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Hallux Valgus; the wrath of fancy shoes

Hallux Valgus; the wrath of fancy shoes. Kelly Hynes PGY-1 June 9, 2011. Definition. Bunion = greek for turnip. Exostosis on the dorsomedial aspect of the first metatarsal head. Hallux Valgus = latin for ‘large toe with outward angulation’. Lateral deviation of the distal 1 st metatarsal

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Hallux Valgus; the wrath of fancy shoes

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  1. Hallux Valgus; the wrath of fancy shoes Kelly Hynes PGY-1 June 9, 2011

  2. Definition Bunion = greek for turnip. Exostosis on the dorsomedial aspect of the first metatarsal head. Hallux Valgus = latin for ‘large toe with outward angulation’. • Lateral deviation of the distal 1st metatarsal • Medial deviation of the 1st proximal phalanx

  3. Etiology - Extrinsic • Constrictive footwear • after WWII in Japan prevalence increased • Almost exclusively in shoe wearing societies • Most prevalent in elderly women • Occupation (on feet, work at heights, footwear)

  4. Etiology - Intrinsic • Pronation of hind foot • Pes planus, splayed foot secondary to age related weakness • Metatarsus primus varus (Angle increases as HV angle increases) • Achilles tendon contracture • Joint laxity, CT disorders • 1st ray hypermobility (3-6% of HV) • Heredity (68% show familial tendency) • Cerebral palsy, stroke

  5. Normal Anatomy 4 Groups of Muscles and Tendons: 1)EHL/EHB dorsal 2) FHL/FHB plantar 3) AbH plantar medial 4)AdH plantar lateral

  6. EHL is anchored by the hood ligaments which interdigitates medially and laterally with the collateral and sesamoid ligaments forming the joint capsule of the 1st MTP Plantar capsule is thick and reinforced by AbH /AdH while the dorsal capsule is thin

  7. AdH becomes deforming force by tethering sesamoids and proximal phalanx as MT goes medially. Also exerts pronation force since it inserts on plantar surface. • Plantar cuff (AbH, FHB, AdH) rotates laterally • EHL goes to first webspace and becomes adduction force.

  8. Secondary changes • Lateral joint capsule contracture • Medial capsule attenuation • Medial Eminence • Pronation of hallux • 2nd toe may underlap or overlap

  9. Sesamoids Medial head of FHB – medial sesamoid Lateral head of FHB – lateral sesamoid Sesamoids are attached to the base of the PP via the plantar plate. FHL is plantar to sesamoid complex Articulate with the intersesamoid ridge (crista) Become laterally subluxed and eventually smooth out the crista (in fact the MT is moving medially away)

  10. History • Occupation and recreation • Character, Onset, duration, disability, severity, course • Relieving, exacerbating factors Get an idea of expectations and take the time to educate.

  11. Presenting Complaints • 80% restriction in wearing shoes • 70% pain over medial eminence • 60% cosmetic concerns • 40% pain underneath 2nd MT head • Pain in distribution of dorsal cutaneous nerve

  12. Physical Exam • Lower extremity alignment • Gait • Pes planus • Achilles tendon tightness • Skin – irritation or breakdown • Vascular exam • Medial eminence • Edema • Magnitude of deformity • Pronation of 1st toe • Manually correct • ROM 1st MTP, ankle, subtalar • Lesser toe deformities • Callosities • Ist ray hypermobility (plantarlateral to dorsomedial asses degree of deviation >9mm abn)

  13. Radiology • Weightbearing AP/Lateral • Axial views to look at sesamoids Subluxation of lateral sesamoid MTC shape and obliquity (increased medial may indicate instability) Evaluate for DJD Look at fore and hindfoot alignment

  14. HV angle < 15 degrees • Intermetatarsal Angle < 9 degrees • Distal Metatarsal Articular Angle < 10 degrees • Proximal Phalangeal Articular Angle • Hallux valgus interphalangeus < 10 degrees

  15. Congruency = correspondence in character Congruent if normal relationship between MT and phalangeal surfaces (i.e. parallel and no subluxation). Less likely to progress. Periarticular procedures indicated. More common in juvenile. Noncongruous when joint surfaces are not aligned with lateral subluxation of PP on MT head. More likely to sublux further with time.

  16. Grading

  17. Nonoperative Treatment • Wider, deeper toe box to eliminate friction • Orthosis if pes planus present • Stretching of achilles • In juvenile often wait until skeletal maturity

  18. Operative Treatment • Associate main symptoms with physical findings • Often involves combined procedures • Want to maintain normal weightbearing • What elements need correction?

  19. Elements of Correction • Medial eminence prominence • Proximal phalanx valgus angulation • Increased intermetatarsal angle • Congruency of MTP joint • Sesamoid subluxation • Pronation of great toe • Hypermobility of 1st ray

  20. Surgical Options • Metatarsophalangeal soft tissue recon • Distal or proximal metatarsal osteotomy (many variations) • Cuneiform osteotomy • Arthrodesis of MTP joint • Excisional Arthroplasty

  21. Akin Procedure • Resection of medial eminence • Medial capsular reefing • Closing wedge osteotomy of proximal phalanx • Does not correct increased 1/2 angle. Indications are: hallux valgus interphalangeus, mild HV without MPV and HV with enlarged ME. Can be combined with metatarsal osteotomy.

  22. Akin Procedure • Medial eminence resected in line with medial border of 1st MT • K Wires for 4-6 weeks • Walk in post op shoe • Avg. HV correction of 13 degrees • Recurrence reported in approximately 20% • Nonunion is uncommon • Not advised in isolation for HV treatment

  23. Distal Soft Tissue Reconstruction • Medial capsulorrhaphy • Medial exostectomy • Lateral capsular and adductor release • Conjoined adductor tendon is dissected off lateral sesamoid • Dorsal incision over 1st webspace and medial incision Indicated in noncongruous HV with HV angle <30 and IM<15 WBAT post op

  24. DSTR - outcomes • Studies at 5 years follow up found avg increase in deformity from pre op. • High (25 -40%) reported reoperation rate • Generally recommended in conjunction with MT osteotomy

  25. Chevron Osteotomy • Distal metatarsal osteotomy • Resection of medial eminence • Medial capsulorrhaphy Indicated HV <30 IM<13 and DMAA<15 Does not correct pronation of great toe.

  26. Chevron Osteotomy • Can combine with Akin with congruous deformity. • Medial eminence resected in line with lateral border of the foot. • Lateral soft tissue release discouraged because of risk of AVN of MT head • K Wire 3-4 weeks. WB on heel for 4 weeks. • Undercorrection, recurrence are most common issues

  27. Distal Metatarsal Osteotomy • Biplanar osteotomy popularized by Mitchell (lateral and plantar displacement) • Medial eminence osteotomy • Lateral structures left intact • Techniques variable, may be transverse or oblique • Indicated in: HV<35 and IM<15, DMAA<15 • Dorsomedial incision

  28. Distal Metatarsal Osteotomy • Fixed with K wires, staples or screws. • 4 weeks NWB • Technically demanding • AVG correction HV 10-20 degrees and IM 5-10 degrees • Some shortening of 1st MT required in correction but if excessive(>1cm) can cause transfer metatarsalgia.

  29. DSTR with Proximal Metatarsal Osteotomy • Moderate or severe (>35 and >13), Congruous DMAA <15 • Opening, closing wedge, proximal chevron, crescentic are all options • Crescentic preserves length • Dorsal incision • K Wire fixation 6 weeks and heel weight bearing • Avg 25 degree correction • Recurrence, nonunion possible

  30. Metatarsal-cuneiform arthrodesis • Mod or severe (>30 HV and >16 IM) with MTP subluxation and hypermobility of 1st MTC • DSTR usually in conjunction • Dorsal incision medial to EHL Biplanar joint resection with goals of: • Lateralize 1st MT • Decrease interMT angle • Flex the 1st ray

  31. MTC Arthrodesis Cancellous bone graft used to promote healing Screw fixation is preferred NWB cast for 4 weeks Described by Lapidus in 1934 but included 2nd MTC as well. Longer post op recovery

  32. Other Procedures 1st MTP arthrodesis – salvage procedure or for hallux rigidus, RA, neuromuscular Keller Excisional Arthroplasty – HV with djd in patients with low mobility requirements. Medial eminence and portion of proximal phalanx is resected

  33. Conclusion • There is a large spectrum of deformities as well a surgical procedures to correct them • Ensure the patient’s complaints and physicial and radiological exam justify the procedure selected.

  34. References Joseph, T.N., Mroczek, K.J. (2007). Decision making in the treatment of hallux valgus. Bulletin of the NYU Hospital for Joint Disesases. 65(91): 19-23 Robinson, A., Limbers, J. (2005). Modern concepts in the treatment of hallux valgus. Journal of Bone and Joint Surgery (BR). 87-B:1038-45 Coughlin, M.J. (1996). Instructional Course Lectures, The American Academy of Orthopedic Surgeons – Hallux Valgus. Journal of Bone and Joint Surgery (AM). 78:932-66 Miller’s review of orthopedics Assistance from Dr. K. Lalonde

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