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Flashcards in hallux valgus Deck (29):
1

Define hallux valgus?

  • Lateral deviation of the great toe with medial deviation of the 1st metatarsal
  • 2 forms exist
    • ​Adult hallux valgux
    • Adolscent & juvenile hallux valgus

2

What is the aetiology of hallux valgus ?

  • Multi factorial
  • INTRINSIC- genetic , lig laxity, pes planus, RA, CP
  • EXTRINISIC- type of shoe- narrow box and high heel

3

What is the epidemiology of hallux valgus?

  • More common in women
  • 70% pts have FHx
    • genetic predisposition with anatomic anomalies
  • Risk Factors
    • Genetic predisposition
    • increased distal metaphyseal articular angle (DMAA)
    • Ligamentous laxity of 1st Tarso-metatarsal joint instability
    • Convex metatarsal head
    • 2nd toe deformity/amputation
    • pes planus
    • Rheumatoid arthritis
    • Cerebral Palsy
    • Extrinsic- shoe with high heel and narrow toe box

4

Describe the pathology of hallux valgus?

  • The medial capsule attenuates due to repetitive loading
  • Ist MT head has no muscultendinous attachments and moves progressively medially, off sesmoids
  • Semsoids remain within FHB tendon & are attached to base of proximal phalanx
  • Lateral deviation of proximal phalanx-> abductor hallicis migrates plantar and lateral
  • Ehl and fhl move lateral
  • Extensor hood stretches --> muscle imbalance to PLANTARFLEX and PRONATE GREAT TOE (ABD H)
  •  Secondary contracture of lateral capsule
  • windlass mechaniams become ineffective
  • leads to transfer metatarsalgia

5

Name any associated conditions?

  • Hammer toe
  • Callosities

6

What are the factors that differentiate juvenile/adolescent hallux valgus ftom adults?

  • Bilateral
  • familial
  • Pain not usually primary complaint
  • Varus of 1st MT with widening of IMA usually present
  • DMAA usually increased
  • Often associated with a flexible flatfoot

complications

  • Recurrence is common >50%
  • Overcorrection 
  • Hallux varus

7

What are the signs and symptoms of HV?

Symptoms

  • Difficulty with shoe wear due to medial eminence
  • Pain over prominence at MTPJ
  • Compression of digital nerve-> symptoms

Signs

  • Hallux rests in valgus and pronated due to deforming forces ( Adbuctor hallucis plantar and lateral)
  • Examine 1st mt for
    • IST MT ROM
    • 1st TMT mobility
    • Callous formation
    • sesmoid pain/arthritis
    • pes planus
    • lesser toe deformities
    • midfoot & hindfoot conditions

8

Can you decribe/ draw the anatomy of the 1st mt and the effect of hallux valgus on this?

Normally

  • EHB dorsal
  • Abductor Hallucis medial with FHB medial - medial plantar
  • Adductor hallucis and FHB lateral -lateral plantar

HV

  • EHB moves Medial
  • Adbuctor hallucis ( moves plantar and lateral ) to becomes plantar to MT
  • FHB medial, FHB lateral and Adductor hallucis move lateral 

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9

What investigations are useful for HV?

  • Standard WB views AP, Lateral and oblique of foot
  • findings
    • Lateral displacement of sesmoids
    • joint congreuency and degenerative changes can be evaluated
    • radiological parameters

10

What is the hallux valgus angle? What is normal?

  • The angle formed by a line along the first metatarsal shaft and a line along the shaft of proximal phalanx
  • Normal < 15 degrees

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11

Describe the first/second intermetarsal angle? What is the normal value?

  • The angle formed by a line along the shaft of the first metatarsal shaft and line along second metatarsal shaft
  • Normal < 9 degrees

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12

Describe the hallux valgus inter phalangeus angle? What is normal?

  • The angle formed by line along shaft of proximal phalanx and a line along the shaft of distal phalanx
  • Normal < 10 degrees

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13

How do you determine congruency of a joint?

  • By comparing the line connecting the medial and lateral edge of the first metatarsal head articular surface with the similar line for the proximal phalanx When parallel the joint is congruent

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14

Described the dmaa angle - what is normal ?

  • The distal metatarsal articular angle
  • The angle formed by a line along the articular surface of the first metatarsal and a line perpendicular to axis of the first metatarsal
  • Normal <15 degrees

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15

What would tx of HV be ?

Non operative

  • Show modification, Pads. Orthosis
    • first line tx
    • orthoses more helpful in pt with pes planus/metatarsalgia

operative

  • not for cosmesis alone
  • Soft tissue proceedure
    • mild disease
  • Distal osteotomy
    • mild disease (IMA <13)
  • Proximal or combined osteotomy
    • More moderate disease IMA >13
  • 1st TMT arthrodesis
    • arthritis at TMTJ or instability
  • Fusion procedure
    • severe deformity/spacticity/arthritis
  • MTP resection arhroplasty
    • elderly pt, low functional demands

16

Describe a Modified Mcbride release for HV?

  • Included release of ADDUCTOR HALLUCIS from lateral sesmoid/prox phlanx
  • Lateral capsulotomy
  • Medial capsular imbrication
  • aim to correct an incongruent MTPJ
  • never appropriate in isolation

combine with 

  • medial eminence resection
  • MT osteotomy
  • 1st TMT athrodesis ( lapidus)

17

What would the tx be for a patient with an IMA <13, HVA <40?

  • DIstal metatarsal osteotomy = CHEVRON +/- Distal soft tissue release Medial eminence resection and capsular repair

18

What would the tx be for a patient with an IMA >13 degrees and a HVA >40?

  • Proximal metatarsal osteotomy = SCARF
  • + Modified Mc Bride
  • + MT eminence resection

19

What would the tx be for a patient with Instability at 1st TMTJ/ joint laxity?

What are the other indications for this proceedure?

  • A Lapidus proceedure-  1ST Metatarsocuneiform arthrodesis with modified McBride release

 

  • Arthritis at TMTJ
  • Metatarsus primus varus
  • Severe deformity V large IMA

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20

What would the tx be for a patient with an increased DMMA >10 degrees?

Distal metatarsal rediretional osteotomy and metatarsal transitional ostoetomy

21

What would the tx be for a patient with an HVA > 10 degrees?

  • Akin osteotomy

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22

What are the indications for 1st MTPJ arthrodesis

  • Cerebral Palsy
  • Down's syndrome
  • RA
  • Gout
  • Severe DJD
  • Ehler- Danlos

23

What would the tx be for an elderly patient with low demands and diffuse angles

  • KELLER's EXCISION ARTHROPLASTY
  • largerly abandoned

24

What are the complications of HV surgery?

  • AVN- medial capsulotomy insult to MT head blood flow
  • RECURRENCE- under correction of IMA, isolated soft tissue proceedure ( modified Mcbride), isolated medial eminence excision
  • DORSAL MALUNION- with transfer METATARSALGIA
    • overload of lesser MT heads 
    • risk with shortening MT
      •  Lapidus
  • HALLUX VARUS
    • over correction of 1st IMA
    • xs lateral release w overtightening of medial eminence
    • overresection of medial 1st MT head
    • lateral sesmoidectomy
  • COCK UP TOE DEFORMITY
    • injury to FHL
    • complx of Kellers
  • 2nd MT transfer METATARSALGIA
    •  seen with weils 
  • ​NEUROPRAXIA
    • ​neuroma from medial branch of dorsal cutaneous nerve - terminal branch of superificial peroneal n. injured ot medial approach for capsular imbrication/MT osteotomy

25

What are the key tx options with Juvenile HV?

Non operative

  • shoe modification - persue until physis closed

Surgical

 


  • best to wait until PHYSIS closed
    - skeletal mature 
  • Can't preform MT Osteotomies/ Lapidus if PHYSIS is OPEN- Cuneiform osteotomy is ok
  • soft tissue proceedure alone not successful
  • if symptomatic wuth IMA>10o and HVA >20o

26

What is the tx for a juvenile with a DMMA of >20?

  • Double MT osteotomy- AKIN for HVI, Biplanar chevron, open wedge cuneiform osteotomy

27

What isi the main complication to juvenile HV post surgery?

  • Reoccurance

28

Can you draw a chevron osteotomy?

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29

Can you draw a scarf osteotomy?

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