Percutaneous Hallux Valgus: An Algorithm for the Surgical Treatment

Abstract

Objective To present the clinical and radiographic results of hallux valgus surgical correction using four percutaneous techniques, chosen according to a predefined radiographic classification. Methods We prospectively evaluated 112 feet in 72 patients with hallux valgus operated over the course of 1 year. Percutaneous distal soft tissue release (DSTR) and the Akin procedure (DSTR-Akin) were performed in mild cases. In mild to moderate hallux valgus with distal metatarsal joint angle > 10°, we added the Reverdin-Isham (RI) osteotomy. In moderate cases with joint incongruity, we performed the percutaneous chevron (PCH). Finally, a Ludloff-like percutaneous proximal osteotomy fixed (PPOF) with a screw was proposed in severe cases with an intermetatarsal angle (IMA) > 17°. According to these criteria, 26 DSTRs-Akin, 36 PCHs, 35 RIs, and 15 PPOFs were performed. The mean follow-up was of 17.2 months (range: 12 to 36 months). The mean age at operation was 58.8 years (range: 17 to 83 years), and 89% of the patients were female. Results The mean preoperative hallux valgus angle (HVA) and the IMA decreased from 21° to 10.2° and from 11.2° to 10.3° respectively in the DSTR-Akin. In the RI, the mean HVA decreased from 26.6° to 13.7°, and the IMA, from 11.2° to 10.3°; in the PCH, the mean HVA decreased from 31° to 14.5°, and the IMA decreased 14.9° to 10.7°; as for the PPOF, the mean HVA decreased from 39.2° to 17.7°, and the IMA, from 11.8° to 6.8°. The average ankle and hindfoot score of the American Orthopaedic Foot and Ankle Society (AOFAS) increased from 49.2 to 88.6. The rate of complications was of 11%. Conclusion Our treatment protocol does not differ much from the classic ones, with similar results as well. We have as advantages less aggression to soft tissues and better cosmetic results. Level of Evidence: level IV, prospective case series.

Keywords: hallux valgus; metatarsal bones; minimally invasive surgical procedures.

Conflict of interest statement

Conflito de Interesses Os autores declaram não haver conflito de interesses.

Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).

Figures

Fig. 1

Angular measurements. (A) Hallux valgus angle (HVA); (B) intermetatarsal angle (IMA); (C) distal metatarsal articular angle (DMAA).

Fig. 2

(A) Dorsolateral incision in the metatarsophalangeal joint of the hallux; (B) fluoroscopy after adductor tendon tenotomy and capsulotomy; (C) Akin procedure on the image intensifier.

Fig. 3

Reverdin-Isham (RI) techinique associated with exostectomy, tenotomy and Akin osteotomy.

Fig. 4

(A) Fluoroscopy control showing the position of the burr, parallel to the articular surface of the first metatarsus during the first cut for the chevron osteotomy; (B) the red line shows the directions for the chevron cut; (C) fixation of the percutaneous chevron with one screw. A Kirschner wire is used to assist on the reduction.

Fig. 5

(A) Position of the burr to perform the Ludloff osteotomy; (B) fixation of the osteotomy with one screw. A Kirschner wire is used to help translate the metatarsal head.

Fig. 6

(A) Pre-operative mild case; (B) pos-operative (exostectomy + distal soft tissue release + Akin) mild case.

Fig. 7

(A) Pre-operative moderate case with altered DMAA; (B) post-operative RI procedure with exostectomy + tenotomy + Akin.

Fig. 8

(A) Pre-operative moderate case with articular incongruence; (B) post-operative percutaneous chevron.

Fig. 9

(A) Pre-operative severe halux valgus; (B) post-operative Ludloff-like osteotomy.

Fig. 1

Medidas angulares. (A) Ângulo de hálux valgo (AHV); (B) ângulo intermetatarsal (AIM); (C) Ângulo articular distal do metatarso (AADM).

Fig. 2

(A) Incisão dorsolateral na articulação metatarsofalangeal do hálux; (B) fluoroscopia após tenotomia do tendão adutor e capsulotomia; (C) procedimento de Akin no intensificador de imagem.

Fig. 3

Procedimento de Reverdin-Isham (RI) associada à exostectomia, tenotomia e osteotomia de Akin.

Fig. 4

(A) Controle de fluoroscopia mostrando a posição da broca, paralela à superfície articular do primeiro metatarso durante o primeiro corte para a osteotomia emchevron; (B) a linha vermelha mostra as direções para o corte em chevron; (C) fixação dochevronpercutâneo com um parafuso. O fio de Kirschner é usado para ajudar na redução.

Fig. 5

(A) posição da broca para realizar a osteotomia de Ludloff; (B) fixação da osteotomia com um parafuso. O fio de Kirschner é usado para ajudar a trasladar a cabeça metatarsal.

Fig. 6

(A) caso leve no pré-operatório. (B) caso leve no pós-operatório (exostectomia + liberação de tecido mole distal + procedimento de Akin).

Fig. 7

(A) caso moderado no pré-operatório com AADM qalterado; (B) procedimento de RI pós-operatória com exostectomia + tenotomia + procedimento de Akin.

Fig. 8

(A) Pré-operatório de caso moderado com incongruência articular; (B) pós-operatório depois dechevronpercutâneo.

Fig. 9

(A) Pré-operatório de caso grave de hálux valgo; (B) pós-operatório de osteotomia similar ao procedimento de Ludloff.