Hallux Valgus Mr. V. Dhukaram Session I Hallux Valgus Mr. V. Dhukaram

Warwick Orthopaedics is a centre of excellence for research, teaching and development of the treatment of musculoskeletal disease. I am delighted to welcome you all for the Warwick Cadaveric Foot and Ankle Surgery course. This course is designed to be practical with no formal lectures. We have put together the educational and product information for you to familiarise prior to the course which would be a valuable adjunct to the course. Vivek DHUKARAM

Patho-Anatomy of Hallux Valgus Normal disposition of intrinsic and extrinsic tendons aroundMetatarso-phalangeal region Displacement of tendons in hallux valgus

Distal Soft Tissue Release (DSTR) Through either Dorsal webspace or Medial approach Release of lateral sesamoid suspensory ligament and phalangeal band If required, release inter-metatarsal Lig.

Scarf osteotomy Most commonly performed osteotomy for Hallux valgus First described by Meyer 1926 Popularised by Barouk

AIM Pathology: Medial displacement of metatarsal head outside the sesamoid sling Aim to relocate the metatarsal head over the sesamoids 4 steps: DSTR, Osteotomy, Bunionectomy, Medial capsulorrhapy

Technique - Barouk Medial Approach Longitudinal capsulotomy Longitudinal cut followed by transverse limbs

Inclination of transverse cut

Screw Fixation Barouk LS. Barouk P. (2007) Scarf Osteotomy : Forefoot Inter active Surgery: a book + CD ROM : Springer, Paris

Degree of correction Depends on the metatarsal width, higher the width will allow greater translation/ rotation (upto 80%) to achieve greater correction Length of osteotomy would vary with the severity of deformity. Shorter length osteotomies are adequate to correct mild deformities Severe deformities require shortening of first MT to MS point with subsequent shortening of lesser metatarsals to prevent transfer metatarsalgia

DMAA / MS Point

Versatile procedure Plane of osteotomy Displacement Deformity Comment Transverse Lateral shift Metatarsus varus Lateral rotation Medial rotation High DMMA Frontal Lowering MT head Lateral Metatarsalgia Achieved by changing the obliquity of longitudinal cut Elevation 1st MT metatarsalgia Cavus foot Sagittal Lengthening Short 1st MT Previous Iatrogenic shortening Risk of Stiffness/ O.A. first MTPJ Shortening Severe deformity Stiff first MTPJ

Complications - Barouk Undercorrection Stiffness Wound complications Prominent screw Dorso-medial N.injury Hallux varus Osteonecrosis of first MT head – higher risk if plantar branch violated

Akin Procedure (1925) Staple Indications: HVI, DMAA >10 º or HV not corrected by index procedure, to remove pressure on 2nd toe Medial wedge resected from base of PP but lateral cortical hinge preserved Fixation method- Staple, screw, k wire. Complications: Nonunion, malunion, AVN

Chevron/ Austin Osteotomy Indications: Mild to Moderate deformities Initially performed with equal limb lengths with apex at centre of MT head Later modified by Johnson with long plantar limb to exit proximally, preserve the vascular supply of MT head Vascular supply

Chevron/ Austin Osteotomy Displacement beyond 50% of its width could compromise its stability Fixation: Screw, k wire, PDS pins Medially based biplanar wedge to correct DMAA Trnka HJ The chevron osteotomy for correction of hallux valgus. Comparison of findings after 2 and 5 years of follow-up. JBJS Am. 2000 Oct;82-A(10):1373-8

Open Wedge Basal Osteotomy Indications: Severe Deformities Medial approach Perform lateral release and bunionectomy Osteotomy 15mm distal to first TMTJ but preserve lateral cortical hinge Osteotomy opened to achieve the degree of correction and fixed with step locking plate Darco BOW plate

Open Wedge Basal Osteotomy Orthosolutions wedge plate Maintains or slightly lengthens the first metatarsal Require distal osteotomy to correct DMAA Modifications – Oblique osteotomy Complications: Non-union, delayed union Saragas NP. Proximal opening-wedge osteotomy of the first metatarsal using a low profile plate. Foot Ankle Int. 2009;30(10):976-980

Lapidus - 1934 Arthrodesis of 1st TMTJ and 1st-2nd inter-metatarsal joint with distal soft tissue realignment. Modified by exclusion of 1st- 2nd inter-metatarsal joint Indications: Hypermobile first ray, severe HV, failed HV especially young adults, metatarsus primus varus with oblique TMTJ

Bone Wedges Plantar wedge Lateral wedge Lapidus – Operative correction of metatarsus varus primus in hallux valgus. Surg Gynecol Obstet 58:183-91, 1934 Myerson M – Metatarso-cuneiform arthrodesis for management of hallux valgus and metatarsus primus varus. Foot Ankle 13:107-115, 1992

Technique Medial approach to first TMTJ Correction of deformity with biplanar wedges with bases inferior and lateral Fixation method – Screws, plate & screws Complications: Dorsiflexion malunion (9% Myerson), non-union (improved with better fixation), Undercorrection, overcorrection. Orthosolutions lapidus plate

Sesamoid Exposure Indications: Sesamoidectomy, shaving plantar prominence, fracture fixation Medial Approach for medial sesamoid, Dorsal webspace for lateral sesamoid, Plantar approach for both sesamoids but leaves sensitive scar