Updated: May 3 2024
Hallux Valgus
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Hallux Valgus, commonly referred to as a bunion, is a complex valgus deformity of the first ray that can cause medial big toe pain and difficulty with shoe wear.
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Diagnosis is made clinically with presence of a hallux that rests in a valgus and pronated position. Radiographs of the foot are obtained to identify the severity of the disease and for surgical planning.
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Treatment can be nonoperative with shoe modifications for mild and minimally symptomatic cases. Surgical management is indicated for progressive deformity and difficulty with shoe wear.
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Epidemiology
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Demographics
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occurs in ~23% of patients 18 to 65 years old
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more common in women (up to 15:1)
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up to 30% of females
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Risk factors
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intrinsic
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genetic predisposition
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70% of patients with hallux valgus have family history
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increased distal metaphyseal articular angle (DMAA)
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ligamentous laxity (1st tarsometatarsal joint instability)
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convex metatarsal head
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2nd toe deformity/amputation
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pes planus
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rheumatoid arthritis
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cerebral palsy
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extrinsic
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shoes with high heel and narrow toe box
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Etiology
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Two forms exist
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adult hallux valgus
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adolescent & juvenile hallux valgus
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Pathoanatamy
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valgus deviation of phalanx promotes varus position of metatarsal
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the metatarsal head displaces medially, leaving the sesamoid complex laterally translated relative to the metatarsal head
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sesamoids remain within the respective head of the flexor hallucis brevis tendon and are attached to the base of the proximal phalanx via the sesamoid-phalangeal ligament
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this lateral displacement can lead to transfer metatarsalgia due to shift in weight-bearing
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medial MTP joint capsule becomes stretched and attenuated while the lateral capsule becomes contracted
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adductor tendon becomes deforming force
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inserts on fibular sesamoid and lateral aspect of proximal phalanx
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lateral deviation of EHL further contributes to deformity
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plantar and lateral migration of the abductor hallucis causes muscle to plantar flex and pronate phalanx
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windlass mechanism becomes less effective
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leads to transfer metatarsalgia
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Associated conditions
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hammer toe deformity
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callosities
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pes planus
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associated with deformity progression
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Marfan syndrome
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Ehlers-Danlos syndrome
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Juvenile and Adolescent Hallux valgus
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factors that differentiate juvenile/adolescent hallux valgus from adults
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often bilateral and familial
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pain usually not primary complaint
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varus of first MT with widened IMA usually present
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DMAA usually increased
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often associated with flexible flatfoot
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complications
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recurrence is most common complication (>50%)
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overcorrection
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hallux varus
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Differential diagnosis
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gout
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hallux rigidus
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rheumatoid arthritis
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turf toe
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hallux valgus interphalangeus
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Anatomy
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Pathoanatomy cascade
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Osteology
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valgus deviation of great toe and varus deviation of first metatarsal
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sesamoids displace lateral to metatarsal head
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loss of the windless mechanism results in transfer metatarsalgia
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Musculature
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muscles forming the plantar plate
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abductor hallucis
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flexor hallucis brevis
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flexor hallucis longus (becomes deforming force)
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adductor hallucis (becomes deforming force)
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Presentation
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History
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slowly progressing deformity
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pain with ambulation
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Symptoms
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presents with difficulty with shoe wear due to medial eminence
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pain over prominence at MTP joint
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transfer metatarsalgia
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compression of digital nerve may cause symptoms
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Physical exam
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Hallux rests in valgus and pronated due to deforming forces illustrated above
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examine entire first ray for
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1st MTP ROM
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1st tarsometatarsal hypermobility
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MTP crepitus and grind test
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callous formation
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sesamoid pain/arthritis
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evaluate associated deformities
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pes planus
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lesser toe deformities
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midfoot and hindfoot conditions
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Imaging
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Radiographs
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recommended views
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standard series should include weight bearing AP, Lat, and oblique views
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optional views
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sesamoid view can be useful
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findings
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lateral displacement of sesamoids
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joint congruency and degenerative changes can be evaluated
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radiographic parameters (see below) guide treatment
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Radiographic Measurements in Hallux Valgus
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Measurement
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Importance
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Normal
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Hallux valgus (HVA)
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Long axis of 1st MT and prox. phalanx
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Identifies MTP deformity
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< 15°
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Intermetatarsal angle (IMA)
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Between long axis of 1st and 2nd MT
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Identifies deformity of the metatarsal
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< 9 °
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Distal metatarsal articular (DMAA)
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Between 1st MT axis and line through base of distal articular cap
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Identifies MTP joint incongruity
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< 15°
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Hallux valgus interphalangeus (HVI)
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Between long axis of distal phalanx and proximal phalanx
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Predisposing factor for hallux valgus
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< 10°
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Metatarsus adductus angle
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Angle between the second metatarsus and the longitudinal axis of the lesser tarsus (using the 4th or 5th metatarso-cuboid joint as a reference)
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Predisposing factor for hallux valgus
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< 10°
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Treatment - Adult Hallux Valgus
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Nonoperative
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shoe modification/ pads/spacers/orthoses
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indications
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first line treatment
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orthoses more helpful in patients with pes planus or metatarsalgia
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Operative
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surgical correction
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indications
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when symptoms persist despite shoe modifications
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do not perform for cosmetic reasons alone
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technique
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soft tissue procedure (modified McBride)
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indications
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only for mild disease (IMA < 11 degrees, HVA < 35 degrees)
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typically performed in combination with an osteotomy (almost never alone)
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usually in patients 30-50 years of age
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outcomes
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no studieshaveassessed deformity correction of modified McBride alone
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akin osteotomy
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indications
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hallux valgus interphalangeus
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congruent joint withDMAA <10°
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as a secondary procedure if a primary procedure (e.g., chevron or distal soft-tissue procedure) that did not provide sufficient correction due to a large DMAA or HVI
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some authors perform Akin together with/at the time of proximal osteotomy+distal soft tissue correction because this results in progressive increase in HVI
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outcomes
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improves pain, radiographic outcomes, and PROMs
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distal osteotomy
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indications
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mild disease (HVA < 30°, IMA < 13°)
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unable to correct pronation deformity
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outcomes
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chevron osteotomy outperformed nonoperative treatment in an RCT
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proximal or combined osteotomy
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indications
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proximal osteotomy: moderate disease (HVA >25°, IMA >13°)
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double osteotomy:severe disease (HVA 41-50°, IMA 16-20°)
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outcomes
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after scarf osteotomy, decrease in VAS pain of 5.8 to 1.1 and improvement in IMA from 13 degrees to 5.6 degrees
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1st TMT arthrodesis (Lapidus)
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indications
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severe deformity (HVA > 40 degrees, IMA > 20 degrees)
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arthritis at TMT joint or ligamentous laxity
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outcomes
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patient satisfaction of 81% with improvement in HVA and IMA at 24 months
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no difference in radiographic outcomes of lapidus versus distal osteotomy in a RCT
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1st MTP arthrodesis
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indications
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severe deformity (HVA > 40 degrees, IMA > 20 degrees)
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cerebral palsy
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down syndrome
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rheumatoidarthritis
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gout
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MTP arthritis
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outcomes
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~90% patient satisfaction
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MTP resection arthroplasty
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indications
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largely abandoned
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only in elderly patients with low functional demands
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Treatment - Juvenile and Adolescent Hallux valgus
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Nonoperative
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shoe modification
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indications
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pursue nonoperative management until physis closes
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Operative
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surgical correction
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indications
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best to wait until skeletal maturity to operate
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can not perform proximal metatarsal osteotomies if physis is open (cuneiform osteotomy OK)
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surgery indicated in symptomatic patients with an IMA > 10° and HVA of > 20°
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consider double MT osteotomy in adolescent patients with increased DMAA
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technique
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soft tissue procedure alone not successful
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first cuneiform osteotomy used for severe disease with open physis
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similar to adults if physis is closed (except in severe deformity)
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Techniques
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Soft Tissue Procedures
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modified McBride
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goal is to correct an incongruent MTP joint (phalanx not lined up with articular cartilage of MT head)
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rarely appropriate in isolation
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usually performed in conjunction with
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medial eminence resection
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MT osteotomy
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1st TMT arthrodesis (Lapidus procedure)
See AlsoWas ist ein Hallux valgus? -
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technique
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includes
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release of adductor from lateral sesamoid/proximal phalanx
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lateral capsulotomy
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medial capsular imbrication
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(original McBride included lateral sesamoidectomy)
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Metatarsal Osteotomies
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distal metatarsal osteotomy
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distal metatarsal osteotomies include
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Chevron
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medial approach
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L-shaped capsulectomy
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osteotomy cut at 55-60 degrees
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fixation options include single screw or absorbable pin
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biplanar Chevron (corrects DMAA)
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same Chevron osteotomy with addition of
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bone removal from dorsomedial and plantar medial limbs
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oblique medial wedge removed
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Mitchell
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distal 1st MT osteotomy (extra-articular).
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may be combined with proximal phalanx osteotomy (Akin-medial closing wedge osteotomy)
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proximal metatarsal osteotomy
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proximal metatarsal osteotomies include
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crescentic osteotomy
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osteotomy made with crescentic saw blade
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distal fragment rotated laterally
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Scarf
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medial approach to the metatarsal shaft
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metatarsal shaft Z osteotomy
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longitudinal plantar sloping cut
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proximal and distal chevron osteotomies
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can correct deformity and adjust length
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fixation with 2 screws
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Broomstick osteotomy
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Ludloff
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double (proximal and distal) osteotomy
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combines a distal and proximal metatarsal osteotomy
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first cuneiform lateral opening osteotomy
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dorsoplantar periosteal incision
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osteotomy
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parallel to TMT joint through 75% of the cuneiform
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avoid completing the osteotomy laterally due to risk of over lengthening
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osteotomy filled with bone graft
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fixation with plate
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Proximal phalanx osteotomies
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Akin osteotomy
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medial approach to the mid shaft of the proximal phalanx
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medial closing wedge osteotomy
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avoid breaching lateral cortex
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fixation either with staple or screw
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Fusion procedures
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Lapidus procedure (1st metatarsocuneiform arthrodesis with modified McBride)
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Lapidus procedure, in isolation, can fail to correct pronation of the first ray
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performed with either 2 separate incisions or extended medial approach
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medial approach to the metatarsal head
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dorsal approach to the TMT joint
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deformity corrected with adduction, supination, and neutral plantar flexion
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fixation with either screws +/- plate
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MTP Arthrodesis
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medial or dorsal approach can be used
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avoid the EHL and dorsomedial cutaneous nerve
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conical reamers used for joint preparation
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position of toe in
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valgus: 5-10 degrees
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neutral rotation
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dorsiflexion: 5-10 degrees
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may use flat platform to simulate weight bearing
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fixation with screws or plate
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Resection arthroplasty
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proximal phalanx (Keller) resection arthroplasty
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remove base of the proximal phalanx
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can add interposition with allograft
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Surgical Indications for Specific Conditions
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Juvenile/Adolescent with open physis
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First cuneiform osteotomy
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Hypermobile 1st MT
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Lapidus procedure
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DJD
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MTP arthrodesis
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Skin breakdown
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Simple bunionectomy with medial eminenceremoval
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Gout
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MTP arthrodesis
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Recurrence with pain in 1st TMT joint
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Lapidus procedure
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Rheumatoid arthritis
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MTP arthrodesis
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Down's syndrome, CP, Ehlers-Danlos
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MTP arthrodesis
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Surgical Indications for Various Techniques to Treat Hallux Valgus
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HVA
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IMA
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Modifier
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Procedure
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Mild
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< 30°
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< 13°
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Distal MT osteotomy
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Chevronosteotomy
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Biplanar if DMAA > 10° with mod McBride
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Moderate
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30-40°
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13-20°
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Proximal MT +/- distal MT osteotomy
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Chevron/mod McBride+ Akin
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Proximal MT osteotomy and mod McBride
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Severe
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> 40°
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> 20°
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Double osteotomy, DMAA > 15°
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Proximal MT osteotomy plus biplanar chevron, mod McBride
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Lapidus procedure plus Akin
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> 40°
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> 20°
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Elderly/very low demand patient
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Keller resection arthroplasty
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> 40°
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> 20°
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Juvenile/Adolescent with DMAA > 20
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Double osteotomy of first ray
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Various Hallux valgus procedures
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Procedure
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Technique
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Indications
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Complications
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Modified McBride
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Includes release of adductor from lateral sesamoid/proximal phalanx, lateral capsulotomy, medial capsular imbrication
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HVA < 35°
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IMA < 11°
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HVI< 15°
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Recurrence
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Hallux varus
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Original McBride
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Includes lateral sesamoidectomy and has been abandoned
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Not indicated
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Hallux Varus
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Chevron
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Distal 1st MT osteotomy (intra-articular).
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Can perform in two planes (Biplanar distal Chevron)
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Reserved for mild to moderate deformities in adults andchildren
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Biplanar chevron--> corrects increased DMAA
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AVN of MT head
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Recurrence
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Dorsal malunion with transfer metatarsalgia
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Mitchell
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Distal 1st MT osteotomy (extra-articular).
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More proximal than Chevron
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Same as Chevron (rarely utilized)
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Recurrence
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Malunion
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Transfer metatarsalgia
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Akin
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Proximal phalanx medial closing wedge osteotomy
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Combined with Chevron in moderate to severe deformities
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Hallux valgus interphalangeus
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Scarf / Ludloff / Mau
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Metatarsal shaft osteotomies.
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HVA > 25°, IMA > 13°
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DMAA is normal or increased
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Dorsal malunion with transfer metatarsalgia
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Recurrence
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Proximal Crescentic or Broomstick
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Proximal metatarsal osteotomy plus modified McBride
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Severe deformity
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IMA > 13°
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HVA > 25°
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Hallux varus
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Dorsal malunion with transfer metatarsalgia
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Recurrence
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Keller resection arthroplasty
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Includes medial eminence removal and resection of base of proximal phalanx
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Largely abandoned due to complications
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Indicated only in older patients with reduced functional demands
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Cock-up toe deformity
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Poor potential for correction of deformity
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MTP arthrodesis
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HVA > 40 degrees, IMA > 20 degrees
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DJD of 1st MTP
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Neuromuscular conditions
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Painful callosities beneath lesser MT heads
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Lapidus procedure
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First TMT joint arthrodesis with distal soft tissue procedures (medial eminence removal, first web space release of AdH, lateral capsule release)
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Moderate or severe deformity
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Hypermobility of first ray
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Nonunion (may or may not be symptomatic)
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Dorsiflexion of the first metatarsal with transfer metatarsalgia
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First Cuneiform Osteotomy
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Opening wedge osteotomy (often requires autograft)
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Children with ligamentous laxity, flatfoot, and hypermobile first ray
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Adolescent with an open physis
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Nonunion (may or may not be symptomatic)
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Complications
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Recurrence
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incidence
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10-47% risk depending on the procedure performed
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risk factors
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most common cause of failure is insufficient preoperative assessment and failure to follow indications
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e.g., failure to recognize DMAA > 10°
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inadequate correction of IMA
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e.g., failure to do adequate distal soft tissue realignment
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more common in juvenile/adolescent population
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rounded shape to the first metatarsal head
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residual tibial sesamoid lateral displacement
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increased preoperative IMA and HVA
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failure to perform a lateral release of the adductor hallucis tendon
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associated with incomplete reduction of the sesamoids
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diagnosis
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clinical exam and radiographs
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treatment
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pain does not correlate with deformity recurrence
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treat with revision surgery if patient is symptomatic
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Avascular necrosis
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incidence
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rare with modern techniques
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risk factors
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medial capsulotomy is primary insult to blood flow to metatarsal head
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distal metatarsal osteotomy and lateral soft tissue release in conjunction do not increase risk for AVN (Chevron plus lateral release thought to increase risk in the past)
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diagnosis
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clinical exam, radiographs +/- advanced imaging
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treatment
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MTP arthrodesis with or without structural graft
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Dorsal malunion with transfer metatarsalgia
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incidence
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about 5%
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risk factors
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due to overload of lesser metatarsal heads
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risk associated with shortening of hallux MT
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Lapidus
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proximal crescentic osteotomies
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diagnosis
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clinical exam and radiographs
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treatment
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osteotomy to correct deformity
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arthrodesis with bone grafting
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Hallux Varus
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incidence
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6% overall risk after surgery
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risk factors
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overcorrection of 1st IMA
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excessive lateral capsular release with overtightening of medial capsule
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over resection of medial first metatarsal head
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lateral sesamoidectomy
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diagnosis
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clinical exam and radiographs
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treatment
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surgical options for symptomatic patients include
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reveres Scarf, reverse Chevron, reverse Akin
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MTP arthrodesis
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Cock up toe deformity
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most severe complication with Keller resection
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incidence
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up to 41%
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risk factors
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due to injury of FHL
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diagnosis
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clinical exam and radiographs
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treatment
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Z-lengthening EHL
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revision Keller resection
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MTP arthrodesis
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2nd MT transfer metatarsalgia
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incidence
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occurs in up to 50% of hallux valgus patients
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risk factors
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often seen concomitant with hallux valgus
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can occur secondary to malpositioning of MTP fusion
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diagnosis
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clinical exam
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treatment
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shortening metatarsal osteotomy (Weil) indicated with extensor tendon and capsular release
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Neuropraxia
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incidence
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overall risk of nerve injury ~3%
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risk factors
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Painful incisional neuromas after bunion surgery frequently involve the medial dorsal cutaneous nerve (a terminal branch of the superficial peroneal nerve).
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It is most commonly injured during the medial approach for capsular imbrication or metatarsal osteotomy.
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diagnosis
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clinical exam
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treatment
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neuropraxia typically improves over several months
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Nonunion
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incidence
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occurs in ~10% of lapidus and MTP arthrodesis patients
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only ~33% are symptomatic
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risk factors
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arthrodesis procedures
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diagnosis
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clinical exam, radiographs +/- advanced imaging
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treatment
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revision arthrodesis with bone grafting
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Prognosis
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may take 6-12 weeks to return to work
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improvement may take 1year
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dissatisfaction
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10-50% risk after surgical intervention
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not related to surgical outcome
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may be related to unmet expectations
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