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Osteotomias del halluxThe osteotomies of the hallux
Sogacot 2004 21 y 22 de mayo
Ferrol
Docteur E. ToullecCentre de Chirurgie du Pied
Polyclinique de Bordeaux –Tondu
Osteotomias del hallux
The second question : how are the joints ?
Cuneometatarsal
arthritis
hypermobility
MTP1arthritis
Osteotomy or fusion?
Age and osteotomy
Osteotomias del hallux
Child : better after physeal fusion
Old patient :OsteoporosisDegenerative joint
The third question : when is the good moment ?
Not really a problem
1 - Preoperative planning
Osteotomias del hallux
X ray 1 - dorsoplantar view
DMAA
M1-M2 angle
M1 lenght/ M2
taloM1
flatfoot
In weightbearing
Preoperative planning
Osteotomias del hallux
2 - Sagittal view
taloM1 angle
Pes cavusflatfoot
In weightbearing
Metatarsus elevatus
Preoperative planning
Osteotomias del hallux
3 - Sesamoid view ( Guntz)
More to see the position of the sesamoidthan to understand the rotation of the 1srt metatarsal
Preoperative planning
Osteotomias del hallux
4 - Oblique view
Not interesting to evaluate the elevation of the 1srt metatarsalOnly for M2 M3 lenght (LS Barouk)
Preoperative planning
Osteotomias del hallux
3 D Scan
Useful in severe deformitiesbut not in weightbearing
Preoperative planning
Osteotomias del hallux
Dynamic Pedobarography
flatfoot Pes cavus Hallux valgus
Interest to evaluate the function of the great toe ,the pressure under the M1 head and P1.
2- How to choose the good osteotomy ?
Osteotomias del hallux
The possibilities of displacement
The location of the osteotomy
The stability
How to choose the good osteotomy ?
Osteotomias del hallux
Take into account of the different displacements :
Elevation /loweringShortening / lenghteningVarisation /valgisationRotation : pronation / supinationDMAA correction
To make the osteotomy on the 1srt metatarsal and sometimes on P1
The differents osteotomies
Osteotomias del hallux
Distal shaft
proximal
On M1
Less translationDMAA correction
Large displacementProblem of stability
All displacementsGood stability but higher strain
Distal and proximal = metaphyseal larger surface= easier bone healing
The differents osteotomies
Osteotomias del hallux
Distal shaft
proximal
On P1
Hallux interphalangeus
Varisation orsmall derotation ,good stability(wedge osteotomy)
All displacementsunstable
The differents osteotomies
Osteotomias del hallux
The stabilityThe osteotomy increase the shear force on the bone
when the area of contact decrease
Shear force with the different cutsA is the most stable
A B C
The differents osteotomies
Osteotomias del hallux
The stability
Stable - chevron- scarf - Mau- Mitchell : only varus / valgus plane- wedge osteotomy = incomplete
Unstable - proximal crescentic- Ludloff- Wilson- Mitchell ( unstable to dorsal displacement )
Early functional recovery
The differents osteotomies
Osteotomias del hallux
The fixationPins ease of application and removal
resistance to translationsingle = no control of the rotation
Screw better than pinproblem of rotation if singlestress riser ( hole)
Plate more difficult and time consumingstrongest fixation : osteoporosis , fracture , graftidealy on the plantar surface but difficult
The bandageStaple stability on one plane
Osteotomias del hallux
Raising because offixation failure
or troughing
The fixation is not always a garanty of stability
The screws are zones of fragility
The differents osteotomies
Osteotomias del hallux
The fixationLoss of fixation
malunion in dorsiflexion and medial migration
= transfer metatarsalgia and recurrence
Factors ( Strokes) : - weight of the patient- inclination of M1- length of M1 and P1- force of plantar flexor musclesand plantar aponeurosis
- MTP1 and CM1 stiffness
M1 non union becausesevere flatfoot non treated
The shear force increase when the inclination decrease
3 - Indications
Osteotomias del hallux
Hallux valgus / metatarsus varus
Hallux varus
flatfoot
Pes cavus
Hallux elevatus & rigidus
The indicationsOsteotomias del hallux
I- Hallux valgus
1 - The distal osteotomies
Chevron distal (Austin)++
Mitchell Wilson
Translation 4 to 7mm , DMAA
SERILinear distal metatarsal Osteotomy
Classical open or percutaneous ?
The indications
Osteotomias del hallux
Hallux valgus
4 displacementstranslation lowering DMAAshortening
2 – The shaft osteotomies
Mau
scarf
Small displacement but rotation ++
The indications
Osteotomias del hallux
Hallux valgus
1 -The lateral translation
Not too much !
Scarf osteotomy
The shortening : the solution but with Weil osteot.
ms
Osteotomias del hallux
Hallux valgus Scarf osteotomy
Osteotomias del hallux
Hallux valgus 3- The proximal osteotomies
Closing wedge osteot.
Ludloff = the best for thelarge corrections but unstable
Chevron proximal
CrescenticOsteot .
! Dorsal elevation
Stable but remove precisely
UnstableEasy to do correction
Osteotomias del hallux
Hallux valgus : the indications ( Nyska)
Stage M1M2 DMAA indicationOf the deformity
Mild < 15 –20° <8° distal chevron
Intermediate 15- 20 8 – 15° scarfdistal chevron
Severe > 20 ° > 15 ° base wedge, crescentic,Ludloff
Scarf or chevron
Scarf
Shortening scarf
The P1 osteotomiesOsteotomias del hallux
Hallux valgus
The basal osteotomies
varisationDerotation = plane oblique ( Diebold)
Load simulation test
The P1 osteotomiesOsteotomias del hallux
Hallux valgusThe shaft osteotomies
shortening derotation varisation
The P1 osteotomiesOsteotomias del hallux
Hallux valgus
Isolated P1 osteotomy
HV without metatarsus primus varus& large medial eminence
HV interphalangeus with congruous MTP1
Overriding and underriding second toe
The indications
Osteotomias del hallux
II - Hallux varusM1 osteotomy used only in a few indication
Scarf reverse
Base medial wedgeremoval osteotomy ( Denis) +++
When M1 is too closest from M2
The P1 osteotomies
Osteotomias del hallux
Hallux varus
Sometimes , only P1 osteotomy with lateral ligament ligamentoplasty
The indications
Osteotomias del hallux
III - flatfootEvans Calcaneal lenghtening osteotomy
Basal M1 lowering ost.Lowering scarf osteot / hallux valgus
& medial arch recontruction
The indications
Osteotomias del hallux
Pes cavus with fixed hindfoot
J. Sammarco : cavo varus foot treated wiht combined calcaneusand metatarsal osteotomies . Foot & Ankle Intern., vol 22, N°1, jan 2001
The indications
Osteotomias del hallux
V - Hallux limitus & hallux rigidusGrade I or II ( Hatttrup and johnson)
M1 Weil osteotomy& P1 dorsal soustraction osteotomy
Better If index plus
Various osteotomies
The indications
Osteotomias del hallux
Hallux limitus & hallux rigidus
Chevron distal (Austin)
To avoid shorteningwith loweringLowering and shortening
The indications
Osteotomias del hallux
Hallux limitus & hallux rigidus
Watermann Logroscino
Shortening without loweringShortening with a large lowering
The indications
Osteotomias del hallux
Hallux limitus & hallux rigidus
Shaft osteotomy
Scarf osteotomy
The indications
Osteotomias del hallux
Hallux limitus & hallux rigidus
Basal osteotomy
Plantar wedge basal osteot.
To correct Metatarsuselevatus
The problem : the stability
The indications
Osteotomias del hallux
Hallux limitus & hallux rigidusStage 1 - 2
Metatarsus elevatus
yes
no
Index plus Scarf , Weil
Index minus Basal ost.
Index plus WeilChevronscarf
Index minus Botton prothesisWatermann
Osteotomias del hallux
CONCLUSION
Before deciding an osteotomy of the hallux ,It is necessary to know :-the position of the 1srt metatarsal in the space-the possibly desease of the adjacent joints-The dynamic function of the foot considering
the axis of the legs and the rotation
and the different possibilities to correct the deformities :the displacements , the stability , …Sometimes , it is necessary to combine proximal anddistal osteotomies
CONCLUSION
Osteotomias del hallux
What do you do ?
Woman , 35 years old Congenital forefoot deformityPain above the 1srt metatarsals
3 months after surgery
CONCLUSION
Osteotomias del hallux
What do you do ?
Man ,19 years old ,Pain on the dorsal part of the MTP1
Scarf osteotomyorProximal and distalOsteotomies ?
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