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A Study of the Proximal Wedge Shelf Osteotomy for Correction of Large IM Angle HAV Deformity.
Fabrikant J, Colarco J. Foot Ankle Spec. 2012 Jan 20.
Many procedures have been identified to correct hallux abducto valgus deformity of the foot. Due to surgical skill level, complexity, and risk of complications, more procedures have been defined for distal than proximal correction. The senior author has used an alternative proximal procedure to correct larger hallux abducto valgus deformities, which may prove to be as effective as traditional procedures. The purpose of this study was to examine the short-term clinical and radiographic results of the proximal wedge shelf osteotomy and evaluate its potential as a satisfactory option for correction of larger bunion deformities. The study revealed many positive outcomes as measured radiographically in preoperative and postoperative hallux abductus, intermetatarsal and metatarsal elevation/declination angles, and clinically by first metatarsophalangeal joint scores and patients' subjective postoperative responses. From a review of the literature and results of the study, the authors conclude that the wedge shelf osteotomy can be used as an effective alternative for correcting larger bunion deformities with an intermetatarsal angle as large as 20° and a hallux valgus angle up to 38°. The advantages of this procedure include ability to correct in more than one plane, good bone-to-bone contact, and ease of fixation with 2 screws in an easily visible dorsal-to-plantar area. Disadvantages include the technical challenge of the procedure and its learning curve and some shortening of the first metatarsal.
Introduction Trends in hallux valgus surgery continue to evolve. Basal metatarsal osteotomy theoretically provides the greatest correction, but is under-represented in the literature. This paper reports our early experience with a plate-fixed, opening- wedge basal osteotomy, combined with a new form of distal soft tissue correction (in preference to Akin phalangeal osteotomy).
Materials and Methods Thirty-three patients are reported here. The basal metatarsal osteotomy is fixed with the ‘Low Profile’ Arthrex titanium plate. No bone graft or filler is required, providing the osteotomy is within about 12mm of the base.
Distal soft tissue correction comprised a full lateral release, and then proximal advancement of a complete capsular ‘sleeve’ on the medial side. The plate serves as a rigid anchoring point for the tensioning stitches. Using this technique, almost any degree of hallux valgus can be corrected, and there is even potential for over-correction.
Functional outcome was assessed using the Manchester-Oxford foot and ankle score (MOXF). Radiographically the intermetatarsal angle was evaluated pre-operatively and at least 6 months postoperatively. Patients’ satisfaction and complication rates were recorded.
Results Clinical 87% (29 of 33) reported high satisfaction with the functional and cosmetic outcome. The opening basal wedge osteotomy slightly lengthens the first ray and as result none of our patients developed transfer metatarsalgia.
Results Radiology Hallux valgus angle (HVA) and inter-metatarsal angle (IMA) were measured on pre- and post-operative weight bearing radiographs. The radiological correction seen was very striking The mean correction of the IMA was 14 degrees; mean HVA correction was … degrees.
Complications One osteotomy was too distal, leading to a non-union, which required revision and bone grafting. Swelling and stiffness were seen in some patients, but these problems resolved steadily, with physiotherapy if needed.
Discussion This operation is a combined proximal/distal, bone/soft tissue procedure. It can obtain correction of almost any degree of hallux valgus. The slight first- ray lengthening is an advantage, as it neutralizes potential second ray problems. However, this is a very early result and long-term outcomes are as yet unknown.