The 19-Year-Old With A Hallux Valgus & Crossover Second Toe: When To Operate, When To Hold Off

1. The 19-Year-Old With A Hallux Valgus & Crossover Second Toe: When To Operate, When To Hold Off Keith L. Wapner, M.D Clinical Professor, Orthopaedic Surgery, University of Pennsylvania Health Systems

2. Disclosures • Consultant –Stryker, Cartiva • Institutional Support –Komfort Kare

3. The Issues Physical Pain Decreased function Emotional Appearance Expectations Parents

4. Physical Pain and decrease of function should be the primary concern Clearly define where the pain is Clearly define what limitation of function this presents Fancy shoes Normal walking Sports

5. Physical Where does it hurt Over the Hallux Valgus Under the 2nd MTP Over the hammer toe Any other areas When does it hurt where Activity driven pain Rest pain

6. Physical Fancy shoes Easier to change the shoe that the foot

7. Physical Normal walking Shoewear Sports Type of sport Dancers Continuing at a college level Recreational

8. Emotional Appearance Foot works well but I don’t like the way it looks

9. Emotional Expectations Pain free Normal function Shoe wear Trading a bump for a scar

10. Emotional Parents Differing agendas

11. Why are all these components so important What are the limitations of what we can achieve with surgery Hallux Valgus correction MTP correction Hammer toe correction

12. Physical - Hallux Valgus Exam Degree of deformity Flexibility of MTP Hypermobility at MTC Juvenile or Acquired Radiology HV, IM, HI angles Pronation, sesamoids Congruent, Incongruent, MTC shape

13. Hallux Valgus correction Results can depend on degree of deformity realignment – fairly predictable range of motion post op – variable pain relief – fairly predictable depends on postop activity

14. Physical – 2nd MTP Exam Degree of deformity Flexibility of MTP Reducible Painful on reduction Radiology Degree of subluxation Length of 2nd metatarsal Deviation of 3rd MTP

15. MTP correction Results can depend on degree of deformity and structures damaged realignment – less predictable range of motion post op – very variable depending on procedure pain relief – less predictable depends on postop activity

16. Physical – Hammer toe Exam Degree of deformity Flexibility of PIP and DIP Fixed or supple Radiology Amount of deformity

17. Hammer toe correction Results can depend on degree of deformity and structures damaged realignment – somewhat predictable range of motion post op – never normal with any procedure pain relief – fairly predictable depends on postop activity

18. Too Fat

19. Too short

20. Too recurvatum

21. Not enough surgery

22. Too much surgery

23. Try Non-Operative Treatment Shoe modifications Wider toe box Sports- men’s shoe Material of the upper

24. OTC Inserts • Metatarsalgia & fat-pad atrophy • Spenco insoles/inlays • Viscopeds • Dr. Scholls • HAPADS

25. Taping of the MTP

26. Surgical Urgency Nobody dies from a bunion or hammer toe

27. Decision for Surgery Failure of non-operative management Acceptance of the limitations of the procedures Willingness to be compliant with post op treatment

28. Choice of Procedure No different than any other aged patient Based on degree of deformity and laxity on physical exam

29. The Choice to Do the Procedure Physical Pain Decreased function Emotional Appearance Expectations Parents