Classical Mitchell's osteotomy in the management of symptomatic hallux vulgus

Abstract

INTRODUCTIONHallux vulgus which literally means lateral deviation of great toe is in fact a complex deformity of the first ray that frequently is accompanied by deformity and symptoms in the lesser toes. It has multi factorial etiology like vulgus of greater toe, metatarsus primus varus, genetic factors, shoe wear and anatomic factors like pronated flat foot, abnormal insertion of tibialis posterior, long 1 st ray, increased obliquity of 1 st metatarso-medial cuneiform joint.1 The earliest records date back to eighteenth century. 2 Its incidence was found to be 31% greater in shoe wearing than nonshoe wearing Chinese population.3 Its main concerns are pain over 1 st metatarsophalyngeal joint (MTP), difficulty in shoe wear and cosmetics. Management is conservative to begin with like broad toe shoe wear, toe spacers, exercises and activity restriction; later on operative which attempt to correct the deformity. Hueter, 1870 suggested sub capital amputation of the metatarsal head as the treatment for hallux vulgus. 4 More than 130 surgical procedures have been described since then for it. These range from soft ABSTRACT Background: Hallux vulgus is common deformity of fore foot frequently resulting in pain at first metatarso phalyngeal joint and cosmetic problems. Hallux vulgus is particularly more common in shoe wearing populations. Ours being a sub Himalayan region with harsh and prolonged winters where shoe wearing is a must this condition is very common. Various surgical procedures have been described for its management. These range from soft tissue procedures to arthodesis of first metatarso phalyngeal joint. Distal first metatarsal osteotomy (Mitchell's osteotomy) is a time tested procedure in its management. Methods: Forty adult patients (56 feet) with symptomatic hallux vulgus, who did not respond to conservative treatment, were managed with Mitchell's osteotomy. Results: Results were assessed as per American Orthopaedic Foot and Ankle Society grading. More than ninety percent of our patients were fully satisfied with their pain relief and foot cosmetics while others were satisfied with some reservations. There was no major complication or non-union at osteotomy site. Conclusions: Management of hallux vulgus is conservative to begin with, measures like life style modifications, broad toed shoes, toe spacers and physical therapy are tried first. Surgical intervention is indicated if conservative measures fail to relieve symptoms. More than 130 surgical procedures have been described for hallux vulgus ranging from soft tissue procedures like MacBride's to arthodesis of first metatarso phalyngeal joint. Distal metatarsal osteotomy was first described by Hawkins in 1945 but was named after Mitchell who published his work in 1958. From our study we conclude that this is a time tested procedure for symptomatic cases of Hallux Vulgus not responding to conservative measures.