Hallus rigides

Degnerative arthritis of MTPJ of big toe

Causes

• Idiopathic
• Trauma
• Hypermobility
• Metatarsus elevatus
• Inflammation/ crystal

O/E

• Tenderness
• osteophytes
• Movement of MTPJ and IP joint(should be mobile)
• Pain on motion: terminal or full range
• Grind test
• Other foot pathology

Wt beating X Ray

• Look for IPJ arthritis: Fusion is relative C/I as the JRF increases and accelerates IPJ arthritis
• Johnson classification
  • Stage 1: normal joint space
  • Stage 2: narrowed Joint
  • Stage 3: Complete loss of joint space

Key points

• “Approach to management include conservative measures such as rocker bottom, limited surgical methods such as EUA and steroid inj, joint preservation surgeries and joint sacrificing procedures.”

Joint preservation

• Cheilectomy
• Proximal phalanx dorsiflexion osteotomy (MOberg)
• MT plantar flexion osteotomy

Joint sacrifice

• Keller excision arthroplasty
• Interposition arthroplasty
• Swanson silastic arthroplasty
• MTPJ arthroplasty
• Arthrodesis is gold standard FABER (20-10-5)

Hallus valgus

Lateral deviation of great toe with medial deviation of 1st metatarsal

Causes

• Intrinsic
  • Idiopathic
  • Hypermobility
  • Inflammatory
  • Neuromuscular
• Extrinsic
  • Foot wear

Pathogenesis

• Increased GRF on medial MTPJ
• Primary metatarsus varus
• 1st TMTJ hypermobility

History

• Age
• Cosmetic:
• Concerns of progression
• Unable to wear shoes
• Pain

Pain

• Extrensic
  • due to deformity
• Intrensic
  • Joint incongruence
  • degeneration
  • synovitis
  • transfer metatarsalgia due to 1st ray disfunction (stone in shoe)

C/E

• Look

  • HV itself
  • Other toes
  • Other proximal deformities
  • Dorsal skin and nail
  • Plantar callosities

• Feel

  • TMTJ tenderness
  • MTPJ tenderness
  • Plantar 2nd MT head tenderness and prominence
  • Pulse
  • Sensation

• Move

  • TMTJ hypermobility
  • Correctability of deformity

• Special

  • Silverskiold test for tight GS
  • Grind test
  • Beighton score

Xray

• Wt bearing xray
  • Measure angles
  • Position of sesamoid
  • Congruent (young) or not (old)
  • OA
  • Lesser toe pathology

Key points

Conservative

• Orthotic, splints
• Wide fitting shoes
• Physio for tight GS
• Reassurance
• Cocrine review: No stat sig benefit

Principle

• 1st ray is dysfunctional in H Valgus
• Aim of surgery is to
• relieve pain,
• correct deformity and
• re function the first ray
• by realigning the hallus

Achieved by

• Lateral soft tissue release to help relocating sesamoid
• Bone correction
  • To place MT over sesamoid
  • to reestablish soft tissue balance
• Medial capsular reefing
  • restore Abd Hallucis

Avoid

• Avoid shortening and elevation of 1st ray
• Avoid plantar dissection to avoid AVN

Procedure of choice

• Scaff +/- Akin with lateral release
• Lapidus if TMTJ is unstable
• Potential problems
  • Surgery is overling
  • Troughing
• Arthritic: Arthrodesis
• Mild: Chevron
• Severe: Basal osteotomy / Lapidus fusion
• Hypermobile/unstable/arthritic TMTJ: Fusion (Lapidus

Lateral release

• Cut Add Hallucis at Phalangeal insertion
• Release suspensory lig
• Do not release collateral

Chevron

• V shaped osteotomy
• Adv
  • small incision
  • Congruent joint
  • combined with lateral release
• Risk
  • AVN
  • Malunion

Scarf

• Allows multiracial displacement
• combined with lateral release
• Adv
  • stable
  • Low AVN
  • Low non union
  • large correction

Lapidus fusion

• Adv
  • powerful correction
  • stabilise 1st ray
• Risk
  • nonunion
  • Alter foot biomechanics
  • Difficult

Akin

• Wedge osteotomy of PP
• Correct HVI and pronation of big toe
• correct pull of EHL and FHL

Post op

• driving 6-8 weeks
• 6 weeks in heel wedge darco