Distal Osteotomies and Soft Tissue Procedures for Treatment of Hallux Valgus

N. Craig Stone, M.D., FRCSC
St. Johns, NL

When surgical management is indicated, most cases of symptomatic hallux valgus can be managed with realignment procedures in the distal portion of the first ray1. If the first intermetatarsal angle (IMA) is not excessive (<14) and there is no degenerative change in the first metatarsophalangeal joint, distal osteotomies and soft tissue procedures can effectively correct the deformity2.

Preoperative planning includes good quality AP and lateral weight bearing radiographs of the affected foot. These films should be used to determine if any joint arthrosis exists, to determine joint congruency, and to measure four important angles necessary for preoperative planning. The hallux valgus angle (HVA), the first intermetatarsal angle (IMA), the distal metatarsal articular angle (DMMA), and the proximal phalangeal articular angle (PPAA) should be determined on the AP radiograph2.

The most common clinical situation where distal alignment alone will suffice is the middle aged female with mild to moderate deformity (HV angle <30), normal IMA, minimal degenerative change, and a slightly incongruent joint (Figure 1). This patient can be treated with a medial eminence excision, distal chevron osteotomy and a reconstruction of the medial joint capsule. A closing wedge Akin osteotomy through the base of the proximal phalanx can be added if the PPAA is increased or the chevron osteotomy alone does not give a satisfactory clinical correction of the deformity (Figure 2). The chevron osteotomy is often inherently stable, however, internal fixation can be used if any concern about stability arises intraoperatively2. The reconstruction of the medial joint capsule should include imbrication to correct both the valgus deformity and also help reduce the subluxed sesamoids.

The younger patient may have a congruent joint with the deformity either due to an increased DMMA or an abnormal PPAA. This deformity should be treated with primarily extra-articular procedures, with only minimal reefing of the medial capsule. Making a congruent joint incongruent by over tightening the medial capsule is a situation that should be avoided. If the DMAA is abnormal, a biplanar chevron osteotomy can be used with a second pass of the saw to remove more bone medially and convert the osteotomy to a slight medial closing wedge osteotomy3. An Akin osteotomy can be added if the metatarsal osteotomy does not give adequate correction or if the PPAA is abnormal.

Rarely, in a mild or moderate incongruent deformity, will a release of the lateral structures (lateral first MTP joint capsule and adductor hallucis tendon) be necessary to realign the joint. If the distal realignment is being done in conjunction with a proximal osteotomy, release of these structures with a medial capsular reefing will realign the incongruent MTP joint. Combinations of distal metatarsal osteotomies and lateral releases should be avoided. This combination may disrupt the intra and extra osseous blood supply to the first metatarsal head and may increase the metatarsal head avascular necrosis rate2.

Postoperatively, a forefoot dressing or toe spacer that protects the correction should be used for four to six weeks. Patients can ambulate in a rigid sole postoperative shoe or cast boot. Full activity can be allowed when the osteotomies have healed clinically and radiographically. Maximum pain relief, complete resolution of swelling and return of full function may take several months. Patients should be warned of some decreased range of motion of the first MTP joint after these procedures, but it is rarely a clinical problem. Historically, patient satisfaction rates, with this approach, have been in the order of 95%4.

References

1. Leventen E.O. The chevron procedure. Orthopedics, 13:973-976, 1990.

2. Coughlin, M.J. Hallux valgus. Journal of Bone and Joint Surgery 1996;78:932-966.

3. Nery C., Barroco R., Ressio C. Biplanar chevron osteotomy. Foot and Ankle Int 2002;23:792-798.

4. Trnka H.J., Zembsch A., Easley, M.E., Salzer M., Ritschl P., Myerson M.S.: The chevron osteotomy for correction of hallux valgus: Comparison of findings after two and five years of follow-up. Journal of Bone and Joint Surgery American 2000;82:1373-1378.

Figure Legends

stonefigure 1

Figure 1: A middle age female with a moderate incongruent hallux valgus and second claw toe deformity, HV = 30. (Normal <15.), IMA = 12. (Normal <11), DMAA = 12. (Normal < 15.), PPAA = 2. (Normal < 10.).

stonefigure 2
Figure 2: Patient in Figure 1 three weeks postoperatively after a medial eminence excision, chevron and Akin osteotomies, medial capsular imbrication, and second claw toe correction.

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