2. SUBJECTIVE
CC: “Bump pain,” “Big toe is moving over,” Typical patient is female although it is unclear whether
there is an actual higher incidence among females, or if there is a higher complaint incidence.
HPI:
• Nature: Throbbing, aching-type pain
• Location: Dorsomedial 1st MPJ is most typical presentation. Pain could also be
moremedial (suggesting underlying transverse plane deformity such as met adductus)
or dorsal (suggesting OA of 1st MPJ).
• Course: Gradual and progressive
Aggravating Factors: Shoe wear, WB
PMH:
• Inflammatory conditions (SLE, RA, Gout, etc.)
• Ligamentous Laxity (Ehlers-Danlos, Marfan’s, Downs syndrome)
• Spastic conditions (40% incidence of HAV among those with CP)
PSH:
• Previous F&A surgery
FH:
• Hereditary component (63-68% family incidence among general population, 94% with
juvenile HAV)
• Johnston reports an autosomal dominant component with incomplete penetrance.
Meds/All: Usually non-contributory
ROS: Usually non-contributory
3. Objective
Physical Exam
Derm:
• Dorsomedial erythema +/- bursa
• Submet 2 lesion
• Nail bed rotational changes
• Pinch callus
Ortho:
• Dorsomedial eminence
• Pes plano valgus
• Underlying met adductus
• Hypermobile 1st ray
• PROM 1st MPJ
• LLD
• Tracking vs. Track-bound 1st MPJ
Vasc/Neuro: Usually non-contributory
6. Phalangeal
Osteotomies
Distal Phalanx
1. Medial Nail Bed Rotation: Corrects soft tissue
mal-alignment
Hallux IPJ
1. Amputation of the distal phalanx: Permanent
correction of abnormal Hallux Interphalangeus
Angle (HIA)
2. IPJ Fusion: Corrects abnormal HAI
7. Phalangeal
Osteotomies
Proximal
Phalanx
1. Distal Akin: Corrects abnormal HAI with a medially-based wedge
osteotomy at distal proximal phalanx
2. Central Akin: Corrects for long proximal phalanx seen with
concurrent HL/HR
3. Oblique Akin: Corrects for distal articular set angle (DASA) midshaft
proximal phalanx
4. Proximal Akin: Corrects for DASA of the proximal phalanx
5. Keller Arthroplasty: Corrects for abnormal Hallux Abductus Angle
(HAA) and with concurrent HL/HR
• Keller-Brandis Arthroplasty: Same as the Keller, but with
removal of 2/3 of the proximal phalanx
6. Bonney-Kessel: Dorsiflexory osteotomy with concurrent HL/HR with
modified forms correcting for abnormal DASA
7. Distal Hemi-Implant: Corrects for abnormal HAA or DASA with
concurrent HL/HR
8. Regnauld: Allows for correction of DASA and abnormal proximal
phalanx length in presence of HL/HR
9. Sagittal Z: Corrects for DASA and abnormal proximal phalanx length
in presence of HL/HR
8. MPJ
PROCEDURES
1. Total Implant: Correction of HAA in presence of HL/HR
2. McKeever arthrodesis: Allows for permanent correction of DASA,
PASA and HAA
3. McBride: Soft tissue reconstruction for correction of HAA
4. Modified McBride: Bone and soft tissue reconstruction for
correction of HAA and medial eminence
5. Silver: Correction of medial eminence
6. Hiss: Modified McBride with Abductor hallucis advancement
7. External Fixation: Double Taylor frame for gradual soft tissue
realignment
8. Hallux Amputation: Permanent correction of abnormal HAA
9. Distal 1st
Met
Procedures
1. Austin: Correction of IMA
2. Bi-correctional Austin: Correction of IMA and PASA
3. Tri-correctional Austin: Correction of IMA, PASA and elevatus
4. Youngswick: Correction of IMA and elevatus
5. Reverdin: Correction of PASA. Incomplete osteotomy.
6. Reverdin-Green: Correction of PASA with incomplete osteotomy and
plantar shelf. (Preserving Sesamoids)
7. Reverdin-Laird: Correction of PASA and IMA with complete
osteotomy and plantar shelf
8. Reverdin-Todd: Correction of PASA, IMA and sagittal plane deformity
(elevatus)
9. Mayo: First met head resection for correction of HAA with HL/HR
10.Stone: Mayo with sesamoid articulation left intact
11.Proximal Hemi-Implant: Correction of PASA and HAA with
concurrent HL/HR
10. Distal 1st
Met
Procedures
1. Peabody: Proximal Reverdin
2. Hohmann: Transverse through and through cut to correct for IMA and
sagittal plane
1. Percutaneous DMO: Percutaneous Hohmann
3. Wilson: Oblique through and through osteotomy to correct for IMA and
metatarsal length
4. DRATO (Derotational Abductory Transpositional Osteotomy): Can be
used to correct frontal plane, IMA, sagittal plane and wedged for PASA
5. Mitchell: Rectangular osteotomy with lateral spicule to correct for IMA,
elevatus and metatarsal length. Perpendicular to first met axis.
1. Miller: Mitchell with osteotomy oblique to first met axis for further
correction of IM and length
2. Roux: Wedged Mitchell to also correct for PASA
6. Distal L: Similar to a Reverdin-Green without correction of PASA
7. Mygind: Mexican hat procedure of distal first metatarsal for correction of
IM and length
8. Short-arm Scarf: Correction of IMA
9. Distal Crescentic: Correction of IMA
10. Distal Crescentic with a shelf: Correction of IMA with greater stability
11. Central 1st
Met
1. Scarf: Correction of IMA
2. Ludloff: Correction of IMA. Dorsal-
proximal to distal-plantar cut.
3. Mau: Correction of IMA. Distal-dorsal to
proximal-plantar cut
4. Kalish: Austin with a long dorsal arm to
allow for screw internal fixation
5. Vogler Offset V: This is NOT the same
procedure as a long arm Austin (Angle is
40 degrees)
12. Proximal 1st
Met
1. Cresentic: Correction of IMA
2. Cresentic Shelf: Correction of IMA with greater
stability
3. OBWO: Correction of IMA
4. Trethowan: OBWO using medial eminence for graft
5. Loison-Balacescu: Closing base wedge proximal
osteotomy. Corrects IMA.
6. Logroscino: CBWO with Reverdin. Corrects IMA and
PASA.
7. Juvara: Oblique CBWO
8. Proximal Austin: Correction of IMA
9. Lambrinudi: Plantar CBWO to correct for sagittal
plane
13. 1st Met-
Cunieform
1. Lapidus with internal fixation
2. Lapidus with external fixation
3. Westman: OBWO of the cuneiform to
correct for transverse plane
4. Cotton: OBWO of the cuneiform to
correct for sagittal plane
5. Cotton-Westman: OBWO of the
cuneiform to correct for transverse and
frontal plane
Misc.
1. 2nd digit amputation
2. EHL lengthening
14. AJM Sheet:
HAV
Complications
1. RECURRENCE
• Early (<1 year)
• Usually due to wrong procedure choice, surgical error,
or a post-operative complication.
• As little as 1% and as much as 14% rate reported
(Kitaoka on 49 feet).
• Late (>1 year)
• Usually due to an unrecognized underlying deformity
(such as met adductus, Ehlers-Danlos, equinus, 1st
met hypermobility, etc.)
• Symptoms usually worse than initial presentation
• Treatment: Distal soft tissue procedures or a proximal
osteotomy usually indicated
15. AJM Sheet:
HAV
Complications
2. Hallux Varus
• Defined as a purely transverse plane adduction
• Hallux Malleus: extension at MPJ with flexion at IPJ
• Etiology
• Underlying causes:
• Long 1st metatarsal
• Round 1stmetatarsal head
• 1st MPJ hypermobility
• Iatrogenic causes:
• Staking of the 1st metatarsal head
• Overcorrection of the IM angle
• Overzealous medial capsulorraphy
• Fibular sesamoidectomy
• Over extensive lateral release
• Overcorrection of the PASA
• Overzealous bandaging
16. Treatment for
Hallux Varus
Complication:
ocedure choice,
operative complication.
uch as 14% rate
feet).
ognized underlying
adductus, Ehlers-
hypermobility, etc.)
e than initial
rocedures or a proximal
plane adduction
MPJ with flexion at
al
rsal head
bility
metatarsal head
f the IM angle
dial capsulorraphy
ectomy
teral release
f the PASA
daging
medial
tenings)
sfer
Hallux Varus
• Defined as a purely transverse plane adduction
• Hallux Malleus: extension at MPJ with flexion at
IPJ
• Etiology
• Underlying causes:
• Long 1st
metatarsal
• Round 1st
metatarsal head
• 1st
MPJ hypermobility
• Iatrogenic causes:
• Staking of the 1st
metatarsal head
• Overcorrection of the IM angle
• Overzealous medial capsulorraphy
• Fibular sesamoidectomy
• Over extensive lateral release
• Overcorrection of the PASA
• Overzealous bandaging
• Treatment:
• Soft tissue rebalancing (medial
releases and lateral tightenings)
• EHB tendon transfer
• Reverse distal osteotomies
• Ludloff/Mau
• Resection arthroplasty,
implant, arthrodesis
of124 140
• Overcorrection of the PASA
• Overzealous bandaging
• Treatment:
• Soft tissue rebalancing (medial
releases and lateral tightenings)
• EHB tendon transfer
• Reverse distal osteotomies
• Ludloff/Mau
• Resection arthroplasty,
implant, arthrodesis
of124 140
• Soft tissue rebalancing (medial releases and
lateral tightenings)
• EHB tendon transfer
• Reverse distal osteotomies
• Ludloff/Mau
• Resection arthroplasty, implant, arthrodesis
17. HAV Dissection and Capsule
Procedures
Anatomic Dissection
• 1st incision is through epidermis and dermis
• Incision is planned along the dorsomedial aspect of the 1st
MPJ, just medial to EHL and lateral to the medial dorsal
cutaneous nerve.
• From midshaft of 1st metatarsal to just proximal to the
hallux IPJ
• Subcutaneous tissue is dissected to deep fascia/ capsular layer
• NV structures: Superficial venous network, medial dorsal
cutaneous nerve
• Be wary of the anterior resident’s nerve (Extensor
capsularis)
Fundamental illustration depicting separation of
the superficial fascia or subcutaneous layer from
the deep fascia which encircles the first MPJ.
This basic dissection principle preserves primary
blood supply and nerve structures which lie
within the subcutaneous layer. Surgical
techniques performed within the collar of the
deep fascia can then be performed with no
violation of the critical neurovascular structures.
18. HAV
Dissection
and Capsule
Procedures
Lateral Release - Sequence of events:
•1. Release of the deep transverse inter-metatarsal
ligament
•2. Release of adductor hallucis tendon from base of
proximal phalanx and fibular Sesamoid
•3. Release of fibular metatarsal-fibular sesamoid
ligament and lateral capsule
•4. Tenotomy of the lateral head of the FHB between
the fibular sesamoid and the proximal phalanx
•5. Optional excision of the fibular sesamoid
19. Medial
Capsulotomies
•Linear
•Washington Monument: Strongest medial
capsulotomy allowing for both transverse and
frontal plane correction
•Lenticular (Elliptical): Allows for transverse
and frontal plane correction with removal of
redundant capsule
•Inverted L: Transverse plane correction with
removal of redundant capsule
•Medial T: Transverse plane correction with
removal of redundant capsule
•Medial H: Transverse plane correction with
removal of redundant capsule
