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Hallux Valgus Correction: Algorithem and Treatment

Hallux Valgus Correction: Algorithem and Treatment. Arash Aminian MD March 17, 2011. Hallux Valgus. All bunions are not created equal Complex array of osseous & soft tissue pathology Lateral deviation of the great toe with medial deviation of the 1 st metatarsal.

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Hallux Valgus Correction: Algorithem and Treatment

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  1. HalluxValgus Correction: Algorithem and Treatment Arash Aminian MD March 17, 2011

  2. Hallux Valgus • All bunions are not created equal • Complex array of osseous & soft tissue pathology • Lateral deviation of the great toe with medial deviation of the 1st metatarsal

  3. Surgical Treatment • >100 procedures for Hallux Valgus • Procedure should address deformity • Soft tissue procedure combined with bony correction most common procedure • Chevron Osteotomy with Silver eminence resection most common procedure

  4. Hallux Valgus: PE • NWB & WB • Gait/shoe wear • ROM • Hyper mobility 1st ray • Adductor tautness • Neurovascular • Footprints

  5. INDICATIONS • Painful HV failed palliative measures • Wider shoes • Activity modification • NSAIDS • No inflammatory • Non paralytic • 1st MTP Fusion

  6. CONTRAINDICATIONS • PVD • Arthritis • Neuropathic • Pure cosmetic • Osteopenia

  7. ALLIIED DEFORMITIES • METATARSALGIA • HAMMERTOES • CLAWTOES • DEVIATED TOES • NEUROMAS • EQUINUS

  8. RADIOGRAPHS STATIC DEFORMITY • AP/Lat & Sesamoid Weight-Bearing • IMA < 9 degrees • DMAA < 9 degrees • HVA < 15 degrees • Sesamoid station & metatarsal length • Congruity

  9. HVA IMA DMAA

  10. RADIOGRAPHIC ANALYSIS • High Intra, Inter-observer reliability for HVA, IMA (<5 degree, 95% confidence) • Measure from the center of MT head to center of MT base • Post-operative measures are less reliable • Anatomy distorted • Functional outcomes failed to correlate with radiographic outcomes (Thordason et al FAI 26:2005)

  11. SURGICAL GOALS • Plantigrade & painless foot • Complex array of pathological bone & soft tissue deformity must be addressed • Each procedure has limitations & indications • Multiple options should be available

  12. SURGICAL TREATMENT

  13. ALGORITHIM • Congruent Joint • Mild deformity • IMA < 15 degrees, HV < 35 degrees • No instability of the 1st Ray Chevron Osteotomy

  14. CHEVRON • Small medial eminence resection • Hallux Varus • Release the capsule through the joint • AVN • Main blood supply to the MT head: Plantar-lateral corner of the MT head • Don’t rely on the capsular plication for deformity correction • Post-op early motion

  15. CHEVRON

  16. ALGORITHIM • Incongruent Joint • Moderate deformity • IMA 15-20 degrees, HV <40 degrees • No instability of the 1st Ray SCARF Osteotomy Modified Chevron

  17. SCARF

  18. MODIFIED CHEVRON

  19. ALGORITHIM • Incongruent Joint • Severe deformity • IMA >20 degrees, HV >40 degrees • Instability of the 1st Ray Lapidus 1st MTP fusion

  20. LAPIDUS

  21. ALGORITHIM • Inflammatory Arthritis • Paralytic deformity 1st MTP fusion

  22. 1st MTP FUSION

  23. KELLER • Resection of the proximal phalanx • Older patient • Less demand • High risk patients (medical co-morbidities)

  24. Complications • AVN • Stiffness of the joint • Hallux Varus • Malunion (Dorsiflexion: transfer metatarsalgia) • Non-union (Lapidus 5%)

  25. AVN • Blood supply: Branches of the • 1st dorsal metatarsal artery • 1st Plantar metatarsal artery • Medial plantar artery • Plexus Lateral plantar corner • JBJS 2007:2018-2021.

  26. Complications: Recurrance • Do not push a procedure beyond its limits • Hypermobile 1st ray=Lapidus • DMAA ? • Loss of fixation ?

  27. Complications: Recurrance • Position of medial sesmoid and axis of 1st MT JBJS 2009: 1637-1645.

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