Hallux valgus Hallux rigidus - Dansk Ortopædisk …...Lateral release Anatomical structures to be...
Transcript of Hallux valgus Hallux rigidus - Dansk Ortopædisk …...Lateral release Anatomical structures to be...
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Hallux valgus
&
Hallux rigidus
A-kursus Aalborg 2015
Overlæge
Jens Kurt Johansen
Fod-ankelsektionen
Køge Sygehus
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Køn
Etnicitet
Familiær ophobning
Alder
BMI
(Fodtøj)
Pes planuvalgus
Hypermobilitet.
Arthrit
Hallux valgus ætiologi
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Associerede fodabnormiteter
Stram achillessene
Platfod
Forfodsvarus
Dorsalflekteret 1. stråle (metatarsus primus elevatus)
Hypermobilitet første stråle ( 1. TMT-led)
Kort 1. metatars
Manglende 2. tå
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Patogenese
◦ 1st TMT eller ustabil
◦ MT -caput medialt sesamknogler, FHL, adductor forbliver lateralt
◦ Add. hallucis &( tryk fra sko) Phalanx valgus
◦ Mediale kapsel strækkes; laterale kapselkontraheres
◦ Lateral deviation af EHL deformitet
◦ Lat. Sesamknogle i 1-2 interspace; tåen pronerer
◦ windlass mekanisme
◦ funktion 1. tå transfermetatarsalgi
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Vurdering AP røntgen
IM vinkel
HV Vinkel
Grad af sesamknogle displacering
”Resten” af foden
Altid stående rtg billeder i 2 planer
Klinisk undersøgelse af hele foden
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DMMA
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Konservativ behandling
Modificering af fodtøj/ortopædisk fodtøj
Tapening, indlæg, metatarsal pad
NSAIDs
Ændring af aktivitetsniveau
Kosmetiske overvejelser
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Operativ behandlingChevron + AKIN
Proksimale osteomier: Crescent/Open wedge
SCARF osteotomi
Lapidus
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Valg af operationsteknik
IM<15 gr.
HV<30 gr.
IM>15 gr.
eller HV>30gr.
- hypermobil
hypermobil
Chevron osteotomi
Proksimal
osteotomi
TMT-dese
Akin osteotomi Akin osteotomi
Akin osteotomi
I kombination med relevante bløddelsprocedurer
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Prox osteotomi
Open wedge eller crecentic teknik giver minimal forkortning af 1. metatars
Korrektion foregår distaltfor CORA
Korrektion i et plan
DMAA / ledfladevinkelændres (ved stor korrektion)
Tab af korrektion
Lapidus
Mere power
Korrektion i alle 3 plan
Historisk set problemer
med knogleheling (2- 25
% non union)
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Scarf Osteomi :
Hallux valgus
Metatarsus varus
Hallux rotation
Kan benyttes Kan ikke benyttes
IM-vinkel for stor
Ustabilt 1st TMT-led
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Komplikationer:
Bløddele:
◦ Sårheling
◦ Nerveskade
◦ infektion
◦ Instabilitet af MTP-1
◦ Arthrofibrose
◦ Recidiv af Hallux valgus
◦ FHL-overskæring
◦ CRPS
◦ Malunion- pseudoarthrose
◦ Hardwaresvigt
◦ Overkorrektion- hallux varus
◦ Underkorrektion- recidiv
◦ Caputnekrose
Knogle/hardware
Hyppigste komplikation:
MTP-I stivhed
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Chevron Osteotomi
Incision midtlinie Markering af centrum
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Chevron Osteotomi
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Chevron Osteotomi
Lateralisering og kompression Efter afsavning af ”tagskæg”
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Lateral release
Anatomical structures to be
released through the dorsal first
web-space approach.
Fig. 2-A The adductor hallucis
tendon is identified
with use of a mosquito forceps.
Fig. 2-B The adductor hallucis
tendon (arrow) has been released
from its insertion at the base of
proximal phalanx of the
great toe.
Fig. 2-C After releasing the fibular
sesamoid-metatarsal ligament, the
fibular sesamoid (arrow) can be
observed.
Fig. 2-D The transverse
metatarsal ligament (arrow) has
been identified and transected.
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Luxation/rotation af kapsel m sesam komplex
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Hallux rigidus
Ætiologi: Traume? Ukendt ?
Symptomer: Smerter og nedsat ROM
MTPJ-1
Rtg: Osteofytose samt
artrose/osteochondral skade
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Konservativ behandling
Modificering af fodtøj (gænge)
Indlæg
NSAIDs
Ændring af aktivitetsniveau
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Hallux rigidusValg af operationstype
Cheilectomi:
Ved generende dorsal knystdannelse.
Moberg:
Supplement til cheilectomi
MTP artrodese:
Ved symptomer fra centrale/plantare del af leddet Keller artroplastik:
Hvor større kirurgi er kontraindiceret.
Ældre pt med nedsat aktivitetsniveau!
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Cheilectomi
Indikationer:
Gener fra fodtøj på grund af dorsalknystdannelse.
Indskrænket bevægelighed og/eller smerter ved max. dorsalflexion og plantarflexion(impingement).
Kontraindikationer
Massiv artrose
Brusk degeneration plantart i leddet (>50% af ledbruskinvolveret).
Smerte ved kompression af leddet i længderetningen under plantarflexion.
Tidligere cheilectomi
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Cheilectomi
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Indikation for MTP- 1 dese
Svær artrose hvor mere
end 50% af brusken på
caput af 1. metatars er
væk.
Tidligere mislykket
cheilectomi
Svær hallux valgus
RA med
forfodsdeformitet.
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MTP-dese
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Cup’n’Cone teknik
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Take home message
Kirurgisk behandling kun ved smerter.
Korrektion af både knogler og bløddele
(sesamkomplex) ved hallux valgus.
Der stiles mod 70-80°dorsalflexion i
1.MTP-led peroperativt.
Undgå (så vidt muligt) forkortning.
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Referenceliste:
Surgery of the foot and ankle, 8th edition Saltzmann et al
McGlamrys Comprehensive textbook of foot and ankle surgery
4th edition Lippincott Williams and Wilkins
Operative techniques in foot and ankle surgery 2011 Mark E. Easley
Lippincott Williams and Wilkins
Master techniques in podiatric surgery: The foot and ankle 2005
Thomas J. Chang, Lippincott Williams and Wilkins
Radiology of the foot and ankle 2nd edition, RA Christmann
Complications of first ray osteotomies
A consecutive series of 475 feet with first metatarsal Scarf osteotomy and first phalanx osteotomy
Hammel E, Abi Chala ML, Wagner T
Rev.chir. Reparatrice Appar. Mot 2007 Nov;93(7):710-719
Comparison of Distal Soft-Tissue Procedures Combined with a Distal Chevron Osteotomy for Moderate to Severe Hallux Valgus:
First Web-Space
Versus Transarticular Approach
Yu-Bok Park, MD, Keun-Bae Lee, MD, PhD, Sung-Kyu Kim, MD, Jong-Keun Seon, MD, PhD, and Jun-Young Lee, MD, PhD
J Bone Joint Surg Am. 2013;95:e158(1-8)
Coughlin, M. J., Saltzman, C. L. & Nunley, J. A. Angular measurements in the evaluation of hallux valgus deformities: a report of the ad hoc
committee of the American Orthopaedic Foot & Ankle Society on angular measurements. Foot Ankle Int. 23, 68–74 (2002).
EVALUATION OF A NEW TECHNIQUE FOR FUSION OF THE FIRST METATARSOPHALANGEAL JOINT
http://www.bjjprocs.boneandjoint.org.uk/content/90-B/SUPP_II/244.3