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Distal First Metatarsal Dome (Crescentic) Osteotomy for Repair of Mild to Moderate Hallux Valgus Deformity
TIPS, QUIPS AND PEARLS “Tips, Quips, and Pearls” is a special section in The Journal of Foot & Ankle Surgery which is devoted to the sharing of ideas to make the practice of foot and ankle surgery easier. We invite our readers to share ideas with us in the form of special tips regarding diagnostic or surgical procedures, new devices or modifications of devices for making a surgical procedure a little bit easier, or virtually any other “pearl” that the reader believes will assist the foot and ankle surgeon in providing better care. Please address your tips to: D. Scot Malay, DPM, MSCE, FACFAS, Editor, The Journal of Foot & Ankle Surgery, PO Box 590595, San Francisco, CA 94159-0595; E-mail: [email protected]
Distal First Metatarsal Dome (Crescentic) Osteotomy for Repair of Mild to Moderate Hallux Valgus Deformity Murat Tonbul, MD,1 Mujdat Adas, MD,1 Ilker Keris, MD,2 and Serdar Zengin, MD2 Hallux valgus is one of the most common foot deformities. Despite the large number of techniques described for hallux valgus correction, there has been much controversy regarding the best procedure to use. Distal osteotomies have long been done for mild to moderate deformities. Although presented previously, based on a review of the literature, this technique does not appear to be regularly used by many surgeons. This article presents a distal metatarsal osteotomy as easy to perform and useful for the repair of mild to moderate hallux valgus deformity, wherein the first metatarsal angle measures less than 14 degrees. ( The Journal of Foot & Ankle Surgery 47(3):259 –262, 2008) Key Words: bunionectomy, crescentic osteotomy, hallux valgus
D istal first metatarsal osteotomies are well-established techniques for the correction of symptomatic mild to moderate hallux valgus deformity. One such commonly employed osteotomy is the distal chevron osteotomy, which can be used to provide transverse and sagittal plane deformity correction and is accepted as being inherently stable in the sagittal plane but not so in the transverse plane (1). Various methods of fixation, ranging from Kirschner wires
Address correspondence to: Murat Tonbul, MD, SB Istanbul Okmeydani Hospital for Research and Education, Department of Orthopaedics and Traumatology, Darulaceze Cad No:25, Sisli-Istanbul-Turkýye. E-mail: [email protected]. 1 Orthopedic Surgeon, MH Istanbul Okmeydani Hospital for Research and Education-Turkýye. 2 Orthopedic Surgery Resident, MH Istanbul Okmeydani Hospital for Research and Education-Turkýye. Financial Disclosure: None reported. Conflict of Interest: None reported. Copyright © 2008 by the American College of Foot and Ankle Surgeons 1067-2516/08/4703-0015$34.00/0 doi:10.1053/j.jfas.2008.01.005
(K-wires), different types of lag screws, including the Herbert-Whipple screw, suture anchors, and bioabsorbable fixation have all been advocated for stabilization of the distal chevron osteotomy (2– 4). On the other hand, without the use of internal fixation, medial displacement of the capital fragment and loss of correction have been reported with incidences varying from 1.8% to 12.5% in different case series (4 – 6). Overall, K-wire fixation remains a popular method of fixation used to increase stability of the distal chevron osteotomy, primarily due to its low cost and simplicity. This article describes a relatively simple technique for repair of a moderate hallux valgus deformity by means of a distal crescentic osteotomy of the first metatarsal head (Figure 1). The osteotomy provides deformity correction in the transverse and sagittal planes, and it is stabilized with diverging K-wires for buttressing the capital fragment. This type of osteotomy has been previously described for repair of fifth metatarsal head lesions (7). Moreover, the use of a distal crescentic first metatarsal osteotomy for the repair of hallux abductovalgus has also been previously described (8); however, based on a review of the literature, VOLUME 47, NUMBER 3, MAY/JUNE 2008
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FIGURE 1 Schematic representation of the distal first metatarsal dome (crescentic) osteotomy. (A) Transverse plane view. (B) Sagittal plane view.
this technique does not appear to be regularly used by many surgeons. We have found this procedure to be useful for the repair of mild to moderate hallux valgus deformity, wherein the first intermetatarsal angle measures less than 14o (Figure 2).
FIGURE 2 Preoperative radiographs of a 25-year-old female with 34o of first metatarsophalangeal (hallux abductus) angle, and 13o of first intermetatarsal angle. (A) Transverse plane view. (B) Sagittal plane view.
Operative Technique The distal aspect of the first metatarsal is approached through a medial, midline longitudinal incision, extending from base of the proximal phalanx to the distal metaphysis of the metatarsal. The capsule is incised in a Y-shape and reflected, after which the medial eminence is excised. A crescentic osteotomy is then made in a through-and-through fashion from medial to lateral, orienting the blade parallel to the articular cartilage and perpendicular to the longitudinal axis of the metatarsal in the sagittal plane. The osteotomy is made using a power crescentic oscillating osteotome that has a thickness of 1 mm, and a 10-mm radius (Aesculap GC 554 Inox 16, Aesculap-Werke AG, Tuttlingen, Germany). We do not routinely release the plantarlateral soft tissue contracture in the first intermetatarsal space. After completion of the distal crescentic osteotomy, the metatarsal head 260
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is displaced laterally while the metatarsal shaft is pulled medially under fluoroscopic guidance. Attention is paid to correct the deformity in both the transverse and, if necessary, sagittal planes. Once a satisfactory structural realignment has been made, two 0.062-inch diameter crossing-Kwires are used to stabilize the capital fragment. The first K-wire is inserted into the dorsal aspect of the proximal segment of the first metatarsal percutaneously, and directed into the capital fragment taking care to avoid violation of the articular surface. A second K-wire is then similarly directed through the medial side of the metatarsal shaft, traversing the osteotomy and seating in the subchondral bone of the metatarsal head (Figure 3). Direct operative visualization and, if desired, image intensification fluroscopy are used to assess final pin placement (Figure 4); and the first metatarsophalangeal joint is manipulated to ensure
FIGURE 3 Intraoperative placement of the Kirschner wires for stabilization of the distal first metatarsal dome (crescentic) osteotomy in a 13-year-old female.
FIGURE 5 Intraoperative appearance of the closed wound with percutaneous Kirschner wire placement in a 13-year-old female. (A) Medial view. (B) Transverse plane view.
FIGURE 4 Fluoroscopic images of the operative placement of the Kirschner wires, in a 13-year-old female. (A) Transverse plane view. (B) Sagittal plane view.
FIGURE 6 Immediate postoperative radiographic appearance of the fixated distal first metatarsal dome (crescentic) osteotomy in a 13-year-old female. (A) Oblique view. (B) Sagittal plane view.
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Discussion We have found this technique to provide adequate correction of mild to moderate hallux valgus deformities, although we do not resort to thisparticular technique if the first intermetatarsal angle measures more than 14o. The procedure also provides the advantage of preserving the length of the first metatarsal (Figures 6 and 7). The configuration and the simplicity of the osteotomy provides correction in both the transverse and sagittal planes. However, it may be difficult to perform such an osteotomy without the crescentic osteotome. Furthermore, the K-wires are driven distally into the head of the first metatarsal in the sagittal plane at an approximately 30o angle to each other, making the fixation less demanding than other options. This method of stabilization also decreases the dependence on fluroscopic guidance since the K-wires can be directly visualized and, if they penetrate into the articular cavity, retrograding the wires under direct visualization readily ensures proper placement. The use of crossing K-wires provides a stable fixation construct, and requires that the capital fragment be manually stabilized against the proximal metatarsal segment prior to driving the wires into the distal fragment. Divergence of the pins, thereafter, provides adequate resistance against displacement of the metatarsal head in all of the body planes.
References
FIGURE 7 Six months postoperative radiographic appearance of the healed distal first metatarsal dome (crescentic) osteotomy, in the 25-year-old female depicted in Figure 2. (A) Transverse plane view. (B) Sagittal plane view. Note that the hallux valgus angle and the first intermetarsal angles have decreased to 22o and 10o, respectively, whereas the length of the first metatarsal is preserved.
that the range of motion is satisfactory and that the sesamoids and phalangeal base move freely about the metatarsal head. The outer (proximal) end of the first K-wire exits through the dorsal surface of the metatarsal shaft, and that of the second K-wire exits through the proximal end of the surgical wound (Figure 5). The sharp ends of the K-wires are cut, bent to a right angle, then covered with a smooth ball or cap. Thereafter, the capsule is plicated in a V-shape and the wound is closed in layers.
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1. Rossi WR, Ferreira JC. Chevron osteotomy for hallux valgus. Foot Ankle 137:378 –381, 1992. 2. DeOrio JK, Ware AW. Single absorbable polidioxanone pin fixation for distal chevron bunion osteotomies. Foot Ankle Int 22:832– 835, 2001. 3. Oznur A. A new technique for fixation of distal chevron osteotomy Foot Ankle Int 23(10):954 –955, 2002. 4. Small HN, Braly WG, Tullos HS. Fixation of the chevron osteotomy using absorbable polydioxanon pins. Foot Ankle Int 166:346 –350, 1995. 5. Hattrup SJ, Johnson KA. Chevron osteotomy: analysis of factors in patients’ dissatisfaction. Foot Ankle 56:327–332, 1985. 6. Jahss MH, Troy AI, Kummer F. Roentgenographic and mathematical analysis of first metatarsal osteotomies for metatarsus primus varus: a comparative study. Foot Ankle 56:280 –321, 1985. 7. Haber JH, Kraft J. Crescentic osteotomy for fifth metatarsal head lesions. J Foot Surg 192:66 – 67, 1980. 8. Rosenthal DC, Callahan DF. Distal transverse crescentic osteotomy for correction of hallux abducto valgus. J Am Podiatry Assoc 748:411– 414, 1984.
Distal First Metatarsal Dome (Crescentic) Osteotomy for Repair of Mild to Moderate Hallux Valgus Deformity Murat Tonbul, MD,1 Mujdat Adas, MD,1 Ilker Keris, MD,2 and Serdar Zengin, MD2 Hallux valgus is one of the most common foot deformities. Despite the large number of techniques described for hallux valgus correction, there has been much controversy regarding the best procedure to use. Distal osteotomies have long been done for mild to moderate deformities. Although presented previously, based on a review of the literature, this technique does not appear to be regularly used by many surgeons. This article presents a distal metatarsal osteotomy as easy to perform and useful for the repair of mild to moderate hallux valgus deformity, wherein the first metatarsal angle measures less than 14 degrees. ( The Journal of Foot & Ankle Surgery 47(3):259 –262, 2008) Key Words: bunionectomy, crescentic osteotomy, hallux valgus
D istal first metatarsal osteotomies are well-established techniques for the correction of symptomatic mild to moderate hallux valgus deformity. One such commonly employed osteotomy is the distal chevron osteotomy, which can be used to provide transverse and sagittal plane deformity correction and is accepted as being inherently stable in the sagittal plane but not so in the transverse plane (1). Various methods of fixation, ranging from Kirschner wires
Address correspondence to: Murat Tonbul, MD, SB Istanbul Okmeydani Hospital for Research and Education, Department of Orthopaedics and Traumatology, Darulaceze Cad No:25, Sisli-Istanbul-Turkýye. E-mail: [email protected]. 1 Orthopedic Surgeon, MH Istanbul Okmeydani Hospital for Research and Education-Turkýye. 2 Orthopedic Surgery Resident, MH Istanbul Okmeydani Hospital for Research and Education-Turkýye. Financial Disclosure: None reported. Conflict of Interest: None reported. Copyright © 2008 by the American College of Foot and Ankle Surgeons 1067-2516/08/4703-0015$34.00/0 doi:10.1053/j.jfas.2008.01.005
(K-wires), different types of lag screws, including the Herbert-Whipple screw, suture anchors, and bioabsorbable fixation have all been advocated for stabilization of the distal chevron osteotomy (2– 4). On the other hand, without the use of internal fixation, medial displacement of the capital fragment and loss of correction have been reported with incidences varying from 1.8% to 12.5% in different case series (4 – 6). Overall, K-wire fixation remains a popular method of fixation used to increase stability of the distal chevron osteotomy, primarily due to its low cost and simplicity. This article describes a relatively simple technique for repair of a moderate hallux valgus deformity by means of a distal crescentic osteotomy of the first metatarsal head (Figure 1). The osteotomy provides deformity correction in the transverse and sagittal planes, and it is stabilized with diverging K-wires for buttressing the capital fragment. This type of osteotomy has been previously described for repair of fifth metatarsal head lesions (7). Moreover, the use of a distal crescentic first metatarsal osteotomy for the repair of hallux abductovalgus has also been previously described (8); however, based on a review of the literature, VOLUME 47, NUMBER 3, MAY/JUNE 2008
259
FIGURE 1 Schematic representation of the distal first metatarsal dome (crescentic) osteotomy. (A) Transverse plane view. (B) Sagittal plane view.
this technique does not appear to be regularly used by many surgeons. We have found this procedure to be useful for the repair of mild to moderate hallux valgus deformity, wherein the first intermetatarsal angle measures less than 14o (Figure 2).
FIGURE 2 Preoperative radiographs of a 25-year-old female with 34o of first metatarsophalangeal (hallux abductus) angle, and 13o of first intermetatarsal angle. (A) Transverse plane view. (B) Sagittal plane view.
Operative Technique The distal aspect of the first metatarsal is approached through a medial, midline longitudinal incision, extending from base of the proximal phalanx to the distal metaphysis of the metatarsal. The capsule is incised in a Y-shape and reflected, after which the medial eminence is excised. A crescentic osteotomy is then made in a through-and-through fashion from medial to lateral, orienting the blade parallel to the articular cartilage and perpendicular to the longitudinal axis of the metatarsal in the sagittal plane. The osteotomy is made using a power crescentic oscillating osteotome that has a thickness of 1 mm, and a 10-mm radius (Aesculap GC 554 Inox 16, Aesculap-Werke AG, Tuttlingen, Germany). We do not routinely release the plantarlateral soft tissue contracture in the first intermetatarsal space. After completion of the distal crescentic osteotomy, the metatarsal head 260
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is displaced laterally while the metatarsal shaft is pulled medially under fluoroscopic guidance. Attention is paid to correct the deformity in both the transverse and, if necessary, sagittal planes. Once a satisfactory structural realignment has been made, two 0.062-inch diameter crossing-Kwires are used to stabilize the capital fragment. The first K-wire is inserted into the dorsal aspect of the proximal segment of the first metatarsal percutaneously, and directed into the capital fragment taking care to avoid violation of the articular surface. A second K-wire is then similarly directed through the medial side of the metatarsal shaft, traversing the osteotomy and seating in the subchondral bone of the metatarsal head (Figure 3). Direct operative visualization and, if desired, image intensification fluroscopy are used to assess final pin placement (Figure 4); and the first metatarsophalangeal joint is manipulated to ensure
FIGURE 3 Intraoperative placement of the Kirschner wires for stabilization of the distal first metatarsal dome (crescentic) osteotomy in a 13-year-old female.
FIGURE 5 Intraoperative appearance of the closed wound with percutaneous Kirschner wire placement in a 13-year-old female. (A) Medial view. (B) Transverse plane view.
FIGURE 4 Fluoroscopic images of the operative placement of the Kirschner wires, in a 13-year-old female. (A) Transverse plane view. (B) Sagittal plane view.
FIGURE 6 Immediate postoperative radiographic appearance of the fixated distal first metatarsal dome (crescentic) osteotomy in a 13-year-old female. (A) Oblique view. (B) Sagittal plane view.
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Discussion We have found this technique to provide adequate correction of mild to moderate hallux valgus deformities, although we do not resort to thisparticular technique if the first intermetatarsal angle measures more than 14o. The procedure also provides the advantage of preserving the length of the first metatarsal (Figures 6 and 7). The configuration and the simplicity of the osteotomy provides correction in both the transverse and sagittal planes. However, it may be difficult to perform such an osteotomy without the crescentic osteotome. Furthermore, the K-wires are driven distally into the head of the first metatarsal in the sagittal plane at an approximately 30o angle to each other, making the fixation less demanding than other options. This method of stabilization also decreases the dependence on fluroscopic guidance since the K-wires can be directly visualized and, if they penetrate into the articular cavity, retrograding the wires under direct visualization readily ensures proper placement. The use of crossing K-wires provides a stable fixation construct, and requires that the capital fragment be manually stabilized against the proximal metatarsal segment prior to driving the wires into the distal fragment. Divergence of the pins, thereafter, provides adequate resistance against displacement of the metatarsal head in all of the body planes.
References
FIGURE 7 Six months postoperative radiographic appearance of the healed distal first metatarsal dome (crescentic) osteotomy, in the 25-year-old female depicted in Figure 2. (A) Transverse plane view. (B) Sagittal plane view. Note that the hallux valgus angle and the first intermetarsal angles have decreased to 22o and 10o, respectively, whereas the length of the first metatarsal is preserved.
that the range of motion is satisfactory and that the sesamoids and phalangeal base move freely about the metatarsal head. The outer (proximal) end of the first K-wire exits through the dorsal surface of the metatarsal shaft, and that of the second K-wire exits through the proximal end of the surgical wound (Figure 5). The sharp ends of the K-wires are cut, bent to a right angle, then covered with a smooth ball or cap. Thereafter, the capsule is plicated in a V-shape and the wound is closed in layers.
262
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1. Rossi WR, Ferreira JC. Chevron osteotomy for hallux valgus. Foot Ankle 137:378 –381, 1992. 2. DeOrio JK, Ware AW. Single absorbable polidioxanone pin fixation for distal chevron bunion osteotomies. Foot Ankle Int 22:832– 835, 2001. 3. Oznur A. A new technique for fixation of distal chevron osteotomy Foot Ankle Int 23(10):954 –955, 2002. 4. Small HN, Braly WG, Tullos HS. Fixation of the chevron osteotomy using absorbable polydioxanon pins. Foot Ankle Int 166:346 –350, 1995. 5. Hattrup SJ, Johnson KA. Chevron osteotomy: analysis of factors in patients’ dissatisfaction. Foot Ankle 56:327–332, 1985. 6. Jahss MH, Troy AI, Kummer F. Roentgenographic and mathematical analysis of first metatarsal osteotomies for metatarsus primus varus: a comparative study. Foot Ankle 56:280 –321, 1985. 7. Haber JH, Kraft J. Crescentic osteotomy for fifth metatarsal head lesions. J Foot Surg 192:66 – 67, 1980. 8. Rosenthal DC, Callahan DF. Distal transverse crescentic osteotomy for correction of hallux abducto valgus. J Am Podiatry Assoc 748:411– 414, 1984.