3. Capsule Tendon Balance

Question 1

capsule tendon balance procedures:

purpose

Answer 1

1. remove the bump
2. assist in relocating the sesamoids back under the metatarsal head
3. derotate the toe

(in this procedure, the metatarsal head is actually RELOCATED over the sesamoid apparatus)

Question 2

capsulotomy:

define

Answer 2

opening up capsule to expose MT head

Question 3

capsulorrhaphy:

define

Answer 3

cutting out a piece of capsule in order to balance the soft tissues

Question 4

skin incisions for bunionectomies:

Answer 4

• (MC) longitudinal (curved to straight) medial to EHL; ~6 cm in length
• medial incision

Question 5

why is the longitudinal incision performed

MEDIAL to the EHL?

Answer 5

when making an incision, it goes from INCISION down to the BONE;

(skin, subQ, capsule); so it needs to be medial to the EHL

(also best to give exposure to medial and lateral side of joint)

Question 6

why does Dr. P not like medial incision for HAV?

Answer 6

higher risk of nerve entrapment;

scar formation in this area will rub/irritated by shoes

Question 7

types of capsulotomies?

Answer 7

Dorsal is more common than medial

• DORSAL capsulotomy:
  
  • Dr. P prefers “Dorsal Linear”; fewer cuts = less fibrosis, still allows you to see everything
  • Others: Lenticular, Washington Monument, inverted L, dorsal I
• MEDIAL capsulotomy:
  
  • “I” shaped is most common of medial
  • The others (Vertical, U, H, and L) all required too much dissection

Question 8

describe the Lenticular capsulorrhaphy:

Answer 8

• ellipse done on an angle; a dorsal capsulorrhaphy
• depending on how you bias the stitches:
  
  • you can get a bit of soft tissue FRONTAL PLANE CORRECTION
  • if bias transversely, can get ST TRANSVERSE plane correction

Question 9

describe the Washington Monument capsulorrhaphy:

Answer 9

• *STRONGEST CAPSULOTOMY/ CAPSULORRHAPHY
• Process:
  
  • similar to “U”, make cut in capsule, take flap and pull it back, do whatever work you need to do; –>
  • then suture bottom part, pull top part to help tighten up medial structures when closing

Question 10

exostectomy:

define

Answer 10

removal of medial eminence

Question 11

exostectomy:

function

Answer 11

• removes the bump
• assists in tightening the medial capsule; (because it “roughs up the bone”)

Question 12

two options for instrumentation for medial eminence removal

Answer 12

• 1st choice: power equipment, including the sagittal saw (less oscillation, more direct of a cut)
  
  • do NOT use an oscillating saw
• 2nd choice: osteotome and mallet

Question 13

sagittal saw/ angle:

technique

Answer 13

slanted plantar and medial to preserve the plantar-medial facet/tibial sesamoid articulation

Question 14

what happens if you resect the bump straight WITHOUT an angle,

what can happen?

Answer 14

1. you might destroy the medial plantar facet –>
2. causing the tibial sesamoid to sublux –>
3. likely causing hallux VARUS/addcutus deformity

Need to angle PLANTARLY to protect tibial articular facet and preserve plantar facet

Question 15

why don’t you complete the exostectomy first in an HAV procedure?

Answer 15

If you resect it first, you might end up resecting too much.

Better to remove a “thin little sliver” so you have what looks like a round circle underneath, and then complete OSTEOTOMY—>

can always take off any remaining bump after

Question 16

hallux varus:

define and etiology

Answer 16

• triplane deformity, when the joint no longer articulates as it should –> cartilage starts to erode
• etiology: iatrogenic; if patient ends up with hallux varus after sx, chances are you did something wrong, regardless of patient compliance

Question 17

what are the capsule tendon balancing procedures?

Answer 17

• silver
• mcbride
• modified mcbride
• hiss
• mini-tightrope