DR. PRUTHVIRAJ NISTANE

Deptt. Of Orthopaedics,Unit II Govt. Medical College and Rajindra Hospital, Patiala

A large proportion of clinical complaints of the foot center on the first metatarsophalangeal (MTP) joint.

This articulation alone bears one-third of the weight of the forefoot and helps stabilize the longitudinal arch

=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

• metatarsus primus varus• hallux valgus• hallux valgus interphalangeus

EtiologyEtiology

•Female/male = 2:1 to 15:1• Heredity: + FH ~63%

•Essential extrinsic factor = shoe

EtiologyEtiology

•Intrinsic ANOTOMICAL cause• Pes planus• Metatarsus primus varus: juvenile form• First metatarsal length• Hypermobility of first ray• Pronated flatfeet• Abnormal insertion of the posterior tibial

tendon

• Amputation of 2nd toe• Cystic degeneration of medial capsule

MTPJ• Achilles tendon contracture• Joint hyperelasticity = Ehlers-Danlos

AnatomyAnatomy

PathoanatomyPathoanatomy•Most commonly LATERAL DEVIATION OF GREAT TOE is primary deformity•Valgus angle of the first metatarsophalangeal joint exceeds 30 to 35 degrees•Increase in angle between first and second metatarsal (metatarsus primus varus) at MTMC joint•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

PathoanatomyPathoanatomy

Pathogenesis • the abductor hallucis moves plantar ward• Only restraining medial structure is the medial

capsular ligament • Dorsiflexion of MTP joint• 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.

PathophysiologyPathophysiology• Valgus deviation of hallux• Attenuatedmedial structure • Varus metatarsal head deviation • Sesamoidsubluxation • Hallux pronation• Lateral

contracture

• the sesamoid ridge on the plantar surface of the first metatarsal head (the crista) flattens

• With this restraint lost, the fibular sesamoid displaces partially or completely into the first space

• Fibular sesamoid, when pulled proximally by the lateral head of the flexor hallucis brevis, pulls the flexor hallucis longus laterally through the sesamoid apparatus and contributes to recurrent hallux

valgus.(so, when the deformity is

severe-excision of the fibular

sesamoid is added to the

procedure)• patient is bearing less weight

on the first ray and more on the

lesser metatarsal heads causing

transfer metatarsalgia, callosities, and stress fractures

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

Consequencesa hammer toe–like deformity of the second

toe the splaying of the forefoot corns often developbursal hypertrophy over the medial eminence

of the first metatarsal head (bunion)Osteoarthritis Callositymetatarsalgia.

The entire forefoot must be evaluated for these multiple components of hallux valgus

History• Chief complaint: oPain over medial eminence ~70%, at the metatarsophalangeal joint or beneath the lesser metatarsal headsoKeratosis•   Associated problems•   Age & level of activity•   Occupation•   Athletic inclinations•   Shoe wear•   Reasons for surgery

Patient evaluation

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

X-ray

Standard preoperative radiographs should include

1.Standing dorsoplantar views

2.Standing Lateral views

3.Nonstanding lateral oblique view

4.Axial sesamoid views

Standing dorsoplantar view

Non-standing lateral oblique view

Standing lateral view Axial sesamoid view

Evaluation of x-rays

•IMA (normal 8-9) •HVA (normal 15-20) •DMAA (normal 10-15) •PAA (normal 7-10)•OA changes•Position of sesamoids•Incongruent or subluxated joint

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

Give initial trial

Shoes with wide toe box

Orthotics• medial arch support• hallux valgus splint

Achilles tendon stretchingExercisesActivity adjustments

Non-operative treatmentNon-operative treatment

•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

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

Extensive peripheral vascular disease Active infection Active osteoarthropathy Septic arthritis Lack of pain or deformity Advanced age Lack of compliance Co-morbidities

Contraindications

 Relieve pain

Correct deformity

Preserve MTP joint motion

Surgical Goals

more than 130 operations recommended for the treatment of hallux valgus,

most procedures to correct hallux valgus still use one or more of the components described:

Removal of the exostosisdissection of the bursatenotomy and transplantation of the tendons, removal of the sesamoidspartial and complete removal of the head of the first metatarsalremoval of the proximal end of the proximal phalanx

together with numerous combinations

   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

   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

IndicationsStress view radiographs - a firm forefoot wrap

reduces the intermetatarsal angle to a normal value and decreases the hallux valgus angle

Middle agedMild to moderatea valgus angle at the metatarsophalangeal joint of

15 to 25 degreesan intermetatarsal angle of less than 13 degrees, valgus of the interphalangeal joint of less than 15

degreesno degenerative changes at the

metatarsophalangeal jointa history of conservative management failure

Modified McBride Bunionectomy

L-SHAPED MEDIAL CAPSULAR INCISION

MEDIAL EMINENCE REMOVAL ADDUCTOR TENDON AND LATERAL CAPSULAR

RELEASE and reattach to 1st MT head between heads of 1st and 2nd MT

MEDIAL CAPSULAR IMBRICATION

FIBULAR (LATERAL) SESAMOIDECTOMY - the adductor hallucis and lateral head of the flexor hallucis brevis are released reducing the valgus.

In addition, the pull of the fibular sesamoid on the flexor hallucis longus through its tendon sheath and pulley system is prevented, reducing another important valgus-producing force on the hallux at the metatarsophalangeal joint

CLOSURE OF THE INVERTED-L CAPSULOTOMY

Modified McBride bunionectomy

DuVries & Mann

Distal Soft tissue handling includes

Medial eminence removal Adductor tendon and lateral capsular releaseMedial capsular imbricationReduction of MTP joint and sesamoids

The decision to perform an osteotomy should be made at the time of surgery by passively reducing the intermetatarsal angle. If the first metatarsal does not move laterally, or if it springs back quickly into varus after the laterally directed pressure is released then an osteotomy should be done

A) KELLER RESECTION ARTHROPLASTY

INDICATIONS

moderate-to-severe hallux valgus (30 to 45 degrees)

mild-to-moderate metatarsus primus varus(intermetatarsal

angles of 13 degrees or less)

pain over the medial eminence

An incongruous first metatarsophalangeal joint caused by lateral

subluxation of the phalanx on the metatarsal head

severe lateral displacement of the sesamoids,

Any evidence of degenerative cartilage changes

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 of the first metatarsal

fibular sesamoidectomy Adductor tenotomy lateral displacement of the first metatarsal complete lateral dislocation of the sesamoids,

marked degenerative changes, and severe pronation of the hallux may benefit

Complications are more

Resection arthroplastyResection arthroplasty

B) DISTAL METATARSAL B) DISTAL METATARSAL OSTEOTOMYOSTEOTOMY

Some studies suggest that VARUS OF THE FIRST METATARSAL WAS THE PRIME OR INITIAL DEFORMITY, and that valgus deviation of the hallux only followed it

Mitchell osteotomy

consists of

(1) Removal of the medial eminence

(2) An osteotomy of the distal portion of the first metatarsal shaft - DOUBLE OSTEOTOMY OF THE METATARSAL NECK

(3) Lateral displacement ,planter flexion and angulation of the capital fragment

(4) Removal of the resulting projection of the first metatarsal

(5) Medial capsulorrhaphy

(6) No interanal fixation

Mitchell osteotomy

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.

ADVANTAGESmade through cancellous boneshortens the metatarsal lessinherently stableFixation of the osteotomy with one or two Kirschner wires, a

cortical screw, or a biodegradable pin adds stability to the osteotomy

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

(5) medial capsulorrhaphy

Modified Chevron Osteotomysimply a more proximal placement of the apex of the

osteotomy in the metatarsal head. can be used for more severe deformities (up to 35 degrees

of hallux valgus and up to 15 degrees of first to second intermetatarsal diversion)

Johnson Modified Chevron Osteotomychanging the length and position of the limbs of the

osteotomy in the metatarsal head - short dorsal arm and long plantar arm

extended the indications for the osteotomy to severe deformities with intermetatarsal angles of 15 or 16 degrees

a 2.7-mm screw is used for internal fixation

Modified Chevron osteotomy

Johnson modified Chevron osteotomy

C) PROXIMAL FIRST METATARSAL OSTEOTOMYvarus of the first metatarsal, whether primary or

secondary, contributes to the hallux valgus complex

correction near the origin of the deformity is reasonable,

combined with a soft-tissue procedure at the first

metatarsophalangeal joint to correct the valgus of the

hallux

a few degrees' shift of the metatarsal at its base causes

marked improvement at the distal end of the metatarsal

Advantages1. Cancellous bone and broad contact surfaces

2. Small changes in position at the osteotomy produce excellent correction

at the distal end of the metatarsal where the symptoms are located

3. The metatarsal is shortened minimally

4. Large angles between the first and second metatarsals can be corrected

5. Slightly tilting the distal fragment plantarward reduces load bearing by

the second metatarsal, decreasing the chance of transfer

metatarsalgia.

Disadvantages

  1.    Extensive soft-tissue dissection is required

   2.    The distal fragment tends to displace dorsally or

medially

3.    The second ray may be overloaded if the

fragment displaces or migrates

   4.    Three incisions are required

   5.    more difficult

   6.    more pain, swelling, and immobility

   7.    Cast immobilization is more frequently needed

Indications

A patient without significant degenerative arthritis in the

first metatarsophalangeal joint

hallux valgus of more than 35 degrees

an intermetatarsal angle of more than 10 degrees

Severe deformities

Types

Types A) Proximal crescentic osteotomy

B) Proximal chevron osteotomy--increased stability at the osteotomy site

C) Ludloff osteotomy.-- oblique osteotomy of the first metatarsal oriented from dorsoproximal to distal plantar.

If fixed with lag screw compression is more rigido less elevation and shorteningo mechanical stability that allows early ambulationo simplicity (involving only a single cut in the bone)o angular correction through bony rotationo plantar flexion of the first metatarsal

Ludloff osteotomy

D.Scarf osteotomy--horizontally directed displacement Z-osteotomy made at the diaphyseal level

o “scarf” refers to a joint made by notching, grooving, or otherwise cutting the ends of two pieces and fastening them together

versatility: o lateral displacement of the plantar bone fragment to reduce

the intermetatarsal angleo medial displacement of the capital fragment to correct hallux

varuso plantar displacement to increase the load of the first rayo elongation or shortening of the first metatarsal. o The stability of the osteotomy allows early weight bearing

Scarf osteotomy

Identify ???

D) MEDIAL CUNEIFORM OSTEOTOMY

Indications

in adolescents with open proximal metatarsal physes

especially patients with an abnormally wide

intermetatarsal angle

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, 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

Indications

  1.    Patient older than 55 years

   2.    Excessive hallux valgus interphalangeus (in

patient of any age)

   3.    Hallux valgus of no more than 25 degrees

   4.    Intermetatarsal angle of less than 13 degrees

   5.    Good metatarsophalangeal joint motion

Contraindications

1.    Rheumatoid arthritis

   2.   osteoarthritis at the metatarsophalangeal joint

   3.    Intermetatarsal angle more than 13 degrees

   4.    Hallux valgus angle more than 30 degrees

   5.    Subluxation laterally of the tibial sesamoid more

than 50% of its width

   6.    Open physis of the proximal phalanx (can be

performed at neck instead of base)

Proximal Phalangeal OsteotomyProximal Phalangeal OsteotomyAkin procedure

Chevron-Akin Double Osteotomycombination of the chevron and Akin osteotomies to

gain greater correction of mild-to-moderate hallux valgus deformities.

F) 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

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.

Why to differentiate ???an increased distal metatarsal articular angle may be the

defining characteristic of juvenile hallux valgus

1.    Pain, either at the metatarsophalangeal joint or

beneath the lesser metatarsal heads, may not be the

primary complaint in many instances

   2.Osteotomy of the first metatarsal is almost always

necessary

3.    Varus of the first metatarsal with a widened

intermetatarsal angle is almost always present  

4.    Hypermobile flatfoot with pronation of the foot during

weight bearing frequently is associated with the deformity

   5.    Recurrence of the deformity is more frequent

   6.    Hallux valgus interphalangeus and deformity in

articular angles may be prominent

   7.    The family history frequently

   8.    Soft-tissue procedures alone are unlikely to result

in permanent correction.

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 is

Pain and shoe-fitting problems

Types of surgerylesser deformities Adductor tenotomy, lateral

capsulotomy, medial eminence removal, and medial capsulorrhaphy

Moderate to severeo metatarsal physis is fully open a distal medial opening wedge

osteotomyo metatarsal physis is closed/ near closureproximal

crescentic osteotomy is recommended

Severe Peterson and Newman double first metatarsal osteotomies, an opening wedge proximally and a closing wedge distally to correct the abnormal distal metatarsal articular angle and the abnormal intermetatarsal angle

Distal osteotomyDistal osteotomyMitchell: double cut, step

Chevron: V shape cut

Diaphyseal osteotomyDiaphyseal osteotomyScarf osteotomy: Z shape, step cut, translation

Ludloff: Rotation

Basal osteotomBasal osteotomCrescentic

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

Hallux Valgus <25Hallux Valgus <25Congruent Joint   Soft tissue procedures Chevron osteotomy  Mitchell osteotomy

Incongruent Joint (subluxation)   Distal soft-tissue realignment +

   Chevron osteotomy   Mitchell osteotomy

Treatment of Hallux ValgusTreatment of Hallux Valgus

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

Severe Hallux Valgus >40Severe Hallux Valgus >40

Congruent Joint

   Double osteotomy

   Akin + 1st metatarsal osteotomy   Akin + 1st cuneiform opening wedge osteotomy

Treatment of Hallux ValgusTreatment of Hallux Valgus

Severe Hallux Valgus >40Severe Hallux Valgus >40Incongruent Joint    Distal soft-tissue realignment +

Proximal osteotomy   First cuneiform opening wedge osteotomy

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

Treatment of Hallux ValgusTreatment of Hallux Valgus

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

Complications of surgeryEven experience, detailed physical and radiographic

evaluations, excellent surgical technique, and careful postoperative care do not guarantee that a complication will not occur

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,

medial eminence pain

clawed hallux

transfer keratotic lesions

development of the opposite deformity, hallux

varus

complication of hallux valgus surgeryBECAUSE

(1) complete release of the lateral structures of the metatarsophalangeal joint combined with excessive plication of the medial capsule, which pulls the sesamoids too far medially;

(2) excessive resection of the medial eminence, leading to loss of medial bony buttress for the proximal phalanx;

(3) excision of the fibular sesamoid;

(4) release of the lateral head of the flexor hallucis brevis at its insertion into the fibular sesamoid

(5) closure of the intermetatarsal angle to neutral or a negative value.

Two typesstatic (supple)

Uniplanar, and passively correctableusually is asymptomatic and mainly is a cosmetic

complication

dynamic (fixed)A multiplanar deformity that is fixed, symptomatic, and

difficult to correct surgically .The term that best describes the deformity is intrinsic minus

deformity of the hallux with a varus component. This is a true intrinsic-extrinsic muscle imbalance. The first metatarsophalangeal joint is hyperextended interphalangeal joint is acutely flexed

CORRECTION OF UNIPLANAR (STATIC) HALLUX VARUSNot all patients with acquired hallux varus require

operative treatmentA conservative program of modified shoe wear and taping

of the hallux should be attempted

A medial capsulotomy, placing the sesamoids in their proper location if subluxed medially, and holding the hallux in 10 to 15 degrees of valgus with a K- wire

Transfer of Extensor Hallucis Longus with Arthrodesis of the Interphalangeal Joint of the Hallux

CORRECTION OF DYNAMIC (MULTIPLANAR) HALLUX VARUSmost often either resection arthroplasty (resecting the

proximal third of the phalanx)

or arthrodesis of the metatarsophalangeal joint

along with an arthrodesis of the interphalangeal joint or a plantar

plate release at the interphalangeal joint with pin fixationIf all components in the all planes are correctable and

passive motion at the metatarsophalangeal joint approaches normal in flexion and extension, soft-tissue repair of the deformity may be successful

adult hallux rigidus most often is caused by degenerative arthritis of the first metatarsophalangeal joint

in adolescents, hallux rigidus usually results from localized cartilage damage to the first metatarsal head.

Earliest lesion in the articular cartilage of the first metatarsal head without any detached subchondral bone,

Earliest radiographic finding was a small depression in the dome of the metatarsal head

Late limited extension. As the disease worsens, an osteophyte at the dorsal articular margin of the metatarsal head presents a mechanical abutment to extension

limitation of motion, and pain.

limitation of motion of the metatarsophalangeal joint of the great toe.

the pathogenesis of hallux rigidus is still not clearly defined,

its unrelenting destructive course is well appreciated. Cartilage damage is believed to initiate the synovitis, which

leads to further cartilage destruction, osteophyte proliferation, and subchondral bone destruction.

may begin in adolescence when a single traumatic event at the metatarsophalangeal joint damages the dorsal articular surface of the metatarsal head.

Repeated microtrauma also may cause articular cartilage damage.

Other causes include osteochondritis dissecans of the first metatarsal head secondary to an osteochondral fracture over the dorsal convexity of the joint surface

Non-operative Treatment In most patients, operative correction is required to relieve

pain and improve function

activity modification, shoe adjustments ensuring adequate

room for the metatarsophalangeal joint, and stiffening the

shoe by inserting either an orthotic device

NSAIDs

Operative Treatment

Cheilectomy The goal of this procedure is to remove the

proliferative bone from around the metatarsal head so as to

remove the buttress preventing dorsiflexion of the proximal

phalanx on the metatarsal head

Arthrodesis of the First Metatarsophalangeal Joint

Resection Arthroplasty (Keller Procedure)

Extension Osteotomy of the Proximal Phalanx

Scenario #1Older PatientSevere deformity (HV angle > 40)Inflammatory diseaseDegenerative Changes

FUSION ? Keller’s ? Prosthetic arthroplasty

Scenario #2Young Patient (congenital Hallux Valgus)Congruent, Increased DMAA, Increased IMA

All Extra ArticularProximal Chevron / Medial closing wedge distallyAkinNO lat release / NO medial tightening

Scenario #3Middle aged patient / wide forefootIncongruent, Increased IMA, Normal DMAA

Proximal osteotomyLateral release / Medial tightening (Modified

McBride)+/- Akin

Scenario #4The most common oneMiddle aged femaleNot severe, Normal IMA, Slightly incongruent

Chevron, medial capsular tightening+/- Akin