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Hallux Valgus With Increased Intermetatarsal Angle: Surgical Treatment With Proximal Opening Wedge Metatarsal Osteotomy
Hallux Valgus With Increased Intermetatarsal Angle: Surgical Treatment With Proximal Opening Wedge Metatarsal Osteotomy Mark Glazebrook, MSc, PhD, MD, FRCS(C), and Peter Copithorne, BSc, MBA, MD Hallux valgus is a common cause of foot pain and deformity in the adult and adolescent population, which often requires surgical treatment when nonsurgical treatments fail. When the condition is associated with an increased intermetatarsal angle, a surgical technique using a proximal first metatarsal osteotomy is often indicated. A proximal opening wedge osteotomy stabilized with a wedge and plate configuration offers a stable, reliable means to correct the increased intermetatarsal angle. This article describes a technique for surgical correction of hallux valgus with an increased metatarsal angle, using a 3-incision technique that includes: (1) a medial bunionectomy with capsular imbrication, (2) a lateral soft-tissue release, and (3) a proximal metatarsal osteotomy fixed with a 4-hole L-shaped plate with a wedge spacer. Oper Tech Orthop 18:226-230 Crown Copyright © 2008 Published by Elsevier Inc. All rights reserved. KEYWORDS hallux, valgus, intermetatarsal, osteotomy, wedge
H
allux valgus is a common cause of foot pain and deformity in the adult and adolescent population. Most often soft-tissue procedures with distal osteotomies are performed to correct the deformity. However, for patients with moderate to severe hallux valgus (HV) with concomitant increased intermetatarsal (IM) angle ⬎ 9°, proximal first metatarsal osteotomies are indicated as they achieve greater correction than distal osteotomies.1-9 Numerous procedures using a proximal first metatarsal osteotomy have been described in the published articles on orthopedics. The proximal opening wedge osteotomy using the exostosis to maintain correction of the osteotomy was first described by Trethowan in 1923,10 as cited by Lindbird et al.11 The technique has subsequently been modified several times. A recent innovation of the proximal opening wedge osteotomy uses a wedge-fixation plate that predictably corrects the angular deformity, prevents dorsal elevation of the metatarsal head, and maintains the correction until bony union.
Division of Orthopedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada. Address reprint requests to Mark Glazebrook, MSc, PhD, MD, FRCS(C), Queen Elizabeth II Health Sciences Center, Division of Orthopedic Surgery, 1796 Summer Street, Halifax Infirmary (Room 4867), Halifax, NS, Canada B3H 3A7. E-mail: [email protected]
226
Cooper et al recently published their early clinical results of the proximal opening wedge osteotomy with plate fixation. In their article, 23 patients with moderate to severe hallux valgus (mean HV angle 43°; mean IM angle 18°) were treated with a proximal opening wedge osteotomy secured with either an L-shaped plate with wedge spacer or a 4-hole locking plate with spacer in combination with a distal softtissue release. They obtained consistent and reliable correction with both techniques with ⬃1.5° of IM angle correction per millimeter spacer size and encountered 4 complications, including 1 wound dehiscence, 2 hallux valgus drifting ⬎ 5°, and 1 delayed union.12
Indications and Contraindications Nonsurgical treatments, such as proper fitting shoes, shoe modifications, orthoses, night splinting, and analgesics, are used. However, there is little evidence that nonsurgical management is useful.13 Surgery is indicated for patients who fail a trial of nonsurgical treatment, when the pain and deformity leads to difficulty with ambulation. Proximal metatarsal osteotomies are indicated for patients with moderate to severe HV, with concomitant increased IM angle ⬎ 9° (Fig. 1).1-3
1048-6666/08/$-see front matter Crown Copyright © 2008 Published by Elsevier Inc. All rights reserved. doi:10.1053/j.oto.2009.01.004
Surgical treatment of hallux valgus with increased intermetatarsal angle
227
Contraindications to a proximal osteotomy should include patients with an active infection, extensive peripheral vascular disease, or neuropathies.
Operative Procedure Patient Preparation and Draping The patient is positioned supine on the operating table. The patient is administered 1 g cefazolin for prophylaxis against infection. The leg is prepared by draping in the usual sterile fashion with betadine. A tourniquet is applied to the thigh and inflated to 350 mm Hg.
Distal Soft-Tissue Procedure and Bunionectomy14 A ⬃3 to 4 cm medial longitudinal incision is made over the first metatarsophalangeal (MTP) joint positioned slightly plantar (Fig. 2) to allow room to avoid communication with the second medial incision (below). A pyramid-shaped MTP capsulotomy (based distally) is then created, followed by bunionectomy of the medial eminence taking care not to be too aggressive to maintain the joint surface of the distal metatarsal (Fig. 3). Capsular repair and closure is deferred until the end of the procedure to accommodate for soft-tissue changes postosteotomy. Through a second incision ⬃ 2 to 3 cm in the dorsal first
Figure 2 Preoperative photograph of a patient’s foot with hallux valgus, illustrating the position of incisions.
web space (Fig. 2), the skin and subcutaneous soft tissues are incised to expose the adductor hallucis tendon (Fig. 4A). The tendon is detached from its insertion onto the base of the proximal first phalanx and from the lateral aspect of the fib-
Figure 1 Preoperative anterior posterior radiograph of a patient with hallux valgus and an increased intermetatarsal angle.
Figure 3 Intraoperative photograph illustrating extent of bunionectomy.
M. Glazebrook and P. Copithorne
228
Figure 5 Intraoperative anterior posterior fluoroscopy showing the appropriate position and orientation of the proximal metatarsal osteotomy with reciprocating saw following the trajectory of the Kirschner wire.
made on the lateral side of the first MTP joint to allow for lateral capsular correction of the hallux valgus deformity (Fig. 4C).
Proximal Open Wedge Osteotomy With LPS System
Figure 4 Intraoperative photograph of lateral soft-tissue release showing: (A) the release of the adductor hallucis tendon from its insertion onto the base of the proximal first phalanx, (B) dissection exposes the transverse metatarsal ligament. With the common digital nerve protected under the tip of a hemostat and (C) longitudinal capsulotomy is made on the lateral side of the first metatarsophalangeal joint with the lateral head of the first metatarsal exposed.
ular sesamoid. Further dissection exposes the transverse metatarsal ligament. With the common digital nerve protected with a Howarth elevator, the transverse metatarsal ligament is released (Fig. 4B). A longitudinal capsulotomy is
Through a ⬃3- to 4-cm medial longitudinal incision (Fig. 2), soft tissues and the periosteum are dissected to expose the proximal first metatarsal in preparation for the osteotomy. Under fluoroscopic guidance, a Kirschner wire is first passed 1.5 cm distal to the tarsometatarsal (TMT) and directed just distal to the medial aspect of the first TMT joint (intracapsular) to aid with the trajectory of the osteotomy. The osteotomy is made perpendicular to the sagittal metatarsal axis to avoid causing plantar or dorsiflexion deformity. The lateral cortex must be left intact to serve as a hinge, thus avoiding distraction of the lateral cortex and subsequent inadvertent loss of intermetatarsal angular correction (Fig. 5). The osteotomy is opened and IM angle examined with intraoperative fluoroscopy. The wedge plate is selected (Athrex Inc, Naples, FL) based on the amount of intermetatarsal correction desired where each millimeter of wedges corresponds to ⬃3° of IM angular deformity correction. The plate is inserted into the osteotomy to maintain the corrected angle (Fig. 6A). The plate is secured with 2.3-mm self-tapping screws. Bone graft (autograft or bone graft substitute) is placed into the osteotomy site to fill the void (Fig. 6B).
Closure The medial capsule is closed with No. 1 Vicryl sutures tensioned to achieve the desired correction. Sometimes a partial
Surgical treatment of hallux valgus with increased intermetatarsal angle
229
Figure 6 Intraoperative anterior posterior fluoroscopy showing (A) the appropriate position and orientation of the opening wedge proximal metatarsal osteotomy plate (Athrex Inc, Naples, FL) (B) (Athrex Inc, Naples, FL) secured with 2.3-mm self-tapping screws. Bone graft (autograft or bone graft substitute) is placed into the osteotomy site to fill the void.
capsulectomy is preformed on the plantar limb of the pyramidal capsulotomy to allow further translation of the sesamoid sling into the corrected position. The skin incisions are closed using 3-0 Ethilon sutures (Fig. 7).
Postoperative Management After wound closure of above procedures, a dry dressing is applied to the foot and a plaster cast applied to maintain
Figure 7 Postoperative photograph and radiograph showing surgical correction of hallux valgus with an increased intermetatarsal osteotomy, using a bunionectomy, lateral soft-tissue release, and proximal opening wedge metatarsal osteotomy.
M. Glazebrook and P. Copithorne
230 correct positioning of the great toe. Patients are treated with non–weight-bearing for 4 to 6 weeks, followed by progressive weight-bearing over 2 to 4 weeks to weight-bearing as tolerated. Complications that are possible with this procedure would include, but are not limited to, infection, nonunion, malunion, wound healing problems, lengthening of the metatarsal, and implant failure.12,15
8.
9.
10.
References 1. Kummer FJ: Mathematical analysis of first metatarsal osteotomies. Foot Ankle 9:281-289, 1989 2. Borton DC, Stephens MM: Basal metatarsal osteotomy for hallux valgus. J Bone Joint Surg Br 76:204-209, 1994 3. Jahss MH, Troy AI, Kummer F: Roentgenographic and mathematical analysis of first metatarsal osteotomies for metatarsus primus varus: A comparative study. Foot Ankle 5:280-321, 1985 4. Mann RA, Coughlin MJ: Hallux valgus—Etiology, anatomy, treatment and surgical considerations. Clin Orthop Relat Res 157:31-41, 1981 5. Sammarco GJ, Brainard BJ, Sammarco VJ: Bunion correction using proximal Chevron osteotomy. Foot Ankle 14:8-14, 1993 6. Cedell CA, Astrom M: Proximal metatarsal osteotomy in hallux valgus. Acta Orthop Scand 53:1013-1018, 1982 7. Graves SC, Dutkowsky JP, Richardson EG: The Chevron bunionec-
11. 12.
13.
14.
15.
tomy: A trigonometric analysis to predict correction. Foot Ankle 14:90-96, 1993 Nyska M, Trnka HJ, Parks BG, et al: Proximal metatarsal osteotomies: A comparative geometric analysis conducted on sawbone models. Foot Ankle Int 23:938-945, 2002 Trnka HJ, Parks BG, Ivanic G, et al: Six first metatarsal shaft osteotomies: Mechanical and immobilization comparisons. Clin Orthop Relat Res 381:256-265, 2000 Trethowan J: in Choyce CC (ed): A System of Surgery. New York, P.B. Hoeber, 1923, pp 1046-1049 Limbird TJ, DaSilva RM, Green NE: Osteotomy of the first metatarsal base for metatarsus primus varus. Foot Ankle 9:158-162, 1989 Cooper MT, Berlet GC, Shurnas PS, et al: Proximal opening-wedge osteotomy of the first metatarsal for correction of hallux valgus. Surg Technol Int 16:215-219, 2007 Ferrari J, Higgins JPT, Prior TD: Interventions for treating hallux valgus (abductovalgus) and bunions. Cochrane Database of Systematic Reviews Issue 1. Art. No: CD000964, 2004 Mann RA: Distal soft tissue procedure and proximal metatarsal osteotomy for correction of hallux valgus deformity. Orthopedics 13:10131018, 1990 Walther M, Menzinger F, Dreyer F, et al: [The proximal open-wedge osteotomy with interlocking plate for correction of splayfoot deformities with hallux valgus]. Oper Orthop Traumatol 20:452-462, 2008
H
allux valgus is a common cause of foot pain and deformity in the adult and adolescent population. Most often soft-tissue procedures with distal osteotomies are performed to correct the deformity. However, for patients with moderate to severe hallux valgus (HV) with concomitant increased intermetatarsal (IM) angle ⬎ 9°, proximal first metatarsal osteotomies are indicated as they achieve greater correction than distal osteotomies.1-9 Numerous procedures using a proximal first metatarsal osteotomy have been described in the published articles on orthopedics. The proximal opening wedge osteotomy using the exostosis to maintain correction of the osteotomy was first described by Trethowan in 1923,10 as cited by Lindbird et al.11 The technique has subsequently been modified several times. A recent innovation of the proximal opening wedge osteotomy uses a wedge-fixation plate that predictably corrects the angular deformity, prevents dorsal elevation of the metatarsal head, and maintains the correction until bony union.
Division of Orthopedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada. Address reprint requests to Mark Glazebrook, MSc, PhD, MD, FRCS(C), Queen Elizabeth II Health Sciences Center, Division of Orthopedic Surgery, 1796 Summer Street, Halifax Infirmary (Room 4867), Halifax, NS, Canada B3H 3A7. E-mail: [email protected]
226
Cooper et al recently published their early clinical results of the proximal opening wedge osteotomy with plate fixation. In their article, 23 patients with moderate to severe hallux valgus (mean HV angle 43°; mean IM angle 18°) were treated with a proximal opening wedge osteotomy secured with either an L-shaped plate with wedge spacer or a 4-hole locking plate with spacer in combination with a distal softtissue release. They obtained consistent and reliable correction with both techniques with ⬃1.5° of IM angle correction per millimeter spacer size and encountered 4 complications, including 1 wound dehiscence, 2 hallux valgus drifting ⬎ 5°, and 1 delayed union.12
Indications and Contraindications Nonsurgical treatments, such as proper fitting shoes, shoe modifications, orthoses, night splinting, and analgesics, are used. However, there is little evidence that nonsurgical management is useful.13 Surgery is indicated for patients who fail a trial of nonsurgical treatment, when the pain and deformity leads to difficulty with ambulation. Proximal metatarsal osteotomies are indicated for patients with moderate to severe HV, with concomitant increased IM angle ⬎ 9° (Fig. 1).1-3
1048-6666/08/$-see front matter Crown Copyright © 2008 Published by Elsevier Inc. All rights reserved. doi:10.1053/j.oto.2009.01.004
Surgical treatment of hallux valgus with increased intermetatarsal angle
227
Contraindications to a proximal osteotomy should include patients with an active infection, extensive peripheral vascular disease, or neuropathies.
Operative Procedure Patient Preparation and Draping The patient is positioned supine on the operating table. The patient is administered 1 g cefazolin for prophylaxis against infection. The leg is prepared by draping in the usual sterile fashion with betadine. A tourniquet is applied to the thigh and inflated to 350 mm Hg.
Distal Soft-Tissue Procedure and Bunionectomy14 A ⬃3 to 4 cm medial longitudinal incision is made over the first metatarsophalangeal (MTP) joint positioned slightly plantar (Fig. 2) to allow room to avoid communication with the second medial incision (below). A pyramid-shaped MTP capsulotomy (based distally) is then created, followed by bunionectomy of the medial eminence taking care not to be too aggressive to maintain the joint surface of the distal metatarsal (Fig. 3). Capsular repair and closure is deferred until the end of the procedure to accommodate for soft-tissue changes postosteotomy. Through a second incision ⬃ 2 to 3 cm in the dorsal first
Figure 2 Preoperative photograph of a patient’s foot with hallux valgus, illustrating the position of incisions.
web space (Fig. 2), the skin and subcutaneous soft tissues are incised to expose the adductor hallucis tendon (Fig. 4A). The tendon is detached from its insertion onto the base of the proximal first phalanx and from the lateral aspect of the fib-
Figure 1 Preoperative anterior posterior radiograph of a patient with hallux valgus and an increased intermetatarsal angle.
Figure 3 Intraoperative photograph illustrating extent of bunionectomy.
M. Glazebrook and P. Copithorne
228
Figure 5 Intraoperative anterior posterior fluoroscopy showing the appropriate position and orientation of the proximal metatarsal osteotomy with reciprocating saw following the trajectory of the Kirschner wire.
made on the lateral side of the first MTP joint to allow for lateral capsular correction of the hallux valgus deformity (Fig. 4C).
Proximal Open Wedge Osteotomy With LPS System
Figure 4 Intraoperative photograph of lateral soft-tissue release showing: (A) the release of the adductor hallucis tendon from its insertion onto the base of the proximal first phalanx, (B) dissection exposes the transverse metatarsal ligament. With the common digital nerve protected under the tip of a hemostat and (C) longitudinal capsulotomy is made on the lateral side of the first metatarsophalangeal joint with the lateral head of the first metatarsal exposed.
ular sesamoid. Further dissection exposes the transverse metatarsal ligament. With the common digital nerve protected with a Howarth elevator, the transverse metatarsal ligament is released (Fig. 4B). A longitudinal capsulotomy is
Through a ⬃3- to 4-cm medial longitudinal incision (Fig. 2), soft tissues and the periosteum are dissected to expose the proximal first metatarsal in preparation for the osteotomy. Under fluoroscopic guidance, a Kirschner wire is first passed 1.5 cm distal to the tarsometatarsal (TMT) and directed just distal to the medial aspect of the first TMT joint (intracapsular) to aid with the trajectory of the osteotomy. The osteotomy is made perpendicular to the sagittal metatarsal axis to avoid causing plantar or dorsiflexion deformity. The lateral cortex must be left intact to serve as a hinge, thus avoiding distraction of the lateral cortex and subsequent inadvertent loss of intermetatarsal angular correction (Fig. 5). The osteotomy is opened and IM angle examined with intraoperative fluoroscopy. The wedge plate is selected (Athrex Inc, Naples, FL) based on the amount of intermetatarsal correction desired where each millimeter of wedges corresponds to ⬃3° of IM angular deformity correction. The plate is inserted into the osteotomy to maintain the corrected angle (Fig. 6A). The plate is secured with 2.3-mm self-tapping screws. Bone graft (autograft or bone graft substitute) is placed into the osteotomy site to fill the void (Fig. 6B).
Closure The medial capsule is closed with No. 1 Vicryl sutures tensioned to achieve the desired correction. Sometimes a partial
Surgical treatment of hallux valgus with increased intermetatarsal angle
229
Figure 6 Intraoperative anterior posterior fluoroscopy showing (A) the appropriate position and orientation of the opening wedge proximal metatarsal osteotomy plate (Athrex Inc, Naples, FL) (B) (Athrex Inc, Naples, FL) secured with 2.3-mm self-tapping screws. Bone graft (autograft or bone graft substitute) is placed into the osteotomy site to fill the void.
capsulectomy is preformed on the plantar limb of the pyramidal capsulotomy to allow further translation of the sesamoid sling into the corrected position. The skin incisions are closed using 3-0 Ethilon sutures (Fig. 7).
Postoperative Management After wound closure of above procedures, a dry dressing is applied to the foot and a plaster cast applied to maintain
Figure 7 Postoperative photograph and radiograph showing surgical correction of hallux valgus with an increased intermetatarsal osteotomy, using a bunionectomy, lateral soft-tissue release, and proximal opening wedge metatarsal osteotomy.
M. Glazebrook and P. Copithorne
230 correct positioning of the great toe. Patients are treated with non–weight-bearing for 4 to 6 weeks, followed by progressive weight-bearing over 2 to 4 weeks to weight-bearing as tolerated. Complications that are possible with this procedure would include, but are not limited to, infection, nonunion, malunion, wound healing problems, lengthening of the metatarsal, and implant failure.12,15
8.
9.
10.
References 1. Kummer FJ: Mathematical analysis of first metatarsal osteotomies. Foot Ankle 9:281-289, 1989 2. Borton DC, Stephens MM: Basal metatarsal osteotomy for hallux valgus. J Bone Joint Surg Br 76:204-209, 1994 3. Jahss MH, Troy AI, Kummer F: Roentgenographic and mathematical analysis of first metatarsal osteotomies for metatarsus primus varus: A comparative study. Foot Ankle 5:280-321, 1985 4. Mann RA, Coughlin MJ: Hallux valgus—Etiology, anatomy, treatment and surgical considerations. Clin Orthop Relat Res 157:31-41, 1981 5. Sammarco GJ, Brainard BJ, Sammarco VJ: Bunion correction using proximal Chevron osteotomy. Foot Ankle 14:8-14, 1993 6. Cedell CA, Astrom M: Proximal metatarsal osteotomy in hallux valgus. Acta Orthop Scand 53:1013-1018, 1982 7. Graves SC, Dutkowsky JP, Richardson EG: The Chevron bunionec-
11. 12.
13.
14.
15.
tomy: A trigonometric analysis to predict correction. Foot Ankle 14:90-96, 1993 Nyska M, Trnka HJ, Parks BG, et al: Proximal metatarsal osteotomies: A comparative geometric analysis conducted on sawbone models. Foot Ankle Int 23:938-945, 2002 Trnka HJ, Parks BG, Ivanic G, et al: Six first metatarsal shaft osteotomies: Mechanical and immobilization comparisons. Clin Orthop Relat Res 381:256-265, 2000 Trethowan J: in Choyce CC (ed): A System of Surgery. New York, P.B. Hoeber, 1923, pp 1046-1049 Limbird TJ, DaSilva RM, Green NE: Osteotomy of the first metatarsal base for metatarsus primus varus. Foot Ankle 9:158-162, 1989 Cooper MT, Berlet GC, Shurnas PS, et al: Proximal opening-wedge osteotomy of the first metatarsal for correction of hallux valgus. Surg Technol Int 16:215-219, 2007 Ferrari J, Higgins JPT, Prior TD: Interventions for treating hallux valgus (abductovalgus) and bunions. Cochrane Database of Systematic Reviews Issue 1. Art. No: CD000964, 2004 Mann RA: Distal soft tissue procedure and proximal metatarsal osteotomy for correction of hallux valgus deformity. Orthopedics 13:10131018, 1990 Walther M, Menzinger F, Dreyer F, et al: [The proximal open-wedge osteotomy with interlocking plate for correction of splayfoot deformities with hallux valgus]. Oper Orthop Traumatol 20:452-462, 2008