First speaker is Scott Ellis, come on up Scott. Scott is on staff here. He is the current chair of the Young Physicians Committee in the AOFAS, very involved in research and education and we're lucky to have Scott here. Thanks Scott. Thank you Matt. We're grateful to have all of you and hope we can teach you a lot today. There's no better topic really to start with than the bread and butter of foot and ankle and that's hallux valgus and bunionette. Okay so let's just get started. So what is hallux valgus? Well it is a condition in which the big toe moves towards the second. There's no better view of it than this patient's right foot. If you think about it really though what's also happening is that the first metatarsal is moving in varus with respect to the second. Let's see if you can see, yeah you can see my arrow, good. Why does it happen? Well there's a number of factors, extrinsic factors such as shoe wear activity. It tends to be in women that wear pointed high heels. It happens a lot in dancers. There are intrinsic factors, genetics, flat feet, particularly when a male has it. I know there's going to be a strong family history of it. It goes hand in hand with flat feet as we can talk about later. More intrinsic causes, like I said there's a genetic component, flat feet. Why does it happen in women? Well we think that women are more flexible or ligamentously lax and there's this concept of the first rate hypermobility which goes hand in hand with that concept. We do really keep an important concept. Patients will come in with a bunion and say it's really not their bunion, it's the second toe that's causing the problem. It's all stemming from the bunion itself. There's a host of second toe metatarsal problems that occur. One is a dislocation or a hammer toe which can lead to dislocation actually of the MTP joint. Stress fracture of the second metatarsal, second metatarsalgia, in other words pain underneath that metatarsalgia, and even arthritis up in the midfoot of the second TMT joint. These are all again occurring from that bunion. How do we evaluate this on x-ray? Well there's three, two but I'll say three really important values that you should know to determine if there's a bunion and the severity of it. The first is a hallux valgus angle and that is the angle that's drawn along the shaft of the first metatarsal with the proximal phalanx. It's called the hallux valgus angle. Remember this number, normal is less than 15. The IM angle is the inner metatarsal angle. That's the angle between the first and second metatarsal and that should be less than nine. The more that metatarsal, first metatarsal comes over the worse that is. And then there's a so-called distal metatarsal articular angle. And this one is one I don't use a lot in principle. I want you to notice that when we reformat these talks the angles got shifted here so it's not quite right. But the concept is this. You're trying to figure out what the angle is of the articular surface of the metatarsal head with respect to the metatarsal and it should be really perpendicular to that metatarsal. If you see a case like this where it's turned a little bit, notice how that articular surface is almost turned towards the second with respect to the first metatarsal. That's called a congruent bunion and that's an abnormal DMAA. We'll talk about that more in a second. I don't really use that much in practice. Some people do. Again, the concept of the inner metatarsal angle, it should be less than nine. As it starts getting more and more it just gets moderate to severe. And then I have a horrible up there, more than 20. What is the non-operative treatment? Well, you always, I would say cross foot and ankle in general. If somebody breaks their ankle or tears their Achilles, and we could debate that too, but it's non-operative. So shoe wear modifications. Wear a wider shoe box. Notice this on the left is a wider shoe box. It helps accommodate those toes more. A higher toe box so that there's more room from the bottom to the top to fit a hammer toe. And activity modification. So when do you do surgery? Well, when there's a lot of pain, despite doing all these things, despite shoe wear modification, despite activity modification. And I try to tell patients to try to do this before the second toe starts really becoming involved, because that surgery becomes a lot harder. This is in general never a cosmetic decision. There is a whole host of surgical procedures that you're going to see, read about as you go through your training. They have a bunch of names that sometimes it's hard to remember, but I'm going to try to go through these and give you an idea, an algorithm, how to decide what to do. The principles, and this is the most important slide, are really this. The worse the deformity, the more proximal that your correction needs to be. In truth and in practice, you want to also get good at one of these surgeries, because the more you do of one, the better you're going to be at fixing a bunion with that. The keys, no matter what surgery you do, are to reduce that first empty P joint. By that I mean here at the first metatarsal phalangeal joint, and get those sesamoids here reduced right underneath the metatarsal. And this is a lapidus that I've done, which is my go-to, but we could talk about that in more detail. The silver is when you shave the medial eminence, okay? So you can see in this case, I've shaved it just nice and flat and smooth. It is almost never done by itself, it's always part of other surgeries. And it also, you go through the medial capsule, it allows you to plicate that capsule to also bring that great toe out of algus. There's a distal soft tissue procedure that you're going to hear about a lot. Essentially, we go through a web-space incision, release the adductor hallucis, release the lateral capsule, and then on the medial side, as I was talking about before with that silver, you can release that capsule and tighten it. You'll hear about the McBride that was going through that first web-space incision, taking out the lateral sesamoid. What you hear about the modified McBride now is you actually don't take out that sesamoid because a lot of those cases would go on to varus. So here's a good surgical algorithm for you. You have somebody with a hallux valgus or bunion. You know right off the bat, if that joint is arthritic, the one go-to procedure is to fuse that big toe joint, okay? Here's an example of one I did. You fuse it, you can correct the bunion, but you also can correct the arthritis as well. So that's the go-to if there's hallux valgus with arthritis. If there's not, the next thing I look for is that hypermobile first ray because if there is, and this is somewhat subjective, you do a lapidus or first TMT fusion. This is a lapidus here. Again, I showed you it's very powerful. It addresses hypermobility. It's also good as a revision procedure. The problem sometimes, it's a long recovery. Patients can't put weight on it for six weeks. There's a small risk of a nonunion, meaning that this joint does not heal. And then you got to be careful where you position that metatarsal because you could, if you elevate it, you can overload that second. It's what we call transfer metatarsalgia. Okay, the next concept is this congruent or not. Again, I don't believe a lot in this, but this is tested all the time on your test. If you have that congruent, you look for congruency. If you have a congruent bunion, that picture I showed you where that metatarsal's head is turned and it's still in line with that proximal phalanx, you'd consider doing two osteotomies. We can ask the other faculty. I've never, in truth, done that. If it's non-congruent, again, vast majority of cases, you want to base your decision on the severity of the IM angle or the Hallux valgus angle. And here we go. So again, Hallux valgus, you have one IM angle, less than nine, which truthfully is normal, remember, and Hallux valgus angle is 25, not bad. You could consider doing a distal soft tissue release, but I want everybody to know it would be extremely rare to just do a distal soft tissue release by itself. You probably shouldn't be doing the bunion. If you have a medium-sized bunion in this range, you can consider other procedures, a distal chevron, for example. And if you have a real severe one, you need a more proximal correction such as a lapidus or an osteotomy. Just to show you briefly some of these, this is a chevron where you cut the metatarsal in this kind of V shape and slide it over. It's probably the most widely used across the country, particularly with podiatrists. The one risk, AVN of that metatarsal head. You can see a picture of that here. The scarf is very widely used, particularly in Europe, but also here. It's kind of a cut along the shaft of the metatarsal, and you slide and rotate that metatarsal and get correction, usually fixed with a couple screws you can see above. I have done in the past these opening wedge osteotomies where you actually make a cut in the proximal part of the metatarsal and just swing it over. And my only problem is I've seen some slight recurrence, which is a whole other topic in and of itself. And the acan, this is where you actually make an osteotomy of the proximal phalanx, and really it's best to use in combination with other procedures or if you still have some valgus, it actually comes through this inner phalangeal joint. Okay, so that's it for Hollich's valgus. There's a lot more we can talk about, but we've got to move in the interest of time. Now bunionette, this is a so-called Taylor's bunion. This is when you have varus, really, of the fifth toe, or valgus of the fifth metatarsal. You can see how this is swinging way over here. People complain of rubbing on the lateral side of their metatarsal head. They get thickened skin and capsule there. This is tolerated a lot more than a bunion, although we commonly find it in the same patients. What do we look at on x-rays? We look at the angle between the fourth and fifth metatarsals. It's again a metatarsal, inner metatarsal angle of sorts, and the normal is nine or less. You can also look at the MTP angle, which is analogous to that Hollich's valgus angle. Look for ten or less. Some people just have simply an enlarged metatarsal head, and there's a classification for this. So type one is just an enlarged metatarsal head, and I'm going to jump straight to how this helps guide you. If you have just an enlarged metatarsal head, you could simply consider shaving that lateral aspect, and that could help that patient. Type two is when you have this bowing. It's like a curving of that metatarsal, and in that case, you probably need to do more than just shave it. Consider distal osteotomy to kind of translate that over. And then patients with an increased IM angle, like this third in stage three, you want to do a larger osteotomy or proximal osteotomy. There's a so-called stage four, which is rheumatoid arthritis, which is a whole different ballgame. How do we treat this? Again, you start non-operative, stretchy shoes, avoid seams over that area. I've seen patients even go as far as to cut a hole in their shoe. You can trim the callus, use a metatarsal pad. In terms of the principles of surgical treatment, we want to address the hallux valgus concomitantly. You want to avoid just resecting that metatarsal head for many reasons, but the biggest one is it can lead to transfer metatarsalgia, the fourth, and lead to painful promise. So just burn this in the back of your mind. This is not a good treatment, that isolated resection. For me, you just shave that prominence very gently. You could tighten that capsule laterally as well to try to bring the toe over. Generally, we do not perform a medial release. And this slide I basically talked to you about before and you'll have it in the enduring materials. This is what can go wrong. I had an outside doctor do this osteotomy as one of the treatment options I showed you. This patient had continuous and severe pain, so I actually had to go back and fix that with a plate. So I'm not so sure this is a great option, but it's well-described and well-used. I tend to favor more proximal osteotomies, what I call Ludloff. It's an osteotomy you make along the shaft of that metatarsal. This one I did in the setting of a bunion as well. It gives you a very powerful correction. You can do different types of osteotomies as well. So in summary, most cases of bunionette do not require surgery, particularly if you have a hallux valgus because if you fix that bunion, it narrows the foot in and of itself and makes that bunionette feel better. In general, my practice, simple lateral excision has been usually insufficient and avoid at all costs just isolating or doing an isolating resection of that metatarsal head. In the interest of time, we'll keep moving.

Scott Ellis

hallux valgus

bunionette

surgical options

metatarsal head resection