Viva Hallux Valgus Flashcards
Hallux Vallgus
Describe the photograph
- This is a clinical photograph, a weight bearing frontal view of both feet showing
Hallux valgus deformity with the hallux over-riding the second toes. I can only
count three lesser toes on the left foot. There is also a small area of scar on the
dorsum of the right foot. - Hallux valgus is defined as a lateral deviation of the proximal phalanx on the 1st
metatarsal head with medial deviation of the 1st MT. - Occurs in female: male 4:1(middle aged group)
Hallux Vallgus
What are the risk factors for this
condition?
Ø Genetic predisposition (70% of patients with Hallux valgus have a family history).
Ø 2nd toe deformity – amputation
Ø Rheumatoid arthritis
Ø Ligamentous laxity
Ø Narrow-toed, high-heeled footwear
Hallux Vallgus
What is the Pathoanatomy of this
condition?
The proximal phalanx deviates laterally → 1st MT deviates medially → the
sesamoid complex assumes a lateral position relative to the 1st MT head →
progressive weakening of the medial capsule of the 1st MTP joint with contracture
of the lateral capsule → The abductor hallucis becomes slightly more plantar to
the medial aspect of the first metatarsophalangeal (MTP) joint(pronation
deformity) → This leaves the adductor tendon unopposed as an increasing
deforming force laterally with its attachment to the proximal phalanx and the
lateral sesamoid → Lastly, the flexor hallucis brevis, flexor hallucis longus, and
extensor hallucis longus all increase their valgus moment on the MTP joint and
further deviate the first ray → with progression the windlass mechanism is lost
leading to loss of weight bearing under the 1st MT and transfer to lesser MTs
(transfer metatarsalgia)
Hallux Vallgus
What are the causes of pain in this
condition?
v Extrinsic pain
* Due to deformity. Extrinsic pain may be managed non-operative management by
Shoes with a wider deeper toe box, Padding the bunion, Pressure from the next
adjacent toe can be managed with a silastic toe spacer.
v Intrinsic pain
* Joint incongruence
* Degeneration
* Synovitis: MTP joint/sesamoid joint. Intrinsic pain is more readily treated by
surgical restoration of joint congruence although orthotics (sole stiffener,
Morton’s extension, forefoot rocker) may have a role.
Hallux Vallgus
How would you treat this patient ?
starting with?
I would like to take history, including questioning about the main complaints of the patient
- (pain (due to inflamed bunion)-difficulty with shoe wear cosmetic)
- relevant conditions such as diabetes, inflammatory arthritis, vascular disease and neuropathy
- also it is important to consider the patient’s activity level and expectations.
Hallux Vallgus
How would you treat this patient ?
after taking history
- I would examine:
Ø Look: The gait and the posture of the weighted foot as hallux valgus is often
associated with a planus foot- calluses- swelling and redness along the medial aspect of MTP due to bursal inflammation- other deformities (hammer lesser toes)
Ø Feel: I would palpate for areas of tenderness, paying particular attention to the
hallux MTP joint and lesser metatarsal heads.
Ø Move: I would assess the degree of active and passive correction possible and the
range of movement of the involved joints. I would assess ROM of the 1st TMT
joint. Neurovascular status must also be assessed.
Ø Special test: Grind test to check for MTP joint arthritis
Hallux Vallgus
How would you treat this patient ?
after examning the patient
I would obtain weight bearing AP, oblique and lateral radiographs of the foot to
evaluate:
Ø MTP joint congruency
Ø position of sesamoids.
Ø Degenerative changes
Ø Radiographic parameters (HVA-IMA-DMAA-PPAA)
Hallux Vallgus
How would you treat this patient ?
Your goals of treatment
- Goals of treatment:
Ø Relive pain and correct deformity
Ø Refunction the 1st ray
Ø reduce the tendency to transfer metatarsalgia
Hallux Vallgus
How would you treat this patient ?
your treatment options
- I would start with non-surgical treatment:
Ø Shoe wear modifications including low heeled shoes-wide toe box.
Ø Bunion pads and toe spacers.
Ø Medial arch support insoles to limit mid and forefoot pronation.
Hallux Vallgus
How would you treat this patient ?
surgical principes 1
***** Surgical principles:
**
Ø Remove the bunion
Ø Correct the hallux valgus angle
Ø Correct the intermetatarsal angle
Ø Correct hallux interphalangeus
Ø Correct and maintain the distal metatarsal articular angle (DMAA)
Ø Restore joint congruence: Most deformities are incongruent and, hence, do not
need DMAA correction. (Congruent HV: no joint subluxation and DMAA >10°;
incongruent HV: Joint subluxation but DMAA is normal.)
Hallux Vallgus
How can you determine congruency of the
first MTPJ?
Congruency is determined by
connecting the medial and lateral edge
of the first metatarsal head articulating
surface with a similar line of the
proximal phalanx
Hallux Vallgus
How would you treat this patient ?
surgical pricipels 2
- Surgical principles:
Ø Avoid first MT shortening and elevation (defunctions first ray)
Ø Stabilise and debulk the medial MTP joint capsule with capsulorhaphy
Ø Avoid plantar dissection to prevent AVN first MT head
Ø Relocate sesamoids under first MT head
Hallux Vallgus
How would you treat this patient ?
General rules
- General rules:
Ø Distal osteotomy for mild deformity.
Ø Proximal and distal osteotomy for severe deformity.
Ø A combination of proximal and distal osteotomy is carried out where proximal
osteotomy adversely affects DMAA
Hallux Vallgus
How would you treat this patient ?
General rules by measurments
* General rules:
- IMA <=13 AND HVA <=40 degrees
- Cheveron
- IMA >13 AND HVA >40 degrees
- Proximal osteomty
- Instability of the first TMT
- Lapidus
- Arthritis of the first TMP
- Fusion
- Increased DMAA
- Distal medial closing wedge osteomty in addition what is required based on the angular
deformity
- Distal medial closing wedge osteomty in addition what is required based on the angular
Hallux Vallgus
How would you treat this patient ?
flow chart 1
Hallux Vallgus
How would you treat this patient ?
flow chart 2
Hallux Vallgus
How would you treat this patient ?
flow chart 3
Hallux Vallgus
How would you treat this patient ?
Other distal metatarsal osteotomies 2
* Proximal Chevron metatarsal osteotomy:
Ø Indicated in moderate to sever deformity.
Ø Adversely affecting the DMAA and a second distal osteotomy can be indicated
* Other proximal osteotomies include:
Ø Mau / Ludloff: Mau is more stable than Ludloff, but provides less degree of correction
Ø Proximal crescentic or Broomstic osteotomy
Ø Scarf osteotomy: mid-shaft Z osteotomy allows lateral translation of the distal metatarsal, it is very
stable osteotomy because: it can be performed very long, so more contact surface for fixation and
healing.
Technique: longitudinal medial incision over MTP joint – care must be taken not to disrupt
the vessels coming from plantar and retrocapital. Longitudinal cut is made parallel to the
weightbearing plane (plantar surface of MT), the proximal transverse angle is made in an angle of
45° with the longitudinal cut and directed posteriorly to allow lateral displacement
Hallux Vallgus
How would you treat this patient ?
Keller’s arthroplasty
* Keller’s arthroplasty:
Ø Resection of the base of the proximal phalanx.
Ø Complications – high level of transfer metatarsalgia – cock up deformity due to injury to FHL.
Ø Limited to individuals with low functional demands
