Chapter 24: Hallux Valgus &

Related Disorders
Goals of HAV Surgery
Anatomical Facts of the 1st MPJ
Predisposing Factors
Biomechanics
Etiology of HAV
Deformity Types
Radiological Measurements for HAV
Physical Examination
Preoperative Considerations
Arthroplasty Procedures
Capsule-Tendon Balancing Procedures
Implant Arthroplasty Procedures
Arthrodesing Procedures
Proximal Phalangeal Osteotomies
Distal Metatarsal Osteotomies
Proximal Metatarsal Osteotomies
Shaft Osteotomies
Combination Procedures
Other Procedures
Hallux Rigidus and Limitus
Hallux Varus
Hallux Hammertoe
Diff. Diagnosis of Pain in the Sesamoid Area
Complications of HAV Surgery
HAV Procedure Chart and Their Indications
 HALLUX VALGUS AND RELATED
DISORDERS
Goals of Hallux Valgus Surgery
1. Pain free joint
2. IM angle less than 100
3. Congruent joint
4. Good range of motion
5. Sesamoids in good position (TSP 3 or less) 6. Cosmetic result
acceptable

Anatomical Facts of the 1st M.P. J.

1. The articular surface of the base of the proximal phalanx is larger
plantarly than dorsally.

2. The medullary canal of the proximal phalanx Is dorsal to middle of

the proximal articular surface; this is due to the concave nature of
the plantar curvature.

3. The bony prominence on the dorsum of the proximal phalanx is

for the EHB.

4. 1st metatarsal has cristae on the plantars

5. The nutrient foramen on the lateral aspect of the shaft is 2.7cm

from the M.PJ.urface of the head to separate the sesamoids.

6. The epiphysis is on the base, so head osteotomies are permissible

on children; but watch the nutrient artery.

7. The ligaments of the 1 st MPJ are:

a. Medial collateral: intracapsular
b. Lateral collateral :intracapsular
c. Tibial plantar sesamoidal
d. Fibular plantar sesamoidal
e. Tibial sesamoidal: intracapsular
f. Fibular sesamoidal: intracapsular
g. Inter-sesamoidal: intracapsular
h. Deep transverse metatarsal
i. Capsule
8. The capsule itself:
a. The sesamoids are invested in the capsule through which the FHB runs
b. The capsule blends with the periosteum and may be removed easily from
the base with an elevator
c. The capsule is strongly attached to the metatarsal head
d. There are medial and lateral collateral ligaments
9. EHL attaches through the hood ligament and lifts the proximal
phalanx into extention (the EHB is under the hood ligament).

10. The hood ligament attaches the dorsal to plantar structures

11. The capsularis is actually a branch of the tibialis anterior

12. The only structure that never changes is the interosseous

ligament

13. The bunion bump Is the abnormal position of the cartilaginous

surface

14. Blood Supply to the 1st MTP and 1st metatarsal are via the 1st
dorsal and plantar metatarsal arteries and the superficial branch of
the medial plantar artery
Predisposing Factors
1. Biomechanical
a. Primarily genetic in nature
b. Acquired factors

2. Arthritic
a. RA
b. Psoriatic arthritis

3. Neuromuscular
a. Cerebral palsy

4. Traumatic (primarily hallux limitus and hallux rigidus)

5. Genetic:
a. Down's syndrome
b. Ehler-Danlos syndrome
c. Marfan's syndrome

Biomechanics
1. The first metatarsal dorsiflexes due to hypermobility and when
dorsiflexed it also inverts (the 1st ray axis is medial/proximal/dorsal
to plantar/lateral/distal).

NOTE* There is almost no transverse plane motion due to the

2. A foot with horizontal positioning of the axis
a low axis to
the transverse plane gets a small amount of abduction/adduction of
the first ray as does a rectus foot. This type will develop more of a
dorsal bunion. The metatarsus adductus foot with a higher 1st ray
axis gets a more medial bunion.

3. As the 1st metatarsal dorsiflexes and inverts, the hallux which is

held to the ground by muscle power, is everting and dorsiflexing as
well as subluxing laterally due to adduction of the first metatarsal.

4. Due to poor weight bearing of the 1st metatarsal, the second gets
transfer lesions and the 1st develops a dorso-medial metatarsal
head hypertrophy to form a bunion.

5. This is an acquired condition due to abnormal pronation in an

adducted foot type or inflammatory disease of the joint which
changes mechanics and muscle direction around the joint due to
edema.

6. There must be a propulsive phase of gait for HAV to develop.

7. A hypermobile 1st ray is the primary cause due to a pronatory

force and weakening of the peroneus longus.

8. Pronatory problems may develop from neuromuscular pathology,

but a neuromuscular problem may not show bunion development
even with pronation due to poor propulsion.

9. The loss of the normal tibial sesamoid position or excision of the

tibial sesamoid will hasten the development of HAV.

10. Factors that affect the rate of progression of HAV are:

a. The amount of pronation during propulsion
b. The amount of adduction of the forefoot
c. The amount of calcaneal eversion (a flatter STJ axis increases eversion and
hastens HAV development)
d. The amount of STJ and MTJ subluxation
e. The presence of inflammation of the 1 st MTPJ
f. The angle and base of gait
g. The stride length (amount of time in propulsion)
h. Obesity
i. Terrain
h. Poor fitting shoe gear

11. If you see HAV prior to age 3-4 suspect an anatomical anomaly
or neuromuscular problem (there is no active propulsion In this age
group)

12. The hallux is prevented from following the metatarsal head due
to the need for ground purchase, therefore, at the 1st MTPJ torque is
formed to sublux the joint. A normal 1st MTPJ does not have frontal
plane motion, so as the metatarsal dorsiflexes and inverts, the
stable hallux dorsiflexes and everts, and subluxation begins.

13. The hallux loses stability at weightbearing due to the

hypermobile base, causing the lesser mets to carry more of the load.

14. Lateral subluxation of the hallux occurs due to weakening of the

peroneus longus and dorsiflexion of the metatarsal with the
transverse head of the adductor pulling on the hallux and enhancing
its lateral migration.

15. The sesamoids migrate laterally to change the abductory forces

on the hallux. This causes bony adaptation on the plantar metatarsal
head so that the crista is gradually worn away, to allow further
lateral shift of the sesamoids.

16. Bony adapation shows medial deposition and lateral absorption

of the metatarsal head.

17. The metatarsal head develops a groove (sagittal groove) where

the phalanx now articulates. This allows for normal
plantar/dorsiflexion in
the plantar part of the metatarsal head, but on the dorsal part you
get abduction and eversion due to the new bony adaptation.

18. As metatarsus adductus increases, HAV develops. The

angulation in the met-cuneiform joint helps this progression.

19. If the bunion develops lateral pressure on the lesser toes look
for:
a. Onychocryptosis of the fibular nail groove of the hallux
b. Interdigital soft corn
c. Hammertoes and underlapping digits.

20. A stable hallux against the second digit causes the retrograde
muscle contraction to cause the 1st ray to adduct, therefore, the IM
angle Increases (this causes the met-cuneiform split).

21. As long as you have a propulsive gait the HAV worsens. It stops
when you have a plodding type of gait.

22. After a long time of dorsiflexion of the 1st ray, there is an

adaptation of the 1st ray into a position of elevatus that is
somewhat rigid.

23. The medial branch of the superficial peroneal nerve may develop
neuritis due to trauma.

24. Rheumatoid complications that help the development of HAV

are:
a. Intra-articular swelling causes the long tendons to migrate laterally
b. Intrinsic muscle spasm causes the sesamoids to migrate laterally
c. Pain of the lesser metatarsals may cause excess pronation to get the
weight off the painful area

Etiology of Hallux Abducto Valgus

1. Excessive pronation during stance phase results in
a. Hypermobile 1st ray due to loss of proper P. longus mechanics
i. Results in dorsiflexion/varus of the 1st MTPJ and mild adduction of the
metatarsal
ii. A stretching and loosening of the medial sesamoid ligaments and adaptive
tightening of the fibular sesamoid ligament (also some lateral subluxation of
the hallux)(GRADE 1)
iii. Valgus hallux due to continuation of 1st metatarsal medially and abnormal
lateral tracking of the sesamoid
iv. Crista starts to erode and transverse adductor helps pull hallux over along
with increased ground reaction force from hypermobile first ray
v. Abductor hallucis becomes displaced plantarly, as the crista continues to
erode and the sesamoids move laterally to change the mechanical advantage
of the adductor hallucis and flexor hallucis brevis to decrease the stability of
the hallux
vi. The hallux moves laterally and buttresses the second toe (GRADE 2)
vii. The IM angle becomes increased due to the retrograde force from the
abductor hallucis position (GRADE 3)
viii. The PASA increases adaptively, the crista erodes more as the joint pain
increases and the lateral metatarsal head degenerates
ix. Eventually there is complete erosion of the crista and fast exacerbation of
the HAV deformity
x. The hallux becomes subluxed and dislocated on the 1st metatarsal
(GRADE 4)
xi. Marked HAV deformity

NOTE* The longer it takes to change from one stage to the next, the less
severe the resultant deformity will be
b. Tibial sesamoid tracking problems
i. Crista erodes

NOTE* When the crista erodes you can transfer the adductor hallucis to the
tibial sesamoidal ligament to hold the sesamoids in the proper position

ii. Chondromalacia
iii. Osteoarthritis
iv. Fibrosis of the 1st MTPJ
v. Marked HAV deformity
1. Structural Deformity (bony): A deformity in which there is osseous
change in either the PASA the DASA or both (so either the PASA or DASA are
abnormal). The structural deformity has as its characteristics the congruous
joint. The HA deformity is also equal to the summation of the PASA and the
DASA.

2. Positional Deformity (soft tissue): There is an abnormality in the HA

angle. The PASA and DASA are normal. The joint is either deviated or
subluxed. The summation of the PASA and DASA are less than the HA angle.
3. Combined Deformity: Has elements of both structural and positional
deformities. Either the PASA or the DASA or both are abnormal, and when
added together they do not equal the HA angle. The joint is either deviated or
subluxed.

NOTE* Structural deformities may exist at levels other than the 1st
Radiological metatarsophalangeal joint and contribute to the
metatarsophalangeal deformity
Measurements For HAV
1. Hallux abductus interphalangeal angle = normal 0-10°
i. When abnormal, a structural abductus deformity of either the head of the
proximal phalanx or the distal phalanx base or both may be present.
However, the abnormality is most often seen at the head of the proximal
phalanx, and regardless of the site is corrected via osteotomies. Valgus
rotations falsely affect the HAI

2. Hallux abductus angle= normal 15°

i. Significance: This measurement is the prime method of quantifying the
abductus in a HAV condition. Can be either structural, positional, or combined

3. Distal NOTE* The HA angle is a combination of PASA+DASA+JOINT DEVIATION

articular
set angle= normal 0-10°
i. Significance: DASA is a structural component of HA. When abnormalities
are detected with this measurement, osteotomies of the hallux proximal
phalanx are indicated

4. Proximal articular set angle= normal 7.5°

i. Significance: PASA represents a structural component of hallux abductus,
and is an attempt to quantify the structural adaptation of the 1st MTPJ
 NOTE* Situations exist where PASA of 12° is normal.
Functional vs. Dysfunctional PASA:
PASA remains functional so long as PASA is less than the IM angle or
Dysfunctional PASA= PASA - IM
Therefore, if the PASA exceeds the IM angle, the PASA should be corrected by
at least the number of degrees difference between the two angles. In cases
that require correction of the IM angle by base/shaft procedures, the
anticipated postoperative IM angle must be determined.
5. 1st Metatarsal Declination Angle = normal 15-20°
i. Significance: Gives information regarding sagittal plane position

6. Joint position: The 1st MTPJ is either parallel, deviated or subluxed

7. Metatarsus primus adductus angle (intermetatarsal angle)=

normal 8-12° in the rectus foot and 8-10° In the adductus foot
i. Significance: When the angle is abnormally increased the condition may be
termed metatarsus primus adductus. The MA angle may determine the
significance of the IM angle. Adducted foot types require correction of the IM
at a lesser angle, therefore, the adducted foot type will require a base/shaft
procedure at lower degrees than a rectus foot type.

8. Metatarsus adductus angle (MA)= normal under 15°

i. Significance: The MA determines the significance of other measurements
(IM, HA, and PASA). MA is influential in the choice of procedures. MA feet
tend to develop HAV more rapidly than rectus feet

9. Metatarsal protrusion distance (MPD)= normal +2 mm. to -2 mm.

i. Significance: An excessively long metatarsal may be the etiologic factor in
hallux limitus or HAV, and an excessively short metatarsal can cause 2nd
metatarsalgia. Procedures should be selected that avoid shortening the MPD
or if unavoidable combine with a plantarflexing procedure

10. Tibial sesamoid position= normal 1-3

1. Significance: TSP documents the stage of progression of HAV. The plantar-
axial view is best to determine the exact position of the sesamoids with
regard to their position in their respective grooves

11. First metatarsal base gapping= normal Is less than a 2mm gap

Physical Examination
1. The foot of the patient is evaluated on a weightbearing and on a
nonweightbearing attitude:
a. Weightbearing:
i. EHL contracture
ii. Hallux purchase
iii. Hallux position with regard to resting calcaneal stance
position/neutral calcaneal stance position
iv. Radiographic analysis (including mineralization, osteophytes, and
cysts)
b. Nonweightbearing:
i. 1st ray ROM
ii. Manual reduction of IM
iii. 1 st MTPJ ROM, quality of motion, and axis of motion
iv. Location of pain
v. Location of bunion
vi. Hallux position relative to 2nd toe
vii. Calluses
viii. EHL contracture (rare)
ix. Associated deformities (2nd hammertoe, etc.)
x. Trackbound (position the toe in a rectus position and dorsiflex and
plantarflex- there is inability for adequate ROM with resultant pain)

2. A complete vascular, neurologic, dermatological, and

biomechanical examination should additionally be performed.

Preoperative Considerations (planning)

1. Decide upon the right choice of procedure based upon radiological
and clinical assessment
2. Remember that capsulotomies will not correct a structural
deformity
3. Use a template in preoperative planning if you are unsure
4. Use fixation method which you are most comfortable with and
that will provide the best stability
5. Try to minimize complications with proper execution of procedure
and normal postoperative recovery period
6. Review the risks and consequences thoroughly with the patient

Arthroplasty Procedures
1. Keller
a. Indications
i. HAV with degenerative joint disease
ii. Second and third degree hallux rigidus

Note* Second degree hallux rigidus

a. Established arthrosis
b. Painful ROM
c. Loss of central articular cartilage
d. Proliferation and enlargement of peripheral osteophytes
e. Ankylosis
Third degree hallux rigidus
a. Complete disappearance of the joint space
b. Ankylosis of the MTPJ
c. Sign (cant hypertrophy of the joint
d. Irregular hypertrophic osteophytes
iii. Geriatric bunion
b. Advantages
i. Relief of pain
ii. Establish/restore 1st MTPJ ROM
iii. IM reduction of 3-5°
iv. Minimal rehabilitation
v. Early return to shoes
c. Disadvantages
i. Short hallux
ii. Loss of purchase
iii. Sesamoid retraction
iv. Altered gait
v. Limited ROM
vi. Limited IM reduction
d. Complications
i. Hallux extensus
ii. Loss of purchase
iii. Retraction of the hallux with loss-of joint space
iv. Metatarsalgia/stress fracture 2nd metatarsal and/or 3rd metatarsal
v. Edema/telescoping of the hallux base
e. Modifications
i. Reattachment of the flexor brevis
ii. EHL lengthening
iii. Purse-stringing the capsule
iv. Capsular flap
v. K-wire splinting
vi. Implant arthroplasty
vii. Anchor the FHL to the sesamoids and the base of the proximal
phalanx

2. Hueter: Complete resection of the 1 st metatarsal head, usually

performed as part of the Hoffman-Clayton

3. Mayo: Resection of one-quarter inch of the 1 st metatarsal head and

medial eminence.

4. Stone: Remodeling of the 1st metatarsal head. An oblique plane resection

of the head, leaving a three-quarter inch space at the 1st MTPJ

5. Regnauld: Resection of a portion of the base of the proximal phalanx with

the fashioning of a "hat-shaped". inverted, or "cork shaped" autogenous
graft. This procedure besides shortening a long proximal phalanx and
increasing ROM in the presence of DJD, will also correct a mildly abnormal
DASA, mildly abnormal HIA by angling the surface of the base of the proximal
phalanx.

6. Valenti "V" Resection:

a. Indications
i. Hallux valgus
ii. Hallux limitus in the elderly
iii. Nonactive patient
iv. Hallux rigidus in cases of implant salvage
b. Surgical technique: A "V" shaped osteotomy at the head of the 1st
metatarsal and the base of the proximal phalanx (a 45° angular resection of
the metatarsal and phalanx) on the dorsal and plantar aspect. A dorsal U-
shaped capsular flap perserves intrinsic attachments at the base of the
proximal phalanx. EHL lengthening
c. Advantages:
i. Restoration of ROM
ii. Preservation of hallux purchase
iii. Immediate weightbearing

Capsule-Tendon Balance Procedures

1. McBride: Originally described with an incision lateral to the EHL, excision
of fibular sesamoid, medial eminence removed, adductor tendon transferred
to the lateral side of the metatarsal head, and the medial capsule and
adductor tendon shortened (several modifications to date)
a. Criteria: Structural deformities of the 1st ray should not be present unless
corrected by other procedures
i. Normal HIA
ii. Normal DASA
iii. Normal PASA
iv. Normal IM angle
v. Hypertrophied medial eminence
vi. Deviated to subluxed 1st MTPJ
vii. Deviation of sesamoids >4 (fibular sesamoid may be arthritic)
viii. Increased HA angle
b. Surgical technique:
i. A 6 cm. dorsolinear incision parallel and medial to the
ii. Inverted "L" capsulotomy
iii. Medial eminence removed
drilling with .045 k-wire to produce fibrocartilage
iv. If erosions in the cartilage are found then perform subchondral
v. Removal of the fibular sesamoid only if it is acting as a deforming force
and an adductor transfer is not being done (just freeing the attachments is
not enough)
vi. Release OR transfer of the Adductor tendon
 The tendon is pulled over the 1st metatarsal neck and sutured into the
medial capsule. This repositions the sesamoids
 The tendon is tied into the metatarsal neck and into the medial capsule
(this helps close the IM angle
vii. Cut EHB

NOTE Do not cut the adductor and remove the fibular sesamoid, you will
predispose to a hallux varus
b. Contraindications:
i. Structural deformities
ii. Hallux rigidus
iii. DJD
c. Complications:
i. Stiff joint
ii. Undercorrection of the deformity
iii. Hallux varus

2. Silver:
a. Indications:
i. Hypertrophied medial eminence
ii. Mild HA angle
iii. No other structural abnormalities
b. Surgical technique: Removal of the medial eminence
c. Complications:
i. Stiff joint
ii. Increase on HA angle following surgery due to cutting of medial stabilizing
structures

3. Hiss: Like the Silver, plus the abductor hallucis is repositioned on the
medial aspect of the 1st MTPJ (trying to balance the abductory component)

Implant Arthroplasties

Implants utilized for the 1st MTPJ are static spacers which relieve pain, allow
for limited painless motion, and give some internal stability to the joint.
Ideally, biocompatibility requires the implant to be:
 Chemically inert or free from biodegradation and sterile
 capable of withstanding stresses imposed upon it
 Durable or possess an integrity of structure without modification of its
physical properties because of the biological environment
 Non-irritation, eliciting only a benign local tissue response
General indications for 1 st MTPJ implant arthroplasty:
 Hallux valgus with subluxation and painful limited ROM
 End stage hallux rigidus
 Revisional surgery
 Rheumatoid arthritis
 Painful DJD
 Gouty arthrosis/arthritis
 Osteochondral fractures
 Intra-articular fractures
General contraindications for Implant arthroplasty:
 infection
 Salvagable joint
1. Hemi implant:
a., Criteria:
i. Joint pain
ii. Adequate bone stock of the proximal phalanx
iii. Normal IM angle unless reduced by another procedure
iv. Normal articular cartilage of the head of the 1st metatarsal (no DJD)
v. Adequate capsular tissue to allow for implant coverage
b. Complications:
i. Implant instability: Pistoning can occur from removal of too much bone as
well as axial rotation of the implant
ii. Implant failure: Mechanical stress can produce microfragmentation with
migration of the silicone particles into the lymphatic system. With this there
will be obvious loss of function and possible deformity. Not so with titanium
implants
iii. Foreign body reaction: lymphadenopathy which is reminiscent of
metastatic Ca clinically
iv. Osteochondritis dessicans: From excessive stripping of the periosteum
and resultant avasular necrosis
v. Detritic synovitis reaction: The surgical area will become red and swollen
with a chronic low grade pain. Once infection is ruled out the patient can be
treated with NSAIDS or remove the implant device (less chance of this with
titanium implants)
vi. Infection: Implant must be removed and not replaced for at least 6 months
to 1 year. If gram negative infection was present, implant should not be
replaced for longer period of time if at all
vii. Pistoning of the implant into cancellous bone (if implant chosen is too
small)
viii. Chronic edema
c. Contraindications:
1. DJD of the 1st metatarsal head contraindicates a hemi implant
ii. Severe osteoporosis of the involved bones
iii. Inability to correct a high IM angle
iv. History of a prior joint infection within the last 6 months
v. History of allergic reaction to implant material

2. Hemi-angled Implant (Well): for accommodation up to 15° lateral

deviation of the 1st metatarsal articular surface

NOTE* This device eliminates the "lateral gap sign" as seen with the standard
hemi-implant, which is. the nonarticulation between hemi- implant and
lateral metatarsal articular surface

a. Criteria: As above plus

i. Abnormal PASA
ii. Revisional surgery for hallux varus (reverse the implant)
b. Complications: As above
3. Total Swanson Implant: Manufactured by Dow-Corning Wright,
comes in 7 anatomical sizes plus the addition of titanium grommets.
A central hinge in a "U" configuration allows for dorsiflexion. An
intramedullary stem on both sides of the implant stabilizes the
implant within the medullary canals. There is no angulation of the
stems in the sagittal or transverse plane. There is a short stem
version available in 6 sizes
a. Criteria: As above plus
i. Good bone stock of the 1 st metatarsal head
ii. Degenerative changes of the 1 st metatarsal head iii. Abnormally low metatarsal
declination angle
b. Complications: As above
c. Contraindications: As above

4. Total Lawrence Implant: Manufactured by Sutter Biomedical and is marketed In

4 sizes. The proximal stem is angled 150 dorsally in the sagittal plane to allow for
normal 1 st metatarsal declination, without sacrificing excursion of the implant to
compensate for this. It is designed for a ROM of 85° of dorsiflexion
a. Criteria: As above plus
i. Normal 15° declination angle
b. Complications: As above
c. Contraindications: As above

5. Total LaPorta Implant: Manufactured by Sutter Biomedical, comes

in right, left, and neutral, referring to the deviation of the stems on
the transverse plane. The right and left implant show a 100
angulation (lateralward) on the transverse plane. It is designed for a
ROM of 60°
a. Criteria: As above plus
i. Normal 150 declination angle or use a neutral LaPorta implant for an
abnormally low metatarsal declination angle.
ii. Can be used for a mildly elevated IM angle without performing a procedure
to reduce it, due to the 100 transverse plane abduction built into the
proximal stem
b. Complications: As above
c. Contraindications: As above

6. Total Bioaction Implant: Newer two-piece device made of high density

polyethelene, cobalt steel and titanium.
a. Criteria: As per total Swanson implant
b. Complications: As above
c. Contraindications: As above

7. Kinetic Great Toe Implant: Two piece titanium/cobalt chromium

implant with an anatomic dorsal flange providing an anatomic range
of motion
a. Criteria: as above
b. Complications: as above
c. Contraindications: as above

NOTE* This device also may be used to replace previous implants that have
failed. This system offers implants that are anatomically and
biomechanically accurate, with instrumentation that is precise to aid in its
installation.
The system consists of four phalangeal components which articulate with all
six metatarsal (three left/three right) components. The metatarsal
component is made from cobalt chromium (CoCr) which is the same
material used for the femoral component of the total knee inn plant. The
phalangeal component is made form titanium alloy as the backing to a high
molecular weight polyethylene bearing surface

NOTE* It is mandatory that all patients after receiving the implant

arthroplasty be advised that prior to any invasive procedure
(medical/ dental) that the patient be given prophylactic
antibiotics, as is the case with all implanted prosthetic devices
Arthrodesis
1. McKeever Type (fusion of the 1st m.p.j.): Originally described as a peg-in-
hole 1st mpj fusion.
a. Criteria:
i. Flail toe
ii. Failed implant arthroplasty
Iii. Arthritis/gout
iv Severe hallux valgus deformity
v. Loss of extensor and/or flexor function
vi. Intra-articular fractures with post-traumatic arthritis
vii. Previously failed bunion procedures
viii. Failed Keller arthroplasty procedure
ix. Prior infection/septic arthritis
x. Hallux limitus/rigidus
xi. Rheumatoid arthritis
xii. Charcot joint/osteoarthropathy
xiii. latrogenic hallux varus
xiv. Tumor
b. Ideal position of fusion
i. Slight dorsiflexion (5-10° from the ground supporting surface)
ii. Slight abduction (parallel to the 2nd toe) or 10-15° on the transverse plane
iii. No frontal plane valgus or varus rotation

NOTE* Position will vary depending on activity, lifestyle, and shoe gear
c. Surgical technique:
i. Cartilage denuding
ii. Metatarsal head resection ( as part of pan-metatarsal head resection)
iii. With bone grafting (i.e. failure of implant cases)
d. Possible ancillary procedures:
i. Tibial or fibular sesamoidectomy
ii. IPJ arthrodesis (most common)
iii. Relocation and arthrodesis of the lesser toes
iv. Possible metatarsal osteotomies
v. Possible Hoffman-Clayton
vi. EHL lengthening
vii. Excision of ipj sesamoid
viii. CBWO/ Lapidus/ OBWO
e. Fixation types:
i. Insertion of crossed .045 k-wires
ii. Monofilament 28 gauge wire loops
iii. 4.0 cancellous screw
iv. 3.5 Cortical screw in a lag technique
v. 2.7 mm. screw in a lag technique
vi. Herbert screw
f. Advantages:
i. Preserves adductor, short flexor, and EDB ms. function
ii. Improved cosmetic appearance
iii. Improved stability
iv. Improved overall balance and gait
vi. Improved position of lesser toes
vii. Restores and maintains weightbearing function to the 1st ray
viii. May be converted to Keller or implant arthroplasty
ix. Relief of pain
x. Simultaneous reduction of IM angle
xi. Recurrence of the deformity is unlikely
g. Disadvantages:
i. May promote arthritic changes at the ipj
ii. Optimum position may be difficult to achieve as it is technically
difficult to perform
iii. May require autogenous graft
iv. May limit shoe gear
v. May result in gait alterations
v. Difficulty in kneeling
h. Complications:
i. IPJ arthritis of the hallux
ii. Delayed union/non-union/malunion/pseudoarthrosis
iii. Fracture
iv. Onychocryptosis
v. Medioplantar calluses
vi. Hallux flexus
vii. Impaired gait
viii. Balance problems
ix. Possible subluxation of toes 2 and 3 x. Improper positioning

2. Lapidus Type (fusion of the 1st metatarsal-cuneiform joint):

a. Anatomy:
i. The joint is arthrodial with its own synovial membrane
ii. The medial cuneiform distal articular surface is reniform in shape with a
convex medial border and concave lateral border
iii. The surface is elongated in the vertical direction with an inferior and
medial inclination
iv. The proximal articular surface of the 1st metatarsal is reniform with upper
and lower parts
v. There is a variable articulation between the 2nd metatarsal at its
proximal medial aspect and the first metatarsal at its proximal lateral aspect
vi. Dorsal and plantar 1st metatarsal-1st cuneiform ligaments are present
vii. There are no interosseous ligaments between the base of metatarsals
1 and 2
viii. There is a strong interosseous ligament between the 1st and 2nd
cuneiform and between the 1st and 2nd cuneiform and 2nd metatarsal
ix. Tibialis anterior tendon inserts at the proximal junction of the medial and
inferior surfaces of the 1st metatarsal
x. Peroneus longus tendon inserts at the proximal junction of the lateral and
inferior surfaces of the first metatarsal
b. Indications:
i. Extreme hypermobility associated with HAV
ii. Correction of sagittal plane deformity
iii. Correction of severe metatarsus primus adductus associated with a
hypermobile or structurally medially deviated M-T-C joint
iv. Repair of fracture or dislocation
v. Hypermobile flatfoot with medial column sag
c. Surgical technique: Via a dorsal longitudinal incision medial to the EHL
tendon, with capsular incision dorsal linear or transverse. Articular cartilage is
resected from the joint surfaces. The metatarsal is then adducted and slightly
plantarflexed and then fixated appropriately with a compression screw,
staple or k-wires. A BK NWB cast is applied until radiographic signs of fusion
and stability are seen. Originally, Lapidus fused the 1st and 2nd metatarsal
bases, but this is rarely necessary. Modifications of this procedure include
i. Transfixation of the 1st to 2nd metatarsals with a threaded k-wire
ii. Fusion of the 1st to 2nd metatarsal base with bone graft obtained from the
medial exostosis of the metatarsal head

NOTE* There exist 3 surgical alternatives for extreme hypermobility cases:

a. Cartilage abrasion and subchondral perforation, manual reduction,
temporary fixation followed by bone screw fixation
b. Joint wedge resection, minimal bone resection, lateral plantar wedge with
bone-screw fixation and -stress receiving graft
c. Joint resection, minimal bone removal with temporary reduction of the
lengthening by means of allogeneic bone, double screw fixation, and
occasional temporary plates.
With each, there must be at least two points of fixation
d. Complications:
i. Prolonged healing time
ii. Malalignment in the frontal, sagittal or transverse planes
iii. Severence of the vascular structures in the proximal intermetatarsal space
iv. Non-union and pseudoarthrosis

Proximal Phalangeat Osteotomies

The Akin-type procedures are generally combined with other types of bunion
procedures to correct deformities around the 1st MTPJ, however, the
cylindrical Akin is often used independently to shorten a long proximal
phalanx
1. Proximal Akin: It is a medial closing wedge osteotomy at the metaphysis
of the proximal phalanx. Is used to correct a high DASA. There should be
adequate bone stock and adequate length of the proximal phalanx. The IM
and HA angles will be unaffected. The lateral hinge is kept intact and the
osteotomy should be fixated.

2. Distal Akin: It is a medial closing wedge osteotomy of the distal part of

the proximal phalanx used to correct a high HI angle. IM angle unaffected.
a. Indications:
i. Pressure of the hallux on the 2nd digit
ii. Epiphysis may be open
iii. Good bone stock
iv. HIA > 100
v. Adequate length of proximal phalanx
vi. DASA is normal
vii. Congruous 1st mpj unless corrected by another procedure
b. Disadvantages:
i. Long healing phase
ii. Fixation needed
iii. Elimination of propulsive phase of gait for 3-6 weeks
c. Complications:
i. Poor correction
ii. Pain postop due to poor fixation
iii. Non-union
iv. Short hallux
v. Hallux elevatus from FHL damage

3. Cylindrical Akin: Removal of cylindrical section to shorten a long

proximal phalanx. The proximal osteotomy is one and one-half cm. from the
base of the proximal phalanx, and the second osteotomy is made distally to
the first cut.

4. IPJ fusion: Used to correct a hallux hammertoe or injury to the ipj. Must
have good ROM of the 1st MTPJ.

5. Kessel-Bonney: A dorsal wedge osteotomy of the base of the proximal

phalanx, used for hallux limitus. This extends pre-existing joint motion more
dorsally.
a. Advantages:
i. Allows the hallux to be in a dorsal position at the propulsive phase of gait
ii. Allows for immediate ambulation
b. Disadvantages:
i. Requires an osteotomy with fixation
ii. Does not really increase overall 1 st MTPJ ROM iii. Often creates a lack of
toe purchase
iv. Does not correct the underlying etiology of the deformity
v. Requires elimination of the propulsive phase of gait for 3-6 weeks
Distal Metatarsal Osteotomies

The major criteria for all distal osteotomies of the 1st metatarsal head are
adequate bone density, adequate ROM, and arthritis-free joint. The
potential complication for all distal 1st metatarsal osteotomies is
avascular necrosis.

1. Austin:
a. Criteria
i. Normal to mildly abnormal PASA
ii. Increased IM angle (max 14°/depends on other factors)

NOTE* 1 mm in lateral shift of the capital fragment equals a reduction of 1°

of IM angle.

NOTE* One can safely shy the metatarsal head laterally one-third of the
width of the bone. So if the metatarsal head measures 21 mm. across,
you can safely shy the bone 7 mm. and thereby close the IM angle 7°
(since the wider the bone the more lateral shifting you can perform)
iii. Normal metatarsal declination
b. Surgical technique: V osteotomy with 60° angular cuts, originally
described with no fixation, but commonly fixation devices utilized.
c. Advantages
i. Reduces the IM angle
ii. Performed in cancellous bone
iii. Stable in the sagittal plane allowing early ambulation
iv. Avoids the sesamoids
d. Disadvantages
i. Technically challenging (easier with Reece osteotomy guide)
ii. Dislocation potential
e. Complications
i. Dislocation of capital fragment
ii. Intra-articular fracture
iii. Aseptic necrosis
 NOTE* It has been reported in the literature that an unusual sequel of this
procedure has been for the capital fragment to pop out of the wound and fall
on the operating room floor. The suggested protocol for this is to:
a. Pick up the fragment with a sterile forceps and place in a basin containing
1 liter of sterile saline + 1 cc. Neosporin G. U. irrigant + 1:100, 000
Bacitracin for 5 minutes.
b. Then transfer to another basin with the same type of solution for another 5
minutes.
c. Then transfer to a third basin containing the same solution and swirl for an
additional 1 minute and replace back into the foot with fixation.
d. Advise the patient of the occurrence.
e. Prophylaxis with 1 gm IV Cefadyl at 8, 16, and 24 hours postoperatively.

2. Austin/Kalish modification: As above but with a smaller angular cut to

allow for longer dorsal wing for placement of 2-2.7mm screws or one 3.5 mm
screw

3. Austin/Youngswick modification:
a. Criteria
i. Normal to slightly abnormal PASA
ii. Increase IM angle (mild)
iii. Metatarsus elevatus
iv. Limited ROM
b. Operative technique: Similar to other Austin procedures except with
removal of rectangular wedge from dorsal arm of the 600 angle of the V.
Additionally the wedge can be placed in the plantar arm of the V cut for
additional plantarflexion of the capital fragment.
c. Advantages
i. Plantarflexes
ii. Shortens- relaxes the tension around the joint, thereby increasing
ROM
iii. Stable if fixated
iv. Done in cancellous bone
d. Disadvantages
i. Potential displacement
ii. Difficult to perform
iii. Needs fixation
iv. Should be non-weight bearing 4-6 weeks
e. Complications
i. Intra-articular fracture
ii. Excessive shortening
iii. Dorsal displacement
iv. Metatarsalgia

4. Austin/Bicorrectional modification:
a. Criteria
i. Abnormal PASA
ii. Increased IM angle
iii. Normal metatarsal declination
b. Operative technique: Same as traditional Austin except another cut is
made which is thicker medially so as to remove a trapezoidal wedge of bone
from the dorso-medial metatarsal head. When! the capital fragment is shifted
laterally and impacted the IM and PASA is subsequently reduced.
c. Advantages:
i. Same as the Austin plus
ii. Reduces the PASA
d. Disadvantages
i. Technically challenging (more so than the traditional Austin)
ii. Dislocation potential
e. Complications
i. Same as the traditional Austin

5. Reverdin:
a. Criteria
i. Increased PASA
ii. Normal IM angle
iii. Normal metatarsal declination
b. Advantages:
i. Reduces the PASA
ii. Performed in cancellous bone
iii. Fixation optional
iv. Good visualization
c. Disadvantages:
i. Potential sesamoid trauma
ii. No IM angle reduction or sagittal plane reduction
d. Complications: DJD

6. Reverdin-Green (distal "L" osteotomy): This is identical to the Reverdin

except with an additional plantar osteotomy cut made parallel to the weight-
bearing surface to protect the sesamoids

7. Reverdin-Laird: Adds transposition of the metatarsal head to the

Reverdin-Green procedure, with reduction of the IM angle

8. Reverdin-Todd: Combined with the Reverdin-Green and Reverdin-Laird,

this modification adds correction of the sagittal plane deformity of the 1st
metatarsal

9. Hohmann: Its modifications are the Mitchell and the DRATO

a. Criteria: Sagittal and transverse plane deformities
i. Increased PASA
ii. Increased IM angle
iii. Elevatus
b. Precautions: Cannot be used for frontal plane deformities, in the presence
of degeneration of the crista or any DJD
c. Advantages:
i. Reduces PASA
ii. Reduces IM angle
iii. Plantarflexes
d. Disadvantages:
i. Highly unstable
ii. Needs 2 point' fixation
iii. Cast required
iv. Extracapsular
v. Performed in cortical bone
vi. Does not remove the medial eminence
e. Complications:
i. Dislocation
ii. Delayed or non-union
iii. Metatarsus elevatus

10. Mitchell: A step down transpositional/angulation osteotomy at the

metatarsal neck
a. Criteria:
i. Normal PASA
ii. Moderate increase in IM angle
iii. Positive metatarsal protrusion
iv. Metatarsal elevatus
b. Advantages:
i. Reduces the IM angle
ii. Removes the medial eminence
iii. Plantarflexes the met head
iv. Avoids the sesamoids
v. More stable than the Hohmann
c. Disadvantages:
i. No PASA correction
ii. Shortens the metatarsal
iii. Performed in cortical bone
iv. Dislocation potential

11. DRATO:
a. Criteria:
i. Abnormal PASA
ii. Mild increase of IM angle
iii. Valgus rotation of the metatarsal head
iv. Sagittal plane deviation of 1st metatarsal head articular cartilage (facing
either plantarward or dorsalward)
b. Advantages: It addresses 4 deformities in one procedure (PASA, sagittal
plane 1st met head, valgus rotation, and IM angle)
c. Disadvantages:
i. Very difficult to perform
ii. Done in cortical bone
iii. Cast/ NWB 6-8 weeks
d. Complications: Same as with other procedures of this type
12. Waterman: Distal metaphyseal dorsal wedge osteotomy that raises the
declination of the metatarsal head. Utilized for hallux limitus.
a. Disadvantages:
i. Does not actually increase the 1st MTPJ ROM
ii. Can create a lack of hallux toe purchase
iii. Does not correct the underlying etiology
iv. Requires removal of the propulsive phase of gait for 3-6 weeks postop.

13. Wilson: An oblique displacement osteotomy that shortens the 1st

metatarsal and decreases the IM angle.

14. Peabody: Similar to the Reverdin except performed more proximally.

15. Lambrinudi: A plantarfiexory osteotomy of the 1st metatarsal. Reserved

for the younger active individual without severe joint disease with hallux
limitus complaints.

Proximal Metatarsal Osteotomies:

These procedures are used when the true IM angle should be reduced 1.
(greater than or equal to 140 in the rectus foot) and/or when a
sagittal plane deformity of the first ray needs to be corrected. These
procedures are performed transversely across the metatarsal,
perpendicular to the long axis, and 1-1.5cm distal to the met-
cuneiform joint.
Trethoan (opening base wedge): Used when the metatarsal is relatively
short. Must utilize a bone graft (best to fixate with a staple to avoid
compression of the bone graft).

2. Louisan-Balacescu (closing base wedge): A transverse closing base

wedge osteotomy. Fixated with a staple. osteoclasp, K-wires, or
monofilament wire. Complications have been elevatus of the metatarsal, non-
unions, and delayed unions. The Juvara modifications allows for AO fixation.

3. Juvara Type A: Oblique base/shaft osteotomy from medial-proximal to

lateral-distal, a wedge of bone removed to close the IM angle, medial hinge is
kept intact, and screw fixation utilized.

NOTE* For screw fixation the osteotomy cut is performed obliquely and must
be at least twice as long as the width of the metatarsal shaft

4. Juvara Type B: As in type A, a wedge is removed for IM angle reduction,

also the hinge is broken after screw insertion for sagittal plane rotation.

5. Juvara Type C: No wedge is removed but the hinge is broken, so that

sagittal plane rotation is possible and axial transposition is possible
(lengthening or shortening).

NOTE* Biomechanics of the Axis:

a. When the axis lies in the plane, no motion occurs in that plane.
b. Motion around an axis occurs in a plane that is perpendicular to the axis.
c. An osteotomy hinge will act as an axis of rotation.
d. A hingeless osteotomy may be rotated in the plane in which the osteotomy
lies (an axis of rotation will exist perpendicular to the plane of the
osteotomy)
e. A hinge should be made perpendicular to the weight bearing surface to
prevent subsequent dorsiflexion of the metatarsal.
f. More significant sagittal plane errors will occur when the hinge erroneously
deviates in the frontal plane
g. Virtually any combination of planal deviations may be obtained if the hinge
(or in the case of hingeless osteotomies) the plane of the osteotomy is
correctly
manipulated (the problem is achieving the exactly desired deviation on each
plane).

6. Arcuate (Weinstock): A proximal dome shaped osteotomy that reduces a

high IM angle and sagittal plane deformity. No cortical hinge is left intact. Its
benefit is that it avoids shortening the metatarsal. Its drawback is that it is
unstable and occasionally difficult to fixate.

7. Van Ness: Plantar closing base wedge osteotomy for reduction of

metatarsal elevatus. K-wire fixation utilized.

Shaft NOTE* Fixation studies of proximal metatarsal osteotomies revealed:

a. Dorsal loop: failed at 1 lb pressure
b. Dorsal loop with .062 k-wire: failed at 3.5 lb pressure
c. Right angle loops: failed at 6 lb pressure
d. Crossed. 062 k- wires: failed at 6 lb pressure
e. 4 mm. cancellous screw: failed at 8 lb pressure
f. 3.5 mm. cortical screw: failed at 9.5 lb pressure
g. Two 2.7 mm. cortical screws: failed at 10 lb pressure (gives better and
more even compression)
h. Right angle loops with .062 k-wires: failed at 10 lbs pressure
Procedures
1. Offset V (Vogler):
a. Criteria:
i. IM angle of 17-18°
ii. PASA between 8-30°

NOTE* It has been reported that there is an average reduction in IM angle of

9.1° and PASA of 7.99°

iii. Minimal to no joint pain

iv. No excessive DJD
b. Operative technique: A long V osteotomy that extends almost to the met-
cuneiform joint enabling reduction of the IM angle and PASA. The apex of the
V is more proximal than the standard Austin (done at the metaphyseal-
diaphyseal junction) with the angle measured at 35°. The dorsal arm is longer
extending between midshaft and the proximal one-third of the metatarsal.
Fixation is achieved with 1 K-wire or 2.7 mm. screw.
b. Complications: As per most osteotomies of this type

2. Scarf:
a. Criteria:
i. Increased IM angle
ii. Increased PASA
b. Operative technique: A long Z osteotomy that reduces the IM angle and
the PASA. Modifications of this procedure include:
i. A medially based incision
ii. The length of the horizontal osteotomy is in direct proportion to the
width of the IM angle
iii. The direction of the osteotomy has been modified such that approx.
two-thirds of the width of bone is dorsal to the osteotomy, proximally,
and one third is plantar, in order to prevent stress fractures from occurring
c. Advantages:
i. The long plantar fragment possesses stability in two planes
ii. Lends itself to AO fixation (tension band effect)
d. Disadvantages:
i. Difficult to perform
ii. Possible vascular compromise
iii. Performed in diaphyseal bone
e. Complications:
i. Aseptic necrosis

3. Mau (Gudas modification for screw fixation): An oblique shaft osteotomy

from plantar-proximal to dorsal-distal. Indicated for IM angle reduction.

4. Ludloff (Engelman modification for screw fixation): An oblique shaft

osteotomy from dorsal-proximal to plantar-distal

Combination Procedures
1. Stamm (opening base wedge + Keller)
2. Logroscino (closing wedge + Reverdin)

Other Procedures
1. Cotton (1st cuneiform opening wedge osteotomy):
a. Criteria:
i. Metatarsus primus adductus
ii. Pronounced obliquity of the 1st met-cuneiform joint
iii. Whenever a double osteotomy is indicated
b. Contraindications:
i. Excessive bony bridging at the opposing surfaces of the osteotomy
c. Operative technique: A wedge is removed from the 1st cuneiform. The cut
is made parallel to the joint and does not enter the met-cuneiform joint
plantarly, and is placed tibial to the intercuneiform joint at the bases of the
1st and second metatarsals. The 1st cuneiform osteotomy is then performed
on the distal 1/3 of the bone. The more distal the osteotomy the more effect
it has on the joint direction. The graft comes from the medial eminence and
is fashioned prior to removal of the cuneiform wedge.
NOTE* Dissection of the 1st cuneiform must be done carefully to avoid
avascular necrosis of this bone
d.
Complications:
i. Inadequate reduction of the deformity
ii. Malalignment of the osteotomy
iii. latrogenic tenotomy of the FHL
iv. Metatarsus primus elevatus
e. Advantages:
i. This procedure can be added if the distal metaphyseal osteotomy proves to
be inadequate to repair the deformity
ii. Postoperative recovery is far easier than a closing base wedge or Lapidus
iii. No cast is required and partial weight bearing can begin several days
postoperatively
iv. Allows surgery in the presence of a short 1st metatarsal as this procedure
lengthens the 1st ray

2. Cheilectomy: Removal of osteophytes from the 1st MTPJ

Hallux Rigidus and Hallux Limitus

1. Etiology:
a. Dorsiflexed 1st metatarsal secondary to abnormal pronation and
hypermobility of the 1st ray.
b. Dorsiflexed 1st metatarsal secondary to muscle imbalance affecting the
1st ray.
c. Dorsiflexed 1st metatarsal secondary to sagittal plane structural
malalignment of the 1st metatarsal.
d. Abnormally long 1st metatarsal.
e. Prolonged 1st MTPJ immobilization.
f. Arthritic conditions of the 1st MTPJ either traumatic or metabolic
g. latrogenic secondary to previous foot surgery affecting the 1st ray.
2. Preoperative Symptoms:
a. Spasms or tendonitis of the EHL.
b. Inability to move the hallux normally and or pain on motion.
c. Inability to wear high heeled shoes.
d. Painful hyperkeratotic lesion under the IPJ of the hallux.
e. Painful hallux nail plate.
f. Enlargement over the dorsal aspect of the 1st MTPJ
3. Preoperative signs:
a. Dorsal bunion with or without skin irritation.
b. Limited or absent 1st MTPJ motion
c. Hallux extention distal to the IPJ
d. Deformation of the hallux nail plate
e. Weakness of the peroneus longus and/or hyperactivity of the anterior
tibial ms.
f. Crepitation and/or pain with 1st MTPJ ROM.
4. Preoperative radiographic signs:
a. Dorsal osteophytic proliferation
b. Dorsiflexed 1st metatarsal relative to talar bisection
c. Narrowing of the 1st MPJ joint space
d. Flattening of the 1st metatarsal head
e. Arthritic changes of the 1st MPJ
f. Subchondral sclerosis

5. Biomechanical considerations: One must determine if there is a

functional component that is producing the deformity, as a functional limitus
is a common finding in the patient with significant uncontrolled pronation
producing hypermobility of the 1st ray. To determine this examine the
patient in a relaxed vs. neutral calcaneal stance position. A functional limitus
only occurs in the relaxed position.

6. Conservative treatment:
a. Orthoses
b. Metatarsal bar
c. Rocker-bottom shoes

7. Surgical treatment- Joint preservation techniques:

a. Soft tissue release: Should be followed by immediate ROM excercises
i. Release of fibrosis on the dorsal aspect of the joint
ii. Release of the dorsal capsule
iii. Release of the medial capsule if previously overcorrected
iv. Release of the plantar adhesions between the sesamoid apparatus and
the plantar aspect of the metatarsal head

b. Cheilectomy: The osseous proliferation around the joint is excised

i. Advantages:
 Easily performed
 Reduces the dorsal enlargement
 Allows for increase in ROM in many cases
 Creates minimal postoperative disability
 Allows for immediate postop propulsive phase ambulation
ii. Disadvantages:
 Potential for capsulodesis
 Does not correct the underlying etiology
c. Kessel-Bonney osteotomy:
i. Advantages:
 Allows the hallux to be in a dorsal position at the propulsive phase of gait
 Allows for immediate postoperative ambulation
ii. Disadvantages:
 Requires an osteotomy with no fixation
 Does not actually increase the overall ROM
 Often creates a lack of hallux purchase
 Does not correct the underlying etiology
 Requires the elimination of the propulsive phase of gait for 3-6 weeks
postop

d. Mitchell-type osteotomy: This produces shortening and plantarflexion of

the metatarsal head
i. Advantages:
 Allows for correction of an abnormally long metatarsal
 Allows for mild plantarflexion of the 1st metatarsal
 Increases overall 1st MTPJ motion by relaxing tension around the joint
produced by a long metatarsal
 Allows for mild correction of an abnormal IM angle
 Does not interfere with an open epiphysis
ii. Disadvantages:
 Requires an osteotomy with fixation
 Allows only minimal plantarflexion of the head
 Requires non-weightbearing for 4-6 weeks postop

e. Watermann osteotomy:
i. Advantages:
 Allows the hallux to become more dorsal without using any additional joint
motion
ii. Disadvantages:
 Does not correct the underlying etiology of the deformity
 Can create a lack of toe purchase, and requires the elimination of the
propulsive phase of gait for 3-6 weeks postop

f. Austin-Youngswick osteotomy: This procedure produces a shortening and

plantarflexion of the head
i. Advantages:
 Allows for correction of an abnormally long 1st metatarsal
 Allows for mild plantarflexion correction
 Relaxes tension around the joint via the shortening
 Allows for immediate postoperative ambulation
 Can be utilized to correct abnormal IM angle
 Does not interfere with an open epiphysis
ii. Disadvantages:
 Requires an osteotomy
 Allows only minimal plantarflexion
 Requires elimination of the propulsive phase of gait for 3-6 weeks postop

g. Plantarflexory wedge osteotomy (Van Ness): A wedge of bone is removed

from the plantar aspect of the 1st metatarsal base i. Advantages:
 Allows for true correction of a structurally dorsiflexed 1st metatarsal
 Increases overall 1st MPJ ROM
ii. Disadvantages:
 Requires non-weightbearing with immobilization for 6 weeks postop
 Does not allow for easy repositioning of the 1st ray intraoperatively if too
much bone is resected

h. Juvara type C osteotomy:

i. Advantages:
 Allows for true correction of a structurally dorsiflexed 1st metatarsal
 Increases overall 1st MTPJ ROM
 Does not require removal of a bony wedge
 Can be modified for reduction of an high IM angle
 Allows for easy intraoperative repositioning of the 1st metatarsal on the
sagittal plane
ii. Disadvantages:
 Requires non-weightbearing with immobilization for 6 weeks postop
 Requires the use of two cortical screws for fixation
8. Surgical treatment- Joint destructive procedures:
a. Keller arthroplasty
i. Advantages:
 Elimination of joint pain
 Allows for increase ROM
 Easily performed
 Allows for immediate propulsive-type gait
ii. Disadvantages:
 Destroys the joint
 Creates instability of the 1st ray
 Does not correct the underlying etiology
 Creates lesser metatarsalgia

b. Arthroplasty with joint prosthesis:

c. Arthroplasty with joint prosthesis and proximal plantarflexory osteotomy

d. Arthrodesis:
i. Advantages:
 Eliminates joint pain
 Creates significant internal stability of the 1st ray
ii. Disadvantages:
 Eliminates all motion of the 1st MTPJ
 Requires fixation for 6-8 weeks with immobilization
 Restricts the type of shoes which can be worn postoperatively depending
upon hallux position in the sagittal plane

Hallux Varus
1. Etiology:
a. Congenital and often accompanied by other congenital abnormalities
b. Most commonly latrogenic following surgical treatment of HAV
i. Excessive resection of the medial eminence
ii. Excision of the fibular sesamoid and release of the adductor tendon
iii. Overcorrection of the IM angle
iv. Overtightening of the medial capsule
v. Overcorrection of the PASA

2. Preoperative Symptoms of latrogenic Hallux Varus:

a. Inability to wear conventional shoe gear comfortably
b. Pain along the medial aspect of the hallux
c. Pain along the medial side of the arch (ms. contracture)
d. Pain may be present at the MPJ with or without shoes

NOTE* Capsulitis of the 2nd MPJ may be the only initial complaint

3. Preoperative Signs of latrogenic Hallux Varus:

a. Presence of an adducted positioned hallux
b. Contracture of the hallux IPJ (sometimes)
c. Contracture of the EHL (sometimes)
d. Contracture of the abductor hallucis (sometimes)
e. Pain and crepitation may be present at the 1st MTPJ
f. Hallux limitus may be present at the 1st MTPJ

4. Preoperative Radiographic Signs:

a. The hallux will be in an adducted position at the 1st MTPJ
b. The IM angle will usually be reduced
c. The head of the 1st metatarsal may be staked
d. The fibular sesamoid may be absent
e. The evidence of a previous osteotomy on the 1st metatarsal may be seen
f. A negative PASA may be present
g. Arthritic changes may be present at the 1st MTPJ
h. Arthritic changes may be present at the hallux IPJ

5. Operative Considerations:
a. The deformity should be corrected as soon as possible to prevent DJD of
the joint
b. There is no one surgical procedure. The causative factor(s) must be
determined and corrected along with any secondary changes that had
developed, by selecting the proper procedures (i.e. reverse Austin, reverse
Akin, reverse hemi-angulated implant , soft tissue balancing, arthrodesis, and
Keller/total implant arthroplasty)

Hallux Hammertoe (etiology)

1. Cavus foot (extensor substitution)
2. Removal of the sesamoids
3. Detachment of the flexor tendons
4. Overzealous HAV surgery
5. Plantar hallux IPJ sesamoid

Differential Diagnosis of Pain in the Sesamoid

Area
1. Joplin's neuroma
2. Sesamoiditis
3. Osteochondritis of the sesamoids
4. Ruptured bipartite sesamoid
5. DJD with an eroded crista
6. Hypertrophic sesamoid
7. Fractured sesamoid
8. Tumor of the sesamoid (a giant cell tumor has been reported)

NOTE* Most bipartite sesamoids are tibial, 75% are unilateral, and
ossification of the sesamoids occurs at age 8-10 years
Complications of HAV Surgery (General)
1. Staking the metatarsal head and producing hallux varus
2. Hallux hammertoe
3. Longitudinal fracture when removing the exostosis
4. Sesamoiditis from invasion of the met-sesamoid articulation by tumor
5. Fracture of the articular cartilage of the MTPJ
6. Unstable osteotomy
7. Non or delayed union
8. Damage to the neurovascular structures
9. Elevatus and iatrogenic hallux rigidus
10. Over or undercorrection
11. Osteoporosis from disuse
12. Infection
13. Problems with the fixation devices
14. Hallux limitus/rigidus
15. Avascular necrosis
Chart of Procedures and Their Indications
Abbreviations:

HI= Hallux Interphalangeus

IM= Intermetatarsal Angle
DASA= Distal Articular Set Angle
MP= Metatarsal Protrusion
PASA= Proximal Articular Set Angle
SES= Sesamoid Position
HA= Hallux Abductus Angle
D/PF= Motion of the 1st ray (dorsi/plantarflexion)
JNT= Condition of the 1st m.p. joint
TYPE= Type of Procedure
N= Normal I= Increased D= Decrease G= Good P= Positional
S=Structural
A= Arthritic