HALLUX VARUS:DIAGNOSIS AND TREATMENT HALLUX VARUS:DIAGNOSIS AND TREATMENT

Andrew Bernhard, MS-IV

Ohio College of Podiatric Medicine

Highlands/Presbyterian St. Luke’s Hospital

ON HALLUX VARUS

HISTORY OF HALLUX VARUS

In 1900, Clarke described hallux varus simply, as being the opposite of hallux valgus.

Hawkins, in 1971, offered the most in depth paper on the cause, prevention, and correction of the deformity.

Hawkins’ home: Toledo, OH

DIAGNOSIS OF HALLUX VARUS

Diagnosis is based on both clinical presentation and radiographic evaluation.

As described by Boike, the deformity is triplanar, with supination and hyperextension of the first MPJ and hyperflexion of the hallucal IPJ.

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PRESENTATION

Patients present with hallucal pain, shoewear difficulty, weakness with pushoff, metatarso-phalangeal joint instability, or possiblymetatarsalgia.

Belczyk describes the presentation as including deformity, pain, decreased range of motion, first MPJ arthrosis, hallucal clawing, and shoewear problems.

From: The Institute for Foot and Ankle Reconstruction at Mercy

From: John Schuberth, DPM

RADIOGRAPHICALLY Patients present with the

following radiographic findings: Negative hallux abductus

angle/Hallux Varus angle Negative IM 1-2 angle Absence of the fibular

sesamoid Medial subluxation of the

tibial sesamoid/ Tibial sesamoid peaking

Hallux IPJ flexion Staking of the 1st

metatarsal head

All of the radiographic angles associated with hallux valgus should also be evaluated with hallux varus

POTENTIAL CAUSES According to Skalley and

Myerson, overcorrection of hallux valgus accounts for around 80% of hallux varus cases.

Other causes include congenital defects, rheumatoid arthritis, psoriatic arthritis, trauma, Poliomyelitis, Charcot-Marie-Tooth, avascular necrosis, or contractures due to burns.

PATHOANATOMY, ADAPTED FROM DONLEY

A brief review of the anatomy shows that four intrinsic and two extrinsic muscles cross the first MPJ.

The crista, along with the medial and lateral sesamoid ligaments help provide balance.

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VARUS AND VALGUS FORCES

The adductor hallucis exerts a valgus force on the joint, while the abductor exerts a varus force.

Once the toe is rotated out of a neutral position, those varus and valgus forces become deforming forces.

PATHWAY FOR CLASSIFICATION

Vanore et. al. published this pathway for diagnosing and treating hallux varus.

It is both very inclusive and arrives at a classification scheme.

VANORE CLASSIFICATION

Based on these three types of deformities, viable treatment strategies are discussed.

BEVERNAGE CLASSIFICATION AND TREATMENT

The first element to consider is mobility and flexibility of the first MPJ, followed by evaluation of the IPJ, and radiographic evaluation.

They state that treatment should be aimed at the initial deforming force, the abductor hallucis.

TREATMENT OPTIONS

As is usually the case, non-operative treatment should be attempted before surgery.

Options include orthotics, splints, and tapings.

Generally, treatment should begin as early as possible.

SURGICAL OPTIONS

The mainstay of treatment is going to be surgery, most of the time.

There are numerous surgical options available but the principles are all the same. Medial soft tissue release Lateral soft tissue

tightening Tendon transfer to correct

deformity/maintain correction

Osseous repair

DYNAMIC TRANSFERS

STATIC TRANSFERS

OSSEOUS BUTTRESSING

If the metatarsal head was too aggressively resected, a bone graft should be used to stabilize the MTP joint.

Bevernage states that this will help restore the intrinsic/extrinsic muscle balance to neutral.

Fig. 11. Hallux Varus: Classification and Treatment from Bernhard Devos Bevernage, MD, Thibaut Leemrijse, MD (A) AP standing radiograph showing an excessive medial eminence resection, associated with an aggressive lateral release distal to the sesamoids, after failed hallux valgus surgery. The first MTP joint is mobile, reducible, and painless. (B) Intraoperative view with nice correction into a physiologic valgus position, illustrating the combination of an osseous allograft buttress and a static reversed abductor hallucis tendon transfer. (C) Postoperative AP standing radiograph at 2-year follow-up. (D) CT scan illustrating the persistence of the osseous trajectory of the tendinous transplant as well as the osteo-integration of the allograft buttress with the metatarsal head.

VANORE TREATMENT ALGORITHM

Vanore’s proposed treatment algorithm, which is fairly similar to Bevernage’s

CONCLUSIONS

Based on clinical findings of a painful, adducted hallux, hallucal clawing, and shoewear problems.

Radiographically, staking of the metatarsal head, tibial sesamoid peaking, negative hallux abductus angle, and a negative IM 1-2 angle are most likely observed.

Medial release and lateral tightening should be performed.

Must address the apex of deformity, which is generally the FHB.

The medial eminence should be addressed if staked.

Transfers of the EHL, adductor hallucis, first dorsal interosseous, abductor hallucis, and EHB muscles or tendons have all been described.

FINALLY,

A roundtable discussion between experienced surgeons from the Cleveland Clinic, UPMC, University of Connecticut School of Medicine, and Belfast, Ireland revealed startling discrepancies.

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QUESTIONS? COMMENTS?

REFERENCES