Minimally invasive correction of hallux valgus

Formanyuk Alexander Nikolaevich , orthopedist-traumatologist at the Multimed clinic (Odessa), specialist in minimally invasive foot surgery

Valgus deformity of the first toe, Hallux Valgus, is a disease that results in deformation of the first toe, leading to deformation of the remaining toes. Hallux Valgus is characterized by a change in the angle between the first and second metatarsals, as well as a change in the angle between the first metatarsal and the main phalanx of the first toe. Almost always, the deformity is complicated by the formation of exostosis (bone growth) of the head of the first metatarsal bone.

According to statistics, approximately 50-60% of women and about 25% of men suffer from this disease.

Etiology and pathogenesis of deformity

• It is believed that the main factor in the development of deformity of the first finger is a hereditary factor . Indeed, almost all patients who come to us with this disease report that their mothers or grandmothers also suffered from deformation of the first finger.
• The second, and quite significant factor in the development of deformity, is wearing narrow, uncomfortable shoes, as well as high-heeled shoes . In this case, such shoes are a trigger for the initiation and development of deformation.
• The next factor that, unfortunately, is increasingly common in the modern world is excess body weight . Excess weight accelerates the appearance of deformation, because... There is constant excess pressure on the feet.
• Flat feet are also the most important factors in the development of the disease, because As a result of incorrect step biomechanics, deformation occurs.
• The last factor, which is partly genetic, is weakness of the ligamentous apparatus of the foot . As a rule, problems with ligaments are typical for women. This explains the percentage advantage in the development of the disease.

All of the above factors, individually or in combination, lead to dysfunction of the foot muscles, tension of the ligamentous apparatus, which, in turn, leads to deformation of the fingers and the appearance of exostosis.

If we talk about the symptoms of the disease, here all patients agree. First, deformation occurs in the area of the first toe; it is complicated by inflammation of the capsule of the first metatarsophalangeal joint, redness, pain, and the appearance of multiple painful corns on the skin of the foot. If no therapeutic measures are taken, the deformity often provokes a hammer-shaped or claw-shaped deformity of the II-V fingers.

Often, hallux valgus deformity of the first toe can provoke the appearance of Morton's neuroma (Morton's neuroma is a benign formation of the nerve tissue sheath, characterized by the appearance of sharp, shooting pains in the foot area when walking) in the second or third intermetatarsal spaces.

Thus, hallux valgus is a serious disease that entails a lot of complications and quite severe pain.

Classification

In the professional literature, there are many different classifications of hallux valgus. In my work, I most often use the classification proposed by MJ Coughlin and RA Mann ( Mann RA, Coughlin MJ Hallux Valgus and complications of hallux valgus. In: Mann RA, ed. Surgery of the foot. 5th ed St. Louis: Mosby, 1986 :65-131 ).

This classification distinguishes three types of deformation: moderate, moderate and significant.

With moderate deformation, the angle of deviation of the first finger is up to 20°, with moderate deformation - from 20 to 40°, with significant deformation - above 40°. As a rule, with a moderate degree of deformation, pressure begins from the first finger on the second and third, which leads to the beginning of their deformation. A significant degree of deformation is always complicated by deformation of the second and sometimes third toes.

Treatment options

This pathology has two treatment methods: conservative and surgical.

Conservative way

We use it to treat initial deformity or to prevent the development of deformity.

The conservative method consists of an annual examination of the patients' feet, wearing comfortable, correct shoes with a wide toe, and the use of orthopedic insoles with supination of the transverse and longitudinal arches of the foot. Daily foot exercises, physiotherapeutic procedures, and kinesiotaping are also required. If there is inflammation in the area of the first metatarsophalangeal joint, anti-inflammatory therapy, injections of hormonal drugs, botulinum toxin, and platelet-rich plasma are used.

Surgical method

This treatment method is also divided into several types. There is a classic, open method of surgical treatment, which is performed through a skin incision using metal fixation (wires, screws, plates) and under spinal anesthesia. There is also a more modern, minimally invasive method of surgical correction of the first toe.

Minimally invasive (percutaneous) foot surgery

This method of treating the disease of deformity of the first finger can be used for all three degrees of deformation.

In the modern world, patients increasingly come to the doctor requesting not only high-quality and painless treatment, but also quick rehabilitation and no hospital stay. And I am very glad that I can offer my patients a low-traumatic percutaneous method for treating toe deformities.

First of all, I would like to talk about the main advantages of percutaneous foot surgery:

• The operation is performed under local, regional anesthesia. This gives us the opportunity to operate on older patients with concomitant diseases. Also, conduction anesthesia has an analgesic effect during the first day, which facilitates the postoperative period.

• Since the operation is performed under local anesthesia, this gives us the opportunity for outpatient treatment. 30-60 minutes after the operation, the patient can safely go home, even to another city. On average, a patient spends 3 to 5 hours in the clinic. After 7 days he arrives for a dressing. Then examinations are carried out on the 14th day and 4 and 6 weeks after surgery.

• The name of the method itself hides its advantage. The operation is minimally invasive, which means that it is performed through micropunctures measuring 0.5 cm, which ensures the absence of postoperative scars. Thus, the patient’s feet are not disfigured by huge scars.

• No metal fixation is used. For many patients, this is a decisive factor when choosing a treatment method, because... Metal fasteners (screws) often need to be removed after surgery, which means another operation.

• The next advantage smoothly follows from the previous one. The absence of metal fixation allows you to simplify the rehabilitation period and start walking immediately after surgery. Yes, the patient puts full weight on his foot immediately after surgery, and special postoperative boots help him with this ( Fig. 1 ). The patient wears these shoes for up to three weeks, and then switches to his own wide and comfortable shoes.

Rice. 1 Postoperative shoes

• Well, one more advantage that I definitely want to mention is the absence of pain. Since the operation is low-traumatic, in the postoperative period there is either no pain at all or minimal pain and, as a rule, lasts only the first 3-5 days.

Minimally invasive surgery protocol

The patient's stay in the clinic is 3-5 hours.

Before the operation, we always conduct another consultation, where we discuss with the patient all the details of surgical treatment and the rehabilitation period. The patient then goes to the operating room, where premedication is given and local anesthesia is performed.

Correction of hallux valgus is done through a small (0.5 cm) skin puncture. Depending on the degree of deformation, there can be from two to three such punctures. A ligamentotomy of the adductor muscle is performed on the medial side of the metatarsal head. Then, using special metal cutters, osteotomies of the metatarsal bone are performed. Typically, the Reverdin-Isham osteotomy is used. It consists of removing the exostosis of the head of the metatarsal bone and directly osteotomy at the level of the body of the metatarsal bone ( Fig. 2 ). In some cases, it is necessary to perform an osteotomy at the level of the body of the main phalanx of the first finger (Akin osteotomy).

After all osteotomies are completed, the skin punctures are sutured, a tight, fixing bandage is applied and a postoperative boot is put on.

All postoperative recommendations are then given, and the patient can go home.

Clinical case

A 70-year-old patient came to me with complaints of constant pain, deformation, inability to select shoes, also deformation of the second toe and the formation of a painful corn ( Fig. 3 ).

Source

A diagnosis was made: significant valgus deformity of the first toe of the left foot, hammertoe deformity of the second toe of the left foot . Due to the patient’s age and active lifestyle, she was offered minimally invasive correction. In the photo ( Fig. 4 ) you see the result of minimally invasive correction of valgus deformity of the first finger and hammertoe deformity of the second finger after 6 weeks.

Minimally invasive foot surgery allows you to walk immediately after surgery. Semi-bed rest is recommended only for the first 7-10 days. Driving a car is possible 10-14 days after the operation, playing sports - after 3-4 months.