Arash Aminian MD March 17, 2011

All bunions are not created equal Complex array of osseous & soft tissue pathology Lateral deviation of the great toe with medial deviation of the 1 st metatarsal

>100 procedures for Hallux Valgus Procedure should address deformity Soft tissue procedure combined with bony correction most common procedure Chevron Osteotomy with Silver eminence resection most common procedure

NWB & WB Gait/shoe wear ROM Hyper mobility 1 st ray Adductor tautness Neurovascular Footprints

Painful HV failed palliative measures Wider shoes Activity modification NSAIDS No inflammatory Non paralytic 1 st MTP Fusion

PVD Arthritis Neuropathic Pure cosmetic Osteopenia

METATARSALGIA HAMMERTOES CLAWTOES DEVIATED TOES NEUROMAS EQUINUS

AP/Lat & Sesamoid Weight-Bearing IMA < 9 degrees DMAA < 9 degrees HVA < 15 degrees Sesamoid station & metatarsal length Congruity

HVA IMA DMAA

High Intra, Inter-observer reliability for HVA, IMA (<5 degree, 95% confidence) Measure from the center of MT head to center of MT base Post-operative measures are less reliable Anatomy distorted Functional outcomes failed to correlate with radiographic outcomes (Thordason et al FAI 26:2005)

Plantigrade & painless foot Complex array of pathological bone & soft tissue deformity must be addressed Each procedure has limitations & indications Multiple options should be available

Congruent Joint Mild deformity IMA < 15 degrees, HV < 35 degrees No instability of the 1 st Ray Chevron Osteotomy

Small medial eminence resection Hallux Varus Release the capsule through the joint AVN Main blood supply to the MT head: Plantar-lateral corner of the MT head Dont rely on the capsular plication for deformity correction Post-op early motion

CHEVRON

Incongruent Joint Moderate deformity IMA degrees, HV <40 degrees No instability of the 1 st Ray SCARF Osteotomy Modified Chevron

Incongruent Joint Severe deformity IMA >20 degrees, HV >40 degrees Instability of the 1 st Ray Lapidus 1 st MTP fusion

Inflammatory Arthritis Paralytic deformity 1 st MTP fusion

Resection of the proximal phalanx Older patient Less demand High risk patients (medical co-morbidities)

AVN Stiffness of the joint Hallux Varus Malunion (Dorsiflexion: transfer metatarsalgia) Non-union (Lapidus 5%)

Blood supply: Branches of the 1 st dorsal metatarsal artery 1 st Plantar metatarsal artery Medial plantar artery Plexus Lateral plantar corner JBJS 2007:

Do not push a procedure beyond its limits Hypermobile 1 st ray=Lapidus DMAA ? Loss of fixation ?

Position of medial sesmoid and axis of 1 st MT JBJS 2009: