Hallux Valgus and Bunion Surgery - Wheeless' Textbook of Orthopaedics




Hallux Valgus and Bunion Surgery - Wheeless' Textbook of Orthopaedics

Hallux Valgus and Bunion Surgery

- See:

- adolescent bunion

- bunionette

- Discussion:

- pathophysiology

- blood supply of MCP joint

- windlass mechanism

- diff dx:

- gout

- hallux rigidus (cheilectomy);

- references:

- Anatomic variations in the first ray: Part I. Anatomic aspects related to bunion surgery.

- Muscle in hallux valgus.

- Kinematics of the first metatarsophalangeal joint.

- Hallux valgus--etiology, anatomy, treatment and surgical considerations.

- Physical Exam:

- vascular status: dorsalis pedis and posterior tibial artery;

- ankle equinus deformity (loss of ankle dorsiflexion may accentuate forefoot pain);

- determine the correctability of the deformity:

- degree to which standing accentuates the deformity;

- passive correctability of the hallux valgus and determine the ROM of the MTP joint in both the corrected and uncorrected positions;

- toe stiffness: note whether the toe is stiff once placed in the corrected position?

- a mildly symptomatic hallux valgus is preferable to a stiff corrected MTP joint;

- note that a technically correct surgical procedure may leave toe stiff once placed in corrected position (due to soft tissue contractures);

- the result may be pain w/ toe off during gait;

- amount of 1st toe pronation (associated w/ severity);

- first MT-cuneiform joint is evaluated for hypermobility and tenderness (involves pushing the MT head into dorsiflexion & plantar flexion);

- ref: Instability of the First Metatarsal-Cuneiform Joint: Diagnosis and Discussion of an Independent Pain Generator in the Foot

- tenderness over medial aspect of MTP joint;

- occurs from irritation of the dorsal cutaneous nerve;

- may occur from hypetrophic bursa;

- generalized ligamentous laxity: note that standard reconstructive techniques may fail in this patients;

- Radiographs:

- is the hallux valgus congruent or incongruent?

- congruent joint are less likely to progress than non congruent joints;

- Non-Operative Treatment:

- pts w/o DJD of MTP joint may benefit from lace up shoes w/ a wide toe box;

- pts w/ equinus contracture may benefit from stretching, which may unload the forefoot and relieve pain;

- pts w/ DJD of MTP (hallux rigidus) may benefit from a stiff soled shoe;

- Operative Treatment:

- surgical approach to MTP joint:

- pertinent blood supply;

- make a curved incision 5 cm long on the medial aspect of the joint;

- begin incision proximal to IP joint, curve it over the dorsum of MP joint just medial to EHL tendon;

- end incision on medial aspect of first metatarsal 2.5 cm proximal to joint;

- dorsally take care to identify:

- medial branch of first dorsal metatarsal artery

- medial branch of 1st dorsal cutaneous nerve (branch of superficial peroneal nerve) which supplies medial side of great toe;

- dissect the fascia from the dorsum down to the bursa over the medial aspect of the metatarsal head;

- ref: Dorsomedial cutaneous nerve syndrome: Treatment with nerve transection and burial into bone.

- surgical options:

- akin procedure

- ref: Late results after correction of hallux valgus deformity by basilar phalangeal osteotomy.

- arthrodesis

- ref: Arthrodesis of the first metatarsophalangeal joint in rheumatoid arthritis. Biodegradable rods and Kirschner-wires in 39 cases.

- chevron osteotomy

- hallux rigidus

- keller procedure

- lapidus procedure

- ludloff osteotomy

- mau osteotomy

- mcbride procedure:

- ref: McBride's operation for hallux valgus. A 2-11-year follow-up of 46 cases.

- mitchell bunion procedure

- proximal MT osteotomy

- silver procedure

- soft tissue release and capsular repair

- surgical treatment based on radiographic anatomy:

- mild deformity:

- for mild to moderate deformity (IM angle from 9 to 13 deg)

- consider soft tissue procedure (modified Mcbride procedure) or distal osteotomy (chevron or Mitchell type)

- moderate deformity:

- moderate to severe deformities (13 to 20 deg) is best treated w/ soft tissue release & proximal MT osteotomy;

- prominent medial eminence: consider a concomitant silver procedure;

- severe deformity:

- w/ hallux valgus deformity > 30 deg w/ IM angle > 12 deg consider distal soft tissue release w/ proximal osteotomy;

- MTP joint arthrodesis is another option;

- lapidus procedure: indicated for severe deformity + hypermobile 1st ray;

- wound closure:

- following the hallux valgus reconstructive procedure, the sesamoids may still lie in a subluxed positioned;
- posterior to anterior closure:
- partial reduction of the sesamoids may be achieved w/ closure of the joint capsule;

- excise the inferior portion of the joint capsule, place the toe in a slightly over-corrected position, and then oppose the inferior joint capsule to the superior joint capsule w/ non absorbable sutures;

- goal of this is to de-rotate sesamoids out of their laterally subluxed position, to a more anatomic position under the metatarsal;

- distal to proximal closure

- figure of 8 closure spaning proximal and distal MTP joint will have the effect of tightening the medial capsule;

- Other Surgical Considerations:
- hammer toe correction

- ankle equinus contracture

- Complications:

- hallux varus:

- excessive resection of medial metatarsal head;

- excision of medial sesamoid;

- excessive capsular plication;

- immobilization of the toe in excessive varus during the post op period;

- ref: The operative treatment of acquired hallux varus.


Wilson's osteotomy for the treatment of hallux valgus.

The modified Wilson osteotomy for hallux valgus.

Distal metatarsal osteotomy for hallux valgus in the middle-aged patient.

Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up.


Year Book: A Comparison of Keller's Arthroplasty and Distal Metatarsal Osteotomy in the Treatment of Adult Hallux Valgus.

The risks and benefits of distal first metatarsal osteotomies.

Principles in bunion surgery.

Monarticular nontraumatic synovitis of the metatarsophalangeal joint: a new diagnosis?

The treatment of hallux valgus with overriding second toe.

Hallux valgus.

Extensor hallucis longus transfer for hallux valgus deformity.

Shortening of the first metatarsal as a complication of metatarsal osteotomies.

A prospective study of forefoot arthroplasty.

Silastic joint arthroplasty of the great toe. A review of 228 implants using the double-stemmed implant.

Repair of hallux valgus with a distal soft-tissue procedure and proximal metatarsal osteotomy. A long-term follow-up.

Survivorship analysis of implant arthroplasty for the first metatarsophalangeal joint.

Original Text by Clifford R. Wheeless, III, MD.
Last updated by Data Trace Staff on Tuesday, September 4, 2012 1:43 pm




AKS: Summary for AK Steel Holding Corporation Co- Yahoo! Finance




AKS: Summary for AK Steel Holding Corporation Co- Yahoo! Finance

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Plantar Fasciitis


There are a number of plantar fasciitis causes. The plantar fascia ligament is like a rubber band and loosens and contracts with movement. It also absorbs significant weight and pressure. Because of this function, plantar fasciitis can easily occur from a number of reasons. Among the most common is an overload of physical activity or exercise. Athletes are particularly prone to plantar fasciitis and commonly suffer from it. Excessive running, jumping, or other activities can easily place repetitive or excessive stress on the tissue and lead to tears and inflammation, resulting in moderate to severe pain.

Pronounced as "plantar fash-ee-eye-tis," plantar means "foot," while fasciitis means "inflammation." Plantar Fasciitis is a serious, painful and progressing illness that occurs when the long, flat ligament along the bottom of the foot develops either tears or inflammation. Serious cases of plantar fasciitis can possibly lead to ruptures of the ligament itself. This ligament is called the plantar fascia and it extends the toes and runs along the bottom of the foot, attaching to your heel. Such repetitive force can pull the fascia from its attachment on your heel and cause damage and plantar fasciitis.

Your next Plantar Fasciitis exercise is stretching of the plantar fascia using a bath towel. Put a rolled up towel under the ball of one foot, holding both ends of the towel with your left and right hand. Next, slowly pull the towel towards you, while keeping your knee straight (the other knee may be bent). Hold this position for 15 to 20 seconds. Repeat 4 times and change to the other foot, if necessary. (It's always good to do these exercises on both feet, even if you only experience heel pain in one foot, as this will help prevent the heel problem to come back in your other foot!)

Pain can sometimes cause a lot more than just discomfort. It can often significantly impact daily activities since any weight placed on the affected area can deliver serious pain which can prevent you from doing daily activities and exercise. Plantar fasciitis causes an aching pain that can be localized in the heel, but also radiate throughout the foot. In most cases, pain is most noticeable and serious in the morning when getting out of bed, or after standing up after prolonged sitting. This is because pain in the inflamed area subsides after the plantar fascia relaxes.

People with plantar fasciitis experience pain when they take their first step after sitting down for too long or when they get out of bed. After few steps the pain and stiffness might reduce a bit. People with this condition may feel the pain more when they climb stairs or after standing for too long. This pain can increase as the days go by, but plantar fasciitis exercises if done regularly can significantly reduce pain and swelling in the tissue. Many people find it easier to pop pain killers, but such treatments can have other side effects.plantar fasciitis shoes

Plantar fasciitis is a foot condition usually felt as pain in the bottom of your foot around the heel. There are about 2 million new cases of this condition reported every year in the USA only. That pain is felt especially when taking the first steps in the morning or after spending some time of the feet. This pain is caused by an injury of the fascia connective tissue at the bottom of the foot. This tissue is called the plantar fascia and it connects the heel bone to the toes. Usually this injury is caused by overload of the foot.

It is the diagnosis of symptoms It is not the diagnosis of the problem The pain may be in your foot– but the problem is not What you will not often find in definitions or explanations of plantar fasciitis on the web is that there is a deeper issue at play The pain in your foot diagnosed as plantar fasciitis can often be traced back up to your gluteus maximus–your butt. These days, we sit too much and our butts muscles wind up not doing much. So they basically shut down or go to sleep–they become inhibited. This is not a good thing.

Stand barefoot, with your feet hip-width apart and with your left foot in a slightly forward position - two to three inches ahead of your right foot. The bottoms of the toes of your left foot should be in contact with a wall in front of you (the wall should be creating a forced dorsiflexion of the toes, so that the sole of the left foot is on the ground but the toes are on the wall), and your left knee should be bent slightly. Keep your weight evenly distributed between your right and left foot to start the exercise (see note below).

Above were some of the plantar fasciitis treatment options. Whether the soreness is light or perhaps severe, it will always be recommended to look for consultation from your foot as well as ankle physician. He can look at things properly as well as recommend an individual the finest therapy for plantar fasciitis depending on your foot framework and the seriousness of pain. This may prevent further problems and also can help you come out of the discomfort swiftly. Bear in mind, like all the other areas of the body, feet are also important. In the end, they may be the ones which support you almost everywhere. About the Author

Night splinting is another treatment which aims to stretch out the plantar fascia. As its name suggests, a night splint is a device you wear while you sleep which keeps your ankle dorsiflexed. The theory is that the “first-step pain” that is the hallmark of plantar fasciitis is caused by the arch healing at night without any tension on it. In the morning, the healing is disrupted by the tension put on the arch when you get out of bed. “The Sock” is a regular knee-high sock with a strap that runs from the toes to the kneecap. plantar fasciitis exercises

Shoe Inserts To Increase Height

heel lifts for heightDo you often want to be taller and are not happy with the height that you are? You may have tried a lot of different products and techniques to try to grow taller and if you are ready to try something that really works, you can find shoe insoles that will make you look inches taller, all without having to take any kind of supplement or other procedure that is designed to make you look taller. The insoles that you can try are called the Levitator shoe lifts, and they are made to easily fit into your shoes without being able to notice that they are there.

In case you are ready to start increasing your height easily without having to pay lots of cash or try products that do not work or are expensive to use, you can try the insoles and shoe lifts that are formed to help make you appear taller and increase your height whenever you wear them in your shoes. They easily slide into the shoes that you want and are comfortable to use. You can wear them with anything and anytime that you want to look taller and have the finest type of insoles to wear and feel better wherever you go knowing that you look taller.

Patients with heel pain caused by plantar fasciitis are often advised by doctors to wear supportive footwear whenever they bear weight so as not to strain and further injure the plantar fascia. The problem is that most footwear lacks good arch support. Podiatrists sometimes advise expensive custom made orthotic inserts for such shoes ; other times they recommend patients try over-the-counter insoles. For those patients, therapeutic shoe inserts can replace the manufacturer's footbeds included in shoes with removable insoles. Unless otherwise directed by a health care provider, use orthopedic insoles in both shoes , even if the heel pain occurs only in one foot.

If your foot pronates too much, the ankle rolls too far downward and inward with each step. This can cause the arch to collapse and muscles and supporting structures to overstretch and lengthen. The ligaments running from the heel to the toes become strained, often leading to inflammation along the bottom of the foot. This inflammation and heel pain is known as Plantar Fasciitis. In response, the bone may also develop a bony growth (heel spur), right in the center of the heel. This too causes heel pain and can prevent an individual from walking with ease. The best shoes for heel pain (plantar fasciitis)

If you are in search of inserts for kids, then you can consult the doctor and buy Spenco Total Support Gel - Arch Support Insoles. These supports are made of special thermoplastic gel and they also have special forefoot impact zone. These are metatarsal arch supports that provide stability and support to arches and heel of the kids. The best thing about these arch support insoles is that they have unique 3 pod cushioning system that are shock absorbent. However, all this is only possible when you will select shoes, slipper or sandals with arch supports that fits the exact foot size of the kids.

No one can imagine his/her life without feet because it is the important part of our body. Foot care is very necessary in our life. The get taller have been popular in the market can be attributed to the fact that the majority of the consumers has come to know using this kind of shoe embellishments as an enormous way to treat the most common foot problems. Unbelievably, using shoe insoles has proved to be the best way for people to evade foot pain and other structural defects. You can easily find shoe inserts for various kinds of occasion like for official purpose, sports day, weddings and casual wear.

If you're looking to buy some insoles for plantar fasciitis, make sure you read this information first. These shoe insoles are a great way to treat plantar fasciitis for a couple of reasons. First of all, these insoles help structure your feet to make it in a more natural position when walking or standing. The main cause of your heel pain is because too much pressure has been applied onto your feet by the weight of your body. It is also common among athletes who go through vigorous training. These sorts of activities can cause strain on your feet, causing discomfort and pain.

It is important that you choose the correct type of shoe inserts if you wish to rid yourself of this condition. That means that you must buy inserts that are placed near the area of the toes and it opposed to the other parts of the feet. Consult with medical experts in order to find out which types of insert will work best for you. People suffer from foot problems in our lives because of several reasons such as wearing wrong size shoes , from normal wear and tear, due to some injury, or some kind of skin disease.

If you're thinking of buying some insoles for plantar fasciitis, be sure you read this information first. These shoe insoles certainly are a smart way to deal with plantar fasciitis for a number of reasons. Firstly, these insoles help structure the feet to produce it in a far more natural place when walking or standing. The main cause of your heel pain is basically because too much stress has been used onto your feet from the weight of one's body. It's also popular among athletes who undergo strenuous training. These kinds of activities could cause strain on your feet, causing suffering and discomfort.

If you have shoe insoles, you probably have figured out that you need to replace them after some time. Replacing your orthotics is important for optimum comfort and protection. There are different indications that will tell you when you have to replace your orthotic insoles or inserts. One is when they don’t fit properly. Insoles that don’t fit well are inefficient and can cause discomfort. If your orthotics are causing you discomfort, you have to return them. If they are already old, they are probably worn out. See if the plastic shell has shown deterioration.

Proven tips for Shoe Inserts

heel lift inserts for heightThese shoe lifts can be worn in your shoes and are comfortable enough to wear all day without you even knowing that they are there. If you want to find a way to look taller without having to use products or other procedures that try to make you look taller, you can find what you are looking for in the height increasing shoe insoles that are easy to use and are comfortable to have in your shoes You can look taller and increase your height, without anyone being able to notice the lifts in your shoes

These shoe lifts can be worn in your Höhe zunehmende einlegesohle and are cozy enough to wear all day without you even knowing they are there. If you need to locate ways to look taller without having to use goods or other processes that strive to make you look taller, you will find what it is you are searching for in the height raising shoe insoles that are easy to use and are comfy to have in your shoes. You-can look taller and improve your height, without anybody being able to see the lifts in your shoes.

Plantar Fasciitis is irrevocably tied to heel pain since this condition is simply an inflammation of a piece of tissue that originates at the heel and ends at the toes called the plantar fascia. This forms the arch of your foot and essentially stretches along the soles of your feet. The size of the plantar fascia hence determines the size of the arch of your foot; a long plantar fascia results in a low arched foot (commonly referred to as flat feet) while a short plantar fascia results in a high arched foot. The disease plantar fasciitis is simply a deposit of calcium in the plantar fascia which causes inflammation.

A foot x-ray is the only way to properly diagnose this condition. With an x-ray, your doctor can verify that a heel spur has developed. Treatments vary from elevating the foot to much more serious solutions like foot surgery. By applying mild heat to the area you can lessen the inflammation. This alleviates the pain by dilating the blood vessels in the foot and increasing blood circulation. Many people notice that simply wearing orthotics can provide help. These devices provide additional arch support and can help correct over-pronation. By reducing the stress on the Plantar Fascia, the tissues in the foot can heal correctly.

Shoe inserts come in a variety of styles for your favorite shoes , even slides or peep-toes! They offer a light cushion to the areas of your foot under the most pressure when you're on your feet. Let's face it ladies, our feet weren't meant to take the kind of torture that we put them through all in the name of fashion. With some sneaky inserts , we don't have to suffer for beauty anymore. Shoe inserts help support and soothe tired feet and may prevent more serious foot conditions in the future. And with such a wide variety available, anyone can afford to feel as good as they look.

No one can imagine his/her life without feet because it is the important part of our body. Foot care is very necessary in our life. The elevator shoe have been popular in the market can be attributed to the fact that the majority of the consumers has come to know using this kind of shoe embellishments as an enormous way to treat the most common foot problems. Unbelievably, using shoe insoles has proved to be the best way for people to evade foot pain and other structural defects. You can easily find shoe inserts for various kinds of occasion like for official purpose, sports day, weddings and casual wear.

According to the American Podiatric Medical Association, feet absorb hundreds of tons of pressure in an average day, making them the most injury-prone part of the bodiy. Wearing protective and supportive shoes is essential for good foot health, particularly when injury has occurred. The plantar fascia, a thick band of tissue that connects the toes and the heel, becomes inflamed when too much stress is placed on the arch of the foot. Wearing proper shoes can help to alleviate the pain of plantar fasciitis, as well as to prevent further injury. A few general rules will guide you to the best shoes for your condition. Moderate Heels

It is important that you choose the correct type of shoe inserts if you wish to rid yourself of this condition. That means that you must buy inserts that are placed near the area of the toes and it opposed to the other parts of the feet. Consult with medical experts in order to find out which types of insert will work best for you. People suffer from foot problems in our lives because of several reasons such as wearing wrong size shoes , from normal wear and tear, due to some injury, or some kind of skin disease.

While you are carrying out rigorous activities like running, jogging, fast walking and playing games, it would be great for you to insert shoe insoles in your shoes You will see that shoe insole is a term which is used for arches as well as cushion supports which can be inserted inside any shoe that you desire to wear. The insoles come in myriads of different options which can be used for different purposes. The main function of the insole is to provide a comfortable cushioning to your foot. They create a shock absorbent and soft surface that helps you in doing rigorous activities without feeling pain or discomfort.

If you have shoe insoles, you probably have figured out that you need to replace them after some time. Replacing your orthotics is important for optimum comfort and protection. There are different indications that will tell you when you have to replace your orthotic insoles or inserts. One is when they don’t fit properly. Insoles that don’t fit well are inefficient and can cause discomfort. If your orthotics are causing you discomfort, you have to return them. If they are already old, they are probably worn out. See if the plastic shell has shown deterioration.
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