Updated: 10/4/2016

Proximal Chevron Osteotomy with Plate Fixation

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Questions
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Evidence
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Videos
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Cases
3
Techniques
2

Preoperative Patient Care

A

Intermediate Evaluation and Management

1

Obtain a focused history and performs focused exam

  • check soft tissue
  • differential diagnosis and physical exam tests

2

Interpret basic imaging studies

  • interpret radiographs AP, lateral and sesamoid views

3

Make informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Provides post-operative management and rehabilitation

  • postop: 2-3 Week Postoperative Visit
  • wound check and remove sutures
  • check radiographs
  • postop: ~ 6 week Postoperative Visit
  • check radiograph
  • full weightbearing
B

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies

  • CT Scan

2

Modifies and adjusts post-operative treatment plan as needed

3

Provides comprehensive assessment of complex fracture patterns on imaging studies

C

Preoperative H & P

1

Obtain history and perform basic physical exam

  • history
  • age
  • gender
  • history of present illness [HPI]
  • past medical history [PMHx]
  • social history
  • physical exam
  • range of motion
  • neurovascular status
  • pain with narrow shoes

2

Screen medical studies to identify and contraindications for surgery

3

Orders basic imaging studies

  • weightbearing AP, lateral and oblique views

4

Perform operative consent

  • describe complications of surgery including
  • wound breakdown
  • superficial and deep infections
  • malposition

Operative Techniques

E

Preoperative Plan

1

Template arthrodesis with radiographs

2

Execute surgical walkthrough

  • describe the steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • MTP plating system

2

Room setup and equipment

  • standard OR table with radiolucent end

3

Patient positioning

  • supine position with a bump under the ipsilateral buttock
G

Midmedial Approach

1

Mark and make skin incision

  • incise the skin and subcutaneous tissue sharply to expose the first MTP joint capsule

2

Protect neurovascular bundle

  • protect the medial dorsal and plantar cutaneous nerves
H

Opening of Capsule

1

Remove a portion of the capsule

  • perform a vertical capsular resection to remove 3 to 5 mm of capsule just proximal to the base of the proximal phalanx
I

Release of the Lateral Joint Structures

1

Release the lateral soft tissues after distraction

  • release the lateral soft tissues from within the MTP joint after distraction of the sesamoids from the first metatarsal with a lamina spreader
  • first use a blunt freer elevator to develop some room cut the capsular tissue with a sharp no. 15 blade

2

Confirm that the release is complete

  • complete release is confirmed when the toe can be brought into about 15 degrees of varus through the MTP joint

3

Expose the proximal first metatarsal dorsally and plantarly

J

Metatarsal Osteotomy

1

Outline the osteotomy

  • confirm the location of the TMT joint
  • mark a point about 20 mm distal from the first metatarsal joint for the apex of the osteotomy and at the midpoint in the dorsal plantar direction

2

Perform the osteotomy

  • perform a chevron osteotomy at an angle of 60 degrees using a microsagittal saw
  • complete the release both in plantarly and dorsally

3

Angulate fragments to the proper position

  • grasp the proximal fragment with a towel clamp
  • angulate the distal fragment laterally
  • the distal fragment should be translated 3 to 5 mm laterally and plantarly enough to coapt the superior portion of the chevron leaving an opening in the plantar portion of the osteotomy
K

Osteotomy Fixation

1

Provide temporary fixation

  • secure the translated position temporarily with a 0.062 inch K wire

2

Prepare the fragments for fixation

  • clean the prominent proximal fragment of periosteum and removed flush with the distal fragment
  • the largest removed portion is placed as bone graft between the fragments at the opening created in the chevron osteotomy from the plantar translation

3

Place the permanent fixation

  • place a four hole locking plate to bridge the osteotomy medially
  • remove the medial eminence 1 mm medial to the sagittal sulcus
  • remove the K wire

4

Confirm the implant

  • confirm the stability
  • confirm the correction and alignment with fluoroscopy
L

Capsule Closure

1

Close the capsule with the toe in the appropriate position

  • close the capsule with 2-0 vicryl
  • while performing the closure hold the toe in slight varus and supination
  • close the deep tissues over the plate
N

Wound Closure

1

Irrigation and Hemostasis

  • copiously irrigate the wound

2

Superficial wound closure

  • use 3-0 vicryl for subcutaneous tissue
  • use 3-0 monocryl for skin

3

Dressing

  • apply bunion dressings

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • prescribe DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • appropriately orders and interprets basic imaging studies
  • check radiographs of the foot in post op

2

Appropriate medical management and medical consultation

3

Physical Therapy

  • heel weightbearing only

4

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up appointment in 2 weeks
R

Complex Patient Care

1

Develops unique, complex post-operative management plans

2

Capable of evaluating and treating postoperative complications

3

Surgically treats complex complications

 

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