a useful presentation .. dedicated for orthopedic residents

1. Ahmad F. Ja’far
PGY3-Orthopaedic resident
JUH

2. Hallux Valgus
• Complex deformity.
• Often accompanied by deformities of lesser toes.
• Associated conditions : hammer toe, calluses
• Definition : Lateral deviation of great toe with medial
deviation of first metatarsal.
• More common in women.
• 70% of pts with hallux valgus have family history
genetic predisposition with anatomic anomalies.
• Adult type.
• Adolescent & juvenile hallux valgus.

3. Risk factors
Intrinsic
• Genetic predisposition.
• Ligamentous laxity.
• Convex metatarsal head.
• Pes planus.
• Rheumatoid arthritis.
• Cerebral palsy.
Extrinsic
• Shoes with high heel.
• Shoes with narrow toe
box.

4. Pathoanatomy
• Valgus deviation promotes varus position of metatarsal
• Sesamoid… complex becomes lateral to the metatarsal
head, which moves medially
• Medial Capsule… joint capsule becomes stretched and
attenuated.
• Lateral capsule… becomes contracted
• Adductor tendon becomes deforming force
– inserts on fibular sesamoid
• Lateral deviation of EHL
• Plantar and lateral migration of the abductor hallucis
causes muscle to plantar flex and pronate phalanx
• Windlass mechanism becomes less effective
– leads to transfer metatarsalgia

5. Pathoanatomy

6. Presentation-symptoms
• Difficulty with shoe wear due to medial eminence
(80%)
• Pain over prominence at MTP joint (70%)
• Cosmetic concerns in (60%)
• Pain underneath the second metatarsal head in 40%.
• Compression of digital nerve may cause symptoms.

7. Physical Exam
• Hallux rests in valgus and pronated due to deforming forces
illustrated above
• Examine entire first ray for
– 1st MTP ROM
– 1st tarsometatarsal mobility
• Evaluate associated deformities
– Pes planus
– Lesser toe deformities
– Midfoot and hindfoot conditions
– Corns, calluses, warts, interdigital neuromas,
bunionettes, hammer toes, and claw toes.
– Generalized ligamentous laxity

8. Physical Exam

9. Radiographs
• Views
– Standard series should include weight bearing AP and
Lat.
– Sesamoid view can be useful.
• Findings
– Radiographic parameters ….. guide treatment
– Displacement of sesamoids
• often displaced laterally
– Joint congruency.
– Presence of first MTP joint and first metatarso-
cuneiform joint degenerative changes should be noted .

11. Hallux valgus angle
Normal < 15°

12. 1st/2nd Intermetatarsal angle (IMA)
Normal < 9°

13. Distal metatarsal articular angle
(DMMA) Normal < 10°
Joint line congruency
Moderately severe hallux valgus w/
a significantly increased DMMA will
be associated w/ a congruent
bunion

14. Halluv valgus interphalangeus
(HVI) Normal < 10°
Joint line congruency

15. Sublaxed Vs Congruent

16. Classification

17. Management
• Conservative
• Shoe modification/ pads/ orthoses
– First line treatment
• Exercises, and activity adjustments.
• Orthoses more helpful in patients with pes planus or
metatarsalgia.

18. Surgical options
• surgical correction ---- Indications
– when symptoms present with 2ry deformities and shoe modification fails
– do not perform for cosmetic reasons alone
• General rules ….
• More than 130 operations …
– Soft tissue procedure
• indicated in very mild disease in young female (almost never alone)
– Distal MTB osteotomy
• indicated in mild disease
– Proximal or combined MTB osteotomy
• indicated in more moderate disease
– Fusion procedures
• indicated in severe disease with 2ry degenerative changes.
– MTP resection arthroplasty
• only indicated in elderly patients with low functional demand

19. Soft tissue:
Modified Mcbride
Distal MTB osteotomy HVA ≤ 40, IMA <
13:
Chaveron.. biplanar Chevron
Mitchel
Proximal MTB osteotomy: HVA >40°, IMA
>13°
Scarf Crescentric
Ludloff Broomstick
Combined MTB osteotomy: severe
disease (HVA 41-50°, IMA 16-20°)
Proximal phalanx osteotomy
Akin
Arthrodesis
1st MTJ
Lapidus-1st metatarsocuneiform

20. Soft Tissue Procedure
• Modified McBride
• Indications
• 30- to 50-year-old woman with clinical
• HVA --- 15 to 25 degrees
• IMA --- less than 13 degrees.
• HVI --- less than 15 degrees
• No degenerative changes at the metatarsophalangeal joint
– never appropriate in isolation
– in conjunction with medial eminence resection and
osteotomy.

21. Modified McBride

22. Distal metatarsal osteotomy-Mitchel
• Distal 1st MT osteotomy (extra-articular).
• More proximal than Chevron.
• Problems : metatarsalgia, attributable to dorsiflexion malunion
of the distal fragment, excessive shortening of the metatarsal or
Both…. recurrence

23. Distal metatarsal osteotomy-Chaveron
• V-shaped lateral translational osteotomy – sagittal plane.
• non-congruent deformity with a normal DMAA.
• More distal than Mitches (Cancellous bone)
• less shortening of the metatarsal, lessa metatarsalgia more
stability.

24. Combined Chaveron-Aiken
osteotomy
• Moderate to sever deformity
• Increased HVI
• Proximal phalanx medial close wedge osteotomy

25. Osteotomy of the proximal
first metatarsal and shaft osteotomy
• Severe deformity
IMA > 20
HVA > 50
• have high corrective power due to their proximal
location providing a long lever arm.
• More demanding.
• Accompanied by soft tissue procedure
Crescentic
Proximal
chaveron
Ludloff
Scarf

26. Combined proximal and distal osteotomies
• Increased intermetatarsal angle (IMA) and distal metatarsal articular angle
(DMAA).

27. Scarf osteotomy
• Added stability
• +/- soft tissue procedure .. +/- pahalangeal
osteotomy

29. 1st metatarsophalangeal joint arthrodesis
Indications
• cerebral palsy
• Down's syndrome
• Rheumatoid arthritis
• Gout
• Severe DJD
• Ehler-Danlos
• Recurrent hallux
valgus.

30. 1st metatarsophalangeal joint arthrodesis
• 15 to 20 degrees of valgus
• 30 degrees of dorsiflexion in relation to metatarsal shaft
or
• 10 to 15 degrees of dorsiflexion in relation to floor

31. Lapidus procedure (1st metatarsocuneiform
arthrodesis)
Indication
• Severe deformity
• Metatarsus primus
varus
• Hypermobile 1st
tarsometatarsal
joint

32. Resection arthroplasty (Keller’s)
• Largely abandoned
• Still indicated in some elderly patient with reduced
function demands
• Include medial eminence removal and resection of
base of proximal phalanx

33. Complications of surgery
Recurrence
• Most common cause of failure is insufficient preoperative
assessment and failure to follow indications
– e.g., failure to recognize DMAA > 15°
– e.g., failure to do adequate distal soft tissue realignment
• More common in juvenile/adolescent population
• Noncompliant patient that bears weight.

34. Complications of surgery
Avascular necrosis
• Medial capsulotomy is primary insult to blood flow to
metatarsal head
• Distal metatarsal oseotomy and lateral soft tissue
release inconjuction do not increase risk for AVN.

35. Complications of surgery
Dorsal malunion with transfer metatarsalgiadue to
overload of lesser metatarsal heads
• Risk associated with
– Lapidus fusion.
– Proximal crescentric osteotomy.
• 2nd MT transfer metatarsalgia often seen
concomitant with hallux valgus
• Shortening metatarsal osteotomy (Weil) indicated
with extensor tendon and capsular release

36. Complications of surgery
Hallux Varus caused by
– Overcorrection of 1st IMA
– Excessive lateral capsular release with
overtightening of medial capsule
– Overresection of medial first metatarsal head
– Fibular sesamoidectomy

37. Complications of surgery
Cock up toe deformity
- Due to injury of FHL
- Most severe complication with Keller resection
Neuropraxia
- Painful incisional neuromas----involve the dorsomedial
cutaneous branch of the superficial peroneal nerve.
- Branches of the deep peroneal nerve to this area are
rare.

38. Juvenile / adolescent hallux valgus
• How much different ??
– Often bilateral and familial
– Pain usually not primary complaint (cosmetic)
– Varus of first MT with widened IMA usually present
– DMAA usually increased
– Often associated with flexible flatfoot
• complications
– recurrence is most common complication and hallux
varus

39. • Nonoperative
– Shoe modification
• indications
– pursue nonoperative management until physis closes
• Operative
– Surgical correction
• indications
– best to wait until skeletal maturity to operate
» Medial cuneiform osteotomy.
» Surgery indicated in symptomatic patients with an IMA > 10°
and HVA of > 20°
– Severe deformity with a DMAA > 20 perform a double MT
osteotomy
Juvenile / adolescent hallux valgus

40. Medial Cuneiform osteotomy.

41. Hallux Rigidus and DJD

42. Hallux Rigidus
• A condition characterized by loss of motion of first
MTP joint in adults due to degenerative arthritis .
• Osteophyte formation leads to dorsal impingement
Pathoanatomy …..primary etiology unknown
• acute trauma and repetitive microtrauma
predispose to arthritic changes
• anatomic variations of first metatarsal may play a
yet unproven role in arthritic predisposition

43. Classification
Exam Findings Radiographic Findings
Grade 0 Stiffness Normal
Grade 1 mild pain at extremes of
motion
mild dorsal osteophyte,
normal joint space
Grade 2 moderate pain with range
of motion increasingly
more constant
moderate dorsal
osteophyte, <50% joint
space narrowing
Grade 3 significant stiffness, pain at
extreme ROM, no pain at
mid-range
severe dorsal
osteophyte, >50% joint
space narrowing
Grade 4 significant stiffness, pain at
extreme ROM, pain at mid-
range of motion
same as grade III

44. Presentation
Symptoms
– First ray and 1st MTP pain and swelling worse with
push off or forced dorsiflexion of great toe
– Shoe irritation due to dorsal osteophytes and
compression of dorsal cutaneous nerve may lead to
paresthesias
– Pain becomes less severe as the disease progresses
Physical exam
– Limited dorsiflexion
– Pain with grind test

45. Radiographs recommended views
– AP, lateral, and oblique views
Findings
– osteophytes, especially dorsal
– joint space narrowing
– subchondral sclerosis and cysts

46. Treatment
• Nonoperative
• NSAIDS, activity modification & orthotics
– Indications
• grade 0 and 1 disease
– Activity modifications
• avoid activities that lead to excessive great toe
dorsiflexion
– Types of orthotics
• Morton's extension with stiff foot plate is the
mainstay of treatment
• stiff sole shoe and shoe box stretching may also be
used

47. Operative
• Joint debridement and synovectomy
• patients with acute osteochondral or chondral defects
• Dorsal cheilectomy
• Grade 1 and 2 disease.
• Pain with dorsiflexion is an indicator of good results with dorsal
cheilectomy
• Shoe wear irritation from dorsal prominence and pain (ideal
candidate)
• contraindicated when pain located in the mid-range of the joint
during passive motion
– Technique
• remove 25-30% of the dorsal aspect of the metatarsal
head along with dorsal osteophyte resection
• the goal of surgery is to obtain 70% to 90% dorsiflexion
intraoperatively.

48. Dorsal cheilectomy

49. Moberg procedure
• Dorsal closing wedge osteotomy of the
proximal phalanx).
– runners with reduced dorsiflexion (60° is needed to
run)
– Failure of cheilectomy to provide at least 30 to 40
degrees of motion

50. Keller Procedure
• Resection arthroplasty
– elderly, low demand patients with significant joint
degeneration and loss of motion
• Technique
– involves removing the base of the first proximal
phalanx
– risk of hyperextension (cock-up deformity),
weakness with push-off, and transfer metatarsalgia
(decreased with capsular interposition)

51. MTP arthroplasty
((controversial))
• Technique
– capsular interpositonal arthroplasty gaining
popularity
– Silicone implants are not recommended due to poor
long-term results
• Outcomes
– silicone implants may have a good short term
satisfaction rate
– osteolysis and synovitis cause mid to long term pain
and joint destruction

52. MTP joint arthrodesis
• Indications
– grade 3 and 4 disease (significant joint arthritis)
– most common procedure for hallux rigidus
• Outcomes
– 70% to 100% fusion rate
– 15% of patients experience degeneration of IP joint
after surgery (mostly asymptomatic)

53. Summary

54. Thank you