Fracture healing stages

I share with you a 33 years old case of severe hallux vulgus with first metatarsophalangeal angle (40 degrees).

She was complaining of pain and deformity of her big toe and lesser toes. 

She has been operated for hallux vulgus deformity correction using Scarf operation and Akin osteotomy. Follow up was done for 6 months. The pain and gait significantly improved and the deformity is corrected.

- Scarf is a combination procedure which includes median eminence resection and medial capsular plication, z shaped longitudinal metatarsal osteotomy that is usually fixed by 2 mini screws, lateral soft tissue release.

- Akin is proximal corrective phalangeal osteotomy and fixed by k wires or a screw.

- The procedures are done in combination.

preoperative X ray AP view of the left foot shows hallux vulgus with first metatarsophalangeal angle (40 degrees)

postoperative X ray shows both Scarf osteotomy fixed by 2 mini screws and Akin osteotomy fixed by 2 K wires. 

Final follow up X ray shows union of both osteotomies. With proper correction of the deformity.

Review of literature

 

Hallux vulgus 

Definition  

 It is a progressive foot deformity in which the first metatarsophalangeal joint is affected and is often associated with significant disability and foot pain. It is the most common foot deformity.

Incidence 

Prevalence of hallux vulgus deformity estimates 23% in adults aged 18-65 years and 35% in elderly people aged over 65 years. Prevalence also increases with age and is higher in females.

Deformity 

It is a malpositioning of the first metatarsophalangeal joint. It is caused by a medial deviation of the first metatarsal bone and a lateral deviation of the great toe. 

Associated deformity 

• hammer toe deformity.
• callosities.
• often accompanied by deformities and symptoms in lesser toe.
  

Causes of hallux valgus deformity 

• Acquired deformity often from high heeled shoes and narrow toe box.
• Congenital  (it runs in some families).
• Women are more affected. 
•  Skewed or splay foot encourage the deformity.
• Traumatic.
• ligamentous laxity (1st tarso-metatarsal joint instability)
  
• 2nd toe deformity/amputation
• pes planus
• rheumatoid arthritis
• cerebral palsy

Types of hallux vulgus 

1- Juvenile and Adolescent Hallux valgus. 

2- adult hallux vulgus. 

Differences between adolescent and adult hallux vulgus 

Adolescent type:

It is often bilateral and runs in families, pain usually is not the first complain, varus of first metatarsal and increased inter-metatarsal angle, associated with flexible flat foot.

Symptoms 

• bulging bump.
• pain.
• Swelling, redness or soreness.
• Corns or calluses — occur because of rubbing between the first and second toes.
• Limited movement of tge big toe.
  

Dysfunctions that are caused by the deformity:

• Gait deviations, the patient tends to keep the body weight on the lateral aspect of the foot. 
• Pronation deformity.
• The patient is unable to supinate the  foot.
• The period of one limb support will be decreased.

Physical examination 

• Lateral deviation deformity of the big toe.
• Swelling of first metatarso-phalyngeal joint.
• Tenderness of MPJ.
• Weakness of hallux abductor muscles.
• 
  

Complications of surgery 

Recurrence is the most common complication, overcorrection and hallux varus.

Radiological measurements of Severity of hallux vulgus 

1- The first metatarsophalangeal angle (the angle between the axis of the 1st metatarsal and the axis of the proximal phalanx)  is used for evaluating the severity of a hallux valgus deformity. It is measured on a radiograph performed in weightbearin.An angle ≤15°. indicates hallux vulgus deformity.

2- The intermetatarsal angle is measured between the 1^st and 2^nd metatarsals axis on AP view of the foot. An angle more than 9 indicates hallux vulgus deformity.

3- The Distal metatarsal articular angle is measured between the 1^st axis and a line at the base of the distal articular surface of first metatarsal. An angle more than 10 indicates hallux vulgus deformity.

4- The Hallux valgus interphalangeus angle measured between the axis of the proximal and distal phalanx of big toe. An angle more than 10 indicates hallux vulgus deformity.

Treatment 

Treatment often focuses on relieving the symptoms.

Non operative treatment 

• Bunion pads and splint: Over the bunion pads can decrease the pain. You can also use medical splint to keep the foot in the correct position. The patient can also place a spacer between the big toe and second digit. 
• Shoes changes: shoes with wide toe boxes can decrease pressure on the toes. 
  
• Pain relievers: NSAIDs and ice packs.
• Physical therapy: Massage, ultrasound therapy and exercises.
• Local Injections: Steroid injection is a late treatment of bunion if the patient does not want surgery 

Operative treatment 

•  If nonsurgical treatments fail, and walking becomes very painful. 
• The first procedure is called a bunionectomy by removing the bunion. 
• Realigns bones by bringing the big toe back into its correct position.
• Techniques of correction include, distal soft tissue procedures, phalangeal osteotomy, first metatarsal osteotomy (distal, shaft, or proximal), arthrodesis of metatarsophalangeal, arthodesis of tarsometatarsal, or resection arthroplasty.