Hallux valgus 2008 (pp tshare)
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Transcript of Hallux valgus 2008 (pp tshare)
Hallux ValgusHallux Valgus
Hallux valgusHallux valgus
= Lateral deviation of the proximal phalanx on the 1st metatarsal head
Complex deformity of the 1st ray that frequently is accompanied by deformity & symptoms in lesser toes
EtiologyEtiology•Essential extrinsic factor = shoe•Female/male = 2:1 to 15:1
EtiologyEtiology•Intrinsic cause
Heredity: + FH ~63%
Pes planus: pronatn of foot = controversial
Metatarsus primus varus: juvenile form
First metatarsal length: 30% of JHV
Hypermobility of MTC joint: quantitation?
EtiologyEtiology•Intrinsic cause
Miscellaneous factors:
Amputation of 2nd toe
Cystic degeneration of medial capsule MTPJ
Achilles tendon contracture
Joint hyperelasticity = Ehlers-Danlos
AnatomyAnatomy
PathophysiologyPathophysiology
• Valgus deviation of halluxValgus deviation of hallux• Attenuated medial structure Attenuated medial structure • Varus metatarsal head Varus metatarsal head
deviation deviation • Sesamoid subluxation Sesamoid subluxation • Hallux pronation Hallux pronation (HVA >30-35)• Lateral contracture Lateral contracture
PathophysiologyPathophysiology
HistoryHistory Chief complaint:
pain over medial eminence ~70% keratosis Associated problems Age & level of activity Occupation Athletic inclinations Shoe wear Reasons for surgery
Patient evaluation
Physical examinationPhysical 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
Standing dorsoplantar view
Non-standing lateral oblique view
Standing lateral view Axial sesamoid view
Coughlin et al.Angular measurements in the evaluation of hallux valgus deformities.Foot Ankle Int 2002.
IMA (normal <9) [8-9]HVA (normal <15) [15-20]DMAA (normal <10) [10-15]
Hallux valgus angle
Intermetatarsal angle
Distal metatarsal articular
angle
Mild Moderate Severe
Hallux Valgus Angle <20 20-40 >40Intermetatarsal Angle<11 11-16 >16Sesamoid Subluxation <50% 50-75% >75%
Hallux valgus classificationHallux valgus classification
Painful joint ROMPainful joint ROMDeformity of the joint complexDeformity of the joint complexPain or difficulty with footwearPain or difficulty with footwearInhibition of activity or lifestyleInhibition of activity or lifestyle
Indications for surgeryIndications for surgery
Associated foot disordersAssociated 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
Extensive peripheral vascular disease Extensive peripheral vascular disease Active infection Active infection Active osteoarthropathy Active osteoarthropathy Septic arthritis Septic arthritis Lack of pain or deformity Lack of pain or deformity Advanced age Advanced age Lack of complianceLack of compliance
ContraindicationsContraindications
MI MI within the previouswithin the previous 6 6 months months Comorbid conditions that place the patieComorbid conditions that place the patie
nt at significant nt at significant CVCV or respiratory risk or respiratory risk
ContraindicationsContraindications
Shoes with wide toe boxShoes with wide toe box
OrthoticsOrthoticsmedial arch supporthallux valgus splint
Achilles tendon stretchingAchilles tendon stretching
Non-operative treatmentNon-operative treatment
Relieve pain
Correct deformity
Preserve MTP joint motion
Surgical GoalsSurgical Goals
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 evaluationPreoperative evaluation
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
Hallux Valgus <25Hallux Valgus <25Congruent Joint Chevron osteotomy Mitchell osteotomyIncongruent Joint Distal soft-tissue realignment (subluxation) Chevron osteotomy Mitchell osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus
Hallux Valgus 25Hallux Valgus 25-40-40Congruent Joint Chevron osteotomy + Akin procedure Mitchell osteotomyIncongruent Joint Distal soft-tissue realignment + proximal osteotomy Mitchell osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus
Severe Hallux Valgus >40Severe Hallux Valgus >40Congruent Joint Double osteotomy Akin + chevron osteotomy Akin + 1st metatarsal osteotomy Akin + 1st cuneiform opening wedge osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus
Severe Hallux Valgus >40Severe Hallux Valgus >40Incongruent Joint Distal soft-tissue realignment + proximal osteotomy First metatarsal crescentic osteotomy First cuneiform opening wedge osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus
Hypermobile 1Hypermobile 1stst MTC Joint MTC Joint Distal soft-tissue realignment + fusion 1st metatarsocuneiform joint
Degenerative joint diseaseDegenerative joint disease Fusion or Keller procedure or prosthesis
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus
DSTPDSTPModified McBride bunionectomy
DuVries & Mann
Metatarsal OsteotomyMetatarsal OsteotomyMitchell osteotomy
Metatarsal OsteotomyMetatarsal OsteotomyModified Chevron osteotomy
Metatarsal OsteotomyMetatarsal OsteotomyJohnson modified Chevron osteotomy
Proximal Metatarsal OsteotomyProximal Metatarsal Osteotomy
Scarf osteotomy
Scarf osteotomyScarf osteotomy
• Z-shaped osteotomy in the transverse plane • Lateral rotation of the distal fragment
Proximal Metatarsal OsteotomyProximal Metatarsal Osteotomy
Ludloff osteotomy
Distal osteotomyDistal osteotomyWilson: oblique cut
Mitchell: double cut, step
Chevron: V shape cut
Diaphyseal osteotomyDiaphyseal osteotomyScarf osteotomy: Z shape, step cut, translation
Ludloff: Rotation
Basal osteotomyBasal osteotomyOpen wedge, close wedge, crescentic
Basal chevron
AVN of 1AVN of 1stst MT head ! MT head !
Avoid shorteningAvoid shorteningMore stable then basalMore stable then basal
Extensive exposureExtensive exposure
High corrective powerHigh corrective power
Mild degreeMild degree
Unstable Unstable
Proximal Phalangeal OsteotomyProximal Phalangeal OsteotomyAkin procedure
Medial Cuneiform OsteotomyMedial Cuneiform OsteotomyRiedl & Coughlin
Resection arthroplastyResection arthroplastyKeller’s procedureKeller’s procedure
Simple resect 1/3 of proximal phalanxDecompress joint and relax tight
lateral structureAllow correction deformity
High recurrence rateLittle improve IMAMetatarsalgiaDifficult salvage of failure procedure
ArthrodesisArthrodesisIndications for fusion in HVArthritis associated with hallux valgusNeuromuscular disease/spasticityInflammatory arthritisSevere deformity with osteoporosisSalvage after failed bunion surgery or failed
arthroplastySalvage after infection (staged
reconstruction)
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 completed