General Principles: HV Pathogenesis Surgical Goals Principles: HV Pathogenesis & Surgical Goals Caio...

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Advances in Hallux Valgus Surgery

General Principles:HV Pathogenesis & Surgical Goals

Caio Nery, M.D.

2015

UNIFESP - Federal University of So Paulo - BrasilEscola Paulista de Medicina

Foot and Ankle Clinic

Disclosures

Caio Nery

Consultant / Speaker

Arthrex, Inc

Editorial Board

Foot and Ankle International

Revista Brasileira de Ortopedia e Traumatologia

Acta Ortopdica Brasileira

Revista da ABTP

Tobillo y Pi

Board of Directors

IFFAS International Federation of Foot and Ankle Societies

June 2015

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Hallux Valgus

Carl Hueter (1870)

INT

EXT

Hallux Valgus

Perera AM, Mason L, Stephens MM. The Pathogenesis of Hallux Valgus. JBJS 2011 93-A: 1650-61.

High-heeled narrow shoes Excessive weight-bearing

Genetics Ligamentous laxity Matarsus Primus Varus

Pes Planus Functional Hallux Limitus

Sexual dimorphism AgeMetatarsal morphology

First ray hipermobility Tight Achilles Tendon

Hallux Valgus

Pathoanatomy

The deformity occurs in steps

Predisposing factors

Series OR Parallel


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Hallux Valgus

Hallux Valgus

Hallux Valgus

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Hallux Valgus

Hallux Valgus

EHL

EHB

LATERALMEDIAL

AdHAbH

FHB latFHB med

FHL

MEDIAL LATERAL

EHLEHB

AdH

AbHFHB med

FHB latFHL

NORMAL

HALLUX VALGUS

Hallux Valgus

P


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Hallux Valgus


Hallux Valgus

Hallux Valgus Etiology

Extrinsic Factors

Footwear

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Genetic Factors

Metatarsal Formula / Dome Height / Hypermobility

Autosomal Dominant with incomplete penetrance

Sex linked Maternal transmission


Sexual Differences

Sex ratio 15 F :: 1 M

Anatomic Differences

Deformity more intense in men


Age

Posture changes Greater HV risk

Age Poor predictor of HV angle

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Hallux Valgus

Metatarsus Primus Varus

Hallux Valgus

MT Head Shape

Round Flat Chevron

Hallux Valgus

DMAA angle

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Hallux Valgus

Ps Planus

Hallux Valgus

Tight Achilles Tendon

Early and Increased forefoot Loading

High correlation with Diabetic Ulcers

No association with HV

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Hallux Valgus Treatment

Treatment Goals

1923 Silver

Exostosis ressection

Lateral soft tissue release

Medial soft tissue tensioning


Treatment Goals

1934 Paul Lapidus

Exostosis ressection

First toe valgus correction

First Metatarsus Primus Varus correction

Sesamoid deviation correction


Treatment Goals

2000 Third Millennium

All the anterior +

Valorize (and correct) Intrinsic Factors (all of them!)

Correct associated deformities

Take care of the whole package

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Treatment Goals

HV Treatment Rationale Roger Mann, 1992

Patients complaints and occupation

Clinical and Radiological signals

Age / Lifestyle

Neurovascular status / General health

Patients expectations

Advances in Hallux Valgus Surgery

Thank you !!!

Caio Nery, M.D.

2015

UNIFESP - Federal University of So Paulo - BrasilEscola Paulista de Medicina

Foot and Ankle Clinic

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MIS Hallux valgus

surgery DR S. Guillo

Sports medical center (Bordeaux, France)

Email: [email protected]

No conflict of interest

The pastLarge incision

stiffness

bleeding

Surgical time

Risk of infection

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The present (and future)

Smaller incisions

Less dissection

Less bleeding

Potentially faster surgery

The History Isham 1990s

Bsch 2000

Portaluri 2000

Giannini 2003, 2007

Maffulli 2005, 2008

Magnan 2005, 2006, 2008

Kadakia 2007

Barragan-Hervella 2008

GRECMIP 2008

......

THE GRECMIP

EXPERIENCE

Minimal invasive forefoot

surgery= 2 tools

Percutaneous

Arthroscopy

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MIS Equipment

basic instrumentation

baever blade holder

Micro-drill & burrs

Arthroscopy

4 mm, 30 scope

4 mm shaver blade

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Surgical Technique

dressing

To maintain the osteotomy without

fixation

Dressing for 15 days

Traditional perspective (lateral release)

Capsulotomy

Bunionectomy

Osteotomy (distal, proximal)

Fixation

Capsulorraphy and tensioning

Arthrodesis (MP and Lapidus)

etc.....

Isham reverdin

Done at the begining

not popular any more

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Hybrid surgery (MIS Chevron)

Percutameous Chevron

Same principal than the Chevron Limitided bunionectomy The release is limtided FIXATION

Proximal osteotomy

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Lapidus

Arthroscopic MTP release

MIS surgery of the fore foot

Lateral metatarsal bone

HALLUX VALGUS:

First Phalanx

M1

EfficiencyDIFFICULTY

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Minimal invasive surgery for hallux

valgus

At list same result

Same quality of correction (fixation)

BUT......

No comparative study

With selection of the patients

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Treatment algorithm of HalluxValgus

Dr. Xavier Martin Oliva

Barcelona University

Surgical treatment goals

Good alignment

Normal articular relationship

- with no pain

- sufficient mobility

Proper weight bearing of the 1st ray

Joint stability and hallux strength

Avoiding complications recurrence of deformity

Surgery When to operate?

Pain, in bunion and metatarsal

Difficulty with footwear

But remember, we should never operate for cosmetic reasons alone

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Examination

Age Forefoot morphotype Lesser toes MTP dislocation Metatarsal cuneiform instability Where does it hurt ?

Metatarsalgia MTP joint

XR Dorso plantar in weight bearing

- Degenerative arthritis of MP joint- Congruence of MTP joint- Lenthening of the first metatarsal- Metatarsal cuneiform articulation- Sesamoideal position

XR Dorso plantar in weight bearing

Metatarsal-Phalangeal Angle (

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1.- Techniques for the metatarsal

DSTP, especially in those cases that havejoint subluxation

Reposition 1st MT head over sesamoids with

an osteotomy that moves 1st MT- laterally

- plantar

- Internal fixation ( Osteosynthesis)

Lateral relaese

Osteotomy, How far can we displace?

< 16 I.M.A. Distal Osteotomy

> 16 I.M.A. Diaphyseal Osteotomy or

Proximal Osteotomy

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Choosing our osteotomy?

Moderate deformities

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To correct the DMAA Biplanar Chevron

We carry out in the dorsal limb of the osteotomy a medially based wedge

Severe deformities > 16 IMADiaphyseal Ostetomy

Diaphyseal Osteotomy

most popular: Scarf, Ludloff, long chevron

Correction of the DMAA also possible

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Scarf

We can achieve

Translation

Rotation

If necessary (Lengthening)

(Shortening)

Scarf

plantar displacement

Other Diaphyseal OsteotomiesLudloff (1918) Long Chevron Osteotomy, Short Scarf

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Proximal OsteotomySevere deformities >16 IMA

Proximal osteotomy

proximal OT

Opening wedge

Closing wedge

Crescentic

Chevron

Disadvantages:

1. Not correct the DMAA

2. more unstable

But remember!!!with ostetomies

- Not to elevate

- Not Cause an excessively shorten the 1st MT

- The correction of the IMA, is with osteotomynot with the capsular closening

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2.- When are Phalangeal Techniques indicated?

Egyptian foot

Hallux valgus interphalangeus

In cases of elevated DASA

2.- Phalangeal Techniques

AKIN osteotomyRemoval of a medial wedge to correct the

valgus angulation

Staple or screw

When is MTP arthrodesis advisible ?

Degenerate/ painful 1st MTP joint

Severe valgus deformity (IMA > 200; valgus > 500 ?)

Unsuccessful previous surgery

Rheumatoid arthritis

Neuromuscular imbalance

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Arthrodesis MTP

Position (20 dorsiflexion)

Compresin

Are there indications for Lapidus?

1st TMTJ fusion

Indications:

Severe deformities

Painful first TMTJ arthritis

Hypermobility TMT joint (HV Combined with flatfoot correction)

The goal is to restore weight-bearing of 1st

ray and also try to reduce the metatarsalgie if

the patient had

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H.V.+ Metat+ Inest T.M.

Should Bunionectomy be carried out as stand alone surgery?We do not recommend it

it usually has a disappointing result

Resection arthroplasty?

(Keller)

Recurrent deformity in up to 50%

Less weightbearing through 1st ray

Lateral transfer metatarsalgia (20%)

Excessive resection can cause a floppy hallux

Insufficient resection can cause painful bone contact

nowadays the Keller procedure is only advised for elderly people with low functional demands

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M.I.S.

RememberIt is still a distal osteotomy,

6 mm max of (safe) correction

Only indicated in moderate deformities 160 : diaphyseal (Scarf) or proximal osteotomy or Lapidus

Abnormal DMAA : do not use proximal osteotomy

Extreme IMA or HV angle

or 1st MTP arthritis: Arthrodesis

1st TMT Hypermobility : Lapidus

Take home message

We must only treat symptomatic H. Valgus

The objective is to correct the Metatarso Phalangeal Angle(HVA), IMA, DMAA

Appropriate M1head re-positioning, by getting the head back over the sesamoids

Good osteotomy stability aids rapid healing and early weightbearing

We must carry out accurete osteotomies and perfectostheosynthesis

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Th. LeemrijseFoot and Ankle Institute

Brussels

B. Devos Bevernage ,P. Maldague,V. Gombault,

P-A Deleu

Hallux valgus surgery

How to manage complications

Cause of failure

Error of concept

Wrong indication

Technical error

The technic is performed badly

Reccurence, relaese

Over correction

Aspecific complications

Necrosis

Non Union

Infection

Analysis of the

symptoms Clinical evaluation

- Joint mobility and pain MTP1

- Reducibility of MTP1

Pain : Joint evaluation

Stiffness : Soft tissue evaluation

- Analysis of the lateral rays

Instability of MTP, luxation, reducibility

Claw toes

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Surgical decision

is a clinical

indication

What is the place of the

radiology ?

Element of

reflection and

planning

Example

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Example

the metatarsus varus

congruent

16 20


congruent

Congruent DMAA 30 Instability, DMAA 1

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congruent

Cause of failure

Error of concept

Wrong indication

Technical error


Reccurence, relaese

Over correction

Complications

Necrosis

Non Union

Infection

Relaese,

always a difficult step,

between excess and deficiency

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Example 1 of technical error

Example of technical error

Six weeks

Instability of the

ORIF

Example of technical error

Revision by a new osteosynthesis

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Simple hallux valgus


Post-operative X Ray

Poor stability

Inadequate ORIF


3 Months, total recurrence of the deformity

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Good indication

but the technic is performed

badly

Example, scarf in situ

or scarf without translationOsteotomy of P1 ?, Weil ? Freiberg ?

Fusion of the SCARF

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Fusion of the SCARF,

Fusion of P1 with an overcorrection in the phalanx,

Overcorrection leads to a sliding effect and a reccurence

of the deformity

Revision by MTP fusion

With poor stabilityEvolution to non-union

MTP Non-Union

Metatarsalgia

Revision of the MTP fusion by

a stable ORIF

P1 shortening of the second ray

Weil 3,4 for the metatarsalgia

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Be careful with the overcorrection

in the phalanx

sliding effect

by the obliquity

of the joint

Troughing effect and fracture

of the metatarsal head

Osteoporotic boneTechnical error

Scarf osteotomy for hallux valgus repair: the dark side. Coetzee, FAI 2003

Modifications of the scarf osteotomy,Lowering and distal osteotomy in the head

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A B

Scarf osteotomy without internal fixation to correct hallux valgus. Leemrijse OTSR 2012

Scarf without fixation

Increases the range

of translation

Decreases the risk of

fracture of the

metatarsal

Example of scarf revision

3 weeks

Reconstruction and results

Revision by dorsal plate One year, results of both side

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How to revise ?

Revision of the

osteotomy

Arthrodesis

Distraction

arthrodesis

Reconstruction for

overcorrection

Failure Chevron, MIS surgery

Painfull joint after

MIS surgery

Revision by open surgery

New scarf with derotation of the joint

Distraction arthrodesis

Failure of the first ray

Complex reconstruction after

Infection, bone loss, Keller.

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Revision after MIS surgery

Distraction-arthrodesisCortico-spongious bone from

the iliac crest

Bone distraction or fusion with Weil ?

Prevents metatarsalgia

Decreases the risk of non-union after

bone bloc distraction

Risk of stifness for the lateral ray

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Overcorrection

Etiology

Iatrogenic hallux varus

Multi-factorial

excessive release = insufficiency

Search for more specific causes to guide a possible surgery

Algorythm

Early, reducible

IP flexible

Young

Delayed, stiff

Coecker deformity

Old patient

Bone loss

Ligament reconstruction

Transfer of the Extensor of 2nd Toe

(Diebold)

Interosseous transfer (Valtin)

Reverse transfer of the abductor

hallucis tendon (Leemrijse)

Ext Hallux Transfer + IP fusion

MTPArthrodesis

Reconstruction, buttress

Hallux varus : classification and treatment, Devos, Leemrijse ;Foot Ankle Clin. 2009 Mar;14

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Reverse transfer of the abductor

hallucis tendon

A new surgical procedure for iatrogenic hallux varus: reverse transfer of the abductor hallucis tendon:

a report of 7 cases. Leemrijse T, Acta Ortho Belgica, 2008

reverse transfer of the abductor

hallucis tendon

Example

5 years evolution

Cause of failure

Error of concept

Wrong indication

Technical error


Reccurence, relaese

Over correction

Aspecific complications

Necrosis

Non Union

Infection

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Conservative surgery and specifics

complications

Distal osteotomy

-Reverdin (per-cutaneous techn.)-Chevron

-Bosch

Disto-diaphyseal osteotomy

- Scarf

- L osteotomy

-Ludloff (but pronating effect)

Proximal osteotomy

- Cressentric

- Lateral closing wedge

Bipolar disto-proximal osteotomy

- Lapidus

Necrosis

Non Union

Mal Union

Necrosis

Mal Union

Non Union

Elevation

Example of complications

after Scarf osteotomy

Example of complications

after Scarf osteotomy

First revision by de-scarf and P1

Non Union, overcorrection of P1

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Complex problem

40 Y old female

Non- and mal-union of M1

Overcorrection of P1

Reconstruction of M1 with bone graft,

Lateral ligamentoplasty, Correction of P1

One year after reconstruction

ROM 10/0/80

Reconstruction after

Avascular Necrosis

Preoperative Xray Necrosis Fusion of the MTP1

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Septic problem,

two-stage procedure

Resection of the septic bone, a ciment spacer with antibiotics

Reconstruction with graft

and allograft at 6 weeks

Fusion at 6 months

Conclusion

Why your correction failed ?

Error of concept, wrong indication ?

Technical problem ?

If the MTP joint is flexible and painfree,

we can propose a reconstruction

If the MTP joint is stiff or painfull, we

always propose an arthrodesis

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Thank you

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