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Introduction
  • Not a single deformity, but rather a complex deformity of the first ray
    • often accompanied by deformities and symptoms in lesser toe
    • two forms exist
      • adult hallux valgus 
      • adolescent & juvenile hallux valgus 
  • Epidemiology of adult hallux valgus 
    • more common in women 
    • 70% of pts with hallux valgus have family history
      • genetic predisposition with anatomic anomalies
    • risk factors
      • intrinsic
        • genetic predisposition
        • increased distal metaphyseal articular angle (DMAA)
        • ligamentous laxity (1st tarso-metatarsal joint instability)
        • convex metatarsal head
        • 2nd toe deformity/amputation
        • pes planus
        • rheumatoid arthritis
        • cerebral palsy
      • extrinsic
        • shoes with high heel and narrow toe box
  • Pathoanatamy
    • valgus deviation of phalanx promotes varus position of metatarsal
    • the metatarsal head displaces medially, leaving the sesamoid complex laterally translated relative to the metatarsal head 
    • sesamoids remain within the respective head of the flexor hallucis brevis tendon and are attached to the base of the proximal phalanx via the sesamoido-phalangeal ligament
    • this lateral displacement can lead to transfer metatarsalgia due to shift in weight bearing
    • medial MTP joint capsule becomes stretched and attenuated while the lateral capsule becomes contracted
    • adductor tendon becomes deforming force
      • inserts on fibular sesamoid and lateral aspect of proximal phalanx
    • lateral deviation of EHL further contributes to deformity
    • 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  
  • Associated conditions
    • hammer toe deformity
    • callosities
  • Juvenile and Adolescent Hallux valgus 
    • factors that differentiate juvenile / adolescent hallux valgus from adults
      • often bilateral and familial
      • pain usually not primary complaint
      • varus of first MT with widened IMA usually present
      • DMAA usually increased
      • often associated with flexible flatfoot
    • complications
      • recurrence is most common complication (>50%), also overcorrection and hallux varus
Anatomy
Presentation
  • Symptoms
    • presents with difficulty with shoe wear due to medial eminence
    • pain over prominence at MTP joint
    • 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
      • callous formation
      • sesamoid pain/arthritis
    • evaluate associated deformities
      • pes planus
      • lesser toe deformities
      • midfoot and hindfoot conditions
Imaging
  • Radiographs
    • views
      • standard series should include weight bearing AP, Lat, and oblique views
      • sesamoid view can be useful
    • findings
      • lateral displacement of sesamoids
      • joint congruency and degenerative changes can be evaluated 
      • radiographic parameters (see below) guide treatment

Radiographic Measurements in Hallux Valgus
Hallux valgus (HVA) Long axis of 1st MT and prox. phal. Identifies MTP deformity Normal
< 15°
Intermetatarsal angle (IMA) Between long axis of 1st and 2nd MT   < 9°
Distal metatarsal articular (DMAA) Between 1st MT long. axis and line through base  of distal articular cap Identifies MTP joint incongruity < 10°
Hallux valgus interphalangeus (HVI) Between long. axis of distal phalanx and proximal phalanx   < 10 °  
 
Treatment - Adult Hallux Valgus
  • Nonoperative
    • shoe modification/ pads/ spacers/orthoses
      • indications
        • first line treatment
      • orthoses more helpful in patients with pes planus or metatarsalgia
  • Operative
    • surgical correction
      • indications
        • when symptoms present despite shoe modification 
        • do not perform for cosmetic reasons alone
      • technique
        • soft tissue procedure
          • indicated in very mild disease in young female (almost never)
        • distal osteotomy
          • indicated in mild disease (IMA < 13)
        • proximal or combined osteotomy
          • indicated in more moderate disease (IMA > 13)
        • 1st TMT arthrodesis
          • arthritis at TMT joint or instability 
        • fusion procedures
          • indicated in severe deformity/spasticity/arthritis
        • MTP resection arthroplasty
          • only indicated in elderly patients with low functional demands
Treatment - Juvenile and Adolescent Hallux valgus
  • Nonoperative
    • shoe modification
      • indications
        • pursue nonoperative management until physis closes
  • Operative
    • surgical correction
      • indications
        • best to wait until skeletal maturity to operate
          • can not perform proximal metatarsal osteotomies if physis is open (cuneiform osteotomy OK)
        • surgery indicated in symptomatic patients with an IMA > 10° and HVA of > 20°
        • severe deformity with a DMAA > 20 consider a double MT osteotomy to correct orientation of MT head articular cartilage
      • technique
        • soft tissue procedure alone not successful
        • similar to adults if physis is closed (except in severe deformity)
Techniques
  • Soft Tissue Procedures
    • modified McBride 
      • indications 
        • goal is to correct an incongruent MTP joint (phalanx not lined up with articular cartilage of MT head). Usually done in patients with
          • a HVA less than 25 degrees  
          • IMA deformity less than 15 degrees
          • usually in patient 30-50 years of age
        • rarely appropriate in isolation
          • usually performed in conjunction with
            • medial eminence resection
            • MT osteotomy
            • 1st TMT arthrodesis (Lapidus procedure)
      • technique
        • includes
          • release of adductor from lateral sesamoid/proximal phalanx
          • lateral capsulotomy
          • medial capsular imbrication
          • (original McBride included lateral sesamoidectomy)
  • Metatarsal Osteotomies
    • distal metatarsal osteotomy
      • indications
        • mild disease (HVA ≤ 40, IMA < 13) 
      • distal metatarsal osteotomies include
        • Chevron     
        • biplanar Chevron (corrects DMAA)
        • Mitchell
        • may be combined with proximal phalanx osteotomy (Akin-medial closing wedge osteotomy)
    • proximal metatarsal osteotomy    
      • indications
        •  moderate disease (HVA >40°, IMA >13°)
      • proximal metatarsal osteotomies include
        • crescentic osteotomy
        • Broomstick osteotomy
        • Ludloff
        • Scarf 
    • double (proximal and distal) osteotomy
      • indications
        • severe disease (HVA 41-50°, IMA 16-20°)
    • first cuneiform osteotomy
      • indications
        • severe deformity in young patient with open physis
  • Proximal phalanx osteotomies
    • Akin osteotomy  
      • indications
        • hallux valgus interphalangeus 
        • congruent joint with DMAA <10°
        • as a secondary procedure if a primary procedure (e.g., chevron or distal soft-tissue procedure) did not provide sufficient correction due to a large DMAA or HVI
        • some authors perform Akin together with/at the time of proximal osteotomy+distal soft tissue correction because this results in progressive increase in HVI
  • Fusion procedures 
    • Lapidus procedure (1st metatarsocuneiform arthrodesis with modified McBride) 
      • indications
        • severe deformity (very large IMA)
        • arthritis at 1st TMT 
        • metatarsus primus varus
        • hypermobile 1st TMT joint
        • concomitant pes planus
    • MTP Arthrodesis
      • indications are hallux valgus in
        • cerebral palsy
        • Down's syndrome
        • Rheumatoid arthritis
        • Gout
        • Severe DJD
        • Ehler-Danlos
  • Resection arthroplasty
    • proximal phalanx (Keller) resection arthroplasty
      • indications
        • largely abandoned
        • rarely indicated in some elderly patient with reduced function demands
 
Surgical Indications for Various Techniques to treat Hallux Valgus
 
HVA
IMA
Modifier
Procedure
Mild
< 25°
<13°
Distal osteotomy
Chevron osteotomy. Biplanar if DMAA > 10° usually with mod McBride
 
Moderate
26-40°
13-15°
Proximal osteotomy +/- distal osteotomy
Chevron/mod McBride + Akin osteotomy
Proximal MT osteotomy and mod McBride
Severe
41-50°
16-20°
Double osteotomy DMAA > 15°
- Proximal MT osteotomy plus biplanar chevron, mod McBride

Lapidus procedure plus Akin
Elderly/very low demand patient
Keller
Juvenile/Adolescent with DMAA > 20
Double osteotomy of first ray
   
Surgical Indications for Specific Conditions
Juvenile/Adolescent with open physis
First cuneiform osteotomy
Hypermobile 1st MT
Lapidus procedure
DJD
MTP Arthrodesis
Skin breakdown
simple bunionectomy with medial eminance removal
Gout
MTP Arthrodesis
Recurrence with pain in 1st TMT joint
Lapidus procedure
Rheumatoid arthritis
MTP Arthrodesis
Down's syndrome, CP, Ehler-Danlos
MTP Arthrodesis


Procedure
Technique
Indications
Complications
Modified McBride

Includes release of adductor from lateral sesamoid/proximal phalanx, lateral capsulotomy, medial capsular imbrication

30-50 y/o female withHVA 15-25
IMA <13
IPA < 15
-Recurrence
-Hallux varus
Original McBride included lateral sesamoidectomy and has been abandoned -never indicated -Hallux Varus
Chevron

Distal 1st MT osteotomy (intra-articular). Can perform in two planes (Biplanar distal Chevron)

reserved for mild to moderate deformities in adults and children, biplanar chevron-->correct increased DMAA

 

-AVN of MT head
-recurrence
-dorsal malunion with transfer metatarsalgia
Mitchell Distal 1st MT osteotomy (extra-articular). More proximal than Chevron) same as Chevron. reserved for mild to moderate deformities, rarely utilized -recurrence
-malunion
-transfer metatarsalgia
Akin  proximal phalanx medial closing wedge osteotomy

-combined with Chevron in moderate to severe deformities
-hallux valgus interphalangeus

 
Scarf / Ludloff / Mau Metatarsal shaft osteotomies. -IMA 14-18°
-DMAA is normal or increased
-dorsal malunion with transfer metatarsalgia
-recurrence
Proximal crescentric or Broomstick Proximal metatarsal osteotomies. (plus modified McBride) Severe deformity
IMA > 20
HVA > 50
-hallux varus
-dorsal malunion with transfer metatarsalgia
-recurrence
Keller resection arthroplasty

Include medial eminence removal and resection of base of proximal phalanx

largely abandoned due to complications. indicated only in older patients with reduced functional demands -cock-up toe deformity
-poor potential for correction of deformity
MTP arthrodesis  

-indicated in moderate to severe hallux valgus
- DJD of 1st MTP
- painful callosities beneath lesser MT heads

 
Lapidus procedure  

first TMT joint arthrodesis with distal soft tissue procedures (medial eminence removal, first web space release of AdH, lateral capsule release)

-moderate or severe deformity
-hypermobility of first ray

Nonunion (may or may not be symptomatic)

dorsiflexion of the first metatarsal with transfer metatarsalgia

First Cuneiform Osteotomy

Opening wedge osteotomy (often requires autograft)

-children with ligamentous laxity, flatfoot, and hypermobile first ray
- adolescent with an open physis

Nonunion (may or may not be symptomatic)

Complications
  • Recurrence
    • most common cause of failure is insufficient preoperative assessment and failure to follow indications
      • e.g., failure to recognize DMAA > 10°
      • inadequate correction of IMA
      • e.g., failure to do adequate distal soft tissue realignment
    • more common in juvenile/adolescent population
    • noncompliant patient that bears weight
  • Avascular necrosis
    • medial capsulotomy is primary insult to blood flow to metatarsal head
    • distal metatarsal oseotomy and lateral soft tissue release inconjunction do not increase risk for AVN (Chevron plus lateral release thought to increase risk in the past)
  • Dorsal malunion with transfer metatarsalgia
    • due to overload of lesser metatarsal heads
    • risk associated with shortening of hallux MT
      • Lapidus
      • proximal crescentric osteotomies
  • Hallux Varus
    • caused by 
      • overcorrection of 1st IMA
      • excessive lateral capsular release with overtightening of medial capsule
      • overresection of medial first metatarsal head
      • lateral sesamoidectomy
  • Cock up toe deformity  
    • due to injury of FHL
    • most severe complication with Keller resection
  • 2nd MT transfer metatarsalgia
    • often seen concomitant with hallux valgus
    • shortening metatarsal osteotomy (Weil) indicated with extensor tendon and capsular release
  • Neuropraxia
    • Painful incisional neuromas after bunion surgery frequently involve the medial branch of the dorsal cutaneous nerve-a terminal branch of the superficial peroneal nerve.  It is most commonly injured during the medial approach for capsular imbrication or metatarsal osteotomy.  
 

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Questions (7)

(OBQ11.240) A 47-year-old woman that works as an attorney has a 3-year history of bilateral painful forefeet that is exacerbated with the dress shoes she wears for work. Physical examination reveals bursal inflammation and calluses at the medial eminence of the first metatarsal with a 1st metatarsalphalangeal (MTP)joint deformity that passively corrects. A clinical image is shown in Figure A and a radiograph is shown in Figure B. The hallux valgus angle (HVA) is measured at 25 degrees and the intermetatarsal angle(IMA) is measured at 12 degrees. Which of the following surgical interventions is most appropriate for correction of her deformities? Review Topic

QID:3663
FIGURES:
1

Distal metatarsal osteotomy (Chevron)

69%

(810/1179)

2

Closing wedge osteotomy of the proximal phalanx (Akin) combined with distal soft tissue release (Modified Mcbride)

23%

(270/1179)

3

Resection of medial eminence (Silver bunionectomy)

3%

(34/1179)

4

Proximal metatarsal osteotomy and first MTP arthrodesis

3%

(31/1179)

5

Metatarsal cuneiform fusion (Lapidus)

2%

(27/1179)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

Distal metatarsal osteotomy (Chevron) includes a lateral translation of the metatarsal head after osteotomy. The Chevron osteotomy can be used for a congruent or incongruent deformity that have hallux valgus angles less than 25-30 degrees and intermetatarsal angles less than 13 degrees.

The review by Easley et al states that an extensive lateral capsular release in addition to a Chevron ostetomy can be used to help correct deformity but can increase the risk of metatarsal head osteonecrosis. The risk of osteonecrosis with these combined procedures has been recently debated.

The Level 1 study by Saro et al prospectively randomized 100 hallux valgus patient to either a Chevron osteotomy or a Lindgren osteotomy. The corrections of the HVA and IMA were better in the Lindgren group. This was probably due to the fact that the Lindgren osteotomy permitted more lateral displacement than the originally described chevron osteotomy. Clinical outcomes demonstrated no differences between the osteotomy procedures.

Trnka et al performed a Level 4 review of 66 patients that underwent a distal Chevron osteotomy for mild hallux valgus. They found that at 5-year follow-up the Chevron osteotomy was found to be a dependable procedure for the correction of mild hallux valgus deformity. The osteotomy did not adversely affect MTP range of motion, had low recurrence, and had clinical outcomes that did not vary with age.

Illustration A and B shows the Chevron and Lindgren osteotomies, respectively.

Illustration C demonstrates how to measure the HVA and IMA on radiographs.

Video A is a surgical demonstration by Dr. Easley in the evaluation of hallux valgus and peforming a Chevron osteotomy.

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(OBQ10.138) A 57-year-old administrative assistant complains of pain over the bunion on her right foot. Physical exam is notable for tenderness over the medial prominence of the first metatarsophalangeal joint and hypermobility of the first ray. Shoe modifications have failed to provide relief. A clinical photograph and radiograph are provided in figures A and B. Surgical treatment with metatarsocuneiform arthrodesis is chosen. Each of the following are associated with a better clinical outcome EXCEPT: Review Topic

QID:3189
FIGURES:
1

Multiple screw fixation across the metatarsocuneiform arthrodesis

9%

(111/1227)

2

Augmentation of the metatarsocuneiform arthrodesis with bone grafting

14%

(166/1227)

3

Dorsiflexion unloading of the first metatarsal

59%

(725/1227)

4

Correction of the first intermetatarsal angle

4%

(47/1227)

5

Failure of conservative treatments prior to surgery

14%

(170/1227)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

The clinical photograph and radiograph demonstrate hallux valgus with a large first intermetatarsal angle. Metatarsus primus varus and hypermobility of the first ray are both indications for including metatarsocuneiform arthrodesis in the surgical correction of hallux valgus. Anatomic plantarflexion of the first metatarsal is crucial to prevent loading of the lesser metatarsals following surgery.

Myerson et al reports the results of 53 patients treated with metatarsocuneiform arthrodesis for hallux valgus and metatarsus primus varus. They found that 92% acheived clinical satisfaction despite numerous complications including 7 superficial pin tract infections, 3 dorsal bunions, 7 nonunions, 1 hallux varus, and 3 neuromas of the deep peroneal nerve. Only 1 of the complications needed secondary surgery.

Sangeorzan et al reports the results of metatarsocuneiform arthrodesis in 33 patients with hallux valgus and a hypermobile first ray and 7 patients with previous failed bunion surgery. Successful union occurred in 90%, and 75% were considered successful clinical results. Best results were achieved with bone grafting, multiple screw fixation, and accurate plantarflexion of the first metatarsal.

Incorrect Answers:
1,2,4,5: These are all associated with improved clinical outcomes.


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(OBQ09.211) A 67-year old female presents with the bilateral foot deformity shown in Figures A and B. All of the following contribute to the risk of recurrence after surgery EXCEPT: Review Topic

QID:3024
FIGURES:
1

Resection of the lateral sesamoid

69%

(1153/1668)

2

Lack of lateral capsular release

7%

(124/1668)

3

Lack of medial metatarsophalangeal joint capsule closure

7%

(117/1668)

4

Use of an Akin procedure alone for a moderate to severe deformity

9%

(158/1668)

5

Undercorrection of the widened 1-2 intermetatarsal (IMA) angle

7%

(114/1668)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The patient has bilateral hallux valgus. Resection of the lateral sesamoid would likely lead to hallux varus and not hallux valgus recurrence. Akin procedure is a closing wedge osteotomy of the proximal phalanx when the proximal phalangeal articular angle >10° but does not correct hallux valgus well. Metatarsal osteotomies, such as the Chevron, are used to bring the metatarsal shaft laterally to reduce the IMA but undercorrection of the IMA would likely lead to hallux valgus recurrence. Lateral soft tissue release and medial capsular reefing can be used to correct hallux valgus in combination with bony procedures, but its important to avoid an extensive lateral capsular release to minimize the risk of metatarsal head osteonecrosis.


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(OBQ08.166) A 55-year-old female attorney complains of progressive pain and deformity of the great toe. The pain is localized to a prominence of the medial metatarsal head. A clinical image is provided in figure A. Which of the following best describes the hallux deformity? Review Topic

QID:552
FIGURES:
1

Valgus and supination

11%

(196/1766)

2

Valgus and pronation

85%

(1509/1766)

3

Valgus and hyperextension

2%

(39/1766)

4

Varus and supination

0%

(5/1766)

5

Varus and pronation

1%

(13/1766)

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PREFERRED RESPONSE 2

Bunions are a common deformity of the great toe that is most prevalent in the aging female cohort. The etiology is multi-factorial including genetic predisposition and chronic exposure to narrow toe box shoes. The static soft tissue constraints attenuate medially and contract laterally, and the plantar dynamic flexors deviate laterally pulling the great toe into valgus and pronation. Illustration A is an example of this deformity. Coughlin summarizes the evaluation, diagnosis, and treatment of hallux valgus.

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(OBQ08.211) A 57-year-old female underwent surgery for severe hallux rigidus. Postoperative radiographs are shown in Figure A. One year later she complains of pain at the 2nd metatarsal head and her exam shows a plantar callosity under the 2nd metatarsal head. What procedure could have been combined with her initial operation to prevent this outcome? Review Topic

QID:597
FIGURES:
1

Second metatarsalphalangeal joint arthrodesis

2%

(14/785)

2

Second metatarsal osteotomy (Weil) with extensor tendon and dorsal capsular release

80%

(627/785)

3

Flexor to extensor tendon transfer (Girdlestone-Taylor)

5%

(39/785)

4

Second metatarsal osteotomy (Helal) with extensor tendon and dorsal capsular release

7%

(55/785)

5

Second metatarsal head resection with extensor tendon and dorsal capsular release

6%

(49/785)

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PREFERRED RESPONSE 2

The second metatarsal osteotomy (Weil), is an intra-articular osteotomy that achieves longitudinal decompression through shortening and will correct the longer 2nd metatarsal in relation to the first metatarsal. The first metatarsal bears half the weight of the forefoot and this patient's plantar callosity under the 2nd metatarsal head is clinical evidence of abnormal pressure transfer due to the longer 2nd metatarsal (seen in Figure A). The foot tripod can also be altered by hallux valgus as the proximal phalanx moves into valgus, the splay between the first and second rays increases (IM angle), the metatarsal moves into varus and elevates, and weight-bearing is transferred from the 1st metatarsal head to the the 2nd metatarsal head. A shortening osteotomy with extensor tendon and dorsal capsular release is the most appropriate option listed to address the second MTP metatarsalgia.

The Weil osteotomy of the metatarsal head is preferable to the Helal osteotomy of the metatarsal shaft to correct metatarsalgia due to higher rates of nonunion and pseudarthrosis with shaft osteotomies as demonstrated in the article by Trnka et al. Illustration A shows the difference between the Weil osteotomy (osteotomy B) and the Helal osteotomy (osteotomy A).

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(OBQ07.237) Which of the following clinical scenarios regarding hallux valgus could be appropriatley treated with a modified McBride procedure? Review Topic

QID:898
1

35-year-old female with a 20 degree HVA, a 11 degree IMA, and an incongruent 1st MTP joint

62%

(802/1294)

2

40-year-old male with a 30 degree HVA, and a 15 degree IMA, and a congruent 1st MTP joint

27%

(344/1294)

3

70-year-old female with a 35 degree HVA, and a 13 degree IMA with a hypermobile 1st ray

6%

(74/1294)

4

65-year-old female with a 25 degree HVA, a 14 degree IMA, and severe hallux rigidus

2%

(30/1294)

5

85-year old minimally ambulatory male with a 45 degree HVA, and a 20 degree IMA

3%

(33/1294)

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PREFERRED RESPONSE 1

The Modified McBride procedure is indicated in patients 30-50 years old with an incongruent joint, a HVA less than 25 degrees, and an IMA deformity less than 15 degrees. This soft tissue procedure should be avoided in moderate or severe hallux valgus deformity due to the increased risk of recurrence. Surgical technique includes release of adductor hallucis, transverse metatarsal ligament, and lateral capsule combined with excision of medial eminence and plication of the capsule medially. In patients with moderate hallux valgus deformity (HVA 26-40 deg, IMA 13-15 deg) a proximal osteotomy should be performed. In patients with moderate deformity and a hypermobile 1st ray, a Lapidus procedure (includes 1st TMT fusion) should be considered. A MTP arthodesis is indicated when concomitant severe hallux rigidus is present, and a Keller (includes partial resection of proximal phalanx) procedure should be considered in an elderly, low demand individual with severe deformity. Illustration A is an AP radiograph of the foot demonstrating the technique used in measuring the HVA and IMA.

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(OBQ06.267) A 34-year-old woman presents with right foot pain and a callus over the 1st metatarsalphalangeal joint. A clinical image is shown in Figure A. Accommodative shoewear has failed to relieve symptoms. Images displaying key radiographic angles in the evaluation of this disorder are shown in Figures B and C. This distal metatarsal articular angle (DMAA) is measured at 15 degrees. Which of the following operative procedures is most appropriate for this deformity? Review Topic

QID:278
FIGURES:
1

Closing wedge osteotomy of the proximal phalanx (Akin)

9%

(112/1242)

2

Distal soft-tissue release

1%

(13/1242)

3

Distal metatarsal osteotomy

25%

(315/1242)

4

Medial eminence resection and exostectomy (Silver)

1%

(15/1242)

5

Scarf osteotomy

63%

(785/1242)

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PREFERRED RESPONSE 5

This patient has a moderate hallux valgus deformity as shown by the intermetatarsal angle of 15 degrees shown in Figure B, and the hallux valgus angle of 40 degrees shown in Figure C. A Scarf osteotomy is the only procedure of the available options in isolation appropriate for this amount of deformity.

If there is an incongruent joint, a soft tissue rebalancing is appropriate to make the joint congruent. With a congruent MTP joint and a DMAA of greater than 10 degrees, the distal articular surface needs to be realigned to create an appropriate correction.

The review article by Jones et al describes multiple methods of proximal osteotomies including crescentic, chevron, and oblique osteotomies. Overcorrection of IMA can lead to hallux varus and dorsiflexion at osteotomy can lead to transfer metatarsalgia. Double osteotomies can also be utilized for moderate deformities with Jones et al describing 92% satisfaction with a combined Akin and scarf osteotomy (Illustration A).

The Level 5 review article by Robinson et al discussing management of hallux valgus. They review several surgeries and note that the distal chevron is most often used in a non-congruent deformity with a normal DMAA. A complication with the Chevron and other distal osteotomies is the development of AVN of the first metatarsal head with an estimated incidence of up to 20% reported in the literature.

Illustration B demonstrates a hallux valgus deformity with a congruent MTP joint, as is also the case for the patient in this question. A distal soft-tissue release, including a release of the lateral structures, would be an appropriate procedure combined with a proximal metatarsal osteotomy if the MTP joint was incongruent.

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