Lateral Soft-Tissue Release with Medial Transarticular or Dorsal First Web-Space Approach Combined with Distal Chevron Osteotomy for Moderate-to-Severe Hallux Valgus

Abstract

Introduction: We describe the medial transarticular and dorsal first web-space soft-tissue approaches, used in combination with an osteotomy, for the surgical correction of painful hallux valgus.

Step 1 medial transarticular approach skin incision and medial capsulotomy: Make a medial longitudinal skin incision over the first metatarsophalangeal joint, perform a longitudinal midline capsulotomy, and excise the medial eminence.

Step 2 medial transarticular approach distal soft-tissue procedure: Distract and widen the first metatarsophalangeal joint, apply manual traction to the great toe, transect the adductor hallucis, and apply varus stress to the first metatarsophalangeal joint.

Step 3 medial transarticular approach distal chevron osteotomy: Create a v-osteotomy, displace the capital fragment laterally, and impact it onto the shaft.

Step 4 medial transarticular approach postoperative management: Patients walk in a postoperative shoe after surgery, and early metatarsophalangeal stretching exercises are encouraged.

Step 1 dorsal first web-space approach skin incision: Make a 3-cm dorsal longitudinal incision centered on the first intermetatarsal web space.

Step 2 dorsal first web-space approach distal soft-tissue procedure: Dissect the adductor hallucis tendon, transect the fibular sesamoid-metatarsal and transverse metatarsal ligaments, and perforate the first metatarsophalangeal joint capsule.

Step 3 dorsal first web-space approach distal chevron osteotomy: Perform as for the medial transarticular approach.

Step 4 dorsal first web-space approach postoperative management: The same as for the medial transarticular approach.

Results: We studied 122 female patients (122 feet) who had undergone distal chevron osteotomy with a distal soft-tissue procedure for the treatment of symptomatic, unilateral, moderate-to-severe hallux valgus.IndicationsContraindicationsPitfalls & Challenges.

Fig. 1

A medial longitudinal skin incision.

Fig. 2

A longitudinal midline capsulotomy.

Fig. 3-A

The first metatarsophalangeal joint is distracted distally with use of two vein retractors and application of manual traction to the great toe to allow clear visualization of the lateral soft-tissue structures.

Fig. 3-B

The lateral joint capsule (arrow) is visualized through the metatarsophalangeal joint, which is distracted with use of a mosquito clamp.

Fig. 3-C

After the lateral joint capsule is released with use of a number-15 blade, the adductor hallucis tendon (arrow) is observed.

Fig. 3-D

The adductor hallucis tendon is released completely. The dotted lines show the released adductor hallucis, the star indicates the remnant of the dorsolateral joint capsule, and the asterisk marks the proximal phalangeal portion of the released lateral joint capsule.

Fig. 3-E

Illustration showing the conjoined tendon of the adductor hallucis tendon transected from its insertion into the base of the proximal phalanx.

Fig. 4

Varus stress is applied to the first metatarsophalangeal joint to complete the release of the adductor hallucis tendon at the proximal phalanx.

Fig. 5-A

A 60° v-osteotomy is created and centered in the first metatarsal head.

Fig. 5-B

The capital fragment is translated about 7 mm laterally and manually impacted onto the shaft to obtain a stable reduction.

Fig. 6-A

Fig. 6-B

Fig. 7

Postoperative shoe.

Fig. 8-A

The adductor hallucis tendon is identified with use of a mosquito clamp.

Fig. 8-B

The adductor hallucis tendon (arrow) has been released from its insertion at the base of the proximal phalanx of the great toe.

Fig. 8-C

After the fibular sesamoid-metatarsal ligament is released, the fibular sesamoid (arrow) can be observed.

Fig. 8-D

The transverse metatarsal ligament (arrow) has been identified and transected.

Fig. 9-A

The preoperative hallux valgus angle was 38°, the first-second intermetatarsal angle was 19°, and the tibial sesamoid position was grade 3.

Fig. 9-B

Preoperative clinical photograph.

Fig. 9-C

Postoperative anteroposterior radiograph.

Fig. 9-D

The hallux valgus angle was 10°, the first-second intermetatarsal angle was 9°, and the tibial sesamoid position was grade 2 at the time of final follow-up.

Fig. 9-E

Clinical photograph at the time of final follow-up.