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Hallux Valgus

Topic updated on 07/24/14 11:20am
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 of distal articular cap Identifies MTP joint incongruity < 15°
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
  • 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 tarsometatarsal joint
    • 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 > 15° 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 pahalanx 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

largerly 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)

-chilren 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 > 15°
      • 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 inconjuction 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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Qbank (10 Questions)

TAG
(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? Topic Review Topic
FIGURES: A   B        

1. Distal metatarsal osteotomy (Chevron)
2. Closing wedge osteotomy of the proximal phalanx (Akin) combined with distal soft tissue release (Modified Mcbride)
3. Resection of medial eminence (Silver bunionectomy)
4. Proximal metatarsal osteotomy and first MTP arthrodesis
5. Metatarsal cuneiform fusion (Lapidus)

PREFERRED RESPONSE ▶
TAG
(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: Topic Review Topic
FIGURES: A   B        

1. Multiple screw fixation across the metatarsocuneiform arthrodesis
2. Augmentation of the metatarsocuneiform arthrodesis with bone grafting
3. Dorsiflexion unloading of the first metatarsal
4. Correction of the first intermetatarsal angle
5. Failure of conservative treatments prior to surgery

PREFERRED RESPONSE ▶
TAG
(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: Topic Review Topic
FIGURES: A   B        

1. Resection of the lateral sesamoid
2. Lack of lateral capsular release
3. Lack of medial metatarsophalangeal joint capsule closure
4. Use of an Akin procedure alone for a moderate to severe deformity
5. Undercorrection of the widened 1-2 intermetatarsal (IMA) angle

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Valgus and supination
2. Valgus and pronation
3. Valgus and hyperextension
4. Varus and supination
5. Varus and pronation

PREFERRED RESPONSE ▶
TAG
(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 should have been combined with her initial operation to prevent this outcome? Topic Review Topic
FIGURES: A          

1. Second metatarsalphalangeal joint arthrodesis
2. Second metatarsal osteotomy (Weil) with extensor tendon and dorsal capsular release
3. Flexor to extensor tendon transfer (Girdlestone-Taylor)
4. Second metatarsal osteotomy (Helal) with extensor tendon and dorsal capsular release
5. Second metatarsal head resection with extensor tendon and dorsal capsular release

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

1. 35-year-old female with a 20 degree HVA, a 11 degree IMA, and an incongruent 1st MTP joint
2. 40-year-old male with a 30 degree HVA, and a 15 degree IMA, and a congruent 1st MTP joint
3. 70-year-old female with a 35 degree HVA, and a 13 degree IMA with a hypermobile 1st ray
4. 65-year-old female with a 25 degree HVA, a 14 degree IMA, and severe hallux rigidus
5. 85-year old minimally ambulatory male with a 45 degree HVA, and a 20 degree IMA

PREFERRED RESPONSE ▶
TAG
(OBQ06.267) A 34-year-old woman presents with right foot pain and and a callus over the 1st metatarsalphalangeal joint. A clinical image is shown in Figure A. Accomodative 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? Topic Review Topic
FIGURES: A   B   C      

1. Closing wedge osteotomy of the proximal phalanx (Akin)
2. Distal soft-tissue release
3. Distal metatarsal osteotomy
4. Medial eminence resection and exostectomy (Silver)
5. Scarf osteotomy

PREFERRED RESPONSE ▶
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