Is it possible to sex up bunions by calling it hallux valgus? Mr David R Tollafield Consultant Podiatric Surgeon Villars Medical Conference Walsall Manor Hospital (Community Health) Spire Healthcare Little Aston, Sutton Coldfield Ramsay Hospital Halesowen

This presentation (objectives):- Avoiding the confusion Looking at x-rays differently Understanding why Tx is required At the heart of bunion surgery – the sesamoid Degeneration & what it means What is good surgery?

Heredity plays more of a part than shoes

1982 Clinic: Longton Stoke on Trent Child aged 9 (from old slide) Mum bought good shoes

Cover up test Squashing a quart into a pint! Is this soft tissue Or is this bony?

Variants: ‘Bunion, Onion, Bursa’ what does it all mean?

A sub-condition known as Metatarsus primus elevatus “The dorsal bunion” Line of declination 15 degrees to the ground

bursa

Affording temporary relief

Based on definition represented in ‘clinical skills in Treating the Foot’ Elsevier. Tollafield D R, Kilmartin T K, Prior T D 2005 Simple staging by clinical observation mildmoderatesevere

“Should I wait until it hurts?” “GP says it is not bad enough yet?” “...don’t like the look of it!” “Want to stop it getting like my mother’s” “Can’t get shoes on I want” So when do we treat? Hallux valgus is more of a lady’s problem than a man’s problem

Should we leave this condition? SECONDARY Broad forefoot Shoe pressure Metatarsalgia Skin wear Ulcerations Impingement Chilblains infections PRIMARY Pain Deformity Degeneration

End of midstance, heel lift, toe propulsion How much movement? The sesamoid Root et al 1977 Suggest 20 degrees required

The sesamoid, above is affected as a patella against a femoral head! Tracking misalignment

8-10 o How does it all happen? – the I-M angle

Side view of first toe (MTP) joint toe metatarsal Axial view of met. head Early life – third decade (female) joint

Early compression erosion

The subchondral cystic lesion Geodes, granulomas, cysts and pseudocysts phalanx First metatarsal joint

Packed with homogenous Cancellous graft

Assessing the damage and adaptation

Depth Surface area synovium / capsule Fluid Osteophytic changes loose bodies sub-cartilage bone density Intra operative considerations

Degenerative change forms one major reason to treat early There are other concerns: metatarsalgia skin pressure ulcers erosions infections

Callus can be painful Other forms of “Metatarsalgia”

Hallux-valgo-rigidusSimple bump with pressure plus vascular

The picture of older age, disability and compromised health?

synovitis Good surgery: principles Align the Sesamoids Select procedure for Degenerative state Fit surgery to patients’ needs Extensor tendon bowstringing Cartilage adapts sesamoids geode

Pre-operative planning Correlate XR Patient preparation Consent Post op care Good monitoring Three P’s Gap opens up Sesamoids aligned Tendon repositioned

Good surgery: principles

Conservative? Limitations Exostectomy Excisional arthroplasty Osteotomy (wide range) Fusion (mcj fusion) Joint replacement arthroplasty (prosthesis) Amputation Selection of treatment is multifactorial A brief word

multi-digital deformity can be challenging

Addressing the whole deformity There is no such thing as a simple bunion: metatarsus adductus

Should Mrs Beckham have surgery? Yes if? Pain Swelling early crepitations Stiffness Strong family history Lesser toes affected Metatarsalgia No if? None of above Down to footwear alone

360 Appraisal evidence Can we sex up bunions? Maybe we can sympathise more if the condition is perceived as not shoe related Conclusion