISTAL OSTEOTOMY
Mitchell osteotomy
Removal of medial eminance
Osteotomy of distal portion of 1st MT shaft
Lateral displacement&angulation of capital fragment
Medial capsulorrrhaphy
44. 1ST METATARSAL DISTAL OSTEOTOMY
Chevron osteotomy
Modification of Mitchell
V-shaped osteotomy in sagital plane through MT
head&neck
Lateral shifting of MT head
Trimming of prox.fragment
Suturing of jointcapsule into abd.hallucis tendon
46. 1ST MT- DISTAL OSTEOTOMIES-MODIFICATIONS
Modified Chevron osteotomy
Apex of osteotomy more proximal
Advantage:
correction of severe deformity
Disadvantage:
stability is lost
47.
48. CHEVRON AKIN DOUBLE OSTEOTOMY
Combination of Chevron&proximal phalangeal
osteotomy
Greater correction of severe deformity
52. OSTEOTOMY OF PROXIMAL MT
Early union
Greater Correction
No Shortening
Narrowing of Forefoot
Extensive Dissection
Transfer of wt to smaller MT
Cast Required
60. ARTHRODESIS OF MTP JOINT
Indications
-severe deformity
- OA
- recurrence
-CP
-post traumatic
-RA
61. POSITION OF ARTHRODESIS
15 degrees of dorsiflexion of MTP
15degrees of valgus
Methods
-Small Plate fixation
-Truncated cone
- Moulded ball & socket
63. HALLUX VALGUS 25 TO 40 DEGREES
Congruent joint
Chevron osteotomy with Akin procedure
Mitchell osteotomy
Incongruent joint
Distal soft tissue realignment with proximal osteotomy
Mitchell osteotomy
64. SEVERE HALLUX VALGUS 25 TO 40 DEGREES
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
68.
Mild deformity-Chevron osteotomy/Mc Bride
Moderate-prox.osteotomy+soft tissue
Severe-double osteotomy(neck&base ofMT/neck of
MT+base of prox.phalanx)
Very severe-triple osteotomy(double+medial
cuniform osteotomy)/arthrodesis
-
69. HV IN CP
Spastic diplegia with equinovalgus
Varus of 1st MT
Indication for surgery
-pain&inability to shoe wear
-walking inability
-skin breakdown
Procedure-arthrodesis
70. CONCLUSION
Surgery for Hallux Valgus , while technically
demanding , has a high rate of success in
appropriately selected pts.
