By Jay Lieberman, DPM, FACFAS Director of Podiatric Medical Education
Northwest Medical Center
Click on the images below for a larger view.
Fig. 1: This x-ray shows the results of a minimally invasive repair of a hallux valgus deformity on a 29-year-old female. The remnant of the osteotomy suggests that a distal medial to proximal lateral bone cut was made in an attempt to trans-locate the capital fragment laterally. Unfortunately, reduction of the intermetatarsal angle was over zealous, resulting in a varus position of the toe. This also resulted in elevation and iatrogenic shortening of the first ray.
Fig. 2: On clinical presentation, the patient demonstrated a large subungual clavus along the medial border of the nail.
Prophylactic care was unsuccessful at controlling the problem in the long term. Transfer metatarsalgia was pronounced because of elevation of the first ray. The metatarsal phalangeal joint was track bound and restricted in a varus position. There was a dorsal medial prominence in the head of the first metatarsal.
Conservative approaches included use of a neutral posted orthotic with Morton's extension in a depth type shoe. This alternative was not practical for a 29-year-old fashion conscious woman.
The patient was brought to surgery. A plantar flexory and adductory osteotomy of the left first metatarsal was performed in conjunction with a reduction (chielectomy) of the dorsal prominence. The osteotomy was oriented in a dorsal distal to proximal plantar direction. A five to six millimeter thick fibular shaft allograft was placed in the space between the capital fragment and the first metatarsal shaft. The osteotomy/bone graft was maintained in place with two twenty four millimeter cannulated screws.
Fig. 3: The residents and I noted the ease in which the varus component of the problem was corrected with a simple L shaped capsular release. The postoperative AP view is deceiving; as it appears that the metatarsal parabola had not been altered significantly. Looking at the lateral view, it becomes clear that the capital fragment is in an improved (declinated) position.
Fig. 4: Graft incorporation is readily visualized on subsequent views. The varus component of the deformity was rectified. Lesser metatarsalgia was addressed by better loading the first ray.
Figs. 5-7: Ten months postoperatively the patient complained of pain along the dorsal mid shaft of the first metatarsal. Initially this was felt to be related to extrusion of the internal fixation. To alleviate the problem, the patient required planing of the dorsal mid shaft of the first metatarsal.
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