Advances in the Management of Forefoot Deformity

Introduction

The common misperception is that forefoot surgery is unsuccessful, painful, or that patients will be unable to walk for prolonged periods of time. Over the years there has been many advancements for bunion surgery and arthritis of the first toe. These advancements have led to predictable and reliable results, less pain, internal fixation devices and development of minimally invasive techniques.

Hallux Valgus deformity

Hallux valgus deformity (bunion) is a common condition of the first MTP joint. The common perception is that there is a growth of bone that can be simply shaved off to correct the problem. The medial prominence is caused by a medial subluxation of the first metatarsal head, with corresponding valgus of the toe. Pain is often related to pressure within shoes. When conservative management consisting of wider fitting shoes or activity modification is no longer effective, surgical correction of the deformity may be considered.

Correction of the deformity involves osteotomy of the first metatarsal head, shifting the head laterally and fixing the displacement with screws. The shaving of the bone is of the remaining prominent shaft rather than prominent head. The operation is commonly performed through an open incision with predictable results of correction and pain relief. The procedure can be performed as day surgery, with the patient relatively pain free after surgery and able to walk on the foot on the same day.

Advancements have been made in the treatment of the condition through percutaneous or minimally invasive techniques to perform the osteotomy and deformity correction. This can be associated with less swelling, stiffness and postoperative pain. The technique can allow bilateral foot correction to be performed as a day surgery procedure.

First MTP joint arthritis

Degenerative arthritis of the first MTP joint is often called a bunion due to the presence of a bony prominence. The clinical difference is the associated stiffness of the joint, pain with joint motion and the dorsal location of joint osteophyte formation. Pain to the joint can be from dorsal pressure in shoes or from the progressive joint space changes.

Initial treatment consists of shoe ware changes to increase the height of the toe box, avoidance of high heels or use of a ridged insert to limit joint motion with walking. When these measures are no longer effective, surgical treatment can consist of joint sacrificing or joint preserving procedures.

Arthrodesis of the joint is still considered the optimal treatment for end stage arthritis of the joint when severe pain and limited joint motion is present. Minimally invasive techniques can be used to perform this procedure. The misperception is that a limitation of joint motion will cause a limp or restrict activities of the foot. With successful arthrodesis, the patient will have a pain free stiff joint that will often allow them to return to normal activities without a limp.

Not all patients will require a fusion to alleviate the pain. Dorsal joint pain from pressure in shoes can be alleviated with removal of the prominence and debridement of the joint. This is often effective when pain is limited to the dorsal prominence only. The biggest dilemma has been the patient with a painful joint wishing to retain joint motion. Recent advancements in joint preservation consist of the Cartiva implant, a synthetic cartilage that can be placed into the metatarsal head to replace the cartilage defect and maintain relative normal motion of the toe.

Foot and Ankle Surgery in Nowra

Dr Cadden has been consulting in Nowra for nearly 10 years at the South Coast Orthopaedic Centre. With the recent expansion of the Nowra Private Hospital Dr Cadden has now been accredited as a VMO to perform his foot and ankle procedures at the hospital on a monthly basis. This will enable patients on the South Coast to receive their foot and ankle surgical care locally.