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Marshall Solomon, DPM
Director of Podiatric Medical Education
Chairman, Department of Podiatric Medicine & Surgery
Farmington Hills, MI
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Male Speaker: Subject is hallux varus. For those scarf bunionectomies that were overaggressive, this is how you would correct those. Essentially, the etiology of hallux varus are three. It could be congenital, iatrogenic or traumatic. Historically, less than 2% to 17% is identified in the literature for iatrogenic hallux varus. McBride in his literature stated that he had between 1 in 12.9% occurrence of hallux varus in his McBride bunionectomies. Of course, there is the possibility of hallux varus with the use of osteotomies, chevron, closing base or opening base wedge osteotomies, and Lapidus procedures, of course, closing base wedge being the highest because of the reduction of the IM angle. A couple of things we normally see is usually the staking of the head of the first metatarsal. This results in resection of the sagittal groove medially. Its purpose is to prevent the drifting of the tibial sesamoid. Actual excision of the fibular sesamoid, which causes an imbalance of the flexor brevis and subsequent decreased volumes based in the apparatus itself and weakens it with a greater pull of the medial head of the flexor brevis. You can create a negative IM. Negative IM causes [indecipherable] [02:01] production in the HA, shifting more to the medial aspect of the metatarsal head, and medial capsulorrhaphy, aggressive resection of caps or causing abduction of the proximal phalanx and the head of the metatarsal. Osteotomy is that correct passive deformity overaggressive osteotomies. How do patients usually present? Well, they present with pain, associated irritation of the medial aspect to the hallux against their shoe gear. They end up having pain along the medial aspect of the first metatarsal because of the spasm of the abductor hallucis. Then, of course, they develop MP joint pain because of the position of the base jamming, causing limitation and subsequent crepitus. Radiographically, it’s pretty classic. We’ll see transverse plane adduction of the hallux, a visible decrease of the IM or even an actual negative IM angle, and we’ll see absence of a fibular sesamoid, and we’ll see some peaking of the tibial sesamoid medial to the head of the first metatarsal. You can have a negative proximal articular set angle that develops because of hallux varus, and of course, the narrowing medially causes jamming in the joint, developing adaptive sclerosis at the head of the metatarsal and actually contouring of the articular surface more medially. Let’s take a look at treatments. There is nonsurgical treatment and we could divide that between early and late hallux varus. Early, if we know that we can accomplish that by strapping, splinting, bandaging, counterbandaging, padding, and then monitor that with serial radiographic x-rays. For late, there’s not a whole lot you can really do. You can pad to avoid irritation. You use shoe modification, lighter shoes and the bigger toe box is about all that you can do. Surgical intervention is also divided into early and late hallux varus. We also divide it into flexible deformity and nonflexible deformity with arthritis.
Essentially, flexible deformity, we’re going to be doing soft tissue procedures, as simple as the medial capsulotomy, abductor release tendon balancing, and Mini TightRope which we’ll talk about. In the non flexible, we’ll combine the tendon balancing procedures with arthrodesis. Then, of course, there is the reverse metatarsal osteotomies that can be performed. An early surgical caps, medial capsulotomy, what we do, essentially that can be done through minimal incision. We can actually take a small blade and identify the medial aspect of the MP joint, insert, and do a capsulotomy and do a partial severing of the abductor hallucis tendon. With this, we’re able to aggressively splint over that and reduce the contraction, but this has to be early. We’re seeing this possibly at the first postoperative band and your first postoperative bandaging. We want to try to accomplish that certainly within the short period of time for it to be effective, if it’s going to be effective. Some of the common tendons and structures that we’re going to be dealing with in tendon transferring is, of course, the DTML is the distal transverse metatarsal ligament, which I’ll refer to as DTML because it’s easier, and of course, the EHL, and the EHB, and the abductor hallucis tendon. Those are sort of color coordinated for you. In earlier repair, the extensor hallucis longus, you can transfer the longus under the DTML and into the proximal lateral base of the proximal phalanx. It’s a soft tissue procedure in the tendon balance. It is dynamic and it will help bring over those early hallux varus deformity. Now, you can do is you can do the same procedure, do a split hallux, hallucis longus transfer. Essentially, it’s the same technique. You’re taking two thirds of the lateral aspect of the extensor hallucis longus and you’re transferring that under the DTML. This helps reduce the possibility of IP joint arthrodesis. You generally don’t need to do that in this procedure. Then, you can use the brevis. This helps us to prevent some stiffness because we don’t interrupt the EHL. The procedure essentially is that we transect the brevis approximately three to four centimeters proximal to its insertion, and three proximally, then we reroute it under the DTML from distal to proximal, and anchor it into the lateral aspect of the first metatarsal head, and then secure it along the lateral capsule. That seems to be an effective procedure. A more technical procedure is using the abductor hallucis brevis transfer. What we do is we take it off from its medial aspect to the base of the proximal phalanx, and tunnel it underneath the metatarsal head in the DTML, and then suture it either by anchor or drill a hole into the base of the proximal phalanx. This is another effective way. It's important to use a K-wire in this procedure, a 0.062 K-wire to allow stability so fibrosis will occur in the corrected position. In the category of early surgical repair, the Mini TightRope, it’s a chapter in the new McGlamry book by Molly Judge. Dr. Molly Judge explains this procedure. It was also in our literature that talked about this. Essentially, two drill holes are made, one at the base of the proximal phalanx, one at the surgical neck of the metatarsal.
Fiber wire is passed medial to lateral through the drill holes, and then back up through the base, and then placed on a button on the proximal phalanx. Subsequently, it is drawn back and you can actually tighten it until you get reduction in the hallux, and you get it in a more rectus position. Then, that’s tied down under the button on the head of the metatarsal and the surgical neck area. That is an effective procedure, relatively new procedure with the use of the Mini TightRope. Let’s move into late repair. These are the patients that have had it for greater than four months and they’re pretty fixed. There is associated complications that are associated with a late surgical repair that needs to be addressed. Essentially, what we do is we do the extensor hallucis longus transfer as we previously described, transecting it at its insertion, bring it proximally back under the DTML, and inserting it laterally on the base of the proximal phalanx, and then fusing the IP joint to prevent hallux malleus. This is a good procedure for reduction of the hallux varus. It’s one thing to also mention that it’s only indicated if there is a preexisting malleus deformity and/or if you have high IP joint arthrosis or pain. The tibial sesamoid is removed as a requirement for the reduction. In late surgical repair, overcorrection of the IM angle, we have the negative IM angle. The goal here is revisional osteotomies should be done at the original area or level of where the osteotomies were performed, so a reverse Austin, or a [indecipherable] [12:45] shaft, or opening or closing base wedge at the base of the metatarsal. It’s important to note that, generally, if you’re going to go back in, you’re going to have to be cognizant of the fact that you’re going to end up shortening this metatarsal. If you shorten this metatarsal, you’re going to get lateral metatarsalgia. It’s important that you use an axial guide, again, to try to plantarflex and try to negate the shortening of your osteotomy, your reverse osteotomy. That’s important to keep in mind. Remember that most osteotomies distally are stable. They may not need nonweightbearing. If they do, if they are closer to the base, then you should keep the nonweightbearing for six to eight weeks. Now, if you were correcting the [indecipherable] [13:51] and it was overly aggressive, then you’ve developed varus, again, an osteotomy can be done, a reverse Reverdin-Green or a vertical osteotomy. Or, if you’re concerned about shortening of the metatarsal, that can be accomplished by a crescentic osteotomy to reduce the shortening. Now, if the head has been staked and there’s lateral subluxation of the metatarsal head, which is a nice way of saying, the hallux varus, essentially, what you want to do is bring that lateral cartilage back to articulate in a congruence fashion with the base of the proximal phalanx. Essentially, this can be done by using a reverse Reverdin-Green or distal crescentic osteotomy. Here, you can make a consideration.
If that patient essentially has low demand and is very sedentary, you might consider doing a Keller bunionectomy, which decompresses the joint, and you can get correction of the hallux varus that way. Or, if there are higher demand, you might consider arthrodesis of the joint. Keep that in mind as potential options. Postoperatively, it’s really procedure dependent. Soft tissue and stable osteotomies can be partial to weightbearing. Proximal osteotomies, nonweightbearing, and they should be placed in a posterior splint or a short leg cast with crutches, wheelchair assist or a Rollabout might be very beneficial for them for about six to eight weeks. Let’s look at the literature real quickly, in review of three major approaches to hallux varus correction. This was in the Journal of Foot and Ankle Surgery, failure of soft tissue release with tendon transfer for a hallux varus. This was a level four evidence study. There were 52 patients with 68 feet, and one of the four procedures of soft tissue transfers of tendons, there were three reoccurrences in the major limitation. In this study, was that 41 of the 68 were with the extensor hallucis longus with the IP fusion category. It really didn’t test out the other procedures. Another was in the Mini TightRope correction. This was a case report from the Journal of Foot Surgery 2010, level four evidence. A followup of 10 months where they had 70 degrees of dorsiflexion and 10 degrees of plantarflexion at the first MP joint without pain or crepitus. Then, in the British Journal of Bone and Joint Surgery, level four evidence, there were 19 patients, 19 feet with one surgeon, 13 Scarffs, six Austins. They had no arthritis. They had nine patients with greater than 60 degrees of dorsiflexion, and their AOFAS scores rose 18% or almost 20%, 20 points. What was impressive was that mean their IM angle preoperatively was a minus 0.3 and did increase to a 3.3, so it’s not too bad. Current references, just to update the references, two references on hallux varus. In text reference form, Josh Gerbert has a new text that came up last year on textbook of bunions. He has an excellent article on hallux varus. In the new McGlamry which came out this year, as I had mentioned before, Molly Judge had a excellent chapter on hallux varus and approaches to repair. Okay. Here are the articles that are referred to in the literature. Okay, any questions? We’re moving right along here. No questions, okay, great.