Congenital medial angulation of the great toe at the metatarso-phalangealnjoint. Varus deformity vary from few degree to 90°

1. CONGENITAL HALLUX VARUS (CHV):
whow to deal with it?
R.Elbaum
CHIREC ORTHOPEDIC GROUP
Clinique Edith Cavell
Hôpital Universitaire Erasme

3. CHV: what it is?
• Congenital medial angulation of the great
toe at the metatarso-phalangealnjoint.
• Varus deformity vary from few degree to 90°

4. CHV: Several types
• Primary type: A taut fibrous band
extends from the medial side of
the hallux to the base of
metatarsal 1
• Associated type with other
congenital deformitied of the
forefoot :(metatarsus varus,
shortening of the first metatarsal
,duplication,polydactyly…)
• Syndromic type (diastrophic
diastrophic)

5. CHV associated with longitudinal
Epiphyseal bracket of Metatarsal 1th (LEB)
• Anomaly of growth plate formation on
the MT1 on the medial side
• It extends as a continuous unit
proximally and distally
• Abnormal growth with shortening and
varus angulation

6. CHV associated with
anomaly of the
abductor Hallucis
• Basmajian and Kerr describe five
variation of insertion of Abductor
Hallucis. In some case the muscle
insertion can act as a pure adductor of
the hallux
• Abnormal contracture and abnormal
tone of the muscle can also cause Hallux
varus deformity.

7. CHV associated
with anomaly of
the abductor
Hallucis
• Basmajian and Kerr describe
five variation of insertion of
Abductor Hallucis. In some
case the muscle insertion can
act as a pure adductor of the
hallux
• Abnormal contracture and
abnormal tone of the muscle
can also cause Hallux varus
deformity.

8. CHV is different
from Adult
Hallux Varus
• Overcorrection of Hallux
Valgus (80%)
• Reumatoid arthritis
• Trauma
• Charcot-Marie –Tooth
• Avascular necrosis
• Contracture on burns
• ….

9. CHV: Consequence
• Inability to wear shoes
• Cosmetic apparence
• The deformity increase with
age.
• CHV may play a role in the
cause of primary metatarsal
deformity or recurrence of
somme forefoot deformity
(metatarsus adductus or CTEV)
• Some cases of Juvenile Hallux
Valgus may result from CHV

10. CHV: Which
solution?
• The difformity increase with
age.
• Orthetic device always
unefficient in children
• Surgery is most often
recommended
• Before or after walking age

11. CHV: Which
solution?
• Removal of accessory bones,
medial sesamoidectomy and
capsulotomy, release of the medial
fibrous band, reinforcement of the
lateral capsule, transfixing of the
metatarsophalangeal joint with a
Kirschner wire and a partial
(McElvenny 1941)
• Rotational skin flap and
syndactylization of the first and
second toes. (Farmer 1958)
• Resection of the entire abductor
hallucis muscle and
tendon,tenotomy of the abductor
hallucis tendon, metatarsal
osteotomy and also arthrodesis
(Tachdjian 2008)

12. Surgical technique: Farmer 1958

13. Which solution in case of LEB?
Bracket chondroosteotomy accompanied by fat interposition
Resection of the LEB with silicone polymer or
polymethylmethacrylate interposition,
Simple bracket excision before ossification,
Distraction osteogenesis and metatarsal osteotomy after complete
closure of the LEB
“The overall goal of any of these procedure is to eliminate the tethering
effect of the growth plate by removing the bar and therefore to
promotegrowth in a lengthwise fashion.”
• Mubarak SJ, O'Brien TJ, Davids JR. Metatarsal
epiphyseal bracket: treatment by central physiolysis.
J Pediatr Orthop.1993;13(1):5-8.
• Schreck MA. Pediatric longitudinal epiphyseal bracket:
reviewand case presentation. J Foot Ankle Surg.
2006;45(5):342-5.

14. Case presentation 1

16. Réalisation des tracés d’incision et de la plastie
du lambeau cutané. Celle-ci se fera au dépens
d’une plastie en Z de la première commissure qui
rejoint l’incision médiale centrée sur l’articulation
métatarso-phalangienne. Ouverture de
l’articulation métatarso-phalangienne. Repérage
du tendon de l’abducteur de l’hallux qui
sera désinséré du gros orteil. Capsulotomie
médiale. Ceci permet déjà d’obtenir une réduction
progressive de la déformation. On se dirige
ensuite sur le premier métatarsien. Dépériostage
et mise en évidence de la plaque épiphysaire
circonférentielle. Sous contrôle scopique,
introduction de deux petites aiguilles proximale et
distale.
On réalise une résection de la plaque épiphysaire
entre ces broches. Contrôlescopique. On réalise
ensuite la plastie cutanée en Z qui perm
et de diminuer l’espace de la première
commissure.
Stabilisation du premier rayon par une broche de
Kichner 1/10 phalango-métatarso-cunéenne.

19. Case presentation 2

22. CHV:CONCLUSION
• CHV is a rare condition in neonate and children
• Surgical correction is generally recommended and various surgical
techniques have been described
• Although the small size of series in litterature define a definitive
conclusion on the optimal treatment strategy.
• Patient’s age is another factor that must be assessed when
considering surgery.
• Resection of a bracket epiphysis should be performed as with other
procedures to prevent recurrent deformity.
• Evaluation with MRI before surgery if the presence of a LEB is
suspected.

23. Bibliography
• Farmer AW. Congenital hallux varus. Am J Surg. 1958;95(2):274-8.
• Herring JA. Tachdjian's pediatric orthopaedics. 4th ed.Philadelphia, PA:
Saunders; 2008. 1172-3.
• Mills JA, Menelaus MB. Hallux varus. J Bone Joint Surg Br1989;71(3):437-40.
• Mubarak SJ, O'Brien TJ, Davids JR. Metatarsal epiphyseal bracket: treatment
by central physiolysis. J Pediatr Orthop.1993;13(1):5-8.
• Glickman SH, Cornfield RH. Surgical reconstruction of ancongenital foot
deformity: hallux varus with brachymetatarsiaof the first metatarsal. J Foot
Surg. 1990;29(5):499-503.
• Joseph B, Jacob T, Chacko V. Hallux varus: a study of thirty cases. J Foot Surg.
1984;23(5):392-7.
• Stanifer E, Hodor D, Wertheimer S. Congenital hallux varus: case
presentation and review of the literature. J Foot Surg. 1991;30(5):509-12.

24. THANK YOU