62 and 63 - HAV II Flashcards
1
Q
Medial eminence procedure
A
- Removal of the bump
- In a normal healthy patient with a bunion, the medial eminence is a radiographic artifact
- In an old person with a long-term bunion, there may actually be a bump on the medial side
2
Q
Hallux varus
A
- A common complication of HAV correction because we have removed a normal part of the joint by removing the medial eminence
- We mean transverse plane – the hallux rotates medially
3
Q
Indications for bunion surgery
A
- Symptoms that interfere with normal daily activities
- Severe or rapidly developing deformity in young patients
- Skin breakdown and ulceration
- NOT a cosmetic procedure??
- You are not going to solve the deformity with a pad – need to explain the options
- If your patient is fully informed, you can schedule surgery on the first appointment
4
Q
Ideal bunion procedure (went through really quick)
A
- Corrects a wide range of deformity
- Useful in broad patient population
- Allows early ROM and ambulation
- Requires minimal tissue disruption
- Consistent healing characteristics
- Low recurrence rate
- Follows established mechanical and biologic rules
5
Q
Surgical planning (went through really quick)
A
- Indications for procedure
- Medical concerns
- Anesthesia
- Hemostasis
- Exposure / Incision
- Osteotomy
- Fixation
- Closure
- Postoperative course
6
Q
Technical considerations (went through really quick)
A
- Blood supply
- Parallelism of cuts / Axis guides
- Troughing
- Bone removal
- Fixation
7
Q
Incision (went through really quick)
A
- Allows access to structures to be manipulated
- Must produce minimal damage to associated structures
- Consider cosmetic factors
- Consider potential local irritation
8
Q
Traditional bunion incision
A
- Dorsal-medial incision
- Medial and adjacent to the extensor hallucis longus
- Subcutaneous dissection for extracapsular lateral release
- Dorsal capsulotomy
- Medial capsulorrhaphy in the subcutaneous pouch
9
Q
Medial exposure to first MPJ – Her procedure of choice***
A
Medial exposure procedure: o Medial midline o Subcapsular dissection o Intracapsular lateral release o Away from vital tendons, synovial folds and blood supply o Well suited to distal osteotomies o Adjunct to proximal procedures
Does not disrupt blood supply: Combination of axial vessels along the fascia and perpendicular vessels from deeper tissue layers
10
Q
Advantages to medial exposure
A
o Less dissection
o Less disruption of blood supply
o Direct visualization of sesamoids
o Preserves the dorsal synovial fold
o Contracture is out of the plane of motion
o Reinforces correction because it is in the plane of deformity
11
Q
Disadvantages of medial exposure
A
o No access for adductor transfer
o Less visualization for lateral release if needed
o No access to EHB
o Hypertrophy of scar may lead to pain in shoes.
12
Q
Scar tissue contracture
A
o Fibrosis of subcutaneous and capsular structures leads to limited motion
o Most detrimental in the plane of motion
o Limited by careful tissue handling, proper placement, and early range of motion
13
Q
Incision landmarks
A
o Midpoint medial on the: shaft, metatarsal head, and proximal phalanx
o Slightly curved in appearance
o Splits the dorsal and plantar neurovascular bundles on the medial side
14
Q
Capsulotomy
A
- Landmarks are the same as for the skin incision
- Minimal reflection is needed to provide exposure for osteotomy
- Dorsal synovial fold is left intact
15
Q
Subcutaneous dissection
A
- Just enough to visualize the capsule
- Neurovascular bundles are left undisturbed in the dorsal and plantar flaps
- Minimal reflection is needed to expose the capsule
16
Q
Joint inspection and sesamoidectomy
A
- Direct visualization
- Lateral ligament release is first
- Dissection is above the long flexor and parallel
17
Q
Closure
A
- Capsule is approximated to reinforce correction
- Subcutaneous layer and skin is closed in standard fashion
18
Q
SOFT TISSUE AND PHALANGEAL OSTEOTOMIES
A
- 1st MPJ Capsulotomies
- Lateral Release
- Silver Bunionectomy
- McBride Bunionectomy
- Adductor Tendon Transfer
- SHOULD ONLY BE PERFORMED ON POSITIONAL DEFORMITIES
19
Q
Contraindications to Isolated Soft Tissue Procedures
A
- Degenerative joint changes
- Restricted ROM at MTPJ
- Pain with joint stress
- A track-bound joint
- Congruous MTPJ
- IM angle > 12
- HAA > 40
20
Q
First MTPJ capsulotomies
A
- There are many different incision shapes… It’s just “surgeon preference”
- Should give good exposure for procedure being performed
- Meticulous closure, do not overlap
- No capsular closure can correct a structural deformity
21
Q
First MPJ capsulorrhaphy
A
- Reefing of the medial capsule
- Removing redundant capsule
- Too aggressive of a capsulorrhaphy can cause hallux varus or a stiff MTPJ with jamming
- Inadequate repair of the capsule can lead to loss of correction (…or is it that we didn’t actually address the deformity)
22
Q
Lateral release (read on your own)
A
- Perform to realign the first metatarsal head over the sesamoids and release contracture (Is this needed if sesamoids are actually where they should be relative to the crista?)
Includes release of:
o Conjoined adductor hallucis tendon,
o Deep transverse intermetatarsal ligament
o Lateral collateral ligament (vertical capsulotomy)
o Fibular suspensory ligament (fibular sesamoid release)
Do not release fibular suspensory ligament if you want the sesamoids to move with the metatarsal head
23
Q
Silver bunionectomy
A
- Partial ostectomy of the first metatarsal head
- Does not correct the etiology of the problem
- Removes bump only (which may indeed be an artifact in many cases)
- Cons: Weakens medial structures, causing more lateral drift, Progression of deformity continues
24
Q
Silver bunionectomy: Indications
A
- Medial bump pain with shoe wear (Neuritic pain)
- Bunion deformity present
- Pain-free and adequate ROM
- Medial bursa
- HAV, mild
25
Silver bunionectomy: Technique
- Access joint
- Saw used to remove medial eminence
- Care to preserve sagittal groove for sesamoid
- Ambulate post-op
26
Staking the head
- Removing too much of the bone and loosing part of the articular surface
- Take more bone dorsally and preserve tibial sesamoid shelf to prevent hallux varus
27
Advantages of silver bunionectomy
- Quick
- Little edema
- Easy
- No special equipment
- Early WB and return to shoe gear
28
Disadvantages of silver bunionectomy
- Doesn’t address etiology
| - Weakens medial MPJ and results in further abductovalgus
29
McBride Bunionectomy
- Removal of medial eminence (Silver)
- Release or transfer of adductor hallucis tendon into medial met head
- May include removal of fibular sesamoid
- Often used in combination with osseous procedures for structural deformities to rebalance soft tissues
30
McBride Bunionectomy: Indications
- Medial bump pain with shoe gear
- Pain with tibial or fibular sesamoid
- HAV deformity
- Pain-free and adequate ROM
- Medial bursa
- Deviated to subluxed 1st MPJ
- Frontal plane deviation of sesamoids
31
McBride Bunionectomy: Technique
- Access joint
- Capsulotomy
- Remove medial eminence with saw
- Lateral release
- Possible removal of fibular sesamoid
- Adductor Hallucis tendon transfer
32
Fibular Sesamoid: To Remove or Not to Remove?
- Controversial
- “Deforming force” (Or is it that we don’t realign it appropriately by addressing the coronal plane?)
- “Must address it”
- Con: if you remove it, “may end up with a hallux varus” - Quoted, but literature does not support
- Likely only if done in conjunction w/ other procedure that put at risk for hallux varus
- Pro: if you remove it, less chance of recurrence (or address the deformity and decrease risk of recurrence)
- Recent evidence does NOT support the removal of the fibular sesamoid this at all
33
McBride bunionectomy
Advantages
o Early WB
o Minimal bone resection
Disadvantages
o Limited correction as isolated procedure
o Cannot be used alone for a structural deformity
34
Adductor tendon transfer (did not talk about – “not common”)
- Transfer tendon to medial aspect of 1st MPJ
- Relocates sesamoids, closes down IM angle
- Requirements for sesamoid realignment: Normal crista, no degenerative sesamoids, no osteotomy in conjunction,
- Frontal plane deviation of sesamoids? The sesamoids are where they should be – the entire complex with the 1st met is rotated
35
Complications of all soft tissue procedures
- Recurrence
- Hallux varus
- Joint jamming
36
Hallux phalangeal osteotomies
- Phalangeal osteotomies originally described by Akin in 1925.
- Original procedure included:
o Resection of medial eminence 1st met head
o Resection of medial base proximal phalanx
o Phalanx osteotomy
- Correct structural deformity at some level within the hallux.
37
Hallux osteotomies: Indications
- Pain
- Hallux abuts 2nd toe
- HAV
- Congruous 1st MTPJ
- Long proximal phalanx
- Structural deformity within the hallux
38
Proximal akin
- Medial closing wedge osteotomy in metaphyseal bone of proximal hallux
- Lateral hinge left intact
- Hinge should be perpendicular to WB surface
39
Proximal Akin: Indications & Technique
- To reduce DASA to zero, make proximal cut parallel to joint and make the distal cut perpendicular to long axis
- Distal osteotomy performed 1st
- Indications:
o Increased DASA
o MPJ must be congruent
o Cannot correct IM, subluxed joint or high PASA
- Can do a “Cheater” Akin when the first procedure you did, IM was not corrected to get toe to look straight
40
Proximal akin fixation
- Monofilament wire, K-wire, staples, screw
41
Distal akin
- Medial closing wedge osteotomy of the distal aspect of the proximal phalanx of the hallux
- Indications:
o Abnormal hallux interphalangeal abductus angle
o Long proximal phalanx
42
Oblique akin
- Abnormal Hallux inter-phalangeus or abnormal DASA
| - Can use cortical lag screw fixation
43
Complications of hallux osteotomies
- Delayed union and non-union
- Loss of correction
- Failure of Fixation
- Angular deviation
- Extensus deformity
44
METATARSAL OSTEOTOMIES
- Do these with LOW IM angle or really high IM angle in conjunction with base
45
List of metatarsal osteotomies
- Reverdin
- Reverdin Green
- Reverdin Laird
- Reverdin Todd
- Peabody
- Roux
- Drato
- Hohman
- Mitchell
- Austin
- Offset – V
- Capp
- Wilson
- Scarf
- Ludloff
- Mau
46
Reveridin
- Osteotomy in metaphyseal are of the 1st metatarsal area of the 1st metatarsal head for correction of abnormal PASA
- Lateral cortex is left intact
- Distal cut is made first, parallel to joint surface
- Proximal cut is made second, perpendicular to long axis of 1st metatarsal
- Indications: slightly increase IMA (less than 8°), increased PASA, congruous or deviated 1st MPJ
- Contraindications: painful ROM, large IMA, short 1st met
- Post-op: WB in a surgical shoe as tolerated
47
Complications to Reveridin
- Decrease in joint ROM
- Sesamoiditis
- No correction of IM angle
- Hallux Varus - overcorrection
48
Reverdin – Green
- Addresses abnormal PASA
- Reverdin with a plantar shelf to protect the sesamoids
- Plantar shelf is made parallel to weightbearing surface
49
Reverdin-Laird
- AKA: Reverdin-Green-Laird
- Addresses abnormal PASA and increased IM angle
- Osteotomy is through and through the lateral cortex
- Plantar shelf protects sesamoid apparatus
- If modify axis for bone cut, can plantarflex or shorten
- Capital fragment is transposed laterally to close down IM
50
Reveridin-Todd
- Addresses PASA, IMA, Elevated Met. Head
| - Protects sesamoid apparatus
51
Hohmann
- Coming back into “vogue” with MIS surgery
- Trapezoid wedge at anatomic neck of metatarsal
- Capital fragment transposed laterally and depressed plantarly
52
Hohmann indications
- Abnormal PASA
- Higher IMA (9-14º)
- Elevatus
53
Hohmann contraindications
- Painful ROM
- Osteopenia
- Short 1st. Met.
54
Hohmann complications
- Instability of capital fragment
- Possible Delayed Healing
- Excessive shortening
55
Mitchell
- Transpostional, step-down osteotomy
- Corrects IM angle and Plantarflexes metatarsal head
- Distal cut made 1st, from medial to lateral across 2/3 of the width
- Proximal cut is made 2nd and is parallel to 1st cut, and is angled
dorsal-distal to plantar-proximal through the lateral cortex
56
DRATO
- Derotational, angulational, transpositional osteotomy
- Performed in neck of metatarsal
- Can dorsiflex capital fragment if needed to increase dorsiflexion of MTPJ
- Very specific criteria, so rarely used
57
Indications for DRATO
- Mild increase in IM
- Abnormal PASA
- Valgus rotation of met. Head
- Plantar deviation of articular cartilage
58
Series of osteotomies in DRATO
- Complete osteotomy at met neck perpendicular to long axis in transverse and sagittal planes
- Capital fragment is derotated (reducing valgus)
- 2nd osteotomy is performed distal to 1st cut, resecting a wedge of bone with the base medial and apex lateral (reducing PASA)
- 3rd osteotomy is performed resecting a wedge of bone with the base dorsal and apex plantar (dorsiflexing articular cartilage)
- Capital fragment is transposed laterally (reducing IMA)
59
Advantages of DRATO
- Addresses 4 deformities
60
Disadvantages of DRATO
- Very difficult to perform
- Done in cortical bone
- Elevatus due to overcorrection
61
Austin
- ***GO-TO PROCEDURE***
- Horizontal “V” osteotomy
- Aka: Chevron
- Apex in central metatarsal head
- Angle of apex is 60 degrees********
62
Austin correctional
- ***Unicorrectional Austin: Reduces IMA
- ***Bicorrectional (with wedge) Austin: Reduces IMA and PASA
- ***Biplane Austin: Reduces IMA and addresses sagittal plane
- Cannot correct frontal plane with any Austin
- Osteotomy cut causes ~1mm of bone loss (for unicorrectional and biplane and an additional ~2mm for screw fixation and bone healing = ~3mm bone loss
63
****Biplane Austin **********
- THEORETICALLY allows you to shorten, lengthen or plantarflex the metatarsal based on the deformity you are trying to correct
o If you have a short metatarsal… Move your pin more PROXIMAL and you will lengthen your osteotomy
o If you have a long metatarsal… Move your pin more DISTALLY and you will shorten your osteotomy
o If you have plantarflexed metatarsal… Move your pin more PLANTARLY and you will dorsiflex/elevate your osteotomy
- If you want to plantarflex and lengthen your first metatarsal, you need to place your pin proximal dorsal medial to lateral plantar distal*** PIN GOES IN MEDIAL TO LATERAL (ALWAYS)
64
Indications for Austin
- Increased IMA (9-15º) – small IMA
- Mild to Moderate HAA
- Variable Metatarsal length
- Congruous to deviated 1st MPJ
65
Contraindications for Austin
- Significant elevatus
- Abnormally high metatarsal protrusion distance
- Limited or painful MPJ ROM
- Narrow metatarsal
- IMA > 18 degrees
66
****Long dorsal arm to increase area for fixation. 55° angle to cut****
- This will help with SCREW FIXATION***
67
Fixation for Austin
- Historically, none performed: stable osteotomy if you impact capital fragment on to shaft of metatarsal
- Now fixation is standard
- PO: WBAT in surgery shoe
68
Complications for Austin
- Fracture at Apex if cut too far distally
| - Risk of Avascular Necrosis
69
METATARSAL OSTEOTOMIES
We're moving on, FYI
70
Scarf
- “Z” osteotomy in diaphyseal and metaphyseal bone
- 3 cuts oriented from medial to lateral through the first metatarsal shaft
- Primary osteotomy is longitudinal and 2 shorter arms exit distal dorsal and proximal plantar
- Arms are angled between 60 to 80 degrees from longitudinal osteotomy
- Dorsal shelf provides resistance of the capital fragment against WB forces
- Straight transposition of the “z” gives same correction as an Austin
- Rotational Scarf allows for maximum IMA reduction (rotation of distal portion medial)
- Rotation of proximal portion of SCARF medial after transverse movement can correct some PASA at the expense of IMA correction
71
Indications of scarf
- Abnormal IMA
- The wider the metatarsal the greater the IMA correction that can be achieved
- Minimal Increase in PASA
72
SCARF – Technique
- Soft tissue dissection 1cm proximal to met-cuneiform joint to hallux
- Axis guides in central metatarsal and midline of bone 1-2 cm distal to met-cuneiform joint
- Axis guides must be parallel to each other
- Longitudinal cut made first
- Traditional SCARF: arms made distal dorsal and proximal plantar (60-80 degrees)
- Inverted SCARF: distal plantar and proximal dorsal
- Post op: Weight bearing in surgery shoe as tolerated
73
Transpositional Scarf
- Not for high IMA
- No gapping with transposition
- Corrects IMA only
74
Rotational Scarf
- High IMA
- Gapping proximal and distal sites
- Corrects IMA and or PASA
75
Z-Scarf osteotomy
Indications:
o “Moderate Bunion” 13-20 degrees
o Relatively short 1st metatarsal
o Okay with open physeal plate
Midshaft Procedure- Bridging procedure between proximal and distal
o Increased stability- do to length of osteotomy, ability to fixate
```
Considerations
o Metatarsal width
o Bone stock, no osteopenia
o Ability to comply with po course (NWB)
o MPJ (arthrosis)
```
76
Traditional/rotational vs inverted Scarf
Traditional/rotational
o Weaker than inverted
o Troughing dorsiflexes head
o Same correction achieved
Inverted scarf
o ***1.6 times stronger than traditional scarf ***
o Troughing plantarflexes head
o Same correction achieved
77
Complications of Scarf
- Troughing: One cortical edge falls into the medullary canal of the other segment
- Results in elevation of the capital fragment
- Seen more with transpositional than rotational SCARF (more overlap of cortex)
78
Advantages of Scarf
- Corrects larger IMA than distal osteotomies
- Immediate WB
- Can lengthen or shorten
- Can achieve mild sagittal plane correction
- Can correct mild PASA
79
Disadvantages of Scarf
- Increased soft tissue dissection
- IMA correction dependent on width of metatarsal
- Technically difficult?
- Troughing
- Correcting PASA reduces IMA correction
- May need bone grafting if gapping is significant
80
Contraindications of Scarf
- High PASA
- Significant sagittal plane deformity
- Narrow metatarsal width
81
PROXIMAL BASE PROCEDURES
Moving on, FYI
82
Basilar Bunionectomy (“Base Wedge”)
- Advantage in large deformities
- Some have better correction in three planes (though not complete)
- More anatomic that distal procedures (Closer to CORA)
- Technically difficult (axis guides, elevation, shortening)
- Many options for cut type (traditional base wedge, oblique base wedge, crescentic, crescentic shelf)
- Longer period of NWB
83
Basilar osteotomies
- Closing Base Wedge (CBWO)
- JUVARA - Oblique osteotomy that extends from proximal-medial
to distal-lateral creating an intact medial cortical hinge
84
Hinge-axis guide
o Perpendicular to metatarsal=dorsiflexion
o Perpendicular to WB surface= no dorsi/plantarflexion
o Frontal plane position of pin results in dorsi/plantarflexion
85
Fixation
o Anchor screw- perpendicular to the metatarsal axis
| o Compression screw-perpendicular to osteotomy
86
Hinge axis concept
- Hinge axis can be altered to create desired dorsiflexion or plantarflexion of distal segment
- Plantarflexion - Superior pole of axis angled lateral creating a dorsal-medial hinge
- Dorsiflexion - Superior pole of axis angled medial creating a plantar-medial hinge
87
Closing base wedge notes
- We are going to make an osteotomy and close it
- Essentially we are going straight in – dorsal to plantar to close down the IM angle
- The orientation of the axis of the ankle joint is medial to lateral so you get opposite movement
- Get motion opposite to your axis
- Transverse plane motion then
- Elevate the 1st metatarsal with a dorsal pin
- If you move the superior pull lateral, you move the proximal
- NO QUESTION ON IT, BUT YOU WILL IN THE FUTURE
88
What to know
Take a little time understanding the open vs closed – WHERE THE WEDGE IS AT – WHERE THE HINGE IS
89
Trethowan
```
- Opening Base Wedge (OBWO)
o Lengthens metatarsal?
o Utilize bone graft
o Plate fixation
- Use bone from medial eminence or from proximal phalanx into the opening site
```
90
Logroscino
- Double first metatarsal osteotomy
| - Base wedge osteotomy (Trethowan)combined with a first metatarsal head procedure (Reverdin)
91
Crescentic
- ****Go to answer if you get a question about repairing a bunion in a patient who already has a short 1st metatarsal because it is only 1 cut and only 1 saw blade going through the bone, so you will only lose 1 mm ***
- Minimal shortening
- Can address large IMA
- Can rotate in frontal plane
- Difficult to fixate (typically k-wires)
- Can add plantar shelf to allow for improved fixation
92
Epiphysiodesis: Juvenile HAV with open physis********* KNOW THIS
- Arrest of the lateral portion of the physis
- Medial portion open and continues to grow – Leads to lateral movement of the 1st metatarsal, closing down the IM 1-2
- Timing is critical… Adequate ossification of the epiphysis needed to secure fixation, enough growth remaining needed to result in IMA reduction
- Somewhat of a guess as to when and how much
- Must address other pathologies (flat foot, metadductus)
93
Notes on epiphysiodesis
o Not done very commonly – need to understand the principle
o Done in a patient with an open growth plate
o The idea is that if you arrest the growth laterally and let it continue to grow medially, it will straighten the deformity
o Really hard to do and not very common – it’s a crap shoot
o Need to understand the timing… Need to have enough time of growth left, but not too much
o Need a way to fixate the lateral portion – REVIEW THIS *******
94
Lapidus arthrodesis (“we have already talked about this”)
- First metatarsal-cuneiform arthrodesis
- Traditionally used for first ray “hypermobility”, juvenile HAV (with closed physis) cuneiform diastasis, large IM angle or degenerative arthritis
- Newer line of thought – Procedure of choice for all bunions without MTPJ arthrosis
- Address the deformity at the CORA and in all three planes
- Corrects ALL deformities
- Adds mechanical stability to foot
- Corrects in three planes better than any other procedure
- Lowest recurrence rate
- Most anatomic, corrects at CORA (apex of deformity)
- Truly realigns the 1st MTPJ
- Most complicated?? This is arguable
- Traditionally must not walk until healed… May be able to do protected WB immediately or relatively early with newer fixation
95
***KNOW THIS – Traditionally sited causes of hallux varus***
- Over correction of IMA
- “Staking” of the metatarsal head
- Overzealous medial capsulotomy
- Over aggrieve lateral release
- Removal of the fibular sesamoid
96
“Trick question” - Resident causes a hallux varus by bandaging too tight
- This is FALSE – Cannot cause a hallux varus unless the procedure was done wrong
