Is it possible to sex up bunions by calling it hallux valgus?

1. Is it possible to sex up bunions by calling it hallux valgus? Mr David R Tollafield Consultant Podiatric Surgeon Villars Medical Conference Walsall Manor Hospital (Community Health) Spire Healthcare Little Aston , Sutton Coldfield Ramsay Hospital Halesowen

2. This presentation (objectives):- • Avoiding the confusion • Looking at x-rays differently • Understanding why Tx is required • At the heart of bunion surgery – the sesamoid • Degeneration & what it means • What is good surgery?

3. Heredity plays more of a part than shoes

4. 1982 Clinic: Longton Stoke on Trent Child aged 9 (from old slide) Mum bought good shoes

5. Cover up test Is this soft tissue Or is this bony? Squashing a quart into a pint!

6. Variants: ‘Bunion, Onion, Bursa’ what does it all mean?

7. A sub-condition known as Metatarsus primus elevatus “The dorsal bunion” Line of declination 15 degrees to the ground

8. bursa

9. Affording temporary relief

10. Simple staging by clinical observation mild moderate severe Based on definition represented in ‘clinical skills in Treating the Foot’ Elsevier. Tollafield D R , Kilmartin T K , Prior T D 2005

11. So when do we treat? Hallux valgus is more of a lady’s problem than a man’s problem “Should I wait until it hurts?” “GP says it is not bad enough yet?” “...don’t like the look of it!” “Want to stop it getting like my mother’s” “Can’t get shoes on I want”

12. Should we leave this condition? PRIMARY Pain Deformity Degeneration SECONDARY Broad forefoot Shoe pressure Metatarsalgia Skin wear Ulcerations Impingement Chilblains infections

13. End of midstance, heel lift, toe propulsion How much movement? The sesamoid Root et al 1977 Suggest 20 degrees required

14. Tracking misalignment The sesamoid, above is affected as a patella against a femoral head!

15. How does it all happen? – the I-M angle 8-10o

17. Early life – third decade (female) joint toe metatarsal Side view of first toe (MTP) joint Axial view of met. head

18. Early compression erosion

19. The subchondral cystic lesion Geodes, granulomas, cysts and pseudocysts First metatarsal phalanx joint

20. Packed with homogenous Cancellous graft

21. Assessing the damage and adaptation

22. Depth • Surface area • synovium / capsule • Fluid • Osteophytic changes • loose bodies • sub-cartilage • bone density Intra operative considerations

23. Degenerative change forms one major reason to treat earlyThere are other concerns: metatarsalgiaskin pressureulcerserosionsinfections

24. Callus can be painful Other forms of “Metatarsalgia”

25. Hallux-valgo-rigidus Simple bump with pressure plus vascular

26. The picture of older age, disability and compromised health?

27. synovitis Cartilage adapts • Good surgery: principles • Align the Sesamoids • Select procedure for • Degenerative state • Fit surgery to patients’ needs geode sesamoids Extensor tendon bowstringing

28. Three P’s • Pre-operative planning • Correlate XR • Patient preparation • Consent • Post op care • Good monitoring Gap opens up Sesamoids aligned Tendon repositioned

29. Good surgery: principles

30. A brief word Selection of treatment is multifactorial • Conservative? Limitations • Exostectomy • Excisional arthroplasty • Osteotomy (wide range) • Fusion (mcj fusion) • Joint replacement arthroplasty (prosthesis) • Amputation

31. multi-digital deformity can be challenging

32. Addressing the whole deformity There is no such thing as a simple bunion: metatarsus adductus

33. Should Mrs Beckham have surgery? Yes if? Pain Swelling early crepitations Stiffness Strong family history Lesser toes affected Metatarsalgia No if? None of above Down to footwear alone

34. 360 Appraisal evidence Conclusion Can we sex up bunions?Maybe we can sympathise more if thecondition is perceived as not shoerelated