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Hallux Valgus Correction With Metatarsal Opening Wedge and Proximal Phalangeal Osteotomies


Indications

  • Painful hallux valgus deformity

  • Failure of shoe modification

  • Symptoms that interfere with daily activities

  • A moderate to severe bunion deformity, with an intermetatarsal angle of ≥13°

  • Hallux interphalangeus (HI) that causes great toe impingement on the second toe

Indications Pitfalls

  • Moderate to severe arthritic changes of the joint are a contraindication to hallux valgus surgery.

  • Blood supply to the foot is compromised.

  • Ulceration over the bunion prominence needs to be treated prior to surgery.

  • A first tarsometatarsal (TMT) joint is hypermobile and requires a Lapidus fusion.

Indications Controversies

  • An opening wedge osteotomy may increase pressure on the first metatarsophalangeal (MTP) joint.

Examination/Imaging

  • Examine the weight-bearing foot ( Fig. 3.1 ).

    FIG. 3.1

  • Examine the interphalangeal joint to determine if an HI is present.This is best appreciated when the interphalangeal joint is flexed.

  • Evaluate hypermobility of the first TMT joint, both in the sagittal and coronal planes.

  • Pes planus may predispose to hallux valgus, but rarely requires simultaneous correction.

  • Standing anteroposterior (AP) radiographs of the foot should be obtained. Measure the 1–2 intermetatarsal, distal metatarsal articular, and hallux valgus angles. Evaluate any metatarsus adductus that may spuriously narrow the intermetatarsal angle measurement ( Fig. 3.2 ).

    FIG. 3.2

  • Oblique views of the foot can help evaluate possible arthritic changes in the great toe MTP or first TMT joints.

Treatment Options

  • There are multiple techniques available to close an increased 1–2 intermetatarsal angle, including a closing wedge osteotomy.

Surgical Anatomy

Positioning

  • The patient is in the supine position.

  • A bump under the contralateral hip may improve exposure of the medial side of the foot.

  • The procedure is performed on an outpatient basis with a regional block.

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