Management

Non-Operative

 

Education regarding shoe wear

- extra wide / large toe box

 

Insoles

- longitudinal arch support

- pre MT dome for metatarsalgia

- podiatry to attend to callosities

 

Toe spacers

 

Analgesia

 

Operative

 

Indications

 

1.  Continued pain and discomfort

2.  Difficulties with shoe wear

- split size shoe requirements 

- difficulty fitting shoes

- only 60% wear "fashionable" shoe post-op

3.  Deformity of lesser toes

4.  Skin problems

5.  Cosmetic appearance – relative indication

 

Contra-indications

 

Poor peripheral arterial circulation

Current sepsis

Uncontrolled diabetes

Peripheral neuropathy (relative)

 

Aims

 

1. Correction of the hallux valgus and intermetarsal angles 

2. Creation of a congruent MTP joint

3. Sesamoid realignment

4. Removal of the medial eminence

5. Retention of functional range of motion of the MTPJ

6. Maintenance of normal weight bearing mechanics of foot

 

Surgical Options

 

Congruent

 

1. DMAA  < 15°

- treat hallux interphalangeus

- Akin with exostectomy

 

2. DMAA > 15°

- Chevron with closing wedge

 

Incongruent

 

Mild

- Chevron

- DSTP (Distal Soft Tissue Procedure) +/- proximal osteotomy

 

Moderate

- DSTP & proximal osteotomy

- Scarf

 

Severe

- DSTP & proximal osteotomy

- arthrodesis

 

Rheumatoid

 

Mild to Moderate / Low demand

- arthroplasty

 

Severe

- arthrodesis

 

Hypermobile TMTJ

- fusion (Lapidus) & DSTP

 

Surgical Procedures

 

1.  Chevron

 

Hallux Valgus ChevronGreat Toe Chevron

 

Indications

- incongruent joint

- HVA < 30o / IMA < 15o

- patient < 60 years

 

Technique

 

Avoid lateral release = AVN 40%

 

Dorsomedial approach in internervous plane

- don't go directly medial as will get sensitive scar

- protect dorsal sensory nerve

- distally based "V" capsular flap

- expose MTP joint

 

Exostectomy

- remove medial eminence with saw

- leave 1- 2 mm medial to medial sulcus

- otherwise risk hallux varus

 

60° osteotomy apex distal

- longer plantar limb to avoid sesamoids and inferior joint surface

- apex 1 cm from articular surface

- translate 5mm

- 1mm displacement corrects IM angle 1º

- can perform medial closing wedge to correct DMMA

 

Fixation

- not always necessary

- sutures / k wire / screw

 

Closure

- imbricate capsule

- advance to tighten medially

 

Second toe releases as needed

 

Post op

- bandage / POP to maintain correction

- check wound at 1 week

- bunion boot / heel walk

- toe spacer

- 6/52

 

Hallux Valgus Toe Spacer

 

Results

 

GE 75% if IMA >12° 

GE 95% if IMA <12°

 

Complications

 

AVN is rare

- ensure apex 8-10 mm from articular surface

- avoid DSTP

 

2.  Distal Soft Tissue Procedure

 

Hallux Valgus Pre DSTPHallux Valgus Post DSTP

 

Modified McBride

- release of tight lateral structures (ADDH, lateral capsule, transverse MT ligament)

- medial exostectomy (just medial to sagittal sulcus)

- medial capsular plication

 

(Modification: no longer excise sesamoid)

 

Indications

- mild HV with incongruent joint

- severe HV when combined with proximal osteotomy

 

Technique

 

1.  Dorsomedial approach

- protect nerve

- V shaped capsulotomy

- remove medial prominence

 

2.  Incision first web space

- protect branches of DPN

- insert lamina spreader

- release ADD hallucis at P1

- cut capsule between sesamoid and MT

- divide transverse MT ligament



Results

 

92% good results

 

Complications

 

Nerve injury

- plantar cutaneous nerve

 

Hallux varus

- from releasing lateral FHB from sesamoid

 

3.  Proximal Osteotomy + DSTP

 

Indications

- severe HV

- correct IMA with osteotomy

- correct HVA with DSTP

 

Results

- in combination with DSTP

- GE 90 %

 

Options

- crescentertic

- opening wedge (lengthens)

- closing wedge (shortens)

 

Opening wedge

- extend medial incision

- incomplete ostetomy with saw at base MT

- use bone from bunionectomy to fill gap

- fixation with small plate

 

4.  Scarf

 

Indications

- moderate HV

- see separate technique

- technically challenging but good results

 

5.  Akin

 

Indications

- congruent joint

- DMAA < 15o

- hallux interphalangeus > 10o

- residual HV after other procedures

 

Technique

- medial closing wedge osteotomy of P1

- combine with cheilectomy

 

6.  Keller Procedure

 

Technique

- resection 1/3 of proximal phalanx

- should use pin to stop cock up deformity & to stiffen joint

 

Indications

- housebound / non ambulator

- elderly

- salvage

- marginal circulation - DM / PVD

- hallux rigidus if cheilectomy or arthrodesis contra-indicated

 

Complications

- instability / cock up deformity

- transfer metatarsalgia (in young)

 

Results

- 80% good results

 

7.  Arthrodesis

 

Indications

- hallux valgus with arthritis

- severe hallux valgus

- neuromuscular disease i.e. cerebral palsy

- RA

- salvage procedure for failed procedures

 

Position

- 15º valgus

- DF 10º relative to plantar aspect of foot

- DF 30° relative to ray

 

Technique

- dorsomedial approach

- release EHB / mobilise EHL / release collaterals

- Coughlin male and female reamers

- secure with cross screws or plate

 

Hallux Valgus Arthrodesis

 

8. Lapidus Procedure

 

Hallux Valgus SevereHallux Valgus Proximal Osteotomy and Lapidus

 

Indications

- TMTJ hypermobility

- fusion TMTJ

 

Problems

- difficult to achieve union

- difficult to get position correct

 

Joint multiplanar

- malrotation poorly tolerated

- shortens medial column

- can get metatarsalgia

 

Technique

- slight plantar flexion and lateral deviation

 

Lapidus APLapidus Lateral

 

Complications of Surgery

 

Transfer Metatarsalgia

 

Recurrence

- incorrect surgery

- poorly performed surgery

- high risk groups i.e. adolescent

 

Nerve injury

- dorsal and plantar cutaneous nerve

 

Cock up Toe

 

Cause

- post Keller’s

 

Management

 

Arthrodesis MP joint

- shorten if don't use graft

- fusion rate 95% (BG) vs 70% (no BG)

 

Hallux Varus

 

Cause

- excessive medial resection

- resection of fibular sesamoid

- excessive lateral release or medial plication

 

Clinical

- not always painful

- cosmetically unacceptable

- difficulties with shoe wear

- cockup deformity

- with time stiffens in extension & medial deviation

 

Options

- soft, well fitting shoe

- arthrodesis

- soft tissue reconstruction

 

EHL Reconstruction           

- lateral two thirds of the tendon removed from its insertion

- detached distally, passed under transverse ligament

- inserted into proximal phalanx

 

AVN

 

Rarely seen in Chevron

- due to disruption of volar blood supply

 

Great Toe AVN Post Chevron

 

Management

- arthrodesis / excise avascular fragment and shorten toe