1. 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

2. 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?

3. Heredity plays more of a part than shoes

4. 1982 Clinic: Longton Stoke on Trent Child aged 9 (from old slide) Mum bought good shoes

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

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

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

8. bursa

9. Affording temporary relief

10. 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

11. “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

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

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

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

15. 8-10 o How does it all happen? – the I-M angle

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

18. Early compression erosion

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

20. Packed with homogenous Cancellous graft

21. Assessing the damage and adaptation

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

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

24. Callus can be painful Other forms of “Metatarsalgia”

25. Hallux-valgo-rigidusSimple bump with pressure plus vascular

26. The picture of older age, disability and compromised health?

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

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

29. Good surgery: principles

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

31. multi-digital deformity can be challenging

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

33. 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

34. 360 Appraisal evidence Can we sex up bunions? Maybe we can sympathise more if the condition is perceived as not shoe related Conclusion