hallux valgus: surgical treatment - medical job...
TRANSCRIPT
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Hallux Valgus:Surgical Treatment
November 3, 2003Dr. N.C. Stone
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Intro
• Clinical Assessment• Investigations• Treatment
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Clinical Assessment
• Severity of Symptoms• Location of pain• ? Secondary cause (i.e. RA)• Patient Expectations• “Not the incision but the decision”
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Clinical Assessment
• Severity of Deformity – wide forefoot• Stiffness / Correctability• Hypermobile 1st ray• Lesser toe problems• Pes planus• Neurovascular exam
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Investigations
• STANDING AP and Lateral• Angles
– DMAA, HV, Intermetatarsal Angle
• Congruent / Incongruent• Degenerative Change
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HV angle IMT angle Incongruent MTPJ
Normal <15deg. <9deg. No
Mild 15-20deg. 9-11deg. No
Moderate 20-40deg. 11-18deg. Yes (unless abnormal DMAA)
Severe >40deg. > 18deg Yes
Classification
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Surgical Decision Making
• Flow charts• Know the principles and a few procedures
– Akin– Chevron (and its modifications)– Proximal 1st osteotomy– Modified Mcbride’s
• 5 common scenarios
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Scenario #1
• Older Patient• Severe deformity (HV angle > 40)• Inflammatory disease• Degenerative Changes• FUSION ? Keller’s ? Prosthetic
arthroplasty
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Scenario #2
• Hypermobile 1st ray• Lapidus Procedure
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Scenario #3
• Young Patient (congenital Hallux Valgus)• Congruent, Increased DMAA, Increased IMA• All Extra Articular
– Proximal – Chevron / Medial closing wedge distally– Akin– NO lat release / NO medial tightening
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Can help fix the DMAA60 degrees
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Proximal 1st Metatarsal Osteotomy
• Dome• Opening/closing wedge• Myerson
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Scenario #4
• Middle aged patient / wide forefoot• Incongruent, Increased IMA, Normal
DMAA– Proximal– Lateral release / Medial tightening
(Modified McBride)– +/- Akin
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Modified McBride
• Adductor Hallucis release• Transverse metatarsal ligament release• Lateral Capsular release
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Scenario #5
• The most common one• Middle aged female• Not severe, Normal IMA, Slightly
incongruent– Chevron, medial capsular tightening– +/- Akin
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Complications
• Non-union• AVN (avoid distal osteotomy and
McBride’s together)• Recurrence• Hallux Varus
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Hallux Varus
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Case 1
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Case 2
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Case 3
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!!Thank You!!