Residency Insight -- A PRESENT Podiatry eZine

Ryan Fitzgerald, DPM
PRESENT RI Associate Editor
Hess Orthopedics &
Sports Medicine,
Harrisonburg, Virginia

CASE PRESENTATION:
Correction of Hallux Varus

HPI: The patient is a 49-year-old female who presents with a painful left hallux. She relates that she previously had a bunion surgery several years ago, and that since that time she has had increasing pain in her left hallux and in the bottom of her left “big toe joint. She presents complaining of pain with motion at the 1st MTPJ and with weight bearing, and she relates difficulty in finding shoes that fit. She relates that her pain has gradually gotten worse over time and that she has previously attempted physical therapy as well as the use of custom molded orthotics—both of which have failed to yield pain free results. She presents today seeking a surgical solution for this problem.

PMH: HTN, osteoarthritis

PSH: Left bunion surgery, Right shoulder SLAP

FMH: RA, breast cancer

MEDS: Effexor XR, multivitamin, calcium with Vitamin D

ALL: PCN

SOCIAL: The patient relates current tobacco usage, and states that she smokes approximately 1 pack every two days.

ROS: The patient denies any other complaints apart from those described above. She denies any recent history of fevers, chills, nausea, vomiting, or any other constitutional symptoms.

VS: BP: 132/84, HR: 82, RR: 18, Temp: 98.1

PE: The patient is awake, alert, and oriented, and in no apparent distress. She presents with palpable pedal pulses that are graded +2/4 at the dorsalis pedis and posterior tibial arteries. There are not varicosities or telangectasias noted in the lower extremity, and the capillary filling time is less than 3 seconds. The patient demonstrates muscle strength that is graded +5/5 in dorsiflexion, plantarflexion, inversion and eversion. She demonstrates a left hallux varus deformity that is passively reducible to neutral with direct pressure. Range of motion of the hallux appears to be track-bound and limited while in the varus position, but with correction to neutral the hallux demonstrates improved motion at the 1st MTPJ. Additionally the patient demonstrates a semi-rigid hallux malleus deformity at the left hallux. There are no skin lesions noted. Protective sensation is grossly intact along the distal distribution of the L4, L5, and S1 nerve roots, and proprioception and vibratory sense are also intact.

Imaging Studies: X-ray images obtained demonstrate evidence of previous fibular sesamoid removal with subsequent medial deviation of the 1st MTPJ (fig. 1). Additionally there is some joint space narrowing noted.

Figure 1: The patient demonstrates clinical and radiographic signs of hallux varus. The 1st MTPJ demonstrates medial deviation

Plan: Taking into account the failure of conservation options and the patient’s persistent pain, the decision was made to bring the patient to the operating room for operative repair of the hallux varus deformity.

Surgical Procedure: Considering the flexible nature of the patient’s deformity, the decision was made to attempt soft tissue reconstruction of the 1st MTPJ to reduce the varus deformity. After obtaining appropriate surgical exposure of the distal aspect of the 1st metatarsal, the 1st MTPJ, and the base of the proximal phalanx of the hallux, the medial structures were identified. There was significant scar tissue formation noted from the previous bunion surgery. A medial release and capsulotomy was performed. The articular surfaces of the 1st MTPJ were evaluated for an osteochondral defects and only mild cartilage erosion was found in two small areas on the metatarsal head. These areas were subsequently fenestrated utilizing a small 2.0 mm drill to promote the in-growth of fibrocartilage. To stabilize the hallux in the corrected position, an Arthrex Mini-Tight-rope kit was utilized along the lateral aspect of the joint to hold the hallux in a rectus position while maintaining physiological motion at the joint (fig. 2A,B). Upon appropriate tensioning, the hallux varus deformity was reduced and the toe was noted to rest to rest in a more appropriate position (fig. 3). The wound was then flushed and a layered closure was preformed.

Figure 2A: The Mini TightRope® system utilizes a cannulated drill bit, 2.7 mm round button, 5.5 mm oblong button, 2.6 mm TightRope® guide pin, 1.6 mm K-wire and #2 Fiberwire Suture.

Figure 2B: The toe held in a reduced position, and the proximal suture is tightened to tension the distal button along the medial aspect of the proximal phalanx.

Figure 3: The left hallux was held in the correction position and the fiber-wire was tensioned to maintain the correction.

Discussion: Hallux varus most commonly develops after the failure of a previous bunion surgery. Often this occurs either through over-correction of the intermetatarsal angle or through excessive tightening of the medial soft tissues via capsulorraphy. In addition to post-surgical hallux varus, there are other conditions that may lead to this condition including trauma, removal of a fibular sesamoid bone at the 1st MTPJ and some forms of arthritis. The treatment of hallux varus depends on the severity of the condition. If the deformity is mild and the toe remains flexible no treatment is required at all. If the toe begins to deviate considerably and is becoming stiff then surgery is usually required. Correction depends on the flexibility of both joints of the big toe and whether or not arthritis is present.

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