Hallux Valgus (Surgery Unit)

Question 1

Radiographic measurments:

1st metatarsal protrusion distance

Normal value A

What is it? Relative B

Answer 1

A: +/- 2 mm

B: Difference in radii of longitudinal bisections of 1st and 2nd metatarsals

Question 2

Radiographic measurment

Metatarsus Primus Adductus Angle

normal A

B is associated with HV development in rectus feet

C in metatarsus adductus feet

Answer 2

A: 8 degrees

B: 12 degrees

C: > 8 degrees

Question 3

Hallux abductus angle

HAA normal A

Answer 3

A: 10-20 degrees

Question 4

Tibial sesamoid position

Normal : A

Relative position of B in relation to the C of 1st metatarsal

Answer 4

A: 4

B: medial sesamoid

C: bisection

Question 5

1st metatrsophalangeal position

How does

Normal Deviated Subluxed

look like?

Answer 5

Question 6

Surgical management for hallux valgus depends on ?

1. Degree of A
2. B of deformity
3. C
4. D mechanics
5. Other factors

Answer 6

1. A: deformity
2. B: Nature
3. C: Physiological age
4. D: Foot
5. General health, Co-morbidity, Home support

Question 7

What are the different classifications for hallux valgus surgery?

1. A
2. B
3. C
4. D
5. E

Answer 7

A: Bupectomy : medial bump, head of 1st head

B: Arthroplasty/ joint implant

C: Osteotomy of hallux

D: first metatarsal osteotomies : distal and proximal

E: Fusion procedures: 1st mtpj and 1st met-cuniform

Question 8

“Bumpectomy”

Silver

Removal of A

Reinforcment of B

Answer 8

A: Medial exostosis

B: Medial capsule

Question 9

‘Bumpectomy’

Silver bunionectomy

What are the indications for silver bunionectomy?

1. A
2. B
3. C
4. D
5. E

Answer 9

Bump pain

1. Bupm pain
2. No sesamoid or joint pain
3. Good ROM
4. No pain or crepitus with ROM examination
5. Elderly patients (Osteoprosis)

Question 10

“Bumpectomy”

Silver bunionectomy

Advantages Disadvantages

1. A post-op recovery 1. Weakens E
2. B post-op oedema 2. poor F
3. C procedure 3. Fails to correct G
4. May be performed in pt with D

Answer 10

1. A: Rapid 1. E: medial aspect of 1st mpj
2. B: Minimal 2. F: long term prognosis
3. C: Simple 3. Structural aetiology
4. D: Osteoprosis

Question 11

Bumpectomy

Mcbride Nubionectomy

A ostectomy

B sesamoidectomy

+/- Transfer of C tendon dorsally to D

Answer 11

A 1st metatarsal

B Lateral

C adductor hallucis D medial capsule

Question 12

Bumpectomy-McBride bunionectomy

What are the indications for this procedure?

1. No A
2. Pain associated with the B
3. Adequate C
4. Mild D
5. E medial eminence
6. Deviated to F
7. H

Answer 12

1. A : pain or creptus with ROM 1st mpj
2. B: lateral sesamoid
3. C: ROM 1st mpj
4. D: Mild axial rotation hallux
5. E: Hypertrophy
6. F: Subluxed 1st mpj
7. H: TSP>4
8. Elderly patients (osteoprosis)

Question 13

Bumpectomy

McBride bunionectomy

What are the advantages?

1. Relatively A
2. More B than Silver
3. May be performed with patients with C

Answer 13

A: Simple

B: Corrective

C: Osteoprosis

Question 14

Bumpectomy

Mcbride bunionectomy

What are the disadvatnages of this procedure?

1. Fails to correct A
2. High incidence of either B

Answer 14

1. A: structural aetiology
2. B: Hallux valgus

Question 15

For both Silver and Mcbride buionectomies what are the Post-op course of action?

1. Patient wears post-op shoe for A
2. Return to B ASAP
3. Wise to use C for 1-2/12 to assist maintaning correction of D
4. Minimal E compared to other bunionectomies

Answer 15

1. A: 2-3 weeks
2. B: normal activities
3. C: IDW D: HAA
4. E: morbidity

Question 16

Arthroplasty/ Joint implant

Keller bunionectomy

Gap arthoplasty 1st MPJ

A removed which is paralled to the shaft

B fixation 2-4/52

Suture C to plantar aspect proximal phalanx

Best reserved for D patients or E

Answer 16

A: 1/3rd- 1/2 base proximal phalanx

B: 1.6 mm K-wire

C: FHL

D: geriatric patients

E: endstage hallux limitus

Question 17

Arthroplasty

Joint implant

Advantages: Disadvantages:

1. A 1. weakens B
2. C recovery 2. secondary D
3. E ROM
4. Eliminated F

Answer 17

1. A: simple 1. B: purchase strength of hallux
2. C: rapid 2. D: central metatarsalgia
3. E: Restores
4. F: O/A pain

Question 18

What are the post-op course of action for Arthroplasty/Joint implant?

1. wears A
2. Relatively B
3. May need to use C

Answer 18

1. A: post-op shoes while k-wires are in situ (The wires might bend)
2. B: early return to normal activity
3. C: IDW postoperatively for a period of surgery was for HV

Question 19

Akin Bunionectomy

Distal Akin

Used to correct A

Rarely performed as B

Shortens C

Fixate with D

E procedure

* distal would have more effect on joint angulation that proximal phalanx

Answer 19

A: high DASA

B: Single procedure

C: prxoximal phalanx

D: ss wire, staple, K-wire, screw

E: Ambulatory

Question 20

Proximal Akin

Used to correct A

Minimal B present

Shortens C

D must be closed

Answer 20

A : high PASA

B: valgus rotation

C: proximal pahalnx

D: Epiphysis proximal phalanx

Question 21

Proximal Akin

Technique / Procedure :

A parallel to base

B perpendicular longitudinal axis proximal phalanx

C Fixation

Answer 21

A: Proximal cut

B: Distal cut

C: Internal

Question 22

Proximal Akin

Post-op course

osteotomy takes A to unite

Protect in B for C

Support with Coban bandage of hallux for further D

Answer 22

A: 6-8 weeks

B: Post-op shoes / C:4/52

D: 2-4/52

Question 23

What is the most commonly performed bunionectomy performed today?

A: ?

Answer 23

A: Austin bunionectomy

Question 24

What are the indications for Austin procedure?

A HV deformity

MPA angle of B

Age C

D bone density

Answer 24

A: Mild-moderate

B: 12-20 degrees

C: 14-75 years old

D: Good

Question 25

What is the first step of the **Austin** procedure? _A_ tenoctomy Release of _B_

Answer 25

A: Adductor hallucis B: lateral sesamoidal ligament

Question 26

What is the 2nd step for **Austin** procedure?

Answer 26

Inverted 'L' shaped capsulotomy

Question 27

What are the 3rd and 4th steps in **Austin** procedure? 3rd: Inspection of _A_ 4th: Removal of _B_

Answer 27

A: metatarsal head B: Medial eminenece

Question 28

What is the next step after removal of the medial eminence in **Austin** procedure?

Answer 28

"V" osteotomy and insertion of K wire at the apex of the V to hold the bone temporarly until they put the screw in

Question 29

What is the next step after "V" osteotomy in the **Austin** procedure?

Answer 29

Lateral re-positioning of the 1st met head and then the removal of prominance metatarsal neck and fixation

Question 30

What are the advantages for **Austin** procedure? _A_ osteotomy Good _B_ (low incidence of _C_) Can _D_ ( reduce incidence of lesser metatarsalgia) Technically _E_

Answer 30

A: Stable B: bone to bone C: AVN D: plantarflex/shorten E: easy

Question 31

What are the _limitations_ of **Austin procedure**? Limitation of _A_ possible _B_ patients

Answer 31

A: amount of correction possible B: Juvenille patients

Question 32

Post-op course for the _Austin_ procedure: Sutures removed at _A_ Post-op shoes for _B_ _C_ for a period Return to normal shoes after _D_ Return to sedentary work _E_ post-op Return to active work _F_ Return to active exercise _G_ Total time to recover _H_

Answer 32

A: 2 weeks B: 4 weeks C: +/- IDW D: 4 weeks + E: 1-2 weeks F: 4-6 weeks G: 2-3 weeks H: 1 or 2 years

Question 33

Obligue closing base wedge osteotomy _A_ base/shaft osteotomy from _B_ to _C_ Create _D_ hinge Use axis guide to _E_ 1st ray to _F_ _G_ essential

Answer 33

A: Oblique B: medial-proximal C:lateral-distal D: medial cortical E: abduct F: abduct/ plantarflex G: internal fixation

Question 34

Oblique closing base wedge what are the advantages? what are the disadvantages? 1. Can reduce _A_ 1. Technically _B_ 2. Can _C_ mildly 2. Can fracture _D_ 3. 3. Needs NWB BK cast for _E_ 4. 4. _F_ , reduced _G_

Answer 34

Oblique closing base wedge 1. A: large MPAA 1. B: difficult 2. C: plantarflex 2. D: medial hinge 3. 3. 6-8 weeks 4. 4. osteoprosis, mpj ROM

Question 35

**Scarf osteotomy** _A_ osteotomy Indication _B_ _Advantages:__Disadvantages:_ 1. Good _C_ 1. Technically _D_ 2. _E_ via use axis guide 2. internal fixation with _F_ 3. May _G_ by removing the dorsal wedge 4. can perform _H_

Answer 35

A: Transverse Z B: High MPAA 1. C: reduction of IMA 1. D: difficulty 2. E: plantarflex 2. F: 2 screws 3. G: shorten 4. H: bilateral surgery

Question 36

What are the complication of bunion surgery? 1. _A_ 2. Displacement of _B_ 3. Post-op _C_ 4. Restricted _D_ 5. _E_ removal 6. Return of _F_ 7. _G_ 8. _H_

Answer 36

1. A: Infection 2. B: osteotomy 3. C: oedema 4. D: ROM 5. E: Fixation 6. F: deformity 7. G: hallux varus 8. H: avascular necrosis 9.

Question 37

What are the causes of oedema post operation? Some oedema is _A_ _B_ _C_ Excessive _D_ Movemenet of _E_

Answer 37

A: normal B: Infection C: hematoma D: walking E: osteotomy site

Question 38

What are the casues car restricted ROM? initially A B Inadequate C Failure to shorten D Treatment: E

Answer 38

A: normal B: Fibrosis capsule, EH capularis C: bone resection D: 1st metatarsal E: Early ROM exercises, steroid injection

Question 39

What are the causes of fixation removal? A screw heads too B Presnece of C Treatment : E

Answer 39

A: K-wires losen B: Prominant C: infection E: placement and choice of fixation E: LA

Question 40

What are the causes of the return of deformity? _A_ reduction Poor _B_ Non _C_ Treatment? No _D_ _E_

Answer 40

A: Inadequate reduction B: Post-op management C: Non-compliance Treatment: D: No treatment E: reoperate

Question 41

What is involved in **Silver procedure**? 1. Removal of ? 2. Lateral ? 3. ? release 4. reinforcement of ?

Answer 41

1. the medial eminence 2. capsulorraphy 3. adductor 4. the medial capsule with V-Y capuloraphy

Question 42

What is the Mcbride procedure based on your Podiatric Medicine book?

Answer 42

Mcbride resected the **adductor hallucis tendon** at its insertion to the **proximal phalanx** and the **fibular sesamoid.** The tendon was then dissected free back to the level of its muscle belly. The **fibular sesamoid** was then **excised** (he emphasized that the most difficult part of removing the sesamoid was freeing the bone from the intermetatarsal ligament). He then resected the **exostosis** from the **head of the metatarsal**. If there was still capsular contracture, Mcbride made a **small stab incision** into the taut lateral capsule. He thaught it was absolutly necessary to have **no remaining contractures** that could keep the hallux in **valgus position**. The **adductor hallucis tendon** was then transplanted to the **shaft of the first metatarsal** and sutured into the periosteium. The purpose of this transfer, according to McBride, was that it no longer had any leverage pull on the digit, and its new location, when contracted would bring the first and second metatarsal toegther.