Discussion of the importance of correcting the frontal plane deformity in HAV and surgical procedures to address the frontal plane deformity.

1. Importance of Frontal Plane
Deformity in Surgical Correction
of Hallux Valgus
Heather Schaefbauer, MS4
Advocate Illinois Masonic Medical Center
August 2015

2. Overview:
• Introduction
• Background:
• Definition
• Etiology
• Anatomy
• History & Clinical Exam
• Surgical treatment
• Literature review
• Conclusion

3. Introduction:
• Accounts for > 200,000 surgeries in the US every year
• > 100 operation techniques
• Traditionally operation may include:
• Capsulotomy
• Bunionectomy
• Lateral soft tissue release
• Medial capsulorrhaphy
• First metatarsal osteotomy
• Lapidus:
• Introduced in 1934
• Arthrodesis of 1st met-cun joint & 1st intermetarsal joint
• Performed < 10% of all HAV procedures

4. Terms & Definition
• 1845: Bunion first described
(Durlacher)
• 1870: Hallux valgus (Heuter)
• 1924: Metatarsus primus
varus (Truslow)
• Hallux abductovalgus
• Hallux abducto valgus with
metatarsus primus adducto
valgus (Dayton et al)

5. Etiology
• Heredity and genetic factors
• Genetic disorders
• Biomechanical abnormalities
• Arthritic conditions
• Neuromuscular disease
• Trauma

6. Anatomy
• Sesamoid apparatus:
• Two sesamoid bones
• Intersesamoid ligament
• Medial and lateral
metatarsosesamoid ligaments
• Medial and lateral
sesamophalangeal ligaments
• Encased by:
• FHB
• Adductor hallucis
• DTML
• Fibers of plantar aponeurosis.

7. History & Clinical Exam
• History:
• Painful overlapping 2nd
toe
• Interdigital heloma
• Pain over medial
eminence
• Adventitious bursa
• Irritation of the first
proper digital nerve
• Clinical Exam:
• Hallux position
• First MTPJ ROM and
quality
• Evaluate for track-
bound joint

8. Radiographic Examination
• Soft tissue
• Osseous structures
• Joint surface
• Structural & positional
relationships

9. Structural & Positional Relationships
• Hallux abductus angle (HAA)
• Proximal articular set angle (PASA)
• Distal articular set angle (DASA)
• First intermetarsal angle (IMA)
• Metatarsophalangeal joint position
• Sesamoid position
• Metatarsus adductus angle (MAA)
• Hallux interphalangeus angle (HIA)
• Shape of the metatarsal head

10. Surgical Correction
Goals of surgery:
• Congruent 1st MTPJ
• Reduction of IMA
• Realignment of the sesamoids
• Restore WB function of first ray
• Maintain first MTPJ ROM
• Rectus alignment of hallux
• Control or correction of cause

11. Positionof 1st Metatarsal in a BunionDeformity
• First ray axis (Hicks)
• Dorsiflexion w/ inversion
• Plantarflexion w/ eversion
• Debate:
• Varus position of 1st metatarsal (Hicks)
• Valgus position of 1st metatarsal
(Roukis & Landsman)
• Current research:
• 1st metatarsal in valgus position
• Primary deformity at 1st TMTJ

12. AddressingtheImpactof FrontalPlaneRotationonBunionRepair
• DiDomenico & Luckino, Podiatry
Today (April 2015)
• Frontal plane often overlooked
• Frontal plane rotation is a significant
factor
• Procedure:
• Modified Lapidus arthrodesis
• 3 planes of correction w/ emphasis
on frontal plane
• No violation of 1st MTPJ
“We’ve ignored the frontal
plane during surgery for
some time – the frontal
plane valgus rotation of the
1st metatarsal.”
–Di Domenico

13. Modified Lapidus Procedure
• Surgical technique:
• 4 cm incision over 1st TMTJ
• Rotate hallux & 1st met out of valgus
• Dorsiflex hallux
• Additional frontal plane correction with use
of “joystick”
• Reduction of sesamoids:
• Manual manipulation
• Ligamentotaxis

14. Other points:
• No true “large medial
eminence”
• Correction achieved @ center of
rotation angulation (CORA)
• Other benefits:
• Restoration of normal or near
normal anatomic alignment
• Improve 1st MTPJ ROM
• Decreased risk of
complications

15. LITERATURE REVIEW

16. IsOurCurrentParadigmforEvaluationandManagementoftheBunion
DeformityFlawed?
ADiscussionofProcedurePhilosophyRelativetoAnatomy
• Dayton, Kauwe, Feilmeier, JFAS (2015)
• Review publications:
• Frontal plane position of first
metatarsal
• Sesamoid alignment
• Pre-op bunion evaluation
• Most procedures only address transverse
and sagittal plane correction
• Procedures should correct the CORA
• Tibial sesamoid position (TSP) reflected
by frontal plane rotation of 1st
metatarsal.

17. Center of Rotational Angulation
(CORA)
• CORA = anatomic axes cross (level of deformity)
• Bisector line
• Angulation correction axis (ACA)

18. Medial Eminence
• Should you resect the medial eminence?
• Medial eminence OR
• Dorsomedial surface of first metatarsal head in valgus position

19. Valgus Position of Metatarsal
• Lapidus procedure
pre- and post-op:
• Roundness of
lateral first
metatarsal head
• Sesamoid
position

20. CorrectionofFrontalPlaneRotationofSesamoid
ApparatusduringtheLapidusProcedure:
ANovelApproach
• DiDomenico et al, JFAS (2014)
• Procedure:
• Modified Lapidus
• Utilization of soft tissues to reduce
sesamoids
• All rotated into neural position as 1 unit
• Fixated with 3.5 mm cortical screw and 6-hole
plate medially

21. ReductionManeuver

22. Advantages of procedure
• No scar tissue formed
along joint
• Gliding mechanism of
tendons maintained
• No risk of staking the
head (less risk of hallux
varus)
• No vascular or nerve
concerns exist

23. RelationshipofFrontalPlaneRotationofFirstMetatarsaltoProximal
ArticularSetAngleandHalluxAlignmentinPatientsUndergoing
TarsometatarsalArthrodesisforHalluxAbductoValgus:ACaseSeries
andCriticalReviewoftheLiterature
• Dayton et al, JFAS (2013)
• Retrospective review of radiographs pre-op and post-
op:
• IMA
• HAA
• PASA
• Tibial sesamoid position
• Purpose:
• Determine if measurements accurately describe the
HAV deformity
• Question the necessity of the 1st MTPJ release & ST
balancing

24. Procedure:
• Lateral sesamoid ligament
release
• Incision over 1st TMTJ
• TMTJ resected
• 2 smooth 2-mm pins
inserted and used as
reference points
• Metatarsal head rotated in
varus direction

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

26. Discussion
• HAV singular deformity with consistent level of deformity
(CORA)
• Radiographic measurements:
• PASA reduced with derotation & TMT corrective arthrodesis
• HAA decreased with accurate realignment of joint
• TMT 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.”

27. Conclusion
• Current studies limited by retrospective design and small
sample size
• Lapidus contraindications
• Risks with Lapidus procedure
• Other things to keep in mind:
• Longer post-operative rehabilitation period
• Higher complication rate
• Technically demanding operation
• Important to consider all planes of HAV deformity in
evaluation and planning of procedure

28. 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.

29. Questions?