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DR CHANDER PAL
DITO,DELHI
introduction
• Complex progressive deformity affecting
forefoot
• Lateral deviation of great toe is most
obvious
• Rotation of hallux
• Metatarsus primus varus
• Overriding of second toe over the hallux
• Overriding of lateral toes
• H...
Bunion
• Swelling that occurs because of medial
eminence of metatarsal head
• Overlying bursitis
• Or may be skin callosity
AnatomyAnatomy
PathoanatomyPathoanatomy
• LATERAL DEVIATION OF GREAT TOE is primary
deformity
•Valgus angle of the 1st
MTP joint exceeds ...
Hallux valgus complex. Note increase in intermetatarsal
angle, lateral dislocation of sesamoids, subluxation
of first meta...
Pathogenesis
• the abductor hallucis moves plantar ward
• Only restraining medial structure is the medial
capsular ligamen...
PathophysiologyPathophysiology
• Valgus deviation
of hallux
• Attenuated
medial structure
• Varus metatarsal
head deviatio...
• Valgus deformity may be
• congruent or
• incongruent
Piggot
EtiologyEtiology
•Female/male = 2:1 to 15:1
• Heredity: + FH ~63% -Adolescents
•Essential extrinsic factor = shoe
•Intrinsic ANOTOMICAL cause
• Metatarsus primus varus: juvenile form
• First metatarsal length
• Hypermobility of first ra...
• Inflammatory arthropathies
• Spastic disorder
• Trauma
• Amputation of second toe
first variant,
the articular surface of the metatarsal head is offset,
resembling a scoop of ice cream sitting at an angle...
Consequences
• a hammer toe–like deformity of the second
toe
• the splaying of the forefoot
• corns often develop
• bursal...
• Often asymptomatic
• Cosmetic deformity
• Pain
PAIN over the medial eminence (Bunion).
• Pressure from footwear is the most
frequent cause of this discomfort.
• Bursal i...
Physical examination
• Vascular / neurologic status
• ROM of MTP joint
• Pronation of hallux
• Callosities under lesser MT...
X-ray
• Standard preoperative radiographs
should include
1.Standing dorsoplantar views
2.Standing Lateral views
3.Nonstand...
Standing
dorsoplantar view
Non-standing
lateral oblique view
Standing lateral view Axial sesamoid view
Evaluation of x-rays
•IMA (normal 8-9°)
•HVA (normal 15)
•DMAA (normal 10)
•PAA (normal 7-10°)
•OA changes
•Position of se...
CLASSIFICATION MILD MODERATE SEVERE
Hallux valgus angle < 20° 20° to 40° >40°
1-2 intermetatarsal
angle
11° or
less.
12- 1...
Give initial trial
Shoes with wide toe box
 Orthotics
• medial arch support
• hallux valgus splint
 Achilles tendon str...
•Painful joint ROM
•Deformity of the joint complex
•Pain or difficulty with footwear
•Inhibition of activity or lifestyle
...
Associated foot disorders
- Neuritis/nerve entrapment
- Overlapping/underlapping 2nd
digit
- Hammer digits
- First metatar...
Extensive peripheral vascular disease
Active infection
Active osteoarthropathy
Septic arthritis
Lack of pain or deformity
...
Relieve pain
Correct deformity
Preserve MTP joint motion
Surgical Goals
• most procedures to correct hallux valgus still use one or more
of the components described:
• Removal of the exostosis
•...
1. Valgus deviation of the great toe
2. Varus deviation of the 1st
metatarsal
3. Pronation of hallux and/or 1st
metatarsal...
7. Excessive mobility or obliquity of the 1st
metatarsomedial cuneiform joint
8. The medial eminence (bunion)
9. The locat...
Indications
• Stress view radiographs - a firm forefoot wrap
reduces the intermetatarsal angle to a normal
value and decre...
Distal Soft tissue handling includes 
• Medial eminence removal
• Adductor tendon and lateral capsular release
• Medial c...
Modified McBride
Bunionectomy
• skin incision
Most medial branch of superficial
peroneal nerve
Modified McBride procedure.
Longitudinal capsular
incision is 3 to 4 mm plantar to skin
incision
Modified McBride procedur...
Modified McBride procedure. Medial eminence
is removed.
Modified McBride procedure: second
incision.
Deep peroneal nerve branch to first
web space is avoided, and
terminal portio...
Fibular sesamoid
is removed.
Medial capsule is
imbricated, with plantar flap over dorsal flap
Toe spacer is worn for 6 weeks
after surgery to
maintain medial capsular
stabilization
Hallux valgus night splint to be
wo...
Complications
• Recurrence
• Hallux varus
A) KELLER RESECTION
ARTHROPLASTY
Resection of proximal phalanx,
release of adductor tendon, and resection of medial eminen...
• Resection hemiarthroplasty of the first
metatarsophalangeal joint- resect 1/3 of
proximal phalanx- mobilizes the hallux,...
osteotomies
Mitchell osteotomy
• Extracapsuler
• Mild to moderate deformity
• HVA of up to 40 degree
• Excision of medial eminence
• S...
Mitchell osteotomy
CHEVRON INTRACAPSULAR
OSTEOTOMY
Indications
• younger patients (adolescence through the 30s)
• hallux valgus angle of 30 d...
Consists of
(1) medial eminence removal
(2) a V-shaped intracapsular through the
first metatarsal head in trasverse plane
...
Proximal metatarsal osteotomy
Scarf osteotomy
• HVA > 25,IMA>13
• Z step cut osteotomy of MT shaft
Scarf osteotomy
Ludloff osteotomy
• Oblique osteotomy of 1st
metatarsal
• Dorsal proximal to distal planter
D) MEDIAL CUNEIFORM
OSTEOTOMY
 Indications
 in adolescents with open proximal
metatarsal physes
 especially patients wi...
Medial Cuneiform OsteotomyMedial Cuneiform Osteotomy
Riedl & Coughlin
E) PROXIMAL PHALANGEAL
OSTEOTOMY (AKIN’S)
• a medially based closing wedge osteotomy at the base of the
proximal phalanx, ...
Proximal Phalangeal OsteotomyProximal Phalangeal Osteotomy
Akin procedure
Medial eminence removal
and adductor tenotomy ph...
Chevron-Akin Double
Osteotomy
• combination of the chevron and Akin osteotomies to gain greater
correction of mild-to-mode...
Chevron
osteotomy cut is made, and metatarsal
head is shifted laterally 2.5 to 3.0 mm. ,
Osteotomy is fixed with 0.045-inc...
Akin cut parallels concavity at base
of proximal phalanx, and 1-mm wedge of
bone is removed. Suture closure of Akin
osteot...
ARTHRODESIS OF THE FIRST
METATARSOPHALANGEAL JOINT
Various fixation methods have been
described.
one-quarter tubular plat...
Indication
1. Severe deformity (an intermetatarsal angle >20 to 22
degrees, a hallux valgus angle >45 degrees, and severe
...
Dorsal skin incision. ,
Excision of metatarsal
head Fusion site placed in 15 to 20 degrees of
valgus. , Approximately 30 d...
Kirschner wire placed. Six-hole, one-
quarter tubular plate in place
• an increased distal metatarsal articular angle may be the
defining characteristic of juvenile hallux valgus
. Pain, eith...
• Hypermobile flatfoot with pronation of the foot during weight
bearing frequently is associated with the deformity
• Recu...
Indicaion for surgery
• Any adolescent 12 to 18 years old
• with cosmetically unattractive hallux valgus deformity
• repor...
Hallux Valgus <25Hallux Valgus <25°°
Congruent Joint
Chevron osteotomy
Mitchell osteotomy
Incongruent Joint (subluxation)
...
Hallux Valgus 25Hallux Valgus 25°°-40-40°°
Congruent Joint
Chevron osteotomy + Akin procedure
Mitchell osteotomy
Incongrue...
Severe Hallux Valgus >40Severe Hallux Valgus >40°°
Congruent Joint
Double osteotomy
Akin+ chevron osteotomy
Akin + 1st
met...
Severe Hallux Valgus >40Severe Hallux Valgus >40°°
Incongruent Joint
Distal soft-tissue realignment +
Proximal osteotomy
F...
Hypermobile 1Hypermobile 1stst
MTC JointMTC Joint
Distal soft-tissue realignment +
fusion 1st
metatarsocuneiform joint
Deg...
Post-operative managementPost-operative management
 Immobilization ~2 weeks
 Weight bearing as tolerated or NWB
Post-operative managementPost-operative management
HV night splint
to be worn for 6-8 wks
after dressing changes
are compl...
Complications of surgery
•nonunion
•recurrence of the deformity
•The most troublesome has been metatarsalgia,
attributable...
• medial eminence pain
• clawed hallux
• transfer keratotic lesions
• development of the opposite deformity, hallux
varus
PAINFUL HEEL
Hallux valgus
Hallux valgus
Hallux valgus
Hallux valgus
Hallux valgus
Hallux valgus
Hallux valgus
Hallux valgus
Hallux valgus
Hallux valgus
Hallux valgus
Hallux valgus
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Hallux valgus

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HALLUX VALGUS

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Hallux valgus

  1. 1. DR CHANDER PAL DITO,DELHI
  2. 2. introduction • Complex progressive deformity affecting forefoot • Lateral deviation of great toe is most obvious
  3. 3. • Rotation of hallux • Metatarsus primus varus • Overriding of second toe over the hallux • Overriding of lateral toes • Hammer and claw deformities
  4. 4. Bunion • Swelling that occurs because of medial eminence of metatarsal head • Overlying bursitis • Or may be skin callosity
  5. 5. AnatomyAnatomy
  6. 6. PathoanatomyPathoanatomy • LATERAL DEVIATION OF GREAT TOE is primary deformity •Valgus angle of the 1st MTP joint exceeds 30 to 35 degrees •Increase in angle between first and second metatarsal (metatarsus primus varus) •Pronation of the great toe •Subluxation/dislocation of the first metatarsophalangeal joint •Excessive valgus tilt of the articular surface of the first metatarsal head and proximal phalangeal articular surface
  7. 7. Hallux valgus complex. Note increase in intermetatarsal angle, lateral dislocation of sesamoids, subluxation of first metatarsophalangeal joint (leaving metatarsal head uncovered), and pronation of great toe associated with marked hallux valgus.
  8. 8. Pathogenesis • the abductor hallucis moves plantar ward • Only restraining medial structure is the medial capsular ligament • The adductor hallucis, which is unopposed by the abductor hallucis, pulls the great toe further into valgus • The flexor hallucis brevis, flexor hallucis longus and extensor hallucis increases the valgus moment, further deforming the first ray. • the metatarsal head to drift medially from the sesamoids.
  9. 9. PathophysiologyPathophysiology • Valgus deviation of hallux • Attenuated medial structure • Varus metatarsal head deviation • Sesamoid subluxation • Hallux pronation • Lateral contracture
  10. 10. • Valgus deformity may be • congruent or • incongruent
  11. 11. Piggot
  12. 12. EtiologyEtiology •Female/male = 2:1 to 15:1 • Heredity: + FH ~63% -Adolescents •Essential extrinsic factor = shoe
  13. 13. •Intrinsic ANOTOMICAL cause • Metatarsus primus varus: juvenile form • First metatarsal length • Hypermobility of first ray • Pronated flatfeet • Ligamentous laxity
  14. 14. • Inflammatory arthropathies • Spastic disorder • Trauma • Amputation of second toe
  15. 15. 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
  16. 16. Consequences • a hammer toe–like deformity of the second toe • the splaying of the forefoot • corns often develop • bursal hypertrophy over the medial eminence of the first metatarsal head (bunion) • Osteoarthritis • Callosity • metatarsalgia. The entire forefoot must be evaluated for these multiple components of hallux valgus
  17. 17. • Often asymptomatic • Cosmetic deformity • Pain
  18. 18. PAIN 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.
  19. 19. Physical examination • Vascular / neurologic status • ROM of MTP joint • Pronation of hallux • Callosities under lesser MTHs • Hammer / claw toes • MTC joint stability • Assess hind foot Patient evaluation
  20. 20. X-ray • Standard preoperative radiographs should include 1.Standing dorsoplantar views 2.Standing Lateral views 3.Nonstanding lateral oblique view 4.Axial sesamoid views
  21. 21. Standing dorsoplantar view Non-standing lateral oblique view Standing lateral view Axial sesamoid view
  22. 22. Evaluation of x-rays •IMA (normal 8-9°) •HVA (normal 15) •DMAA (normal 10) •PAA (normal 7-10°) •OA changes •Position of sesamoids •Incongruent or subluxated jo Hallux valgus angle Intermetatarsal angle Distal metatarsal articular angle
  23. 23. 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%
  24. 24. Give initial trial Shoes with wide toe box  Orthotics • medial arch support • hallux valgus splint  Achilles tendon stretching Exercises Activity adjustments Non-operative treatmentNon-operative treatment
  25. 25. •Painful joint ROM •Deformity of the joint complex •Pain or difficulty with footwear •Inhibition of activity or lifestyle 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 Indications for surgeryIndications for surgery
  26. 26. Associated foot disorders - Neuritis/nerve entrapment - Overlapping/underlapping 2nd digit - Hammer digits - First metatarsocuneiform joint exostosis - Sesamoiditis - Ulceration - Inflammatory conditions (bursitis, tendinitis) of 1st metatarsal head Indications for surgeryIndications for surgery
  27. 27. Extensive peripheral vascular disease Active infection Active osteoarthropathy Septic arthritis Lack of pain or deformity Advanced age Lack of compliance Co-morbidities Contraindications
  28. 28. Relieve pain Correct deformity Preserve MTP joint motion Surgical Goals
  29. 29. • most procedures to correct hallux valgus still use one or more of the components described: • Removal of the exostosis • dissection of the bursa • tenotomy and transplantation of the tendons, • removal of the sesamoids • osteotomies
  30. 30. 1. Valgus deviation of the great toe 2. Varus deviation of the 1st metatarsal 3. Pronation of hallux and/or 1st metatarsal 4. Hallux valgus interphalangeus 5. Arthritis and limitation of motion of the 1st metatarsophalangeal joint 6. Length of the 1st metatarsal relative to lesser metatarsals Preoperative evaluation
  31. 31. 7. Excessive mobility or obliquity of the 1st 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 evaluationPreoperative evaluation
  32. 32. Indications • Stress view radiographs - a firm forefoot wrap reduces the intermetatarsal angle to a normal value and decreases the hallux valgus angle • Middle aged • Mild to moderate • a valgus angle at the metatarsophalangeal joint of 15 to 25 degrees • an intermetatarsal angle of less than 13 degrees, • valgus of the interphalangeal joint of less than 15 degrees • no degenerative changes at the metatarsophalangeal joint • a history of conservative management failure
  33. 33. Distal Soft tissue handling includes  • Medial eminence removal • Adductor tendon and lateral capsular release • Medial capsular imbrication • Reduction of MTP joint and sesamoids
  34. 34. Modified McBride Bunionectomy • skin incision Most medial branch of superficial peroneal nerve
  35. 35. Modified McBride procedure. Longitudinal capsular incision is 3 to 4 mm plantar to skin incision Modified McBride procedure. Capsule is opened, and attachment of capsule on metatarsal neck (arrow) is carefully preserved.
  36. 36. Modified McBride procedure. Medial eminence is removed.
  37. 37. Modified McBride procedure: second incision. Deep peroneal nerve branch to first web space is avoided, and terminal portion of first dorsal intermetatarsal artery is exposed Adductor hallucis is exposed and released
  38. 38. Fibular sesamoid is removed. Medial capsule is imbricated, with plantar flap over dorsal flap
  39. 39. Toe spacer is worn for 6 weeks after surgery to maintain medial capsular stabilization Hallux valgus night splint to be worn for 6 to 8 weeks after dressing changes are completed.
  40. 40. Complications • Recurrence • Hallux varus
  41. 41. A) KELLER RESECTION ARTHROPLASTY Resection of proximal phalanx, release of adductor tendon, and resection of medial eminence.
  42. 42. • Resection hemiarthroplasty of the first metatarsophalangeal joint- resect 1/3 of proximal phalanx- mobilizes the hallux, allowing marked correction of valgus • removal of the medial eminence • fibular sesamoidectomy • Adductor tenotomy • lateral displacement of the first metatarsal
  43. 43. osteotomies
  44. 44. Mitchell osteotomy • Extracapsuler • Mild to moderate deformity • HVA of up to 40 degree • Excision of medial eminence • Step cut osteotomy at metaphyseal diphyseal junction • Medial capsulorrhaphy
  45. 45. Mitchell osteotomy
  46. 46. CHEVRON INTRACAPSULAR OSTEOTOMY Indications • younger patients (adolescence through the 30s) • hallux valgus angle of 30 degrees or less • an intermetatarsal angle of less than 13 degrees. ADVANTAGES • made through cancellous bone • shortens the metatarsal less • inherently stable • Fixation of the osteotomy with one or two Kirschner wires, a cortical screw, or a biodegradable pin adds stability to the osteotomy
  47. 47. Consists of (1) medial eminence removal (2) a V-shaped intracapsular through the first metatarsal head in trasverse plane (3) lateral displacement of the capital fragment (4) removal of the resulting projection of the first metatarsal
  48. 48. Proximal metatarsal osteotomy
  49. 49. Scarf osteotomy • HVA > 25,IMA>13 • Z step cut osteotomy of MT shaft
  50. 50. Scarf osteotomy
  51. 51. Ludloff osteotomy • Oblique osteotomy of 1st metatarsal • Dorsal proximal to distal planter
  52. 52. D) MEDIAL CUNEIFORM OSTEOTOMY  Indications  in adolescents with open proximal metatarsal physes  especially patients with an abnormally wide intermetatarsal angle
  53. 53. Medial Cuneiform OsteotomyMedial Cuneiform Osteotomy Riedl & Coughlin
  54. 54. E) PROXIMAL PHALANGEAL OSTEOTOMY (AKIN’S) • a medially based closing wedge osteotomy at the base of the proximal phalanx, combined with medial eminence removal • mostly as an adjunctive procedure to the primary bunion repair • alone rarely is indicated • limited value if the sesamoid apparatus is subluxed • 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
  55. 55. Proximal Phalangeal OsteotomyProximal Phalangeal Osteotomy Akin procedure Medial eminence removal and adductor tenotomy phalangeal closing wedge osteotomy Final position of hallux.
  56. 56. Chevron-Akin Double Osteotomy • combination of the chevron and Akin osteotomies to gain greater correction of mild-to-moderate hallux valgus deformities. Resection of medial eminence parallel to medial border of foot
  57. 57. Chevron osteotomy cut is made, and metatarsal head is shifted laterally 2.5 to 3.0 mm. , Osteotomy is fixed with 0.045-inch smooth pin, and protruding medial border of metatarsal is osteotomized flush with metatarsal head.
  58. 58. Akin cut parallels concavity at base of proximal phalanx, and 1-mm wedge of bone is removed. Suture closure of Akin osteotomy corrects residual valgus of hallux
  59. 59. ARTHRODESIS OF THE FIRST METATARSOPHALANGEAL JOINT Various fixation methods have been described. one-quarter tubular plate with one oblique interfragmentary screw one-third tubular plate two ⅛-inch Steinmann pins placed through the hallux into the first metatarsal
  60. 60. Indication 1. Severe deformity (an intermetatarsal angle >20 to 22 degrees, a hallux valgus angle >45 degrees, and severe pronation of the hallux) 2. with Degenerative arthritis / rheumatoid arthritis 3. motion of the metatarsophalangeal joint is limited and painful 4. Recurrent hallux valgus 5. Hallux valgus caused by muscle imbalance in patients with neuromuscular disorders, such as cerebral palsy, to prevent recurrence 6. Posttraumatic hallux valgus with severe disruption of all medial capsular structures that cannot be adequately reconstructed.
  61. 61. Dorsal skin incision. , Excision of metatarsal head Fusion site placed in 15 to 20 degrees of valgus. , Approximately 30 degrees of dorsiflexion in relation to metatarsal shaft or 10 to 15 degrees of dorsiflexion in relation to floor.
  62. 62. Kirschner wire placed. Six-hole, one- quarter tubular plate in place
  63. 63. • an increased distal metatarsal articular angle may be the defining characteristic of juvenile hallux valgus . Pain, either at the metatarsophalangeal joint or beneath the lesser metatarsal heads, may not be the primary complaint in many instances Varus of the first metatarsal with a widened intermetatarsal angle is almost always present
  64. 64. • Hypermobile flatfoot with pronation of the foot during weight bearing frequently is associated with the deformity • Recurrence of the deformity is more frequent • The family history frequently • Soft-tissue procedures alone are unlikely to result in permanent correction.
  65. 65. Indicaion for surgery • Any adolescent 12 to 18 years old • with cosmetically unattractive hallux valgus deformity • report to be progressive • family history is positive for hallux valgus • Pain and shoe-fitting problems
  66. 66. Hallux Valgus <25Hallux Valgus <25°° Congruent Joint Chevron osteotomy Mitchell osteotomy Incongruent Joint (subluxation) Distal soft-tissue realignment + Chevron osteotomy Mitchell osteotomy Treatment of Hallux ValgusTreatment of Hallux Valgus
  67. 67. Hallux Valgus 25Hallux Valgus 25°°-40-40°° Congruent Joint Chevron osteotomy + Akin procedure Mitchell osteotomy Incongruent Joint Distal soft-tissue realignment + proximal osteotomy Treatment of Hallux ValgusTreatment of Hallux Valgus
  68. 68. Severe Hallux Valgus >40Severe Hallux Valgus >40°° Congruent Joint Double osteotomy Akin+ chevron osteotomy Akin + 1st metatarsal osteotomy Akin + 1st cuneiform opening wedge osteotomy Treatment of Hallux ValgusTreatment of Hallux Valgus
  69. 69. Severe Hallux Valgus >40Severe Hallux Valgus >40°° Incongruent Joint Distal soft-tissue realignment + Proximal osteotomy First cuneiform opening wedge osteotomy Treatment of Hallux ValgusTreatment of Hallux Valgus
  70. 70. Hypermobile 1Hypermobile 1stst MTC JointMTC Joint Distal soft-tissue realignment + fusion 1st metatarsocuneiform joint Degenerative joint diseaseDegenerative joint disease Fusion or Keller procedure or prosthesis Treatment of Hallux ValgusTreatment of Hallux Valgus
  71. 71. Post-operative managementPost-operative management  Immobilization ~2 weeks  Weight bearing as tolerated or NWB
  72. 72. Post-operative managementPost-operative management HV night splint to be worn for 6-8 wks after dressing changes are completed
  73. 73. Complications of surgery •nonunion •recurrence of the deformity •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) •excessive shortening of the metatarsal,
  74. 74. • medial eminence pain • clawed hallux • transfer keratotic lesions • development of the opposite deformity, hallux varus
  75. 75. PAINFUL HEEL

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