Osteotomies for Hallux Valgus Correction

• 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

• 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.

• Power saw with 9-mm blades
• Standard foot tray

• 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.

• 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.

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

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

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.

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.

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%)