Includes release of adductor from lateral sesamoid/proximal phalanx, lateral capsulotomy, medial capsular imbrication
Distal 1st MT osteotomy (intra-articular). Can perform in two planes (Biplanar distal Chevron)
reserved for mild to moderate deformities in adults and children, biplanar chevron-->correct increased DMAA
-combined with Chevron in moderate to severe deformities-hallux valgus interphalangeus
Include medial eminence removal and resection of base of proximal phalanx
-indicated in moderate to severe hallux valgus- DJD of 1st MTP- painful callosities beneath lesser MT heads
first TMT joint arthrodesis with distal soft tissue procedures (medial eminence removal, first web space release of AdH, lateral capsule release)
Nonunion (may or may not be symptomatic)
dorsiflexion of the first metatarsal with transfer metatarsalgia
Opening wedge osteotomy (often requires autograft)
-children with ligamentous laxity, flatfoot, and hypermobile first ray- adolescent with an open physis
Please rate topic.
Average 4.2 of 62 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 47-year-old woman that works as an attorney has a 3-year history of bilateral painful forefeet that is exacerbated with the dress shoes she wears for work. Physical examination reveals bursal inflammation and calluses at the medial eminence of the first metatarsal with a 1st metatarsalphalangeal (MTP)joint deformity that passively corrects. A clinical image is shown in Figure A and a radiograph is shown in Figure B. The hallux valgus angle (HVA) is measured at 25 degrees and the intermetatarsal angle(IMA) is measured at 12 degrees. Which of the following surgical interventions is most appropriate for correction of her deformities?
Distal metatarsal osteotomy (Chevron)
Closing wedge osteotomy of the proximal phalanx (Akin) combined with distal soft tissue release (Modified Mcbride)
Resection of medial eminence (Silver bunionectomy)
Proximal metatarsal osteotomy and first MTP arthrodesis
Metatarsal cuneiform fusion (Lapidus)
Select Answer to see Preferred Response
Distal metatarsal osteotomy (Chevron) includes a lateral translation of the metatarsal head after osteotomy. The Chevron osteotomy can be used for a congruent or incongruent deformity that have hallux valgus angles less than 25-30 degrees and intermetatarsal angles less than 13 degrees.
The review by Easley et al states that an extensive lateral capsular release in addition to a Chevron ostetomy can be used to help correct deformity but can increase the risk of metatarsal head osteonecrosis. The risk of osteonecrosis with these combined procedures has been recently debated.
The Level 1 study by Saro et al prospectively randomized 100 hallux valgus patient to either a Chevron osteotomy or a Lindgren osteotomy. The corrections of the HVA and IMA were better in the Lindgren group. This was probably due to the fact that the Lindgren osteotomy permitted more lateral displacement than the originally described chevron osteotomy. Clinical outcomes demonstrated no differences between the osteotomy procedures.
Trnka et al performed a Level 4 review of 66 patients that underwent a distal Chevron osteotomy for mild hallux valgus. They found that at 5-year follow-up the Chevron osteotomy was found to be a dependable procedure for the correction of mild hallux valgus deformity. The osteotomy did not adversely affect MTP range of motion, had low recurrence, and had clinical outcomes that did not vary with age.
Illustration A and B shows the Chevron and Lindgren osteotomies, respectively.
Illustration C demonstrates how to measure the HVA and IMA on radiographs.
Video A is a surgical demonstration by Dr. Easley in the evaluation of hallux valgus and peforming a Chevron osteotomy.
Easley ME, Trnka HJ.
Foot Ankle Int. 2007 Jun;28(6):748-58. PMID: 17592710 (Link to Abstract)
Easley, FAI 2007
Saro C, Andren B, Wildemyr Z, Fellander-Tsai L
Foot Ankle Int. 2007 Jul;28(7):778-87. PMID: 17666169 (Link to Abstract)
Saro, FAI 2007
Trnka HJ, Zembsch A, Easley ME, Salzer M, Ritschl P, Myerson MS.
J Bone Joint Surg Am. 2000 Oct;82-A(10):1373-8. PMID: 11057464 (Link to Abstract)
Trnka, JBJS 2000
Please rate question.
Average 2.0 of 18 Ratings
A 57-year-old administrative assistant complains of pain over the bunion on her right foot. Physical exam is notable for tenderness over the medial prominence of the first metatarsophalangeal joint and hypermobility of the first ray. Shoe modifications have failed to provide relief. A clinical photograph and radiograph are provided in figures A and B. Surgical treatment with metatarsocuneiform arthrodesis is chosen. Each of the following are associated with a better clinical outcome EXCEPT:
Multiple screw fixation across the metatarsocuneiform arthrodesis
Augmentation of the metatarsocuneiform arthrodesis with bone grafting
Dorsiflexion unloading of the first metatarsal
Correction of the first intermetatarsal angle
Failure of conservative treatments prior to surgery
The clinical photograph and radiograph demonstrate hallux valgus with a large first intermetatarsal angle. Metatarsus primus varus and hypermobility of the first ray are both indications for including metatarsocuneiform arthrodesis in the surgical correction of hallux valgus. Anatomic plantarflexion of the first metatarsal is crucial to prevent loading of the lesser metatarsals following surgery.
Myerson et al reports the results of 53 patients treated with metatarsocuneiform arthrodesis for hallux valgus and metatarsus primus varus. They found that 92% acheived clinical satisfaction despite numerous complications including 7 superficial pin tract infections, 3 dorsal bunions, 7 nonunions, 1 hallux varus, and 3 neuromas of the deep peroneal nerve. Only 1 of the complications needed secondary surgery.
Sangeorzan et al reports the results of metatarsocuneiform arthrodesis in 33 patients with hallux valgus and a hypermobile first ray and 7 patients with previous failed bunion surgery. Successful union occurred in 90%, and 75% were considered successful clinical results. Best results were achieved with bone grafting, multiple screw fixation, and accurate plantarflexion of the first metatarsal.
1,2,4,5: These are all associated with improved clinical outcomes.
Myerson M, Allon S, McGarvey W.
Foot Ankle. 1992 Mar-Apr;13(3):107-15. PMID: 1601337 (Link to Abstract)
Sangeorzan BJ, Hansen ST Jr.
Foot Ankle. 1989 Jun;9(6):262-6. PMID: 2744666 (Link to Abstract)
Average 3.0 of 33 Ratings
A 67-year old female presents with the bilateral foot deformity shown in Figures A and B. All of the following contribute to the risk of recurrence after surgery EXCEPT:
Resection of the lateral sesamoid
Lack of lateral capsular release
Lack of medial metatarsophalangeal joint capsule closure
Use of an Akin procedure alone for a moderate to severe deformity
Undercorrection of the widened 1-2 intermetatarsal (IMA) angle
The patient has bilateral hallux valgus. Resection of the lateral sesamoid would likely lead to hallux varus and not hallux valgus recurrence. Akin procedure is a closing wedge osteotomy of the proximal phalanx when the proximal phalangeal articular angle >10° but does not correct hallux valgus well. Metatarsal osteotomies, such as the Chevron, are used to bring the metatarsal shaft laterally to reduce the IMA but undercorrection of the IMA would likely lead to hallux valgus recurrence. Lateral soft tissue release and medial capsular reefing can be used to correct hallux valgus in combination with bony procedures, but its important to avoid an extensive lateral capsular release to minimize the risk of metatarsal head osteonecrosis.
Average 3.0 of 41 Ratings
A 55-year-old female attorney complains of progressive pain and deformity of the great toe. The pain is localized to a prominence of the medial metatarsal head. A clinical image is provided in figure A. Which of the following best describes the hallux deformity?
Valgus and supination
Valgus and pronation
Valgus and hyperextension
Varus and supination
Varus and pronation
Bunions are a common deformity of the great toe that is most prevalent in the aging female cohort. The etiology is multi-factorial including genetic predisposition and chronic exposure to narrow toe box shoes. The static soft tissue constraints attenuate medially and contract laterally, and the plantar dynamic flexors deviate laterally pulling the great toe into valgus and pronation. Illustration A is an example of this deformity. Coughlin summarizes the evaluation, diagnosis, and treatment of hallux valgus.
J Bone Joint Surg Am. 1996 Jun;78(6):932-66. PMID: 8666613 (Link to Abstract)
Coughlin, JBJS 1996
Average 3.0 of 17 Ratings
A 57-year-old female underwent surgery for severe hallux rigidus. Postoperative radiographs are shown in Figure A. One year later she complains of pain at the 2nd metatarsal head and her exam shows a plantar callosity under the 2nd metatarsal head. What procedure could have been combined with her initial operation to prevent this outcome?
Second metatarsalphalangeal joint arthrodesis
Second metatarsal osteotomy (Weil) with extensor tendon and dorsal capsular release
Flexor to extensor tendon transfer (Girdlestone-Taylor)
Second metatarsal osteotomy (Helal) with extensor tendon and dorsal capsular release
Second metatarsal head resection with extensor tendon and dorsal capsular release
The second metatarsal osteotomy (Weil), is an intra-articular osteotomy that achieves longitudinal decompression through shortening and will correct the longer 2nd metatarsal in relation to the first metatarsal. The first metatarsal bears half the weight of the forefoot and this patient's plantar callosity under the 2nd metatarsal head is clinical evidence of abnormal pressure transfer due to the longer 2nd metatarsal (seen in Figure A). The foot tripod can also be altered by hallux valgus as the proximal phalanx moves into valgus, the splay between the first and second rays increases (IM angle), the metatarsal moves into varus and elevates, and weight-bearing is transferred from the 1st metatarsal head to the the 2nd metatarsal head. A shortening osteotomy with extensor tendon and dorsal capsular release is the most appropriate option listed to address the second MTP metatarsalgia.
The Weil osteotomy of the metatarsal head is preferable to the Helal osteotomy of the metatarsal shaft to correct metatarsalgia due to higher rates of nonunion and pseudarthrosis with shaft osteotomies as demonstrated in the article by Trnka et al. Illustration A shows the difference between the Weil osteotomy (osteotomy B) and the Helal osteotomy (osteotomy A).
Trnka HJ, Mühlbauer M, Zettl R, Myerson MS, Ritschl P.
Foot Ankle Int. 1999 Feb;20(2):72-9. PMID: 10063974 (Link to Abstract)
Trnka, FAI 1999
Which of the following clinical scenarios regarding hallux valgus could be appropriatley treated with a modified McBride procedure?
35-year-old female with a 20 degree HVA, a 11 degree IMA, and an incongruent 1st MTP joint
40-year-old male with a 30 degree HVA, and a 15 degree IMA, and a congruent 1st MTP joint
70-year-old female with a 35 degree HVA, and a 13 degree IMA with a hypermobile 1st ray
65-year-old female with a 25 degree HVA, a 14 degree IMA, and severe hallux rigidus
85-year old minimally ambulatory male with a 45 degree HVA, and a 20 degree IMA
The Modified McBride procedure is indicated in patients 30-50 years old with an incongruent joint, a HVA less than 25 degrees, and an IMA deformity less than 15 degrees. This soft tissue procedure should be avoided in moderate or severe hallux valgus deformity due to the increased risk of recurrence. Surgical technique includes release of adductor hallucis, transverse metatarsal ligament, and lateral capsule combined with excision of medial eminence and plication of the capsule medially. In patients with moderate hallux valgus deformity (HVA 26-40 deg, IMA 13-15 deg) a proximal osteotomy should be performed. In patients with moderate deformity and a hypermobile 1st ray, a Lapidus procedure (includes 1st TMT fusion) should be considered. A MTP arthodesis is indicated when concomitant severe hallux rigidus is present, and a Keller (includes partial resection of proximal phalanx) procedure should be considered in an elderly, low demand individual with severe deformity. Illustration A is an AP radiograph of the foot demonstrating the technique used in measuring the HVA and IMA.
Average 3.0 of 34 Ratings
A 34-year-old woman presents with right foot pain and a callus over the 1st metatarsalphalangeal joint. A clinical image is shown in Figure A. Accommodative shoewear has failed to relieve symptoms. Images displaying key radiographic angles in the evaluation of this disorder are shown in Figures B and C. This distal metatarsal articular angle (DMAA) is measured at 15 degrees. Which of the following operative procedures is most appropriate for this deformity?
Closing wedge osteotomy of the proximal phalanx (Akin)
Distal soft-tissue release
Distal metatarsal osteotomy
Medial eminence resection and exostectomy (Silver)
This patient has a moderate hallux valgus deformity as shown by the intermetatarsal angle of 15 degrees shown in Figure B, and the hallux valgus angle of 40 degrees shown in Figure C. A Scarf osteotomy is the only procedure of the available options in isolation appropriate for this amount of deformity.
If there is an incongruent joint, a soft tissue rebalancing is appropriate to make the joint congruent. With a congruent MTP joint and a DMAA of greater than 10 degrees, the distal articular surface needs to be realigned to create an appropriate correction.
The review article by Jones et al describes multiple methods of proximal osteotomies including crescentic, chevron, and oblique osteotomies. Overcorrection of IMA can lead to hallux varus and dorsiflexion at osteotomy can lead to transfer metatarsalgia. Double osteotomies can also be utilized for moderate deformities with Jones et al describing 92% satisfaction with a combined Akin and scarf osteotomy (Illustration A).
The Level 5 review article by Robinson et al discussing management of hallux valgus. They review several surgeries and note that the distal chevron is most often used in a non-congruent deformity with a normal DMAA. A complication with the Chevron and other distal osteotomies is the development of AVN of the first metatarsal head with an estimated incidence of up to 20% reported in the literature.
Illustration B demonstrates a hallux valgus deformity with a congruent MTP joint, as is also the case for the patient in this question. A distal soft-tissue release, including a release of the lateral structures, would be an appropriate procedure combined with a proximal metatarsal osteotomy if the MTP joint was incongruent.
Robinson AH, Limbers JP.
J Bone Joint Surg Br. 2005 Aug;87(8):1038-45. PMID: 16049235 (Link to Abstract)
Robinson, BJJ 2005
Jones S, Al Hussainy HA, Ali F, Betts RP, Flowers MJ
J Bone Joint Surg Br. 2004 Aug;86(6):830-6. PMID: 15330023 (Link to Abstract)
Jones, BJJ 2004
Average 2.0 of 38 Ratings
Hallux Valgus: Proximal vs Distal Osteotomy: Samuel Flemister, MD(CSFA #24, 2017...
Beautiful video depictingAkin Osteotomy:
Demonstrates a Scarf osteotomy used for moderate to severe hallux valgus deformi...
Demonstrates evaluation of hallux valgus and Chevron osteotomy
HPI - Active patient, denies trauma, bilateral painless hallux valgus deformity since adolescence, no associated neuromuscular conditions, shoe modifications have failed to provide relief
Which foot would you operate on?
HPI - Patient with hallux valgus with first surgery consisted Chevron technique
What procedure do you perform ?
HPI - denies trauma, pain for several months
How would you treat this?