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

2. 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

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

4. 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.

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

6. 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

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

8. Inclination of transverse cut

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

10. 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

11. DMAA / MS Point

12. 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

13. 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

14. 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

15. 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

16. 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 Oct;82-A(10):1373-8

17. 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

18. 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):

19. Lapidus
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

20. 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: , 1992

21. 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

22. 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