Osteotomies for Hallux Valgus Correction

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Hallux valgus <25 degrees
    • Congruent joint
      • Chevron osteotomy
      • Mitchell osteotomy
    • Incongruent joint
      • Distal soft-tissue realignment
      • (Subluxation) chevron osteotomy
      • Mitchell osteotomy
  • Hallux valgus 25-40 degrees
    • Congruent joint
      • Chevron osteotomy with Akin procedure
      • Mitchell osteotomy
    • Incongruent joint
      • Distal soft-tissue realignment with proximal osteotomy
      • Mitchell osteotomy
  • Severe hallux valgus 25-40 degrees
    • Congruent joint
      • Double osteotomy
      • Akin procedure and chevron osteotomy
      • Akin procedure and first metatarsal osteotomy
      • Akin procedure and first cuneiform opening wedge osteotomy
    • Incongruent joint
      • Distal soft-tissue realignment with proximal osteotomy
      • First metatarsal crescentic osteotomy
      • First cuneiform opening wedge osteotomy
    • Hypermobile first metatarsocuneiform joint
      • Distal soft-tissue realignment and fusion of first metatarsocuneiform joint
CONTRAINDICATIONS
  • Surgery simply to correct a cosmetic deformity is a relative contraindication.
  • Other contraindications include severe peripheral vascular disease, significant osteoarthritis of the metatarsophalangeal (MTP) joint, active infection, and advanced age.
EQUIPMENT
  • Power saw with 9-mm blades
  • Standard foot tray
ANATOMY
  • Anatomic basis of hallux valgus
    • The bunion deformity begins at a normal or slightly angulated metatarsophalangeal (MTP) joint.
      • Through uncertain etiologic factors, the metatarsophalangeal (MTP) joint becomes vulnerable to valgus pressures and hallux valgus occurs.
    • If the valgus angle of the first metatarsophalangeal joint exceeds 30 to 35 degrees, pronation of the great toe usually results.
    • With this abnormal rotation, the abductor hallucis moves farther plantarward.
      • The abductor hallucis is normally plantar to the flexion-extension axis of the first metatarsophalangeal joint.
      • Consequently, the medial restraints are lessened.
        • The only restraining medial structure is the medial capsular ligament.
    • The adductor hallucis is now unopposed by the abductor hallucis.
      • It pulls the great toe farther into valgus.
      • The medial capsular ligament (particularly the capsulosesamoid) is stretched and consequently attenuated.
      • This allows the metatarsal head to drift medially from the sesamoids.
    • In addition, the flexor hallucis brevis, flexor hallucis longus, adductor hallucis, and extensor hallucis longus increase the valgus moment at the metatarsophalangeal joint.
      • This further deforms the first ray.
        • The deep transverse intermetatarsal ligament runs between the plantar plates at the metatarsophalangeal joints and does not insert into bone on the adjacent sides of the metatarsal heads.
    • Finally, the sesamoid ridge on the plantar surface of the first metatarsal head (the crista) flattens because of pressure (abutment) from the tibial sesamoid.
    • With this sesamoid ridge restraint lost, the fibular sesamoid displaces partially or completely into the first intermetatarsal space.
      • In this situation the patient is bearing less weight on the first ray and more on the lesser metatarsal heads, increasing the likelihood of transfer metatarsalgia, callosities, and stress fracture of a lesser metatarsal.

PROCEDURE
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  • Clinical pearls providing practical clinical tips from medical experts
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  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: Distal Chevron Osteotomy (Johnson; Corless)
  • Post-Procedure: Modified Chevron Osteotomy
  • Post-Procedure: Modified Chevron Osteotomy (Johnson)
  • Post-Procedure: Proximal Crescentic Osteotomy with Distal Soft-Tissue Procedure (Mann and Coughlin)
  • Post-Procedure: Proximal Chevron First Metatarsal Osteotomy (Sammarco and Conti)
  • Post-Procedure: Ludloff oblique metatarsal osteotomy (Chiodo, Schon, and Myerson)

Post-Procedure: Distal Chevron Osteotomy (Johnson; Corless)

POST-PROCEDURE CARE
  • Three days after surgery, the bulky soft dressing is removed.
  • A small dressing and a short-leg walking cast with dorsal and plantar toe plates are applied.
  • Touch-down weight bearing is allowed with crutches until the osteotomy has healed (6 to 8 weeks).
COMPLICATIONS
  • Recurrent pain
  • Recurrence of the hallux valgus deformity
    • More likely when subluxation or dislocation of the first metatarsophalangeal joint is present
  • Transfer metatarsalgia
  • Osteonecrosis
  • Metatarsophalangeal (MTP) joint arthrofibrosis
  • Postoperative neuritic symptoms
ANALYSIS OF RESULTS
  • The age of patients does not appear to influence outcome.
  • At 10-year follow-up, the rate of revision for chevron osteotomies is less than 1%.
OUTCOMES AND EVIDENCE
  • Schneider et al
    • At 10-year follow-up only 1 of 112 chevron osteotomies had required a revision procedure because of recurrence of the hallux valgus deformity.
    • They also noted that their patients showed further improvement over time.
      • The progression of arthritis of the first metatarsophalangeal joint was significant between the 6-year and 12-year follow-up evaluations, but did not affect the clinical results.
Procedure: Distal Chevron Osteotomy (Johnson; Corless)

Post-Procedure: Modified Chevron Osteotomy

POST-PROCEDURE CARE
  • The dressing and sutures are removed at 19 to 23 days.
  • A toe spacer is worn to hold the hallux in the proper position.
  • A wood-soled shoe is worn for 4 weeks, and then a deep, wide jogging shoe with a toe spacer is worn for the next 6 to 8 weeks.
    • A short leg walking cast worn for 4 weeks after surgery is an alternative, but it is not routinely recommended except in adolescents.
  • The Kirschner wires can be removed at 3 months or earlier if they cause symptoms, or they may be left if the patient is asymptomatic.
COMPLICATIONS
  • Recurrent pain
  • Recurrence of the hallux valgus deformity
  • Transfer metatarsalgia
  • Osteonecrosis
  • Metatarsophalangeal (MTP) joint arthrofibrosis
  • Postoperative neuritic symptoms

Procedure: Modified Chevron Osteotomy

Post-Procedure: Modified Chevron Osteotomy (Johnson)

POST-PROCEDURE CARE
  • Partial weight bearing with crutches for the first 3 to 4 days.
  • The dressing is changed and a short-leg walking cast is applied at postoperative day 3 to 4.
    • The cast should extend distal to the great toe for gentle support.
      • The cast is primarily for comfort and patient mobility allowing ambulation without crutches or a walker.
    • The cast is removed approximately 1 week later.
  • Gentle exercises of the great toe are begun when the cast is removed.
  • A hallux valgus night splint is applied to protect the medial capsular repair.
  • A stiff-soled postoperative shoe is worn for approximately 3 weeks; after this a deep, wide, soft shoe can be worn.
COMPLICATIONS
  • Recurrent pain
  • Recurrence of the hallux valgus deformity
  • Transfer metatarsalgia
  • Osteonecrosis
  • Metatarsophalangeal (MTP) joint arthrofibrosis
  • Postoperative neuritic symptoms
Procedure: Modified Chevron Osteotomy (Johnson)

Post-Procedure: Proximal Crescentic Osteotomy with Distal Soft-Tissue Procedure (Mann and Coughlin)

POST-PROCEDURE CARE
  • The bulky compression dressing holding the hallux in a corrected position is changed the following day.
    • It is then changed at weekly intervals for 6 to 8 weeks, holding the hallux in the corrected position.
  • Weight bearing to tolerance is allowed the day of surgery.
    • The patient usually prefers to walk on the lateral border of the foot or to use crutches for a few days.
COMPLICATIONS
  • Hallux varus
  • Dorsiflexion malunion of the osteotomy site with transfer metatarsalgia
  • Limitation of motion of the first metatarsophalangeal joint
ANALYSIS OF RESULTS
  • 90% of patients report satisfactory results with no new symptomatic callosities beneath the second metatarsal heads.
  • Correction of moderate to severe hallux valgus is maintained in 90% of patients with a follow-up greater than 10 years.
OUTCOMES AND EVIDENCE
  • Mann, Rudicel, and Graves popularized the proximal crescentic osteotomy with a distal soft-tissue repair and documented their results in 109 feet.
    • 93% of their patients had satisfactory results.
    • Only 7% were dissatisfied and continued to have pain or recurrence of the deformity.
    • No new symptomatic callosities beneath the second metatarsal heads were noted.
    • 28% of the feet had slight dorsiflexion of the first metatarsal on weight-bearing lateral radiographs.
    • 30 of 48 feet that had symptomatic callus before surgery had complete resolution afterward; 13 remained unchanged but were no longer painful; only 5 remained painful.
      • The authors concluded that slight dorsiflexion malunion does not lead to symptomatic overload of the metatarsal head with callus formation.
  • Veri, Pirani, and Claridge
    • Correction of moderate to severe hallux valgus deformities in almost 90% of their 25 patients (35 feet) was maintained at long-term follow-up of 12 years.
    • The mean hallux valgus angle correction was 24 degrees and intermetatarsal angle was 10 degrees, and 94% of patients said they would have the operation again.
    • Complications included 2 patients (5%) who had overcorrection into varus, and 4 patients (11%) who had undercorrection and developed asymptomatic recurrences.
Procedure: Proximal Crescentic Osteotomy with Distal Soft-Tissue Procedure (Mann and Coughlin)

Post-Procedure: Proximal Chevron First Metatarsal Osteotomy (Sammarco and Conti)

POST-PROCEDURE CARE

None available

COMPLICATIONS
  • Distal chevron osteotomy
    • Recurrent pain
    • Recurrence of the hallux valgus deformity
    • More likely when subluxation or dislocation of the first metatarsophalangeal joint is present
    • Transfer metatarsalgia
    • Osteonecrosis
    • Metatarsophalangeal (MTP) joint arthrofibrosis
    • Postoperative neuritic symptoms
  • Proximal crescentic osteotomy with distal soft-tissue procedure
    • Hallux varus
    • Dorsiflexion malunion of the osteotomy site with transfer metatarsalgia
    • Limitation of motion of the first metatarsophalangeal joint
ANALYSIS OF RESULTS

Good to excellent results are obtained in approximately 80% of patients.

OUTCOMES AND EVIDENCE
  • Sammarco, Brainard, and Sammarco
    • Fifty-one feet had moderate to severe bunion deformity with hallux valgus and metatarsus primus varus.
    • The hallux valgus angle was reduced an average of 19 degrees.
    • The intermetatarsal angle was reduced an average of 7.3 degrees.
    • Using the Maryland Foot Score Profile, good to excellent results were obtained in 78%.
  • Sharma et al
    • Biomechanical analysis
    • Determined that the average load-to-failure and stiffness of a proximal chevron osteotomy fixed with a plantar-to-dorsal lag screw configuration were significantly greater than an osteotomy fixed with the more conventional dorsal-to-plantar configuration.
Procedure: Proximal Chevron First Metatarsal Osteotomy (Sammarco and Conti)

Post-Procedure: Ludloff oblique metatarsal osteotomy (Chiodo, Schon, and Myerson)

POST-PROCEDURE CARE
  • Patients are allowed to immediately bear weight as tolerated on the heel and lateral forefoot in an open, hard-soled surgical shoe, followed by gradual resumption of full weight-bearing on the flat foot as tolerated.
  • Dressing changes are done at 7 to 10 days, and the postoperative shoe is discontinued between 4 and 6 weeks when evidence of bone healing and stability of the osteotomy are noted radiographically.
  • A bunion splint with a toe spacer is worn at night.
COMPLICATIONS
  • Prominent hardware requiring removal
  • Hallux varus deformity
  • Delayed union
  • Superficial infection
  • Neuralgia
ANALYSIS OF RESULTS
  • Three years after the surgery, most patients are pain-free.
  • The occurrence of transfer lesions is rare.
  • The degree of deformity is greatly reduced in most patients.
OUTCOMES AND EVIDENCE
  • Easley, Trnka, Gruber, and Jankovsky
    • Prospective evaluation of 88 patients (97 feet) with Ludloff osteotomies.
    • At average follow-up of 3 years, 90% were pain-free.
    • AOFAS score improved from 53 to 87 points, IMA from 18 to 8 degrees, HVA from 41 to 15 degrees.
    • Complications included hallux varus (12%), hallux rigidus (3%), recurrence of deformity (3%), deep infection (1%), cellulitis (1%); no dorsiflexion malunions.
  • Chiodo, Schon, Myerson
    • 70 feet with Ludloff osteotomies, followed for 30 months
    • Mean HVA reduced from 31 to 11 degrees, mean IMA from 16 degrees to 7 degrees
    • AOFAS score improved from 54 to 91 points
    • No symptomatic transfer lesions
    • Complications included prominent hardware (7%), hallux varus (6%), delayed union (4%), superficial infection (4%), neuralgia (4%)
Procedure: Ludloff oblique metatarsal osteotomy (Chiodo, Schon, and Myerson)
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