Bunion Evaluation PASA + DASA ≠ HA, but PASA and DASA WNL, then positional and soft tissue correction PASA + DASA = HA, and PASA or DASA abnormal, then structural and osseous correction PASA + DASA ≠ HA, and PASA or DASA abnormal, then combined deformity, so osseous and soft tissue correction Etiologies of Hallux Abducto Valgus:

1. Abnormal biomechanics of the 1st ray and MPJ*** 2. Abnormal pronation with unstable 1st ray (hypermobile) 3. Metatarsus Primus Elevatus (dorsiflexed 1st ray) 4. Long 1st ray 5. Abnormal intermetatarsal angle

Stages of Hallux Abducto Valgus: Stage 1- -normal hallux abductus angle -normal intermetatarsal angle -1st MTPJ is congruent Stage 2- -abnormal hallux abductus angle -normal intermetatarsal angle -deviated 1st MTPJ Stage 3- -abnormal hallux abductus angle -abnormal intermetatarsal angle -deviated 1st MTPJ Stage 4- -abnormal hallux abductus angle -abnormal intermetatarsal angle -subluxed 1st MTPJ

Bunion Angles Metatarsus Adductus Angle: determines the relationship of the longitudinal axis of the lesser tarsus with the longitudinal axis of the second metatarsus, normal <15 degrees Intermetatarsal Angle: measures the relationship between the 2nd metatarsal long axis and the first metatarsal long axis, normal 8-12 degrees in rectus foot (8-10 adducted foot) True IMA : Subtract 15 from the MAA, then add the IMA to that number Total Adductus Angle: determined by adding the MAA and IMA, normal 20-22 degrees Hallux Abductus Angle: measures the abduction of the longitudinal bisection of the proximal phalanx of the hallux relative to the longitudinal bisection of the first metatarsal, normal <16 degrees (variable) Proximal Articular Set Angle: detects structural abnormalities of the metatarsal head, normal <8 degrees Significance:

• A functional PASA is less than or equal to the IMA

• A dysfunctional PASA is present when the PASA exceeds the IMA. Distal Articular Set Angle: detects abnormalities of the proximal phalangeal base, normal <7.5 degrees Hallux Abductus Interphalangeus Angle: detects structural abnormalities of the head of the proximal phalanx (most common) or the base of the distal phalanx, normal <10 degrees Metatarsal Width : normal 17-25 mm in females, 21-26 mm in males Significance:

• 1/3 of metatarsal head width is the max transposition before decrease in stability Proximal Phalanx Length: a non-quantitative comparison of the hallux proximal phalanx length relative to the lengths of the other proximal phalanges

Soft Tissue Bunion Procedures Silver Procedure: partial osteotomy of the 1st metatarsal head, removal of medial eminence Mcbride -Type Bunionectomy:

- 2 incisional approach - Capsulotomy and capsulorrhaphy - Adductor transfer - Removal of fibular sesamoid - Transfer of EHB - Silver

Lateral Release Steps: EHB tenotomy, Deep Intermetatarsal Ligament release, Adductor Hallucis tendon release, Fibular Sesamoid Ligament, Lateral Capsulotomy

Proximal Phalanx Procedures Proximal Akin: used to correct abnormal DASA -transverse osteotomy that addresses structural problems within the proximal phalanx -performed by resection of the medial eminence and adjacent lip at the base of the proximal phalanx followed by medial wedge removal from the proximal phalanx Advantages: 1. structural correction 2. avoids MTPJ Disadvantages: 1. fixation required 2. longer healing time, 6 weeks post-op shoe Complications: 1. short hallux 2. hallux elevatus (lack of toe purchase) Distal Akin: used to correct Interphalangeal Angle abnormalities -requires normal DASA Oblique Akin: used to correct abnormal DASA with screw fixation Cylindrical Akin: used to shorten a long proximal phalanx -requires an abnormal HIPA or DASA

-can be done in children -usually fixated with monofilament or crossed K-wires Regnauld Procedure: used to shorten a long proximal phalanx associated with Hallux Limitus (aka Mexican Hat Procedure) -requires normal HIPA or DASA -fixate with small fragment screw or absorbable pins and screws -requires non-weight bearing for 6 weeks Sagittal Z Procedure: used to shorten or lengthen proximal phalanx and correct sagittal plane deformities -requires normal HIPA or DASA -distal arm cut extends medially, proximal arm cut extends laterally -fixated with one or two 2.0 or 2.7 mm cortical screws or K-wires -post-op shoe

Metatarsal Head Procedures

Austin: used to relatively reduce abnormal IM angle

-a horizontal V osteotomy beginning at the proximal border of the tibial sesamoid extending through the 1st metatarsal head, performed at 60 degrees -unicorrectional Austin-corrects only one structural deformity -bicorrectional Austin- corrects two structural deformities on the same body plane -biplane Austin- corrects several structural deformities on different body planes Advantages: 1. IMA correction 2. PASA correction 3. Ability to Shorten or Lengthen Metatarsal by altering the cut relative to the long-axis of the 1st or 2nd metatarsal 4. Immediate weight-bearing in post-op shoe 5. Ability to perform on skeletally immature patients Disadvantages: 1. Can not be performed with narrow metatarsal width 2. No frontal plane correction

Youngswick-Austin Modification: used to correct abnormal IM angle, mild metatarsus elevatus, and a long metatarsal Disadvantage: no immediate improvement of ROM (takes 4-5 months)

Kalish: long arm Austin modification which allows for screw fixation (traditional Kalish is actually 55 degrees)

Reverdin: used to correct abnormal PASA

-angulated osteotomy performed 1 cm proximal and parallel to the joint surface of the 1st metatarsal head Advantages: 1. Structural correction of HAV 2. Ability to perform on skeletally immature patients 3. Immediate weight-bearing in post-op shoe Disadvantages: 1. No correction of IM 2. No correction of sagittal plane deformity 3. Potential to damage sesamoids Reverdin - Green: horizontal L osteotomy created to avoid possible damage to the sesamoids (can be done in children)

Reverdin - Laird: Reverdin-Green with a complete vertical osteotomy through lateral cortex --can be used in kids where the epiphyseal plate is not closed

Advantages: 1. Relative reduction of IM angle 2. Mild sagittal plane correction (plantarflexion) 3. Can be used to shorten metatarsal Disadvantages: 1. Requires fixation (screws will work) 2. Less stable than Reverdin Reverdin -Todd: complete Reverdin osteotomy

Watermann: wedge osteotomy used in association with Hallux Limitus, plantar cortex remains intact

Green-Watermann: modified Watermann osteotomy used in association with Hallux Limitus which preserves sesamoid articulation Peabody: identical to Reverdin but performed at the metatarsal neck to avoid the sesamoids

Metatarsal Neck Procedures

Hohmann’s Dual-Plane Displacement Osteotomy: used to correct abnormal IM angle, abnormal PASA, and sagittal plane deformities -complete osteotomy of metatarsal neck performed in the shape of a trapezoid with the base being medial -NO removal of medial eminence -totally unstable and therefore no longer performed as originally described Mitchell Procedure (modified Hohmann): used to correct mildly abnormal IMA, and metatarsus elevatus with medial eminence resection - modified Hohmann, a step-cut osteotomy where the lateral cortex remains intact -fixate with crossed K-wires Disadvantages: 1. Requires non-weight bearing for 4-6 weeks 2. Slower healing because it is performed in cortical bone 3. Significant Shortening Derotational, Angulational, Transpostional Osteotomy (DRATO) Procedure: a complete osteotomy of the metatarsal neck which allows for manipulation at any angle in any plane -must have (1) varus/valgus deformity, (2) abnormal PASA, (3) normal DASA, (4) abnormal IMA, (5) plantarflexed first ray Disadvantage: 1. Requires non-weight bearing for 8 weeks 2. Unstable Wilson: neck osteotomy which shortens and laterally displaces the 1st metatarsal head to correct for mild IMA and PASA deformities

Metatarsal Shaft Procedures

SCARF Osteotomy: used to correct large IM angles, mildly abnormal PASA, sagittal plane deformities, and can shorten or lengthen the metatarsal - diaphyseal osteotomy resembling a Z, creates a dorsal shelf that provides resistance of the capital fragment against weight-bearing forces - fixation with two cortical screws from dorsal to plantar Advantages: 1. Large IM Angle correction 2. Immediate weight-bearing in post-op shoe 3. Ability to Lengthen or Shorten 4. PASA correction 5. Sagittal plane correction Disadvantages: 1. Degree of correction is dependent on metatarsal width 2. Technically difficult to perform 3. Can not be performed with other procedures Complication: Troughing (elevation of 1st metatarsal head) Reverse SCARF: arms directed distal plantar and proximal dorsal, mechanically stronger than traditional SCARF Ludloff: translational osteotomy directed proximal dorsal to distal plantar used to correct abnormal IM angle Disadvantage: Troughing

Mau: rotational, oblique, complete osteotomy directed plantar proximal to dorsal distal used to correct abnormal IM angle, shortening and plantar displacement Advantage: Screw fixation Lambrinudi: used to correct metatarsus primus elevatus Offset V: modification of Ludloff, long arm V osteotomy angled at 45 degrees Sagittal Z Osteotomy: modification of Giannestra, a dorsal-to-plantar ostetomy through the 1st metatarsal head that allows for plantarflexion and either lengthening or shortening Advantage: Screw fixation (two points of fixation) Disadvantage: 1. non-weight bearing 4-6 weeks 2. no transverse plane correction

Hinge/Axis Concept The intact portion of bone following closing base wedge becomes a hinge (axis of motion). If an axis of motion lies completely within a plane then no motion can occur. Conversely, an axis is perpendicular to a plane, all motion occurs within that plane. (pg 197)

• Dorsiflexion can be obtained with closure of the osteotomy by directing the hinge from dorsal-medial to plantar-lateral

• Plantarflexion can be obtained with closure of the osteotomy by directing the hinge from dorsal-lateral to plantar-medial.

Metatarsal Base Procedures

Loison-Balacescu: traditional closing abductory wedge osteotomy used for correction of large IM angle deformities and to shorten the metatarsal

Advantage: 1. Large IM angle correction 2. Can be performed on a narrow metatarsal 3. Completely within cancellous bone (good for healing) 4. Can be modified to include some sagittal plane correction 5. Ability to Shorten metatarsal Disadvantage: 1. Requires non-weight bearing for 6 weeks 2. Requires internal fixation but does not lend to screw placement 3. Requires skeletally mature individual Complication: Hinge Fracture Juvara Osteotomy:

Juvara (continued) Type A (same indications as Loison-Balacescu) -Oblique osteotomy extending from proximal-medial to distal-lateral across the metatarsal base and shaft leaving the medial cortex intact Advantage: 1. Ability to fixate with screw Disadvantage: 1. Performed partially in diaphyseal bone 2. Cannot be performed on narrow metatarsals Type B1 and B2 used to correct abnormal IM angles and metatarsus elevatus -Same osteotomy as Type A but the medial cortical hinge is not preserved -B1 corrects transverse and sagittal planes. -B2 corrects transverse and sagittal planes as well as length. Advantages: 1. Ability to fixate with screw 2. Ability to Shorten or Lengthen 3. Ability to correct significant Sagittal plane deformities Disadvantages: Same as Type A, but is also more technically difficult Type C1 and C2 -C1 is sagittal correction only -C2 is sagittal plane correction and length abnormalitites -same technique as Juvara Type B but without wedge removal Advantages: 1. Easy positioning for sagittal plane correction 2. Ability to fixate with a screw 3. Can be performed on a narrow metatarsal Disadvantages: Same as Type A and B, but only Sagittal Plane Correction Crescentic Osteotomy: used to correct an abnormal IMA and abnormal PASA without having to remove or insert bone

Advantages: 1. No shortening 2. Performed in Cancellous Bone 3. One cut corrects sagittal and transverse planes Disadvantages: 1.Less stable than other head or base procedures 2. Requires special instrumentation 3. Requires non-weight bearing

Crescentic Shelf Osteotomy: Advantages: 1. More stable osteotomy because of screw fixation 2. Corrects sagittal plane (proximal procedure) 3. Can be performed on metatarsal base or head Disadvantages: 1. Distal procedure does not correct sagittal plane 2. Proximal procedure requires non-weight bearing Trethowan: Opening Abductory Wedge Osteotomy used to correct abnormally high IM angles and short metatarsals

-Stamm: used the resected base of the proximal phalanx as a bone graft Advantages: 1. Corrects high IM angle 2. Can be performed on short metatarsals 3. Corrects structural deformity Disadvantages: 1. Requires Internal Fixation 2. Requires Bone Graft 3. Longer non-weight bearing period

Double Osteotomy of the 1st Metatarsal

Logroscino:

-corrects all structural deformities that occur intrinsic to the first metatarsal -can be combined with a hallux osteotomy that corrects a structural deformity of PASA -can be combined with any MTPJ soft tissue procedure or capsulorrhaphy -non-weight bearing for at least 6 weeks

Lapidus: Arthrodesis of the 1st Metatarsocuneiform joint

-often used in juvenile HAV Advantages: 1. Eliminates 1st metatarsocuneiform hypermobility 2. Stabilizes Medial Column 3. Corrects for large planar deviations Disadvantages: 1. Shortening 2. Prolonged post-op rehab, non-weight bearing 6 weeks Complications: 1. injury to the medial dorsal cuntaneous nerve 2. injury to deep plantar artery

Minimally Invasive Lapidus Arthrodesis: used when a fusion of the 1st metatarsocuneiform joint is necessary, but no procedure is needed on the MTPJ Keller: a joint destructive arthroplasty of the 1st MTPJ wherein the base of the proximal phalanx and the medial aspect of the 1st metatarsal head are resected -indicated in hallux limitus (stage 4) with and in severe hallux valgus -excellent choice for the elderly because of quick mobility -excellent choice for patients unable to undergo vascular reconstruction who have preulcerative areas as a result of MPJ pathology Advantages: 1. Eliminates joint pain 2. Immediate weight-bearing in post-op shoe 3. Eliminates retrograde forces on the MTPJ 4. Can be performed on a mal-aligned 1st ray without correcting the underlying structural defect Disadvantages: 1. Shortening 2. Loss of MTPJ function 3. Loss of toe purchase and ability to weight bear 4. Need post-op orthotics with a Morton’s extension Complications: 1. Transfer Metatarsalgia 2. Stress Fractures

Muscles which insert on the base of the proximal phalanx: abductor hallucis brevis, adductor hallucis brevis, flexor hallucis brevis, and extensor hallucis brevis = can lead to flail toe from the loss of insertion for the extensor hallucis brevis

Functional Keller: attempts to maintain some stability of the MTPJ in order to prevent post-op complications Options-

• Minimal Base Resection with insertion of a dell to allow for a gliding motion of the 1st MTPJ

• Interpositional Flap to provide a biologic spacer to prevent retrograde irritation to the remaining proximal phalanx on the metatarsal head, and to maintain a fibrous false joint space

• Soft Tissue Rebalancing to control the forces acting on the 1st MTPJ • Temporary K-Wire Joint Distraction

Implants The guideline for the size of all implants is the smallest implant possible that will bridge the resected cortices of the proximal phalanx. Criteria: -hallux limitis or rigidus with severe DJD -pain and crepitation with ROM -systemic arthridities (total only) -hallux varus with DJD Hemi-Implants: all are metallic -allow for immediate ambulation with a post-op shoe Total Flexible Hinge Implants: destructive joint procedure, indicated for Stage IV Hallux Limitus, all are silicone elastomers that are designed with a central hinge and stems for both the 1st metatarsal and the proximal phalanx Two-Component Implants: engineered to follow the anatomic radii of the 1st metatarsal even in extremes of dorsiflexion and plantarflexion, preserves FHB, high failure rates

Implant Complications

Biggest problem with implants, wear debris – dedritic synovitis All complications seen with implants are believed to be associated with one of the following: infection, failure of the implant, reaction to the implant, or failure of surgical technique. Infection:

• The number of organisms need to cause an infection is decreased from 105 organisms per gram of tissue to 102 with an implant.

• Reported rates of infection in 1st MPJ implants is 1%-2% • Pain and inflammation do not necessarily indicate infection

Implant Destruction and Fracturing- • Fatigue Fracturing- fracturing of an implant into large fragments, may be asymptomatic or

symptomatic • Caused from cutting/modifying the implant, using the implant in a situation that exceeds the limits

of its design and physical properties, or because of its silicone composition Reactive Synovitis and Metallosis-

• Particulate silicone generates a foreign body giant cell and inflammatory reaction • Microfragments are created as a result of abrasion of the implant with the bone • Generally require implant removal and synovectomy

Ectopic Bone Formation-

• Bony proliferation that occurs around the margins of the implant which limits motion and is symptomatic to patients

Subchondral Cyst Formation-

• Reported in 75% of patients • Incidental finding, only problematic if there is a collapse or fracturing of the bone

Telescoping of Bone-

• Associated with using too small of an implant • Causes shortening of the hallux, jamming of the implant, and limitation of ROM

Arthrodesis McKeever: 1st MTPJ Arthrodesis Advantages: 1. Eliminates MTPJ pain 2. Provides MTPJ Stability 3. 1st Ray can bear load 4. Maintains length Disadvantages: 1. Prolonged disability, non-weight bearing 4-6 weeks 2. Often requires bone graft 3. Loss of MTPJ motion Abrasional Arthroplasty: procedure of choice for primary arthrodesis, goal is to maintain the ball-and-socket configuration of the 1st metatarsal head with the base of the proximal phalanx -Cheilectomy plus curettage and subchondral drilling of cartilage defects -allows for adjustments in all three body planes -provides enhanced stability

Hallux Limitus/Hallux Rigidus

- 65-75° 1st MPJ motion needed for gait - “Dorsal flag sign” due to windlass mechanism

o Related to tight medial slip of plantar fascia - Plantarflexion of 1st met. created by peroneus longus Etiology:

1. Biomechanical- dorsiflexed 1st metatarsal secondary to abnormal pronation and hypermobility of the first ray

2. Traumatic- • Intraarticular fracture of 1st MTPJ • Dislocation of 1st MTPJ • Fracture or dislocation of hallucal sesamoids

3. Soft Tissue Contractures and Imbalances- • Muscle imbalance affecting the first ray such as a weak peroneus longus and

overpowering of the anterior tibial, producing a metatarsal elevatus • Contracture of the plantar intrinsics of the 1st MTPJ, the plantar fascia, or both

4. Structural- • Dorsiflexed 1st metatarsal • Abnormally long 1st metatarsal relative to the second (results in an abnormal IMA or

dorsiflexed metatarsal)

• Abnormally long proximal phalanx 5. Metabolic- arthritic conditions affecting the 1st MTPJ 6. Iatrogenic- secondary to previous foot surgery affecting the 1st MTPJ, the first ray, or both

Classification System: Olaff Jacobs Stage 1- -non-weight-bearing 1st MTPJ dorsiflexion of <65 degrees -weighting-bearing 1st MTPJ dorsiflexion

a. functional limitus: less than 20 degrees in RCSP 20-30 degrees in NCSP

b. structural limitus: less than 20 degrees in RCSP and NCSP -Pain on ROM -No 1st MTPJ crepitus on ROM -No Degenerative changes Stage 2- -non-weight-bearing 1st MTPJ dorsiflexion of 50-64 degrees -1st MTPJ pain on ROM -No crepitus on ROM -Mild degenerative changes Stage 3- -non-weight-bearing 1st MTPJ dorsiflexion of 30-45 degrees -1st MTPJ pain on ROM -Some crepitus on ROM (especially near end dorsiflexion) -Moderate degenerative changes Stage 4- -non-weight-bearing 1st MTPJ dorsiflexion of less than 20 degrees -weighting-bearing 1st MTPJ dorsiflexion usually absent -Pain on ROM -Crepitus on ROM -Severe degenerative changes Functional Limitus: motion is limited only in the RCSP and increases significantly as the foot is inverted or placed in a NCSP Conservative Treatments:

• Manipulation of the 1st MTPJ under anesthesia • Corticosteroid injection (phosphate…for joints, water soluble) • Active and Passive 1st MTPJ ROM exercises • Physical Therapy

Joint Preservative Surgical Treatments: contraindicated in stage 4 hallux limitus, grade 3 procedures (joint sparing or destructive) should be determined intraoperatively -Soft Tissue Release (Fibrosis, Capsulodesis, Plantar Adhesions) -Cheilectomy: excision of osseous proliferation overlying the joint -Chondral Abrasion Arthroplasty -Regnauld Procedure -Hohmann -Watermann -Youngswick-Austin

-Dorsal V Osteotomy -Plantarflexory Wedge Osteotomy (Van Ness Procedure) -Mau Osteotomy -Juvara Modification- Type -Crescentic Osteotomy -Sagittal Z Osteotomy Joint Destructive Surgical Techniques: -Resectional Arthroplasty (Keller-type) Procedure -Resectional Arthroplasty with Silicone Joint Prosthesis -Resectional Arthroplasty with Two-Component Joint Prosthesis -Resectional Arthroplasty with Joint Prosthesis and Metatarsal Base Osteotomy -1st MTPJ Arthrodesis

Hallux Varus Etiologies: Aquired

1. Iatrogenic-overcorrection during a hallux valgus surgery (most common) 2. Traumatic- trauma to sesamoid apparatus, capsule, or ligaments that stabilize the MTPJ 3. Metabolic- inflammatory arthropathy 4. Neuromuscular- neurologic dysfunction involving the motor system resulting in an imbalance of

the muscles

Pathomechanics of Iatrogenic Hallux Varus

• Excessive medial capsulorrhaphy • Improper post-op bandaging into adductus • Excessive medial eminence resection (staking) • Lateral subluxation of the 1st metatarsal head • Medial subluxation of the tibial sesamoid • Negative PASA from overcorrection or Avascular necrosis • Abnormally low IMA • Aggressive lateral release with or without a fibular sesamoidectomy

Conservative Treatment: reserved for individuals who are not surgical candidates, consists of shoe modifications, accommodative foot orthotics, palliative care Surgical Treatment: Step-Wise

1. Medial Soft tissue Release- abductor hallucis brevis tenotomy, medial capsulotomy, lateral capsule oraphy

2. extensor expansion release (medially) 3. EHL is relocated laterally 4. tibial sesamoidectomy if needed

• if both sesamoids are then absent, fuse the IPJ • FHL should be transferred to the phalangeal base (prevent hallux malleus)

5. if low IMA is due to binding of 1st and 2nd metatarsal heads together, the soft tissue should be released or excised

6. Reconstruction of lateral ligaments or “reefing” or “tightening” the lateral capsule 7. Transfer the EHL tendon under the deep transverse intermetatarsal ligament and into the proximal-

lateral base of the proximal phalanx 8. Extensor Hallucis Brevis Transfer/Tendodesis 9. Abductor Hallucis Brevis Transfer

Overcorrection of IM Angle • Revisional osteotomy, should be performed at the level of the original procedure

Overcorrection of the PASA • With a negative PASA, a reverse Reverdin-Green procedure or a distal crescentic-shelf (realign

the articular cartilage) Staked 1st Metatarsal Head or Lateral Subluxation of Metatarsal Head

• Reverdin-Green or Distal Crescentic Shelf

Nonsalvageable 1st MPJ • Implant • Arthrodesis

Lesser Digital Deformities Hammertoe Pathomechanics of lesser digital deformities:

1. Flexor stabilization Occurs in a pronated foot in the late stance phase of gait when the FDL or FDB gains mechanical advantage over the interossei. An adductovarus of the 4th and 5th toes usually occurs. This usually occurs because the QP loses its mechanical advantage, so the FDL pulls on the toes at an angle. This condition has a hypermobile forefoot that is pronation induced. Also, this is the most common cause of hammertoes. Flexor stabilization is often associated with pes plano valgus and a pronated STJ.

2. Flexor substitution

Occurs in a supinated foot in the late stance phase of gait when the flexors have gained a mechanical advantage over the interossei. There is no adductovarus of the lateral 4th or 5th toe. There is usually a straight contraction of all the lesser toes (2-5). This usually occurs when the triceps surae are weak and the deep posterior and lateral leg muscles try to substitute for the weak triceps.

3. Extensor substitution

This condition is seen in the swing-phase of gait with excessive digital contraction. There is excessive digital contraction is due to the EDL gaining a mechanical advantage over the lumbricales. There is usually a severe dorsal hyperextension at the lesser MTPJ. There may be a bowstringing of the EDL tendons and a plantar prominence of the metatarsal heads. A flexible pes cavus foot type, an ankle equinus, weakness of the lumbricales, spasticity of the EDL, and reaction metatarsalgia can all lead to the EDL gaining advantage over the lumbricales. Swing phase hammertoes (2-5), and can be treated with orthotic. Go right to fusion.

Hammertoes: usually a sagittal plane deformity, occurs when the normal delicate balance of power surrounding the lesser MTPJ is lost Etiologies:

1. plantarflexed 1st metatarsal 2. pronated foot with hypermobile 1st ray 3. unusually long 2nd toe 4. neuromuscular loss of intrinsic muscle function 5. absence, removal or detachment of both sesamoids 6. loss of the ability of the proximal phalanx to purchase the ground due to restrictions in 1st

MTPJ pathology

Surgical Treatment: step-wise (Kallekian push-up test performed between each step)

1. Resection of the head of the proximal phalanx 2. Extensor hood recession 3. Extensor tenotomy or lengthening 4. Capsulotomy 5. Plantar capsule release 6. Flexor tendon transfer to the proximal phalanx (Girdlestone – suturing two ends of flexor together

on the dorsal surface of proximal phalanx) 7. Arthrodesis of PIPJ 8. Extensor hood transfer to the metatarsal 9. Proximal phalangeal base resection with muscle tendon balancing

Deformities of the 5th Ray 5th ray axis of motion: 20° from the transverse plane and 35° from the sagittal plane Tailor’s Bunion: the most common symptomatic condition of the 5th metatarsal, a prominence that may be caused by hypertrophy or irritation of bone or soft tissue about the dorsolateral or lateral aspect of the 5th metatarsal head Etiologies: Structural: - dumbbell shaped met head - increased IM - lateral bowing - accessory ossicle - hypertrophy of soft tissue

Functional - Uncompensated RF varus - Uncompensated FF varus - Compensated varus - FF valgus (orthotics work in flexible ff valgus)

Splay Foot: an abnormal widening of the metatarsals in the transverse plane in relation to the heel, generally between the 1st and 2nd metatarsals and the 4th and 5th metatarsals -splay foot when the IMA between the 1st and 2nd is >12 degrees -splay foot when the IMA between the 4th and 5th metatarsals is >8 degrees -Root: caused by the loss of function of the adductor hallucis muscle resulting in transverse instability of the metatarsals Intermetatarsal Angle: 4th and 5th Metatarsals -normal 6-6.5 degrees, greater than 8.71 degrees associated with Tailor’s bunion -IMA between 2nd and 5th metatarsals is 16 degrees (+ or – 2) Lateral Deviation Angle: normal 2-3 degrees, greater than 8 degrees associated with Tailor’s bunion (Fallat and Buckholtz) 5th Metatarsal Declination Angle: >10 degrees represents a plantarflexed metatarsal Surgical Treatments: Reverse Silver- exostectomy, removal of the prominent lateral eminence of the 5th metatarsal head (aka Davis or DeVries)

- indicated in patients with a stable 5th ray, little angular deviation, or with isolated hypertrophy of the metatarsal head, or when osteotomy is not feasible -can be used in conjunction with a metatarsal osteotomy Reverse McBride- removal of lateral eminence plus lateral prominence on the base of the proximal phalanx (aka Amberry) McKeever - arthroplasty, resection of ½ to 2/3 of the 5th ray -indicated in patients with severe deformity in whom osteotomies are contraindicated, when the metatarsal head is destroyed or not viable, or in patients with arthritis Brown- resection of the entire 5th ray and toe Distal Metaphyseal Osteotomies: -indicated with a mild to moderate increase in the IMA, with the majority of the bowing in the distal 1/3 of the metatarsal -corrects mild IMA and lateral deviation angle abnormalities

1. Hohmann- simple transverse osteotomy of the neck 2. Reverse Wilson- oblique neck osteotomy (aka Sponsel or Keating) 3. Yu- distal OCBW 4. Reverse Mitchell- block wedge neck osteotomy (aka Leach and Igou) 5. Crescentic osteotomy (aka Haber and Kraft) 6. Cheveron (mini-Austin) 7. Reverse Reverdin- aka Mercado 8. Kaplin- closing adductory wedge in the neck

Shaft Osteotomies:

1. Yancy – transverse closing base wedge at midshaft Proximal Base Osteotomies: -indicated with significantly increased IMA or with splay foot deformities -non-weight bearing following surgery -fixate with K-wire or cortical screw

1. Mann- proximal oblique osteotomy 2. Proximal opening wedge osteotomy (good for short 5th metatarsals) 3. Proximal V Osteotomy 4. Gerbert- proximal transverse closing base wedge

Forefoot Problems

Neuroma: Etiologies-

• Mechanical entrapment neuropathy of deep transverse intermetatarsal ligament • Pronated foot type • Pointed or narrow toed shoes

Clinical Findings-

• Burning sensation often localized to the third and fourth metatarsal plantar metatarsal heads and may radiate distally into adjacent toes

• Numbness of toes • Positive Mulder’s sign • Sullivan’s sign – digital divergence with neuromas (splayfoot-like divergence)

Conservative Treatment- • Wider shoes, no high-heels • Metatarsal pads • Injection therapy with local anesthetic • Alcohol Sclerosing Injection- 4% by volume of dehydrated ethyl alcohol. Remove 2 ml of 0.5%

Marcaine with Epi from a 50 ml bottle. Then add 2 ml of dehydrated ethyl alcohol to bottle. Surgical Treatment-

• Resection via Hoadley/Betts (longitudinal plantar), Nissen (transverse plantar), McElvenny (web-splitting), or McKeever (dorsal) incision

Sesamoiditis: Etiologies-

• Repetitive, excessive pressure on the forefoot • Trauma to sesamoids • Stress fractures

Clinical Findings-

• Gradual onset • Mild pain that gradually increases with activity • Loss of ROM of MPJ

Conservative Treatments-

• Rest • Modified shoegear • Padding • Taping • Anti-inflammatory • Short leg walking cast

Stress Fractures: Etiologies-

• Repetitive or overuse • Trauma • Malnourishment

Clinical Findings-

• patients may relate an increase in activities, but generally do not remember any trauma • pinpoint tenderness with palpation overlying the fracture site

Conservative Treatments-

• Supportive shoe • Cast immobilization • Padding • Removable splint

Tarsal Tunnel Syndrome: Etiologies-

1. trauma (inversion ankle sprain, etc.) 70% 2. systemic disease 3. structural abnormalities (pes valgus and pes cavus, forefoot valgus) 4. tarsal coalitions 5. infection 6. ganglia 7. lipomas

Clinical Findings-

• tenderness with direct palpation over the sinus tarsi or increased tenderness when standing on uneven surfaces

• instability on uneven terrain • relief of pain with a diagnostic block of a local anesthetic • failure to identify clinical or radiographic evidence of instability

Conservative Treatment-

1. Local anesthetic injection 2. Steroid injection 3. Taping 4. Supports or orthotics 5. Physical Therapy (ultrasound, hydrotherapy) 6. Oral anti-inflammatories 7. Immobilization via soft or hard cast

Surgical Treatment-

1. Sinus Tarsi evacuation 2. subtalar joint arthroscopy 3. subtalar or triple arthrodesis

Predislocation Syndrome- Etiologies-

1. long second metatarsal 2. progressive inflammation of the MPJ with subsequent rupture of plantar plate and collateral

ligaments 3. structural or biomechanical deformities 4. previous HAV surgery 5. increase or change in activity

Clinical Findings- • acute or subacute inflammatory condition localized to the plantar aspect of the joint • patients feel as if they are walking on a stone • swelling at the base of the toe • absence of toe purchase • medial deviation of toe

Conservative Treatment- • NSAIDs • Corticosteroids • Offloading MPJ and support of the toe in the proper position • Taping • Splinting • Extra-depth shoe with rocker bottom sole(sagittal plane motion)

Surgical Treatment-

• Primary repair of the plantar plate • Reinforcement of weakened collateral ligaments • EDB transfer • Base resection • Head and neck osteotomies

Complications in Surgery General: - Infection - Hematoma - Scar (painful) - Wound Dehiscence - CRPS - Swelling

Specific for Bone-Cutting: - Delayed: >6 months without healing - Non-union: healing problem lasting

>9months - Fracture - Over/Under Correction - Shortening - AVN - Osteomyelitis - Painful Internal Fixation

Sesamoid Removal: - Flail toe - Bunion formation - Hallux varus

Neuroma: - Stump Neuroma - Toe deviation

Internal Fixation K-Wires: available in 0.028, 0.035, 0.045, and 0.062 inch -use a 0.045 in K-wire if stopping at the proximal phalanx -use a 0.062 in K-wire if going into the capsule or into the metatarsal Steinmann Pins: used for larger bone surgery, the most common size used in podiatric surgery is the 2.0 mm (5/64 inch) Cortical Screws- have a smaller pitch (20-32 threads per inch) that allows for a greater number of threads to engage compact or dense bone Cancellous Screws- have a larger pitch because cancellous bone is less dense more porous, also have a greater thread-to-core ratio Self-Tapping Screws: designed with two sharp flutes at the tip to cut thread pattern and to remove bone debris as the screw is advanced Cannulated Screws: have a hollow central core that allows the screw to be advanced through bone over a guidewire, available in 3.0, 3.0 and 7.3 mm Lag Screw: unique method placement that results in approximation and subsequent compression of two osseous segments, performed with either full threaded or partially threaded screws Fully Threaded Screw- placement of the screw only engages the far cortex of bone, advancing the screw eventually results in abutment of the screw head against the cortex of the near fragment

Insertion- Fully-Threaded 2.7 mm Cortical 1. Guide hole 2.0 mm drilled across fracture line 2. Glide 2.7 mm 3. Countersink 4. Measure 5. Tap 6. Insert 2.7 mm screw

Partially Threaded Screw- designed as lag screw; they do not engage the far and near segments simultaneously

Insertion- 1. Guide hole 2. Countersink 3. Measure 4. Tap 5. Insert Screw

Countersinking- increases surface contact between the screw head and bone, reducing risk of stress fractures; also reduces the prominence of the screw head post-op

Minifragment Set: mainly used in forefoot (4 drill bits 1.1, 1.5, 2.0, 2.7)

Guide Glide CS Depth Tap 1.5 1.1 1.5 - - 1.5 2.0 1.5 2.0 - - 2.0 2.7 2.0 2.7 - - 2.7

Small Fragment Set: mainly used in rearfoot (3 drill bits 2.5, 3.5, 4.0)

Guide Glide CS Depth Tap 3.5 cortical 2.5 3.5 - - 3.5 4.0 PT canc. 2.5 Not Needed - - 4.0 4.0 FT canc. 2.5 Not Needed - - 4.0 4.0 FT canc.

LT 2.5 4.0 - - 4.0

Problems: you go to insert a 2.7 mm cortical and it does not contact bone, what do you do? -Ask for 3.5 mm cortical from small set -3.5 mm glide hole (drill bit) -Countersink -Tap with 3.5 mm