A distal soft-tissue realignment and proximal first metatarsal crescentic
osteotomy is utilized to correct a moderate or severe hallux valgus deformity
characterized by a subluxated metatarsophalangeal joint. The proximal
orientation of the crescentic metatarsal osteotomy places the center of
rotation of the osteotomy at the metatarsocuneiform joint.
A requisite of the distal soft-tissue realignment is that the
metatarsophalangeal joint be free of degenerative arthritis. The joint must
also be subluxated, as this allows repositioning of the base of the proximal
phalanx as the intermetatarsal angle is narrowed. A closing-wedge phalangeal
osteotomy is added as needed to correct residual pronation or hallux valgus
interphalangeus (Figs. 1-A and
1-B).
The procedure is performed with use of regional anesthesia and the patient
in the supine position. The leg is exsanguinated with an Esmarch bandage,
which is used as an ankle tourniquet. The foot and ankle are covered with a
stockinette to minimize compression of the skin, and, with medium tension, the
foot is wrapped with the bandage. In the supramalleolar region, the bandage is
overlapped three times and is then tucked beneath the last wrap.
Intermetatarsal Approach
A 3-cm longitudinal incision is centered over the first intermetatarsal web
space, and the interval between the first and second metatarsal heads is
exposed. The incision is deepened in the web space, and the dissection
proceeds until the bursa is identified between the first and second metatarsal
heads. The conjoined adductor hallucis tendon is identified. An incision is
then made along the dorsal aspect of the lateral sesamoid, releasing the
adductor hallucis and the soft-tissue contracture between the lateral sesamoid
and the first metatarsal head (Fig.
2).
Approximately 3 cm proximal to the insertion of the adductor hallucis, the
tendon is severed and a suture is placed in the distal tendon stump
(Fig. 3). The proximal muscle
is allowed to retract. Any remaining attachments to the lateral sesamoid are
released, but the sesamoid is not routinely excised unless there is
substantial degenerative arthritis.
A Weitlaner retractor is inserted into the interspace to distract the first
and second metatarsal heads. With tension placed on the transverse metatarsal
ligament, the ligament is incised (Fig.
4). Care is taken to avoid injury to the underlying common digital
nerve and vessel in the first web space. From a dorsal approach, and with use
of parallel dorsal and plantar incisions at the metatarsophalangeal joint
level, the lateral aspect of the metatarsophalangeal joint capsule is then
released from its attachment to the metatarsal head and the proximal phalanx.
The capsular attachments are preserved both distally and proximally away from
the joint space (Figs. 5-A and
5-B). This release of the contracture allows the
metatarsophalangeal joint to be adequately realigned but avoids creating a
tissue gap laterally as the phalanx is reduced on the metatarsal articular
surface. At the conclusion of the procedure, the conjoined adductor tendon
stump is sutured in an oblique fashion into the proximal part of the first
metatarsophalangeal joint capsule to reinforce the lateral aspect of the
capsule and help prevent hallux varus (Fig.
6).
Medial Approach
A longitudinal incision is centered over the medial eminence and extended
from the midportion of the proximal phalanx to a point 2 cm proximal to the
medial eminence. The incision is deepened along this line through the
subcutaneous tissue to the capsule and then is carefully extended in dorsal
and plantar directions along this capsular plane, creating a full-thickness
flap. In the dissection deep to the medial aspect of the capsule, care is
taken to identify and protect the medial dorsal cutaneous nerve
(Fig. 7).
An inverted L-shaped capsular release is used to expose the medial eminence
(Figs. 8-A and 8-B). The
capsule is released dorsally and proximally at its two weakest points of
attachment, leaving the strong distal and plantar capsular attachments intact.
This allows excellent exposure of the medial eminence, the medial sesamoid,
and the metatarsophalangeal joint. The metatarsophalangeal joint is inspected
for any evidence of degenerative arthritis. The sagittal sulcus is identified.
Alone it is an unreliable reference point for resection of the medial
eminence. With a small medial eminence, the sulcus may represent the actual
site of the osteotomy (Fig. 9);
however, with a more severe deformity, the sulcus may have migrated too far
laterally to be used as a reference point and bone resection at this point
would be excessive.
The medial eminence is resected with the sagittal saw starting at
approximately 2 mm medial to the sagittal sulcus in a line parallel with the
longitudinal axis of the first metatarsal shaft (Figs.
10 and
11). Excessive resection
should be avoided as it may lead to a hallux varus deformity. Sharp edges are
removed with a rongeur.
Osteotomy of the First Metatarsal
A third longitudinal incision, 3 cm in length, is centered over the dorsal
aspect of the first metatarsal just medial to the extensor hallucis longus
tendon. It is deepened to the first metatarsal shaft, and the periosteum is
reflected with an elevator. A 0.045-in (0.114-cm) Kirschner wire is inserted
through the proximal incision into the dorsal aspect of the first cuneiform
perpendicular to the metatarsal shaft in the coronal plane. It is used as a
reference guide for the crescentic osteotomy
(Fig. 12).
The dorsal midline of the first metatarsal shaft is marked, and a
crescentic osteotomy is performed 1 cm distal to the first metatarsocuneiform
joint (Fig. 13) with use of a
crescentic blade. The concavity of the crescentic blade is directed
proximally, and the osteotomy is made in a plane perpendicular to one midway
between that of the sole of the foot and the plantar surface of the first
metatarsal (Figs. 14-A through
15). It is important that the
osteotomy penetrate both the lateral and the plantar cortex of the metatarsal
shaft; it may be completed with use of a 3-mm osteotome. A small amount of
bone is removed from the proximal-medial and proximal-lateral aspects of the
metatarsal shaft to facilitate displacement of the osteotomy site
(Fig. 16).
Next, a small Freer elevator is positioned along the lateral aspect of the
osteotomy site for stabilization (Fig.
17) and the distal fragment is rotated and displaced laterally
approximately 2 to 4 mm around the proximal fragment.
Once displaced, the osteotomy site is provisionally stabilized with a
0.062-in (0.157-cm) Kirschner wire along its medial aspect
(Fig. 18). A fully threaded
3.5-mm self-tapping screw is lagged across the osteotomy site after a 3.5-mm
hole is drilled into the distal fragment and a 2.5-mm hole is drilled into the
proximal fragment. Care must be taken not to overtighten the screw, as that
may fracture this narrow bone bridge (Fig.
19).
Attention is then directed to the medial incision. With the great toe held
in a derotated and supinated position, the dorsal-medial and proximal-medial
aspects of the capsule are repaired with several interrupted sutures. To do
this, a small vertical metaphyseal drill-hole is first used to anchor the
capsule proximally and then the interrupted sutures are placed to secure the
capsular repair (Fig. 20).
Through the intermetatarsal incision, the conjoined tendon stump is placed
obliquely across the lateral aspect of the metatarsophalangeal joint and
secured with interrupted 2-0 absorbable sutures. One or two reinforcing
capsular sutures are used to reef the lateral aspect of the
metatarsophalangeal joint capsule.
Occasionally, a phalangeal (Akin) osteotomy is performed to gain additional
angular or rotational correction (Figs.
21-A and 21-B). The medial incision is extended 1 cm distally, and
the periosteum is reflected, exposing the diaphysis of the proximal phalanx. A
sagittal saw is used to remove a 2 to 3-mm medially based wedge of bone from
the phalanx. The osteotomy site is closed and is derotated to correct any
hallux valgus interphalangeus or residual pronation. Fixation can be
accomplished with a compression pin or smooth 0.062-in Kirschner wires.
Prior to closure of the skin, intraoperative fluoroscopy is performed to
confirm proper alignment of the osteotomy site and successful realignment of
the metatarsophalangeal joint.
A gauze-and-tape compression dressing is applied at the conclusion of the
operation to hold the hallux and metatarsal in proper alignment. The patient
wears a postoperative rigid-soled shoe and is allowed to walk with crutches,
bearing weight on the heel and the lateral aspect of the foot. One to two days
following the surgery, the compression dressing is changed and a smaller
compression dressing is applied with 5-cm-wide gauze and 2.5-cm-wide adhesive
tape to create a toe spica. These dressings are changed every ten days for a
period of eight weeks following the surgery. Radiographs are made at the first
visit and at six weeks following the surgery.
At six weeks after the surgery, if adequate healing of the osteotomy site
is noted radiographically, the screw-and-pin fixation of the proximal part of
the first metatarsal is removed in the physician's office with the patient
under local anesthesia. We have found that many of the screws and most of the
Kirschner wires penetrate or actually cross the first metatarsocuneiform
joint. Removal prevents later arthrosis. It also prevents implant fracture,
which may complicate hardware removal should it become necessary.
Passive and active range-of-motion exercises are commenced ten days
following the surgery. On occasion, a physical therapist may supervise
range-of-motion and ambulatory activities. The use of crutches is routinely
discontinued three or four days after the surgery. Eight weeks following the
surgery, use of the dressings is discontinued. Athletic activities are
initiated twelve weeks following the surgery
(Figs. 22-A and 22-B).
CRITICAL CONCEPTSINDICATIONS:A subluxated or incongruent hallux valgus deformity of the firstmetatarsophalangeal joint (Fig.
23).A hallux valgus angular deformity of =30° or an intermetatarsal
angle of=12°.A patient's desire for correction of the deformity with a procedure that
preserves the metatarsocuneiform joint and motion of the first
metatarsophalangeal joint.CONTRAINDICATIONS:A hallux valgus deformity of >50° or an intermetatarsal angle of
>25°.A congruent metatarsophalangeal joint.Clinically relevant arthritis of the metatarsophalangeal joint.Generalized spasticity.Substantial osteopenia may be a contraindication. Alternatively, different
internal fixation may be used—i.e., a dorsal but-tress plate may be
applied to secure fixation of the osteotomy site.An open proximal epiphysis of the first metatarsal does not constitute a
contraindication but care should be taken to avoid iatrogenic epiphyseal
injury.PITFALLS:Malalignment of the osteotomy site. This can result from undercorrection or
overcorrection at the osteotomy site, a problem that can be minimized with the
use of intraoperative fluoroscopy. In addition, dorsiflexion of the osteotomy
site can occur, either as a result of early weight-bearing on osteopenic bone
or because of rotation of the saw in a medial direction as the osteotomy site
is displaced (Figs. 24-A, 24-B, and
24-C). Much less commonly, lateral rotation can lead to plantar
flexion of the osteotomy site. Use of the vertical Kirschner wire helps to
orient the osteotomy site in the correct coronal plane.In our experience, a severe hallux valgus deformity has appeared to be
associated with a greater risk of hallux varus overcorrection as a result of
the minimal amount of tissue present on the lateral aspect of the capsule. The
use of the conjoined adductor tendon to create a pseudocapsule has reduced
this tendency.Overcorrection can occur as a result of excessive plication of the medial
aspect of the capsule and/or excessive resection of the medial eminence.When a patient has an open epiphysis, care should be taken to avoid injury
to the epiphyseal plate.AUTHOR UPDATE:Experience with complications associated with the operative procedure has
led to minor modifications.Initially, the orientation of the crescentic osteotomy was with the
concavity facing
distally1-3.
This placed the center of the rotational axis distal to the osteotomy site,
leading to the creation of a bump along the medial arch when the osteotomy
site was displaced. Also, it increased the chance of overcorrection, leading
to hallux varus. When the concavity of the osteotomy was reversed and directed
proximally, the risk of overcorrection was reduced and the center of rotation
of the osteotomy was transferred to the first metatarsocuneiform
joint4.To achieve proper orientation of the crescentic saw blade in the coronal
plane, a Kirschner wire is used to orient the blade perpendicular to the
longitudinal axis of the first metatarsal and the plantar aspect of the foot.
We have found this to be a reliable technique for minimizing dorsiflexion and
malunion5.The other common cause of inappropriate dorsiflexion of the osteotomy site
is osteopenic bone. The use of a dorsal but-tress plate has minimized the
occurrence of this
problem6.Initially, the conjoined tendon was released at the joint and the remainder
of the lateral aspect of the capsule often was perforated and
torn7. The
modification utilizing the conjoined adductor tendon stump for reinforcement
and leaving a portion of the lateral part of the capsule intact has reduced
the incidence of hallux varus.A compression pin is now used to secure the phalangeal osteotomy site.
CRITICAL CONCEPTS
INDICATIONS:
A subluxated or incongruent hallux valgus deformity of the firstmetatarsophalangeal joint (Fig.
23).A hallux valgus angular deformity of =30° or an intermetatarsal
angle of=12°.A patient's desire for correction of the deformity with a procedure that
preserves the metatarsocuneiform joint and motion of the first
metatarsophalangeal joint.
A subluxated or incongruent hallux valgus deformity of the first
metatarsophalangeal joint (Fig.
23).
A hallux valgus angular deformity of =30° or an intermetatarsal
angle of
=12°.
A patient's desire for correction of the deformity with a procedure that
preserves the metatarsocuneiform joint and motion of the first
metatarsophalangeal joint.
CONTRAINDICATIONS:
A hallux valgus deformity of >50° or an intermetatarsal angle of
>25°.A congruent metatarsophalangeal joint.Clinically relevant arthritis of the metatarsophalangeal joint.Generalized spasticity.Substantial osteopenia may be a contraindication. Alternatively, different
internal fixation may be used—i.e., a dorsal but-tress plate may be
applied to secure fixation of the osteotomy site.An open proximal epiphysis of the first metatarsal does not constitute a
contraindication but care should be taken to avoid iatrogenic epiphyseal
injury.
A hallux valgus deformity of >50° or an intermetatarsal angle of
>25°.
A congruent metatarsophalangeal joint.
Clinically relevant arthritis of the metatarsophalangeal joint.
Generalized spasticity.
Substantial osteopenia may be a contraindication. Alternatively, different
internal fixation may be used—i.e., a dorsal but-tress plate may be
applied to secure fixation of the osteotomy site.
An open proximal epiphysis of the first metatarsal does not constitute a
contraindication but care should be taken to avoid iatrogenic epiphyseal
injury.
PITFALLS:
Malalignment of the osteotomy site. This can result from undercorrection or
overcorrection at the osteotomy site, a problem that can be minimized with the
use of intraoperative fluoroscopy. In addition, dorsiflexion of the osteotomy
site can occur, either as a result of early weight-bearing on osteopenic bone
or because of rotation of the saw in a medial direction as the osteotomy site
is displaced (Figs. 24-A, 24-B, and
24-C). Much less commonly, lateral rotation can lead to plantar
flexion of the osteotomy site. Use of the vertical Kirschner wire helps to
orient the osteotomy site in the correct coronal plane.In our experience, a severe hallux valgus deformity has appeared to be
associated with a greater risk of hallux varus overcorrection as a result of
the minimal amount of tissue present on the lateral aspect of the capsule. The
use of the conjoined adductor tendon to create a pseudocapsule has reduced
this tendency.Overcorrection can occur as a result of excessive plication of the medial
aspect of the capsule and/or excessive resection of the medial eminence.When a patient has an open epiphysis, care should be taken to avoid injury
to the epiphyseal plate.
Malalignment of the osteotomy site. This can result from undercorrection or
overcorrection at the osteotomy site, a problem that can be minimized with the
use of intraoperative fluoroscopy. In addition, dorsiflexion of the osteotomy
site can occur, either as a result of early weight-bearing on osteopenic bone
or because of rotation of the saw in a medial direction as the osteotomy site
is displaced (Figs. 24-A, 24-B, and
24-C). Much less commonly, lateral rotation can lead to plantar
flexion of the osteotomy site. Use of the vertical Kirschner wire helps to
orient the osteotomy site in the correct coronal plane.
In our experience, a severe hallux valgus deformity has appeared to be
associated with a greater risk of hallux varus overcorrection as a result of
the minimal amount of tissue present on the lateral aspect of the capsule. The
use of the conjoined adductor tendon to create a pseudocapsule has reduced
this tendency.
Overcorrection can occur as a result of excessive plication of the medial
aspect of the capsule and/or excessive resection of the medial eminence.
When a patient has an open epiphysis, care should be taken to avoid injury
to the epiphyseal plate.
AUTHOR UPDATE:
Experience with complications associated with the operative procedure has
led to minor modifications.
Initially, the orientation of the crescentic osteotomy was with the
concavity facing
distally1-3.
This placed the center of the rotational axis distal to the osteotomy site,
leading to the creation of a bump along the medial arch when the osteotomy
site was displaced. Also, it increased the chance of overcorrection, leading
to hallux varus. When the concavity of the osteotomy was reversed and directed
proximally, the risk of overcorrection was reduced and the center of rotation
of the osteotomy was transferred to the first metatarsocuneiform
joint4.To achieve proper orientation of the crescentic saw blade in the coronal
plane, a Kirschner wire is used to orient the blade perpendicular to the
longitudinal axis of the first metatarsal and the plantar aspect of the foot.
We have found this to be a reliable technique for minimizing dorsiflexion and
malunion5.The other common cause of inappropriate dorsiflexion of the osteotomy site
is osteopenic bone. The use of a dorsal but-tress plate has minimized the
occurrence of this
problem6.Initially, the conjoined tendon was released at the joint and the remainder
of the lateral aspect of the capsule often was perforated and
torn7. The
modification utilizing the conjoined adductor tendon stump for reinforcement
and leaving a portion of the lateral part of the capsule intact has reduced
the incidence of hallux varus.A compression pin is now used to secure the phalangeal osteotomy site.
Initially, the orientation of the crescentic osteotomy was with the
concavity facing
distally1-3.
This placed the center of the rotational axis distal to the osteotomy site,
leading to the creation of a bump along the medial arch when the osteotomy
site was displaced. Also, it increased the chance of overcorrection, leading
to hallux varus. When the concavity of the osteotomy was reversed and directed
proximally, the risk of overcorrection was reduced and the center of rotation
of the osteotomy was transferred to the first metatarsocuneiform
joint4.
To achieve proper orientation of the crescentic saw blade in the coronal
plane, a Kirschner wire is used to orient the blade perpendicular to the
longitudinal axis of the first metatarsal and the plantar aspect of the foot.
We have found this to be a reliable technique for minimizing dorsiflexion and
malunion5.
The other common cause of inappropriate dorsiflexion of the osteotomy site
is osteopenic bone. The use of a dorsal but-tress plate has minimized the
occurrence of this
problem6.
Initially, the conjoined tendon was released at the joint and the remainder
of the lateral aspect of the capsule often was perforated and
torn7. The
modification utilizing the conjoined adductor tendon stump for reinforcement
and leaving a portion of the lateral part of the capsule intact has reduced
the incidence of hallux varus.
A compression pin is now used to secure the phalangeal osteotomy site.