9 and 10 Hallux Valgus 1 and 2

Pregunta	Respuesta
Clinical Assessment	HISTORY • Pain • Location / nature / any trauma? • Impact on mobility • Work • Social activities, sports • Footwear Issues • Level of Deformity • Previous Surgery or previous foot problems • Medical History • Diabetes or Vascular disease • Inflammatory conditions • General fitness for surgery • Smoking • Expectations • Standing / Walking • Gait • Arch • Hindfoot alignment • Lesser toe deformities • Sitting • Shape – how bad? • Calluses • Hindfoot alignment • Skin – intact?Examination 1st MTPJ –Movement –Crepitus –Correctability –Tenderness • Hypermobility 1st TMT joint • 1st toe IPJ • Gastrocnemius tightness • Pulses • Sensation –General –First ray
Radiological Assessment	Weightbearing views are essential for surgical planning • IM angles increase during weight bearing views. • HA angles increase on non-weightbearing views.
Radiological views - 4	Dorsoplantar view Lateral View Oblique View Sesamoid Axial View
NORMAL grade HV angle? INTER-METATARSAL ANGLE?	<15 degrees <9 degrees
MILD HALLUX VALGUS ANGLE INTER-METATARSAL ANGLE	15 - 30 degrees 9 - 11 degrees
MODERATE HALLUX VALGUS ANGLE INTER-METATARSAL ANGLE	30 - 40 degrees 11 - 14 degrees
SEVERE HALLUX VALGUS ANGLE INTER-METATARSAL ANGLE	>40 degrees >14 degrees
Normal Distal Articular Set Angle and Proximal Articular Set Angle?	0-8 degrees
Congruent Hallux Valgus - 4 factors	*mild or moderate deformity •Intermetatarsal angle normal •Articular surface is ‘off-set’ •Conventional osteotomies will make the deformity worse!
Interphalangeal Hallux Valgus • Often associated with ? • May be the main deformity in ? • Treated by?	• long standing hallux valgus • adolescents • phalangeal osteotomy (medial wedge removed) – Akin procedure
Tarso-Metatarsal Joint Instability Usually associated with? • Noted on clinical exam but what can confirm this?	very severe long standing deformities Lateral radiographs can confirm Develops secondary to the deformity
Treatment Options - NON-OPERATIVE (4)	• Footwear advice (Orthopaedic shoes) • Orthotics / splints / silicone spacers • Analgesics and NSAIDs • Corticosteroid injection (xray before injections).
HV Surgery Considerations (4)	-Age (level of activity) • Expected Results • Condition of the joint • Associated conditions / Predisposing factors
Soft Tissue Release (McBride’s) description	Usually through an incision in the first dorsal webspace, the adductor hallucis and lateral joint capsule are released. This allows the sesamoids to be reduced underneath the first metatarsal head. The adductor tendon is transferred from the base of the proximal phalanx onto the lateral first met head. The lateral collateral ligament is left intact as its release predisposes to hallux varus. The medial eminence of the first metatarsal is excised with plication of the medial joint capsule
Exostectomy (Silver’s procedure)	Removal of the medial bony prominence.
Excision Arthroplasty (Keller’s)	One third of the proximal phalanx of the big toe is removed. This decompresses the joint and relaxes the tight lateral structures, allowing correction of the deformity. Should be considered for an elderly patient with low functional demands.
Complications - 5	-Too much removed • Too little removed • Exacerbates metatarsalgia • Increases lateral loading • Exposes 2nd
Excision Arthroplasty (Mayo’s)	Partial resection of the metatarsal head
Complications (3)	Significant risk of Metatarsalgia • Short hallux • Recurrent deformity
Osteotomy	A surgical operation where a bone is cut to shorten, lengthen or change its alignment.
Ideal Osteotomy	Easy to Perform • Stable • Good Healing Potential • No Shorterning • Minimise risk of avascular necrosis • Metatarsal head should not be elevated
The Modified Mau-Reverdin Double Osteotomy	-Not Easy to perform • Not Stable • Not Good healing potential
Mitchell Osteotomy	For mild to moderate deformities.Involves a double cut through the first metatarsal neck, leaving a step in the lateral cortex. This step is used to hitch on to the metatarsal head. The capital fragment is displaced laterally and plantarward and held with a suture through drill holes
Mitchell Osteotomy - 2 disadvantages	-Shortening of 1st metatarsal • Transfer metatarsalgia.
Chevron osteotomy	Indicated for mild to moderate deformities. This is a V shaped osteotomy through the metatarsal neck followed by lateral displacement of the capital fragment.
Complications with Chevron and other distal osteotomies	Blood supply to met head can be damaged and can lead to avascular necrosis.
Scarf Osteotomy	This is a z-shaped step-cut osteotomy. A longitudinal cut is made along the length of the diaphysis sloping plantarward as it passes laterally, allowing plantar displacement and off-loading of the lesser rays. Chevrons are made at each end of the osteotomy to connect it to the dorsal cortex distally and the plantar cortex proximally. The head and the plantar cortical fragment are then translated laterally and the osteotomy held with two compression screws.
Troughing	Troughing occurs as the cortex of the dorsal half of the first metatarsal shaft collapses and wedges into the softer cancellous bone, thus leading to functional elevation of the first ray and, in due course, a pronated foot position with overload of the lesser metatarsals.
Feathering	When the saw is cutting the longitudinal line on the met shaft you can't see the other side of the bone. So you don't know if it's going along the same straight line and because of this you can get feathering.
BASAL OSTEOTOMY	Correction of moderate to severe deformity. Normally combined with a distal soft-tissue procedure. The medial eminence is removed and a wedge cut out of the base of the proximal met. • Multiple techniques
LAPIDUS PROCEDURE/First tarsometatarsal joint arthrodesis	Joint fusion and combined with a distal soft-tissue procedure in a patient with hypermobility of the first tarsometatarsal joint
ARTHRODESIS indications? 3	Severe deformity • Arthritic joint • Recurrent deformity
Akin osteotomy	An Akin osteotomy is a medial closing wedge osteotomy of the proximal phalanx of the great toe. It is used to correct hallux valgus interphalangeus.
Common Practice in Glasgow • Mild deformities?	• Chevron osteotomy
Moderate deformity	• Scarf osteotomy and soft tissue rebalancing +/- Akin osteotomy
• Severe deformity - 2	Scarf osteotomy and soft tissue reblancing; • Lapidus procedure (First TMTJ fusion) and soft tissue rebalancing.
• First MTPJ arthritis:	•Arthrodesis
First ray hypermobility / First TMTJ arthritis:	Lapidus procedure

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	Creado por Morgan Morgan hace más de 9 años