Ch.

1 Preoperative Evaluation of the Bunion Patient

Etiologic Factors
o Abnormal biomechanics of the 1st ray and 1st MPJ during the propulsive phase of gait are the primary
underlying factors in the development of most cases of HAV and Hallux Limitus
o Rarely found congenitally
o Thought to be hereditary only to the point of inheritance of the predisposing biomechanical traits that lead
to abnormal 1st ray and 1st MPJ function
o Primary Causes of HAV
1. Abnormal biomechanics of 1st ray/1st MPJ
2. Abnormal pronation with unstable 1st ray
3. Dorsiflexed 1st ray (metatarsus primus elevatus)
4. Long 1st ray
5. Abnormal IM angle
o Primary Causes of Hallux Limitus
1. Abnormal biomechanics of 1st ray/1st MPJ
2. Abnormal Pronation with unstable 1st ray
3. Dorsiflexed 1st ray (metatarsus primus elevatus)
4. Long 1st ray
Normal Biomechanics
o When the foot is plantigrade in midstance period of gait, there normally is 20-30 of available hallux
dorsiflexion
o When the foot enters propulsive phase of gait, the 1st MPJ mobility is used up
o As propulsive phase of gait continues, greater 1st MPJ mobility is required, so the 1st MPJ axis shifts
within the 1st metahead, made possible by the 1st met plantarflexing relative to the 2nd met.
Plantarflexion of the 1st met is achieved through posterior gliding of the met on the sesamoids
Plantarflexion of the 1st met in the propulsive phase of gait is facilitated through supination of the
STJ, creating a stable MTJ, which allows the Peroneus Longus to function effectively
Abnormal Biomechanics
o Most common abnormalities for interrupting 1st MPJ function are abnormal foot pronation, dorsiflexed 1 st
ray (metatarsus primus elevatus), and long 1st ray
When the foot is pronating during the propulsive phase of gait
Excess medial forefoot load bearing is created, dorsiflexing the 1 st met
The Peroneus Longus is impaired in its ability to impart a plantar-lateral moment on the
1st ray
A reverse Windlass effect is created in which the plantar fascia strongly opposes the 1 st
MPJ
Line of progression of plantar forces shifts medially
Common causes of pronation (involving HAV and Hallux Limitus)
Flexible flatfoot valgus
Gastrocnemius Equinus
o HAV Progression
As the hallux progressively subluxes laterally in the development in HAV, retrograde forces
create adductory deformation of the 1st ray alignment
HAV is a gradual, progressive medial subluxation of the 1st metahead out of the
phalangeal/Sesamoidal/ligamentous cup

Stages of Hallux Abducto Valgus

Stage 1

Stage 2

Stage 3

Stage 4

HAA = normal
IM Angle = normal
Congruous Joint
* This stage is almost indistinguishable from
Stage 1 Hallux Limitus
HAA = abnormal
IM Angle = Normal
Deviated Joint
HAA = abnormal
IM Angle = abnormal
Deviated Joint
HAA = abnormal
IM Angle = abnormal
Subluxed Joint

Hallux Limitus Progression

As the proximal phalanx repetitively impacts the 1st met articular surface in gait over time, the
patient can develop not only symptoms, but also progressive changes at the joint that restrict
motion further and lead to degeneration of the joint

Stages of Hallux Limitus

Stage 1
(Hallux Limitus)

Stage 2
(Hallux Limitus)

Stage 3
(Hallux Limitus)

Stage 4
(Hallux Rigidus)

NWB 1st MPJ Dorsiflexion 65

WB 1st MPJ Dorsiflexion:
Functional Limitus = <20 RCSP and 20-30 NCSP
Structural Limitus = <20 RCSP and NCSP
May have some pain with activity with 1st MPJ ROM
1st MPJ Crepitus on ROM = Absent
1st MPJ Radiographic Degenerative Changes = Absent
NWB 1st MPJ Dorsiflexion 50-64
WB 1st MPJ Dorsiflexion: <20 - could be functional or structural limitus, both
1st MPJ pain on ROM found at end of dorsiflexion during palpation
1st MPJ Crepitus on ROM = Absent
1st MPJ Radiographic Degenerative Changes = Absent or mild dorsal exostosis
NWB 1st MPJ Dorsiflexion 30-45
WB 1st MPJ Dorsiflexion: <20 - could be functional or structural limitus, both
Pain with 1st MPJ ROM
1st MPJ Crepitus on ROM is Present, especially near end dorsiflexion
1st MPJ Radiographic Degenerative Changes = Moderate changes
NWB 1st MPJ Dorsiflexion <20 total
WB 1st MPJ Dorsiflexion = usually Absent
Pain with 1st MPJ ROM
1st MPJ Crepitus on ROM is Present
1st Radiographic Degenerative Changes = Severe Changes

Evaluation
o Typical pain from pressure on a bunion is aching in nature
Shaper pain may indicated joint pathology, and when associated with maximal dorsiflexion, may
indicate a functional or structural hallux limitus
o Pain in shoe gear is typical
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Physical Exam
o NWB Exam
Measure excursion of 1st ray (with STJ in neutral)
Normal = 5mm
Hypermobility can be defined by a total excursion > 15 mm
o Hypermobility of the 1st ray may indicate need for a metatarsocuneiform
arthrodesis
o Commonly see metatarsalgia and/or callus beneath the 2 nd MPJ
Unstable 1st Ray = normal excursion, but does not become stable and plantarflex relative
to the 2nd met in the propulsive phase of gait
o Abnormal pronation is the most common reason for an unstable 1 st ray
Metatarsus Primus Elevatus (dorsiflexed 1st ray)
o Greater excursion in dorsiflexion than in plantarflexion and demonstrates a
resting position above the plantar plane of metaheads 2-5
o More prominent in hallux limitus than HAV
o Can lead to lesser metatarsal transfer symptoms (metatarsalgia)
Measure ROM of 1st MPJ
There is usually no transverse plane motion of the 1 st MPJ
Normal Dorsiflexion = 65-75
Normal Plantarflexion = > 15
Presence of crepitus with or without pain may strongly suggest that the articular surface
is damaged and not salvageable
Tracking = Any tendency to drift back into the abnormal position during motion
represents joint axis deviation
Trackbound = The inability to move the hallux completely into a corrected position,
representing severe axis deviation
Hallux Interphalangeal Joint
Hallux Abductus Angle
o Normal = < 10
Hyperkeratotic Lesions
A plantarmedial pinch callus may indicate abnormal pronatory roll-off
A callus directly under the 1st metahead may indicate:
1. A prominent sesamoid
2. Plantarflexed 1st met
3. Rigid FF valgus
A callus under the 2nd metahead may indicate:
1. Functional or Structural abnormality of the 1st ray (dorsiflexed)
2. Retrograde plantarflexion of the 2nd met due to dorsal contraction of the 2nd MPJ
(either due to HAV or a hammertoe deformity)
3. Short 1st met
4. Long 2nd met
5. Plantarflexed 2nd met
6. Loss of hallux purchase
o WB Exam
Increases in the HAA or IM angle may indicate a higher degree of hypermobility than was
suspected
Must assess passive 1st MPJ dorsiflexion while WB to detect a possible functional hallux limitus
Normal Dorsiflexion from WB surface = 20-30
o Radiographic Evaluation
Patient must be WB
Angles
3

Met Adductus Angle (MAA)

o Normal: < 15
IM Angle (IMA)
o Normal: 8-12 (rectus foot); 8-10 (adductus foot)
Total Adductus Angle (TAA)
o TAA = MAA + IMA
o Normal: 20-22
Hallux Abductus Angle (HAA)
o Normal: 15-20 (depending on source)

Type of MPJ Deformity in HAV

Type of Deformity
Structural
Positional
Combined

PASA/DASA
Abnormality
PASA DASA Abnormal
PASA and DASA Normal
PASA DASA Abnormal

Joint Congruency
Congruent
Deviated/Subluxed
Deviated/Subluxed

PASA
o Normal: 7.5
o Functional PASA = when the PASA is less than or equal to the IMA
o Dysfunctional PASA = when the PASA is greater than the IMA
DASA
o Normal: 7.5
Hallux Abductus Interphalangeus Angle (HAIA)
o Normal: 10
Met Protrusion
o 2 mm
Metatarsal Width
o Transverse intercondylar 1st metahead width:
Males: 21-26 mm
Females: 17-25 mm
1st MPJ Congruency
o Congruous = lines are parallel
o Deviated = lines intersect outside of the joint
o Subluxed = lines intersect inside of the joint
Tibial Sesamoid Position (TSP)
o Normal: Positions 1-3
First Metatarsal Declination Angle
o Normal: > 15
st
1 Metatarsal Relative to the Talus
o Bisection of the neck of the talus should pass through the metahead
st
1 Metatarsal Relative to the 2nd Metatarsal
o Dorsal shafts should be parallel and should overlie each other
Gapping Between the 1st Met Base and 2nd Met Base
o Normal: < 2 mm

Ch. 2 Specific Perioperative Considerations

Pre-Op
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Anatomy- Knowing the contour of the MTs, phalanges helps with planning the hinge axis for CBWOs, etc. Recognizing
that a fascial plane exists between sub-Q tissue and the joint capsule allows surgeon to use blunt dissection to separate
capsule and fascia. Understanding vascular anatomy decreases chance of AVN, delayed union, or non-union.
Charting- Document a WB and NWB exam, biomechanical exam, and radiographs
Templates- Plain white typing paper is used over an outline tracing of the film. 1) Allows accurate pre-op determination
of bone excision/addition 2) Eliminates eyeballing 3) Less time-consuming than math eqns 4) Minimal materials needed
5) Can be done w/o patient present 6) Allows realignment of segment when multiple osteotomies are performed.
IMPORTANT: Level of correction must correlate so measure to reference point (MPJ, IPJ, etc.) and remember template
doesnt consider bone loss due to width of power saw
Orthotic Devices, etc.- No studies prove fxnl orthoses prevent formation or progression of a bunion deformity. However,
pronation can -> bunion or functional hallux limitus.
Intra-Op
Capsulotomies- Distract first. Mediovertical-remove medial capsule + TV plane correction. Medial U- Same as
Mediovertical + allows relocation of hallucal sesamoids. Basing U distally makes TV plane correction easier. Medial HBenefits of U + dont have to resect proximal or distal capsule but poor choice for resectional arthroplasties. Medial TGood exposure with same benefits as Mediovertical. Inverted L- Dorsal and Medial exposure of 1st MT head w/ same
benefits as Mediovertical. Dorsolinear- Good dorsal exposure but poor for soft tissue correction. Dorsal T- Dorsolinear +
allows ST removal and TV plane correction. Lenticular- Mediovertical + FRONTAL plane correction
Fibular Sesamoid, etc- Fibular sesamoid excision controversial but rarely leads to hallux adductus/varus. Almost always
sever LCL b/c if hallux abducted its likely contracted and contributing to the deformity
Fixation- Stainless steel wire should be inverted so as to purchase > 1 cortical surface. Staples are mostly used for
opening wedge osteotomies and arthrodesis. Absorbable pins are good as secondary fixation or for intra-articular fracture
repair. ST anchors assist for adductor tendon transfers. Bone plates stabilize fusion sites with bone graft and CBWOs of 1st
MT.
Radiography/Fluoroscopy- Position of dorsal cortex of 1st MT relative to lesser MTs does NOT change from WB to
NWB radiographs so its good to check for alignment
Post-Op bandage- Be careful not to dorsiflex or over-pad (and thus adduct) the hallux when bandaging
Post-Op

Radiographs immediately and @ 3-6 weeks

Steri-strips or Silicone dressing sheets effective over incision site
Bandages are removed @ 2 weeks so a removable bunion splint is helpful after that time
PT good to initiate ASAP to increase ROM and decrease edema
Crutches, Casting, or Post-op shoe as needed according to patient, procedure

Ch. 3 Soft Tissue Procedures

Silver Bunionectomy (Partial Ostectomy of the 1st Metatarsal Head)
Partial ostectomy of the first metatarsal head
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 Removes bump only the etiology if the deformity is NOT corrected!

Usually used for compromised patients (i.e. advanced age or medical problems)
Indications
o When a true dorsomedial or medial prominence is present at 1 st met head
o Medial bump pain with shoe wear
o Bunion deformity present
o Pain-free and adequate ROM
o Medial bursa
o HAV, mild (little hallux valgus or increase in IM angle)
o Neuritic pain at 1st met head
Advantages
minimal surgery
o Little edema
o Easy
o No special equipment
o Early WB and return to shoe gear
Disadvantages
o Etiology not addressed
o Weakens medial MPJ; therefore results in further HAV
o Poor long -term results
Technique
1. Access joint
2. Saw used to remove medial eminence
- If the base of the proximal phalanx is overhanging, remove it too
3. Care to preserve sagittal groove
- Take more bone dorsally and preserve tibial sesamoid shelf to prevent hallux varus

Improper removal of medial eminence vs. proper removal

Post-op Care
1. Post-op shoe (solely to accommodate bandages, it is not necessary to eliminate propulsive phase of gait with
this procedure)
2. A removable bunion splint my help maintain hallux position and prevent lateral drift
3. Back to regular shoe gear after suture removal at 10-14 days
Potential Complications
o Continued abducted hallux position
o Chronic Swelling
o Limited 1st MTPJ ROM
McBride Bunionectomy
Includes: removal of medial eminence with release or transfer of adductor hallucis tendon into lateral met head
and removal of fibular sesamoid
Often used in combination with osseous procedures for structural deformities to rebalance soft tissues (rarely
used as an isolated procedure)
Indications
o Medial bump pain with shoe gear
o Pain with tibial or fibular sesamoid
o HAV deformity
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Pain-free and adequate ROM

Medial bursa
Deviated to subluxed 1st MPJ
Frontal plane deviation of sesamoids
May have DJD of fibular sesamoid
May have hypertrophy of medial eminence
No crepitus
May have mild valgus rotation of hallux
Normal alignment of 1st ray
Key: flexibility of the 1st ray (the IM angle will only reduce with a soft tissue procedure if the angle is
flexible and reducible prior to surgery. Success is less likely with limited ROM)
Advantages
o Early WB
o Minimal bone resection; therefore minimal edema
o Allows for transverse plane correction of the hallux
Disadvantages
o Limited correction as isolated procedure
o CANNOT be used alone for a structural deformity
Technique
1. Access joint
2. Capsulotomy
3. Remove medial eminence with saw
4. Lateral release
5. Removal of fibular sesamoid
6. Adductor Hallucis tendon transfer
Post-op Care
o Post-op shoe
o Elimination of toe-ff in propulsive phase of gait only important if lengthening or tendon transfers done
Potential Complications
o Tibial sesmoiditis or hyperkeratosis beneath the tibial sesamoid
o Recurrence of HAV
Other Information
o Removal of fibular sesamoid or no removal of fibular sesamoid?
- Controversial
- It is a deforming force in any significant HAV deformity and must be addressed
- Modified McBride = without excision of fibular sesamoid
- Con: if you remove it, may end up with a hallux varus
- Pro: if you remove it, less chance of recurrence
o
o
o
o
o
o
o
o
o
o

Adductor Tendon Transfer

- Used in conjunction with McBride to either relocate the sesamoids on the frontal plane or to help reduce
and maintain the IM angle
- Transfer tendon to medial aspect of 1st MPJ
- Relocates sesamoids and closes down IM angle
Requirements for sesamoid realignment
Normal crista
No degenerative sesamoids
No osteotomy in conjunction
Frontal plane deviation of sesamoids on X-Ray
Requirements for IM reduction
Manually reducible IM
Good bone stock if tendon is to be transferred through metatarsal (Joplin procedure)
Normal met protrusion distance
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 Normal sagittal plane alignment of metatarsal

Advantages
With transfer to relocate Hallucal sesamoids:
- No increase in post-op management
- Reinforces medial capsular correction
With transfer to reduce the IM angle:
- Less post-op management than standard osteotomy
- Immediate post-op ambulation
- Can reduce a significant IM angle
Disadvantages
With transfer to relocate Hallucal Sesamoids:
- Must have a normal-size tendon
- Can get overcorrection
- Requires normal crista and absence of DJD
With transfer to reduce the IM angle:
- Requires transverse plane mobility of the 1st met
- Requires normal sagittal plane alignment of 1st met
- Requires a normal to short 1st met
- Requires good bone stock
- Requires a normal-size tendon
- Absence of significant dysfunctional PASA
Contraindications
Relocation of hallucal sesamoids:
- Atrophied adductor tendon
- Crista erosion
- DJD of sesamoids
Reduction of the IM angle:
- Positive MPD
- Lack of transverse plane mobility of the 1st met
- Medial gapping of 1st met-cuneiform joint
- Abnormal sagittal plane malalignment of 1st met
- Atrophied adductor tendon
- Dysfunctional PASA of 1st met head
- Poor bone stock of 1st met
Techniques
1. Transfer to medial capsule - to relocate sesamoids
2. Transfer into metatarsal neck - to reduce IM angle
3. Transfer through the metatarsal neck (Joplin Procedure) to reduce IM angle

Complications of Soft Tissue Procedures

1. Recurrence (not enough)
2. Hallux varus (too much)
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3. Joint jamming

Ch. 4 Hallux Osteotomy Procedures

General indications for hallux osteotomies

o Pain associated with 1st ray complex is present
o Pressure of hallux against 2nd toe may be present
o Movement is pain-free when the hallux is taken through the ROM with foot in loaded-position
o Hallux abductus present when foot is WB
o Minimal valgus rotation of the hallux
o Congruous 1st MPJ is present unless corrected by an additional procedure
o Significant degenerative changes of the articular surfaces of the 1 st MPJ and hallux interphalangeal joint is
absent
o Normal bone density of proximal phalanx
o Proximal phalanx is not abnormally short

Complications of the Akin-type Procedures

o Undercorrection or Overcorrection of deformity
o Pain at osteotomy site
o Delayed union or nonunion at osteotomy site
o Shortened hallux
o Pain within MPJ or IPJ
o Hallux elevatus
o Lack of hallux purchase

Distal Akin Procedure

o Medial closing wedge osteotomy of distal aspect of the proximal phalanx of hallux
o Indications
Epiphysis of proximal phalanx may be open
Normal DASA
Abnormal Hallux Interphalangeal abductus angle
Normal to mildly elongated proximal phalanx
o Advantages
Ability to correct transverse plane hallux deformity without relying on soft
tissue alignment
Ability to correct a hallux deformity without disturbing the 1 st MPJ relationship
o Disadvantages
Longer healing, as compared with a soft tissue bunionectomy
Need for fixation of the osteotomy
Elimination of the propulsive phase of gait for 6 weeks
o Operative Technique
Distal arm is parallel to the hallux interphalangeal joint surface
Proximal arm is perpendicular to the long axis of the proximal phalanx
o Post op = patient put in surgical shoe and allowed to ambulate immediately
9

Oblique Akin Procedure

o Criteria
Abnormal Hallux-Interphalangeus Angle (HIPA) or abnormal DASA
Normal length and width of the proximal phalanx
Closed epiphysis
o Advantages
Ability to correct transverse hallux deformity without relying on soft tissue alignment
Ability to correct a hallux deformity without disturbing the 1 st MPJ relationship
Lends itself to screw fixation
o Disadvantages
Longer healing compared to a soft tissue bunionectomy
Need for fixation of the osteotomy
Elimination of the propulsive phase of gait for 6 weeks

Procedures to Shorten or Lengthen the Proximal Phalanx

1. Cylindrical Akin Procedure
Criteria
Abnormally long proximal phalanx
Abnormal HIPA or DASA
Open epiphysis may be present
Advantages
Ability to correct hallux transverse plane deformity without relying on
soft tissue alignment
Ability to correct a hallux deformity without disturbing the 1 st MPJ
relationship
Ability to shorten the hallux and preserve the intrinsic muscles of the hallux
Ability to have patient WB immediately, provided adequate fixation
Disadvantages
Longer healing compared to a soft tissue bunionectomy
Need for fixation device of the osteotomy
Elimination of propulsive phase of gait for 6 weeks
Delayed healing compared with other Akin procedures
Operative Technique
Proximal cut is perpendicular to the long axis of bone, distal cut angulated to correct
deformity
Post-op = WB in surgical shoe
2. Regnauld Procedure
Criteria
Abnormally long proximal phalanx
Normal HIPA or DASA
Adequate bone density
Hallux limitus

10

Advantages
Ability to correct an abnormally long hallux
Ability to increase 1st MPJ ROM by decompression of the joint and
creating soft tissue relaxation
Disadvantages
Longer healing than other hallux osteotomies
Requires good manual dexterity to fashion graft and prepare
medullary canal of proximal phalanx
NWB for 6 weeks
With removal of the base of the proximal phalanx from the wound,
this portion of bone now becomes an autogenous bone graft when
reinserted
Procedure will release the intrinsic muscle attachments into the phalanx and compromise
hallux purchase
Operative Technique
The base of the proximal phalanx is transected perpendicular to the long axis of the bone
and removed from the body (now becomes an autogenous bone graft)
o A peg is then created on the distal end of the removed base of the proximal
phalanx and re-inserted into the medullary canal of the remaining proximal
phalanx
Post-op = NWB for 4-6 weeks

3. Sagittal Z Procedure
Criteria
Abnormally long or short phalanx
Normal HIPA or DASA
Sagittal plane malalignment of the hallux may be present
Advantages
Ability to correct a sagittal plane hallux deformity without disturbing 1 st MPJ
relationship
Ability to shorten the hallux and preserve the intrinsic muscles to the hallux
More stable than a cylindrical Akin procedure
Lends itself to screw fixation
Can both shorten and lengthen the hallux
Disadvantages
Longer healing as compared with a soft tissue bunionectomy
Need for fixation of the osteotomy
Loss of the propulsive phase of gait
Operative Technique
The 2 arms are cut first (distal cut exits medially, proximal cut exits laterally)
To shorten, take bone from arms. The lengthen, separate the cuts longitudinally
Post-op = WB in surgical shoe

Proximal Akin Procedure

o Medial, closing wedge osteotomy of the metaphyseal base area of the proximal phalanx to correct an
abnormal DASA
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o
o

Criteria
Abnormal DASA must be present
Normal length of the proximal phalanx
Close epiphysis at the proximal phalanx
Normal HIPA
Advantages
Corrects abnormal DASA
Disadvantages
Need for closed epiphysis
Longer healing, as compared with a soft tissue bunionectomy
Need for fixation of the osteotomy
Elimination of the propulsive phase of gait for 6 weeks
Operative Technique
Distal arm is parallel to the hallux interphalangeal joint surface
Proximal arm is perpendicular to the long axis of the proximal phalanx
Post-op = WB in surgical shoe

Ch. 5 Austin-Type Bunionectomy

This bunion procedure is a horizontal V osteotomy (chevron) through the 1 st met. Head. This procedure was
initially used for reduction of the intermetatarsal angle. Today many modifications have been made to the original
for various forms of correction
Types of Austin Procedures: Indications and Advantages included
1) Unicorrectional Austin- only able to correct one structural deformity = relative reduction of the
intermetatarsal angle

2) Bicorrectional Austin- when two structural deformities that exist on the same body plane are
corrected= reduction of intermet. Angle (transverse plane) and proximal articular set angle (transverse
plane)

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3) Biplane Austin- when several structural deformities on different body planes are corrected=
reduction of intermet angle (transverse) and plantarflexion of the met head (sagittal plane). K-wire is
placed medial to lateral through bone and angled to achieve sagittal plane motion

4) Kalish Modification- when a traditional Austin cut is made the dorsal and plantar arms are angled at
60 degrees from the center point, enabling the surgeon to impact the capital fragment after
transposition w/out screw fixation. With the Kalish modification either the plantar or the dorsal arm
is made longer which decreases the angle (55 degrees) allowing the surgeon to utilize 2 screw fixation

5) Youngswick Modification- this is a plantar displacing and shortening modification to the Austin
procedure. The main focus is the shortening ability, which can be utilized to decompress the 1 st MPJ
increasing the ability to dorsiflex the joint. In this Austin procedure a dorsal section of bone is
removed from the dorsal arm of the V cut leading to shortening of the met and decompression

7 main general disadvantages of the Austin procedure: 1) true IM angle is not reduced, there is only a relative
reduction of the distance between the metatarsal heads. 2) amount of IM correction is dependant on the width of
the metatarsal neck. 3) no frontal plane correction 4) significant metatarsal elevatus cannot be corrected. 5) pt.
must remain in a non-propulsive shoe for 3 weeks post op and away from high impact activities for 2 months. 6)
adequate bone stock is necessary 7) 1 mm bone loss for basic Austin, however if performing the bicorrectional or
biplane bone loss is 3mm

3 main contraindications: 1) significant bone cysts in met head. 2) abnormally narrow met neck= cant reduce
relative IM angle. 3) severe DJD of 1st MPJ

Post operative care: immediate post op patient is placed in an apropulsive surgical shoe and allowed to
ambulate. At three weeks radiographs are taken and assessed and if healing is good patient can now ambulate in a
soft soled shoe that allows propulsive gait. High impact activity (running) avoided for 2 months

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Ch. 6 - Osteotomies of the 1st Metatarsal Head

General findings
1. Hallux abductus
2. Pain with normal shoes
3. Painless MPJ ROM
4. Normal to positive met protrusion distance
General Complications
1. Limited ROM at MPJ
2. Hallux varus
3. Delayed union or nonunion
4. Avascular necrosis (not common)
Reverdin Procedure
An osteotomy preformed in the metatarsal head to correct abnormal PASA. The Peabody is the same except it is done in
the neck (less stability and potential for slower healing).
Criteria/Advantages
1. Abnormal increase in PASA
2. Normal metatarsus primus adductus angle
3. Normal metatarsal declination
4. Can be done before epiphyseal closure
Disadvantages
1. Potential sesamoidal trauma (inducing arthritis)
2. No reduction in IMA
3. No correction of sagittal plane deformity
Post-op: Ridged-sole post-op shoe for 3-4 weeks; increasing ambulation to tolerance.
Reverdin-Green Procedure
This procedure protects against possible damage to the dorsal articular surface of
sesamoids and the sesamoidal groves on the metatarsal. This has essentially replaced
the Reverdin procedure. Same indications with addition of protection of the sesamoids.
There is and added complication of potential Intraarticular fracture.
Reverdin-Laird Procedure
The vertical osteotomy cut is through the lateral cortex, making it possible for a relative reduction of the metatarsus
primus adductus angle. By altering the apical axis on the horizontal cut, the head can be plantarflexed or shortened.
Criteria/Advantages
1. Abnormal PASA and metatarsus primus adductus angle
2. Normal to minimally abnormal metatarsal declination
3. (Same as Reverdin and Reverdin-Green)
Disadvantages/Complications
1. No correction of sagittal plane unless surgeon alters the apical axis
2. Less stability than the Reverdin
3. Potential dislocation of capital fragment
4. Relative IMA correction dependant on width of metatarsal
5. Transfer metatarsalgia
6. Intraarticular fracture

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Hohmann Dual-plane Displacement Osteotomy

Simultaneously addresses abnormalities in metatarsus primus adductus angle, sagittal
plane and PASA. A trapezoid shaped piece of bone is removed, the widest part of the
removed piece of bone is medial. This is no longer done because of instability.

Mitchell Procedure (Hohmann Modification)

A transpositional, step-cut osteotomy to correct IMA, resection of the medial eminence, and angulational displacement of
osteotomy to plantarflex the metatarsal head (to reduce incidence of post-op 2 nd metatarsalgia).
Criteria
1. Mild increase in IMA
2. Metatarsus elevatus
3. Normal PASA and DASA
4. Positive metatarsal protrusion distance
Disadvantages/Complications
1. No PASA correction
2. Shortening of metatarsal
3. Slower healing because cuts are more proximal (excessive callus or non-union)
4. Potential dislocation
5. Technically difficult
6. Prolonged disability and immobilization
7. Dorsal displacement which may result in metatarsalgia and limited 1 st MPJ ROM
Post-op: NWB with a posterior splint 4-6 weeks followed by 2 weeks of ambulation in a post-op shoe.
Derotational, Angulational, Transpositional Osteotomy (DRATO) Procedure
Preformed in the neck, can incorporate dorsiflexion of the capital fragment to increase dorsiflexion of the MPJ. Rarely
preformed due to specific criteria.
Criteria
1. Frontal plane rotation of the metatarsal head
2. Abnormal PASA
3. Plantarward adaptation of the articular surface of the 1 st metatarsal
4. Mild increase in IMA
5. Normal DASA
Disadvantages/Complications
1. Difficult to perform
2. Slow healing because in proximal cortical bone
3. NWB
4. Dislocation potential
5. Transfer metatarsalgia
6. Hallux elevatus secondary to excessive dorsiflexion of head
Post-op: NWB with posterior splint or cast for 8 weeks (the splint/cast prevent passive pull of EHL that occurs when the
foot dangles in plantarflexion).
The dorsal aspect of the osteotomy may be wider than the base to provide dorsiflexion of the head of the metatarsal. The
head will also be rotated.

15

Ch. 7 - SCARF Procedure

SCARF design made up of three cuts oriented from medial to lateral through first metatarsal shaft. Primary osteotomy is
made longitudinally with two shorter arms; one arm exits dorsally-distally and the other arm proximally-plantarly. The
angle on the arms is between 60 and 80 degrees.
PRE-OP INDICATIONS FOR PERFORMING THE PROCEDURE
1. Hallux abductus bunion deformity
2. Pain free ROM of the first MPJ not functionally adapted
3. Normal Metatarsal Protrusion distance
4. Adequate Bone density
5. Abnormal IMA
6. Abnormal PASA
7. Closure of first met epiphysis
8. Malaligned sagittal plane position of the first met
Technique Modification: SCARF Procedure
1. Inverted SCARF is stronger than Traditional SCARF.
2. Inverted SCARF= plantar arm of SCARF identical to Austin Cut Osteotomy
3. Troughing can still be present. Troughing results in plantarflexion of capital fragment.
4. Inverted and Traditional design still provide structural correction.
POST-OP MANAGEMENT
1. The DARCO POST-OP Shoe the osteotomy heals for period of 4-6 weeks
2. First MTPJ ROM done after first few days of surgery.
3. Use of removable bunion splint helps maintain soft tissue correction
4. Physical therapy needed
Advantages
1. Correcting larger IMA
2. Stability allow early wt bearing
3. Lengthening or shortening within osteotomy design
4. Mild sagittal plane correction of metatarsal
5. Correct abnormal PASA
Disadvantage
1. Increase soft tissue dissection for execution of osteotomy
2. Degree of intermetatarsal correction is dependent on width of metatarsal.
3. Osteotomy technically difficult procedure to perform
4. Troughing
5. Correction of PASA will take away correction of intermetatarsal
6. Cannot use other osteotomies or first MPJ implants
7. Traditional SCARF WEAK MECHINACLLY
8. May require bone grafting
Contraindications
1. Moderate to high abnormal PASA
2. Sagittal Plane deformity of first met
3. Osteoporosis
4. Abnormally narrow met width
Potential Inherent Complications
1. Delayed healing or non healing
2. Limitation of first MPJ ROM
3. Elevation of first met
4. Metatarsalgia
5. Chronic edema
6. Overcorrection of big toe

16

Ch. 8 Closing Abductory Wedge Osteotomy of the First Metatarsal

and Its Modifications
The CAWO of the first met base is used for reduction of metatarsus primus adductus associated with hallux abducto
valgus deformity. Deformities associated with the HAV that occur at the level of the met head or within the hallux must
be corrected by additional procedures. CAWO are for big bunions (large IM angle).
Two important components to performance of these osteotomies and to the task of multiplanar correction are (1) the
concept of the medial cortical hinge as an axis of rotation (hinge axis concept) and (2) the application of the Reese
osteotomy guide.
Hinge Axis Concept: if an axis of motion lies completely within a plane, absolutely no motion can occur within that
plane. As the deviation of an axis from a plane increases, motion in that plane increases. If an axis is perpendicular to a
plane, all motion occurs in that plane. Concurrent dorsiflexion can be obtained with closure of the osteotomy by
directing the hinge from dorsal-medial to plantar-lateral in the frontal plane. Concurrent plantarflexion is
obtained by orienting the hinge from dorsal-lateral to plantar medial. The amount of sagittal plane motion that will
result from closure of the osteotomy is proportional to the degree that the axis deviates from vertical in the frontal plane.
Pole is Medial = Dorsiflexion

Pole is Lateral = Plantarflexion

Reese Osteotomy guide: the four-component system enables a surgeon to more precisely place the osteotomy hinge axis
and keep the bone cuts in proper orientation relative to the axis. The clinical results of application of the hinge concept
are made more predictable with this system. Ensures both arms of the osteotomy are in the same plane of motion, the
wedge of bone is uniform, and that the osteotomy closes in a plane of motion that is perpendicular to the hinge axis,
ending with uniform bone contact. Consists of: K-wire (axis guide), handheld osteotomy guide that slides over the axis
pin, angular osteotomy guide, and compass with a hole in the center for placement of another K-wire.
Transverse osteotomy: Loison/Balacescu (traditional)
Oblique osteotomies: Juvara A, B and C
Postoperative management: NWB 6 weeks

17

Traditional CAWO (Loison-Balacescu type)

Transverse closing abductory wedge. Provides less correction than oblique osteotomy. Harder to fixate. Fixated
with monofilament wire or k-wire

Preoperative Radiographic Signs

o When the MAA is less than 15, with an IM angle of 15-20 occasionally and usually 20 or greater, this
indicates the need for a basilar met correction. When the MAA is 15 or greater, the TAA is used as a
guide. A TAA of 25-30 occasionally, and usually 30 or greater, indicates the need for a basilar met
correction.
o Normal to slightly positive MPD is desired.
o Closure of the Physeal plate is desired

Operative Technique
o When performing a CWO at the base of the fist met, distal procedures for correction of the HAV
deformity should be performed first, because the first met is more stable before performing the osteotomy.

Advantages
o Ability to reduce deformity at the level of its pathologic conditions
o Ability to shorten a mildly long first met
o Can be modified to obtain some dorsiflexion or plantarflexion of the first met (Hinge axis concept)
o No bone graft source is needed
o Can correct for greater deformity of the IM angle than with a neck osteotomy or the SCARF
o May be performed with other procedures distal to the osteotomy site for correction of other pathologic
conditions
o Performed completely in cancellous bone, which has good blood supply.
o Can be performed on a met shaft with a narrow width

Disadvantages
o Internal fixation is required
o NWB status should be maintained for approx 6 weeks
o Adequate bone stock is needed
o The physeal plate should be closed
o It is associated with some shortening of the first met
o Because of the osteotomy design, screw fixation is not advisable

18

Modified Juvara Osteotomy (Type A)

The osteotomy is oriented obliquely across the first met base and shaft, at a 45-65 degree angle to the long axis of
the metatarsal.

Because of the apparent advantages of rigid internal screw fixation, this osteotomy type is now in more common
usage than the Loison-Balacescu-type osteotomy.

Preoperative clinical symptoms and signs, radiographic signs, and biomechanical considerations are the same as
the L-B type osteotomy, except that a narrow met may preclude the use of a Juvara type A procedure in some
situations.

Advantages
o In addition to the advantages 1-6 for the L-B, the oblique osteotomy allows for screw fixation and its
advantages, including the ability to use earlier ROM exercises.

Disadvantages (In addition to disadvantages 1-5 for the L-B)

o NWB status may be necessary for a longer period than with the L-B
o Because of the oblique osteotomy, if fixation and hinge failure occurs with premature WB, a greater
amount of shortening may be sustained than with the transverse osteotomy.
o A narrow met may contraindicate this procedure
o More dissection is required to accomplish this procedure than with the L-B

19

Modified Juvara Osteotomy (Type B)

- The medial cortical hinge is not preserved with this osteotomy. Significant deformity of first met alignment in
both the transverse and sagittal planes can be corrected (type B1). The Juvara type B can be modified further to
correct an excessively long or short metatarsal (type B2). The most common use for this procedure has been for
correction of metatarsus primus adductus with metatarsus primus elevatus.
- Type B1 (transverse and sagittal plane correction only)
o Same as for the Juvara A except the screw is placed perpendicular to the osteotomy site and the distal
segment of the metatarsal is rotated about the screw to correct a sagittal plane deformity. (The transverse
plane deformity is corrected with the osteotomy)
The screw is loosened and works
as a hinge. The screw is then
tightened when the proper
sagittal position is obtained.

o
-

Type B2 (Transverse plane, sagittal plane, and length correction)

o Same as A and B1 except the osteotomy surfaces are manually juxtaposed and axially transposed to
correct the length abnormality.

Advantages
o The oblique osteotomy allows for screw fixation and its advantages, including the ability to use earlier
ROM exercises than with less stable fixation constructs
o Ability to correct significant abnormalities of first met sagittal plane position
o Ability to correct an abnormally short or long met (type B2 only)

Disadvantages
o NWB status may be necessary for a longer period than with the L-B osteotomy
o Because of the oblique osteotomy, if fixation and hinge failure occurs with premature weight bearing, a
greater amount of shortening may be sustained than with a transverse osteotomy.
o A narrow met may contraindicate this procedure
o More dissection is required to accomplish this procedure than with the L-B
o Lenghting of a short first met is not as readily accomplished as shortening a long first met, and
lengthening can potentially jam the first MPJ (type B2 only)
o Screw fixation for the type B2 procedure is technically more difficult than for screw fixation of an
osteotomy with an intact cortical hinge.

20

Modified Juvara Osteotomy (Type C)

- The medial cortical hinge is not preserved. This modification allows for correction of only sagittal plane (type
C1) or sagittal plane and length abnormalities of the first ray (type C2)
- Preoperative signs
o Significant abnormality of sagittal plane first ray alignment should be present
o A normal IM angle should be present
- Type C1 (sagittal plane correction only)
o The procedure is the same for the Juvara B1 except that no wedge is removed.
- Type C2 (sagittal plane and length correction)
o Same as Juvara B2 except no wedge is removed.
- Advantages
o Intraoperative sagittal plane positioning technique and ability to easily reposition intraoperatively is
advantageous over dorsiflexing or plantarflexing wedge osteotomies
o A narrow met does not contraindicate the procedure
o The oblique osteotomy allows for screw fixation and its advantages, including the ability to use earlier
ROM exercises than with less stable fixation constructs
o Ability to correct significant abnormalities of first met sagittal plane position
o Ability to correct an abnormally short or long met (type C2 only)
- Disadvantages
o NWB status may be necessary for a longer period than with the L-B osteotomy
o Because of the oblique osteotomy, if fixation and hinge failure occurs with premature weight bearing, a
greater amount of shortening may be sustained than with a transverse osteotomy.
o More dissection is required to accomplish this procedure than with the L-B
o Lengthening of a short first met is not as readily accomplished as shortening a long first met, and
lengthening can potentially jam the first MPJ (type C2 only)
o Screw fixation for the type C2 procedure is technically more difficult than for screw fixation of an
osteotomy with an intact cortical hinge.
Complications
- Dorsiflexion of the first met
- Shortening of the first met
- Overcorrection of the IM angle
- Under correction of the IM angle
- Fracture of the medial cortical hinge
- Delayed union or nonunion of the osteotomy site
- Plantarflexion of the first met

Comparison of Pathologic Conditions Addressed by the Osteotomies

Osteotomy
Metatarsus
Dorsiflexed first
Plantarflexed first
Primus adductus
ray
ray
Loison-Balacescu
++
+
+
Juvara A
++
+
+
Juvara B1
++
++
++
Juvara B2
++
++
++
Juvara C1
++
++
Juvara C2
++
++
++pathologic conditions readily addressed
+pathologic conditions reasonably well addressed
-pathologic conditions not readily addressed

Short first ray

+
+

Long first ray

+
+
+
++
++

21

Ch. 9 Crescentic Osteotomy of the 1st Met

Distal Crescentic shelf osteotomy:
Indications:
1. Abnormal PASA
2. Metatarsal protrusion < +4mm
3. Normal IMA
4. Pain 2nd to shoe, HAV, Pain free joint motion, bone stock
Contraindication:
1. > +4mm Met protrusion
2. Abnormal IMA
3. Abnormal sagittal deformity
Post-op:
1. Immediate wt-bearing, running shoe at 3wk,full activity at 8wk
Distal Crescentic osteotomy:
Indications: Same as distal shelf plus,
1. Abnormal Sagittal plane alignment
-May have limited range of motion
-Pain/Callous under 1st or 2nd met head
Contraindications: same as distal shelf (except some sagittal deformity permitted)
Post-Op:
1. Non-wt bearing 4-6wks, surgical shoe 1-2wk, full 10wks
Proximal Crescentic shelf osteotomy:
Indications:
1. IMA >15 rectus or TAA >25 in adductus
2. Met protrusion <+4mm
3. Can have moderate sagittal plane deformity
4. Epiphysis closed
5. Pain 2nd to shoe, Pain with motion of MPJ, HAV, bone stock,
Contraindications:
1. Abnormal PASA
2. Significant sagittal deformity
Post-Op:
1. Non-wt bearing 4-6wks, surgical shoe 1-2wk, full 10wks
Proximal Crescentic osteotomy:
Indications: same as Proximal Crescentic shelf plus,
1. More Abnormal Sagittal plane alignment
-May have limited range of motion
-Pain/Callous under 1st or 2nd met head
-Significant plantarflex/dorsiflexed 1st met
-May have dorsal bunion
Contraindications: Abnormal PASA
Post-Op:
1. Non-wt bearing 6-7wks, 1-2 wk surgical shoe, full at 12wk

General Advantages:
1. Less bone shortening
2. Mainly in cancellous bone
3. Shelf allows better stabilization and fixation
4. Distal allows articular reorientation
5. No bone wedge removed or needed
22

General Disadvantages:
1. Distal shelf allows only slight sagittal correction
2. Distal = no IMA correction
3. Less stable than other head/base procedures
4. Special instrument
Biomechanical considerations: functional Hallux limitus treat with functional orthosis post op, hypermobility not
controlled by orthosisneed lapidus, Long 1st met is a cause of deformity find another procedure

Ch. 10 Opening Abductory Wedge

The Procedure A medial opening wedge is made in the base of the 1st met to correct an abnormally high IM angle in a
short 1st met, since this procedure lengthens the 1st met, whereas a closing base wedge will shorten it further. However,
the Juvara type B2 closing base wedge allows for much more flexibility in lengthening the met than an opening wedge,
without the added complications and recovery time of a bone graft. The bone graft can come from the resected medial
eminence if large enough, from any wedge removed from a concurrent capsular osteotomy, from the calcaneus (requiring
an additional surgery site) or from allograft. The form of fixation used must provide a buttressing effect, taking any
compressive forces itself rather than transferring them to the osteotomy site. This is to prevent the graft from being
resorbed secondary to compression. This limits fixation to staples (authors choice), bone plates or external fixators.
Preoperative Indications
1. Pain with pressure on the bunion deformity
2. Pressure of hallux against adjacent digits may be present
3. Hallux abductus or hallux abducto valgus deformity is present
4. A bursa may be present over the bunion
5. Splayfoot may be present
6. Normal hallux interphalangeal abductus angle is present unless corrected by an additional procedure
7. Abnormal hallux abductus angle
8. IM angle over 15 degrees in rectus foot or TA angle over 25 degrees in adductus-type foot
9. Negative met protrusion distance
10. Normal PASA unless corrected by an additional procedure
Biomechanical Considerations Any 1st ray hypermobility must be controlled post-op to prevent recurrence of the
bunion. Uncontrolled pronation does not cause any problems.

Post-op A very prolonged period of non-weight bearing is a hallmark of this procedure. Weight bearing must be
delayed until radiographic evidence of graft incorporation is noted, which may take up to 12 weeks. If stable fixation is
achieved, the patient is put in a posterior splint and 1 st MPJ ROM exercises begin immediately. If fixation is unstable, a
NWB below knee cast must be used and ROM postponed. PT is usually needed once the cast is removed. Return to
normal activity varies between patients but will be at least 2-4 weeks longer than a closing base wedge osteotomy.
Advantages
1. Decreases a high degree of metatarsus primus adductus associated with a hallux abducto valgus deformity
2. Can be performed on a short first metatarsal
23

3. If a double osteotomy is performed on the fits met to correct an abnormal PASA, by performing an opening
abductory wedge osteotomy bone length can be maintained and jamming will not occur at the first MPJ.
4. The structural pathology is corrected at the level of the deformity.
Disadvantages
1. Internal fixation is required
2. NWB required for a longer period of time due to the bone graft
3. Osteoporosis can ensue from lengthy immobilization
4. Dislocation of subluxation can occur at the osteotomy site
5. Complete bone healing is prolonged with an opening abductory wedge osteotomy as compared with a closing
abductory wedge osteotomy
Complications
1. Over- or undercorrection of the IM angle. Avoid by using preop templates and not inserting an excessive or
inadequate bone wedge.
2. Loss of correction of the IM angle. Usually from a bone graft that does not adequately fill the opening wedge or
to inadequate internal fixation.
3. Fracture of the lateral cortex, producing dorsiflexion of the distal segment. This can be minimized by keeping the
foot NWB until adequate graft incorporation has occurred.
4. Dislodging of or irritation from the internal fixation device may occur postop, necessitating removal of the device.

Ch. 11 Double Osteotomy of the First Metatarsal

What it is:

24

This procedure has traditionally been known as a Logroscino which is a combination of a

distal Reverdin osteotomy to correct the PASA as well as a Loison-Balacescu or other CBWO
of the 1st metatarsal to correct the IM angle. However, medial opening base wedge osteotomies
or other procedures and combinations are also possible to achieve the desired results. An
important end goal of both osteotomies is to orient the PASA perpendicular to the 2 nd
metatarsal for optimal hallux alignment.
Indications:
Structural adaptation in 1st MT head (tracking or trackbound)
Abnormal HAA
IM angle >15 degrees in rectus foot or >25 degrees in adductus foot
Dysfunctional PASA before or after base wedge osteotomy MUST BE PRESENT
Contraindications:
Inadequate bone density
Advantages:
Ability to reduce deformity at level of pathology
Ability to make all structural corrections on the 1st MT
Ability to make absolute rather than relative correction
Disadvantages:
All disadvantages pertinent to Reverdin-Green or individual base procedures
Prolonged NWB
Extensive dissection required
Having 2 osteotomies increases difficulty in achieving proper structural alignment
Pertinent to the Procedure:
Different combinations of procedures can be used to shorten or lengthen the 1 st MT as needed. The wedge
from one site can serve as the graft for the other.
If deformity is purely structural (1st MPJ congruous), than MPJ doesnt need disarticulation
Use Green modification of Reverdin to stay in metaphyseal bone and protect sesamoids
Juvara is base procedure of choice-corrects length, IM angle, and sagittal deformity
Post-Op Care:
NWB 6-12 weeks depending on whether bone graft is used
X-rays within 24 hours and at 3 and 6 weeks
Normal ambulation and shoe gear at 8-10 weeks

Ch. 12 Lapidus Procedure

25

The Lapidus procedure is a 1st metatarsocuneiform joint arthrodesis

Indications: the main indication to perform this procedure is a hypermobile 1st ray, which leads to a hallux
valgus deformity
This procedure has great success in reducing hallux valgus, limitus and rigidus and also stabilizes the
medial column
For a patient with dorsiflexed first metatarsal the surgeon is able to remove
more bone plantarly than dorsally from the metatarsocuneiform joint and upon
closure the 1st met will be in a more plantarflexed position
Advantages: elimination of 1st metcuneiform hypermobility, stable medial
column and enables surgeon to correct large planar deviations
Disadvantages: extensive soft tissue exposure is necessary and can result in
healing problems. Due to bone removal the 1st ray will be shortened (however in
cases where pt has a short 1st met to begin, a bone graft can be incorporated into
the fusion site to maintain bone at its length. Patients will have a much longer
postoperative recovery time.
Complications: as with any type of fusion there is a possibility of a nonunion or a
malunion across the fusion site.
Post operative care: patient must remain non weightbearing in a cast for 6 weeks following
the Lapidus procedure. At the six week mark if adequate bony union is noted then the patient starts protective
weight bearing in a stiff post op shoe.

Ch. 13 - Keller Procedure

Overview - The Keller procedure is a joint destructive procedure used when there is pain or deformity at the 1 st MPJ and
certain patient complications contradict the use of other procedures. These complications include patients who cannot
tolerate non-weight bearing (unable to use crutches or other assistive gait devices), vascular disease that limits the
potential for bone and wound healing, patients who will have health degeneration secondary to prolonged recovery times,
and osteoporotic patients. The Keller is a better choice for these patients because it allows for immediate weight bearing,
there is minimal surgical intervention, little to no bone healing is required, and the procedure can be performed
subperiosteally, quickly and in a wet field.
The Procedure The proximal 1/3 of the proximal phalanx and the medial eminence of the 1 st met head are removed.
This removes the painful joint and stops the retrograde pressure of the abducted hallux on the 1 st met head, decreasing the
IM angle. There are two types, the simple Keller and the functional Keller. The first is the most basic procedure,
removing the bone and reclosing the joint capsule. The second takes steps to prevent some of the complications, such as
rebalancing soft tissue, placing interpositional flaps within the joint to prevent ankylosis, and distracting the joint with a
K-wire. The Keller is one situation where the met head can be staked, or excessively resected with intent. Much more
bone is removed from the met head than a typical bunion procedure would call for due to the inability to perform an
osteotomy.
Preoperative Indications
1. Stage 4 hallux limitus (hallux rigidus)
2. Severe hallux abductus or valgus with increased metatarsus primus varus in the geriatric or medically
compromised patient who is ambulatory challenged.
3. 1st MPJ implant failure
4. 1st MPJ arthrodesis failure
5. Hallux varus in which the first MPJ cannot be salvaged
6. Significant 1st MPJ pain with motion in the geriatric patient.
7. Preulcerative area at the 1st MPJ secondary to a significant bunion deformity in a patient with underlying vascular
disease.
8. Chronic or recurrent dermal ulceration beneath the hallux interphalangeal joint as a result of limited 1 st MPJ
motion in the insensate foot.
Radiographic Criteria (only whats interesting)
1. Osteoporosis may be present
26

Cystic changes within 1st met head may be present

Arthrosis of hallux interphalangeal and metatarsocuneiform joints may be present.
Abnormal shape or length of proximal phalanx may be present
Metatarsus elevatus, short 1st met or long 2nd met may be present but increase chance of transfer metatarsalgia post
op.
Biomechanical Considerations Removal of the proximal phalanx causes many biomechanical problems, many of
which lead to transfer metatarsalgia. These include inability of the hallux to plantarflex against the ground, metatarsus
elevatus due to the extensor expansion retracting proximally, and failure of the windlass mechanism. An abducted,
pronated gait also results from the loss of the windlass mechanism.
2.
3.
4.
5.

Post-op Ambulate immediately in hard soled shoe. Sutures removed 10-14 days. K-wire removed at 3 weeks. Post-op
radiographs taken only once as a baseline for future reference (no bone healing to monitor). Use orthotic with Mortons
extension. PT only needed if edema persists.
Advantages
5. Eliminates joint pain
6. Minimal post-op disability
7. Early return to normal shoe gear
8. Minimal tissue dissection
9. Retrograde forces on MPJ eliminated
10. 1s ray can be malaligned without correcting defect
Contraindications
1. Salvageable 1st MPJ
2. Active individual (athlete, dancer)
3. Spastic neuromuscular disease (need 1st MPJ stability)
Disadvantages
1. Creates short hallux
2. Loss of MPJ function
3. Loss of hallux toe purchase
4. Loss of 1st ray ability to bear load
5. Central metatarsalgia
6. Central met stress fractures
7. Need orthosis with Mortons extension
8. Potential for painful pseudoarthrosis or ankylosis of insufficient bone is resected from proximal phalanx.
9. Salvage procedure is difficult due to amount of bone loss.

Ch. 14 Implant Procedures

An alternative to the Keller bunionectomy

Implant arthroplasty is considered when there is pain or deformity in association with the loss of articular
cartilage
Primary goals of 1st metatarsophalangeal prosthesis: relieve pain, normal joint mobility, structural stability of the
joint, and good cosmetic appearance

27

Never use steroids with implants the decrease in the patients immunologic response is inappropriate with the
implantation of a foreign body
Types
1. Hemi - Base of proximal phalanx replaced
2. Total - Base of proximal phalanx and 1st met head removed (there are one- and two-component totals)
Materials
1. Silicone
- Very popular in the 80s
- Found to break down over time
2. Metal
a. Cobalt chromium
b. Titanium
- Strong and corrosion resistant
- Integrates well with bone
- Contains nickel
- Light weight
b.
- Not as durable
c. Sterilization and handling of implant
o Handle as minimally as possible only with blunt instruments!
o Silicone implants develop a static charge after sterilization; therefore must immerse in
solution before
implantation (metallic implants too)
d. Modification of implant
o Modifications can weaken implant not recommended!
o Can shorten stem if needed (Dr. Smith says this wont work)
e. Size use the smallest size possible because allows for most motion
f. Pistoning
o Necessary for silicone
- Disperses forces better
- Prolongs implant life
- Allows more motion to occur at the joint
o Avoid with metal implant
- Will cause bone resorption and loosening of implant
g.
Indications
o End stage hallux limitus/rigidus
o Hallux varus with severe degenerative changes at
o Pain and crepitation with ROM of 1st
1st MTPJ
o Adequate bone stock to accept stem of implant
MTPJ
o Osteoarthritis, traumatic arthritis, or
o No active infection
o No allergy to implant material
systemic arthritides
o Normal alignment of 1st MPJ (unless another
o Failed Keller arthroplasty
o Arthrodesis revision
procedure done to realign bone)

28

h.
i.
j.

Types
o Hemi = base of proximal phalanx replaced
o Total = base of proximal phalanx and 1st met head removed
k.
Hemi-Implant
o Only metallic are currently available
o Specific preoperative criteria:
1. Degenerative changes of 1st MTPJ that involve only the base of the proximal phalanx
2. Adequate ROM of 1st MTPJ (no hallux limitus/rigidus!)
3. Normal IM angle
4. Normal PASA
o Contraindications: the presence of uncontrollable pronatory forces
o Technique
1. Remove base of proximal phalanx
2. Cheilectomy (if doing the implant for hallux limitus)
3. Check size of implant
4. Drill or tamp hole in base of proximal phalanx for implant stem
5. Insert the implant
l.
Total Implants
Flexible Hinge Implant (one component system)
Made of silicone
Has stems for proximal phalanx and 1st met with central hinge
- The hinge can face dorsally or plantarly
Acts as a dynamic spacer
- Get some motion but not as much as hemi or 2 component systems
Stabilizes joint
Grommets
Thin titanium shield that fits over stem
Protects silicone from shearing forces and sharp bone edges
Preoperative Criteria
- Joint arthrosis of 1st MTPJ that involves the head of the 1st met, base of the proximal phalanx, or both
- Hallux limitus or rigidus
- Normal 1st met alignment
2. Two Component Systems
Replaces base of proximal phalanx and 1st met head
- Phalanx component = polyethylene
- Metatarsal component = metal alloy
Allows for greater postop range of motion than 1 component system
Difficult to salvage if failure (will need arthrodesis with bone graft)
Preoperative Criteria
- Good bone stock
- Normal alignment of 1st met (in both transverse and sagittal planes)
- Normal to short 1st met
- Ability to preserve at least one of the hallucal sesamoids
- Ability to control biomechanical aberrations postoperatively
- Absence of metabolic arthritic process
m.
Post-op
1. Post-op shoe
2. Early passive and active ROM for hemi and 2 component systems - start at 1-2 weeks
3.
May need continued compression for up to 4 weeks
4. Any abnormal pronation much be controlled with an orthosis
n.

o. Ch. 15 First Metatarsophalangeal Joint Arthrodesis

1.
2.
3.
4.
5.
6.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
1.
2.
3.
4.
5.

p. Goals of arthrodesis is to 1) eliminate pain in the 1 st MPJ and 2) provide stability to the first ray. With a mild
equinus the surgeon can place the hallux in a more dorsiflexed and abducted position and shorten the hallux.
Positioning of hallux when fused: 0 frontal plane, parallel with 2 nd toe (12-15 abduction), and 10-20 = 510mm dorsiflexion (high if pt has mild equinus or wants to wear higher heeled shoes). Keep the sesamoids
to avoid transfer metatarsalgia; if arthrosis exists, remove the cartilage obtaining ultimate fusion.
q.
r. Indications
Pain with ROM of 1st MPJ, with and without shoes
No pain in other joints of 1st ray
Possible pain or callus under 2nd metatarsal head (or others) due to 1st ray dysfunction
Possible presence of unstable 1st MPJ secondary to neuromuscular disease, prior trauma, or prior surgery
Adequate circulation for healing
Primary arthrodesis in hallux rigidus pt
s.
t. Disadvantages/Complications
Prolonged disability as compared with other MPJ destructive procedures
Often requires bone graft
Need for shoe modification
Limitation of certain activities
Potential for causing arthrosis in hallux IPJ or MC joint
Fixation may need to be removed
Potential for malalignment (too dorsiflexed or plantarflexed) which may necessitate revision
Potential 2nd toe irritation, or metatarsalgia
Hallux pain distally or nail deformity: subungual clavus, subungual exostosis, onychauxis or onychocryptosis
Sesamoiditis or plantar callus
Shoeing difficulties
Delayed union or nonunion
Stress fx of first or second ray
u.
v. Contraindications (Absolute)
Expectation by pt of wearing various shoe styles and heights
Expectation of participating in activities that require bending the MPJ
Severe osteoporosis or osteopenia
Sedentary elderly pts or significantly medically compromised pts who will do better with other procedures with less
morbidity post-op
Active infection
w.
x. Post-op: Guarded WB or NWB according to literature 4-6 weeks. If bone graft used 8-12 weeks NWB
followed by 2 weeks guarded WB. May need rocker sole, deeper toe box or lower heel. If removal of plate
desired, guarded WB 4-6 weeks due to risk of fx.
y.
z.
aa.
ab.
ac.
ad.
ae.
af.
ag.
ah.

ai.

Ch. 16 Hallux Limitus/Hallux Rigidus

aj. Hallux Limitus- a limitation of ROM of the 1st MTPJ.

MTPJ motion.

Hallux Rigidus- significant loss of first

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ak. Etiology of Hallux limitus/rigidus= biomechanical, traumatic, Soft tissue contracture and imbalances,
structural,
al.
metabolic, iatrogenic
am. BIOMECHANICAL= dorsiflexed first metatarsal caused by pronation and hypermobility.
an. TRAUMATIC= Intraarticular fracture of first MTPJ, dislocated 1 st MPJ, fracture of sesamoids
ao. SOFT TISSUE CONTRACTURES AND IMBALANCES= weak Peroneus Longus and overpowering
anterior tibial
ap.
muscle which causes metatarsal elevatus
aq. Contracture of plantar intrinsic of 1st MPJ or plantar fasciitis
ar. STRUCTURAL= 1) Dorsiflexed first ray
as.
2) Long first metatarsal makes abnormal IMA or compensate in sagittal plane creating dorsiflexed
metatarsal
at.
3) Long proximal phalanx
au. Metabolic= arthritic conditions affecting the first MTPJ
av.
aw. Post-operative after bunion surgery the surgeon must make sure no decrease in ROM due to:
Dissection of synovial reflections of the first MPJ
Excision of bone from met head produce capsulodesis
Bad capsulorrhaphy
Traumatic tissue dissection
Structurally adapted 1st MPJ with soft tissue rebalance
Lengthening of first met due to an osteotomy
Dorsiflexion of metatarsal an improper hinge axis or improper wedge removal.
Do not correct pre-op first met elevation
Hallux limitus due to pronation
Malalignment of first met on transverse plane
Dorsiflexion of metatarsal when wt-bearing started too early.
Poor patient compliance when it comes to 1st MPJ ROM
Intraarticular damage to first MPJ
Avascular necrosis of capital fragment
ax. Classification System: Oloff and Jacobs
(Grade 1 and 2 = joint preservation;
Grade 4 =
joint destruction)
ay.
Grade 1: pain at end ROM for 1st MPJ
az.
Limitation of first MTPJ ROM IN RCSP
ba.
Pronation
bb.
Elevatus of first met
bc.
Plantar subluxation of proximal phalanx of first met head
bd.
Grade 2: pain at end ROM of 1st MPJ
be.
Limited ROM 1st MPJ NWB
bf.
Osteochondral effect flattening of first met head
bg.
Dorsal exostosiso1st met head
bh.
Intra-op viable articular cartilage over majority of met head
bi.
bj.
Grade 3: Pain and crepitation with first MPJ ROM
bk.
Limited ROM NWB
bl.
Large dorsal exostosis of first met head
bm.
Osteophytic proliferation on dorsal aspect of base of proximal phalanx
bn.
Narrowing of 1st MPJ
bo.
Flattening of first met head
bp.
Significant degeneration of articular surface of first head intra-op
bq.
br.
Grade 4: Pain and crepitation with MTPJ ROM
bs.
Less than 20 degrees of total first MPJ ROM NWB
bt.
Total obliteration of the first MPJ
bu.
Radiographic findings more severe than stage 3
bv.
Loose bodies within first MPJ capsule

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Nonsalvageable articular surface

bx. PRE-OPERATIVE SYMPTOMS
Spasms, cramps, tendonitis of EHL
Not able to move hallux
Cant wear high heel shoes
Pain along the dorsal aspect of first MPJ because of shoes
Hyperkeratotic lesion under hallux interphalangeal joint
Hallux nail painful
Enlargement over dorsal aspect of the first MPJ area
Painful 1st MPJ motion
by. PRE-OPERATIVE SIGNS
Dorsal bunion
Limited or absent first MTPJ
Crepitation or pain with first MPJ ROM
Hallux extension distal to IPJ
Hypermobility of hallux IPJ
Hyperkeratotic lesion of hallux interphalangeal joint
Hallux nail deformation
Weakness of Peroneus Longus muscle, hyperactivity of anterior tibial muscle
Irritation of skin overlying dorsal aspect of 1st MPJ area without bursa formation
bz. PRE-OPERATIVE Radiographic Signs
Dorsal osteophytic proliferation at base of proximal phalanx and first met head
Dorsiflexed first met head versus 2nd and 3rd met head
Narrowing of first MPJ
Flattening of first met head
Arthritic changes
Subchondral sclerosis
Positive metatarsal protrusion
Pronatory changes in foot
ca. Biomechanical Consideration:
cb.
Functional limitus is a common finding with uncontrolled pronation with excessive supination around the
long axis of midtarsal joint producing elevation first ray produces jamming of the first MPJ. Treatment: orthoses.
cc.
Determine functional hallux limitus put patient RCSP and NCSP. In Relaxed Calcaneal Stance Position
functional hallux limitus the motion is limited. Motion increases as the foot is inverted to NCSP.
cd. Conservative Treatment Considerations (NON-BIOMECHANICAL)
Manipulation of the first MPJ under local anesthesia maximally dorsiflex and plantarflex 1 st MPJ
Periarticular corticosteroid injection
Stretching exercise using Tube Gauze during warm water soaks. Pull on the gauze thereby putting the hallux into
maximally dorsiflexed position. Leave in the position for ten to twelve minutes.
Active 1st MPJ ROM exercises
Passive 1st MPJ ROM
First ray ROM while patient at home after the foot has been soaking in warm water
Hallux glide Maneuver
Distraction maneuver of the first MPJ
Physical therapy modalities.
ce.
cf. Surgical Treatment Plans
cg. Soft tissue release to treatment soft tissue contractures
ch. First Category: Excessive fibrosis around the joint has to excise the fibrosis.
ci. Second Category: Capsulodesis dorsally produce limitation of rom. Surgical correction provided by doing
u-shaped capsular high rate of recurrence
cj. Third Category: Plantar adhesion of sesamoid apparatus. Surgery releases the adhesion of the sesamoid
apparatus.
ck. Post-op first MPJ ROM done immediate, proper exercise for maintaining joint motion, see physical therapy.
cl.
cm.

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cn.
co.
cp. Cheilectomy= osseous proliferation found overlying the joint
were excised
cq. Advantages:
Easy procedure
Reduce dorsal enlargement
Increase joint motion
Immediate post-op ambulation
Minimal post-op disability
cr. Disadvantages:
Capsulodesis resulting limited ROM
Does not correct underlying conditions
cs.
ct. Chondral Abrasion Arthroplasty reserved for younger patients with significant articular surface
degeneration.
cu. Procedure: Debridement of osteophytic proliferation from around the joint curettage and subchondral drilling
of all cartilage defects. First MPJ must be moved as soon as possible.
cv. Advantages:
Allows preservation of first MPJ
Immediate first MPJ ROM
Performed with other procedures.
cw. Disadvantages
Requires at least 50% articular surface be viable
Not correct Etiology
Nonpropulsive gait
Compliant patient
cx.
cy. Regnauld Procedure= one third of base of proximal phalanx is resected hemi-implant configuration.
Reinserted back into the proximal phalanx, shortening of proximal phalanx
cz. Advantages:
Correction of abnormally long hallux
Relaxation of soft tissue
Allow preservation of the joint
Increases overall first MTPJ motion by relaxing tension around the joint
da. Disadvantages:
Dexterity to make bone graft
Healthy and pain free 1st MPJ
Not correct any osseous sagittal plane malalignment.
Bone grafting complications
Internal fixation
NWB
db.
dc. Hohmann-Type Procedure= complete osteotomy through metatarsal neck, shortening lateral transposition
of capital
dd.
fragment, plantar displacement, reorientation of the articular cartilage dorsally, and plantarly.
de. Advantages
Corrects long first metatarsal
Reduce IMA
Sagittal plane displacement of the met head
Increase overall first MPJ motion
Reorientation of articular surface of first met head
Can be done with open epiphysis
df. Disadvantage:
Not correct sagittal plane
Will not correct IMA
4-6 weeks NWB

4. Unstable osteotomy
dg.
dh.
di.
dj. Watermann Procedure= dorsal closing wedge osteotomy of first met head plantar cartilage is directed more
dorsally.
dk. Advantages
1. Hallux function more dorsally
2. Good viable Plantar articular surfaces on the met head
3. Not interfere with an open epiphysis
dl. Disadvantage
1. Can create lack of hallux toe purchase post-op
2. Does not increase overall first MTPJ ROM
3. Does not correct structural deformity of first ray
4. Elimination of propulsive phase of gait for 3-6 weeks
dm.
dn. Youngswick-Austin= producing shortening of first metatarsal and mild plantar displacement of the heads.
do. Advantages:
1. Correct abnormally long first metatarsal
2. Mild plantar displacement of first met head
3. Increases overall first MPJ motion by relaxing tension around the joint
4. Corrects IMA
5. Corrects PASA
6. Immediate post ambulation
7. Does not interfere with open epiphysis
dp. Disadvantage:
1. Minimal plantar displacement of first met head
2. Elimination of propulsive phase of gait for 3-6 weeks post-op
3. Requires adequate articular cartilage
dq.
dr. Dorsal V Osteotomy= V osteotomy at neck of first metatarsal from dorsal to plantar apex distally toward
the joint.
ds. Advantages:
1. Correction of a mild moderate metatarsal elevatus
2. Inherent transverse and frontal plane stability
3. Shortening of elongated metatarsal
4. Increase overall first MPJ
dt. Disadvantage:
1. Can only correct for a mild to moderate metatarsal elevatus
2. Damage the hallucal sesamoids
3. Can only correct elongated first metatarsal
4. Cannot correct PASA
5. Cannot correct for a transverse plane abnormality of the first met
6. Requires adequate articular cartilage
7. 4-6 WEEKS NON-WT BEARING
du.
dv. Plantarflexory Wedge Osteotomy= wedge of bone removed from plantar aspect of first met base allows
plantarflexion of first met.
dw. Advantages:
1. True correction of metatarsal elevatus
2. Correct mild positive metatarsal protrusion distance
3. Increase overall first MPJ motion
4. Screw fixation
dx. Disadvantage:
1. Cant correct IMA
2. Difficult to correct IMA

3. NWB 6-7 WEEKS

4. Requires adequate cartilage on dorsal first met head
5. Closure of first met epiphysis
dy.
dz.
ea.
eb. Mau Osteotomy= oblique complete osteotomy first met dorsally from met neck to plantar aspect of
shaft/base area.
ec. Advantage:
1. Shortening of first metatarsal
2. Moderate plantar displacement of the first metatarsal
3. Allows transverse plane correction of first metatarsal
4. Increase MPJ motion
5. Allow screw fixation
ed. Disadvantage:
1. Does not allow for correction metatarsal elevatus
2. Plantar displacement of first met dependent upon shortening of surgeon
3. Requires 4-6 weeks NWB
ee.
ef. Juvara Modification Type C= osteotomy performed from dorsal to plantar at metatarsal base for
plantarflexion.
eg. Advantage:
1. True correction of a significant structural metatarsal elevatus
2. Increase overall first MPJ motion
3. Does not require removal of any bone
4. Transverse plane correction of the first metatarsal
5. Screw fixation
eh.
ei. Crescentic Osteotomy= plantar displacement of first met head or shaft.
ej. Advantage:
1. Plantar displacement of met head or shaft for a mild metatarsal elevatus
2. Do not remove wedge of bone
3. Performed at met base correct abnormal IMA
ek. Disadvantage:
1. Not correct linear abnormality of first met
2. Not correct abnormal PASA performed at met base
3. Adequate articular surface at first met head
4. 6 weeks NWB
el. Sagittal Z Osteotomy= modification of the Giannestra stepcut recession for lesser metatarsal dorsal-plantar
osteotomy allows plantarflexion, lengthening and shortening.
em. Advantages:
1. Plantarflexion of the met
2. Lengthening and shortening of met
3. Screw fixation
4. Increase first MPJ ROM
en. Disadvantage:
1. Not permit correction of a transverse plane deformity of met
2. Two points of fixation
3. Adequate articular cartilage at met head
4. 4-6 weeks NWB
eo. Resectional Arthroplasty Keller Type Procedure= resectional arthroplasty eliminates the distal half of the
first MPJ by removing base of proximal phalanx.
ep. Advantages:

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Elimination of joint pain

Increase MPJ in joint motion
Easily done
Immediate propulsive type gait post-op
Minimal post-op disability
eq. Disadvantage:
Destroy joint
Instability first ray
Not correct underlying deformity
Lesser metatarsalgia
er. Resectional Arthroplasty with Silicone Joint Prosthesis: Keller Type technique with insertion of a double
stem (total) implant.
es. Advantage:
Elimination of joint pain
Increased joint motion
Immediate propulsive type gait post-op
Increased internal stability of the joint and first ray regular Keller type procedure
Minimal post-op disability
et. Disadvantage:
Silicone degrades over time, removal replacement of the implant
Good Bone Stock
Requires normal osseous alignment of the first metatarsal
eu.
ev. Resectional Arthroplasty with Two-Component Joint Prosthesis= two-component joint prosthesis is
Keller-type technique two component metallic implant.
ew. Advantages:
Elimination of joint pain
Increase joint motion
Immediate propulsive-type of gait post-op
Increased internal stability of the joint and first ray compared with a regular Keller Procedure
Creates minimal post-op disability for patient
ex. Disadvantage:
Metallic prosthesis degradation over time removal replacement of implant.
Require Good bone stock
Normal OSSEOUS alignment
Viable tibial hallucal sesamoid
ey.
ez. Resectional Arthroplasty with Joint Prosthesis and Metatarsal Base Osteotomy= joint prosthesis and
metatarsal base osteotomy double stem implant. Osteotomy corrects in transverse or sagittal plane
malalignment.
fa. Advantage:
Allow for elimination of joint pain
Allow for increased joint motion
Increased Internal stability
Structural malalignment of first metatarsal
fb. Disadvantage:
Use of two silicone or metallic implant
Require good bone stock
Osteotomy at first metatarsal base area fixation
Possible complication replacement of the implant
fc.
fd. First Metatarsophalangeal Joint Arthrodesis= resects the first MPJ and fuses the proximal phalanx to the
first metatarsal.
fe.
Advantage:
1. Eliminate joint pain
2. Internal stability of the first ray

3. Does not use implants

ff.
Disadvantage
1. Eliminate motion of the first MPJ
2. Require fixation of the fusion site
3. 6-8 weeks of immobilization
4. Restricts type of shoes
fg.
fh.
fi.

fj.Ch. 17 Hallux Varus

1. The etiologies of hallux varus.
a. Congenital
b. Acquired
i. Iatrogenic
1. Overcorrection during hallux valgus surgery is the most common cause of acquired hallux
varus. Due to the following causes:
a. Excessive Medial Capsulorrhaphy
i. During closure of the medial joint capsule, any excessive tightening or
excessive resection of redundant medial capsular tissue will alter joint
balance.
b. Improper postoperative bandaging into adductus
c. Excessive medial eminence resection (staking of the met head)
i. Allows for destruction of the medial sagittal groove and tibial sesamoidal
groove, which serve as articular guides for the proximal phalangeal base and
tibial sesamoid. The proximal phalanx will have a tendency to displace
medially, which most often results in medial subluxation of the tibial
sesamoid.
d. Lateral subluxation (rotation) of the First met head
i. A complication of a distal met head osteotomy performed during bunion
surgery. Can result in hallux varus due to altering the joint axis.
e. Medial subluxation of the tibial sesamoid
i. Can result from staking the met head, an excessive lateral release with
fibular sesamoidectomy, or over-correction of the IM angle
f. Negative PASA from overcorrection or avascular necrosis
g. Abnormally low IM angle
i. From overcorrection, adductor tendon transfer, suturing the met heads
together, scarring or adhesions between the first and second MPJs, or
retrograde force on the fist met resulting from a hallux adductus
h. Aggressive lateral release with or without a fibular sesamoidectomy
i. Excision of the fibular sesamoid by itself does not cause a hallux varus;
however, it is often a contributing factor when combined with any of the
other listed causes. A similar situation develops with an aggressive lateral
release.
ii. Traumatic
1. Trauma to the sesamoidal apparatus, capsule, or the ligaments that stabilize the fist MPJ can
result in hallux varus. Trauma to any of the muscles or their tendinous insertions, which
normally act to abduct or stabilize the proximal phalanx onto the met head, can also result in
hallux varus.
iii. Metabolic
1. Inflammatory arthropathy: RA or other inflammatory arthropathies eventually cause loss of
integrity of the stabilizing ligaments, bone erosion, and subluxation of the first MPJ, which
may result in hallux varus.

iv. Neuromuscular
1. Idiopathic neuromuscular disease: neurologic dysfunction involving the motor system may
result in an imbalance of the muscles that bring about motion of the first MPJ, resulting in
hallux varus.
fk.
fl.
fm.
fn.
2. The procedures to correct hallux varus deformities.
a. When Soft tissue contraction with or without hallux hammertoe or medial sesamoid subluxation is present
i. Extensor Hallucis Longus Transfer in Combination with Interphalangeal Joint Arthrodesis
1. Transferring the EHL tendon under the deep transverse intermetatarsal ligament and into the
proximal-lateral base of the proximal phalanx. IPJ of hallux must be fused.
ii. Split Extensor Hallucis Longus Transfer
1. To avoid morbidity associated with the previous procedure, a partial transfer of the EHL was
developed where the lateral two thirds of the EHL rather than the entire tendon is sacrificed
and rerouted as previously described. Arthrodesis of the IPJ is not necessary because the
medial portion of the EHL remains to keep the IPJ in the extended position.
iii. Extensor Hallucis Brevis Transfer/Tenodesis
1. Transferring the EHB as a static tenodesis in order to reinforce the lateral repair. Routed
from distal to proximal beneath the intermetatarsal ligament and then anchored into the
lateral met. This is the recommended technique for augmenting the hallux varus repair. It
provides stability to the lateral side of the joint, and it does not compromise the EHL or
require a fusion of the IPJ.
iv. Abductor Hallucis Brevis Transfer
1. Detaching the tendon of the abductor hallucis at its insertion on the base of the proximal
phalanx and transferring it into the lateral plantar aspect of the proximal phalanx by routing
it plantar to the first met neck. Whereas the other tendon transferring or tenodesis
procedures require an intact or rudimentary intermetatarsal ligament, this method of transfer
does not. Therefore, in situations where the intermetatarsal ligament or adhesion between
the mets must be release or where there is no EHB tendon, this procedure is indicated. It
also does not compromise the EHL or require fusion of the IPJ of the hallux, and it can be
performed in the absence of an EHB or intermetatarsal ligament.
b. Overcorrection of the IM angle
i. In principal, the revisional osteotomy should be performed at the level of the original procedure. If
the procedure was performed at the head, a reverse Austin can be performed. If the osteotomy was
originally performed at the base and only minimal increase in the IM angle is needed, a reverse
Austin can still be considered. However, any situation that requires a significant increase in IM
angle will require a metatarsal shaft (Juvara type) or base procedure (opening wedge, closing
abductory). A reverse SCARF procedure will allow the patient to bear weight post op. However, the
other base or shaft osteotomies will require NWB in the post op period for 6-8 weeks.
c. Overcorrection of the PASA
i. In situations involving a negative PASA, a reverse Reverdin-Green procedure in which the vertical
wedge osteotomy is based laterally or a distal crescentic shelf-type osteotomy can be performed in
order to realign the articular cartilage. The distal crescentic shelf-type osteotomy is preferred
because it can be finely adjusted and creates minimal bone shortening.
d. Staked First Met Head or Lateral Subluxation (rotation) of Met head
i. In certain situations involving a staked or laterally subluxed but still salvageable first met head,
the remaining articular cartilage can be transposed medially into a more suitable position in order to
establish a better surface for articulation with the base of the proximal phalanx. A Reverdin-green or
a distal crescentic shelf-type osteotomy can be performed in order to realign the cartilage.
e. Nonsalvageable First MPJ

i. In situations where the joint is not salvageable, either from excessive resection of the medial
eminence (staked) or from significant DJD, joint-destructive procedures are indicated.
3. The complications of the corrective procedures for hallux varus.
a. EHL transfer in combination with interphalangeal Joint Arthrodesis
i. To prevent hallux malleus caused by an unopposed FHL, the IPJ of the hallux must be fused with
this procedure. This adds more overall morbidity to the hallux varus repair procedure and sacrifices
the EHL. Its performance should be considered only if the IPJ of the hallux is to be fused for some
other reason, such as a preexisting hallux malleus or IPJ arthrosis, or when the tibial sesamoid has to
be removed during hallux varus repair, resulting in absence of both sesamoids.
b. Symptomatic first MPJ stiffness along with weakness in dorsiflexion was a common finding postoperatively
when either the partial or total transfer of the EHL was performed.
fo.

fp.
fq.
fr.

Ch. 18 Intraoperative Complications

Medial Eminence:
Staking the Head: excessive resection, tibial sesamoid can sublux
50% or > exposedremove tibial sesamoid (HAV likely to reoccurlateral release and tightening
medial capsule)
If removing both sesamoidsHallux IPJ fusion (prevents hallux hammertoe from weak Brevis)
Large piece remove replace with fixation: may need fusion later due to arthritis
Capsulotomy:
Tearing capsule: suture back in place, if not possible extensor tendon graft (free onlay or distal end
sutured while proximal is still intact)
Excessive medial capsule resection: split capsule thickness of proximal portion and suture to distal
capsule. If too thin, remove capsule from proximal attachment and advance distally.
Tendon:
Extensor Hallucis Longus tendon severed
o Release tourniquet, re-anastamosis
If severed during lengthening:
o Overlay technique- see diagram
o Inlay technique- free tendon graft
Flexor Hallucis Longus: re-anastomosed through interspace
Osteotomy:
Bone Cyst: alter angle to place cyst in proximal part of bone
cut then remove
once Austin is moved laterally, never place screw in a cyst (curette if unable to remove).
Osteoporotic: cuts soft and yellow marrow, screws will probably not bite thus avoid
Excessive length via bone graft: >1-1.5cm must be gradualcompromise vascular
Complete transaction of bone: intra-op radiograph
Excessive bone wedge removed: leave partially open (fixate with staple, crossed pins, plate) NWB
Screws/plates
Articular damage: 4-6wk post-op shoe or non-wt bearing, immediate ROM
Excessive medullary remodeling:
Thinning/Fx of proximal phalanx: drill dorsally as possible,
If defect small and distal you can still use implant

fs.

ft.

fu.

fv.

fw.
fx.
fy.
fz.

ga.
gb.
gc.
gd.
ge.
gf.
gg.

gh.

Ch. 19 Implant Complications

gi. Implant complications may not be apparent or symptomatic to the patient and they typically fall into one of
the following categories:
gj. Infection
10 organisms per gram of tissue are normally required to cause an infection but this number drops to 100
organisms/gram of tissue with implants
Rates of infection with implants are only 1-2%
Deep infections mandate removal of the implant
Osteomyelitis can only be diagnosed with bone biopsy/culture of PP and MT
Once osteo cleared, re-implantation is possible at 6 mos-1 year
gk. Failure of Implant
Modifying implant/using it inappropriately may cause it to fracture
Most common modification is cutting or changing a stem
Examples of misusing an implant: Using a hemi-implant in presence of significant MT head arthrosis or in presence
of functional hallux limitus which cant be controlled, using an implant in a patient with a spastic neuro disorder,
using an implant when 1st MT is malaligned in the transverse or sagittal planes
Failure is usually due to material NOT design, and contraindicated in young patients
Deformation to the implant may occur in situations such as when its used without correcting a large IM angle
gl. Reaction to the Implant
The body reacts to large silicone pieces by encapsulation and to small silicone fragments with an inflammatory
reaction and foreign giant cell formation; the SMALLER the fragment the greater the inflammatory reaction and
pain!
Silicone particles which migrate may cause lymphadenopathythus implants which cause reactive synovitis must be
removed with synovectomy to relieve symptoms
Silicone, polyethylene, polymethylmethacrylate cement, and metal have all caused reactive synovitis and granuloma
formation
Metal can have a toxic effect on surrounding cells and cause release of mediators of bone resorption
Aseptic loosening or bone fracturing is a problem due to mechanical/material properties of the implants. Ex: 2-piece
implants 10-20x more rigid than bone
Foreign body reaction/Host rejection phenomenon is very RARE (<0.01%) and will manifest very early. Remove
implant
Ectopic bone formation can decrease motion and cause irritation
Subchondral Cyst formation contiguous with the implant is a VERY COMMON complication (as much as 75%) and
occurs with silicone AND metal devices
gm.
Failure of Surgical Technique
Dislocation/Malposition may result from overzealous soft tissue release, excessive bone resorption, remodeling of
the implant, excessive reaming, or failure to release/correct deforming forces

Limited post-op ROM/Jamming may occur. Assess sesamoids for adhesion-if they do not retract they may block
motion of the implant
Uncontrolled pronation leads to MT elevatus and thus is a contra-indication for hemi- or two-component implants
Excessive fibrosis caused by post-op edema will also greatly reduce ROM. Therefore use compression dressings and
PT aggressively
Hallux elevatus may result from improper angulation of bone cuts, inappropriate fashioning of stem holes, improper
bandaging, EHL contracture or FHL laceration
Aseptic necrosis is rare and usually due to overzealous bone work. It usually requires prolonged NWB
Bone fracturing is uncommon but may be caused by using an implant with an elastic modulus > bone such as 2component implants or metallic hemi-implants
Telescoping asstd with using too small an implant and requires removal
Recurrence of HAV deformity most common with hemi-implants and correction determined by nature of recurrence
and symptoms
Hallux adductus/varus is rare but caused by overcorrection or inappropriate bone cuts. Secondary complications to
this include EHL contracture-> hallux extensus.
Sesamoiditis seen with systems that maintain plantar intrinsic attachments. If sesamoids cant be preserved this is a
contraindication for using the implants
Intrinsic muscle instability of the hallux may result from arthroplasty with or w/o implants. Functional elevation of
the 1st MT with possible sesamoid removal increases pressure on lesser MTs leading to transfer lesions, stress
fractures, etc.
gn.

go.

Ch. 20 Postoperative Complications

Avascular Necrosis
safe zone have been recommended for the osteotomy and the release at the 1 st MTPJ
- the osteotomy: should stay between the perforators of the 1st met head and the nutrient artery
- the lateral release: consists of a straight lateral capsulotomy at the joint level
Signs and Symptoms
Nonspecific aching to the MTPJ with occasional swelling
2. Pain with palpation and stiffness at the joint (very similar symptoms seen in hallux limited or DJD)
3. Sclerotic areas on X-Ray
4. Occasional subchondral collapse of the met head that is followed by dissolution of the bone
Treatment
2. Determined by clinical severity and radiographic findings
3. Most cases DO NOT require treatment
4. With radiographic signs, if there is no pain, treatment is not necessary
5. MTPJ arthrodesis or joint resection if the joint collapse
Overcorrection and Undercorrection
Caused by not fixing both the functional and structural components in HAV deformity
gp. Transverse plane
o Hallux varus
- Cause by overcorrection of the transverse plane component
- Either a soft tissue or osseous overcorrection or a combination of both
o Recurrent hallux abductus
- Often seen with inadequate soft tissue release or inadequate structural correction
Regardless of the procedure, the sesamoids should ALWAYS be centralized under the met
head if they cannot be adequately reduced with a lateral release, then the fibular sesamoid
should be excised to assist in complete soft tissue reduction and prevent the hallux from
following the sesamoid position and recreating the HAV deformity
Poor medial capsulorrhaphy also causes recurrence of HAV
Two important factors when choosing the correct procedure:

2.

4.

1. Metatarsus Adductus Angle: HAV will return if a distal procedure is done with an
increased MAA
2. Metatarsal width: limits the amount of translocation that is possible with moderate
deformities
Treatment - Consists of recognizing the cause of the recurrent hallux abductus and
correcting it
- Generally use lapidus or base wedge procedure for a recurrence caused by unrecognized
metatarsus adductus
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gr.
Sagittal Plane
1. Plantarflexion
o
Chronic sesmoiditis can result from aggressive plantarflexion or plantar rotation of the capital fragment
o
Signs and Symptoms
- Keratosis under 1st met head
- Pain with palpation of sesamoid complex
- Hallux extensus that become a hallux hammertoe due to the overpowering of the extensor
tendons
o Treatment
- Accommodative orthotic with a reverse Mortons extension
- Dorsiflexory rotational osteotomy
Metatarsal Elevatus
o Some sagittal drift always occurs with weight-bearing during the 6-12 week period
o Signs and symptoms
- Hallux limitus/rigidus
- Lateral metatarsalgia with subsequent MTPJ pathology
- Radiographic evidence of metatarsus primus elevatus
- Hallux equinus or plantarflexion at MTPJ
- Functional collapse of medial column
o Treatment
- Elongation of the met + met plantarflexion (but be careful not to jam the 1 st MTPJ)
- The procedure to do is a distal osteotomy with an oblique or horizontal plantar arm
- If significant elevation exists, a proximal osteotomy should be considered
3. Limitation of Joint Motion
o Swelling common in weight-bearing joints after surgery; thus creating more scar tissue
o Failure to preserve the dorsal and plantar synovial folds during soft tissue dissection cause this
o Lack of patient compliance resulting in deceased ROM exercises
o Signs and symptoms: pain and limited plantarflexion and dorsiflexion during
ROM
o Treatment
- Aggressive PT
- Possibly steroid injection to minimize pain during ROM and anesthetic block for break-up of the
scar adhesions
Metatarsalgia
o Commonly caused by elevation or shortening of the met head after osteotomy
o Signs and symptoms
- Lateral metatarsalgia with 2nd MTPJ pathology
- Pain and swelling at 2nd MTPJ
- Possible stress reaction/fracture of the lesser mets
- Transverse and sagittal plane contractures of the lesser digits
- Possible dislocation of the lesser MTPJs
- Functional collapse of the medial column
o Treatment
- Conservative treatment that supports the 1st MTPJ and loads more weight to the medial column
(orthotic)
- Metatarsal osteotomy to lengthen or plantarflex the capital fragment

Lapidus for excessive hypermobility along medial column

Treatment directed at the lesser mets: 2nd met shortening procedure (Giannestris step-down, Vtype osteotomy, or modified Mau technique), hammertoe correction, flexor tendon transfer
5. Delayed Union, Nonunion, and malunion
o Delayed Union = delayed bone healing of >6 months
o Nonunion = delayed bone healing for >9 months
o Causes
- Inadequate reduction of osteotomy
- Poor fixation technique
- Improper postoperative immobilization and protection
- Patient noncompliance
- Infection
- Poor patient selection
o Signs and Symptoms
- Pain with palpation
- Chronic edema
- Pain or crepitus with WB and ROM
- Possible elevation of the 1st met
- Radiographic lucency at the osteotomy site
- Sclerosis at the edges of the osteotomy site
o Treatment
- Vascularity at the area of concern determines the treatment plan
1. Immobilization (often 1-2 months) required!
2. Electrical bone growth stimulation
3. Surgical intervention if the position of the bone will cause future functional problems
Bone grafting (autogenous is the gold standard)
6. Infection
o Other causes of erythema and edema that look like an infection: suture reaction, hematoma, and
wound dehiscence
- Hematomas most resemble infection. They can be ruled out by aspiration
o An aggressive workup and treatment are key with infections
o Bone biopsy is the gold standard for diagnosis of osteomyelitis
o I &D with delayed primary closure in infection that is rapidly spreading
o Emergency I &D for: diabetic infections, ischemic infections, anaerobic infections, and plantar
space infections
o Antibiotic of choice determined by culture and sensitivity
- Soft tissue infections treated for 2-3 weeks
- Bone infections treated for 6-8 weeks (shortened if complete surgical debridement of
infected bone is done because this converts the infection to a soft tissue infection)
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ha.

Hammertoes Etiologies

hb. Flexor Stabilization

hc. Most common cause of hammertoes. Occurs in pes planovalgus. When the STJ is pronated, the MTJ is
supinated and unstable, resulting in an unstable forefoot. The flexors (FHL, FHB, FDL, FDB) fire earlier
and longer in an attempt to stabilize the forefoot. They are unable to do this, but it does lead to them
overpowering the interossei. The forces that keep the toes straight are unbalanced and contraction occurs,
leading to hammer and claw toes. An adductovarus rotation of the 5 th, sometimes the 4th and occasionally the
3rd digits will usually accompany hammertoes secondary to flexor stabilization. This is because the pull of
the quadratus plantae on the FDL is disrupted by the collapse of the midfoot, so the FDL pulls with a medial
vector in addition to its axial one, rotating the lateral toes medially.
hd. Flexor Substitution
he. Least common etiology. This occurs when the triceps surae muscle is weak. In an attempt to plantarflex the
foot, all the deep posterior muscles and both the peroneals fire earlier and longer, as all of these have the
ability to create some plantarflexion. That plantarflexion does not amount to much, however, every one of
those muscles except the peroneus brevis also cause the STJ to supinated. This leads to a very supinated foot
during gait. The flexors easily overcome the interossei and create hammertoes, which this time are straight
since the quadratus plantae is able to pull the FDL into the correct alignment.
hf. Other ways the flexors can overcome the interossei are when there is intrinsic muscle weakness due to
peripheral neuropathy, leading to weak interossei, or when theres spasticity of the FDL.
hg. Extensor Substitution
hh. Happens anytime the extensors gain mechanical advantage over the lumbricales. This is often due to a
flexible pes cavus. The dorsal curve in the forefoot means the extensor tendons have further to travel, so are
passively pulling on the toes. That passive pull adds to their active pull, giving them a mechanical advantage
during active extension, during the swing phase of gait. This leads to contracted digits during swing phase
that disappear when the foot is weight bearing, since the flexible pes cavus resolves during weight bearing.
Bowstringing of the extensor tendons and prominence of the met heads on the ball of the foot will be seen.
Over time, the contractures will become rigid, and the dorsiflexed MPJs will constantly plantarflex the met
heads, creating a more cavus foot and a vicious cycle.
hi. Another cause of extensor substitution is an ankle equinus. All the anterior extrinsic muscles will fire earlier
and longer in an attempt to dorsiflex the foot. The FDL cannot start dorsiflexing the ankle until it has
maximally dorsiflexed the MPJs, again resulting in contracted digits. As before, intrinsic muscle weakness
or spasticity of the extensors will also lead to contracted digits.
hj.
hk.
hl.
hm.
hn.
ho.

hp.

hq.

1.
2.
3.

hy.
hz.

ic.

Lesser Digital Deformities Treatment

hr.
hs. Conservative Treatments
Crossover taping
Toe splints
Oral antiinflammatories
Padding, accommodative foot gear
ht.
hu. Contraindications to Surgical Correction
Active skin infection
Impaired neurovascular status
Co-morbid medical conditions
hv.
hw. Hammertoe Correction
Best approached in a stepwise manner
Degree of fixed (structural) deformity is determined by the push-up test
How to tell load the foot = push up on the metatarsal heads to simulate weight bearing
Remember to load the forefoot to determine level of hammertoe deformity (Kelikian Push-up Test)
Kelikian Push-up test helps dictate necessity of procedure (soft tissue vs bone) and where (MPJ, PIPJ and/or DIPJ)
hx.
Surgical correction of Digital Deformities
Soft Tissue Procedures
Tenotomy (flexible to semiflexible)
Tenotomy and Capsulotomy (semiflexible)
Flexor tendon transfer (floating toe, metatarsalgia, dorsally contracted MPJ, when flexor has mechanical
advantage over intrinsics)
ia.
Osseous Procedures
Arthroplasty (flexible to semi-rigid)
Arthrodesis
ib.
Sequential Release
id.
1. IPJ Tenotomy *
ie.
2. Arthroplasty *
if.
3. Extensor hood(wing/sling) release *
ig.
4. MPJ capsulotomy(dorsal and/or medial/lateral) *
ih.
5. Flexor capsulodesis release with McGlamry elevator *
ii.
*Kelikian push-up test performed after each step

ij.
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ir.Clinical and Radiographic Findings for Lesser Digital

Deformities

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is. Mallet Toe

it.
Clinical findings
Distal phalanx flexed on the middle
Often associated with a long digit
Hyperkeratosis of distal aspect and heloma dura dorsal
Limited extension of DIP
Causes include: poor visual acuity(used for tactile sensation), long toe and short shoe, fusion of IPJ and
stroke(spasticity of long flexors)
Radiographic
Flexed DIPJ, middle superimposed on distal
Gun barrel sign
iv. Treatment
Release long flexors or shorten the toe (resection of middle phalanx head)
iw.
ix. Curly toes (Varus toes)
iy. Clinical findings
Most often congenital of 3,4,and 5th toes, often bilat
Flexion and varus rotation of DIPJ; If severe PIPJ adduction
Hyperkeratosis of lateral DIPJ or PIPJ
Lister corn (painful nail groove callus of usually the 5 th)
Radiographic
Varus rotation of phalanges, medial deviation of DIPJ or PIPJ
Treatment
Infants: splinting toes
Child flexible: tenotomy or derotational skin ellipse
Child or adult with less flexible: arthroplasty
jb.
jc. Hammertoe
jd. Clinical findings
Phalanges: Proximal dorsiflexed, middle plantarflexed, distal either
Biomechanical >>> shoegear as cause
Long metatarsal (especially 2nd and 3rd), hypermobile 1st ray, metatarsalgia,
Heloma as dorsal PIPJ and/or DI PJ and end of toe
Plantar lesion beneath MPJ with plantar protrusion of metatarsal
Radiographic
Hammertoe position of phalanges
IPJ, MPJ degenerative changes with chronic
Dislocation of MPJ
jf.
Claw Toe
Clinical findings
Middle and distal phalanges flexed, dorsiflexed proximal
More severe than hammtoe, associated with Cavus foot/neuromuscular problem
Often involves all lesser toes (also many with hallux involvement)
Plantar protrusion with hyperkeratosis and metatarsalgia
MPJ subluxed or dislocated often
Early flexible, late not flexible via push-up test/wt bearing
Radiographic
Severe deformity on non-wt bearing and wt bearing(worse)


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jy.
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kc.
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Gun barrel of proximal phalanges on AP

Treatment
Surgical realignment and prevention of deforming forces
jk. Digitus Adductus
jl.
Clinical findings
ADduction at IPJ or MPJ, saggital deformity with time
Congenital often DIPJ
Acquired often MPJ derangement, iatrogenic, traumatic
jm. Digitus Abductus
jn. Clinical findings
ABduction at IPJ or MPJ
IPJ often Congenital
MPJ often derangement of tendons and flexor plate (Rheumatoid arthritis)
jo. Heloma Molle (soft corn)
jp. Clinical findings
Underlapping 5th toe (can be other toes less frequently)
Typically: Head of 5th Proximal against base (lateral condyle) of 4th Proximal phalanges
Painful lesion of PIPJ or DIPJ or interdigital clavus at web space
Chronic may lead to infection, intertrigo and sinus tract to bone
jq. Radiographic
Exostoses of 5th and 4th proximal phalanx
Synostosis of 5th/4th DIPJ possible
Long or short 4th toe, 5th metatarsal may be short
Treatment
Remodel head of 5th and base of 4th
Arthroplasty, condylectomies, phalangectomy, syndactyly
js.
METATARSAL DISORDERS:
Metatarsal Cavus (Equinus)
Clinical findings
Retrograde buckling of deformed digit but can be rare developmental condition
Plantar declination: Apex at the Lisfrancs Joint (if at Choparts=forefoot cavus)
jx.
Long Metatarsal
Clinical/Radiographic findings
Long Met can be associated with long toe
Long Met also protrudes plantarly
Hereditary, Most common 2nd and 3rd
Symptomatic callus(propulsion lesion; more distal) and metatarsalgia
Treatment
Correct digit deformity and possibly shortening metatarsal osteotomy
kb.
Brachymetatarsia (multiple= brachymetapody)
Clinical findings
Premature closure of growth center
Bears no wtflexor plate not loadedunstable and floating digit
Deep sulcus below short met
Overloads adjacent Metatarsals (callus, metatarsalgia)
Adjacent digit deformities: move into vacant space, extensor loading phenomenon
Radiographic
Short underdeveloped metatarsal
May see deficient bone content in general and osteoporosis of metatarsal head in particular

kf.

kh.
kj.

kk.

kl.

Treatment
Lengthening via callus distraction or bone graft
kg.
LESSER MPJ DERANGEMENT
ki. (Basically covered in Metatarsalgia topic)
Flexor dislocation
Flexor tendons dislocate distally, medially, or laterally to Meta head due to inflammation
Tendon may become attenuated or ruptured
Extensor tendon unopposeddorsal contracture
Radiographic: rotation of proximal phalanx, medial/lateral displacement of proximal phalanx with Meta head
displaced opposite direction
MPJ Adductus or Abductus
Overlapping toes
Medially: Inflammation weakening of supportive structures of the joint
Laterally: RA
Digital deformity may be present
Push-up testAB/ADdution at MPJ
Flexion result in AB/ADuction not flexion
Tx: align MPJ and replace flexor beneath Meta head, stabilize digit (read more pg 273)
MPJ limitation
Chronic inflammationflexor plate adhere to Metatarsal neck (limiting dorsiflexion)
Plantarflexion limitation by dorsal capsule scarring or contraction
Radiographically:
o MPJ space narrowing and Meta head flattening
o Dislocated/subluxed MPJ
Tx: reduction of joint with appropriate release/procedures of soft tissue, possible arthroplasty
km.

kn.

Metatarsalgia Objectives

1. The etiologies, clinical findings, diagnostic modalities, conservative and surgical treatment of intermetatarsal
neuroma, sesamoiditis, metatarsal stress fracture, tarsal tunnel syndrome, and pre-dislocation syndrome of
the lesser digits.
a. Intermetatarsal Neuroma (Mortons Neuroma)
i. Etiologies
1. Benign enlargement of 3rd common digital branch of medial plantar nerve
2. Located between and distal to 3rd and 4th metatarsal heads
3. This IM space is supplied by communicating branch from lateral plantar nerve
4. Nerve runs deep to deep transverse intermetatarsal ligament
5. Tendon from 3rd lumbrical inserts into hood on medial 4th toe
6. Can occur in other IM spaces (2nd), rare in 1st and 4th
7. IM bursa
8. Entrapment neuropathy
ii. Clinical Findings
1. Sharp pain, burns into toes
2. lump in shoe
3. Splaying of toes with WB
4. Aggravated by shoe wear
5. Relieved with shoe removal and rubbing foot
6. Arch cramping
7. Often induced by small traumatic event
iii. Diagnostic modalities
1. Mulders Click
2. Radiographs

3. NCV
4. MRI
5. US
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iv. Conservative treatment
1. Arch supports with metatarsal pad
2. Corticosteroid injection
3. 4% alcohol sclerosing injections
v. Surgical treatment
1. Decompression with release of Deep transverse intermetatarsal ligament
2. Resection of nerve and allow stump to contract into soft tissue
3. Infiltrate with steroid to avoid stump neuroma
4. Dorsal or plantar incision
5. Endoscopic Neuroma Surgery
a. Percutaneously release the deep transverse intermetatarsal ligament
b. Sesamoiditis
i. Etiologies
1. Sesamoiditis is usually caused by repetitive, excessive pressure on the forefoot. It typically
develops when the structures of the first MPJ are subjected to chronic pressure and tension.
The surrounding tissues respond by becoming irritated and inflamed. Any activity that
places constant force on the ball of the footeven walkingcan cause sesamoiditis.
2. Damage to the sesamoid bone may also result in sesamoiditis. Stress fractures can produce
this condition.
3. Complication from bunion surgeryseen with implant systems that maintain the plantar
intrinsic attachments.
ii. Clinical Findings
1. gradual onset. The foot pain usually begins as a mild ache and increases gradually if the
aggravating activity is continued. It may build to an intense throbbing.
2. In most cases, sesamoiditis causes little or no bruising or redness. Pain and swelling can
limit the ability of the first MPJ to dorsiflex or plantarflex, causing a loss of range of motion
in the big toe and difficulty walking.
iii. Diagnostic modalities
iv. Conservative treatment
1. Strict period of rest and the use of a modified shoe or a shoe pad with a cutout to reduce
pressure on the affected area.
2. A metatarsal pad
3. Great toe may be bound with tape or athletic strapping to immobilize the joint as much as
possible and allow healing to occur.
4. Oral anti-inflammatory drugs can be used to reduce swelling
5. Severe cases may require a below-the-knee walking cast for 2 to 4 weeks and the injection
of steroids into the inflamed first MPJ
v. Surgical treatment
1. Sesamoidectomy last resort
c. Metatarsal stress fracture
i. Etiologies
1. Powerful muscle contractions during activity bow the bone, resulting areas of stress or
weakness
2. Stress distribution in the bone is changed as a result of continued activity in the presence of
muscle fatigue
3. Change in training routine leads to high repetition of stress, even in light of low stress loads
4. Change in running or training surface

5. Underlying medical condtions change bone integrity, leading to weakened bone (thyroid
disease, osteoporosis)
6. Change if foot loading patterns secondary to surgery
a. Especially the first ray (bunion correction)
i. Can lead to excessive stress to adjacent metatarsals
b. Arthrodesis procedures
i. Stress adjacent structures
7. Long bouts of NWB weaken bony architecture
8. Increased intensity, duration, or frequency of exercise
9. New footwear
10. Insufficient rest periods
11. Continuing to train despite pain
12. Osteopenia/osteoporosis
13. Rheumatoid arthritis
14. Neuropathic foot
15. Female athletic triad
16. Classifications
a. Fatique Fracture
i. Occurs in normal bone undergoing increased amount of stress (march
fractures in military recruits)
b. Insuffeciency Fracture
i. Occurs in abnormal bone weakened by an underlying disease or condition
(osteoporosis)
c. Pathological Fracture
i. Occurs in bone invaded by a tumor (aneurysmal bone cyst)
ii. Clinical Findings
1. History
a. Recent increase in activity
b. Change in medical status
i. Pregnancy
ii. Nutritional abnormalities
iii. Menstrual Irregularities
iv. Osteoporosis
c. Important to determine if medical status change is an underlying etiology, so that it
can be addressed medically
d. Pain that is localized
e. Focal edema
f. May have erythema and warmth but not always (can confuse with gout or infection)
g. Recollection of specific trauma unlikely
2. Physical
a. Edema
b. Pain with guided palpation
c. Calcaneus positive heel squeeze test
d. 128 Tuning fork can cause pain due to periosteal irritation
iii. Diagnostic modalities
1. Physical
2. Radiographs
3. Tech 99 Bone scan
4. CT/MRI
iv. Conservative treatment
1. Rest and cessation of inciting activity
2. Edema and pain control
a. Ace wrap, Unna boot
b. Oral NSAID
c. Immobilization

i. Surgical shoe, Cam-walker, Cast

ii. Weight bearing, Non-weight bearing
v. Surgical treatment
1. Stress fractures not treated can progress to a full fracture, which can necessitate more
advanced care, including surgery and long bouts of NWB
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d. Tarsal Tunnel Syndrome
i. Etiologies
1. Tarsal tunnel syndrome is most common in active adults
2. Compressed tibial nerve attempts to send signals between the foot and brain.
3. When the tibial nerve is compressed by another structure, the neurological impulses through
it are restricted. This causes pain, a burning sensation, and tingling. In many cases, the
compression is caused by an adjacent muscle that grows too large for the area or from scar
tissue that forms.
4. People with exceptionally flatfeet can develop tarsal tunnel syndrome because the flattened
arch causes strain on the muscles and nerves around the ankle and changes their route
slightly, producing compression on the tibial nerve.
5. cyst in this area.
6. RA, diabetes
7. trauma to the ankle, such as a fracture. When the injury heals, fibrous tissue, similar to a scar
develops. If too much scar tissue forms, it can restrict movement in the tarsal tunnel and
cause entrapment of the nerve.
ii. Clinical Findings
1. Burning
2. Tingling
3. Pain-the key diagnostic criterion-aggravated by active motion-rest pain common
4. Muscle atrophy and weakness-usually not evident until process present for some time
5. Paresthesias common
6. Usually there is no recollection of trauma
7. Decreased two-point discrimination over sensory distribution of entrapped nerve is early
finding
8. + Tinels sign-percussion of the nerve at the suspected point of entrapment causes distal
radiation of pain and paresthesia along the sensory distribution of the nerve
9. + Valleix sign-same as Tinel except radiation occurs proximally
10. Active or passive manipulation of extremity exacerbates symptoms
iii. Diagnostic modalities
1. Local anesthetic injection at point of suspected entrapment to relieve pain can be diagnostic
if pain decreased (can also sometimes be curative)
2. Manual muscle testing not helpful initially
3. NCV shows decreased conduction velocity (<35-45 meters/sec)
4. EMG not useful unless complete conduction blockade present
iv. Conservative treatment
1. Removal of external pressure, if evident
2. NSAIDs

3. Mechanical immobilization in the form of orthotics, splints, casts to prevent motion which
may be aggravating entrapment
4. Periodic injection therapy with local anesthetic and phosphate steroid (acetate steroid may
cause further nerve inflammation)- no more than 3 per year
5. Physical therapy normally a part of therapy (phonophoresis, iontophoresis, electrical nerve
stimulation, range of motion exercises, splints if muscle weakness evident to prevent joint
contractions)
v. Surgical treatment
1. All conservative options should be exhausted before surgery, because any form of nerve
surgery, especially internal neurolysis, difficult and results very unpredictable
2. Often may create more fibrosis and neuroma formation which makes problem worse
3. External neurolysis
a. release intact nerve from all scar tissue external to nerve trunk
b. consider transposing nerve after neurolysis to a nearby soft tissue bed (between
muscle bellies or within fatty tissue)
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4. Internal neurolysis-performed when there is a palpable neuroma-in-continuity
a. release of interfascicular fibrosis and scarring
b. usually requires use of loupe magnification or microscope
c. incise epineurium and gently tease apart individual fascicles
5. Resection of entrapped portion of nerve and allowing proximal and distal stumps to retract
into soft tissue (most common form of surgery for Mortons neuroma)
6. Before dressing applied, steroid is often infiltrated along course of exposed nerve, external
to nerve, itself to limit post-surgical fibrosis which can recreate original signs and symptoms
of entrapment
e. Pre-dislocation syndrome
i. Etiologies
1. Benign history, maybe increase in activity
2. Drastic disruption of a previously active lifestyle
ii. Clinical Findings
1. 2nd MPJ most common site
2. Discomfort in periarticular soft tissues
3. Tenderness with palpation plantar and just distal to MPJ, out of proportion
4. Early on: no digital deformity
5. Late stage: malalignment, crepitus, hypertrophy, instability
6. Contracted digit usually does not have PIPJ dorsal heloma dura, rarely a hyperkeratotic
lesion under met head
7. Healthy middle-aged male or female
8. 30-50 years old
9. Acute or sub-acute onset of pain and irritation on plantar aspect of lesser MPJ
10. Feel like walking on a lump or bruise
11. Quality and duration of pain are disproportionate to physical findings
12. Small amount of edema at dorsal MPJ initially
13. Loss of contour of EDL at joint due to edema
14. Painful with barefoot WB
15. Walk on outside of foot to off-load area
iii. Diagnostic modalities
1. High degree of clinical suspicion
2. Ancillary studies confirm clincial diagnosis and rule out other pathology
3. Vertical Stress Test
4. Radiographs (FF axial, AP, Lateral, MO)
a. Elongated 2nd metatarsal
b. Hypertrophy of diaphyseal cortex of affected metatarsal
c. Altered MPJ congruity

d. Positive drawer sign

5. Arthrogram
6. 3 phase bone scan
7. MRI
iv. Conservative treatment
1. Metatarsal pad
2. Budin splint
3. Crossover taping
4. Medrol Dose Pak
5. NSAID
6. Ultrasound/whirlpool
7. Conservative therapy brings 70-90% relief
v. Surgical treatment
1. For recalcitrant cases, subluxed or dislocated cases
2. Sequential release, FDL transfer, PIPJ arthrodesis, repair of plate
kw.
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ky.

Tailors Bunion

What is it? Abnormally prominent 5th met head usually associated with an adductovarus deformity of the 5 th toe.
Shoe friction causes adventitial bursa to form causing pain
kz.
Etiologies: two subsets are structural vs functional
o Structural- 3 main deformities that cause a tailors bunion are 1) a dumbbell shaped 5 th met head 2)
increased intermetatarsal angle between the 4 th and 5th mets and 3) lateral deviation or bowing of the 5th
met (very common)
o Functional- these following etiologies are associated with biomechanical pathology. 1) uncompensated
forefoot and rearfoot varus 2) compensated varus deformity and 3) forefoot valgus deformity. A very
common presentation is a patient with abnormal STJ pronation and a hypermobile 5 th ray. When these
factors combine with fixed shoe pressure the 5th ray is forced into a dorsiflexed, abducted and everted
position.
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Radiographic Criteria: 3 main criteria used are Intermetatarsal angle, lateral deviation angle and 5 th met declination
angle.
o 4th and 5th Intermet angle: normal range is 6.22-6.47 degrees. > than 6.47 is pathological. Some patients
will present with a Splay Foot- 1st and 2nd intermetatarsal angle is >12 degrees and the 4th and 5th
intermetatarsal angle is > 8 degrees.
o Lateral Deviation Angle: this is also known as lateral bowing of the 5th metatarsal. Normal bowing is 2.647.5 degrees and > 8 degrees is abnormal.
o 5th Metatarsal Declination Angle: > than 10 degrees is pathologic
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Conservative and Surgical Treatment
o Conservative: continuous debridement of hyperkeratotic lesion, padding, modify the shoegear, and
injections.
o Surgical Treatment: 3 types- Exostectomy, Arthroplasty and Osteotomies
o Exostectomy- removal of the lateral prominence of the 5th met head, poor procedure, usually not
successful.
o Arthroplasty- joint destructive, usually reserved as a last resort procedure. Can result in a retraction
of the 5th toe.
o Capital, Shaft and Basilar Osteotomies

Capital- 4 types: Hohmann- transverse neck osteotomy, not used due to fixation failure.
Reverse Wilson- oblique osteotomy from distal lateral to proximal medial= more stable
fixation, but still many complications. **Chevron- most common procedure for tailors
bunion, most stable fixation. Mercado- distal closing wedge, good fixation but difficult to
do.
Shaft Procedure- Yancey- closing wedge osteotomy at the 5th met shaft. Since the shaft is a
majority cortical bone there is a diminished healing potential and higher risk of nonunion.
Base Procedure- Gerbert- this procedure is a basilar closing wedge osteotomy. Not a
popular procedure due to the decreased healing potential of the watershed zone at the 5 th Met
base. Seen only with huge 4th -5th IM angles.
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Methods of Internal Fixation: use of cortical screws for compression seem to be the fixation of choice
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Postoperative Management/Complications:
o Exostectomy and Arthroplasty- patients are able to weight bear immediately post op. Exostectomies fail to
correct the cause of the deformity and arthroplasties can lead to a retractable 5 th toe post op.
o Chevron- like the Austin procedure for a 1st met bunion this osteotomy in the 5th met head is stable post
fixation. Patients are able to ambulate in a post op shoe that inhibits the propulsive phase of gait. Patient
able to return to high impact physical activity around 8 weeks post op
o Hohmann, Reverse Wilson, Mercado, Yancey and Gerbert- these procedures are not as stable post op as
the chevron osteotomy and so the patient is usually placed in a cast and told to remain nonweight bearing for
6-8 weeks until bone healing is evident.
o Non union, mal union and hardware failures are common complications seen with the osteotomies
listed above

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