Management

 

Operative

 

Indications

 

Pain / discomfort

Difficulty shoe wear

Lesser toe deformity

Skin issues

 

Contra-indications

 

Poor peripheral arterial circulation

Diabetes

 

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

 

Surgical Options

 

 

DTSP (distal soft tissue procedure) - incongruent joint

 

Metatarsal osteotomy +/- DTSP

- Distal - Chevron

- Midshaft - Scarf

- Proximal - opening / closing wedge, Chevron, crescenteric

 

Proximal phalanx osteotomy (Akin) (interphalangeus)

 

TMT fusion / Lapidus

 

MTPJ fusion

 

Congruent	Incongruent	Mobile TMTJ Metatarsus varus	OA / Degenerative / Rheumatoid
DMAA  < 15° - treat hallux interphalangeus - Akin with exostectomy	Mild - Chevron - DSTP +/- MT osteotomy	Lapidus fusion + DTSP	Arthrodesis
DMAA > 15° - Chevron with closing wedge	Moderate - DSTP + osteotomy
	Severe (HVA > 40o, IMA > 20o) - DSTP + osteotomy +/- Akin - DSTP + Lapidus - Arthrodesis

 

Peng et al J Orthop Surg Res 2024

- systematic review of Chevron versus Scarf osteotomy

- 6 RCTs and 500 feet

- better correction of HVA with Chevron

- no difference in functional outcomes or complications

 

Distal Soft Tissue Procedure / McBride's

 

 

Indications

- joint incongruency

 

Modified McBride concepts

1. MTPJ lateral release

2. Medial exostectomy (just medial to sagittal sulcus)

3. Medial capsular plication / capsulorraphy

 

Indications

- mild HV with incongruent joint

- moderate / severe HV - combine with osteotomy

 

Technique

 

McBride DTSP surgical technique PDF

 

 

1.  Dorsomedial approach

- protect nerve

- V shaped capsulotomy

- remove medial prominence

 

2.  Incision first web space and lateral release

- protect branches of DPN

- insert lamina spreader

- release abductor tendon from lateral sesamoid

- release intermetatarsal ligament from lateral sesamoid

- release lateral metatarsosesamoid suspensory ligament from lateral sesamoid

- open lateral capsule / LCL

 

3.  Medial capsulorraphy

 

Chevron osteotomy +/- DSTP

 

 

Indications

- incongruent joint

- mild hallux valgus: HVA < 30^o / IMA < 15^o

 

Technique

 

 

Vumedi Chevron osteotomy video

 

Dorsomedial approach

- distally based "V" capsular flap

- expose MTP joint

- remove medial eminence with saw

 

60° osteotomy apex distal

- apex 1 cm from articular surface

- longer plantar limb to avoid sesamoids and inferior joint surface

 

Translation

- 5 mm medial

- 1mm displacement corrects IM angle 1º

- can perform medial closing wedge to correct DMMA

 

Fixation

- sutures / k wire / screw

 

Closure

- imbricate medial capsule

 

Scarf osteotomy + DSTP

 

 

Indications

- moderate hallux valgus

 

Technique

 

 

Vumedi Scarf osteotomy video

 

Dorsomedial approach

- distal soft tissue release

- medial eminence resection

- preserve blood supply at plantar aspect of the metatarsal neck

 

Longitudinal cut

- oblique: plantar proximal / dorsal distally

- leave strong plantar portion of head to prevent dorsiflexion

 

Transverse cuts

- plantar proximal / dorsal distal

- angle of 45^o with the long cut

 

Translation

- plantar fragment medially

- can rotate to reduce pronation

 

Fixation with screws

 

Proximal Osteotomy + DTSP

 

Options

- crescentertic

- Chevron

- opening wedge (lengthens)

- closing wedge (shortens)

 

Arthrex proximal opening wedge video

 

Arthrex proximal Chevron osteotomy video

 

Akin osteotomy

 

 

Indications

- hallux interphalangeus > 10^o

 

Technique

- medial closing wedge osteotomy of P1

 

Arthrex Akin osteotomy video

 

 

Minimally invasive Hallux Valgus Surgery

 

Definition

- incisions < 2 cm

 

Alimy et al CORR 2023

- systematic review

- 6 RCT of open versus MIS

- no difference in clinical or radiographic outcomes

 

 Lapidus Procedure / TMT arthrodesis + DTSP

 

 

 

Indications

- moderate to severe HV

- TMTJ hypermobility

- metatarsus primus varus

 

Technique

 

Vumedi Lapidus procedure video

 

Triplanar correction - coronal / sagittal / rotational

 

Results

 

Do et al Orthop Clin North Am 2022

- systematic review of 1800 Lapidus

- complication rate 17%

-  hardware pain 3%

- nonunion 3%

- delayed union 2%

- wound complication 1%
 

Arthrodesis

 

 

Indications

- hallux valgus with arthritis

- severe hallux valgus

- neuromuscular disease i.e. cerebral palsy

- rheumatoid arthritis

- salvage procedure for failed procedures

 

 Technique

 

Vumedi surgical technique 1st MTPJ fusion medial approach video

 

Vumedi surgical technique 1st MTPJ fusion dorsal approach video

 

Vumedi surgical technique MIS 1st MTPJ fusion video

 

Approach

- dorsal approach

- medial approach

 

Position

- 10 - 15° valgus

- 10- 15° dorsiflexion relative to plantar surface / 20 - 25° relative to metatarsal shaft

 

Fixation

- screws / plate / screws + plate

 

 

Complications of Surgery

 

Complications

 

Sieloff et al J Foot Ankle Surg 2023

- systematic review of 1500 scarf osteotomies with 2 year followup

- recurrence 5%

- 3.5% troughing

- 1% AVN, 2% infection

- 2% nonunion, 3% malunion, 3% hallux varus

- 5% CRPS

 

Infection

 

 

Hallux Varus

 

Cause

- excessive medial resection

- resection of lateral sesamoid

- excessive lateral release or medial plication

 

Issues

- difficulties with shoe wear

 

Options

- 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

 

 

Management - arthrodesis