correction of hallux valgus using lateral soft-tissue release and

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2007;89:82-89. doi:10.2106/JBJS.G.00483 J Bone Joint Surg Am.Woo-Chun Lee and Yu-Mi Kim

Proximal Chevron Osteotomy Through a Medial IncisionCorrection of Hallux Valgus Using Lateral Soft-Tissue Release and

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Correction of Hallux Valgus Using Lateral Soft-Tissue Release and Proximal

Chevron Osteotomy Through a Medial IncisionBy Woo-Chun Lee, PhD, MD, and Yu-Mi Kim, MD

Introductions the degree of hallux valgus increases, the lateralcapsule of the first metatarsophalangeal joint andthe adductor tendon become contracted. In most

surgical procedures designed to correct moderate to severedegrees of hallux valgus, the soft-tissue structures on thelateral aspect of the first metatarsophalangeal joint need tobe released in order to reduce the subluxated joint. Thereare two surgical approaches for lateral soft-tissue release forthe correction of hallux valgus. One is the dorsal approachbetween the first and second metatarsals1-6, and the other isthe medial approach, which passes under the first metatar-sal head7-11. We think that a medial approach is cosmeticallyas well as functionally better because it does not create adorsal scar, which can be unsightly (Figs. 1-A and 1-B), and

because it is less likely to cause stiffness of the first or secondmetatarsophalangeal joint. It is, however, difficult to releasethe lateral soft tissues, including the adductor tendon andthe capsule, through a medial incision because, in patientswith hallux valgus, the lateral sesamoid is displaced later-ally and dorsally. Thus, the dorsal approach between thefirst and second metatarsals is more widely used among footsurgeons.

Some surgeons12,13 prefer to perform a distal osteotomybecause of its inherent stability even for correction of a mod-erate to severe deformity either with or without a lateral soft-tissue release. However, it is very difficult to obtain enoughcorrection with a distal osteotomy in the case of severe de-formity, and inadequate correction or recurrence of the de-formity is not uncommon. We have devised a method of

A

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nora member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a com-mercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center,clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated orassociated.

J Bone Joint Surg Am. 2007;89(Suppl 3):82-9 • doi:10.2106/JBJS.G.00483

Fig. 1-A

Medial scars (Fig. 1-A), which are barely visible when viewed from above, and dorsal scars (Fig. 1-B) between the first and second metatarsals.Fig. 1-B

Lee.fm Page 82 Monday, September 10, 2007 1:56 PM

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THE JOU R N A L OF BO N E & JO I N T SU RG ER Y · JB JS .ORG

VO LUM E 89-A · SU P P L E M E N T 3 · 2007COR RE CT ION OF HAL LUX VAL G U S US I N G LA TE R A L SO F T-TI S SU E RE L E AS E A N D PROX IM AL CH E V RON OS TE OTOMY

lateral soft-tissue release under direct vision through a dorsalapproach combined with a proximal metatarsal osteotomy,all performed through the same medial incision14.

Materials and Methodshe charts and radiographs of thirty-seven consecutivepatients (forty-five feet) who had been managed with

correction of a hallux valgus deformity by a single surgeon

(W.-C.L.) between August 2003 and May 2004 were retrospec-tively reviewed. Eight patients (ten feet) lacked adequatefollow-up and were excluded. The results of our operativeprocedures for the remaining twenty-nine patients (thirty-fivefeet) were investigated. The indication for surgery was chronicpain and deformity.

Radiographic criteria included a hallux valgus angle of>30°, a first-second intermetatarsal angle of >12°, and lateralsubluxation of the sesamoids. Twenty-eight patients were fe-male, and one was male. The average age at the time of surgerywas 51.0 years (range, thirty-three to seventy-one years). Theaverage duration of follow-up was 26.5 months (range, twenty-four to thirty-two months).

An American Orthopaedic Foot and Ankle Society (AO-FAS) hallux-interphalangeal score was obtained both preoper-atively and at the time of the most recent follow-up visit. Thepatients were also questioned as to whether they would un-dergo surgery again and, if so, with or without reservations.

Radiographic EvaluationAll preoperative radiographs included weight-bearing dor-soplantar and lateral views and a sesamoid view. The hallux val-gus angle and the first-second intermetatarsal angle and theextent of sesamoid subluxation were assessed on the dorsoplan-tar radiograph. The talus-first metatarsal angle was measuredon the standing lateral radiograph. The hallux valgus angle andthe first-second intermetatarsal angle were measured with themethod of Hardy and Clapham15. Sesamoid position was de-fined by the position of the medial sesamoid in relation to theaxis of the first metatarsal. A normal position was classified as

T

Fig. 2

The medial incision is made parallel to the plantar surface of the foot,

beginning 1 cm distal to the metatarsophalangeal joint and ending 1 cm

distal to the metatarsocuneiform joint.

Fig. 3

Intraoperative photograph showing the full-thickness dorsal flap, including skin and subcutane-

ous tissue.


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grade 0, and the most severe lateral subluxation, in which themedial sesamoid was displaced laterally beyond the midaxis by>75% of its width, was classified as grade 3.

Surgical TechniqueThe procedure is performed with the patient under spinal an-esthesia. An approximately 6-cm-long medial incision is made;the incision begins 1 cm distal to the first metatarsophalangealjoint, curves slightly dorsally over the bunion, continues proxi-mally parallel to the plantar surface of the foot (not along thefirst metatarsal), and ends 1 cm distal to the first metatarsocu-neiform joint (Fig. 2). If the incision is made along the shaft ofthe first metatarsal, the scar ends up on the dorsum of the footafter correction, and it can be seen when the patient stands.

A full-thickness dorsal flap including skin and subcuta-neous tissue is then elevated to the first web space (Fig. 3).

The dorsomedial cutaneous nerve over the first meta-tarsal head is exposed and separated from the flap, and fur-ther dissection progresses laterally just superficial to theextensor hallucis longus and brevis tendons (Fig. 4). A verti-cal medial capsular resection involving the removal of ap-proximately 4 mm of capsule is performed just proximal tothe base of the proximal phalanx. A medial axial longitudinalincision is made in the capsule, extending to the neck of thefirst metatarsal. The medial eminence of the first metatarsalhead is resected with use of a micro-oscillating saw after dor-

Fig. 4

Intraoperative photograph showing the dissection just superficial to the

extensor hallucis longus and brevis tendons.

Fig. 5

Intraoperative photograph showing the intermetatarsal space with the

hemostat placed under the deep transverse metatarsal ligament.

Fig. 6

Intraoperative photograph showing the adductor release from the lat-

eral sesamoid.


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sal and plantar capsular flaps have been elevated from themedial eminence.

The deep fascia and areolar tissue between the first andsecond metatarsals are then incised at about 2.5 cm proximal tothe first metatarsophalangeal joint, and the incision is extendeddistally. A lamina spreader is inserted between the first and sec-ond metatarsal necks and is opened to widen the first inter-space. A curved hemostat is inserted under the deep transversemetatarsal ligament, and the ligament is incised (Fig. 5). Bothtendons of the adductor hallucis are released (Fig. 6), and a lon-gitudinal incision in the capsule is made along the dorsal mar-gin of the lateral sesamoid (Fig. 7). The lateral capsule of thefirst metatarsophalangeal joint, however, is not incised verti-cally. In our series, we did not transfer the adductor tendon tothe neck of the first metatarsal, but we think that this procedurecould be performed through this approach.

At this point, the phalanx is abducted to test if the lateralsoft-tissue release is adequate. If the phalanx cannot be angu-lated 20° medially with regard to the long axis of the firstmetatarsal (Fig. 8), the longitudinal incision along the dorsalmargin of the lateral sesamoid is extended further distally, andthe capsular attachment laterally at the base of the proximalphalanx is released.

A proximal chevron osteotomy is performed with use ofa micro-oscillating saw (Fig. 9). The apex of the chevron isproximal and is located 7 mm distal to the first metatarsal-cuneiform joint. The angle of each arm of the chevron is madeat 30° to the metatarsal axis.

After completion of the osteotomy, a small curette isplaced on the lateral side of the dorsum of the proximal frag-

ment to lever the proximal fragment medially as much as possi-ble while the distal fragment is displaced and angulated laterally.

Two 0.062-in (0.16-cm) Kirschner wires are insertedfrom proximal to distal into the metatarsal head (Figs. 10-A

Fig. 7

Intraoperative photograph showing the articular surface of the lateral sesamoid after release.

Fig. 8

Intraoperative photograph showing an adequate amount of lateral soft-

tissue release.


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Fig. 9

Intraoperative photograph showing the proximally apexed proximal chevron osteotomy.

Fig. 10-A

Radiographs showing the preoperative deformity (Fig. 10-A) and the postoperative correction secured with two Kirschner wires (Fig. 10-B).Fig. 10-B


87



and 10-B). An additional Kirschner wire is inserted if neededto achieve secure fixation. The degree of correction should bechecked with fluoroscopy. If the first and second metatarsalsare not parallel, the wires are removed and the osteotomy siteis remanipulated. Proximally, the medial protruding bone isremoved flush with the distal fragment. This bone and thebone that has been resected from the medial eminence of themetatarsal head is pushed into the osteotomy gap mediallyand applied to the lateral aspect of the osteotomy site.

A medial capsulorrhaphy is performed with use of in-terrupted 2-0 nonabsorbable and absorbable sutures. Theperiosteum is approximated with 2-0 absorbable sutures,and closure is completed with a running 4-0 nonabsorbablesuture after about 3 mm of skin is excised from the plantarskin flap (Fig. 11).

Postoperative CareThe foot is placed in a splint for about one week postopera-tively. Weight-bearing on the heel and the lateral border of thefoot is permitted on the day after surgery. The compressivedressings are changed on the third or fourth postoperativeday, and the sutures are removed two to three weeks postoper-atively. Weight-bearing on the first ray is not allowed until theseventh postoperative week, and the Kirschner wires are re-moved during the ninth postoperative week.

Statistical AnalysisThe hallux valgus angle, first-second intermetatarsal angle,sesamoid position, and AOFAS hallux-interphalangeal scoreat the time of the most recent follow-up visit were compared

Fig. 11

Intraoperative photograph showing a completed correction.

Fig. 12

Graphs illustrating changes in the AOFAS score, the hallux valgus

angle (HVA), and the first-second intermetatarsal angle (IMA) from

preoperatively to the time of the latest follow-up (at a mean of 26.5

months) for thirty-five feet in twenty-nine patients.


88



with preoperative values, and paired Student t tests were done.The level of significance was set at p < 0.05.

Resultshe hallux valgus angle improved by an average of 27.8°,from a preoperative average of 35.8° ± 7.9° (range, 27.3° to

52.7°) to a postoperative average of 8.0° ± 7.6° (range, −10.6° to22.6°) (p < 0.001) (Fig. 12). The first-second intermetatarsal an-gle improved from a preoperative average of 16.8° ± 2.8° (range,12.0° to 21.8°) to a postoperative average of 5.0° ± 3.2° (range,−0.1° to 12.2°) (p < 0.001). The sesamoid position was reducedby an average of 2.5 grades, from a preoperative average of 3.0to a postoperative average of 0.5 ± 0.6 (range, 0 to 2). The meanlateral talus-first metatarsal angle was 6.5° ± 8.4° (range, −6.3°to 19.4°) preoperatively and 9.1° ± 7.9° (range, −3.7° to 33.7°)postoperatively (p = 0.03). There was one hallux varus defor-mity of 5°, but the patient had no discomfort.

The average AOFAS hallux-interphalangeal score im-proved from 54.8 preoperatively to 93.3 postoperatively (p <0.01). With regard to pain, patients reported that twenty-eightof thirty-five feet were completely pain-free and that seven feethad only occasional or slight discomfort. Postoperative mo-tion (dorsiflexion plus plantar flexion) was regarded as nor-mal or mildly restricted (>75°) in thirty-one feet andmoderately restricted (30° to 74°) in four feet.

Twenty-three of the twenty-nine patients stated thatthey would undergo the same procedure again without reser-vations. Five patients reported that they would undergo thesurgery with minor reservations because of the immediatepostoperative pain and the aggravation of Kirschner wire re-moval. One patient stated that she would not undergo surgeryagain because she had a dorsiflexion malunion that requiredrevision surgery. There were three cases of marginal woundnecrosis, which healed secondarily without the need for anyfurther surgery.

Discussion ne concern with this approach is its safety. The main bloodsupply over the medial surface of the foot originates from

the medial plantar artery, and the dorsal area of the medial partof the foot is supplied primarily by the dorsalis pedis artery16,17.The dorsal margin of the angiosome of the medial plantar ar-tery is 2 to 3 cm above the medial glabrous junction16. Thus, themain concern during exposure is the possibility of necrosis ofthe dorsal flap. If the main blood supply to some part of thedorsal flap is from the medial plantar artery, there would be ahigh risk of flap necrosis because the skin incision crosses theborderline between the dorsal and plantar angiosomes. We haveused this approach to perform a proximal chevron osteotomy in>200 feet since August 2003. Marginal wound necrosis devel-oped in three patients in that group, and in all three it healed

uneventfully without additional surgery. We believe that mak-ing the incision plantar to the metatarsal shaft and parallel tothe sole of the foot may protect the blood supply to the dorsalflap. We think that this approach, with careful handling of thedorsal flap, can be used safely, with only a slight possibility ofmarginal wound necrosis.

Another concern with this approach is the possibility ofan inadequate lateral soft-tissue release, resulting in a less-than-satisfactory correction of the hallux valgus deformity.The final hallux valgus angle, the first-second intermetatarsalangle, and the sesamoid position were all satisfactory in thepresent series, so we think that we can achieve a sufficient lat-eral soft-tissue release through this approach.

In addition to the correction of alignment, we have ob-tained satisfactory joint motion that is comparable with that de-scribed in any other report on hallux valgus correction. Wethink that this approach creates less scar in the first web spacebecause the skin and subcutaneous tissue are not dissected andthe lateral capsule is not disrupted parallel to the joint line.

The apex of the proximal chevron osteotomy can bemade distally1,3,8,9 or proximally6,18. The potential risk associatedwith making the apex proximally is the creation of a fractureof the proximal fragment, but, to our knowledge, this compli-cation has not been reported. The primary difference betweenmaking the apex of the osteotomy proximally or distally is thelocation of the pivot point for correction of the first metatarsalangulation. If the apex points distally, the pivot point is moredistal. Thus, if the apex is proximal, the location of the pivotpoint is closer to the metatarsocuneiform joint, and we believethat it is geometrically better to correct a deformity as close aspossible to the origin of the deformity.

With a proximal chevron osteotomy, the correction oc-curs through a combination of lateral translation and angula-tion. Geometrically, more translation is possible if the apex ismade distally; however, in our experience, we have been ableto achieve a sufficient amount of translation and therefore weprefer the proximal-apex osteotomy.

In conclusion, the present study suggests that we can re-lease the lateral soft tissues sufficiently by approaching the firstweb space dorsal to the first metatarsal after elevating the skinand subcutaneous tissues. We believe that satisfactory correc-tion of moderate to severe hallux valgus deformities can beobtained by combining this approach with a proximallyapexed proximal chevron osteotomy.

Corresponding author:Woo-Chun Lee, PhD, MDDepartment of Orthopaedic Surgery, Seoul Paik Hospital, Inje University, 82, Jeo-dong, Jung-gu, Seoul, 100-032, Korea. E-mail address: [email protected]

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correction of hallux valgus using lateral soft-tissue release and

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