Review Question - QID 219426

This patient has a mild to moderate symptomatic hallux valgus deformity that has failed non-operative treatment in the setting of cerebral palsy. Patients with neuromuscular disease warrant MTP fusion for the surgical management of hallux valgus.

In patients without neuromuscular disorders, treatment for hallux valgus is largely dictated by the degree of deformity with avoidance of MTP arthrodesis. Generally, an HVA of >40 degrees and an IMA of >13 degrees warrant a proximal metatarsal osteotomy, whereas less severe disease typically does well with a distal osteotomy +/- soft tissue releases. Soft tissue release should never be performed alone, and sesamoidectomy is to be avoided. Arthrodesis is indicated in patients with certain conditions, including Down syndrome, rheumatoid arthritis, gout, severe DJD, cerebral palsy, and other neuromuscular disorders, due to the high rate of recurrence in this population.

Smith et al. provide a review article on treating hallux valgus with increased DMAA. This is usually associated with juvenile and adolescent bunions, and they endorse the use of double and triple osteotomies to address this condition.

Robinson et al. reviewed modern concepts in the treatment of hallux valgus. They note that more than 130 different operations to address this condition have been described, sometimes making the operative plan challenging. They describe different patient populations and radiographic parameters conducive to certain soft tissue procedures and osteotomies.

Easley et al. provide a similar review article for reference. Regarding first MTP arthrodesis, they state that indications include severe hallux valgus, associated arthritis, failed prior surgical correction, neuromuscular disorders, and reconstruction for the rheumatoid forefoot. They conclude that first MTP arthrodesis appears to offer satisfactory outcomes in patients with severe hallux valgus.

Figure A demonstrates a mild to moderate hallux valgus deformity of the left great toe.

Incorrect Answers:
Answer 1: This proximal phalanx osteotomy is not indicated in a patient with cerebral palsy.
Answer 2: An Evans osteotomy is a calcaneal lengthening osteotomy utilized in the treatment of pes planovalgus.
Answer 3: This describes soft tissue releases about the MTPJ that are rarely performed in isolation and not indicated in this patient.
Answer 5: This procedure is rarely indicated for some elderly, low-demand patients and is associated with cock-up toe deformity.