Arthritic and Osteoarthritic Halluces Valgi

A. Osteoarthritic Hallux Valgus

It is imperative to find out if the patient shows signs of osteoarthritis in the 1st metatarso-phalangeal (MTP) before undergoing treatment, because it should be adapted to the condition. Not only the surgeon has to correct the Hallux Valgus, but he or she also has to take care that the joint be loosened so it is not as tight as well as make sure to avoid premature joint contacts.
1. Cheilectomy (Exostectomy of the Osteophytes)

On top of a proper metatarsal osteotomy, the osteophytes which are in premature contact are resected.

2. Decompressing Phalangeal Osteotomies

Moberg’s Osteotomy: Closed bevel osteotomy with dorsal tip, to reduce the premature contact of the osteoarthritic dorsal area from the proximal phalanx.

3. Akin-Moberg Osteotomy: Decompression to reduce the toe’s « valgus ».

This is a two-plane osteotomy which combines :

Akin (to partially correct the lateral deviation of the toe with a median closed bevel)
Moberg (closed-bevel dorsal osteotomy with dorsi-flexion of the proximal phalanx)

        This will add 40º to the MTP dorsi-flexion (or « extension ») to the loss of 25º of the plantar flexion (without, however, any functional change in the patient’s stride).

        This is combined with a metatarsal osteotomy which corrects the Hallux Valgus following the degree of deformation and the clinical stage. However, the aim of the metatarsal osteotomy is to shorten the metatarsal (with Scarf osteotomy or a modified Mitchell’s), so as to loosen the joint.

        However, the other metatarsals must be assessed so they can also be shortened at the same time if need be. Otherwise the secondary metatarsalgies might give as much, if not more, pain than the initial condition.

4. Decompressing Chevron Osteotomy (Vanore-O’Keefe)

Here a complete « slice » is re-sected at the superior area of the chevron (by opposition to a DMAA Chevron, which resects a “bevel” with a medial tip in the superior area of the chevron.

When reducing this osteotomy, not only the metatarsal is shortened, but a significant lowering of the metatarsal head is also obtained.

B. Osteoarthritic Hallux Valgus

The most common type of this Hallux Valgus is rheumatoid arthritis. There can be other rather destructive rheumatoid problems, as, for instance, psoriasic arthritis hereunder.

Treatments follow the following criteria :

The extent of the damage to the joint
Stabilization (remission stage) of the rheumatoid disorder

Rhumatoid Polyarthritis

1. Hallux Valgus with a good control of the disorder; injury to the front of the foot stable for a good while; little damage to the joint cartilage at the head; absence of displacement of the other metatarso-phalangeal bones.

            The adjustment of the 1st metatarsal has to be « bony » and substantially bonded, especially in the case of osteopenia. Special care should be taken that the osteotomy does not shorten the 1st metatarsal.

            Herewith : Basal crescent osteotomy (R. Mann’s)

            Alternative procedures: Ludloff-Merson or scarf osteotomies.

        2.    Hallux Valgus with a good control of the disorder for a good time; little damage to the joint cartilage of the 1st metatarsal head; displacement of the other metatarso-phalangeal bones but without cartilage loss.

        If the head cartilage is not too damaged, a shortening and raising osteotomy can be attempted (i.e.: a modified Weil osteotomy).
        Herewith : The osteotomy must shorten the 1st metatarsal, especially if it was a bit too long to start with. Alternative procedure: Scarf with shortening.
            3.    Hallux Valgus with no change in the disorder in a while; little damage to the joint cartilage of the 1st metatarsal head; untreatable displacement of the other metatarso-phalangeal bones, cartilage loss and callosities.

What the surgeon must do here is to re-sect the metatarsal heads. To cure the Hallux Valgus, he must include a shortening osteotomy, otherwise the big toe will be way too long and out of proportion next to the other toes. It is important to affix the osteotomy in these cases of osteopenia to avoid a mal-union in dorsi-flexion. Another technique is Scarf osteotomy with shortening.

4. Acute Hallux Valgus with joint damage in all metatarsal heads

So, in acute conditions, the surgeon has to fuse (arthrodesis) the 1st metatarso-phalangeal and resect the metatarsal heads, which will give the best long-term results in severely rheumatoid patients.

[Haut de la page]