Importance of Frontal Plane Deformity in Surgical Correction of HAV

Importance of Frontal Plane Deformity in Surgical Correction of Hallux Valgus Heather Schaefbauer, MS4Advocate Illinois Masonic Medical Center August 2015

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Overview:IntroductionBackground:DefinitionEtiologyAnatomyHistory & Clinical ExamSurgical treatmentLiterature reviewConclusion

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Introduction:Accounts for > 200,000 surgeries in the US every year> 100 operation techniquesTraditionally operation may include:CapsulotomyBunionectomyLateral soft tissue releaseMedial capsulorrhaphyFirst metatarsal osteotomyLapidus:Introduced in 1934Arthrodesis of 1st met-cun joint & 1st intermetarsal jointPerformed < 10% of all HAV procedures

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Terms & Definition

1845: Bunion first described (Durlacher)1870: Hallux valgus (Heuter)1924: Metatarsus primus varus (Truslow)Hallux abductovalgusHallux abducto valgus with metatarsus primus adducto valgus (Dayton et al)

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EtiologyHeredity and genetic factorsGenetic disordersBiomechanical abnormalitiesArthritic conditionsNeuromuscular diseaseTrauma

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AnatomySesamoid apparatus:Two sesamoid bonesIntersesamoid ligamentMedial and lateral metatarsosesamoid ligamentsMedial and lateral sesamophalangeal ligamentsEncased by:FHBAdductor hallucis DTMLFibers of plantar aponeurosis.

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History & Clinical ExamHistory:Painful overlapping 2nd toeInterdigital helomaPain over medial eminenceAdventitious bursaIrritation of the first proper digital nerveClinical Exam:Hallux positionFirst MTPJ ROM and qualityEvaluate for track-bound joint

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Radiographic ExaminationSoft tissueOsseous structuresJoint surfaceStructural & positional relationships

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Structural & Positional RelationshipsHallux abductus angle (HAA)Proximal articular set angle (PASA)Distal articular set angle (DASA)First intermetarsal angle (IMA)Metatarsophalangeal joint positionSesamoid positionMetatarsus adductus angle (MAA)Hallux interphalangeus angle (HIA)Shape of the metatarsal head

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Surgical CorrectionGoals of surgery:Congruent 1st MTPJReduction of IMARealignment of the sesamoids Restore WB function of first rayMaintain first MTPJ ROMRectus alignment of halluxControl or correction of cause

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Position of 1st Metatarsal in a Bunion DeformityFirst ray axis (Hicks)Dorsiflexion w/ inversion Plantarflexion w/ eversionDebate:Varus position of 1st metatarsal (Hicks)Valgus position of 1st metatarsal (Roukis & Landsman)Current research:1st metatarsal in valgus positionPrimary deformity at 1st TMTJ

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Addressing the Impact of Frontal Plane Rotation on Bunion RepairDiDomenico & Luckino, Podiatry Today (April 2015)Frontal plane often overlookedFrontal plane rotation is a significant factorProcedure:Modified Lapidus arthrodesis3 planes of correction w/ emphasis on frontal planeNo violation of 1st MTPJ

Weve ignored the frontal plane during surgery for some time the frontal plane valgus rotation of the 1st metatarsal. Di Domenico

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Modified Lapidus ProcedureSurgical technique:4 cm incision over 1st TMTJRotate hallux & 1st met out of valgusDorsiflex halluxAdditional frontal plane correction with use of joystickReduction of sesamoids:Manual manipulationLigamentotaxis

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Other points:No true large medial eminenceCorrection achieved @ center of rotation angulation (CORA)Other benefits:Restoration of normal or near normal anatomic alignmentImprove 1st MTPJ ROMDecreased risk of complications

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Literature review

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Is Our Current Paradigm for Evaluation and Management of the Bunion Deformity Flawed? A Discussion of Procedure Philosophy Relative to AnatomyDayton, Kauwe, Feilmeier, JFAS (2015)Review publications:Frontal plane position of first metatarsalSesamoid alignmentPre-op bunion evaluationMost procedures only address transverse and sagittal plane correctionProcedures should correct the CORATibial sesamoid position (TSP) reflected by frontal plane rotation of 1st metatarsal.

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Center of Rotational Angulation (CORA)CORA = anatomic axes cross (level of deformity)Bisector lineAngulation correction axis (ACA)

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Medial EminenceShould you resect the medial eminence?Medial eminence ORDorsomedial surface of first metatarsal head in valgus position

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Valgus Position of MetatarsalLapidus procedure pre- and post-op:Roundness of lateral first metatarsal headSesamoid position

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Correction of Frontal Plane Rotation of Sesamoid Apparatus during the Lapidus Procedure: A Novel ApproachDiDomenico et al, JFAS (2014)Procedure:Modified Lapidus Utilization of soft tissues to reduce sesamoidsAll rotated into neural position as 1 unitFixated with 3.5 mm cortical screw and 6-hole plate medially

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Reduction Maneuver

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Advantages of procedureNo scar tissue formed along jointGliding mechanism of tendons maintainedNo risk of staking the head (less risk of hallux varus)No vascular or nerve concerns exist

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Relationship of Frontal Plane Rotation of First Metatarsal to Proximal Articular Set Angle and Hallux Alignment in Patients Undergoing Tarsometatarsal Arthrodesis for Hallux Abducto Valgus: A Case Series and Critical Review of the LiteratureDayton et al, JFAS (2013)Retrospective review of radiographs pre-op and post-op:IMAHAAPASATibial sesamoid positionPurpose: Determine if measurements accurately describe the HAV deformity Question the necessity of the 1st MTPJ release & ST balancing

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Procedure:Lateral sesamoid ligament releaseIncision over 1st TMTJTMTJ resected2 smooth 2-mm pins inserted and used as reference pointsMetatarsal head rotated in varus direction

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ResultsMean post-op measurements (IMA, HAA, PASA, TSP) were all significantly lower than mean pre-op values.No complications in post-op period

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DiscussionHAV singular deformity with consistent level of deformity (CORA)Radiographic measurements:PASA reduced with derotation & TMT corrective arthrodesisHAA decreased with accurate realignment of jointTMT arthrodesis can address all 3 planes of HAV deformity at the deformities CORA.We believe that the frontal plane component is a key component of first MTPJ misalignment in HAV deformity and must be addressed during correction to provide anatomic alignment of the first MTPJ.

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ConclusionCurrent studies limited by retrospective design and small sample sizeLapidus contraindicationsRisks with Lapidus procedureOther things to keep in mind:Longer post-operative rehabilitation periodHigher complication rateTechnically demanding operationImportant to consider all planes of HAV deformity in evaluation and planning of procedure

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REFERENCES:Coetzee, C., Resig, S. G., Kuskowski, M., & Saleh, K. J. (2003). The Lapidus Procedure as Salvage After Failed Surgical Treatment of Hallux Valgus. Journal of Bone and Joint Surgery , 60-65.Coughlin, M. J., Mann, R. A., & Saltzman, C. L. (2007). Surgery of the Foot and Ankle. Philadephia, PA: Mosby.Dayton, P., Feilmeier, M., Kauwe, M., & Hirschi, J. (2013). Relationship of Frontal Plane Rotation of First Metatarsal to Proximal Articular Set Angle and Hallux Alignment in Patients Undergoing Tarsometatarsal Arthrodesis for Hallux Abducto Valgus: A Case Series and Critical Review of the Literature. Journal of Foot & Ankle Surgery , 348-354.Dayton, P., Kauwe, M., & Feilmeier, M. (2014). Clarification of the Anatomic Definition of the Bunion Deformity. Journal of Foot & Ankle Surgery , 160-163.Dayton, P., Kauwe, M., & Feilmeier, M. (2015). Is Our Current Paradigm for Evaluation and Management of the Bunion Deformity Flawed? A Discussion of Procedure Philosophy Relative to Anatomy. Journal of Foot & Ankle Surgery , 54, 102-111.DiDomenico, L. A., & Luckino, F. A. (2015, April). Addressing the Impact of Frontal Plane Rotation on Bunion Repair. Podiatry Today .DiDomenico, L. A., Fahim, R., Rollandini, J., & Thomas, Z. M. (2014). Correction of Frontal Plane Rotation of Sesamoid Apparatus during the Lapidus Procedure: A Novel Approach. Journal of Foot & Ankle Surgery , 248-251.Schmid, T., & Krause, F. (2014). The Modified Lapidus Fusion. Foot Ankle Clin N Am , 223-233.Shapiro, J. (2014). The Next Paradigm Shift in Hallux Valgus Surgery - Addressing the Frontal Plane. Present Podiatry .Southerland, J. T., Boberg, J. S., Downey, M. S., Nakra, A., & Rabjohn, L. V. McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia, PA: Wolters Kluwer.

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Questions?

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