Reconstructive Procedures

Hallux Valgus - Bunion Busters

Lateral deviation of great toe (valgus) & medial deviation of 1st metatarsal (varus).

• Key Angles:
  • HVA (Hallux Valgus Angle): Normal < 15°
  • IMA (Intermetatarsal Angle): Normal < 9°
  • DMAA (Distal Metatarsal Articular Angle): Normal < 10°
• Severity (approx.):
  • Mild: HVA 15-20°, IMA 9-11°
  • Moderate: HVA 21-39°, IMA 12-17°
  • Severe: HVA ≥ 40°, IMA ≥ 18°
• Surgical Principles: Correct deformity, relieve pain, restore function. Involves soft tissue release (e.g., adductor hallucis), medial eminence resection, osteotomies, or arthrodesis.
• Common Procedures:
  • Chevron/Austin (distal osteotomy): Mild to moderate deformity.
  • Scarf (diaphyseal osteotomy): Moderate to severe deformity.
  • Lapidus (1st TMT arthrodesis): Severe deformity, hypermobility, arthritis.
  • Akin (phalangeal osteotomy): Adjunct for residual hallux valgus interphalangeus.

⭐ The position of the tibial sesamoid relative to the first metatarsal head is a key radiographic indicator of hallux valgus severity (Hardy and Clapham classification).

AAFD - Flat Foot Fixes

AAFD: Progressive flatfoot from Posterior Tibial Tendon Dysfunction (PTTD).

Ankle Arthritis - Joint Relief Roadmap

• Etiologies: Post-traumatic (most common), inflammatory (e.g., RA), primary OA.

• Clinical/Radiographic: Pain, ↓ROM, swelling. X-ray: ↓joint space, osteophytes, subchondral cysts/sclerosis.

• Ankle Arthrodesis (Fusion):

  • Indications: Younger, active patients; severe deformity; failed TAA; infection; heavy labor.
  • Outcome: Durable pain relief, stability; sacrifices ankle motion.

• Total Ankle Arthroplasty (TAA):

  • Indications: Older (>60 yrs), lower-demand patients; desire to preserve motion; bilateral disease.
  • Contraindications: Active infection, severe talar AVN, significant deformity, young/high-demand.

Arthrodesis vs. TAA Comparison:

Charcot Foot - Stability Strategies

• Patho: Neurotraumatic (insensate microtrauma) & Neurovascular (↑ flow → osteolysis).
• Risk: DM + peripheral neuropathy.
• Eichenholtz Stages (X-ray):
  • 0 (Prodromal): Inflammation, normal X-ray.
  • I (Development): Fragmentation, dislocation, debris.
  • II (Coalescence): Debris absorption, early fusion.
  • III (Reconstruction): Remodeling, deformity (rocker-bottom).
• Clinical: Acute (hot, red, swollen, bounding pulses) vs. Chronic (deformity, instability).
• Goal: Stable, plantigrade, shoeable foot.
• Management:
  • Offloading: TCC crucial (gold standard).
  • Medical: Bisphosphonates (controversial).
  • Surgical (instability, deformity, ulcers): Exostectomy, osteotomy, arthrodesis, fixation.

⭐ Total Contact Casting (TCC) is the gold standard for offloading in acute Charcot foot, achieving healing in up to 90% of cases when combined with appropriate wound care.

High‑Yield Points - ⚡ Biggest Takeaways

• Triple arthrodesis: Fuses TC, TN, CC joints for rigid hindfoot deformity.
• Lapidus procedure: 1st TMT fusion for hallux valgus with 1st ray hypermobility.
• Keller arthroplasty: Resection for hallux rigidus in elderly, low-demand patients.
• Ankle arthrodesis: Gold standard for end-stage ankle arthritis, ensuring stability.
• Tendon transfers: Key for dynamic correction in conditions like PTTD (e.g., FDL transfer).
• Lisfranc injuries: Often require ORIF or primary arthrodesis for stable reduction.
• Charcot foot: Reconstruction aims for plantigrade, stable foot, often with arthrodesis.