Foot and Ankle cases 2
A 55-year-old woman complains of great toe pain and arrives in your office wearing narrow, high-heeled shoes. She notes that the pain is worse with shoewear and activity. She states that she doesn’t want her feet to end up like her mother’s. Physical examination demonstrates a prominent, tender medial eminence without pain on passive range of motion of the first metatarsophalangeal joint (MTPJ). She demonstrates no instability or pain at the first tarsometatarsal joint (TMTJ). An AP foot radiograph is obtained (Fig. 5–2).
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Figure 5–2 AP radiograph of the foot showing a hallux valgus deformity.
The most appropriate initial treatment recommendation is:
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Correction with distal soft tissue release and first TMTJ corrective arthrodesis
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An orthotic with a Morton’s extension
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Toe spacer, shoe wear modification, and a ball-ring shoe stretcher
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First MTPJ medial capsule imbrication, lateral soft tissue release, and corrective osteotomy
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First MTPJ arthrodesis
Discussion
The correct answer is (C). The initial treatment for hallux valgus is nonsurgical and is focused on eliminating the use of constrictive shoes and passively correcting the deformity. Morton’s extensions are primarily used for hallux rigidus. Surgical options are employed after nonoperative measures have failed. Among the surgical options, first TMTJ arthrodesis is typically reserved for patients who demonstrate first TMTJ instability or excessive metatarsus primus varus. First MTPJ arthrodesis is reserved for bunions that are associated with arthritic change and pain with first MTPJ range of motion.
The patient returns 6 months later, having changed to flat shoes with a wide toe box. She notes that NSAIDs have had a diminishing effect in helping her pain. She asks you to explain her radiographs to her.
The AP radiograph (Fig. 5–2) demonstrates all but which of the following?
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Increased hallux valgus angle (HVA)
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Increased intermetatarsal angle (IMA)
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Uncovered fibular sesamoid
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Prominent medial eminence
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Congruent joint
Discussion
The correct answer is (E). This radiograph reflects a moderate deformity (Table 5–1) with evidence of an increased HVA, IMA, uncovered fibular sesamoid, and a prominent medial eminence. This radiograph demonstrates an incongruent joint at the first MTPJ with lateral subluxation of the proximal phalanx base relative to the metatarsal head.
Table 5–1 HALLUX VALGUS DEFORMITY SEVERITY IS DEFINED BY HALLUX VALGUS ANGLE (HVA) AND INTERMETATARSAL ANGLE (IMA)
|
|
HVA (degrees) |
IMA (degrees) |
|
Mild |
<20 |
<11 |
|
Moderate |
20–40 |
11–16 |
|
Severe |
>40 |
>16 |
Satisfied that you know what you are talking about, she asks you to discuss the complications associated with the various treatment options.
Which is the incorrectly paired procedure and complication?
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Proximal opening wedge osteotomy—hallux stiffness
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Fibular sesamoid excision—hallux varus
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First TMTJ arthrodesis—capital necrosis
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Ludloff osteotomy—transfer metatarsalgia
Discussion
The correct answer is (C). First TMTJ arthrodesis is not typically associated with capital segment necrosis. Capital necrosis is more classically associated with the combination of a distal osteotomy with an aggressive soft tissue release about the first MTPJ. A Ludloff osteotomy is a first metatarsal osteotomy that has the potential to shorten the first MT relative to the lateral metatarsals, which may result in transfer metatarsalgia. A proximal opening wedge osteotomy relatively lengthens the first ray and, when combined with distal soft tissue correction of hallux valgus, can result in stiffness of the tendons that cross the first MTPJ. Fibular sesamoid excision, lateral FHB tenotomy, excessive imbrication of the medial capsule, and excessive metatarsal head resection (lateral to the sagittal sulcus) can all result in hallux varus.
Objectives: Did you learn...?
Describe radiographic findings associated with hallux valgus? Identify initial treatment options for hallux valgus?
Describe the spectrum of severity for hallux valgus?