Orthopedic Case 2





HALLUX VALGUS

This fifty-five year old woman presents with a rather severe hallux valgus deformity which is non-responsive to conservative measures such as modification of shoe wear. She describes extreme tenderness along the medial eminence and has noted having to modify her lifestyle, in that she no longer exercises due to pain in the foot. She is noted to have increased motion of the hindfoot, that is in the ankle, subtalar, and transverse tarsal joints. This is noted to be bilateral. There is noted to be a hallux valgus angle of 40 degrees with subluxation of the sesmoids. The hallux valgus deformity is noted to be incongruent. .An increased mobility of the first tarsal-metatarsal joint with the appearance of a callous beneath the second metatarsal head is noted.

Options:

1. Chevron distal metatarsal osteotomy.

2. Lapidus procedure.

3. Proximal osteotomy with distal soft tissue release.

4. First metatarsophalangeal joint fusion.

5. Implant resection arthroplasty.



Commentary: When one suspects hypermobile first ray, thought should be given toward providing an increased stability to the first tarsal-metatarsal joint. Unfortunately, it is often times difficult to assess the term "hypermobile." Some authors have advocated the presence of a IPK beneath the second metatarsal as evidence of such hypermobility. Others have advocated merely assessing the saggital dorsi and plantar motion of the first metatarsal to determine if there appears to be "too floppy" of a medial ray. The definition remains elusive.



The deformity is clearly beyond what one would normally attempt with a Chevron due to the fact that the amount of correction required in order to correct the hallux valgus deformity may shift the distal osteotomy so far lateral, that there may be difficulty with it healing. A proximal osteotomy with distal soft tissue release is a reasonable procedure, provided that the first tarsal-metatarsal joint is not too unstable. The arthrodesis of the first metatarsophalangeal joint is an option, however, if there is increased mobility at the first metatarsocuneiform joint this will result in further instability and stress to be placed upon this joint. Shown in figure 8 is the appearance of an articular facet proximally, which if present precludes any distal osteotomies or pure soft tissue releases as a way to reduce the intermetatarsal angle. When this is present, a proximal osteotomy or arthrodesis of the first tarsal-metatarsal joint must be considered.