Non-Operative
Education regarding shoe wear
- extra wide / large toe box
Insoles
- longitudinal arch support
- pre MT dome for metatarsalgia
- podiatry to attend to callosities
Toe spacers
Analgesia
Operative
Indications
1. Continued pain and discomfort
2. Difficulties with shoe wear
- split size shoe requirements
- difficulty fitting shoes
- only 60% wear "fashionable" shoe post-op
3. Deformity of lesser toes
4. Skin problems
5. Cosmetic appearance – relative indication
Contra-indications
Poor peripheral arterial circulation
Current sepsis
Uncontrolled diabetes
Peripheral neuropathy (relative)
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
5. Retention of functional range of motion of the MTPJ
6. Maintenance of normal weight bearing mechanics of foot
Surgical Options
Congruent
1. DMAA < 15°
- treat hallux interphalangeus
- Akin with exostectomy
2. DMAA > 15°
- Chevron with closing wedge
Incongruent
Mild
- Chevron
- DSTP (Distal Soft Tissue Procedure) +/- proximal osteotomy
Moderate
- DSTP & proximal osteotomy
- Scarf
Severe
- DSTP & proximal osteotomy
- arthrodesis
Rheumatoid
Mild to Moderate / Low demand
- arthroplasty
Severe
- arthrodesis
Hypermobile TMTJ
- fusion (Lapidus) & DSTP
Surgical Procedures
1. Chevron
Indications
- incongruent joint
- HVA < 30o / IMA < 15o
- patient < 60 years
Technique
Avoid lateral release = AVN 40%
Dorsomedial approach in internervous plane
- don't go directly medial as will get sensitive scar
- protect dorsal sensory nerve
- distally based "V" capsular flap
- expose MTP joint
Exostectomy
- remove medial eminence with saw
- leave 1- 2 mm medial to medial sulcus
- otherwise risk hallux varus
60° osteotomy apex distal
- longer plantar limb to avoid sesamoids and inferior joint surface
- apex 1 cm from articular surface
- translate 5mm
- 1mm displacement corrects IM angle 1º
- can perform medial closing wedge to correct DMMA
Fixation
- not always necessary
- sutures / k wire / screw
Closure
- imbricate capsule
- advance to tighten medially
Second toe releases as needed
Post op
- bandage / POP to maintain correction
- check wound at 1 week
- bunion boot / heel walk
- toe spacer
- 6/52
Results
GE 75% if IMA >12°
GE 95% if IMA <12°
Complications
AVN is rare
- ensure apex 8-10 mm from articular surface
- avoid DSTP
2. Distal Soft Tissue Procedure
Modified McBride
- release of tight lateral structures (ADDH, lateral capsule, transverse MT ligament)
- medial exostectomy (just medial to sagittal sulcus)
- medial capsular plication
(Modification: no longer excise sesamoid)
Indications
- mild HV with incongruent joint
- severe HV when combined with proximal osteotomy
Technique
1. Dorsomedial approach
- protect nerve
- V shaped capsulotomy
- remove medial prominence
2. Incision first web space
- protect branches of DPN
- insert lamina spreader
- release ADD hallucis at P1
- cut capsule between sesamoid and MT
- divide transverse MT ligament
Results
92% good results
Complications
Nerve injury
- plantar cutaneous nerve
Hallux varus
- from releasing lateral FHB from sesamoid
3. Proximal Osteotomy + DSTP
Indications
- severe HV
- correct IMA with osteotomy
- correct HVA with DSTP
Results
- in combination with DSTP
- GE 90 %
Options
- crescentertic
- opening wedge (lengthens)
- closing wedge (shortens)
Opening wedge
- extend medial incision
- incomplete ostetomy with saw at base MT
- use bone from bunionectomy to fill gap
- fixation with small plate
4. Scarf
Indications
- moderate HV
- see separate technique
- technically challenging but good results
5. Akin
Indications
- congruent joint
- DMAA < 15o
- hallux interphalangeus > 10o
- residual HV after other procedures
Technique
- medial closing wedge osteotomy of P1
- combine with cheilectomy
6. Keller Procedure
Technique
- resection 1/3 of proximal phalanx
- should use pin to stop cock up deformity & to stiffen joint
Indications
- housebound / non ambulator
- elderly
- salvage
- marginal circulation - DM / PVD
- hallux rigidus if cheilectomy or arthrodesis contra-indicated
Complications
- instability / cock up deformity
- transfer metatarsalgia (in young)
Results
- 80% good results
7. Arthrodesis
Indications
- hallux valgus with arthritis
- severe hallux valgus
- neuromuscular disease i.e. cerebral palsy
- RA
- salvage procedure for failed procedures
Position
- 15º valgus
- DF 10º relative to plantar aspect of foot
- DF 30° relative to ray
Technique
- dorsomedial approach
- release EHB / mobilise EHL / release collaterals
- Coughlin male and female reamers
- secure with cross screws or plate
8. Lapidus Procedure
Indications
- TMTJ hypermobility
- fusion TMTJ
Problems
- difficult to achieve union
- difficult to get position correct
Joint multiplanar
- malrotation poorly tolerated
- shortens medial column
- can get metatarsalgia
Technique
- slight plantar flexion and lateral deviation
Complications of Surgery
Transfer Metatarsalgia
Recurrence
- incorrect surgery
- poorly performed surgery
- high risk groups i.e. adolescent
Nerve injury
- dorsal and plantar cutaneous nerve
Cock up Toe
Cause
- post Keller’s
Management
Arthrodesis MP joint
- shorten if don't use graft
- fusion rate 95% (BG) vs 70% (no BG)
Hallux Varus
Cause
- excessive medial resection
- resection of fibular sesamoid
- excessive lateral release or medial plication
Clinical
- not always painful
- cosmetically unacceptable
- difficulties with shoe wear
- cockup deformity
- with time stiffens in extension & medial deviation
Options
- soft, well fitting shoe
- 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
Rarely seen in Chevron
- due to disruption of volar blood supply
Management
- arthrodesis / excise avascular fragment and shorten toe