Hallux

Varus
W7117

Sneha Suthar - PGY 1
Iatrogenic or Acquired
Due to destabilization of MTPJ by an
overaggressive lateral release with or w/o lateral
sesamoidectomy.
When adductor tendon is released with the lateral
head of the FHB
The aggressive release of the lateral structures
leaves the medial head of FHB and abductor
tendon unopposed resulting in medial deviation and
loss of joint congruity (joint subluxation occurs)
EHL can overpower FHB and create a malleus
component
McGlamrys 2013, Ch. 37, p. 461-468
Other factors:
long or short 1
st
met
rounded 1
st
met head
low or negative 1-2 IMA
ligament laxity
overly aggressive bandaging after HAV surgery
staking of sagittal groove of 1
st
met head

McGlamrys 2013, Ch. 37, p. 461-468

Staking of MTH
Once the sagittal groove has been violated and the
articulation for the hallux base and tibial sesamoid
are lost, the hallux no longer has an articular
buttress preventing it from slipping into varus
position.

McGlamrys 2013, Ch. 37, p. 461-468
Overcorrections in bunion
sx:
Excessive medial exostectomy
staking of sagittal groove of 1
st
met head
Overaggressive medial capsulorrhaphy
Transfer of adductor tendon beneath EHL and attaching to
medial capsule
Overaggresive plantar lateral release
Adductor tendon, fib. sesamoidal lig, lateral head FHB, fib
sesamoidectomy, lateral capsulotomy
Overaggressive osseous correction
Negative IM/PASA
McGlamrys 2013, Ch. 37, p. 461-468
Diagnosis and Treatment of First
Metatarsophalangeal Joint Disorders.
Section 3: Hallux Varus CPG by ACFAS
Adduction of the hallux and medial subluxation of the 1
st

MTPJ
Hx of bunion sx, abnormal position makes wearing
shoes difficult and painful
Loss of toe purchase occurs and hallux hammertoe
develops (flexion at HIPJ)
Journal of Foot and Ankle
Surgery, 2003
Imaging

Classification from Section 3:
Hallux Varus CPG by ACFAS
Type 1 - MTP adduction
1A deformity - ROM full, pain free, reducibility
1B deformity plus arthrosis ROM limited
Type 2 MTP adduction plus IPJ flexion
2A deformity - hallux stability is lost, IPJ flexion, ROM
full and pain free
2B deformity plus arthrosis painful, limited
Type 3 Complex multiplanar deformity
All 3 planes involved, hallux purchase is lost,
symptomatic and nonreducible
Procedure Selection
Joint simply luxated medially medial capsulotomy and
digital splintage
Hallux subluxed complete ST release and MT
osteotomy
Semi-reducible, ROM limited modified osteotomy
Length of MT DMO
Reducible with MTH morphology reconstruction of
articular groove for the hallux and tibial sesamoid

Joint destructive MTPJ arthrodesis is the POC
McGlamrys 2013, Ch. 37, p. 461-468
ST rebalancing
Medial incision in line with the direction of the contracture
Reflect SQ tissue with blunt dissection
Stepwise exploration begins medially Abductor hallucis,
medial head of FHB, tibial sesamoidal ligament and medial joint
capsule
The medial contracture at the joint capsule is a major culprit for
deformity, and can be lengthened (V to Y, Z plasty, U
lengthening)
Position of the joint is assessed for addition of osseous
procedure
Dissection to the level of the DTIL for lateral joint assessment
Post-op fibrous adhesions may be producing negative IMA



McGlamrys 2013, Ch. 37, p. 461-468
Osseous procedures
DMO original site may be used if bone is
sufficient there
PMO bone insufficiency led to malunion then go
more proximal
AD chronic deformity and joint incongruity

McGlamrys 2013, Ch. 37, p. 461-468
Zahari & Girolami. Hallux Varus: a step-wise
approach for correction, JFAS, 1991.
30(3):264-266
Step-Wise correction for Hallux Varus:
1. Skin incision: scar revision (z-plasty)
2. Soft tissue dissection release from the joint, is the deformity
positional, structural or both
3. Medial Capsuloplasty, V-Y or Z plasty or advancement
4. Degloving the articulation/total intracapsular release
5. Adductor tendon release if contributing to deformity
6. Abductor tendon transfer to lateral side
7. If dislocated, tibial sesamoidectomy (if, at this point, both sesamoids
have been removed do an IPJ arthrodesis)
8. EHL lengthening
9. Osseous correction IM negative/PASA Reverse Akin, Reverse
Austin
10. Arthrodesis


Banks et al. Surgical repair of Hallux Varus. J
Am Pod Med 78:339-347, 1988
1. Skin incision lengthening plasty
2. Medial Capsulotomy U shaped, V-Y flap, - more length in transverse
plane
3. Lateral release, DTIL
4. Total intracapsular release degloving 1
st
MTH with metatarsal elevator
5. Correction of structural deformity negative IM/PASA (reverse Austin,
opening base wedge, reverse Reverdin
6. Tendon release/transfers Adductor H. plicated or re-transferred to
inferior lateral base of pp, dorsal to MT and attach to lateral capsule
7. Hawkins abductor hallucis released and transferred to lateral base of
pp (planatar to MT and superior to FHB)
8. EHL overpowering FHB do Z-lengthening and ext. hood release,
Johnson and Spigel transferred EHL plantar to DTIL to lateral base of pp
(action: acts as abductor and plantarflexes hallux)
9. Tibial sesamoidectomy after transection of medial head of FHB, IPJ
fusion
10. 1
st
MPJ Arthrodesis


Congenital conditions
(increased muscle tone to proximal leg
muscles)
McGlamrys 2013, Ch. 37, p. 461-468
MD, MS, hypertonicity and spasticity ofintrinsic/extrinsic mm.
A musculotendinous imbalance and dysfuntion about the 1st MPJ
Abductor is unopposed by adductor and lateral capsular structures, the
normal stabilizing pull of the ABH becomes a deforming force, pulling the
hallux beyond neutral position
Hallux begins to flex at the IPJ in attempt to maintain WB function
Hallux deviates in transverse and sagittal planes, medially deviating
at the MTPJ and flexing at the IPJ
hallux adductus + hallux malleus
The more medial the hallux
deviates, more the flexor power of the
FHB is converted into a varus and
the FHB rotate into a dorsomedial
position.
Hallux goes into varus and the FHL
tendon prompts retrograde buckling
the IPJ