Introduction

The hallux valgus [1] presents pains troubles in the bunion region and the associated metatarsalgium impede the putting on one’s shoes as well as the walk by oneself, the correction of various deformities at the hallux will make both the putting on one’s shoes and the walk alone easier. The osteotomy sub capital of Hohmann corrects in only once all the deformities related to the hallux valgus

Figure 1

Photography I : perioperative view

The objectives in this work is to study both the therapeutic variations and improvements to set up surgical indications according to the degree of deformity.

Material And Method

The series

Anaesthesia

Surgical procedure [2]

The way is at first internal; the neck of the 1rst metatarsal is unblocked in sub- periosteal without opening the articulation. The adductor of the big toe which slipped in plantar position is disintegrated in a distal way

Figure 2

Photography II : incision

With the oscillating saw, we resect a corner at lower and internal base. Hohmann intervention ensures the correction in only one site, by an extra-articular gesture, all the deformities of the hallux valgus, by carrying out an osteotomy

Figure 3

photography III : Exposition of the first metatarsal

- of variation and supination, which corrects the valgus and the pronation of the big toe, by bringing back the sesamoid to their place and the axis of the big toe parallel with the axis of the foot i.e. the 2nd metatarsal;

Figure 4

Photography VI : Osteotomy sub-capital external and lower base

- of external translation decreasing the width of the metatarsus without resection of exostosis and cancelling the metatarsus varus

- the deflection to compensate for the defect of support of the 1st ray and its metatarsalgium.

We make the osteotomy by synthesis with 2 parallel pins and a stay by a trans-bone resorbable wire stay. Then putting back in tension of the strained internal capsule

Figure 5

Photographies: V & VI: correction of the deformity with fixing by a stay

and reintegration of the adductor laterally in good position with the internal side P1.

Owing to a stable osteosynthesis of the osteotomy, the post-operative immobility recommended by Hohmann was used only in 27% of cases. The resumption of immediate walk by using a special light sandal so that there is no valgisating pressure on the big toe was possible in 73% of cases of that series. Currently, it is systematic.

The support on the metatarsal head is well sustained. The post-operative inter digital variation is corrected in a few weeks.

Result

The duration of hospitalization is 8 days on average, with a heightening of the foot.60% of cases are hospitalized less than 8 days, 29% from 8 to 12 days and 4% only more than 15 days.

The cicatrization was impeded in nearly 25% of cases cutaneous necrosis and 13% of delay, cicatrization delayed at 3 weeks).

The bone consolidation was obtained in less than 2 months in 48% of cases, from 2 to 3 months in 42% of cases and more than 4 months in 8% of cases, 4 pseudarthroses re operated that is 1,5% of cases.

The resumption of usual shoe, because of oedema, is often delayed at the 3^rd/4^th month in 57% of cases, later in 43% of cases and less than 3 months in 29% of cases. The cuneiform resection is in 23% of cases of more than 30°, in 67% of cases from 16° to 30° and in 10% of 15°.

The external translation was of ¼ of diaphysis in 54% of cases, a half of diaphysis in 37% of cases and more in 6% of cases. (Zero in 3% of the cases).

That corrects the metatarsus varus, thus angle M1/M2 were standardized below 10 °in 69% of cases with the concluding control (check- up), and whereas 51% presented a metatarsus varus preoperative superior to 10° .The external head translation of M1 decreased the width of the metatarsus on comparative radiographies in support by the measurement of the width m1/m5.

Figure 6

Table 1 : Width M1 M5 59 Hohmann

This angle > than 28 °, was noted in preoperative and in 32% of cases during the last control (revision).

The ideal reduction let persist a valgus of less than 10 of the big toe. It was insufficient in ¼ cases with an angle M1/P1 > to13°, which can support the repetitions (recurrences) with deformity > to 25°.

The osteotomy with bone resection leads to a shortening of M1 of variable importance according to the resected corner (40% have a shortening of less than 5 mm, 47% from 5 to 10 mm and 13% from 10 to 15 %.

The harmful effect of this shortening is compensated by the flexing osteotomy which gives again a support on the 1st ray what avoids or improves the metatarsalgium.

The pathological pronation of the hallux valgus disappears by the derotation of the toe during the osteotomy, what brings back the metatarsal head on the sesamoids.

This can be seen on radiographies full face in support where the position of the sesamoid is considered to be normal in 25% of cases, and moved to the 1st degree in 67% of the cases, to the 2nd degree in 7% of the cases, and to the 3rd degree in less than 1% of the cases .That encourages us to better reduce the head by translation derotation

The operation of Hohmann improves greatly these subjective signs as it is shown on tables II and III.

Figure 7

Table 2: Per operative Clinical Signs of Hohmann 284

Figure 8

Table 3: Post operative clinical results of Hohmann 284

From an objective point of view, we note a normal mobility of the big toe only in 24% of cases, which is decreased in 49% of cases; very stiff cases were detected in 27% of the cases, what encourages us to require more functional rehabilitation.

On the other hand, the support on the ground of the pulp of the big toe objectified by the sheet of paper test is excellent in 85% of cases, which helps the unfolding and the impulse of the step. In 9% of cases the contact on the ground can be carried out but without any strength. Among 5 cases, the big toe remains above ground-level.

Total results

Discussions

The delay of cicatrization and the duration of the bone consolidation for hallux valgus treatment are unquestionable disadvantages of the osteotomy of Hohmann compared with the other methods.

The per cutaneous technique seems less invasive [3]

We deplore 16% of the hallux valgus recurrences which occur during the first 3 months. They are linked to the importance of M1/P1 initial angle and also, preoperatively with an external insufficiency of translation of the sub capital osteotomy, thus we note14% of recurrences for hallux valgus from 26° to 39° and 41% of recurrence among 39 cases and 40% whose gain of correction of the deformity is nevertheless higher than 20°, which is very appreciable.

The recurrence also depends on the presence of an inter phalangeal hallux becoming pathological according to Gauthier (4) beyond 10°, justifying a reintervention by a P1 complementary osteotomy, fixed by a suture skin clip of Barouk (5) or by pins with this hallux valgus inter phalangeal excessive, we now associate with the operation of Hohmann an osteotomy of P1 if P1/P2 angle is higher than 15°.

Actually, the patients come for a consultation especially for the pain felt at the bunion level as well as the troubles occurred while putting on one’s shoes .The correction of M1/P1 angle is not the most significant for the treatment but the reduction of the metatarsus width, which we can obtain by the translation-without rotation from M1 head.

Both the bursectomy and the exostosectomy are not necessary contrary to Mitchell practice [6]

To fight against the detrimental effects (misdeeds) of shortening, Wilson [7] proposes an oblique osteotomy but the flexing osteotomy compensates it well.

Conclusions

Hohmann intervention helps in regulating in only one site all the deformities related to the Hallux valgus. The cuneiform osteotomy sub capital of the first metatarsal at internal and lower base whose reduction in variation of rotation brings back the big toe in the axis of the foot and the head of the first metatarsal to the top of the sesamoids, the external translation reduces the width of the metatarsus and makes disappear the friction inside the shoe, the flexing gives again a support with the first ray improving the metatarsalgium and helping the impulse of the step.