Management of Primary and Revision Hallux Valgus, An issue of Foot and Ankle Clinics of North America (eBook)

Andrew Molloy (Autor)

eBook Download: PDF | EPUB

2014 | 1. Auflage
193 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-29938-1 (ISBN)

Infos

This issue of Foot and Ankle Clinics will cover all of the basics of primary and revision bunion surgery, including serveral different osteotomies, techniques, and one section dedicated to pediatric care.

Inhalt

Front Cover 1
Management of Primary and Revision Hallux 
2 
copyright 
3 
Contributors 4
Contents 6
Foot And Ankle Clinics 
9 
Preface 
10 
Scarf Osteotomy 12
Key points 12
Etiology 12
Pathoanatomy 13
Technique 13
Results 18
Complications 22
Summary 24
References 24
Minimally Invasive Osteotomies 28
Key points 28
Introduction 28
Principles of minimally invasive surgery 29
Evolution of minimally invasive first metatarsal osteotomies 29
Minimally invasive Chevron-Akin 30
MICA surgical technique 30
Results 33
Potential complications 35
Summary 35
References 35
Correction of Moderate and Severe Hallux Valgus Deformity with a Distal Metatarsal Osteotomy Using an Intramedullary Plate 38
Key points 38
Introduction 38
Surgical technique 40
Discussion 43
Summary 46
References 46
Rotational and Opening Wedge Basal Osteotomies 50
Key points 50
Rotational osteotomy 50
Introduction 50
Preoperative Assessment 51
Ludloff Osteotomy 53
Decision making 53
Surgical technique 53
Postoperative protocol 56
Basal opening wedge osteotomy 56
Decision Making 56
Surgical Technique 58
Postoperative Protocol 62
Discussion 62
Summary 65
References 65
The Modified Lapidus Fusion 70
Key points 70
Introduction: nature of the problem 70
Indications/contraindications 71
Surgical technique/procedure 72
Preoperative Planning 72
Authors' Preferred Technique 73
Postoperative care 76
Complications and management 76
Summary 77
References 78
Pediatric Hallux Valgus 82
Key points 82
Introduction 82
Pathogenesis 82
Investigation and assessment 83
Conservative management 85
Operative intervention 85
Outcomes of surgery 87
Pathologic hallux valgus 88
Summary 89
References 89
First Metatarsophalangeal Arthrodesis for Hallux Valgus 92
Key points 92
Introduction 92
Pathogenesis of hallux valgus 92
Indications 93
Evolution of the surgical technique 94
Plate design 94
Mechanism of correction 95
Hallux Valgus Correction 97
Intermetatarsal Angle Correction 97
Severity of IMA 97
Operative technique 97
Incision 98
Joint Preparation 98
Positioning and Fixation 98
Results 98
Important surgical issues 98
Poor Bone Quality 98
Severe Hallux Valgus Angle 99
Poorly Correcting Intermetatarsal Angle 99
Infected Bunion 100
Associated Interphalangeal Joint Arthritis 101
Smoking 101
Functional outcomes 101
Pedobarograph and Gait Changes 101
Time to Fusion 102
Return to Work 102
Driving 102
Summary 102
References 102
Recurrence of Hallux Valgus 106
Key points 106
Epidemiology 106
Patient Risk Factors: Anatomic 107
Nonanatomic Patient Factors 107
Surgeon-Related and Surgery-Related Risk Factors 108
Reasons for recurrence 109
Presenting Symptoms 109
Choice of Surgery 110
Surgical Technique 111
Postoperative Complications 111
Primary HV algorithm 111
Treatment of revision hallux valgus 111
Nonoperative Treatment 112
Operative Treatment 112
Metatarsophalangeal Fusion 113
Lapidus Procedure 114
First Metatarsal Osteotomy 115
Discussion 117
Summary 119
References 120
The Treatment of Iatrogenic Hallux Varus 122
Key points 122
Introduction 122
Classification and treatment 123
Clinical examination and investigation 123
Nonoperative treatment 123
Operative treatments 124
Soft-Tissue Rebalancing 124
Tendon Transfer Procedures 124
Tenodeses 125
Synthetic Ligamentous Reconstructive Procedures 125
Corrective Osteotomies 126
Reconstruction of the Medial Eminence of First Metatarsal Head 127
Arthrodesis 129
Summary 130
References 130
Transfer Metatarsalgia Post Hallux Valgus Surgery 132
Key points 132
Introduction 133
Pathomechanics 133
Forefoot, metatarsalgia, and gait 134
Clinical examination 136
Radiological evaluation 136
Treatment of transfer metatarsalgia after hallux valgus surgery 138
Conservative 138
Orthoses 139
Shoes 139
Surgical 139
First metatarsal 139
First metatarsal nonunion 139
First metatarsal malunion 141
Undercorrection/Recurrence 141
Overcorrection/Hallux varus 142
Shortening 142
Elevation 142
Plantarflexion 144
Others 144
Lesser metatarsals 144
Metatarsal head resection 144
Condylectomy 145
Tilt-up osteotomy 146
Proximal osteotomies 146
Cervico-cephalic distal Weil and triple Weil osteotomy 146
References 152
Treatment of Shortening Following Hallux Valgus Surgery 156
Key points 156
Introduction 156
Incidence of shortening after first MT osteotomy 156
When is first MT shortening symptomatic? 157
Clinical features 158
Treatment of first MT shortening 158
Lengthening Step-Cut Osteotomy 158
Distraction Bone Block Arthrodesis 161
Summary 162
References 162
Index 164

Textauszug

Minimally Invasive Osteotomies

David Redfern, FRCS(Tr&Orth)a∗[e-mail] and Anthony Michael Perera, FRCS(Orth)ab,     aLondon Foot & Ankle Centre, Hospital St John & St Elizabeth, 60 Grove End Road, London NW8 9NH, UK; bSpire Cardiff Hospital, Croescadarn Road, Cardiff, CF23 8XL, UK

∗Corresponding author.

As orthopedic surgery continues to head in the direction of less invasive surgical techniques, this article explores the application and evolution of minimally invasive/percutaneous techniques in the surgical correction of hallux valgus deformities. Modern techniques are described and available literature is reviewed.

Keywords

Hallux valgus

Bunion

Minimally invasive

Percutaneous

MICA

Chevron

Key points

• Specific cadaveric training is mandatory for any surgeon considering performing minimally invasive surgical techniques.

• Cadaveric training is absolutely vital in avoiding unnecessary complications and minimizing the surgeon's learning curve.

• Available data suggest that the minimally invasive Chevron-Akin procedure is a safe alternative to open techniques for hallux valgus correction, although whether minimally invasive techniques such as this offer significant advantages for patients in terms of postoperative morbidity, reduction of stiffness, return to function, and outcome requires further scientific scrutiny.

• Minimally invasive surgical techniques for correction of a wide variety of forefoot and hindfoot abnormalities are currently gaining popularity among European surgeons, and this is an interesting area of development.

Introduction

During the past 20 years, surgery has seen an inexorable trend toward less invasive and keyhole approaches. For instance, in the field of general surgery, laparoscopic cholecystectomy and appendicectomy have become firmly established as the surgical gold standards. If an equivalent technical result to an open surgical procedure is possible to achieve with a safe but less invasive approach, then better patient outcomes ought to follow, and the profession should continue to strive in this direction.

Orthopedics has not been left behind in this less invasive evolution. Arthroscopic ankle cheilectomy and arthroscopic ankle fusion are replacing open approaches. However, minimally invasive hallux valgus surgery has been slower to establish. In fact, the number of proposed open procedures to treat this condition continues to increase. However, the Arbeitsgemeinschaft für Osteosynthesefragen (AO) group's principles of minimizing soft tissue trauma and periosteal stripping are just as relevant to hallux valgus surgery as they are to fracture management.

Perhaps this reluctance to embrace minimally invasive techniques in hallux valgus correction is partly explained by the general perception that bunions are “easy to do and easy to get wrong.”

In fact, a literature review shows that approximately 85% of patients report good outcome after open hallux valgus correction. Analysis of the remaining 15% reveals frequent issues with stiffness and pain related to the soft tissues rather than purely osteotomy issues. Thus, perhaps the key to improving outcome after hallux valgus surgery lies in a less invasive soft tissue approach rather than which of the myriad described osteotomies is used. That said, early minimally invasive techniques failed to adhere to the AO principles of rigid internal fixation and early mobilization and have been associated with poor outcomes, adding fuel to concerns that “minimally invasive” equates to “easier to get it wrong.”

Principles of minimally invasive surgery

The term minimally invasive refers to the skin incision/approach, not the type of osteotomy used. Despite this, several disparate operations using minimally invasive techniques are frequently grouped together under the “minimally invasive” banner in a way that does not make sense and does not occur when referring to open techniques. The ability to differentiate between different techniques is important for meaningful and rational comparison to be made.

Evolution of minimally invasive first metatarsal osteotomies

Less invasive procedures were promoted by Wilson1 and Bösch and colleagues2 in the 1980s. The latter was a more percutaneous approach and used a subcapital Hohmann osteotomy3 through a short vertical incision at the level of the neck of the metatarsal. However, the first truly minimally invasive technique to gain prominence was a modification of the Reverdin osteotomy4 developed by Stephen Isham5 published in 1985 (and more recently popularized by Mariano De Prado in Spain).6 Isham5 developed a modification of the Shannon burr with end and side cutting performance to perform an oblique medial closing wedge osteotomy of the head of the first metatarsal. The osteotomy was extra-articular but intracapsular. He combined this with a minimally invasive Akin operation, bunionectomy, and adductor release. He believed that this construct was sufficiently stable that no internal fixation was required, and used postoperative rehabilitation as for a minimal incision Silver-Akin procedure, using postoperative splint dressings to stabilize the correction.

Isham and Nunez7 stated that a marked improvement of short-term and long-term results were immediately apparent. However, although these investigators acknowledge that the average shortening is 5 mm and that this can be greater, they do not describe any related complications.

The lack of fixation and the degree of shortening inherent in this procedure are causes for concern, and the results have not been reproduced8 despite the large-scale uptake by podiatrists in the United States in the 1970s to1990s. In fact, sparse independent literature exists on the Reverdin-Isham procedure.

Perhaps because of poor experiences associated with these early minimally invasive techniques,9 little interest has been shown in minimally invasive surgery in the United States in recent years. The next stage of development has occurred in Europe, where several centers have been developing minimally invasive techniques and showing positive results with reduced inpatient stay and better recovery,10 which has served to reignite interest and add momentum to the evolution.

The Bosch osteotomy has regained interest in Europe and was popularized by Magnan and colleagues11,12 and Giannini and colleagues,13 who called his modification the SERI (Simple, Effective, Rapid, Inexpensive). Excellent results with full correction, mean American Orthopaedic Foot & Ankle Society (AOFAS) scores of 91.8, and no significant complications have been published,14 even at 10-year follow-up.15 However, it is concerning that these procedures use an inherently unstable vertical osteotomy at the level of the neck, which is splinted by a single K-wire (passed through the soft-tissues of the medial hallux and then run down the medullary canal of the metatarsal) rather than rigidly internally fixed.

Independent analyses of this technique have generally failed to reproduce good results,16 even with a second K-wire to transfix the osteotomy.17 In a prospective study, Kadakia and colleagues9 reported almost universally poor results even at short-term follow-up, with some patients experiencing major complications, such as dorsal malunion (70%), recurrence (40%), osteonecrosis, and wound complications. The investigators discontinued the study after only 3 months because of the magnitude and frequency of the complications observed.

Minimally invasive Chevron-Akin

The wish to pursue the sound (AO) principles of modern fracture fixation must lead not only in the direction of less invasive (or perhaps better described as less disruptive) soft tissue surgery but also toward stable internal fracture fixation. Thus, applying this to hallux valgus surgery, the objective should be to achieve an accurate and controllable osteotomy with stable internal fixation without compromising the soft tissue envelope of the fracture or adjacent hallux metatarsophalangeal joint (MTPJ). It is from these objectives that the minimally invasive Chevron-Akin (MICA) has been proposed. Developed by Joel Vernois and David Redfern in the United Kingdom,18 this technique involves the use of percutaneous surgical techniques to create a chevron-type osteotomy at the level of the distal diaphyseal-metaphyseal junction of the first metatarsal and an Akin-type osteotomy of the hallux proximal phalanx, both of which are internally fixed with compression screws and combined with a percutaneous distal soft tissue release.

The MICA technique is the first minimally invasive hallux valgus correction technique to truly marry the perceived advantages of an extracapsular first metatarsal osteotomy in which the fracture soft tissue envelope is preserved with rigid...

Produkt-Details

• Erscheint lt. Verlag: 9.8.2014
• Sprache: englisch
• Themenwelt: Medizinische Fachgebiete ► Chirurgie ► Unfallchirurgie / Orthopädie
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete ► Orthopädie
• ISBN-10: 0-323-29938-5 / 0323299385
• ISBN-13: 978-0-323-29938-1 / 9780323299381