Patient Education and Consent
The patient should be educated on selection of proper footwear. Size is an important criterion. Because feet swell at the end of the day, shoe shopping is best done in the evening. A useful aid in determining an appropriate size is to draw the outline of the foot on tracing paper and then to ensure that the insert of the shoe covers the tracing completely.
Equipment
Traditionally, a tourniquet is applied at the level of the thigh. Over the years, however, it has been found that tourniquets applied more distally in the leg just above the ankle work just as well and decrease the area that is unnecessarily exsanguinated, thereby limiting the reperfusion injury or effects. In addition, a more distal tourniquet need not be inflated to the same high pressure; typically, 250 mm Hg or 100 mm Hg higher than the systolic blood pressure is sufficient.
Patient Preparation
Anesthesia
Hallux valgus corrective procedures can be undertaken with a local anesthetic block around the base of the first metatarsal and in the first web space or with an ankle block if other toes will also be undergoing surgical intervention. A calf- or ankle-level tourniquet can be uncomfortable, and if such a tourniquet is required, a popliteal level block is also a suitable alternative. The block can be supplemented by sedation; alternatively, the procedure can be undertaken with laryngeal mask or endotracheal anesthesia, depending on the preferences of the patient and the anesthesiologist.
Regardless of whether the patient receives a general anesthetic or not, the author highly recommends preemptive analgesia and anesthetic techniques that are multimodal and give excellent preoperative anesthesia and postoperative pain control, which is an important objective (especially for prevention of chronic pain).
On the day of surgery, if no contraindications exist, a cyclooxygenase (COX)-2 inhibitor is given in the morning. The author has a motto ("needle before knife") and believes in injecting a mixture of short-acting and long-acting local anesthetic before making the skin incision in an effort to preemptively block noxious stimuli during surgery. Postoperatively, oral analgesics are started before the local anesthetic effect wears off and continued at the prescribed intervals for 2-3 days. With this regimen, patients can potentially go through the entire experience with little or no pain.
Positioning
Patient is positioned supine with pressure points padded. The author uses a triangular support under the knee, which helps keep the foot flat on the table and makes orientation easier to follow. [11] The foot is elevated over a bump of double-brick height and shape to clear it from the other limb, allowing unobstructed ease of access for the use of instruments (eg, the saw or drill) and fluoroscopy. The knee support also stabilizes the limb and lessens the need or reliance on assistance for maintaining position of the limb or the foot.
Monitoring & Follow-up
The patient is instructed to keep the dressings clean and dry and the leg elevated to minimize postoperative edema or swelling in the foot. Active exercises of the knee and hip are encouraged.
The first clinic visit after surgery should take place between postoperative days 7 and 10, at which time the wound is checked and dressings changed. The dressings are reapplied in a manner similar to their original placement, and either an accommodative shoe or a cast is applied for protection for the next 4-5 weeks. The patient is allowed to bear weight on the heel.
At 6 weeks, all dressings are taken down. Kirschner wires (K-wires), if used, are removed, and a weightbearing radiograph is obtained. Exercises of the great toe can begin, and the patient is allowed return to activities and full weightbearing as tolerated.
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Chevron osteotomy to correct severe hallux valgus deformity: deformity on left side and on right side operated previously.
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Chevron osteotomy to correct severe hallux valgus deformity: preoperative anteroposterior radiograph with patient standing.
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Chevron osteotomy to correct severe hallux valgus deformity: preoperative anteroposterior radiograph with measurements of hallux valgus angle and intermetatarsal angle.
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Chevron osteotomy to correct severe hallux valgus deformity: intraoperative radiograph of anteroposterior and oblique views showing K-wire being used as "buttress."
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Chevron osteotomy to correct severe hallux valgus deformity: intraoperative radiograph of lateral views showing chevron-shaped osteotomy cut and K-wire.
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Chevron osteotomy to correct severe hallux valgus deformity: foot in follow-up period at 6 weeks and tip of K-wire on medial side of great toe.
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Chevron osteotomy to correct severe hallux valgus deformity: anteroposterior radiograph showing correction of deformity and improvement in hallux valgus angle and intermetatarsal angle.
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Chevron osteotomy to correct severe hallux valgus deformity: lateral radiograph showing healed chevron osteotomy.
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Chevron osteotomy to correct severe hallux valgus deformity: great toe in improved alignment as compared with preoperative photograph.
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Osteotomy to correct severe hallux valgus deformity: hallux valgus deformity in left foot.
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Scarf osteotomy to correct severe hallux valgus deformity: preoperative anteroposterior radiograph with measurements of hallux valgus angle and intermetatarsal angle.
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Scarf osteotomy to correct severe hallux valgus deformity: exposure for scarf osteotomy on medial aspect of foot.
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Scarf osteotomy to correct severe hallux valgus deformity: fluoroscopic image and needle used to determine proximal extent for osteotomy.
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Scarf osteotomy to correct severe hallux valgus deformity: vertical cut and saw blades in horizontal cuts at either end of first metatarsal.
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Scarf osteotomy to correct severe hallux valgus deformity: vertical cut and saw blades in the horizontal cuts at either end of the first metatarsal parallel to each other.
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Scarf osteotomy to correct severe hallux valgus deformity: fluoroscopic image of displacement held with clamp.
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Scarf osteotomy to correct severe hallux valgus deformity: intraoperative photograph of corrected hallux valgus deformity.
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Scarf osteotomy to correct severe hallux valgus deformity: anteroposterior radiograph showing correction of deformity and improvements in hallux valgus angle and intermetatarsal angle measured at 3 months.
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Scarf osteotomy to correct severe hallux valgus deformity: lateral radiograph showing healed scarf osteotomy and 2 screws used to stabilize osteotomy.
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Scarf osteotomy to correct severe hallux valgus deformity: great toe in improved alignment as compared with preoperative photograph.
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First web space release as adjunctive procedure to correct severe hallux valgus deformity: hallux valgus deformity in left foot.
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First web space release as adjunctive procedure to correct severe hallux valgus deformity: incision marked out for approach that is hidden in first web space.
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First web space release as adjunctive procedure to correct severe hallux valgus deformity: deeper tissues exposed, delineating adductor tendon.
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First web space release as adjunctive procedure to correct severe hallux valgus deformity: capsule incised longitudinally and head of metatarsal exposed after release of sesamometatarsal ligament.
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First web space release as adjunctive procedure to correct severe hallux valgus deformity: wound suture hidden in web space.
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First web space release as adjunctive procedure to correct severe hallux valgus deformity: intraoperative photograph of corrected hallux valgus deformity.
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First web space release as adjunctive procedure to correct severe hallux valgus deformity: great toe in improved alignment as compared with preoperative photograph.
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Chevron osteotomy with three-point fixation: preoperative anteroposterior radiograph shows hallux valgus deformity.
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Chevron osteotomy with three-point fixation: intraoperative radiograph shows use of Kirschner wire (K-wire) engaging three cortices: lateral and medial cortices of proximal fragment in shaft of first metatarsal and third cortex in lateral aspect of head of metatarsal. This kind of fixation gives more rigid fixation than K-wire engaging only two cortices across osteotomy.
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Chevron osteotomy with three-point fixation: radiograph shows healing of chevron and Akin osteotomy at final follow-up with correction of hallux valgus deformity.
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Chevron osteotomy with three-point fixation: photograph of patient at final follow-up shows correction of deformity and great toe in neutral rotation.