Hello, I'm Edward Halff, I'm an assistant professor at the Mayo Clinic in Jacksonville, Florida. Today we're going to be talking about Haloxvirus, what's new and current in managing this condition. Here's my disclosures, nothing pertinent to this talk. Here's our outline. First, we're going to talk about diagnosis and management strategies and kind of some key pearls to treating these patients and identifying them. And then we're going to spend the majority of the time talking about surgical options, which are going to be soft tissue releases and transfers, osteotomies, selective joint fusions and other adjuncts. So from a diagnosis standpoint, I think this is not, this is a very easy thing to diagnose. You almost don't need x-rays. The hard part, though, is going to be deciding on the etiology of the condition. The majority of them showing up in our clinics are going to be man-made Haloxvirus, are going to be iatrogenic from a previous bunion corrective procedure. There are other causes, however, that can be congenital or acquired due to traumaty or deformity, like metaductus and skew foot deformities or things involving the entire foot may cause them, or it may just be something related to first rate insufficiency that ends up leading to Haloxvirus and abnormal gait. With regards to first rate insufficiency, I think it's also important to know that it's also a significant associated condition that I feel like you can't miss to treat these patients successfully with surgery. So be aware of that. We're going to talk about that quite a bit during this talk. As far as non-operative management is concerned, there are kind of two categories of compliance. One is the stuff that isn't painful that the patient doesn't like about Haloxvirus. That's going to be the cosmetic deformity. It is a disfiguring appearance of the foot with the Haloxvirus. The second part of that is going to be it's just hard for them to wear shoes. They may also form calluses and rubbing against the medial border of the shoewear due to this deformity. If they end up getting a clawed IP joint, which is something to be aware of, that can also be a source of callusing rubbing against the shoes. Those would be the less painful versions of the complaints. As it pertains to pain, typically it doesn't hurt at the Halox NP joint itself where the center of the deformity is. Usually if they have pain, it's going to be lateral forefoot pain due to transferment of tarsalgia. I think if they do hurt at the NP joint, you really start to worry if there are degenerative changes present there, which may push you towards a Halox NP joint fusion. You're also going to worry about first-rate insufficiency or Halox IP joint clawing. The non-operative management is going to be shoewear and activity modifications, strapping, splinting, stretching the toes, typical stuff. The decisions about how we treat these patients need to be guided by their complaints. While doing the shoewear and activity modifications, for example, if lateral forefoot pain is the main concern, you may also consider getting them different versions of cushioning or orthotics in the shoes. Nonetheless, if non-operative management fails, in my own experience at least in clinic, the reason non-operative management may fail is that they have transferment of tarsalgia-related pain or Halox NP joint pain. Both of these may be something that pushes you towards orthodesis later when it comes to surgical options simply because it means that the patient isn't weight-bearing through the first-rate the way they should. Like I said, I was highlighting lateral forefoot pain and Halox NP joint pain because these may be signs that they end up doing joint fusions. Those would be primary reasons that this may fail. Interestingly, the Halox various deformity itself, will it really improve with non-operative management? It may not, but there are previous papers that show that as long as the degree of deformity is less than 10 or 15 degrees, the patient may not ever require surgery anyway. So definitely need to exhaust non-operative management before moving forwards. As far as trying to decide what to do for surgery, this is an algorithm that was published in a recent review paper. The highlights here is that once you start with Halox various on the left, if you have an irreducible deformity, then you're going to be moving towards Halox NP joint orthodesis. We'll talk about orthodesis a fair amount as time goes on just based on patient expectations and a definitive surgery. But nonetheless, if you can't reduce the joint with all other means, you're going to end up with a fusion. Examples here for mobile joints, if it's just imbalanced tendons, well, examples of some things that can lead to that would be sesamoidectomies or previous tendon transfers, like there's no way to balance the tendon forces again. That's also going to lead to orthodesis. I think that's another example of something that's irreducible. So let's say the tendons are still balanced. You're going to decide what to do next according to these authors, based on what's abnormal. So if there's abnormal first rate, that's what R1 here is referring to, abnormal first rate anatomy, then you'd base your osteotomy on where that anatomy is abnormal and try to basically undo what was previously done at the first surgery. So that would either be a reverse scarf for first metatarsal, that's what they mean by M1 here, or reverse acan for proximal phalanx problems. And then the M1 bone defect would be an overly aggressive medial eminence resection, a too large of a piece of the head was removed and the toe is subluxating off the medial side. That's something you could graft by placing a graft there to block it from being able to subluxate medially. So it's something to keep in mind. As far as normal first rate anatomy, this is something that would lead you to procedures that are corrective in nature, but still preserve motion. So that would either be ligament reconstructions, typically the lateral, the medial collateral ligament needs to be lengthened or released. The lateral collateral ligament needs to be tensioned or restored or reconstructed in some manner. And then tendon transfers could also be used at that point. Those are well-described historically, whether they actively restore the toe into motion or they work by a tinnitus effect, basically the exact same as a ligament reconstruction, I think is a matter for a different discussion. So examples of those R1 anatomy underminers would be the iatrogenic osteotomy overcorrections and kind of like we talked about here. Things that would lead you to the normal first rate anatomy, however, still require correction would be iatrogenic soft tissue overcorrections or just congenital contracturing of the foot. Obviously those are things that are included, but not limited to just those things. But as it pertains to surgery, everybody is going to end up needing some sort of soft tissue release to balance the foot, or I should say almost everybody. If their joint is contracted at the hallux and P joint, you're going to be releasing the tight side, which is going to be the medial side. This is typically an open Z or H-plasty, something to lengthen the medial collateral ligament while leaving it intact and able to be repaired. And then you may also be considering restoring balance to the flexor and extensor tendon mechanisms. You'd have to address these piecemeal. The nice thing about tendon transfers in this situation is that you can convert deforming forces to restoring forces. And again, how this may end up functioning is it's not going to turn into a normal toe, but the tendinitis effect can create almost like a pseudo fusion or create a check rain. It's not going to allow the toe to go back into various other options that are available. The kind of the classic is hallux and P joint arthrodesis. The big upsides of this is that it's definitive. There's excellent corrective power. There's excellent restoration. The first rate weight bearing on the first, you know, along that hallux and P joint, the downsides are going to be that it sacrifices motion at the MP joint, which for some people it's just not going to be acceptable. And then it may also lead just like any, we already know well that hallux and P joint arthrodesis that it may lead to adjacent joint arthritis and the motion saving options. I'm going to kind of lump all these together as far as the benefits and risks, you know, that motion saving meaning osteotomy, soft tissue, release transfers, ligament reconstructions, all the upsides of those that are going to be motion preserving at the MP joint. But again, there's not going to be a normal motion there. You're almost certainly going to end up creating some stiffness as you're trying to imbricate tissues laterally or do tendon transfers. There's still excellent corrective power here. The big downside I think that people should know about would be that transfers themselves create morbidity. You're having to borrow from Peter to pay Paul there. So you know, the transfer donor will obviously never perform his job anymore. They are less definitive. There are reports of these either failing and being a kind of a second failed procedure for that patient. So I think it's something I like to highlight with these patients is that this may end up leading to another surgery if they failed. And I think most patients, it's very unsavory to think about having three surgeries on their forefoot. The last downside here is that these things, there's a chance for an overcorrection back into symptomatic hallux valgus, which has been reported before. Something to be aware of. So what all these treatments are actually even new? As far as it pertains to transfers and soft tissue corrections, there's not really not much that's new. These transfers, whether it's a transfer of EHB, EHL, the abductors, those are all things that were reported kind of at the latest in 1996. A systematic review was done in 2011 looking at all these, and they found out that there's about an 11% complication rate at these procedures, where three of them required, recurred in the varus requiring revision in this setting, and four ended up going on to symptomatic hallux and P joint DJD and ended up requiring fusions. And so while that does mean that, you know, greater than 50 of these included patients in these series ended up doing fine afterwards, nonetheless, it's not a perfect procedure. Obviously nothing is, but something to be highlighted. These are all level four studies too, so how much can you really use to base it upon your decision making? I think that should be taken into account. So those are transferring, doing tendon transfers. There's also an option, instead of attempting to use the patient's own tendons to do the correction, you can do something to reconstruct the lateral collateral ligament. So these are adjuncts to these releases that we already talked about, or transfers. You can use suture tape, allograft tendons, autograft tendons, whatever you want. But if it's going to be a lateral check grain, something recreating the lateral collateral ligaments job, that's what I'm referring to here. There are reports of using an allograft tendon, you know, as early as in the 1990s. The first reported suture tape or kind of synthetic ligament augmentation was in 2011. And since that time, there's been a lot of case reports or technique tip style papers are showing different ways to do that. Again, these patients almost always are going to be folks that are presenting as revisions from hallux valgus operations. And so as you're planning where to put the tunnels and other implements you're going to be using for osteotomies, fusions, or this kind of stuff, it should be carefully taken into account. So I think a lot of the recent technique papers related to this are trying to do this with things that have smaller footprints, like perhaps using instead of two tunnels with an allograft going between them, either using an onlay on one side or things of that nature. The osteotomies and then what we can do to correct them, like we said, a reverse acan can be used to undo what was previously a P1 problem from like the other, the first acan being too large. The corrective power is excellent. Kind of the historical way to do this would be an open dorsal approach. You know, the way that the acan is done is typically that medial and midaxial approach to get to the, do the medial closing wedge. However, if the, you can't do that from the first web space, or at least it's not typically performed in that manner to just do the other toes getting in the way. So you can do this from the top. Something that can be done pretty simply, MIS to the Shannon burr, if you wanted to do that as well. And then the thing to keep in mind is that there's traffic with other soft tissue reconstructions. Okay. The first amount of tarsal problems can be treated with an osteotomy as well, either a reverse scar for a proximal osteotomy. They have excellent corrective power. I mean, you're going to be able to put them right back into Alex valgus. As far as I know, there are no reports of being able to do this minimally invasively, but I'm sure that you could, again, you'll have traffic with soft tissue reconstruction tunnels. And with either of these, more so with the first amount of tarsal osteotomies, you have to be beware of causing too much shortening of the first amount of tarsal. So here's a few examples of what these things look like. So the, on the left, there's a patient that had a significant metoductus, but had a previous distal first amount of tarsal osteotomy with a medial eminence resection and an ache. And obviously they have Halex varus, and I guess it's worth noting here that the Halex varus, the apparent Halex varus is significantly worse basically because the lesser toes have a valgus MP joint predilection at the MP joint. So there's lesser toe MP joint valgus, and Halex varus, it's going to look like a disfigurement. Afterwards, they'd perform this medial closing wedge osteotomy through an open approach, and we're able to move the first amount of tarsal head back into a more medial position. And you can tell based on the sesamoidal station here, how much of a correction that was performed. Then the Halex becomes in a symmetric MP joint valgus to its neighboring toes. For a reverse scarf, this would be a similar procedure, or similarly accomplished where here the lesser toe MP joints are straight, they're not in valgus, but nonetheless there's an obvious Halex varus deformity where the medial sesamoid kind of peeking out from the side. This is an open approach done with a classically cut scarf, just slid in the opposite direction. I think that something that's interesting here is you can tell how much of a correction was performed based on this medial, or excuse me, lateral ledge. This ledge of bone, when it's on the medial side of the Halex valgus operation is frequently resected with the saw, but in this case you can't get to it through a medial miniaxial incision, and so you can still see it. Otherwise, it's transfixed with two screws. You can also look at where the joint is pointing here, the joint's kind of pointing in line with the segment of tarsal, but in the image on the right, you can tell the first amount of tarsal head portion of the Halex NP joint is now pointing almost medially. They got a big correction out of this, and then the toes are in a cosmetically acceptable position. If there's arthritis or other instability with the first TMT joint, you can do this and then also perform a correction, I should say, of the first metatarsal and the primus varus through your joint fusion preparation. So here would be an example where that was performed and then internally fixed with a modified lapidus, correcting this first array into a more anatomic position. The other adjuncts that should be mentioned, if the patients have lesser toe NP joint varus, you may end up needing to correct those as well, basically to make room for the Halex when you bring that into a corrective position. How you're going to perform this is either going to be distal metatarsal osteotomies and or in combination with things you typically do for hammer toe corrections, so phalangeal osteotomy or joint fusions, maybe even tendon transfers. For transfer metatarsalgia, I think the big question that I would always ask myself is, can I do it all with my first ray correction? If I can't, or if I'm worried about shortening, then I can shorten the lesser metatarsals too. That could be a traditional, wild osteotomy style thing to shorten the lesser metatarsals or this can be done percutaneously with DMMOs or other distal metatarsal osteotomies that can be performed with a Shannon Burr. So here's some of my own cases. The first one we talked about, these are mostly Halex-Velocis revisions, but the first one I had in practice is actually a patient with congenital Halex-Velocis deformities. She did not have lateral forefoot pain. I think that's a key decision point that we talked about before. Mostly her complaints were cosmetic and difficulty shoeing. She had exhausted her ability to basically modify the shoes, really wasn't able to do anything other than walk barefoot, and so she wished to pursue a surgery. The options here, I discussed with her, kind of the full field of options are available. There has been a previous tendon transfers or otherwise bridges burned, so we could have done corrective osteotomies. There is no issue with length here. The first metatarsal is almost longer than the second, although that is somewhat of like a rotational deformity of the foot. She also had hammer toes of the lesser toes involving the second and third toes, and so that's something we would need to address as well. This is something that kind of before I learned minimally invasive techniques when I first started in practice, and so she wanted a definitive procedure, and so we performed corrective Halex NP joint arthro-DCs, and then I performed hammer toe corrections by fusing the PIP joints and doing an eccentric flexor-to-extensor transfer for the toes that needed it on both sides. Here she is about a year out, doing great. This case is a little bit trickier. This is an iatrogenic Halex varus, and I think this is the frequent scenario that we talk so much about. This patient had some significant lateral forefoot pain, and I think that's her main actual complaint. The deformity bothered her, but what really bothered her is that she was having a lot of pain when walking on the lateral forefoot, not the Halex NP joint. She also, based on the way she healed her previous osteotomy, had really significant first metatarsal head elevation, and so I'm going to highlight that with a couple different spots since you don't get the physical examiner the way that I did. So she has a stress reaction forming the second metatarsal shaft. Here's a coronal standing CT scan that kind of shows where the first metatarsal head is elevated in relation to the others. It's not exactly a validated way to look at the first metatarsal head, but nonetheless just my way of trying to convey it to you. And then here's the 3D recon that you can see the first metatarsal head kind of peeking out to the side there. To me, this almost looked like the patient had a distal first metatarsal osteotomy that was rotated inappropriately, leading to her to Halex Varus. And so as far as options are concerned that we want to talk to her about things to do, the most important thing for me was that we needed to reestablish weight-bearing through the first ray and address her lateral forefoot pain. She is the proprietor of an evening gown business and needs to be able to wear high heels, so she refused the Halex NP joint fusion. So I was going to perform this through a modified Lapidus with a plantar flexion closing wedge component with the joint preps. I did an open LCL reconstruction to address the Halex Varus and then did hammer toe correction of the second. Oops. Oops. I was able to kind of cannulate her old hammer toe implant with a wire and perform an Akinet of the second toe of the Shannon Burr. And also simply because I was going to be shortening her first ray quite a bit with the plantar flexion closing wedge, I also performed percutaneous osteotomies of the third, fourth, and fifth. And during the case, it did not need to do it in the second since it also seemed elevated in relation to the first ray. Here she is about a year out. There has been a little bit of a recurrence of the Halex Varus. However, the patient is asymptomatic. She's otherwise very happy because the lateral forefoot pain has been addressed. So the last case I have to show is another iatrogenic Halex Varus. This patient has kind of all the complaints. She doesn't like the cosmesis. She has difficulty wearing shoes and she has significant lateral forefoot pain. So the options, you know, again, is it osteotomy versus fusion? We need to deal with the second toe. We have to deal with the lateral forefoot pain. This patient also refused arthrodesis. And so, you know, I discussed different options with her about performing osteotomies or lateral collateral ligament reconstruction. The patient didn't really want to have any other further bone work done. And so we ended up performing an open lateral collateral ligament reconstruction medial release. Then to address the lateral forefoot pain, since I wasn't changing the weight bearing of the forefoot, I decided to shorten the lateral metatarsals as well. So here's that post-op, and this was only about three weeks ago, so I don't have another standing x-ray yet. But you can see that I did DMMOs of 2, 3, 4, and 5, and then an open LCL reconstruction there and an aconite of the second toe. So, you know, kind of a hybrid procedure where there is an open reconstruction of the first ray and then percutaneous of everything from the lateral forefoot and the second toe. And so far, so good. We'll see if it has a durable correction there. I worry because I feel like this patient's proximal phalangeal base has really kind of tipped off the inside of that medial first ray. So we'll see long term. That's it for me today. Thank you for your time. If you have any questions, feel free to contact me through the AOFAS website, but otherwise, thank you very much for your time.

Hallux Valgus

surgical management

iatrogenic

non-operative management

congenital deformities

osteotomies