Hallux valgus.pptx

hallux valgus

1. Hallux Valgus
Siwaporn Khureerung
Roi-Et Medical School
3 Sep 2014

2. Introduction
•Hueter defined the deformity as an
abduction contracture in which the great
toe is turned away from the mid-line of the
body.
•The adjective valgus implies a static
deformity and should not be used
interchangeably with abductus
which refers to movement
caused by muscle function

3.  Lateral deviation of the great toe
and medial deviation of the first
metatarsal
 Progressive subluxation of the
first metatarsophalangeal (MTP)
joint
Introduction

4. Anatomy
Four groups that encircle the first MTP
joint
1)Extensor hallucis longus and brevis
2)Flexor hallucis longus and brevis
3)Abductor
4)Adductor
Deforming Musculature
1. Abductor Hallucis
-Inserts in the plantar aspect of the proximal
phalanx
-Can draw the phalanx medial and push
metatarsal
head lateral
2. Adductor Hallucis
-2 origins
-common tendon to plantar aspect of proximal
phalanx and lateral aspect of plantar
plate/sesamoid complex

5. Anatomy
Plantar Plate
•2 seasmoids
incorporated into
tendons of FHB
•Plantar Plate formed
by tendons of
Adductor Hallucis,
Abductor Hallucis,
FHL and Joint
Capsule

6. Collateral Ligaments
Sesamoid Ligaments
Hood Ligament

9. Dermographic
•Age of oset : >20y
•Gender : female
•Bilaterality :> 84%

10. Footwear
Occupation
 Heredity- 60% to 90%
 Pes Planus
 Hypermobility of
Metatarsocuneiform joint
 Ligamentous laxity
 Achilles Contracture
 Neuromuscular disorders
 Systemic conditions like RA
 Misc factors: 2
nd
toe amputation;
 Cystic degneration of medial capsule

14. Windlass Mechanism

15. This windlass mechanism is responsible for:
•Depression of 1
st
Metatarsal Head
•Weight transfer to hallux.
In HV this mech is disrupted
Transfer of weight laterally
*Surgery must minimize disruption of the windlass.

16. Patho anatomy
•Increased metatarsophalangeal angle
-plantar shift of abd.hallucis
-unopposed action of add.hallucis pulls
greater toe to further valgus
-medial capsular stuctures stretched and
attenuated
-medial shift of metatarsal head

17. CONT….
•FHL,FHB&EHL increase valgus stress
•Lateral sesamoid displaced into first
webspace

18. normal Hallux valgus

19. •

20. Clinical Presentation
PAIN over the medial eminence (Bunion).
•Pressure from footwear is the most frequent cause of
this discomfort.
•Bursal inflammation
•Irritation of the skin
•Breakdown of the skin may be noted.
•Bunion consists of:
•Bony exostosis / prominence of the metatarsal head
•Overlying subcutaneous bursa
•Hyperkeratosis of dermis

21. Signs and Symptoms
•Asymptomatic
•Pain- The primary
symptom of hallux
valgus is PAIN over the
medial eminence.
•Pressure from footwear
is the most frequent
cause of this
discomfort.
•deformity
•Tenderness
•Aesthetic
•Look for presence of:
–neurologic disorder
–ligamentous laxityDtTohmyrt-r•Hg rg r1HbbTJr>HbcTy
ir 0magHbr3dg m hm
ir G arFtm
ir 0muHuHoytymyHdtgarIoughTbHugt
ir 8toytdmagHbrvTuH mtTyrAmojm
ir FoH y-mor0muHuHoyHbcgH
Sources of Pain in Hallux Valgus
• Medial Eminence
• 2nd Toe
• Metatarsosesamoid Articulation
• Dorsomedial Cutaneous Nerve
• Transfer Metatarsalgia

22. Pronated Toe Fig 6

23. PHYSICAL EXAM
•Skin
–calluses, areas of redness
•Sites of pain
•Motion of 1st MTP joint-increased or decreased
•Mobility and structure of foot in general
•Gait analysis
•The patient sitting and standing
–accentuated with weightbearing
•Pes planus deformity
•Contracture of the Achilles tendon
•Magnitude of the Hallux Valgus deformity
•Pronation of the great toe

24. •Passive and active range of motion of the
MTP joint is measured
–Pain or crepitus, or both, with motion of
the MTP joint
•Metatarsocuneiform joint for hypermobility
–Examiner grasps the first metatarsal
with the thumb and index finger and
pushes it in a plantar lateral-to-
dorsomedial direction.
– Mobility of more than 9 mm represents
hypermobility

25. Radiologic assesment
•Antero-posterior- wt bearing
•Lateral- wt bearing
•Medial Oblique wt bearing
•Sesamoid view.

26. Standing
dorsoplantar view
Non-standing
lateral oblique view
Standing lateral viewAxial sesamoid view

27. Radiographic Examination
Weightbearing AP/Lateral non weightbearing
oblique view and axial views (sesamoid)
•Assess for bone and joint deformity
•Length and shape of 1st MT
•Congruent vs. Incongruent joint
•Osteoarthrosis
•Forefoot alignment is evaluated for
metatarsus Adductus
•Hindfoot is Inspected for Pes Planus or Pes
Cavus.

28. IMA (normal <9°) [8-9]
HVA (normal <15°) [15-20]
DMAA (normal <10°) [10-15]
Hallux
valgus
angle
Intermetatarsal
angle
Distal
metatarsal
articular
angle

29. Measure Angles
–Hallux Valgus angle:
Intersection of longitudinal axis
of 1st MT and proximal
phalanx. Normal < 15
0
–Intermetatarsal angle
Intersection of 1st and 2nd
MT. Normal < 9
0
; increased
with metatarsus primus varus

30. Radiographic measurements
•Distal Metatarsal Articular Angle(DMMA)
Defines the relationship of the distal articular
surface of the 1st MT to the longitudinal axis.
Quantities the magnitude of lateral slope of
articular surface.
With subluxation, the articular surface deviates
laterally in relationship to the 1st Metatarsal.
Usually < 6
0
.

33. Radiographic measurements
•Hallux Interphalyngeal angle

34. CLASSIFICATION MILD
MODERA
TE
SEVERE
Hallux valgus angle < 20° 20° to 40° >40°
1-2 intermetatarsal
angle
11° or less. 12- 15° 16° or more
Subluxation of the
lateral sesamoid, as
measured on an AP
radiograph
< 50% 50% to 75% > 75%
SEVERITY OF
DEFORMITY

36. TREATMENT
•Non-operative vs. Operative
•All patients should be treated non-operatively
first.
Despite conservative measures, some patients
eventually need surgical intervention.

37. Nonoperative

Footwear modification
•Widen toe box
–decrease lateral deviation of great toe
–decrease inflammation and pain
•Decrease heel height
–prevent forward slide of the foot
•Arch support
–may negate effects of pes planus
•Contracture of the Achilles tendon
–Stretching exercises
–Lengthening of the Achilles tendon

39. Painful joint ROMPainful joint ROM
Deformity of the joint complexDeformity of the joint complex
Pain or difficulty with footwearPain or difficulty with footwear
Inhibition of activity or lifestyleInhibition of activity or lifestyle
Indications for surgeryIndications for surgery

40. Associated foot disordersAssociated foot disorders
- Neuritis/nerve entrapment
- Overlapping/underlapping 2
nd
digit
- Hammer digits
- First metatarsocuneiform joint exostosis
- Sesamoiditis
- Ulceration
- Inflammatory conditions (bursitis, tendinitis)
of 1
st
metatarsal head
Indications for surgeryIndications for surgery

41. Extensive peripheral vascular disease Extensive peripheral vascular disease
Active infection Active infection
Active osteoarthropathy Active osteoarthropathy
Septic arthritis Septic arthritis
Lack of pain or deformity Lack of pain or deformity
Advanced age Advanced age
Lack of complianceLack of compliance
ContraindicationsContraindications

42. MI MI within the previouswithin the previous 6 6 months months
Comorbid conditions that place the Comorbid conditions that place the
patient at significant patient at significant CVCV or respiratory risk or respiratory risk
ContraindicationsContraindications

43. Relieve pain
Correct deformity
Preserve MTP joint motion
Surgical GoalsSurgical Goals

44. 1. Valgus deviation of the great toe
2. Varus deviation of the 1
st
metatarsal
3. Pronation of hallux and/or 1
st
metatarsal
4. Hallux valgus interphalangeus
5. Arthritis and limitation of motion of the
1
st
metatarsophalangeal joint
6. Length of the 1
st
metatarsal relative to
lesser metatarsals
Preoperative evaluationPreoperative evaluation

45. 7. Excessive mobility or obliquity of the 1
st

metatarsomedial cuneiform joint
8. The medial eminence (bunion)
9. The location of the sesamoid apparatus
10. Intrinsic and extrinsic muscle-tendon
balance and synchrony
Preoperative evaluationPreoperative evaluation

46. Hallux Valgus <25Hallux Valgus <25°°
Congruent Joint
Chevron osteotomy
Mitchell osteotomy
Incongruent Joint
Distal soft-tissue realignment
(subluxation)
Chevron osteotomy
Mitchell osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus

47. Hallux Valgus 25Hallux Valgus 25°°-40-40°°
Congruent Joint
Chevron osteotomy + Akin procedure
Mitchell osteotomy
Incongruent Joint
Distal soft-tissue realignment +
proximal osteotomy
Mitchell osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus

48. Severe Hallux Valgus >40Severe Hallux Valgus >40°°
Congruent Joint
Double osteotomy
Akin + chevron osteotomy
Akin + 1
st
metatarsal osteotomy
Akin + 1
st
cuneiform opening wedge
osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus

49. Severe Hallux Valgus >40Severe Hallux Valgus >40°°
Incongruent Joint
Distal soft-tissue realignment +
proximal osteotomy
First metatarsal crescentic
osteotomy
First cuneiform opening wedge
osteotomy
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus

50. Hypermobile 1Hypermobile 1
stst
MTC Joint MTC Joint
Distal soft-tissue realignment +
fusion 1
st
metatarsocuneiform joint
Degenerative joint diseaseDegenerative joint disease
Fusion or Keller procedure or prosthesis
Modified from Mann RA: Decision making in bunion surgery, ICL 1990.
Treatment of Hallux ValgusTreatment of Hallux Valgus

51. Surgical Algorhythm
HVA IMA Procedure
< 40° < 13° to 15° modified McBride or
distal chevron osteotomy
< 40 ° > 13° to 15° modified McBride and
proximal osteotomy
>40° > 20° modified McBride and
proximal osteotomy or arthrodesis

52. DSTPDSTP
Modified McBride bunionectomy
DuVries & Mann

53. Procedure
•Medial approach
•L-shaped capsulotomy
•Medial eminance removed
•Adductor tenotomy &lat.capsular release
•Lat.sesamoidectomy(Dorsal Approach/Plantar
Approach)
•Medial capsular imbrication&wound closure

54. •Mitchell osteotomy
Removal of medial eminance
Osteotomy of distal portion of 1
st MT shaft
 Lateral displacement&angulation of capital fragment
Medial capsulorrrhaphy

55. Metatarsal OsteotomyMetatarsal Osteotomy
Mitchell osteotomy

56. Metatarsal OsteotomyMetatarsal Osteotomy
Modified Chevron osteotomy

57. Metatarsal OsteotomyMetatarsal Osteotomy
Johnson modified Chevron osteotomy

58. Post-operative managementPost-operative management
 Immobilization ~2 weeks
 Weight bearing as tolerated or NWB

59. Post-operative managementPost-operative management
HV night splint
to be worn for 6-8 wks
after dressing changes
are completed

60. Complications
SURGERY
•Recurrent deformity 20-30%
•Hallux Varus
•Pronation deformity
•Pain
•Neurologic Injury
•Osteonecrosis
•Physeal injury/arrest
•Nonunion/malunion