Hallux Valgus

1
Hallux Valgus
2
Hallux Valgus

• Lateral deviation of the great toe and medial
  deviation of the first metatarsal
• Progressive subluxation of the first
  metatarsophalangeal (MTP) joint

3
Hallux Valgus

• Static deformity due to valgus angulation of the
  distal articular surface of the first metatarsal
  or the proximal phalangeal articular surface.

4
Pathophysiology of Deformity

• no single cause
• generalized ligamentous laxity
• footwear
• female sex
• family history
• intrinsic or anatomic conditions
• extrinsic causes

5
Pathophysiology - Extrinsic

• Almost exclusively in shoe-wearing societies
• Coughlin MJ, Thompson FM The high price of
  high-fashion footwear, in Jackson DW (ed)
  Instructional Course Lectures 44. Rosemont, IL,
  American Academy of Orthopaedic Surgeons, 1995,
  pp 371-377.

6
Pathophysiology

• Sim Fook L, Hodgson AR A comparison of foot
  forms among the non-shoe and shoe-wearing Chinese
  population. J Bone Joint Surg 195840A1058-1062
• Kato T, Watanabe S The etiology of hallux valgus
  in Japan. Clin Orthop 198115778-81

7
Pathophysiology - Intrinsic

• Pronation of the Hindfoot
• Inman VT Hallux valgus A review of etiologic
  factors. Orthop Clin North Am 1974559-66.
• Hohmann G Der hallux valgus und die ubrigen
  Zehenverkrummungen Ergeben. Chir Orthop
  192518308-376

8
Pathophysiology - Intrinsic

• Pes planus - allows pronation of 1st MT and
  decreases the effect of the abductor--reported
  50 incidence
• Metatarsus Primus Varus - lateral deviation of
  MTP
• Contracture of the Achilles tendon
• Generalized joint laxity
• Hypermobility of the first metatarsocuneiform
  joint
• Neuromuscular disorders (including cerebral palsy
  and stroke).

9
Pathophysiology - Heredity

• Hardy and Clapham noted that 63 of the 91
  patients in their series had a parent who had
  hallux valgus
• Coughlin reported that a bunion was identified in
  94 of 31 mothers of children who had hallux
  valgus.

10
Anatomy

• The Great toe is different than lesser toes
• Sesamoid mechanism
• A set of intrinsic muscles that stabilize the
  joint and provide motor strength to the first ray

11
Anatomy

• Four groups that encircle the first MTP joint
• Extensor hallucis longus and brevis
• Flexor hallucis longus and brevis
• Abductor
• Adductor

12
Anatomy

• Long and Short Flexors
• Hood ligaments
• Medial and Lateral Heads of the Flexor Hallucis
  Brevis inserting into the Medial and Lateral
  Sesamoids.

13
AnatomyPlantar Plate

• 2 seasmoids incorporated into tendons of FHB
• Plantar Plate formed by tendons of Adductor
  Hallucis, Abductor Hallucis, FHL and Joint Capsule

14
AnatomyDeforming Musculature

• 1. Abductor Hallucis
• -Inserts in the plantar aspect of the proximal
• phalanx
• -Can draw the phalanx medial and push metatarsal
  
• head lateral
• 2. Adductor Hallucis
• -2 origins
• -common tendon to plantar aspect of proximal
• phalanx and lateral aspect of plantar
• plate/sesamoid complex

15
AnatomyDeforming Musculature
16
Pronated Toe Fig 6
17

18
Fig 8

19
History and Physical Examination

• The primary symptom of hallux valgus is PAIN over
  the medial eminence.
• Pressure from footwear is the most frequent cause
  of this discomfort.
• Bursal inflammation
• irritation of the skin
• breakdown of the skin may be noted.

20
Patient EvaluationHISTORY

• Must include entire patient
• Family history
• Symptoms
• pain or just deformity
• Look for presence of
• neurologic disorder
• ligamentous laxity

21
Patient EvaluationHISTORY

• Educate the patient with regard to the problem
• alternatives for treatment
• risks and complications when surgery is indicated
  
• A patient's preoperative expectations play a
  major role in his or her postoperative
  satisfaction.

22
Patient EvaluationHISTORY

• Relief of pain is frequently the major objective
• Improved appearance of the foot
• Ability to wear smaller or narrower shoes

23
Patient EvaluationHISTORY

• Mann RA Decision-making in bunion surgery, in
  Greene WB (ed) Instructional Course Lectures
  XXXIX. Park Ridge, IL, American Academy of
  Orthopaedic Surgeons, 1990, pp 3-13.
• while 59 of patients were able to wear their
  choice of shoes after repair of a hallux valgus
  deformity, 41 were not.

24
Patient EvaluationPHYSICAL EXAM

• Skin
• calluses, areas of redness
• Sites of pain
• Motion of 1st MTP joint-increased or decreased
• Mobility and structure of foot in general
• Gait analysis

25
Patient EvaluationPHYSICAL EXAM

• The patient sitting and standing
• accentuated with weightbearing
• Pes planus deformity
• Contracture of the Achilles tendon
• Magnitude of the Hallux Valgus deformity
• Pronation of the great toe

26
Patient EvaluationPHYSICAL EXAM

• Passive and active range of motion of the MTP
  joint is measured
• Pain or crepitus, or both, with motion of the MTP
  joint
• Metatarsocuneiform joint for hypermobility
• Examiner grasps the first metatarsal with the
  thumb and index finger and pushes it in a plantar
  lateral-to-dorsomedial direction.
• Mobility of more than 9 mm represents
  hypermobility

27
Patient EvaluationRadiographic Examination

• Weightbearing AP
• Lateral
• Axial (Sesamoid)

28
Patient EvaluationRadiographic Examination

• Weightbearing AP/Lateral
• Assess for bone and joint deformity
• Length and shape of 1st MT
• Congruent vs. Incongruent joint
• Osteoarthrosis
• Forefoot alignment is evaluated for metatarsus
  Adductus
• Hindfoot is Inspected for Pes Planus or Pes
  Cavus.

29
Patient EvaluationRadiographic Examination

• Measure Angles
• Hallux Valgus angle
• Intermetatarsal angle
• Distal Metatarsal Articular Angle (DMMA)
• Proximal Phalangeal Articular Angle (PPAA)

30
Patient EvaluationRADIOGRAPHY

• Hallux Valgus Angle
• Intersection of longitudinal axis of 1st MT and
  proximal phalanx.
• Normally lt 15 degrees

31
Patient EvaluationRADIOGRAPHY

• Intermetatarsal Angle
• Intersection of 1st and 2nd MT
• normally lt 9 degrees
• increased with metatarsus primus varus

32
Patient EvaluationRADIOGRAPHY

• Distal Metatarsal Articular Angle
• Defines the relationship of the distal articular
  surface of the 1st MT to the longitudinal axis.
• Quantities the magnitude of lateral slope of
  articular surface.

33
Patient EvaluationRADIOGRAPHY

• With subluxation, the articular surface deviates
  laterally in relationship to the 1st Metatarsal.
• Usually lt 6 degrees.

34
Patient EvaluationRADIOGRAPHY

• Congruency of MTP joint
• Will determine appropriate surgical repair.
• An intra-articular repair, or soft tissue repair
  in the presence of a congruent joint is at a high
  risk to develop postoperative stiffness or
  recurrence.

35
Patient EvaluationRADIOGRAPHY

• Metatarsocuneiform Joint
• Key role in alignment of first ray.
• Increased IM angle consistent with juvenile HV
• Theorized that IM deformity or metatarsus primus
  varus is often the primary deformity and hallux
  valgus follows.
• Hypermobility may predispose to recurrence.

36
Classification

• Mild, Moderate, and Severe

37
Classification Mild

• Hallux valgus angle of less than 20
• First-second intermetatarsal angle of 11 or
  less.
• Subluxation of the lateral sesamoid, as measured
  on an AP radiograph, is less than 50.

38
Classification Moderate

• Hallux valgus angle of 20 to 40
• First-second intermetatarsal angle of less than
  16 .
• 50 to 75 Subluxation of the lateral Sesamoid.

39
Classification Severe

• Hallux Valgus angle of more than 40
• First-second intermetatarsal angle of 16 or more
• More than 75 subluxation of the lateral
  sesamoid.

40
Treatment

• Non-operative vs. Operative
• All patients should be treated non-operatively
  first.
• Important to decide who wants the
  treatment--parents or the patient.
• Pain more important than cosmesis.

41
TreatmentNON-OPERATIVE

• Footwear Modification
• Widen toe box
• decrease lateral deviation of great toe
• decrease inflammation and pain
• Decrease heel height
• prevent forward slide of the foot
• Arch support
• may negate effects of pes planus

42
TreatmentNON-OPERATIVE

• Contracture of the Achilles tendon
• Stretching exercises
• Lengthening of the Achilles tendon

43
TreatmentNON-OPERATIVE

• Grioseo, Jorge JBJS 1992
• 56 pt. between ages of 1 mo. and 16 yr.
• Treated with thermoplastic night splint and
  passive and active exercises until maturity.
• Follow up 2-6 yr.
• 50 had improvement in HV or IM angle.
• No recurrences in those that improved.

44
TreatmentNON-OPERATIVE

• Active Exercises

45
TreatmentSURGICAL

• Despite conservative measures, some patients
  eventually need surgical intervention.

46
TreatmentSURGICAL

• Indications
• Persistent symptoms not cosmetic complaints
• Progression of deformity
• Failure of non-operative treatment
• Goals
• Correct all pathologic elements and yet maintain
  a biomechanically functional forefoot
• Usually will not result in a foot with normal
  appearance

47
TreatmentSURGICAL

• The chosen surgical technique must correct all
  elements of the problem
• prominence of the medial eminence
• increased valgus angulation of the proximal
  phalanx
• increased first-second intermetatarsal angle
• congruency of the MTP joint
• subluxation of the sesamoids,
• pronation of the great toe.

48
TreatmentSURGICAL

• Distal Soft-Tissue Reconstruction
• Silver popularized it by performing medial
  capsulorrhaphy, a medial exostectomy, and a
  lateral capsular and adductor release.
• McBride, who advocated removal of the lateral
  sesamoid and transfer of the adductor tendon to
  the lateral aspect of the first metatarsal head.

49
TreatmentSURGICAL

• Distal Soft-Tissue Reconstruction
• Medial and lateral procedures
• If done in the presence of a congruent joint can
  create a non-congruous articulation.
• Hallux Valgus angle lt30 degrees
• IMA lt 15 degrees
• High rate of recurrence if done without bony
  procedure
• Medial and lateral procedures at the same time
  contraindicated.

50
TreatmentSURGICAL

• Medial Procedures
• Tighten lax capsule
• advancement, plication or resection
• Abductor must not be detached

• Lateral Procedures
• Capsular release
• adductor longus release or transfer
• Division of transverse MT ligament
• risk NV bundle

51
TreatmentSURGICAL

• Medial side procedure recommended
• Be aware of cutaneous branch of medial plantar
  nerve.

52
TreatmentSURGICAL

• Lateral procedure
• Can be more difficult than medial procedure
• Neurovascular risk

53
TreatmentSURGICAL

• Bony Procedures
• Most will require osteotomy
• Combine with DSTP
• Types
• Phalangeal osteotomy
• Distal MT osteotomy
• Proximal MT osteotomy
• Combination osteotomies
• Metatarsocunieform procedures

54
TreatmentSURGICAL

• Proximal Phalanx Osteotomy-Akin
• Correction of a hallux valgus deformity with a
  medial eminence resection and medial capsular
  reefing, combined with a medial closing-wedge
  phalangeal osteotomy

55
TreatmentSURGICAL

• Akin
• Used primarily for Hallux Valgus Interphalangeus
  deformity.
• Can combine with 1st MT osteotomies for greater
  correction in congruent joint.

56
TreatmentSURGICAL

• Distal Metatarsal Osteotomy
• Done for IM angle 12-15 degrees
• Numerous types
• Mitchell step cut osteotomy
• Wilson
• Chevron

57
TreatmentSURGICAL

• Wilson Osteotomy
• Oblique osteotomy
• Allows the MT head to slide proximally and
  medially.
• Large cancellous area for healing.
• May shorten 1st MT, transfer weight to lateral MT
  heads--metatarsalgia results.

58
TreatmentSURGICAL

• Mitchell Osteotomy
• Step cut
• MT head displaced laterally without shortening.

59
TreatmentSURGICAL

• Problems with the Mitchell
• May allow MT head to displace dorsally.
• In cortical bone--slower healing.
• Ball and Sullivan Orthopaedics 8(10) 1985
• showed recurrence in 11/18 cases done for
  adolescent HV
• 6/18 marked loss of motion
• 61 were satisfied with the procedure

60
TreatmentSURGICAL

• Chevron Type Osteotomy
• IM angles lt 15
• Correction is less than the Mitchell.
• Reduces risk of dorsal displacement
• May use internal fixation of K-wire or
  post-operative external immobilization.

61
TreatmentSURGICAL

• Chevron Technique
• Distal fragment should not be displaced
  laterally more than 1/3
• Medial plication

62
Zimmer, Johnson and KlassenFoot Ankle 9(4)
1989

• 20 patients, 35 feet with symptomatic HV
• Treated all with chevron osteotomies
• Average F/U 64 months
• 85 expressed overall satisfaction
• 90 approved of cosmetic results
• 1/3 still could not wear footwear of choice

63
Donnelly, Saltzman, Kile and JohnsonModified
Chevron Osteotomy for Hallux ValgusFoot Ankle
1994 15(12)

• Chevron osteotomy altered to facilitate screw
  fixation, decrease likelihood of malunion and AVN
• 36 adults with 42 feet
• 35/42 satisfied without reservations
• no malunion/AVN

64
TreatmentSURGICAL

• Proximal Metatarsal Osteotomy
• Appropriate for larger gt15 IM angles
• Medial opening wedge, lateral closing wedge,
  cresentic or dome
• Must avoid growth plate in Adolescents
• Should combine with DSTP

65
TreatmentSURGICAL
Proximal Cresenteric Osteotomy
66
TreatmentSURGICAL

• Double Osteotomy
• Peterson and Newman JPO 1993
• Double osteotomy of 1st MT with longitudinal IM
  pin fixation
• Valgus art surface corrected with distal closing
  wedge
• Metatarsus Primus Varus corrected with proximal
  opening wedge
• 13/15 with excellent results
• 2 poor due to post op hallux varus

67
TreatmentSURGICAL

• Double Osteotomy Technique

68
TreatmentSURGICAL

• Arthrodesis
• 1st MTP joint limited indications--JRA or
  neuromuscular diseases.
• 1st metatarsocuneiform arthrodesis (Lapidus) can
  be considered with hypermobile first ray
• Lapidus should be combined with DSTP

69
TreatmentSURGICAL-LAPIDUS

70
ComplicationsSURGERY

• Recurrent deformity
• Hallux Varus
• Pronation deformity
• Pain
• Neurologic Injury
• Osteonecrosis
• Physeal injury/arrest
• Nonunion/malunion

71
ComplicationsSURGERY

• Recurrence
• reported rate 20-30
• Geissele and Stanton JPO 1990
• reported recurrence rate to be 16 in 32 feet
  treated operatively
• felt to be due to lack of correction of IM angle

72
TreatmentALGORITHM

1. Non-operative splinting
2. Surgery only for persistent symptoms and
   progression.
3. Combine soft tissue procedures with bony
   procedures in almost all cases.
4. Akin for abnormal proximal phalangeal angle.

73
TreatmentALGORITHM

1. Distal First MT osteotomy, preferably a chevron,
   for moderate deformity. (IMlt15)
2. If deformity is severe, proximal osteotomies may
   be combined with distal procedures depending on
   deformity and surgical expertise.
3. Post operative immobilization/splintng is a must

74
TreatmentALGORITHM
Couglin Surgery of FA 1993
75
TreatmentALGORITHM
Couglin Surgery of FA 1993
76
TreatmentALGORITHM
Couglin Surgery of FA 1993