Essential Insights On Hallux Valgus

By Richard O. Lundeen, DPM

   Back when I left the didactic world of podiatry school and entered my residency, I was ready for a transition that would blend the books with practice. Of course, the first two surgeries I performed did not fit the mold. The first one was a cartilage articulation preservation procedure (CAPP) and the other was a Keller procedure.

   The CAPP procedure was familiar to me only in books and the Keller seemed “outdated.” To my surprise, both surgeries turned out well and gave me an appreciation that diverse types of procedures can have a good outcome when they are performed well and on the proper patients.

   Granted, there were old standards like the first metatarsophalangeal fusion and Lapidus procedures but during my residency, new surgical procedures like the Austin and Scarf were coming down the pike for hallux valgus. There were also innovative new procedures (such as the Swanson total joint arthroplasty and Juvara basal osteotomy) that enthusiastic residents like myself quickly adapted.

   During the first part of my residency, base wedge osteotomies were the norm. We would commonly do them bilaterally, with or without a pin for fixation, and use circlage wire across the osteotomy. Patients usually walked on these osteotomies the day of surgery. Today, a base wedge would not be treated in this manner. The latter days of my training revolved around the Austin procedure. At first, we would not fixate the capital fragment but after a couple of metatarsal heads dislocated, they were all fixated. The Austin was certainly easier to perform than the base wedges and healed a lot faster with fewer complications. Patients were up and in shoes faster.

Five Salient Points On Hallux Valgus Procedures

   After performing thousands of hallux valgus procedures of almost every type described in the literature, I would like to share what I have learned from my experience.

   Closure of the intermetatarsal (IM) angle should not be the primary reason to select a particular surgical procedure. Experience and the literature support the fact that a basilar osteotomy of the first metatarsal will only reduce the IM angle 3 to 4 degrees. In addition, it provides relative elongation of the metatarsal and increases the proximal articular set angle (PASA), creating a “tighter” joint with dorsal jamming on weightbearing. This may necessitate additional distal procedures to reduce these complications. It is also well known that base osteotomies commonly elevate the metatarsal even after periods of nonweightbearing. Reducing the IM angle is still important but it should not be the primary goal in addressing hallux abducto valgus repair.

   Decompression of the first metatarsophalangeal joint (MPJ) is necessary to allow IM angle reduction and prevent postoperative jamming of the joint and valgus subluxation of the hallux. In my experience of performing first MPJ arthroplasties with or without total joint replacement and fusion, resecting either component of the first MPJ (i.e., via Keller or Mayo procedures) reduces the retrograde forces from the hallux valgus deformity. This leads to decompression of the joint. As a result, the IM angle reduces usually as much or more than with a base wedge procedure. Only in rare cases would one see a very large and rigid IM angle that requires a metatarsal cuneiform fusion or base osteotomy.

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