EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Abd El-Fattah
MODERATE TO SEVERE HALLUX VALGUS DEFORMITY:
CORRECTION WITH PROXIMAL MEDIAL CLOSED WEDGE
METATARSAL OSTEOTOMY
AND DISTAL SOFT-TISSUE RELEASE
By
Ahmed Saleh Abdel-Fattah
Department of Orthopedic Surgery and Traumatology
Minia Faculty of Medicine
ABSTRACT:
Purpose: The purpose of this study was to evaluate the management of hallux valgus
with a wedge osteotomy of the proximal metatarsal combined with a distal soft tissue
procedure.
Material and methods: In this study, 15 feet in 12 patients managed by closed wedge
osteotomy and distal soft tissue release. Ten patients were female, and two was male.
The average age at the time of surgery was 26 years (range, 18 to 39 years). Results:
The mean follow-up period was 18 months (ranged 12 to 30 months). The mean
intermetatarsal angle was 16° preoperatively, and 5° postoperatively while the mean
hallux valgus angle was 39° preoperatively, and 15° postoperatively. Patients noted an
average preoperative AOFAS score of 53 points compared with 91 points
postoperative.
Conclusion: Correction of hallux valgus deformity by proximal medial closed wedge
metatarsal osteotomy and distal soft-tissue release may be preferable in terms of ease,
low complication rate and patient satisfaction.
KEYWORDS:
Hallux valgus
Proximal osteotomy.
In an attempt to reliably control
the sagittal position of the first
metatarsal, an increasing number of
surgeons have employed the proximal
chevron
and
modified Ludloff
osteotomies, both of which are
performed through a medial approach
as opposed to the dorsal approach used
for the crescentic osteotomy 4,9,10.
INTRODUCTION:
Symptomatic hallux valgus
associated with a first intermetatarsal
angle of 15° is typically corrected
with a proximal first metatarsal
osteotomy combined with a distal softtissue procedure when nonoperative
treatment fails 1, 2.
While the crescentic proximal
first metatarsal osteotomy has been
associated with acceptable clinical
outcomes3-6, concern about dorsiflexion malunion (which has been noted
in association with as many as 28% of
procedures performed
with
that
3,4,7,8
technique
has prompted the
development of surgical alternatives.
The purpose of this study was
to evaluate the management of hallux
valgus with a wedge osteotomy of the
proximal metatarsal combined with a
distal soft tissue procedure.
MATERIAL AND METHODS:
Between January 2003 and
January 2006 fifteen feet of 12
233
EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Abd El-Fattah
patients, with three being bilateral,
underwent surgery by proximal medial
closed wedge metatarsal osteotomy
and distal soft-tissue for the treatment
of symptomatic hallux valgus.
An American Orthopaedic Foot and
Ankle Society (AOFAS) halluxinterphalangeal score that evaluate
pain, function and alignment was
obtained both preoperatively and at the
time of the most recent follow-up visit.
The indication for surgery was
chronic
pain
and
deformity.
Radiographic criteria included a hallux
valgus angle of >30°, a first-second
intermetatarsal angle of >15°, and
lateral subluxation of the sesamoids.
11
Anteroposterior and lateral
radiographs
were
taken
preoperatively, post-operatively and at
final follow-up with the patient
standing. The hallux valgus angle
(HVA) and the angle between the first
and second metatarsals (IMA) were
measured.
Ten patients were female, and
two was male. The average age at the
time of surgery was 26 years (range, 18
to 39 years).
In addition tibial sesamoid
position, according to the description
by Hardy et al 12, was recorded to
evaluate if the intraoperative rotation
of the great toe into supination was
sufficient to correct the preoperative
pronation (fig.: 1).
The contraindications to the
procedure were osteoarthritis of the
first metatarsophalangeal joint and
severe instability of the first tarsometatarsal joint.
Fig. 1:The position of the tibial sesamoid as described by Hardy et al., 12
Supination of the great toe is performed in order to correct the preoperative
pronation and is checked by the degree of reduction of the tibial sesamoid into a
more anatomical position under the medial part of the 1st metatarsal head (M :
medial, L : lateral).
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Surgical technique: (Fig. 2):
A dorsal 3-cm longitudinal
incision is made over the first web
space. The lateral joint capsule and the
metatarsosesamoid
ligament
are
divided immediately superior to the
lateral sesamoid. The transverse and
oblique tendons of the adductor
hallucis are released. The lateral
capsule is fenestrated at the first
metatarsophalangeal joint, and a varus
stress is applied to the hallux to
complete the lateral release. The
transverse intermetatarsal ligament is
not routinely divided.
Abd El-Fattah
planter based closing wedge osteotomy
was made using oscillating saw to
correct varus and dorsal angulation (if
present).
Lateral rotation (supination) of
the distal fragment was done to correct
pronation, then the distal fragment was
fixed by two 1.6 K-wires from first to
second metatarsal, and a third wire
from the plantar aspect of proximal
phalanx to first metatarsal crossing the
osteotomy site.
Immediately after surgery, a
removable posterior slap was used to
maintain the surgically corrected
position. Once the surgical wound was
stabilized, a plaster cast was applied as
soon as the swelling subsided, patients
were allowed to initiate weight-bearing
walk.
A longitudinal incision is
centered over the medial eminence
about
3
cm,
through
which
bunionectomy and double breasting of
the medial capsule were done.
A third dorsomedial incision, 3 cm in
length, over the proximal part of the
first metatarsal was done. It is
deepened along the medial aspect of
the extensor hallucis longus tendon to
the bone. The periosteum is reflected
1.5 cm distal to the metatarsocuneiform joint where a medial and
Kirschner wires were removed
6 to 8 weeks after surgery following
radiographic confirmation of bone
union.
235
EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
(A)
(B)
Abd El-Fattah
(C)
(D)
(E)
Figure ( 2) Operative technique: A)Preoperative photography, B) The three
incsions, C)The osteotomy site, D) Application of the three K wires, E) Final
appearance.
Aftercare:
Provided
that
satisfactory
fixation of the osteotomy site is
achieved intraoperatively, the patient is
permitted to walk immediately in a
postoperative shoe, bearing weight on
the heel only. In the rare instance in
which fixation is not optimal, we
recommend the use of a short leg
walking cast for six weeks. Once there
is radiographic evidence of healing at
the osteotomy site, transfer of weight to
the forefoot in a regular shoe is
advanced, typically at six weeks. When
osseous callus formation is noted at the
osteotomy site on the six-week
radiographs, we recommend delaying
transfer of weight-bearing onto the
forefoot to eight to ten weeks.
RESULTS:
The mean follow-up period was 18
months (ranged 12 to 30 months).
Objective evaluations included
the hallux valgus angle, the
intermetatarsal angle. The mean
intermetatarsal
angle
was
16°
preoperatively, and 5° postoperatively
while the mean hallux valgus angle
was 39° preoperatively, and 15°
postoperatively.
Subjective evaluation was
made with the use of AOFAS score
preoperatively and postoperatively.
Patients noted an average preoperative
AOFAS score of 53 points compared
with 91 points postoperative.
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Abd El-Fattah
Twelve feet had complete pain
relief, or only minor complaints. 2 feet
had moderate complaints, and 1 foot
demonstrated no pain relief.
position 4 of Hardy) in all feet. Postoperatively it was located centrally or
medially (better than position 3 of
Hardy) in 14 feet.12
The overall patient satisfaction
was excellent in 8 cases, good in 4
cases, fair in 2 cases and poor in 1 case
who had diffuse complaints in the
whole foot without a specific site or
joint as the cause.
Complications
and
subsequent
procedures:
Three patients had either
paresthesia or hyposthesia near the
incsion. Superficial wound infection,
which was controlled by oral
antibiotics in two patients. Shortening
of the first metatarsal with an average
of 3 mm was observed in two patients.
Preoperatively
the
tibial
sesamoid was located laterally (beyond
(A)
(B)
(C)
Fig. 2: Female patient 25 years old. A) Preoperative x-ray shows HVA of 40° and
IMA of 25°. B) Immediate postoperative after wedge osteotomy and distal soft tissue
release which was fixed by k-wire. C) Follow up x- ray shows healing of osteotomy
site, improved HVA to 15°, IMA to 5° and pronation of first metatarsal was corrected
as sesamoid changed position from Hardy 6 to 4.
237
EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
Abd El-Fattah
respectively. Shortening of the first
metatarsal bone (mean 3 mm) occurred
in five patients and dorsiflexion
deformity of the metatarsal head in one
patient. 17
DISCUSSION:
More than 130 operations for
hallux valgus in adolescents have been
reporte. They fall into 4 main
categories: proximal metatarsal osteotomies, distal metatarsal osteotomies,
soft tissue procedures and combinations of the above procedures. 13
In this study, 15 feet in 12
patients managed by closed wedge
osteotomy and distal soft tissue release,
the mean intermetatarsal angle was 16°
preoperatively, and 5° postoperatively
while the mean hallux valgus angle
was 39° preoperatively, and 15°
postoperatively. Patients noted an
average preoperative AOFAS score of
53 points compared with 91 points
postoperative.
Basal metatarsal osteotomies
has
the
following
advantages:
Cancellous bone and broad contact
surface promote early stability and
union. Proximal osteotomies allow a
greater correction of the increased
intermetatarsal angle than distal
osteotomies which are usually used for
mild or moderate deformities. 14,15
We did not encounter bone
healing problems, probably because
the contact area between the two parts
of the osteotomised bone is wide.
The metatarsal is shortened
minimally, because the width of
osteotomy cut is compensated for by
the straightening of the bone (medial
angulation shorten the bone). Slightly
tilting the distal fragment planter ward
reduces load bearing by the second
metatarsal. Narrowing of the forefoot
improves the variety of footwear
possible and gives an excellent
cosmetic result. 16
Fixation of osteotomy site in
our cases were done by three K-wires.
The first wire pass from the big toe to
the medial cuneiform along the axis of
the first metatarsal bone that
preventing varus or valgus angulation.
Supination of the first metatarsal was
maintained in place by 2 wires fixing it
to the rest of metatarsals, that restores
the normal anatomical relationship.
The disadvantages of this
technique: Three incisions are required
and cast immobilization is frequently
needed. 16
CONCLUSIONS:
Proximal medial closed wedge
metatarsal osteotomy allows early
stability and union, greater correction
of the increased intermetatarsal angle,
slightly tilting the distal fragment
planter ward reduces load bearing by
the second metatarsal. Correction of
pronation
restores
the
normal
anatomical relationships in the metarsophalangeal region.
Mann et al., 1992 on 79 adult
patients (109 feet) using basal
osteotomy, the average hallux valgus
correction was 24° and the average
correction of the intermetatarsal angle
was 8°. The incidence of under
correction was 2% and 12% had a
hallux varus deformity. 6
Pehlivan O, 2002 on 25 adult
male patients using basal osteotomy,
the mean corrections in the hallux
valgus angle and the intermetatarsal
angle were 22.1° and 10.8°,
The results suggest that
correction of hallux valgus deformity
by proximal medial closed wedge
metatarsal osteotomy and distal soft-
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EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007
tissue release may be preferable in
terms of ease, low complication rate
and patient satisfaction.
Abd El-Fattah
correction with proximal crescentic
osteotomy and distal soft-tissue
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9. Sammarco GJ, Brainard BJ,
and Sammarco VJ: Bunion correction
using proximal Chevron osteotomy.
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10. Chiodo CP, Schon LC, and
Myerson MS: Clinical results with the
Ludloff osteotomy for correction of
adult hallux valgus. Foot Ankle Int; 25:
532-6, 2004.
11. Kitaoka HB, Alexander IJ,
Adelaar RS, Nunley JA, Myerson MS
and Sanders : Clinical rating system for
the ankle-hindfoot, midfoot, hallux and
lesser toes. Foot Ankle Int,; 15(7):
349-53, 1994.
12. Hardy RA and Clapham JCR:
Observations on hallux valgus. Based
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Surg; 33-B: 376-391, 1951.
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JP: Modern concepts in the treatment
of hallux valgus J Bone Joint Surg; 87B: 1038 – 1045, 2005.
15. Okuda R, Kinoshita M,
Morikawa J, Yasuda T and Abe M:
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435: 191-6, 2005.
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Vaughn RA and Stephenson KA:
Keller resection arthroplasty for
treatment of hallux valgus deformity:
increased correction with fibular
sesamoidectomy. Foot Ankle Int;23:
699-703, 2002.
17. Pehlivan O: Short-term results
of proximal oblique Crescentic
osteotomy in hallux valgus. Acta
Orthop Traumatol Turc; 36 (5): 41722, 2002.
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‫‪EL-MINIA MED., BULL., VOL. 18, NO. 1, JAN., 2007‬‬
‫التشوه المتوسط الي الشديد البهام القدم االروح‬
‫التصليح بعمل قطع عظمي انسي قريب وتحرير االنسجه الرخوه البعيده‬
‫احمد صالح عبد الفتاح‬
‫مدرس جراحه العظام واالصابات‬
‫كليه الطب جامعه المنيا‬
‫لقد تم عالج ‪ 12‬مريضا بهم ‪ 15‬قدما مصابه بعمل قطع عظمي اسفيني مشطي مغلق انسي‬
‫قريب وتحرير االنسجه الرخوه البعيده لعالج التشوه المتوسط الي الشديد البهام القدم االروح‬
‫ويتم استخدام اسالك كيرشنر وبطح الجزء البعيد ‪ .‬وكان متوسط اعمارهم ‪ 26‬سنه وكان‬
‫متوسط فتره المتابعه ‪ 18‬شهر‪ .‬التقييم الموضوعي تضمن الزاويه االبهاميه االروحيه والزاويه‬
‫البين مشطيه وقبل العمليه كانت الزاويه البين مشطيه ‪ 16‬والزاويه االبهاميه االروحيه ‪ 39‬بينما‬
‫بعد العمليه كانت ‪ 5‬و ‪ 15‬بالترتيب‬
‫التقييم الشخصي تم باستخدام مقياس الجمعيه االمريكيه للقدم والكاحل قبل وبعد العمليه‪ .‬وقد‬
‫حقق المرضي متوسط ‪ 53‬نقطه علي مقياس الجمعيه االمريكيه قبل العمليه بالمقارنه ب ‪91‬‬
‫نقطه بعد العمليه‪.‬‬
‫الخالصة‪ :‬بينت النتائج ان تعديل تشوه ابهام القدم االروح بعمل قطع عظمي اسفيني قريب انسي‬
‫مشطي وتحرير لالنسجه الرخوه قد يتميز بالبساطه و انخفاض معدل المضاعفات ورضا‬
‫المريض ‪.‬‬
‫‪240‬‬