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Hallux valgus operation using Ilizarov external fixator
Foot and Ankle Surgery 1997
3: 183–188
Hallux valgus operation using Ilizarov external fixator N. NISHIMURA AND Y. YAMANO Department of Orthopaedic Surgery, Osaka City University Medical School, Osaka City, Japan
Summary The authors performed Hallux valgus operations on ten patients in 20 feet using Ilizarov external fixator, which is a useful apparatus for treating severe foot deformities. This fixator consists of a halfring which is made of carbon, six male or female posts, six wirefixing bolts, and three olive wires 1.5 mm in diameter. The total weight of the instrument is only about 200 g. Instrument fixation lasted around 5–6 weeks. The method of osteotomy comprised 20 distal soft tissue procedures, and the basal metatarsal osteotomy was fixed by two Kirschner (K)-wires 1.8 mm in diameter. The deformity of the Hallux valgus was successfully corrected in all 20 feet. The authors found that all patients were able to walk without crutches immediately after the operation, and the forefoot transverse arch was reconstructed. Keywords: Hallux valgus; Mann’s procedure; Ilizarov external fixator
Introduction Hallux valgus is a deformity of the first metatarsophalangeal (MTP) joint with an associated diminution of the transverse forefoot arch. The authors attempted to treat the deformity with an Ilizarov external fixator.
Materials and methods The authors performed 20 operations for idiopathic Hallux valgus on ten patients (one man, nine women) using Ilizarov external fixator. The preoperative roentgenogram showed an Hallux valgus angle (HAV) of 31–45° (mean 36.5°); the intermetatarsal I–II Correspondence: Norihisa Nishimura, MD, Department of Orthopaedic Surgery, Osaka City University Medical School, 1-57, Asahi-machi, Abeno-ku, Osaka City, 545, Japan. 1997 Blackwell Science Ltd
angle (M1M2) was between 15° to 25° (mean 16.2°); and the intermetatarsal I–V angle (M1M5) was between 35° to 47° (mean 38.3°). The age at operation ranged from 26 to 76 years (mean 54.3 years). The degree of sesamoid bone deviation was type III for 14 feet, type II for two feet, and medial sesamoid bone defect (anomaly) for four feet. Follow-up time ranged from 6 to 21 months with a mean of 11 months.
Decision making At the Osaka City University Medical School, an operative procedure and/or technique best suited for individual clinical situations is determined according to Mann’s criteria for decision making [1]. If the M1M2 angle is greater than 15°, a distal soft tissue procedure with basal metatarsal ostotomy is
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Figure 1 The Ilizarov external fixator used for Hallux valgus operation. (a) Immediately after operation; (b) 3 weeks after operation.
indicated. If the M1M2 angle is less than 15°, Chevron procedure is used. In general, the Ilizarov external fixator is used in the case of bilateral simultaneous distal soft tissue procedures.
Surgical technique First, a distal soft tissue procedure is performed for Hallux valgus deformity. The basal metatarsal osteotomy is fixed by two Kirscher (K)-wires 1.8 mm in diameter. Next, an Ilizarov external fixator is applied to the operated foot. This fixator consists of a half-ring which is made of carbon, six male or female posts, six wire-fixing bolts, and three olive wires 1.5 mm in diameter, and weighs no more than about 200 g. Instrument fixation lasted around 5–6 weeks. The first olive wire is inserted from the fifth metatarsal bone to the first metatarsal bone. The second olive wire is inserted from the first metatarsal bone to the second metatarsal bone. The third olive wire is inserted from the cuboid bone to the first (medial) cuniform bone [2]. The half-ring is positioned between the second and third wires. The tension stress of the olive wire is only about 20 kg/cm2 (Figure 1).
Follow-up evaluation Patients were assessed according to toe pain felt when putting on shoes or other footwear, sensory disturbance of first toe, muscle weakness of the first MTP joint, pin tract discharge or infection, and nonunion of osteotomy.
Figure 2 Deviation of the medial sesamoid bone according to Katoh’s criteria. (1) Medial sesamoid; (2) crista; and (3) lateral sesamoid.
Roentgenographic assessment was based on HVA, M1M2, M1M5, and the deviation of the sesamoid bone according to Katoh’s criteria [3]. This is divided into three types: i.e., type I is a slight dislocation of the medial sesamoid bone; type II is a moderate dislocation of the medial sesamoid bone; and type III is the complete dislocation of the medial sesamoid bone, which completely passes the criste of the sesamoid (Figure 2). Glynn’s criteria [4] were used for overall assessment of therapeutic results. The final therapeutic results were divided into three types: i.e., excellent, good, and unsatisfactory.
Results Favourable clinical and radiological results were obtained with the Ilizarov fixator in all cases.
Clinical results All patients were able to walk without crutches within 1 week of operation. Pin tract discharge, a 1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 183–188
HALLUX VALGUS OPERATION USING ILIZAROV EXTERNAL FIXATION
Table 1 Radiological results Preop. HVA M1M2 M1M5
36.5° 16.2° 38.3°
Postop. → → →
18.1° 7.1° 24.5°
Table 2 Deviation of sesamoid Type III→II III→I II→I
5 feet 9 feet 2 feet
complication of the external fixator, was observed in only three feet; and there were no instances of pin tract infection. The bone union of osteotomy was completed in all cases. Initial toe pain was caused by putting on shoes or other footwear in two feet; sensory nerve palsy in the first toe occurred in none of the feet; and muscular weakness of the first MTP was recognized in two feet.
Radiological results HVA averaged 18.1°; M1M2 averaged 7.1°; and M1M5 averaged 24.5°. Changes in the degree of deviation of the sesamoid bone before and after treatment were as follows: type III→type II in five feet; type III→type I in nine feet and type II→type I in two feet (Tables 1 and 2).
Overall assessment Therapeutic results, measured according to Glynn’s criteria, were rated excellent in 16 cases, good in four cases and unsatisfactory in none.
Case reports Case 1 A 50-year-old woman with bilateral idiopathic Hallux valgus (Figure 3), suffered from severe Hallux valgus deformity with attendant first MTP joint pain. On the preoperative roentgenogram, M1M2 was 20° and 1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 183–188
185
M1M5 42° in the left foot. By comparison, M1M2 was 20° and M1M5 was 45° in the right foot. Then, a distal soft tissue procedure was performed using an Ilizarov external fixator on both feet simultaneously. One year after operation, the deformity of the feet were completely corrected. From the latest follow-up roentgenogram, M1M2 was determined to be 8° and M1M5 to be 26° in the left foot; while M1M2 was 5° and M1M5 was 24° in the right foot. The patient is satisfied with the therapeutic results.
Case 2 A 70-year-old woman with bilateral idiopathic Hallux valgus (Figure 4), complained of a severe bilateral deformity with first MTP joint pain and bursitis. Moreover, there was dislocation of the left second and third MTP joints. From the preoperative roentgenogram, in the left foot M1M2 was 18° and M1M5 was 44°. In the right foot M1M2 was 16° and M1M5 was 40°. A distal soft tissue procedure was performed using an Ilizarov external fixator on both feet simultaneously. In the left second and third MTP joints, the joint dislocation was improved by extensor lengthening and capsulotomy. After the operation both feet became normal. Roentgenograms taken 8 months later revealed that in the left foot M1M2 was 6° and M1M5 was 26°; while in the right foot M1M2 was 8° and M1M5 was 28°. The patient is quite satisfied with the results of this operation.
Discussion More than 100 procedures for Hallux valgus operation have been developed and are already in use [5]. In the Osaka City University Medical School, until 1992, the Mitchell’s operation had been performed as the procedure of choice. This is the most popular operation in Japan [6]. However, this operative method was found to have the drawbacks of producing gross muscular weakness of the first toe flexor tendon, sensory nerve palsy of the medial MTP joint, and forefoot pain of the first MTP joint. The authors therefore decided to introduce a new Hallux valgus operation with two requirements. First, the length of the first metatarsal bone must not be short. Second, the sesamoid complex must not be opened. Therefore, the authors introduced the distal soft tissue procedure in the case of a severe foot
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(b)
(a)
(c)
deformity, and the Chevron procedure in the case of a mild or moderate foot deformity. Certainly, the distal soft tissue procedure is a complete operative method [7], but the surgeon has to make three skin incisions. First metatarsal osteotomy is a difficult operation: union is completed slowly, and it requires lengthy (about 6 weeks) immobilization. With this method, therefore, the
Figure 3 Case 1: a 50-year-old woman with bilateral Hallux valgus. (a) Before operation; (b) 4 weeks after operation; (c) 1 year after operation.
authors had to use plaster fixation of about 2–4 weeks’ duration. During this period the patient was unable to walk. Recent evidence indicates that the Ilizarov external fixator is useful for the correction of foot deformity [8]. The foot region is especially suited to the application of the Ilizarov external fixator; due to the sparseness of soft tissue, pin tract discharge or infection is unlikely to occur. Now, the authors have been using the Ilizarov external fixator for various orthopaedic conditions. This apparatus is indicated for limb lengthening, pseudoarthrosis, osteotomy, and correction of deformity, etc. In 1993, the authors used the Ilizarov external fixator for the first time in Hallux valgus cases. This apparatus can be used advantageously simultaneously on bilaterally deformed feet, being surprisingly light (about 200 g). In the author’s clinical experiences, complications were an exceedingly rare occurrence. There were no cases of non-union or nerve palsy; and the Ilizarov external fixator is a useful tool for Hallux valgus operation. As the fixation method of basal metatarsal osteotomy is performed both by K-wires and the Ilizarov external fixator, the patient is able to walk in Japanese-style shoes (Zohri) immediately after the operation. Also, this method is able to reconstruct the transverse forefoot arch because of the tension 1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 183–188
HALLUX VALGUS OPERATION USING ILIZAROV EXTERNAL FIXATION
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(a)
(b)
(c) (d)
(e) Figure 4 Case 2: a 70-year-old woman with bilateral Hallux valgus. Radiographs showing (a) before operation; (b) 2 weeks after operation; (c) 8 months after operation; (d) clinical appearance before operation; (e) 8 months after operation.
1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 183–188
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N. NISHIMURA & Y. YAMANO
stress of the olive wire. However, the postoperative follow-up observation period is still too limited to permit any conclusive statement; it is necessary to check this technique for its efficacy by further followup studies.
Conclusions The authors performed Hallux valgus operations on ten patients (20 feet) using the Ilizarov external fixator, which is a useful apparatus for correcting severe foot deformities. The osteotomy method used was Mann’s procedure, with the device being removed between 5 to 6 weeks after operation. Judging from the postoperative roentgenogram, the correction of the foot deformity was complete in all
cases. All patients were able to walk without crutches immediately after operation, and their forefoot transverse arch was reconstructed.
References 1 Mann RA. Decision-making in bunion surgery. Instr Course Lect 1990; 39: 3–13. 2 Sarrafian SK. Anatomy of the Foot and Ankle. Philadelphia: Lippincott, 1993. 3 Katoh T. Hallux valgus. Seikeigeka 1986; 37: 371–375. (Japanese). 4 Glynn MK. The Mitchell distal metatarsal osteotomy for Hallux valgus. J Bone Joint Surg 1980; 62: 188–191. 5 Hedel B. Surgery for adolescent Hallux valgus. Clin Orthop 1981; 157: 50–63. 6 Johnson KA. Surgery of the Foot and Ankle. New York: Revin Press, 1989. 7 Mann RA. Surgery of the Foot, 5th ed. St. Louis: Mosby, 1986. 8 Grant DG. The Ilizarov technique in correction of complex foot deformities. Clin Orthop 1992; 280: 94–103.
1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 183–188
3: 183–188
Hallux valgus operation using Ilizarov external fixator N. NISHIMURA AND Y. YAMANO Department of Orthopaedic Surgery, Osaka City University Medical School, Osaka City, Japan
Summary The authors performed Hallux valgus operations on ten patients in 20 feet using Ilizarov external fixator, which is a useful apparatus for treating severe foot deformities. This fixator consists of a halfring which is made of carbon, six male or female posts, six wirefixing bolts, and three olive wires 1.5 mm in diameter. The total weight of the instrument is only about 200 g. Instrument fixation lasted around 5–6 weeks. The method of osteotomy comprised 20 distal soft tissue procedures, and the basal metatarsal osteotomy was fixed by two Kirschner (K)-wires 1.8 mm in diameter. The deformity of the Hallux valgus was successfully corrected in all 20 feet. The authors found that all patients were able to walk without crutches immediately after the operation, and the forefoot transverse arch was reconstructed. Keywords: Hallux valgus; Mann’s procedure; Ilizarov external fixator
Introduction Hallux valgus is a deformity of the first metatarsophalangeal (MTP) joint with an associated diminution of the transverse forefoot arch. The authors attempted to treat the deformity with an Ilizarov external fixator.
Materials and methods The authors performed 20 operations for idiopathic Hallux valgus on ten patients (one man, nine women) using Ilizarov external fixator. The preoperative roentgenogram showed an Hallux valgus angle (HAV) of 31–45° (mean 36.5°); the intermetatarsal I–II Correspondence: Norihisa Nishimura, MD, Department of Orthopaedic Surgery, Osaka City University Medical School, 1-57, Asahi-machi, Abeno-ku, Osaka City, 545, Japan. 1997 Blackwell Science Ltd
angle (M1M2) was between 15° to 25° (mean 16.2°); and the intermetatarsal I–V angle (M1M5) was between 35° to 47° (mean 38.3°). The age at operation ranged from 26 to 76 years (mean 54.3 years). The degree of sesamoid bone deviation was type III for 14 feet, type II for two feet, and medial sesamoid bone defect (anomaly) for four feet. Follow-up time ranged from 6 to 21 months with a mean of 11 months.
Decision making At the Osaka City University Medical School, an operative procedure and/or technique best suited for individual clinical situations is determined according to Mann’s criteria for decision making [1]. If the M1M2 angle is greater than 15°, a distal soft tissue procedure with basal metatarsal ostotomy is
183
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N. NISHIMURA & Y. YAMANO
Figure 1 The Ilizarov external fixator used for Hallux valgus operation. (a) Immediately after operation; (b) 3 weeks after operation.
indicated. If the M1M2 angle is less than 15°, Chevron procedure is used. In general, the Ilizarov external fixator is used in the case of bilateral simultaneous distal soft tissue procedures.
Surgical technique First, a distal soft tissue procedure is performed for Hallux valgus deformity. The basal metatarsal osteotomy is fixed by two Kirscher (K)-wires 1.8 mm in diameter. Next, an Ilizarov external fixator is applied to the operated foot. This fixator consists of a half-ring which is made of carbon, six male or female posts, six wire-fixing bolts, and three olive wires 1.5 mm in diameter, and weighs no more than about 200 g. Instrument fixation lasted around 5–6 weeks. The first olive wire is inserted from the fifth metatarsal bone to the first metatarsal bone. The second olive wire is inserted from the first metatarsal bone to the second metatarsal bone. The third olive wire is inserted from the cuboid bone to the first (medial) cuniform bone [2]. The half-ring is positioned between the second and third wires. The tension stress of the olive wire is only about 20 kg/cm2 (Figure 1).
Follow-up evaluation Patients were assessed according to toe pain felt when putting on shoes or other footwear, sensory disturbance of first toe, muscle weakness of the first MTP joint, pin tract discharge or infection, and nonunion of osteotomy.
Figure 2 Deviation of the medial sesamoid bone according to Katoh’s criteria. (1) Medial sesamoid; (2) crista; and (3) lateral sesamoid.
Roentgenographic assessment was based on HVA, M1M2, M1M5, and the deviation of the sesamoid bone according to Katoh’s criteria [3]. This is divided into three types: i.e., type I is a slight dislocation of the medial sesamoid bone; type II is a moderate dislocation of the medial sesamoid bone; and type III is the complete dislocation of the medial sesamoid bone, which completely passes the criste of the sesamoid (Figure 2). Glynn’s criteria [4] were used for overall assessment of therapeutic results. The final therapeutic results were divided into three types: i.e., excellent, good, and unsatisfactory.
Results Favourable clinical and radiological results were obtained with the Ilizarov fixator in all cases.
Clinical results All patients were able to walk without crutches within 1 week of operation. Pin tract discharge, a 1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 183–188
HALLUX VALGUS OPERATION USING ILIZAROV EXTERNAL FIXATION
Table 1 Radiological results Preop. HVA M1M2 M1M5
36.5° 16.2° 38.3°
Postop. → → →
18.1° 7.1° 24.5°
Table 2 Deviation of sesamoid Type III→II III→I II→I
5 feet 9 feet 2 feet
complication of the external fixator, was observed in only three feet; and there were no instances of pin tract infection. The bone union of osteotomy was completed in all cases. Initial toe pain was caused by putting on shoes or other footwear in two feet; sensory nerve palsy in the first toe occurred in none of the feet; and muscular weakness of the first MTP was recognized in two feet.
Radiological results HVA averaged 18.1°; M1M2 averaged 7.1°; and M1M5 averaged 24.5°. Changes in the degree of deviation of the sesamoid bone before and after treatment were as follows: type III→type II in five feet; type III→type I in nine feet and type II→type I in two feet (Tables 1 and 2).
Overall assessment Therapeutic results, measured according to Glynn’s criteria, were rated excellent in 16 cases, good in four cases and unsatisfactory in none.
Case reports Case 1 A 50-year-old woman with bilateral idiopathic Hallux valgus (Figure 3), suffered from severe Hallux valgus deformity with attendant first MTP joint pain. On the preoperative roentgenogram, M1M2 was 20° and 1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 183–188
185
M1M5 42° in the left foot. By comparison, M1M2 was 20° and M1M5 was 45° in the right foot. Then, a distal soft tissue procedure was performed using an Ilizarov external fixator on both feet simultaneously. One year after operation, the deformity of the feet were completely corrected. From the latest follow-up roentgenogram, M1M2 was determined to be 8° and M1M5 to be 26° in the left foot; while M1M2 was 5° and M1M5 was 24° in the right foot. The patient is satisfied with the therapeutic results.
Case 2 A 70-year-old woman with bilateral idiopathic Hallux valgus (Figure 4), complained of a severe bilateral deformity with first MTP joint pain and bursitis. Moreover, there was dislocation of the left second and third MTP joints. From the preoperative roentgenogram, in the left foot M1M2 was 18° and M1M5 was 44°. In the right foot M1M2 was 16° and M1M5 was 40°. A distal soft tissue procedure was performed using an Ilizarov external fixator on both feet simultaneously. In the left second and third MTP joints, the joint dislocation was improved by extensor lengthening and capsulotomy. After the operation both feet became normal. Roentgenograms taken 8 months later revealed that in the left foot M1M2 was 6° and M1M5 was 26°; while in the right foot M1M2 was 8° and M1M5 was 28°. The patient is quite satisfied with the results of this operation.
Discussion More than 100 procedures for Hallux valgus operation have been developed and are already in use [5]. In the Osaka City University Medical School, until 1992, the Mitchell’s operation had been performed as the procedure of choice. This is the most popular operation in Japan [6]. However, this operative method was found to have the drawbacks of producing gross muscular weakness of the first toe flexor tendon, sensory nerve palsy of the medial MTP joint, and forefoot pain of the first MTP joint. The authors therefore decided to introduce a new Hallux valgus operation with two requirements. First, the length of the first metatarsal bone must not be short. Second, the sesamoid complex must not be opened. Therefore, the authors introduced the distal soft tissue procedure in the case of a severe foot
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N. NISHIMURA & Y. YAMANO
(b)
(a)
(c)
deformity, and the Chevron procedure in the case of a mild or moderate foot deformity. Certainly, the distal soft tissue procedure is a complete operative method [7], but the surgeon has to make three skin incisions. First metatarsal osteotomy is a difficult operation: union is completed slowly, and it requires lengthy (about 6 weeks) immobilization. With this method, therefore, the
Figure 3 Case 1: a 50-year-old woman with bilateral Hallux valgus. (a) Before operation; (b) 4 weeks after operation; (c) 1 year after operation.
authors had to use plaster fixation of about 2–4 weeks’ duration. During this period the patient was unable to walk. Recent evidence indicates that the Ilizarov external fixator is useful for the correction of foot deformity [8]. The foot region is especially suited to the application of the Ilizarov external fixator; due to the sparseness of soft tissue, pin tract discharge or infection is unlikely to occur. Now, the authors have been using the Ilizarov external fixator for various orthopaedic conditions. This apparatus is indicated for limb lengthening, pseudoarthrosis, osteotomy, and correction of deformity, etc. In 1993, the authors used the Ilizarov external fixator for the first time in Hallux valgus cases. This apparatus can be used advantageously simultaneously on bilaterally deformed feet, being surprisingly light (about 200 g). In the author’s clinical experiences, complications were an exceedingly rare occurrence. There were no cases of non-union or nerve palsy; and the Ilizarov external fixator is a useful tool for Hallux valgus operation. As the fixation method of basal metatarsal osteotomy is performed both by K-wires and the Ilizarov external fixator, the patient is able to walk in Japanese-style shoes (Zohri) immediately after the operation. Also, this method is able to reconstruct the transverse forefoot arch because of the tension 1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 183–188
HALLUX VALGUS OPERATION USING ILIZAROV EXTERNAL FIXATION
187
(a)
(b)
(c) (d)
(e) Figure 4 Case 2: a 70-year-old woman with bilateral Hallux valgus. Radiographs showing (a) before operation; (b) 2 weeks after operation; (c) 8 months after operation; (d) clinical appearance before operation; (e) 8 months after operation.
1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 183–188
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stress of the olive wire. However, the postoperative follow-up observation period is still too limited to permit any conclusive statement; it is necessary to check this technique for its efficacy by further followup studies.
Conclusions The authors performed Hallux valgus operations on ten patients (20 feet) using the Ilizarov external fixator, which is a useful apparatus for correcting severe foot deformities. The osteotomy method used was Mann’s procedure, with the device being removed between 5 to 6 weeks after operation. Judging from the postoperative roentgenogram, the correction of the foot deformity was complete in all
cases. All patients were able to walk without crutches immediately after operation, and their forefoot transverse arch was reconstructed.
References 1 Mann RA. Decision-making in bunion surgery. Instr Course Lect 1990; 39: 3–13. 2 Sarrafian SK. Anatomy of the Foot and Ankle. Philadelphia: Lippincott, 1993. 3 Katoh T. Hallux valgus. Seikeigeka 1986; 37: 371–375. (Japanese). 4 Glynn MK. The Mitchell distal metatarsal osteotomy for Hallux valgus. J Bone Joint Surg 1980; 62: 188–191. 5 Hedel B. Surgery for adolescent Hallux valgus. Clin Orthop 1981; 157: 50–63. 6 Johnson KA. Surgery of the Foot and Ankle. New York: Revin Press, 1989. 7 Mann RA. Surgery of the Foot, 5th ed. St. Louis: Mosby, 1986. 8 Grant DG. The Ilizarov technique in correction of complex foot deformities. Clin Orthop 1992; 280: 94–103.
1997 Blackwell Science Ltd, Foot and Ankle Surgery, 3, 183–188