hallux valgus -concise from campbell

1. HALLUX VALGUS (BUNION)
It is a deformity in which the great toe is deflected laterally, and a bony
prominence develops secondarily over the medial aspect of 1st
metatarsal head and neck

2. Components
• Hallux valgus
• Pronation
• Metatarsus varus
• Bunion
• Hammer toe 2nd digit
• Callosity
• Corns
• Hallux rigidus (end point)

3. Pathoanatomy
• Unopposed
adductor(contracture develops)
• Sesamoid subluxation(lateral
shift)
• Crista flattening
• Medial capsule stretching
• Plantar shift of abductor

6. Anatomical variants
• the articular surface of the metatarsal head is offset
• resembling a scoop of ice cream sitting at an angle on a cone .
• distal metatarsal articular angle
• 10 to 15 degrees(normal)
• the articular angle of the base of the proximal phalanx in relation to
its longitudinal axis is offset.
• phalangeal articular angle.
• 7 to 10 degrees
• No forceful straightening: incongruent articular surface
• Osteotomy preferred

8. • Hallux valgus angle- n<15
• intermetatarsal angle- n<9
• distal metatarsal articulation angle- n<10
• hallux valgus interphalangeus

9. Clinical features
• hammer toe–like deformity of the second toe
• the splaying of the forefoot makes the wearing of shoes more
difficult
• corns often develop,
• bursal hypertrophy over the medial eminence of the first metatarsal
head (bunion).
• osteoarthritis
• calluses, and
• metatarsalgia

12. Classification ??
Normal Mild Moderate Severe
Intermetatarsal
angle
<9 9-13 13-20 >20
Hallux valgus angle <15 15-25 25-40 >40

13. Causes /associations???
• metatarsus primus varus
• lateral deviation of the great toe
• Hypermobility of the first ray
• Pronated flatfeet
• abnormal insertion of the posterior tibial tendon
• increased obliquity of the first metatarsomedial-cuneiform joint
• an abnormally long first ray,
• incongruous articular surfaces of the first metatarsophalangeal joint, and
• excessive valgus tilt of the articular surface of the first metatarsal head
and proximal phalangeal articular surface

14. Treatment algorithm

16. Radiographs
• standing dorsoplantar
• hallux valgus angle and
• the first-second intermetatarsal angle
• hallux valgus interphalangeus angle
• distal metatarsal articular angle
• degenerative arthritic changes :first MTP, metatarsocuneiform joints
• Standing lateral views,
• a nonstanding lateral oblique view, and
• axial sesamoid views

17. Soft-Tissue Procedures
• Indication
• 30- to 50-year-old woman with clinical symptoms and
• a valgus angle at the MTP 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, and
• a history of conservative management failure

18. Silver procedure:added in every procedure
• Simple exostectomy
• Flush with the medial border of foot
• If done excessively: hallux varus can occur

19. Modified Mc Bride procedure
• longitudinal capsular incision (the original McBride capsular incision was
transverse)
• Free the capsule subperiosteally on its dorsomedial surface
• Silver procedure
• All attachments of the adductor into its conjoined insertion with the lateral
head of the flexor hallucis brevis muscle into the fibular sesamoid must be
severed
• deep transverse intermetatarsal ligament severed
• =/- FIBULAR (LATERAL) SESAMOIDECTOMY
• MEDIAL CAPSULAR IMBRICATION

20. Toe spacer is worn for 6 weeks after surgery to
maintain medial capsular stabilization

22. Keller Resection Arthroplasty
• Indication
• >50 years with
• moderate-to-severe hallux valgus (30 to 45 degrees);
• intermetatarsal angles of 13 degrees or less, indicating mild-to-moderate
metatarsus primus varus; and
• pain over the medial eminence with any shoe worn, so the variety of shoes
the patient can wear is severely limited.
• An incongruous first metatarsophalangeal joint caused by lateral
subluxation of the phalanx on the metatarsal head,
• severe lateral displacement of the sesamoids, and
• any evidence of degenerative cartilage changes in the joint

23. • resection hemiarthroplasty of
the first metatarsophalangeal
joint
• Modification
• fibular sesamoidectomy and
• lateral displacement of the first
metatarsal

24. Mitchell osteotomy
(metatarsal neck
osteotomy)
• (1) removal of the medial
eminence,
• (2) an osteotomy of the distal
portion of the first metatarsal
shaft,(DOUBLE OSTEOTOMY OF
THE METATARSAL NECK ) (prox
to chevron)
• (3) lateral displacement and
angulation of the capital
fragment, and
• (4) medial capsulorrhaphy

25. Distal Chevron Osteotomy
• (1) medial eminence removal,
• (2) a V-shaped intracapsular osteotomy through the first metatarsal
head,
• (3) lateral displacement of the capital fragment,
• (4) removal of the resulting projection of the first metatarsal, and
• (5) medial capsulorrhaphy.

26. • Indication
• <50 years old with a
• hallux valgus angle of less than 40 degrees and
• an intermetatarsal angle of less than 20 degrees.
• advantages over metatarsal neck osteotomy
• It is made through cancellous bone,
• shortens the metatarsal less, and
• is inherently stable

28. Modified Chevron Osteotomy
• changing the length and position of the limbs of the osteotomy in
the metatarsal head,
• which extended the indications for the osteotomy to severe
deformities with intermetatarsal angles of 15 or 16 degrees.
• Also, in the modified procedure, a 2.7-mm screw is used for internal
fixation,
• 2nd osteotomy at an angle of 70 degrees to the first limb of the
osteotomy short dorsal arm and long plantar arm

29. Chevron-Akin Double Osteotomy

30. Osteotomy of the Proximal First Metatarsal
• If varus of the first metatarsal, whether primary or secondary, contributes to
the hallux valgus complex, correction near the origin of the defor
• Indication
• without significant degenerative arthritis in the first metatarsophalangeal
joint and
• with hallux valgus of more than 35 degrees and
• an intermetatarsal angle of more than 10 degrees
• Types
• crescentic,
• chevron,
• Ludloff, and
• scarf osteotomies

32. • A, Proximal crescentic
osteotomy.
• B, Proximal chevron osteotomy.
• C, Ludloff osteotomy.
• D, Scarf osteotomy

33. Scarf osteotomy
• “scarf” refers to a joint made by
notching, grooving, or
otherwise cutting the ends of
two pieces and fastening them
together so that they overlap
and join to form one continuous
piece
• horizontally directed
displacement Z-osteotomy
made at the diaphyseal level

34. Indication
• mild-to-moderate deformities
• intermetatarsal angle of 11 to 18 degrees and
• hallux valgus angle 20 to 40 degrees

35. Advantages
• high level of intrinsic stability
• broad surface area of bony healing.
• versatility:
• it allows lateral displacement of the plantar bone fragment to reduce the intermetatarsal angle,
• medial displacement of the capital fragment to correct hallux varus,
• plantar displacement to increase the load of the first ray, and
• elongation or shortening of the first metatarsal.
• The stability of the osteotomy allows early weight bearing and return to activities.
• The scarf osteotomy usually is combined with a
• lateral soft-tissue release,
• excision of the medial bony eminence, and
• medial capsulorraphy.
• proximal phalangeal osteotomy.

36. Ludloff Osteotomy
• oblique osteotomy of the first
metatarsal
• oriented from dorsoproximal to
distal plantar
• Inherent instability: has to be
fixed
• Simple
• angular correction through
bony rotation

37. Osteotomy of the Medial Cuneiform: for
metatarsus varus

38. Proximal Phalangeal Osteotomy(akin):hallux
valgus interphalangeus

41. Arthrodesis of the First
Metatarsocuneiform
Articulation (Lapidus
Procedure)