Hallux Valgus Osteotomy Technique

Updated: Apr 04, 2016
  • Author: Vinod K Panchbhavi, MD, FACS; Chief Editor: Erik D Schraga, MD  more...
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Technique

Approach Considerations

Osteotomies for hallux valgus are performed via a medial approach. A longitudinal incision along the midline at the junction of plantar and dorsal skin on the medial border of the foot straddling the metatarsophalangeal (MTP) joint is marked and made with a No. 15 blade. Careful dissection is carried out in the loose areolar tissue plane that is naturally there, created by movement of skin and subcutaneous tissue over the capsular structures. Dissection in this plane is safer and easier and creates full-thickness soft-tissue flaps superficial to the level of the joint capsule.

The dorsal and plantar flaps thus created carry the dorsomedial and plantar-medial digital nerves and are kept retracted and away from instruments for rest of the procedure. Then, the capsule is incised along the line of incision, exposing the medial eminence. The proximal and distal extension of the exposure depends on the exposure needed and the type of osteotomy planned. The bunion prominence on the medial aspect of the head of the metatarsal is excised in line with the medial aspect of the foot. Excessive resection can lead to hallux varus.

Generally, the more severe the deformity is, the more proximal or longer the osteotomy on the first metatarsal will have to be, and the more likely it is that more than one level will have to be involved (eg, an additional osteotomy in the proximal phalanx). Selection of a particular osteotomy is also dependent on the surgeon's familiarity and experience with the various surgical options.

For mild deformities, a distal metatarsal osteotomy, such as a chevron osteotomy, is sufficient. For moderate and severe deformities, a midshaft or proximal osteotomy along with a phalangeal osteotomy may be necessary. The midshaft osteotomies commonly performed are the scarf osteotomy (or Z osteotomy) and the Ludloff osteotomy. A closing or opening wedge osteotomy at the base of the metatarsal or the cuneiform is also an option for severe deformities. Commonly performed osteotomies are described further below.

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Chevron Osteotomy

A chevron osteotomy, as the name indicates, is chevron-shaped and is located in the broad metaphyseal region at junction of head and neck. A 0.062-in. drill hole is useful to mark the apex of the chevron on the metatarsal head. The drill hole is started on the medial surface of the head at or just proximal to the center of an imaginary sphere that is the head of the metatarsal and driven in a direction that is medial to lateral and in line that is parallel to the plantar surface and the articular surface of the head of the metatarsal (see the images below).

Chevron osteotomy to correct a severe hallux valgu Chevron osteotomy to correct a severe hallux valgus deformity: the deformity on left side and on the right side operated previously.
Chevron osteotomy to correct a severe hallux valgu Chevron osteotomy to correct a severe hallux valgus deformity: the preoperative anteroposterior radiograph with patient standing.
Chevron osteotomy to correct a severe hallux valgu Chevron osteotomy to correct a severe hallux valgus deformity: the preoperative anteroposterior radiograph with measurements of the hallux valgus and the intermetatarsal angles.

The limbs of the chevron consist of two cuts made by a sagittal saw, starting at the hole. These cuts extend proximally at a 60º angle, with the plantar cut exiting the plantar cortex proximal to the sesamoid articulation.

As the osteotomy is performed, irrigation is carried out to dissipate heat. As the saw blade approaches the lateral cortex care must be taken not to overpenetrate the cortex and enter the lateral soft tissues, to prevent damaging the blood supply to the metatarsal head. Badwey et al reported that the capital fragment can be displaced laterally up to 6 mm in males and 5 mm in females; this amounts to displacement of approximately 30% of the metatarsal's width. [7]

To displace the osteotomy, holding the proximal portion of the metatarsal with a small towel clip while pushing the metatarsal head laterally is sometimes useful. The osteotomy is then fixed with a single Kirschner wire (K-wire). The author uses the K-wire as a buttress (see the images below). [8]

Chevron osteotomy to correct a severe hallux valgu Chevron osteotomy to correct a severe hallux valgus deformity: the intraoperative radiograph of anteroposterior and oblique views showing the K–wire being used as a "buttress."
Chevron osteotomy to correct a severe hallux valgu Chevron osteotomy to correct a severe hallux valgus deformity: the intraoperative radiograph of lateral views showing the chevron-shaped osteotomy cut and the K-wire.

The tip of the wire is held flat against the displaced head and first brought out distally through a long soft-tissue sleeve; the proximal tip of the wire is then cut blunt. With the displacement held, the blunt tip is introduced into the shaft of the proximal fragment and advanced proximally by tapping on its distal end until the blunt end lodges securely in the subchondral region at the base of the metatarsal. The excess sharp projection at the displaced distal medial end of the shaft of the first metatarsal is trimmed (see the images below).

Chevron osteotomy to correct a severe hallux valgu Chevron osteotomy to correct a severe hallux valgus deformity: the foot in the follow-up period at 6 weeks and the tip of the K-wire on medial side of the great toe.
Chevron osteotomy to correct a severe hallux valgu Chevron osteotomy to correct a severe hallux valgus deformity: the anteroposterior radiograph showing the correction of the deformity and improvement in the hallux valgus and intermetatarsal angles measured.
Chevron osteotomy to correct a severe hallux valgu Chevron osteotomy to correct a severe hallux valgus deformity: the lateral radiograph showing the healed chevron osteotomy.
Chevron osteotomy to correct a severe hallux valgu Chevron osteotomy to correct a severe hallux valgus deformity: the great toe in an improved alignment compared to the preoperative photograph.
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Scarf Osteotomy (Z Osteotomy)

A scarf osteotomy is an osteotomy with an outline that resembles the letter Z; for this reason, it is also referred to as a Z osteotomy. The metatarsal shaft is essentially split into dorsal and plantar halves. This longitudinal split extends into the metaphysis distally into the head and proximally in the base, but it stops 1-2 cm short of the articular surfaces. Transversely directed cuts from medial to lateral in the dorsal half distally and the plantar half proximally create two segments of the first metatarsal, with the plantar half carrying the head segment and the dorsal half carrying the base. (See the images below.)

Osteotomy to correct a severe hallux valgus deform Osteotomy to correct a severe hallux valgus deformity: the hallux valgus deformity in the left foot.
Scarf osteotomy to correct a severe hallux valgus Scarf osteotomy to correct a severe hallux valgus deformity: the preoperative anteroposterior radiograph with measurements of the hallux valgus and the intermetatarsal angles.

The exposure described for the chevron osteotomy is used but is extended proximally to expose the medial surface of the first metatarsal. (See the image below.)

Scarf osteotomy to correct a severe hallux valgus Scarf osteotomy to correct a severe hallux valgus deformity: the exposure for scarf osteotomy on medial aspect of the foot.

After the resection of the medial eminence, the osteotomy to be executed is drawn out. A 0.045-in. K-wire is drilled 1 cm away from the articular surface of the head, halfway between the dorsal and plantar surface in a medial-to-lateral direction and also aimed in about a 15º plantar and proximal orientation. Another wire is drilled parallel to this wire—again, halfway between the dorsal and plantar surfaces under fluoroscopy to ensure that it is at least 1 cm distal from the articular surface at the base (see the image below).

Scarf osteotomy to correct a severe hallux valgus Scarf osteotomy to correct a severe hallux valgus deformity: the fluoroscopic image and a needle used to determine the proximal extent for the osteotomy.

These wires form the apices of the Z and limit the cut that is along the long axis of the shaft. A sagittal saw is used to execute the longitudinal cut, again with the saw blade directed plantarward from medial to lateral (see the images below).

Scarf osteotomy to correct a severe hallux valgus Scarf osteotomy to correct a severe hallux valgus deformity: the vertical cut and saw blades in the horizontal cuts at either end of the first.
Scarf osteotomy to correct a severe hallux valgus Scarf osteotomy to correct a severe hallux valgus deformity: the vertical cut and saw blades in the horizontal cuts at either end of the first metatarsal bone parallel to each other.

At either end of this longitudinal cut, another cut is made along the width, directed from medial to lateral and angled proximally. The distal cut is made dorsal and the proximal cut plantar to the K-wires in this location; additionally, care is taken not to enter the joint at base of the metatarsal. After the osteotomy is conducted, the plantar capital fragment is displaced laterally and the dorsal basal fragment displaced medially to reduce the intermetatarsal angle; additionally, the capital fragment can be rotated out to correct articular set angle by taking appropriate sized medial based wedges at either end.

Once the deformity is reduced satisfactorily, as determined clinically and radiologically, the displacement is secured with bone clamps and later with two cortical screws 2.5 mm in diameter (see the images below).

Scarf osteotomy to correct a severe hallux valgus Scarf osteotomy to correct a severe hallux valgus deformity: the fluoroscopic image of the displacement held with a clamp.
Scarf osteotomy to correct a severe hallux valgus Scarf osteotomy to correct a severe hallux valgus deformity: the intraoperative photograph of the corrected hallux valgus deformity.
Scarf osteotomy to correct a severe hallux valgus Scarf osteotomy to correct a severe hallux valgus deformity: the anteroposterior radiograph showing the correction of the deformity and improvement in the hallux valgus and intermetatarsal angles measured at 3 months.
Scarf osteotomy to correct a severe hallux valgus Scarf osteotomy to correct a severe hallux valgus deformity: the lateral radiograph showing the healed scarf osteotomy and the 2 screws used to stabilize the osteotomy.
Scarf osteotomy to correct a severe hallux valgus Scarf osteotomy to correct a severe hallux valgus deformity: the great toe in a improved alignment compared to the preoperative photograph.
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Ludloff Osteotomy

A Ludloff osteotomy is an oblique osteotomy that begins dorsally a few millimeters distal to the joint at the base of the first metatarsal and is directed plantarward at a 30º angle; it is carried out into the shaft region and stopped just before it exits the plantar surface. A 3.5-mm screw is placed proximally at right angles to the osteotomy; before it is countersunk, the rest of the osteotomy is completed. The capital fragment is then rotated with the screw as an axis to reduce the hallux valgus deformity.

After the desired correction is obtained and checked clinically and radiologically, the screw is tightened and an additional screw is inserted distal to the first screw to secure the displacement.

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Akin Osteotomy

An Akin osteotomy is a medial-based closing wedge osteotomy that is performed at the base of the proximal phalanx. It is important to retract the flexor hallucis tendon and the extensor tendon dorsally and to use fluoroscopy to ensure that the proximal articular surface is not violated.

The first cut is made from medial to lateral across the width and is parallel to the base of the proximal phalanx, stopping short of the lateral cortex. The second cut starts just distal to this cut and is aimed to meet the first cut on the lateral cortex, again leaving it weakened but not cut. The wedge-shaped wafer of bone between these two cuts is removed.

The lateral opening is then closed with the weakened lateral cortex as a hinge. The osteotomy is secured with a K-wire that is driven from the plantar medial corner at the base of the proximal phalanx across the osteotomy into the dorsal distal shaft, just enough to engage it.

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First Web Space Soft-Tissue Release

Although this procedure has commonly been referred to as distal soft-tissue release, first web space soft-tissue release is a more appropriate name for it, both because no "proximal" soft tissues can be released and because the latter term defines the operation more aptly. First web space soft-tissue release is performed to release the contracted lateral structures so that a subluxed head of the metatarsal can be relocated in the joint (see the image below).

First web space release as an adjunctive procedure First web space release as an adjunctive procedure to correct a severe hallux valgus deformity: the hallux valgus deformity in the left foot.

This procedure, as described here, employs a newer technique and a newer approach that is sequential and hidden in the web fold and that is therefore more cosmetic than a dorsal approach, which yields a visible scar on top of the foot. [9]

With the toes held apart, a vertical incision from dorsal to ventral is made in the first web space in such a way as to include the transverse fold of skin (see the image below).

First web space release as an adjunctive procedure First web space release as an adjunctive procedure to correct a severe hallux valgus deformity: the incision marked out for an approach that is hidden in the first web space.

Blunt dissection is carried out proximally in the web space to identify the structures while the plantar digital neurovascular bundle is retracted plantarward with a Langenbeck retractor. The soft-tissue structures are identified and then cut in the following sequence:

  • Step 1 - The superficial and deep intermetatarsal ligaments are cut with tenotomy scissors
  • Step 2 - The adductor tendon just proximal to its insertion is outlined and detached at its attachment to the fibular sesamoid (see the first imnage below)
  • Step 3 - The capsule is incised longitudinally at the level of the metatarsophalangeal (MTP) joint with a No. 11 blade
  • Step 4 (physical examination) - The reduction of the deformity and the range of first MTP joint motion are checked; the forefoot is held squeezed with one hand while the other hand assesses the range of motion (ROM) at the first MTP joint; if ROM is restored at this stage with the release of the soft-tissue structures mentioned in steps 1-3, the next step is not undertaken, but if ROM is still limited, the lateral sesamoid metatarsal ligament is released as described in step 5
  • Step 5 - The contracted lateral sesamoid metatarsal ligament is cut with scissors, with one blade of the scissor inside the capsule and the other outside just dorsal to the fibular sesamoid (see the second image below)
  • Step 6 - Two 2-0 polyglactin sutures are placed in the capsule of the first and second metatarsals and the detached stump of the adductor tendon; an assistant holds the forefoot squeezed while the two sutures are tied to bring together the heads of the first and second metatarsals
First web space release as an adjunctive procedure First web space release as an adjunctive procedure to correct a severe hallux valgus deformity: the deeper tissues exposed delineating the adductor tendon.
First web space release as an adjunctive procedure First web space release as an adjunctive procedure to correct a severe hallux valgus deformity: the capsule incised longitudinally and the head of metatarsal exposed after release of the sesamometatarsal ligament.

The wound is irrigated and closed with a subcuticular polyglactin suture either at this stage or after any concomitant procedures planned (eg, scarf osteotomy of the first metatarsal) have been performed.

Panchbhavi et al carried out a retrospective chart review of 76 patients (88 procedures) and a functional outcome analysis of 38 patients (44 procedures) who underwent first web space release with the aforementioned technique. [10] The mean follow-up period was 3.8 years; the mean age was 50.8 years (range, 24-74); and 98% of the patients were female.

Most of the patients (89%) had good or excellent results. [10] The surgical scar was hidden between the first and second toes in the web fold. The average Olerud-Molander score was 86.4 out of 100. None of the patients reviewed had nerve injury, recurrence of deformity, hallux varus, or revision surgery. The authors concluded that first web space soft-tissue release is a reliable technique that can be used as an adjunctive surgical procedure in correction of hallux valgus. Because the incision is in the web fold, the resulting scar is hidden.

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Wound Closure

The correction leaves the capsule on the medial surface of the head redundant. The plantar capsular flap is folded into a V-shaped fold, which is raised in the plantar capsular flap. Enough is folded to take up the slack, and it is excised. This leaves a straight vertical cut, which is then repaired by placing an absorbable suture. The dorsal flap is drawn under the plantar flap and sutured in a pants-over-vest manner with mattress sutures. The rest of the wound is closed with a continuous nonabsorbable subcuticular stitch.

A nonadherent dressing is applied next to the wound and then covered with 4- × 4-in. gauze pieces. A 2-in. gauze roll is then rolled in a figure-eight manner so as to include the base of the big toe and forefoot. A soft roll of cotton is then applied in a similar manner. The aim of the dressing is to ensure that the great toe is held aligned.

A well-padded posterior splint can then be applied for pain relief and protection. Alternatively, a postoperative accommodative shoe with a rocker sole can be used in a reliable patient.

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Complications

Complications related to iatrogenic or inadvertent injury caused during exposure or execution of the osteotomy and wound closure include the following:

  • The digital nerves, especially the branch of the superficial peroneal nerve supplying the dorsomedial part of the big toe, are at risk for injury
  • The tendons, especially the flexor hallucis longus tendon, are at risk during execution of an Akin osteotomy
  • The blood vessels can be damaged by overpenetration of the saw blade during an osteotomy in the head and neck region or during capsular or soft-tissue release in the first web space
  • The head of the first metatarsal may fracture if the apex of a chevron osteotomy is too close to the articular surface
  • The deformity may be under- or overcorrected

Complications related to the immediate postoperative period include the following:

  • Wound infection may develop, presenting as redness and increased local pain with discharge from the incision site
  • Wound dehiscence (separation of the wound edges) may occur with or without infection
  • Pin-site infection may occur in association with hardware left prominent outside the skin for ease of removal

Long-term complications include the following:

  • Avascular necrosis of the head of the metatarsal can occur if the blood supply has been damaged
  • The first MTP joint at the base of the big toe can become stiff
  • The first metatarsal may end up reduced in length, either structurally (if a wafer of bone is removed or the osteotomy is sloped proximally) or functionally (if the osteotomy site heals with elevation of the head); this may create biomechanical shift in load sharing away from the first metatarsal head onto the second and other lesser metatarsals, causing a condition known as transfer metatarsalgia
  • The hallux valgus deformity may relapse as the musculotendinous structures contract in length over time relative to skeletal length, causing the first ray to buckle at the first MTP joint
  • Hallux varus deformity can occur, especially if the medial prominence on the head is excessively resected, the capital fragment is displaced too laterally, or excessive lateral soft-tissue release is performed
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