34 Journal of the American Academy of Orthopaedic Surgeons

Hallux valgus and hallux rigidus arethe most common disorders of thefirst metatarsophalangeal (MTP)joint. Selection of the optimal treat-ment for either of these painful con-ditions must be based on carefulconsideration not only of objectiveclinical and radiographic findings butalso of subjective factors, such as thepatient’s lifestyle and expectations.

Hallux Valgus

The hallux valgus deformity can pre-sent in many forms. The main problemmay be a prominent medial eminence(bunion) or may be due to the lateraldeviation of the proximal phalanx onthe first metatarsal, which results in asecond-toe problem. The precise typeof the deformity, the patient’s clinicalcomplaints, and the physical examina-tion and radiographic findings form

the basis for rational decisions regard-ing treatment of the deformity. Thereis no single operative procedure to cor-rect all types of hallux valgus deformi-ties, since no two bunion deformitiesare exactly alike. The surgeon must bevery specific in the selection of theoperative procedure, which must thenbe carried out in a technically correctmanner and carefully followed post-operatively to obtain the maximumcorrection and to minimize com-plications.

Historical Overview of SurgicalTreatment

Keller1 approached hallux valgusby decompression of the MTP jointthrough resection of the base of theproximal phalanx and removal of themedial eminence. Unfortunately,this approach destabilizes the firstMTP joint due to loss of the windlassmechanism and results in transfer

metatarsalgia and deformity of thegreat toe due to lack of stability. Fur-thermore, many physically activepatients had poor function.

To alleviate the chief complaint ofpain over the medial eminence, Sil-ver2 advised excision of the medialeminence and plication of the medialjoint capsule. This relatively simpleprocedure resulted in alleviation ofthe painful bunion, but the correctionof the first MTP joint abnormality wasnot achieved in most cases, except inthose with a minimal deformity.

It became recognized that therewere some patients in whom theproblem was more than just a defor-mity at the MTP joint, and that theintermetatarsal (IM) angle must alsobe corrected. The McBride proce-dure3 consists of excision of the fibu-lar sesamoid, removal of the medialeminence, plication of the medial jointcapsule, and implantation of theadductor tendon into the firstmetatarsal in order to reduce the IMangle. This procedure provided bet-ter long-term results than just excisingthe medial eminence and plicating the

Disorders of the First Metatarsophalangeal Joint

Roger A. Mann, MD

Dr. Mann is Associate Clinical Professor ofOrthopaedic Surgery, University of CaliforniaSchool of Medicine, San Francisco, and is Direc-tor of the Foot Fellowship Program in his privatepractice in Oakland, Calif.

Reprint requests: Dr. Mann, 3300 WebsterStreet, No. 1200, Oakland, CA 94609.

Copyright 1995 by the American Academy ofOrthopaedic Surgeons.

Abstract

The two most common disorders of the first metatarsophalangeal (MTP) joint arehallux valgus and hallux rigidus. The hallux valgus deformity has been the sub-ject of numerous clinical studies in the past decade. This information has enabledthe creation of an algorithm to assist the clinician in evaluating the patient withhallux valgus and selecting the appropriate surgical procedure. The technicalaspects of various operative procedures and the most common complications arereviewed. The other major disorder of the first MTP joint is arthrosis, whichresults in hallux rigidus. As the arthrosis progresses, there is often proliferationof bone on the dorsal aspect of the metatarsal head, which results in impingementof the proximal phalanx during dorsiflexion. The impingement causes jamming,instead of gliding, of the proximal phalanx on the metatarsal head, which resultsin pain. The treatment for this condition consists of debridement of the MTP jointto relieve the dorsal impingement and, in most cases, the pain. If the arthrosis isadvanced in an active individual, arthrodesis is indicated.

J Am Acad Orthop Surg 1995;3:34-43

capsule, since it did address, to a cer-tain extent, the increased IM angle.Overall results were satisfactory, butovercorrection of the MTP jointoccurred, resulting in hallux varus,probably mainly due to the imbalancebrought about by excision of the fibu-lar sesamoid and plication of themedial joint-capsule structures.

To diminish the incidence ofvarus, DuVries4 proposed that theadductor tendon no longer be placedinto the metatarsal, but rathersutured adjacent to it, whichresulted in satisfactory alignmentbut inconsistent results. Osteotomythen began to be used increasingly.

OsteotomiesThe recognition that the abnormal

IM angle must also be addressedresulted in metatarsal osteotomies ofmany shapes and forms designed toaddress this component of the defor-mity. Ideally, the most useful osteot-omies correct the IM angle withminimal shortening and provide ade-quate stability of the osteotomy site.Most metatarsal osteotomies are car-ried out either distally or proximally,although the degree of correction thatcan be obtained with a distal osteotomyis not as great as with a proximalosteotomy. As a rule, the distalosteotomy is used for the mild to low-moderate deformity, and the proximalosteotomy is used for the more severedeformity. Regardless of the site, 2 to 3mm of shortening is inevitable.

Further, it has been recognized thatmetatarsal osteotomy alone is insuffi-cient to correct the entire deformity.A distal soft-tissue procedure mustbe added, including release of the lat-eral soft-tissue contracture. Thisrelease involves the adductor hallucisfrom the proximal phalanx and fibu-lar sesamoid, the lateral joint capsule,and the transverse metatarsal liga-ment. The medial eminence isexposed and excised in line with themedial aspect of the metatarsal shaft.The medial joint capsule is plicated.

Occasionally, some dorsiflexionresults after osteotomy. Precisely howmuch shortening and dorsiflexion canbe tolerated without causing a clinicalsymptom remains uncertain. Dorsi-flexion of the first MTP joint doesbring about plantar flexion of the firstmetatarsal, which, in turn, will allowfor a certain degree of shorteningand/or elevation of the metatarsal. Ina recent study of our patients with aproximal osteotomy,5 about 30% werefound to have some element of dorsi-flexion of the metatarsal, but 43 of 48patients with a preexisting lesionbeneath the second metatarsal hadrelief of symptoms, and no transferlesion developed in any case.

FusionsInstability of the metatarso-

cuneiform joint is a factor in 2% to 3%of patients with a hallux valgus defor-mity.6 If there is marked instability, ametatarsocuneiform arthrodesis isnecessary. Without arthrodesis, anearly recurrence of the deformityresults. This procedure has limitedapplication and should probably notbe used in the patient with high ath-letic ambitions.

Arthrodesis of the MTP joint willproduce excellent correction of asevere deformity or can be used to sal-vage a failed operative procedure.The result will not deteriorate withtime, and patients can resume mostactivities. This procedure is not rec-ommended for persons engaged incompetitive athletics. It is not neces-sary to correct even a significantdeformity of the IM angle when anarthrodesis is carried out; the metatar-socuneiform joint will self-correctafter arthrodesis due to the motionthat normally occurs at the joint.7

Clinical EvaluationIn addition to the medical history,

it must be determined whether thepatient’s main concern is cosmesis,transfer metatarsalgia, second-toedeformity, problems with shoe fit, or

pain. The patient’s occupational andrecreational requirements are alsoimportant; professional dancers andhigh-performance athletes needvery special consideration beforeany type of foot surgery.

A critical factor is patient expecta-tions. It is crucial that the patientunderstand precisely what can beachieved surgically and what cannot.Unfortunately, patients may have beenled to believe there is a “quick fix” formany foot problems. In a study of ourpatients, we found that prior to surgeryfor hallux valgus only one third of thepatients could wear the type of shoethey desired. After surgery, two thirdsachieved their goal, which unfortu-nately left one third unsatisfied.

Physical ExaminationPhysical examination begins with

the patient standing in order toobserve the alignment of the lowerextremities, the longitudinal arch,and the great toe and the relationshipof the lesser toes to it. With thepatient in a sitting position, it usuallyis impossible to fully appreciate thedynamic instability in the foot. Therange of motion of the ankle and thesubtalar and transverse tarsal jointsof the forefoot is assessed. Overalltissue elasticity is evaluated, and thepresence of a tight Achilles tendon issought, especially in the juvenile.

The range of motion of the firstMTP joint is carefully observed bydorsiflexing and plantar flexing thejoint while attempting to realign thegreat toe. The degree of restriction ofdorsiflexion indicates how much cor-rection can be obtained surgically. Ifthe great toe cannot be brought intofairly good alignment without severerestriction of dorsiflexion, the sur-geon and the patient should under-stand that full motion will not beachievable. The degree of pronationof the great toe should also be noted.As a general rule, the more severe thedeformity, the greater the degree ofpronation.

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Roger A. Mann, MD

36 Journal of the American Academy of Orthopaedic Surgeons

Other physical findings of noteinclude synovial thickening, dorsalosteophytes, sesamoid pain, and crepi-tation. Significant callosities under thefirst metatarsal head are secondary toprominence of the tibial sesamoid;under the second metatarsal, they aredue to the increased weight-bearingbrought about by instability of the hal-lux. The second MTP joint must beevaluated for instability, medial devia-tion, and the presence of a hammer toe.Not infrequently, the second toe ismore symptomatic, in terms of painand deformity, than the hallux eventhough the great toe has initiated theproblem.

The stability of the first metatarso-cuneiform joint is evaluated by hold-ing the second metatarsal head inone hand and the first metatarsal inthe other. The first metatarsal headis deviated dorsomedially and thenplantarward and laterally. Unfortu-nately, because there are no preciseguidelines for instability, the exami-nation cannot be quantified. Signif-icant instability is observed in about2% to 3% of patients with hallux val-gus, often associated with a moder-ate to severe flatfoot deformity.

Finally, the neurovascular statusof the foot should be evaluated. Ifthere is any doubt about theintegrity of the circulation, furtherstudies should be obtained beforeany surgery is contemplated.

Radiographic EvaluationThe foot should always be evalu-

ated with weight-bearing radio-graphs, because non-weight-bearingradiographs often fail to indicate theseverity of a deformity. The follow-ing factors should be assessed:

Hallux Valgus AngleThe extent of hallux valgus defor-

mity is determined by measuringthe angle between the long axes ofthe proximal phalanx and the firstmetatarsal (Fig. 1). The normalvalue is less than 15 degrees.

Intermetatarsal AngleThe IM angle is the angle between

the first and second metatarsals (Fig.1). The normal value is less than 9degrees.

Distal Metatarsal Articular (DMA)Angle

The DMA angle describes the rela-tionship between the distal articularsurface and the long axis of the firstmetatarsal (Fig. 2).8 The normalvalue is less than 10 degrees of lat-eral deviation.

Hallux Valgus InterphalangeusHallux valgus interphalangeus is a

deformity involving only the pha-langes of the hallux. The presence ofthis abnormality is identified on thebasis of the relationship between thearticular surface of the base of the prox-

imal phalanx and the long axis of theproximal phalanx and the relationshipbetween the long axis of the proximalphalanx and that of the distal phalanx(Fig. 3). A deformity may exist at oneor more levels. The normal value is lessthan 10 degrees of lateral deviation.

Obliquity of the MetatarsocuneiformJoint

The angle of the metatarsocuneiformjoint is quite variable radiographically.If there appears to be more than 15degrees of medial deviation, oneshould reevaluate the patient for possi-ble instability of this joint (Fig. 4).

Disorders of the First Metatarsophalangeal Joint

Fig. 1 The hallux valgus (HV) angle isformed by the intersection of lines bisectingthe proximal phalanx and the firstmetatarsal. Normal is less than 15 degrees.In this case, it measures 40 degrees. The IMangle is formed by the intersection of thelines that bisect the first and secondmetatarsals. Normal is less than 9 degrees.In this case, it measures 16 degrees.

Fig. 2 Top, The normal DMA angle is lessthan 10 degrees of lateral deviation. In thiscase, it is 0 degrees. Bottom, An abnormalDMA angle of 27 degrees.

Sesamoid PositionThe position of the sesamoids in

relation to the metatarsal head pro-vides information regarding the

severity of the hallux valgus defor-mity, the degree of pronation of thehallux, and possible pathologicchanges in the sesamoids.

Arthrosis of the MTP JointArthrosis is not common, but may

occur in hallux valgus and can influ-ence the treatment outcome.

Determination of the Congruence of theMTP Joint

A congruent MTP joint has no lat-eral subluxation of the proximalphalanx on the metatarsal head.9 Anincongruent or subluxated jointdemonstrates lateral deviation ofthe proximal phalanx from themetatarsal head (Fig. 5).

Decision MakingEssentially, all hallux valgus

deformities can be treated conserva-tively with use of a wide, soft shoethat provides an adequate toe boxand sufficient insole padding tomake the patient comfortable. Asurgical option is considered if thepatient is not satisfied with that con-servative approach.

The most important factor indetermining the surgical approachis the congruence of the MTP joint.A congruent joint is one in whichthe articular surfaces of the proxi-mal phalanx and metatarsal headare parallel. The operative proce-dure should protect the integrity ofan anatomically aligned joint. Ifthere is incongruence, or lateralsubluxation, the surgical correctionshould attempt to bring the proxi-mal phalanx back onto themetatarsal head, thereby recreatinga congruent joint.

The other major determining fac-tor is the presence of arthrosis of thejoint. Realignment of the joint willresult in satisfactory correction ofthe deformity; unfortunately, how-ever, significant joint stiffness andusually pain will result. In the 2% to

3% of patients who have hypermo-bility of the metatarsocuneiformjoint, stabilization of that joint mustbe achieved to obtain a satisfactorylong-term result.6

The algorithm presented in Figure6 presents an approach the surgeonmay find useful in the selection of anoperative procedure from amongthe more than 130 options. Thechoices presented in the algorithmhave evolved over a period of timeand have undergone extensive clini-cal evaluation. The selection of aprocedure is guided by the severityof the deformity. The measurementsgiven in the algorithm to assess thedeformity are guidelines, and therecertainly is a moderate degree of lee-way in the selection process. Thephysical and radiographic findingsmust always be correlated whenmaking a decision.

For the patient with significantarthrosis of the MTP joint, anarthrodesis is recommended, al-though a carefully performedKeller procedure can give a satis-factory result in the patient withlimited ambulatory capacity. Cur-rently, the use of a prosthesis inprimary bunion surgery is not re-commended because of the less-than-optimal long-term results andthe silicone-related problems thatoften occur, such as significant syno-vitis, osteolysis, and migration ofsilicone particles to the regionallymph nodes.10,11

For the patient with a congruentjoint, the chevron procedure, the dis-tal soft-tissue procedure, and theAkin procedure with excision of themedial eminence are alternatives.The chevron procedure is probablythe most reliable, particularly in thepatient with a large medial emi-nence.

Incongruent deformities are classi-fied as mild (hallux valgus angle lessthan 30 degrees and IM angle lessthan 13 degrees), moderate (halluxvalgus angle less than 40 degrees and

Vol 3, No 1, Jan/Feb 1995 37

Roger A. Mann, MD

Fig. 3 Hallux valgus interphalangeus isidentified on the basis of the angle betweenthe lines bisecting the proximal and distalphalanges of the metatarsal. Normal is lessthan 10 degrees. In this case, it is 30 degrees.

Fig. 4 The metatarsocuneiform jointdemonstrates marked obliquity, which mayindicate instability. A radiographic appear-ance such as this indicates that the patientshould be reevaluated clinically.

IM angle greater than 13 degrees),and severe (hallux valgus anglegreater than 40 degrees and IM anglegreater than 20 degrees). As a generalrule, most patients have a mild tomoderate deformity. For the mild

deformity, the chevron procedureusually will yield a satisfactory result,as will the distal soft-tissue proce-dure. However, if the indications arestretched, an incomplete correctioncan result. The Mitchell procedure is

an excellent alternative, but it is tech-nically somewhat more difficult toperform, and the osteotomy is not asstable as that created by the chevronor more proximal metatarsalosteotomies.

For advanced moderate andsevere deformities, a distal soft-tis-sue procedure with a proximalosteotomy will give a reproduciblesatisfactory result in most cases,although it is technically demand-ing. The MTP arthrodesis is anexcellent procedure for treating asevere hallux valgus deformity, par-ticularly in older patients and thosewith rheumatoid arthritis, spasticity,or arthrosis. Occasionally, a Kellerprocedure, particularly in the lessactive individual, or a double-stemmed hinged silicone prosthesiscan be considered.

When there is hypermobility ofthe metatarsocuneiform joint,metatarsocuneiform arthrodesis isused along with the complete distalsoft-tissue procedure. Complica-tions of arthrodesis are stiffness ofthe foot and nonunion.

The various operative procedurespresented in the algorithm will now

38 Journal of the American Academy of Orthopaedic Surgeons

Disorders of the First Metatarsophalangeal Joint

Congruent joint Incongruent joint

Hallux valgus

Degenerative joint disease

Fusion, orKeller procedure, orprosthesis

Akin procedure andexostectomy, or

chevron, orDSTP

IM angle <13˚HV angle <30˚

IM angle >13˚HV angle <40˚

IM angle >20˚HV angle >40˚

Hypermobilefirst MC joint

Chevron (age <50 yr), orDSTP with or without

proximal crescenticosteotomy, or

Mitchell procedure

DSTP with proximalcrescentic osteotomy, or

Mitchell procedure

DSTP with proximalcrescentic osteotomy, or

MTP joint fusion

Fusion of first MCjoint and DSTP

Fig. 6 Algorithm for selecting the operative approach to treatment of hallux valgus (HV). DSTP = distal soft-tissue procedure; MC =metatarsocuneiform. (Adapted with permission from Mann RA: Decision-making in bunion surgery. Instr Course Lect 1990;39:3-13.)

Fig. 5 A, In a congruent joint, the joint surfaces are parallel, and there is no lateral subluxa-tion of the proximal phalanx on the metatarsal head. B, In an incongruent or subluxated joint,the joint surfaces are no longer parallel, and there is lateral subluxation of the proximal pha-lanx on the metatarsal head.

BA

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Roger A. Mann, MD

be discussed in terms of their indica-tions, contraindications, main compli-cations, and special technical aspects.

Proximal Phalangeal Osteotomy(Akin Procedure)12,13

IndicationsThe indications for this proce-

dure are hallux valgus interpha-langeus, a congruent joint with alarge medial eminence with a DMAangle of less than 10 degrees, anduse as a secondary procedure if aprimary procedure (e.g., chevronor distal soft-tissue procedure) didnot provide sufficient correctiondue to a large DMA angle or halluxvalgus interphalangeus.

ContraindicationsThe contraindications are an

incongruent joint and hallux valguswith a DMA angle greater than 15degrees.

ComplicationsHallux valgus deformity will fre-

quently increase if the procedure isattempted on an incongruent joint.13

Technical AspectsThe osteotomy must be distal to

the concavity of the proximal pha-lanx to prevent violation of the joint.

CommentThe Akin procedure occupies a

small niche in foot surgery. Itsmain indication is to treat halluxvalgus interphalangeus or to aug-ment a chevron or distal soft-tissueprocedure in order to gain completecorrection. It is not recommendedas a primary bunion procedure foran incongruent joint since the cor-rection will deteriorate with time.

Chevron Procedure 14

IndicationsThis procedure is used to treat a

mild deformity (hallux valgus angle

of less than 30 degrees and IM angleof less than 13 degrees).

ContraindicationsThe sole contraindication is a

deformity with a hallux valgusangle greater than 35 degrees and anIM angle greater than 15 degrees.15

ComplicationsPossible complications include

incomplete correction if the halluxvalgus deformity is too advanced,loss of position of the capital frag-ment secondary to lack of internalfixation, and avascular necrosis (in1% to 2% of cases).15-17

Technical AspectsA medial approach is used to

avoid the dorsal medial cutaneousnerve (Fig. 7). Soft-tissue strippingis limited. Internal fixation is pre-ferred. If the DMA angle is greaterthan 10 to 15 degrees, a medial clos-ing-wedge osteotomy is added torotate the articular surface fromexcessive lateral deviation into thenormal range.

CommentThe chevron osteotomy is an

excellent procedure for the mild tomoderate hallux valgus deformity.Complications are most likely tooccur when the indications areexceeded. Incomplete correctionwill occur if the DMA angle isgreater than 10 to 15 degrees andmore bone needs to be removedfrom the medial aspect of the prox-imal metatarsal, thereby creating amedial closing-wedge effect to cor-rect the articular surface. Thiseliminates the need for the addi-tion of the Akin procedure to gainfull correction. The medial closingwedge is achieved by removing anadditional 1 to 3 mm of bone fromthe proximal portion of theosteotomy so that the articular sur-face can be rotated medially.18 Theprevalence of avascular necrosis is

probably 1% to 2%, but can be min-imized by l imiting soft-t issuestripping.

Distal Soft-Tissue Procedure18

IndicationsThis procedure is recommended

in the treatment of mild hallux val-gus deformities (hallux valgus angleless than 30 degrees and IM angleless than 13 degrees).

ContraindicationsThe contraindications include (1)

a deformity with a hallux valgusangle greater than 35 degrees and anIM angle greater than 15 degrees, (2)a deformity with a DMA anglegreater than 15 degrees (a chevronprocedure with a medial closing-wedge osteotomy would be prefer-able), and (3) arthrosis of the MTPjoint.

ComplicationsRecurrence of the deformity is

due to failure to include a metatarsalosteotomy, inadequate lateralrelease, or the poor quality of themedial capsular tissue. Halluxvarus may occur, especially if toomuch of the medial eminence isexcised or if the fibular sesamoid isremoved.

Technical AspectsTwo incisions should be used:

one in the first web space and theother on the medial side of the joint.The medial eminence should beexcised in line with the medialaspect of the metatarsal. Ametatarsal osteotomy should beadded if the first and secondmetatarsals do not close down eas-ily at the time of surgery. The post-operative dressings, which consistof 2-inch conforming gauze (Kling,Johnson & Johnson Medical Prod-ucts, Arlington, Texas) and 0.5-inchadhesive tape, are used for 8 weeks.The dressing binds the metatarsal

40 Journal of the American Academy of Orthopaedic Surgeons

heads together and maintains thehallux in correct alignment.

CommentThis procedure will give satis-

factory results when used withinits limitations. Failure to add ametatarsal osteotomy, however,often results in recurrence. Thesoft tissues on the lateral aspectmust be completely released forthe medial plication to be effective.Excision of too much of themetatarsal head can result in a hal-lux varus deformity.

Distal Soft-Tissue Procedure PlusProximal Metatarsal Osteotomy5

IndicationsThe indication for this procedure

is a deformity with a hallux valgusangle greater than 30 degrees and an IM angle greater than 13degrees.

ContraindicationsThe contraindications are a con-

gruent joint and the presence ofarthrosis.

ComplicationsExcessive lateral deviation of the

metatarsal head will result in halluxvarus. Excessive dorsiflexion of theosteotomy and excessive shorten-ing may also occur.

Technical AspectsI prefer a crescentic osteotomy

carried out through a dorsal inci-sion, with the concavity directedproximally toward the heel. Internalfixation of the osteotomy site is rec-ommended. The postoperativedressing requires careful manage-ment, as described for the distal soft-tissue procedure.

CommentThe distal soft-tissue procedure

with a proximal osteotomy can beused for most hallux valgus defor-mities. A variety of osteotomieshave been advocated, rangingfrom a proximal crescentic os-teotomy to a horizontal chevronor an opening or closing wedge.The basic principles of theosteotomy are to correct the IMangle with minimal shortening and

to avoid overdisplacement of themetatarsal head laterally, whichwould result in an incongruentjoint and possibly hallux varusdeformity.

Mitchell Procedure19,20

IndicationsThis procedure can be useful in

treating a deformity with a halluxvalgus angle greater than 30 degreesand an IM angle greater than 13degrees.

ContraindicationsThis procedure is not appropri-

ate in the presence of a congruentjoint or a deformity with a halluxvalgus angle greater than 40degrees and an IM angle greaterthan 20 degrees.

ComplicationsLoss of position of the capital

fragment can occur due to dorsalmigration, and transfer meta-tarsalgia can occur secondary todorsif lexion of the metatarsalhead. Other possible complica-

Disorders of the First Metatarsophalangeal Joint

B CA

Fig. 7 Biplanar chevronosteotomy to correct alaterally sloping distalmetatarsal articular sur-face. A, Placement of thenormal chevron osteo-tomy. B, Removal ofmedial bone wedge mea-suring 1 to 3 mm. Thispermits medial devia-tion of the articular sur-face of the metatarsalhead, thereby correctingthe DMA angle. C, Dis-tal articular surface aftercorrection. The osteo-tomy site should be fixedwith a pin.

Vol 3, No 1, Jan/Feb 1995 41

Roger A. Mann, MD

tions are avascular necrosis andnonunion.

Technical AspectsSoft-tissue stripping should be

minimized. Adequate fixation of theosteotomy site is necessary.

CommentThe Mitchell procedure will

result in satisfactory correctionwhen used within its limitations.However, it is technically moredemanding than the chevron proce-dure and the distal soft-tissue pro-cedure with osteotomy, and theosteotomy site is somewhat less sta-ble. For these reasons, the proce-dure has not been used as much inrecent years.

Distal Soft-Tissue ProcedureWith MetatarsocuneiformFusion6,21

IndicationsThis procedure is appropriate in

the presence of an unstable metatar-socuneiform joint or a deformitywith a hallux valgus angle greaterthan 35 degrees and an IM anglegreater than 15 degrees.

ContraindicationsThis procedure is contraindicated

in the presence of a congruent joint.It is also not appropriate for an ath-letic younger patient or for a patientwith normal metatarsocuneiformjoint stability.

ComplicationsPossible complications include

increased stiffness of the foot sec-ondary to the arthrodesis, nonunionof the arthrodesis site, and overcor-rection of the metatarsal head later-ally, resulting in hallux varus.

Technical AspectsThe metatarsocuneiform joint

should be redirected plantarward

and laterally along the lines of thenormal movement of the articularsurfaces. The arthrodesis is carriedout with the joint in this position,and the joint is fixed with a screw orplate. Local bone graft may be used.The distal soft-tissue procedure isalso carried out to correct the halluxvalgus deformity.

CommentA metatarsocuneiform joint

arthrodesis is indicated in the 2% to3% of patients with hallux valguswho have an unstable metatarso-cuneiform joint. The procedure istechnically difficult. It also adds tothe stiffness of the foot and shouldnot, therefore, be overutilized, par-ticularly in the athletic patient.

MetatarsophalangealArthrodesis22

IndicationsThis procedure can be useful in

the presence of arthrosis of the MTPjoint or a severe hallux valgus defor-mity with dislocation of the MTPjoint. It may also be useful in thepatient with spasticity or as a sal-vage procedure.

ContraindicationsUse of this procedure is not appro-

priate for less severe deformities thatcan be managed with other proce-dures.

ComplicationsPossible complications include

nonunion, malalignment, and de-generative changes in the interpha-langeal joint.23

Technical AspectsAlignment is critical; the joint

should be placed into approximately15 degrees of dorsiflexion in relationto the floor, 15 degrees of valgus,and neutral rotation. Rigid internalfixation should be used. I prefer the

use of an interfragmentary screwand a dorsal plate.

CommentThe arthrodesis is an excellent

choice in patients with advancedarthrosis or rheumatoid arthritis.24 Itis also useful as a salvage procedure.The long-term results are excellent,although changes may occur at theinterphalangeal joint, especially ifthere is malalignment. The arthrode-sis is an integral part of the recon-struction of the rheumatoid forefoot.

Keller Procedure1

IndicationsThis procedure is most useful in

less active patients with advancedhallux valgus deformity or witharthrosis of the MTP joint (as analternative to fusion).

ContraindicationsThis procedure is not appropriate

for active individuals.

ComplicationsPossible complications include

instability of the medial aspect ofthe foot, due to loss of the windlassmechanism; drifting of the halluxinto varus or valgus rotation or dor-siflexion; transfer metatarsalgia;and significant shortening of thehallux.

Technical AspectsAn attempt should be made to

insert the intrinsic muscles back intothe proximal phalanx to prevent acock-up deformity. The joint shouldbe stabilized with a pin for 3 to 4weeks to permit scarring around theMTP joint to occur.

CommentBecause this procedure destabi-

lizes the first MTP joint, it shouldnot be used for patients who arevery active. There are other proce-

dures that will give a more stablefoot with fewer complications. It isan excellent procedure for thehousebound ambulator or for thepatient who places fewer demandson the foot.

Juvenile Hallux ValgusSymptomatic hallux valgus

deformity is uncommon in chil-dren, but it does occur. Unfortu-nately, surgical correction of thejuvenile form is associated with a significant rate of recurrence andvariable clinical outcomes com-pared with the adult form.19,25

Most surgeons advocate delay-ing surgery until skeletal maturityhas been achieved unless anunusual degree of pain and defor-mity significantly interferes withactivities.

The evaluation of the patientwith juvenile hallux valgus isextremely critical. There is a highprevalence of pes planus and liga-mentous laxity. There also appearsto be an increased incidence of lat-eral deviation of the distal articularsurface of the first MTP joint,which may account for the highincidence of failure in the juvenilepatient. When there is an unrecog-nized lateral slope of the distalarticular surface, either the defor-mity recurs or the joint becomesstiff despite maintenance of cor-rection.

When considering treatment forthe patient with juvenile hallux val-gus, one can follow the same deci-sion-making precepts based on theseverity of the deformity alreadyoutlined in the algorithm in Figure6. However, if there is an openmetatarsal epiphysis at the time ofsurgery, it should be avoided toprevent possible growth distur-bance. One should even be cau-tious in placing pins across theepiphysis, since this can theoreti-cally result in closure or alterationof its growth.

Hallux Rigidus24,26,27

Hallux rigidus is a painful afflictionof the first MTP joint secondary toarthrosis and is associated withrestriction of dorsiflexion. The con-dition can occur in adolescence,although it is uncommon; in thoseinstances, it is usually associatedwith an osteochondritic lesion.28

Clinical EvaluationThe condition usually occurs

insidiously without a history oftrauma. The main complaints arepain, loss of dorsiflexion, andincreased bulk of the joint, whichmakes shoe wearing difficult. Thepatient’s level of activity must becarefully evaluated, particularly thelimitations that have been necessi-tated by the condition.

Physical examination revealsincreased bulk of the joint and lossof dorsiflexion, which should bequantified. Marginal osteophytesare typically present dorsally andlaterally. Forced dorsiflexion willusually reproduce the patient’s pain,as will lateral deviation if a lateralosteophyte is present. Often, thedorsal medial cutaneous nerve issensitive.

The radiographic evaluationincludes weight-bearing anteropos-terior, lateral, and oblique views.Bone proliferation along the lateralaspect of the joint is evaluated on theanteroposterior radiograph; thatalong the dorsal aspect, on the lateralradiograph. The extent of joint nar-rowing is determined from theoblique radiograph.

Conservative management con-sists of use of a shoe with adequatewidth and depth to accommodatethe increased bulk of the joint andwith a rigid rocker sole to diminishjoint motion. If there is significantbone proliferation or pain with dor-siflexion, a cheilectomy or debride-ment of the MTP joint should beconsidered. It is important to ex-

plain the expected outcome beforesurgery, since an arthritic joint willstill be present, which may be symp-tomatic when stressed.

I have observed that patients with arelatively mild to moderate degree ofrestriction of dorsiflexion tend to dovery well with a cheilectomy, which Ibelieve is due to reestablishing someof the normal gliding that occurs atthe MTP joint. More severe andadvanced degenerative changes, par-ticularly marked osteophytes, areassociated with less certain outcomes,and a certain degree of residual dis-comfort can be expected. The alterna-tive is to carry out an arthrodesis ofthe joint, which will eliminate the painand permit a return to most activitiesat a nonprofessional level.

The Keller procedure or animplant arthroplasty can be consid-ered in less active individuals withsignificant arthrosis, although thelong-term results of these proceduresdo not compare favorably with thoseof cheilectomy or fusion.11

Operative ProceduresCheilectomy is carried out through

a dorsal approach, with the incisionbeing carried down through theextensor hood on either side of theMTP joint. The capsule is opened,and a complete synovectomy is car-ried out. Proliferative bone isremoved along the lateral side of themetatarsal head, in line with the longaxis of the metatarsal, and over thedorsal aspect by removing 20% to30% of the metatarsal head. Dorsalbone must be removed until approx-imately 60 to 70 degrees of dorsiflex-ion at the MTP joint has beenachieved. If less bone is removed,dorsal impingement will persist, andthe patient will usually not be satis-fied with the result. The averageincrease in dorsiflexion is about 25degrees, but it varies considerably.The main benefit is relief of the dorsalimpingement, which is the mainsource of pain.

42 Journal of the American Academy of Orthopaedic Surgeons

Disorders of the First Metatarsophalangeal Joint

Vol 3, No 1, Jan/Feb 1995 43

Roger A. Mann, MD

The patient wears a postoperativeshoe until the wound is healed (atabout 10 days), after which activerange of motion is encouraged. As ageneral rule, maximum improve-ment will occur by approximately 3to 4 months. The advantage ofcheilectomy is that if the procedurefails, one can still carry out a fusion,possibly a Keller procedure orimplant arthroplasty.

Occasionally, a patient with hal-lux rigidus still does not have ade-quate dorsiflexion after surgery,which may be a source of pain.Under these circumstances, one

might consider doing a dorsal clos-ing-wedge osteotomy of the proxi-mal phalanx (Moberg procedure),29

which makes use of the fact thatplantar flexion can still occur at theMTP joint. With this procedure, oneis able to gain approximately 25degrees of dorsiflexion, whichdecreases the stress on the MTPjoint.

As a general rule, proximal pha-langeal osteotomy should not be car-ried out at the same time ascheilectomy, since the cheilectomyrequires early motion and the proxi-mal phalangeal osteotomy requires

a period of immobilization for ade-quate healing.

Summary

Satisfactory bunion surgery ispredicated on the integration of thepatient’s chief complaints, the find-ings from a thorough physical andradiographic evaluation, and selec-tion of the appropriate surgicalprocedure. The postoperativemanagement must be meticulouslycarried out to ensure optimal align-ment of the hallux.

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