Orthopedics - Oleksa A.P. 2006

Congenital and Acquired Deformities of the Lower Extremity
Orthopedic Foot Deformities
Hallux Valgus

Hallux valgus is one of the most common FOOT deformities encountered in clinical practice (Fig. 212), and it is typically bilateral.

Historically, this pathology was attributed to the deviation of the great toe caused by wearing fashionable shoes (the vestmentary theory). However, numerous population surveys and clinical observations have established that hallux valgus also occurs in adolescents and men who have never worn such footwear. Furthermore, The Theory of primary Muscle weakness—which is well-documented in longitudinal Flatfoot—was not confirmed here. The transverse splay of the forefoot is associated with static factors caused by weakness of the Ligamentous apparatus of the foot and insufficiency of the plantar aponeurosis.

The first metatarsal bone adducts, while the fifth abducts, whereas the second through fourth metatarsals remain in place. It has been proven that the heads of these metatarsals do not actually form a transverse arch, and callosities in the region of the second and third metatarsal heads do not develop in all cases of splayfoot. Nevertheless, hallux valgus does not occur without a splayed forefoot.

The first metatarsal gradually adducts, resulting in metatarsus primus varus. This varus deviation can vary relative to the normal range (8–15°). Simultaneously, valgus deviation and pronation of the great toe occur at the metatarsophalangeal joint due to the tension of the m. abductor hallucis, which attaches to the Base of the proximal phalanx. In turn, this causes the second hammer toe to overlap the abducted great toe (digitus secundus superductus), and occasionally, in severe deformities, both the second and third toes override it.

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Fig. 212. Schematic diagram of a triple arthrodesis: a — bone resection sites, b — adapted bone surfaces following resection.

Fig. 212. Hallux valgus deformity of the foot.

Fig. 213. Subluxation of the great toe in hallux valgus.

As the great toe abducts, the transverse and medial ligaments as well as the capsule of the metatarsophalangeal joint are stretched, whereas the lateral ligament shortens with capsular contraction. Over time, toe subluxation develops (Fig. 213), along with a lateral exostosis near the base of the first metatarsal HEAD and concomitant bursitis. In advanced cases, deforming arthrosis of the metatarsophalangeal joint develops, causing the metatarsal head to lose its normal shape. This is frequently accompanied by the second toe overlapping the valgus-deviated great toe (Fig. 212).

A predisposing factor for the onset of hallux valgus can be hypermobility and obliquity of the articulatio metatarsocuneiformis, which serves as a congenital driver for the progressive adduction of the metatarsal bone.

Additionally, congenital pronated foot, as well as Achilles tendon contracture resulting from secondary cerebral disorders, can sometimes contribute to The Development of hallux valgus.

Patients typically consult an orthopedist due to pain in the metatarsophalangeal joint area that makes wearing standard footwear difficult. Initially, the pain is caused by bursitis around the exostosis near the base of the metatarsal head, whereas in advanced cases, it stems from the second toe overlapping the hallux valgus or from deforming arthrosis (Fig. 214).

Furthermore, patients experience pain while walking due to plantar Skin callosities in the region of the depressed second—and sometimes third—metatarsal head.

Fig. 214. Schematic diagram showing the Location of bursitis in hallux valgus.

Physical examination reveals a classic foot deformity with varying degrees of hallux valgus deviation. The forefoot is splayed. The head of the first metatarsal prominently juts out on the medial side. Skin hyperemia in this area and palpable bursitis are occasionally present. An exostosis can also be palpated in the same region, along with a painful plantar callus beneath the second metatarsal head. The great toe is in lateral subluxation; its movements—particularly adduction—are restricted or impossible, and painful in the presence of arthrosis.

To determine the degree of deformity and The Nature of changes within the metatarsophalangeal joint, standard radiographs of the foot in two projections are mandatory. The anteroposterior (AP) radiograph is used to measure the degree of first metatarsal adduction in degrees (normal is 8°), forefoot splaying, the degree of great toe deviation (normal is 15°) or subluxation, the condition of the metatarsophalangeal and metatarsocuneiform joints, and the degree of sesamoid bone displacement. The lateral radiograph assesses the degree of flatfoot along with the condition of the metatarsophalangeal, subtalar, and other JOINTS OF THE foot.

The Treatment plan is formulated based on clinical and radiographic findings.

Conservative treatment is indicated for patients with early-stage deformities or those with significant deformities who have contraindications to surgery or refuse surgical intervention.

Patients are prescribed shoe inserts featuring a special "pear-shaped" pad for regular footwear or a Seitz pad to offload and elevate the transverse arch of the forefoot. For pronounced deformities, custom orthopedic footwear of various designs is recommended; it must be spacious, conform to the foot shape, and avoid putting pressure on the first metatarsal head area and the callus of the overlapping second toe.

For the same purpose, transverse banding of the forefoot with a spacer placed between the First and Second toes, along with other corrective devices for the great toe, is sometimes recommended.

Concurrently, foot muscle massage and warm foot baths are prescribed, alongside anti-inflammatory therapy in cases of bursitis.

However, conservative treatment is essentially symptomatic therapy that fails to address the ROOT cause of hallux valgus. Therefore, surgical management remains the method of choice to prevent the progression of the deformity and correct existing pathological changes.

Although about a hundred types of surgical Procedures have been proposed for hallux valgus, clinical practice employs only those that improve foot function, eliminate pain, or are pathogenetically justified (Fig. 215). This provides a basis for dividing these operations into palliative and radical.

Palliative procedures include the Schade operation, which, unfortunately, is still performed by some surgeons today.

Surgical technique. Under local novocaine anesthesia or general anesthesia, a curved dorsomedial tissue incision is made (Fig. 216), avoiding the head of the first metatarsal bone along with its tuberosity and bursitis. The periosteum is incised in a U-shape and stripped distally together with the medial ligament down to the base of the head, occasionally opening the joint cavity. An osteotome is used to excise the exostosis near the base of the head, ensuring it does not impede toe adduction. The bursa is then removed, the toe is brought into a normal position (up to 15° of abduction), and fixed transarticularly with a Kirschner wire. The ligament-periosteal flap is sutured back into place under tension, and the wound is closed. A plaster cast is applied.

Fig. 215. Diagrams of surgical procedures for Hallux Valgus: a - Kocher's; b - Babich's; c - Logroscino's; d:

1 - Schade's; 2 - Reverdin's; 3 - Juvara's; e: 4 - Wredden-Hüter-Mayo's; 5 - Albrecht-Luason's; 6 - Brenner-Rudel's.

After the wound heals, the splint is removed, the wire is withdrawn after three weeks, and comfortable footwear is prescribed.

The Schade operation improves the patient's condition by eliminating pain in the area of callosity, former exostosis, and bursitis, but it does not address the root cause and frequently results in recurrences.

Another palliative Procedure is the Brandes-Keller operation, which involves resection of the proximal part of the proximal phalanx of the first toe (Fig. 217, b). Creating a diastasis between the head of the first metatarsal bone and the toe relieves pain associated with deforming arthrosis and arthroarthritis of this joint, but the long-term outcomes of this surgery are not always satisfactory.

Fig. 216. Surgical approach to the first metatarsophalangeal joint.

The Hohmann operation, which involves wedge resection of the neck of the first metatarsal bone (Fig. 217, c), is considered unjustified. Although removing the wedge along with the exostosis medialize the metatarsal head and the first toe, the entire first metatarsal bone remains adducted, eventually leading to a recurrence of the deformity with an even greater subluxation of the toe. It would be more rational to perform such a wedge osteotomy at the proximal end of the first metatarsal bone. Proper positioning relative to the second metatarsal bone and the longitudinal axis of the foot would then correct THE POSITION OF the first toe and prevent its valgus deviation.

Likewise, the Hueter-Mayo operation (Fig. 217, a)—resection with removal of the head of the first metatarsal bone—has not proven effective, as it alters the static and dynamic conditions of the foot and causes pain due to load redistribution.

However, marginal resection with exostosis removal and remodeling of the first metatarsal head (arthroplasty) yields satisfactory results in elderly patients, although it does not eliminate the underlying cause of the deformity.

Pathogenetically justified operations include those that correct the adduction of the first metatarsal bone and the valgus deviation of the first toe.

Fig. 217. Surgical procedures for hallux valgus: a - Hueter-Mayo, b - Brandes-Keller, c - Hohmann.

H.M. Kramarenko (1955) corrected transverse splayfoot and adduction of the first metatarsal bone by binding it at the level of the necks to the fifth metatarsal bone (Fig. 218).

Surgical technique. Under anesthesia, a curved dorsomedial incision is made in the area of the neck and over the protruding exostosis of the first metatarsal bone. The exostosis is knocked off with an osteotome, and the neck is exposed circumferentially with a raspatory. A second small incision is made on the lateral aspect of the foot corresponding to the PROJECTION OF THE neck of the fifth metatarsal bone. The neck is exposed using a raspatory. A tunnel is created from the plantar side past the Tarsal Bones using a coring forceps, connecting both wounds. Thick lavsan or silk threads are then passed through the tunnel, crossing in the middle of the foot on the plantar side to form a "figure-of-eight" loop encircling the necks of the fifth and first Metatarsal Bones. An assistant manually compresses the distal part of the foot transversely to increase the arch height, while the surgeon ties the ends of the threads so that the knot is positioned beneath the neck of the first metatarsal bone.

Because the threads frequently ruptured under the load of the foot, the Introduction of lavsan tapes led surgeons to use them for binding the first and fifth metatarsal bones together. This procedure was supplemented by exostosis excision and capsuloplasty.

The Kramarenko operation provides excellent results in mild foot deformities because it restores the normal alignment of the metatarsal bones and corrects the valgus deviation of the first toe.

A drawback of this method is the development of pressure sores with bone erosion caused by the pressure of the threads or tape on the neck regions (Fig. 218).

We observed one case of complete erosion through the fifth metatarsal bone with subsequent bone healing four years postoperatively, which preserved the normal axis of the bone. In another female patient where a lavsan tape was used, the fragments displaced, necessitating a secondary surgical intervention.

Radical and pathogenetically justified operations are those based on osteotomy to normalize the position of the adducted first metatarsal bone and the abducted first toe. To this end, various authors have proposed A number of surgical techniques.

Fig. 218. Kramarenko procedure for hallux valgus.

Osteotomies of the first metatarsal bone are performed in its distal part for minor deviations, and in the proximal part for significant ones, which are considered more justified interventions.

In Ukraine, orthopedic surgeons use Kochev's procedure, which involves drilling a hole in the bone and performing an osteotomy to shift the distal fragment, thereby abducting the metatarsal bone up to 15° and impacting it at the osteotomy site. Any existing exostosis is excised.

Logroscino's procedure is also quite common; it involves a wedge osteotomy near the head of the first metatarsal bone, with the bone wedge being transplanted into the gap created at the proximal end of the bone following its osteotomy, thereby repositioning it to normal alignment. This surgery is supplemented by shaving down the exostosis and capsuloplasty.

Occasionally, Mitchell's distal shape-forming osteotomy is performed, which involves shifting the head of the first metatarsal laterally and downward after resecting the exostosis.

Other procedures are either not used at all or very rarely, such as Babich's shape-forming osteotomy combined with the excision of the exostosis near the metatarsal head.

Currently, the most frequently performed procedure is the one shown in Fig. 219, which is a modification (by Mann R.A., 1993) of the McBride procedure (McBride E.D., 1954).

Surgical technique. Under anesthesia, sometimes using a tourniquet, the distal part of the first metatarsal bone is exposed via a standard dorsomedial approach. A U-shaped incision is made to create a fibrous-ligamentous flap, which is elevated from the exostosis and, following the capsulotomy, retracted toward the toe. An osteotome is used to resect the exostosis in the region of the head base.

Soft Tissues are bluntly dissected from the lateral side of the metatarsophalangeal joint, and the tendon of the m. abductor hallucis along with the transverse ligament connecting the medial sesamoid bone to the second metatarsal are isolated and incised. If necessary, a lateral capsulotomy is performed, after which the hallux is easily adducted, and the sesamoid bone returns to its normal position. During this procedure, it is crucial to avoid damaging the dorsal and plantar NERVES OF THE big toe, as well as the intermetatarsal nerve.

Fig. 219. Surgical techniques for hallux valgus according to Mann R.A. (1993).

After repositioning the hallux to its normal alignment, it can be fixed transarticularly to the metatarsal head using a Kirschner wire, or a spacer can be inserted between it and the second toe.

If the first metatarsal bone is significantly adducted, an osteotomy at its proximal end is required, accompanied by positional correction and percutaneous fixation with a Kirschner wire or a screw (Fig. 220). The surgical wounds are closed, and a short leg walking cast is applied. After wound healing, the wires are removed at three weeks. If an osteotomy was performed, the cast is removed once bone union is achieved.

Because significant valgus deviation of the hallux causes the second toe to lie beneath or overlap it and project upward, shoe pressure causes it to develop a hammer-toe deformity with callosity around the proximal interphalangeal joint.

The pain in the callus area can become excruciating when walking, even in loose footwear, prompting the patient to seek medical attention.

In such cases, simultaneously with the hallux valgus correction, a modeling procedure of the head or a resection of the distal part of the proximal phalanx of the second toe along with head excision is performed. The resulting diastasis between the base of the proximal phalanx and the middle phalanx lowers the toe and corrects its position. In the postoperative period, the callus atrophies and the pain disappears.

In the presence of advanced osteoarthritis of the metatarsophalangeal joint associated with severe pain and restricted mobility of the hallux, arthroplasty or, more commonly, arthrodesis in a functionally advantageous position is performed (Fig. 221, a).

Surgical technique. Under anesthesia, a dorsal incision medial to the tendon of the extensor hallucis longus exposes the metatarsophalangeal joint. The Joint Capsule is excised, and the articular surfaces of the first metatarsal bone and the proximal phalanx of the toe are sparingly resected. Resection is planned based on radiographs so that the hallux fuses at an angle of 15° of valgus deviation and 30° of extension relative to the axis of the metatarsal bone (Fig. 221, b). Following the apposition of the resected surfaces, the toe is fixed transosseously and percutaneously with two Kirschner wires or a plate. The wound is closed, and a short leg cast is applied, which is removed after bone ankylosis has developed.

Fig. 220. Corrected fragments of the first metatarsal base fixed with a Kirschner wire.

Fig. 221. Tilt angles of the proximal phalanx of the hallux during arthrodesis of the metatarsophalangeal joint.

However, in such cases, metatarsophalangeal joint arthroplasty (endoprosthetic replacement) is a more rational option (Fig. 221, c).