Hallux Valgus Pathway Updated: 10/4/2016

Proximal Chevron Osteotomy with Plate Fixation

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TECHNIQUE STEPS
Preoperative Patient Care
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
 

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