Transcript Hallux Valgus Correction: Algorithem and Treatment

Arash Aminian MD
March 17, 2011
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All bunions are not created equal
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Complex array of osseous & soft tissue
pathology
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Lateral deviation of the great toe with medial
deviation of the 1st metatarsal
 >100
procedures for Hallux Valgus
 Procedure should address deformity
 Soft tissue procedure combined with bony
correction most common procedure
• Chevron Osteotomy with Silver eminence resection
most common procedure
 NWB
& WB
 Gait/shoe wear
 ROM
 Hyper mobility 1st ray
 Adductor tautness
 Neurovascular
 Footprints
 Painful
HV failed palliative measures
• Wider shoes
• Activity modification
• NSAIDS
 No
inflammatory
 Non paralytic
• 1st MTP Fusion
PVD
 Arthritis
 Neuropathic
 Pure cosmetic
 Osteopenia
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METATARSALGIA
HAMMERTOES
CLAWTOES
DEVIATED TOES
NEUROMAS
EQUINUS
 AP/Lat
& Sesamoid Weight-Bearing
 IMA < 9 degrees
 DMAA < 9 degrees
 HVA < 15 degrees
 Sesamoid station & metatarsal length
 Congruity
HVA
IMA
DMAA
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High Intra, Inter-observer reliability for HVA,
IMA (<5 degree, 95% confidence)
• Measure from the center of MT head to center of MT
base
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Post-operative measures are less reliable
• Anatomy distorted

Functional outcomes failed to correlate with
radiographic outcomes (Thordason et al FAI 26:2005)
 Plantigrade
& painless foot
 Complex array of pathological bone & soft
tissue deformity must be addressed
 Each procedure has limitations & indications
 Multiple options should be available
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Congruent Joint
Mild deformity
• IMA < 15 degrees, HV < 35 degrees
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No instability of the 1st Ray
Chevron Osteotomy
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Small medial eminence resection
• Hallux Varus
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Release the capsule through the joint
• AVN
• Main blood supply to the MT head: Plantar-lateral corner of
the MT head
 Don’t
rely on the capsular plication for deformity
correction
 Post-op
early motion
CHEVRON
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Incongruent Joint
Moderate deformity
• IMA 15-20 degrees, HV <40 degrees
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No instability of the 1st Ray
SCARF Osteotomy
Modified Chevron
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Incongruent Joint
Severe deformity
• IMA >20 degrees, HV >40 degrees
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Instability of the 1st Ray
Lapidus
1st MTP fusion
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Inflammatory Arthritis
Paralytic deformity
1st MTP fusion
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Resection of the proximal phalanx
Older patient
Less demand
High risk patients (medical co-morbidities)
AVN
 Stiffness of the joint
 Hallux Varus
 Malunion (Dorsiflexion: transfer
metatarsalgia)
 Non-union (Lapidus 5%)
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Blood supply: Branches of the
• 1st dorsal metatarsal artery
• 1st Plantar metatarsal artery
• Medial plantar artery
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Plexus Lateral plantar corner
JBJS 2007:2018-2021.
 Do
not push a procedure beyond its limits
 Hypermobile 1st ray=Lapidus
 DMAA ?
 Loss of fixation ?
 Position
of medial sesmoid and axis of 1st MT
JBJS 2009: 1637-1645.