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45 y/o female who had tibial and fibular sesamoid removal (as teenager due to a fracture) and IPJ fusion. She developed Hallux Varus within the year following. Through the last 30 years she has modified her shoes to accomodate this flexible deformity. It is getting increasingly difficult to accomodate this with shoes and limiting her athletic ability. X-rays show almost negetive IM (retrograde force of Hallux?). Deformity increases with weight bearing and active plantarflexion of Hallux against resistance. It almost appears as though the FHL tendon moves medially during firing. Any thoughts on surgical options?

Hi Pejka33:

Re: surgical options;

It's been my experience that soft tissue repair is doomed to long term failure (with long standing deformities like this one.)
Too bad they didn't leave some of the sesamoid behind.

If she has a negative IM angle then you need to direct attention to this. An opening wedge, reverse closing wedge, Met/cun fusion with angular correction, reverse Mitchell/Austin/Chevron. Your choice depending on the 1st MTPJ location and metatarsal length pattern.

If the long flexor slips medially, which it most likely does, you'll need to repair this, which is not simple because of the lack of surgical exposure with a normal Bunion incision.
You can reroute this tendon through plantar soft tissue - use non absorbable sutures for this part of the procedure.

You need to be sure, as well, that the MTPJ is redirected to it's normally slightly valgus position. A reverse Reverdin, Green, Modified Austin, etc.....

If the EHL has contracted over the years this also needs to be lengthened.

Hope this helps
Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

the articular margins of the proximal phalanx and 1st mt are probably non-viable for reconstruction of the 1st mtp jt and probably requires fusion of 1st mtp jt.the negative im angle is the etiology and even if you address this, the joint wont function properly due to the lenghth of time passed since first recognized.the arthrodesis will arrest the problem and pain.
dlbdpm@yahoo.com

It probably depends on what X-ray/MRI shows. She certainly won't be happy with an arthrodesis if she is an athlete.

In the rather unlikely event that the MTPJ is viable then, as Steve suggests, a modified reverse Reverdin or Austin might address the I.M. angle. A reverse Akin might be necessary to correct the varus hallux but don't forget to address the adductor and lateral head of FHB which was probably disrupted when the lateral sesamoid was removed.

Whatever your decision, warn her of the strong probability of less than 100% reduction and that she will require orthoses following surgery. Better a little abduction than adduction.

Good luck.

Bill

patients do very well status post arthrodesis of 1st mtp jt.the idea is to eliminate pain and re-establish weight bearing to a non functional joint.xray/mri is not going to provide viability of articular margins which is clearly an intra operative decision.arthrodesis is a time tested procedure with high patient satisfaction.reconstruction is potentially viable with a master surgeons' ability,recognizing parabola length,im angle,compensation for shortening/lengthening of metatarsal and appropriate bone grafting with fixation.consider your alternatives carefully.by the way,patients can still run after fusion,the stride will merely be shorter.
dlbdpm

"patients can still run after fusion,the stride will merely be shorter" -

Do you tell patients (runners) that they can continue running after fusion?
I'd be interested to know if you have found a way to allow patients to do this.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

The fusion of the 1st MTP jt directs extension/dorsiflexion through the hallux IP jt.I have patients that still play tennis after the fusion of the 1st mtp jt as well as retired military personel that still run.I guess if running is considered a 6 minute mile, these patients would remain joggers, but they remain participatory in the sport. no orthotic,no lesser metatarsalgia.The fusion is not only a satisfying result for the patient but also for myself.
dlbdpm

Steve:

I have a competitive over 60 male triathlete that I performed a 1st MPJ fusion on and he is running much more than before, with no pain. Actually, in my patients with structural hallux limitus, many of them can run more comfortably than they can walk. For example, one of my patients (45 y/o white male) with only 10 degrees of hallux dorsiflexion during nonweightbearing examination regularly ran the Western States 100 Mile Run without pain, but couldn't walk a mile without pain. This phenomenon occurs probably because there is less 1st MPJ dorsiflexion required for running than for walking.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Update:

Sorry for the incorrect information. Patient doesn't have a negetive IM (8). Her only pain is from the toe rubbing medial/dorsal on the shoe. The joint is viable (radiographically) and she has no limitation of motion here and no pain. The deformity worsens significantly with plantarflexion against resistance. I have photos and x-rays if anyone is interested. Considering re-routeing long flexor (if needed) splitting and anchoring to proximal phalanx to stabilize the deforming force, medial release, lateral tightening with hinged ex-fix ???? Thoughts?

Can you post x-rays?

I agree with Steve on this one. Osseous realignment is probably the preferred surgical procedure for this patient. The way I approach these patients is to consider what the primary deforming structure(s) is and then plan the surgery around correcting that deforming structure(s). Also required is an accurate analysis of the forces/moments acting across the joint(s) in question so that the biomechanics of this patient's specific problem may be more completely understood.

In this patient's case, it is likely that the soft tissue structures plantar to the 1st metatarsophalangeal joint (MPJ) that cause a 1st MPJ plantarflexion moment are also causing a 1st MPJ adduction moment which results in the patient having an adducted hallux (i.e. hallux varus deformity). Why? Because the adduction deformity of the hallux increases with weightbearing and with active plantarflexion of the hallux against resistance.

The next question then becomes, what are the soft tissue structures plantar to the 1st MPJ that can cause a 1st MPJ plantarflexion moment? Normally, this would include:
1. medial band of the central component of the plantar aponeurosis;
2. adductor hallucis
3. abductor hallucis
4. flexor hallucis brevis
5. flexor hallucis longus

We must assume from the clinical evidence, that one or more of these structures, when they are exerting a hallux plantarflexion moment, are also acting medial enough to the vertical axis of the 1st MPJ so that a strong hallux adduction moment is also created. This hallux adduction moment will also cause the hallux to exert a laterally directed retrograde force on the first metatarsal head that will cause an increase in the external rotation moment on the first ray. This will, in turn, tend to cause a decrease in 1st intermetatarsal angle when these plantar soft-tissue structures generate either passive or active tensile forces on the hallux during weightbearing activities.

Therefore, with these biomechanical facts in mind, appropriate surgical solutions for this patient may include the following:

1. Closing or opening base wedge osteotomy of the first metatarsal to increase the 1st intermetatarsal angle.
2. Lapidus procedure to arthrodese, stabilize and adduct the first metatarsal.
3. Metatarsal neck osteotomy to shift the 1st metatarsal head more medially.
4. Reverse-Akin type osteotomy to shift the insertion of the FHL tendon more laterally.
5. Release of tight medial capsular structures/tendons and tightening of lateral capsular structures/tendons at 1st MPJ.
6. Arthrodesis of 1st MPJ.

Personally, I would likely, with the information presented to me here, perform a reverse-Reverdin-Laird osteotomy (i.e. horizontal L-osteotomy) to abduct and medially shift the capital fragment relative to the 1st metatarsal shaft. After the head had been shifted and temporarily pinned in place, the first metatarsal would be loaded from plantar to assess hallux position intraoperatively. If the correction observed was not satisfactory, then a reverse-Akin procedure could be performed additionally to place the FHL tendon more lateral relative to the first MPJ vertical axis.

There are many ways of appoaching this problem surgically, and no one approach is the best. The type of procedure chosen, however, should be carefully considered along with the biomechanics of the 1st MPJ/1st ray complex for each individual patient, since as more surgeries are attempted, the likelihood of a successful surgical result for the patient diminishes.

Hope this helps and good luck.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Thanks Kevin for your detailed thoughts.

Carie