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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Proximal Metatarsal Osteotomy for Hallux Valgus


- See: Hallux Valgus:

- Discussion:
    - indicated for moderate to severe deformities (HV angle of 13 to 20 deg);
    - proximal osteotomy may be combined w/ other reconstructive procedures such as Silver procedure or a Mcbride type of soft tissue release;
    - inadvertent dorsiflexion of 1st metatarsal is avoided because this dorsiflexion will cause a dorsal bunion and transfer metatarsalgia to 2nd metatarsal;

- Contra-indications:
    - congruous joint and a distal metatarsal articular angle more than 15 deg;


- Radiographs:
    - on the AP view measure the length of both the first and second metatarsals;
    - in the vast majority of patients, the lengths of the first and second metatarsals will be equal, in which case a concentric osteotomy is probably indicated;
    - if the first metatarsal is shorter than the second, then consider an opening wedge osteotomy, or an oblique metaphyseal-diaphyseal
           osteotomy which not only corrects the IMA deformity, but also helps lengthen the metatarsal;
    - non wt bearing AP:
           - useful because, it can be compared to intraoperative radiographs;


- Types of Osteotomy:
    - opening wedge
         - indicated when first metatarsal is shorter than the second metatarsal;
         - when a Silver procedure is included in the procedure, the resected medial eminence is made into a wedge for an opening proximal osteotomy;
    - cresentric proximal osteotomy 
    - proximal chevron osteotomy:
            - Correction of Hallux Valgus Using Lateral Soft-Tissue Release and Proximal Chevron Osteotomy Through a Medial Incision
            - Plantar-to-dorsal compared to dorsal-to-plantar screw fixation for proximal chevron osteotomy: a biomechanical analysis.
            - Stability of a cannulated screw versus a K wire for the proximal crescentic osteotomy of the first metatarsal: a biomechanical study.
            - Bunion correction using proximal chevron osteotomy: a single-incision technique
            - Bunion correction using proximal Chevron osteotomy
            - Proximal metatarsal osteotomy in hallux valgus correction: a comparison of crescentic and chevron procedures.
            - Prospective, randomized comparison of proximal crescentic and proximal chevron osteotomies for correction of hallux valgus deformity.
            - Bunion correction using proximal Chevron osteotomy.
            - Mobility Changes of the First Ray after Hallux Valgus Surgery: Clinical Results after Proximal Metatarsal Chevron Osteotomy and Distal Soft Tissue Procedure

    - closing wedge osteotomy:
         - shortens the MT, can sometimes lead to a dorsiflexion deformity & transfer lesion (to second MT);
         - proximal closing wedge osteotomy can result in shortening & occassionally dorsiflexion of the first metatarsal;
         - disadvantage w/ the closing wedge is that it is associated w/ slight shortening of 1st metatarsal & potential transfer metatarsalgia;
         - this procedure is most indicated when the first metatarsal is longer than the second metatarsal;
    - crescentric shelf osteotomy:
         - has emerged as the osteotomy of choice because it provides good stability and avoids transfer metatarsalgia;
         - dorsal half of proximal metatarsal is cut in the traditional manner (concentric osteotomy 1.5 cm from metatarsalcunieform joint) and then subsequently
                     plantar half is cut in the saggital plane;
         - distal fragment is then slid and rotated laterally to effect the desired correction;
         - the overlapping medial edge of the proximal fragment is cut flush with the remained of the metatarsal;
         - if needed, the distal fragment can also be slid distally (the gap will have to be bone grafted);
         - fixation is achieved with a 3.5 mm lag screw 
         - reference:
               - Comparison of two proximal metatarsal osteotomies for the treatment of hallux valgus.  

                     


- Complications:
     - transfer metatarsalgia:
           - note that medialization of the metatarsal shaft also tends to shift it dorsally;
                  - this dorsal shift tends to unload the first metatarsal head and transfer the load laterally;
           - patients w/ a short first metatarsal or w/ a pronation deformity of the forefoot are at higher risk for this complication;
           - it isnoted that non compliance w/ wt bearing restrictions may cause progressive elevation of metatarsal following surgery (leading to dorsal malunion);
                  - this complication may be more common with a proximal concentric osteotomy, especially if there is inadequate fixation             


Late results after correction of hallux valgus deformity by basilar phalangeal osteotomy.

Mechanical comparison of biplanar proximal closing wedge osteotomy with plantar plate fixation versus crescentric osteotomy with screw fixation for the correction of metatarsus primus varus.   

Crescentric osteotomy for hallux valgus: a biomechanical study of variables affecting the final postion of the first metatarsal

Strength of fixation constructs for basilar osteotomies of the first metatarsal.     

Osteotomy of the first metatarsal base for metatarsus primus varus.    

Proximal crescentic metatarsal osteotomy: the effect of saw blade orientation on first ray elevation. 

Hallux Valgus and First Ray Mobility. A Prospective Study




Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, June 1, 2012 1:28 pm