osteotomias del hallux - Docteur Eric Toullec … del hallux The osteotomies of the hallux Sogacot 2004 21 y 22 de mayo Fe rr ol Docteur E. Toullec Centre de Chirurgie du Pied Polyclinique

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 first question : how is the 1srt metatarsal ?


The second question : how are the joints ?

Cuneometatarsal

arthritis

hypermobility

MTP1arthritis

Osteotomy or fusion?

Age and osteotomy


Child : better after physeal fusion

Old patient :OsteoporosisDegenerative joint

The third question : when is the good moment ?

Not really a problem

1 - Preoperative planning


X ray 1 - dorsoplantar view

DMAA

M1-M2 angle

M1 lenght/ M2

taloM1

flatfoot

In weightbearing

Preoperative planning


2 - Sagittal view

taloM1 angle

Pes cavusflatfoot

In weightbearing

Metatarsus elevatus



3 - Sesamoid view ( Guntz)

More to see the position of the sesamoidthan to understand the rotation of the 1srt metatarsal



4 - Oblique view

Not interesting to evaluate the elevation of the 1srt metatarsalOnly for M2 M3 lenght (LS Barouk)



3 D Scan

Useful in severe deformitiesbut not in weightbearing



Dynamic Pedobarography

flatfoot Pes cavus Hallux valgus

Interest to evaluate the function of the great toe ,the pressure under the M1 head and P1.

But not to make measure

2- How to choose the good osteotomy ?


The possibilities of displacement

The location of the osteotomy

The stability

How to choose the good osteotomy ?


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


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



Distal shaft

proximal

On P1

Hallux interphalangeus

Varisation orsmall derotation ,good stability(wedge osteotomy)

All displacementsunstable



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 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 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


Raising because offixation failure

or troughing

The fixation is not always a garanty of stability

The screws are zones of fragility



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


But what happen after ?

Different osteotomies at 1 month and 1 year

3 - Indications


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


Hallux valgus

4 displacementstranslation lowering DMAAshortening

2 – The shaft osteotomies

Mau

scarf

Small displacement but rotation ++

The indications


Hallux valgus

1 -The lateral translation

Not too much !

Scarf osteotomy

The indications


Hallux valgus

2 - The lowering

Scarf osteotomy

The indications


Hallux valgus

3 – the DMAA correction

The scarf osteotomy

The indications


Hallux valgus

4 - The shortening

Scarf osteotomy

The shortening : the solution but with Weil osteot.

ms


Hallux valgus Scarf osteotomy


Hallux valgus

The shortening : Maestro cut

Scarf osteotomy


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


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


Hallux valgusThe shaft osteotomies

shortening derotation varisation


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


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 indications

Hallux varus

Basal soustraction osteot. & P1 varisation

The P1 osteotomies


Hallux varus

Sometimes , only P1 osteotomy with lateral ligament ligamentoplasty

The indications


III - flatfootEvans Calcaneal lenghtening osteotomy

Basal M1 lowering ost.Lowering scarf osteot / hallux valgus

& medial arch recontruction

Woman – 69 years old - Flatfoot & hallux valgus -T.P.tendinopathy

Evans osteot.& lowering scarf osteot.

23°

20°

0°

28°Case 1

Before surgery 6 months after

Dynamic pedobarography

The indications


IV - Pes cavus with flexible hindfoot

BRT osteotomy

The indications


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


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


Hallux limitus & hallux rigidus

Chevron distal (Austin)

To avoid shorteningwith loweringLowering and shortening

The indications



Watermann Logroscino

Shortening without loweringShortening with a large lowering

The indications



Shaft osteotomy

Scarf osteotomy

The indications



Basal osteotomy

Plantar wedge basal osteot.

To correct Metatarsuselevatus

The problem : the stability

The indications


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


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


What do you do ?

Woman , 35 years old Congenital forefoot deformityPain above the 1srt metatarsals

3 months after surgery

CONCLUSION


What do you do ?

Man ,19 years old ,Pain on the dorsal part of the MTP1

Scarf osteotomyorProximal and distalOsteotomies ?

Gracias por su atencion

Sogacot 2004 21 y 22 de mayo

Ferrol

Documents

osteotomias del hallux - Docteur Eric Toullec … del hallux The osteotomies of the hallux Sogacot 2004 21 y 22 de mayo Fe rr ol Docteur E. Toullec Centre de Chirurgie du Pied Polyclinique