​Kembara Xtra - Medicine - Bunion ( Hallux Valgus)

​Kembara Xtra - Medicine - Bunion ( Hallux Valgus)  

Introduction
The Latin term "Hallux abducto valgus," which means "big toe askew," refers to the great toe's lateral displacement.
First metatarsophalangeal (MTP) joint medial prominence as a result of associated medial deviation of the first metatarsal, sometimes referred to as a "bunion"; latter stages of progressive subluxation of the first MTP joint; impacted system(s): musculoskeletal/skin

Incidence and prevalence in Epidemiology 

Age group with the highest prevalence: adults
Females outnumber males by around two to one; they also tend to be bilateral and more prevalent in communities who wear shoes.
Incidence
unknown and challenging to evaluate

Prevalence
Age-related prevalence rises, especially in females.
In adults (18 to 65 years old), the frequency is thought to be 23%.
 Adults aged 65 and older: estimated prevalence of 35.7%
Females account for more incidences of juvenile hallux valgus (>80%).


Etiology and Pathophysiology 
contentious and multifactorial. Underlying anatomy and recurring external influences may be contributing factors:
The medial MTP joint capsule and medial collateral ligament are chronically stretched and may eventually rupture, decreasing stability and causing progressive subluxation of the 1st MTP joint. The absence of muscles that directly stabilize the 1st MTP allows relatively unopposed forces to influence lateral deviation of the proximal phalanx and medial deviation of the 1st metatarsal head.
The great toe is moved into plantar flexion and lateral pronation by the abductor hallucis muscle's lateral and plantar migration.

Genetics: Twin and cohort studies point to heritability; genome-wide association studies point to sex-specific variations in genetic processes.

Risk factors include: genetic predisposition; abnormal biomechanics (flexible flat feet); foot deformities such as pes planus (fallen arches); metatarsus primus varus; amputation of the second toe; inflammatory joint disease; neuromuscular disorders such as cerebral palsy and stroke; and inappropriate footwear such as high heels and narrow toe boxes.


Prevention
Wearing the right shoes can perhaps slow the disease's progression.


Accompanying Conditions 

 Plantar callus Metatarsalgia Medial bursitis of the 1st MTP joint (most frequent) Hammertoe deformity of the 2nd phalanx 
Pronated feet and ankle equinus, onychocryptosis (ingrown toenail), entrapment of the medial dorsal cutaneous nerve, and synovitis of the MTP joint are all symptoms of first metatarsal head cartilage degeneration (hallux rigidus).

Signs and Symptoms 

Radiographs are used for staging and are based on clinical examination.


clinical assessment
Shoes that don't fit properly, a painful MTP joint (the most prevalent symptom in adults), an abnormal position of the great toe, and an enlargement of the MTP joint medially (patients complain of a "bump").
Aching when walking Skin rashes, blisters, or calluses at the first MTP

clinical assessment 

Examine the entire first metatarsal and toe for: Great toe overriding or underriding the second toe, medial prominence at the MTP joint, skin alterations such as erythema, blistering, callus, or ulceration, and the following:
- Mobility of the first tarsometatarsal (TMT), the first MTP, and the neurovascular system
Osteoarthritis that is degenerative


Differential diagnosis Trauma: stress fracture, sesamoiditis, and turf toe
Joint disorders include osteoarthritis, rheumatoid arthritis, pseudogout, and gout. Infections include osteomyelitis and septic arthritis.
Tendon disorders include tendinosis, tenosynovitis, and tendon rupture. Other conditions include bursitis, ganglion cysts, and foreign body granuloma.

Diagnostic and Laboratory Tests 
Initial examinations (lab, imaging) Weight-bearing AP and lateral radiographs with the option of a sesamoid view to determine:
- Joint alignment and deteriorative alterations
- Lateral displacement of the sesamoid bone
- Longer and more rounded first metatarsal head
Radiographic specifications:
- Hallux valgus angle (HVA): The typical angle between the proximal phalanx and the first MT is about 15 degrees.
- Intermetatarsal angle (IMA): The normal angle between the long axes of the first and second metatarsals is 9 degrees.
- Distal metatarsal articular angle (DMAA): Normally, there is a 15-degree angle between the first metatarsal long axis and the line across the base of the distal articular cap.
- Hallux valgus interphalangeus: Normally, there is a 10 degree angle between the long axes of the proximal and distal phalanges.

Treatment 
There are both conservative (nonoperative) and surgical treatments, with pain serving as the main indication for treatment.

The only way to fix the hallux valgus deformity is through surgery.
Surgery has associated risks but is typically more effective at reducing pain.


General Strategy 

Although there is insufficient high-quality evidence, nonoperative therapy approaches may alleviate symptoms and slow the progression of hallux valgus deformity:
Low-heeled, wide-toed footwear is recommended to reduce stress on the MTP joint.
Correct foot alignment with orthotics (pes planus and overpronation). A better gait may avoid the development of bunions and relieve pressure on the MTP.
Splinting is a theoretical method for balancing and stabilizing soft tissue structures surrounding the MTP. There is some indication that mild hallux valgus improves in degree of angulation. 
Use of a dynamic splint may lessen pain.
In moderate hallux valgus, foot mobilization, exercise, and use of a toe separator may reduce discomfort levels and increase strength and range of motion.
Spacers and pads: Spacers and pads reduce friction at the MTP joint. The first interdigital space toe spacer may ease discomfort.


Pain can be managed with medicine, both topical (NSAIDs) and oral (NSAIDs, acetaminophen). The topical option of capsaicin cream is another.
Corticosteroid injections (rarely used outside of the surgical situation) may reduce pain.


Patients who experience significant pain, dysfunction, or enduring symptoms that do not go away with conservative therapy should be referred for surgery.

Further Therapies 

When compared to no treatment, custom orthoses are a safe intervention that may reduce pain at 6 and 12 months; however, this improvement is less pronounced than that seen with surgical intervention.


Surgical Techniques 
There are more than 100 distinct surgical procedures available to treat hallux valgus, none of which have been shown to be superior, and minimally invasive techniques are becoming more common.
The choice of approach is influenced by the disease's severity, radiological findings, and circumstances unique to the patient or surgeon:
- Arthrodesis: fusion of the first MTP joint, utilized to treat severe and/or recurring hallux valgus; fusion of the first TMT joint (modified Lapidus), taken into consideration for treating TMT joint hypermobility.
- Arthroplasty: removal of the joint or prosthetic replacement; high rate of revision
- Exostectomy/bunionectomy: the removal of the MTP joint's medial bony protrusion (less prevalent anymore).
- Soft tissue realignment: affects the way the nearby ligaments and tendons function; used to treat minor abnormalities or as a supplement to bone correction methods
- Osteotomy and realignment: a variety of methods that can treat severe abnormalities but lack long-term success data - A FiberWire is used in the mini-tight rope treatment to realign the malformation.
Despite treatment, some individuals' symptoms may not significantly improve. In pediatric patients, surgery should typically be postponed until skeletal maturity. Providers should set realistic expectations prior to surgery.

Further Treatments 
An application of marigold ointment may lessen bunion-related discomfort and soft tissue edema.


Follow-Up Postoperative treatment options include manual manipulation, supportive footwear, physical therapy, and physiotherapy.
The length of time until you can bear all of your weight varies on the surgery.

Prognosis 
The treatment method employed, the severity of the deformity, and the biomechanical considerations all affect the patient's success. Surgical results are predicted by the radiologic HA angle. Compared to individuals with a HA angle >37 degrees, those with a HA angle 37 degrees had a better likelihood of having the deformity successfully treated through surgery.

Complications hazards of surgery include infection, protracted discomfort, and a subpar cosmetic outcome. Other hazards differ depending on the surgical treatment.
The following issues could also arise:
Reduced feeling over the first metatarsal or phalanx; Early swelling; Hallux varus; Recurrence of bunion; Metatarsal fracture

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