Ahmad F. Ja’farPGY3-Orthopaedic resident

JUH

Hallux valgus & Hallux rigidus

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.

Risk factorsIntrinsic

• Genetic predisposition.• Ligamentous laxity.• Convex metatarsal head.• Pes planus.• Rheumatoid arthritis.• Cerebral palsy.

Extrinsic• Shoes with high heel.• Shoes with narrow toe

box.

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

Pathoanatomy

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.

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

Physical Exam

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 .

Hallux valgus angle

Normal < 15°

1st/2nd Intermetatarsal angle (IMA)

Normal < 9°

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

Halluv valgus interphalangeus (HVI) Normal < 10°

Joint line congruency

Sublaxed Vs Congruent

Classification

Management• Conservative • Shoe modification/ pads/ orthoses

– First line treatment• Exercises, and activity adjustments. • Orthoses more helpful in patients with pes planus or

metatarsalgia.

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

Soft tissue:

Modified Mcbride

Distal MTB osteotomy HVA ≤ 40, IMA < 13:

Chaveron.. biplanar ChevronMitchel

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

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.

Modified McBride

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

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.

Combined Chaveron-Aiken osteotomy

• Moderate to sever deformity• Increased HVI • Proximal phalanx medial close wedge osteotomy

Osteotomy of the proximalfirst 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

Combined proximal and distal osteotomies

• Increased intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA).

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

osteotomy

1st metatarsophalangeal joint arthrodesis

Indications• cerebral palsy• Down's syndrome• Rheumatoid arthritis• Gout• Severe DJD• Ehler-Danlos• Recurrent hallux

valgus.

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

Lapidus procedure (1st metatarsocuneiform arthrodesis)

Indication• Severe deformity• Metatarsus primus

varus• Hypermobile 1st

tarsometatarsal joint

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

Complications of surgeryRecurrence• 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.

Complications of surgeryAvascular 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.

Complications of surgeryDorsal 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

Complications of surgeryHallux Varus caused by

– Overcorrection of 1st IMA– Excessive lateral capsular release with

overtightening of medial capsule– Overresection of medial first metatarsal head– Fibular sesamoidectomy

Complications of surgeryCock 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.

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

• 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

Medial Cuneiform osteotomy.

Hallux Rigidus and DJD

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

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

PresentationSymptoms

– 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

Radiographs recommended views – AP, lateral, and oblique views

Findings – osteophytes, especially dorsal– joint space narrowing– subchondral sclerosis and cysts

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

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.

Dorsal cheilectomy

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

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)

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

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)

Summary

Thank you