Proximal First Metatarsal Opening Wedge Osteotomy with a Low Profile Plate

2009 ◽  
Vol 30 (9) ◽  
pp. 865-872 ◽  
Author(s):  
Paul S. Shurnas ◽  
Troy S. Watson ◽  
Timothy W. Crislip
Keyword(s):  
Hallux Valgus ◽  
Case Series ◽  
Wedge Osteotomy ◽  
Opening Wedge ◽  
First Metatarsal ◽  
Vas Score ◽  
Hallux Varus ◽  
Hallux Valgus Deformity ◽  
Significant Difference ◽  
The Mean

Background: Many surgical procedures have been described for the correction of metatarsus primus varus associated with hallux valgus deformity. The purpose of this study was to present the results of the proximal metatarsal opening wedge (PMOW) osteotomy using the Arthrex LPS® first metatarsal system. Materials and Methods: Eighty-four patients (90 feet) underwent PMOW osteotomy with distal bunionectomy. There were 78 patients (93%) and 84 (93%) feet available for followup. Mean followup was 2.4 (range, 2.0 to 3.2) years from the time of the index surgery. Pre- and postoperative clinical examination, level of activity, patient derived subjective satisfaction score, radiographic measurements, and visual analogue scale (VAS) score for pain were obtained and evaluated retrospectively. Results: The mean preoperative VAS score was 5.9 (± 2.2), compared with a mean postoperative score of 0.5 (± 0.8). The mean 1–2 IMA preoperatively was 14.5 (±3.3) degrees, compared with postoperative measurements of 4.6 (± 2.8) degrees. The mean hallux valgus angle (HVA) improved from a mean of 30 (range, 22 to 64) degrees preoperatively to 10 (range, −15 to +18) degrees. The mean time to radiographic union was 5.9 (range, 4 to 14) weeks. There was one nonunion, one delayed union, mild hallux varus in two patients, severe hallux varus in two patients, recurrent hallux valgus in three patients (including the nonunion) and no instances of plate failure there was no significant difference in mean preoperative (74.8 degrees ± 11) compared to postoperative (67.9 degrees ± 10) total MTP joint range of motion. Ninety percent of patients reported good to excellent subjective results after the index surgery. Conclusion: We believe PMOW osteotomy was near ideal in terms of reliable, predictable correction and healing. Length of the first metatarsal was maintained and patients ambulated safely in a CAM walking boot immediately after surgery. We believe a first web space release may result in hallux varus and increased distal metatarsal articular angle (DMAA) was associated with hallux valgus recurrence. Level of Evidence: IV, Retrospective Case Series

scholarly journals First Tarsometatarsal Joint Loading After Sequential Correction of Hallux Valgus Using a Proximal Opening Wedge Metatarsal Osteotomy and Distal Soft Tissue Procedure

2021 ◽  
Vol 6 (3) ◽  
pp. 247301142110269
Author(s):  
Jonathan Kraus ◽  
Michael J. Ziegele ◽  
Mei Wang ◽  
Brian Law
Keyword(s):  
Soft Tissue ◽  
Hallux Valgus ◽  
Contact Force ◽  
Contact Stress ◽  
Soft Tissue Release ◽  
Wedge Osteotomy ◽  
Opening Wedge ◽  
First Metatarsal ◽  
Joint Contact ◽  
The Mean

Background: The proximal opening wedge osteotomy (POWO) of the first metatarsal (TMT-1) is commonly performed in the operative treatment of hallux valgus. Limited work has been dedicated to study POWO’s effect on the TMT-1 joint, however. The purpose of this study is to evaluate the changes in TMT-1 joint contact stress following POWO of the first metatarsal. Methods: Five fresh-frozen cadaveric below-knee specimens (mean age: 73 years) with hallux valgus deformities (mean hallux valgus angle [HVA]: 37.4 ± 8.5 degrees) were studied. The specimens were loaded to 400 N on an MTS servohydraulic load frame. Joint contact characteristics at TMT-1 joint were measured with a Tekscan pressure sensor (Model 6900, 1100 psi; Tekscan Inc, Boston, MA) with various opening wedge sizes of 3, 5, and 7 mm both without and with a distal soft tissue release (DSTR). The contact force, area, and peak contact stress were compared among groups using analysis of variance and post hoc multiple comparisons over the untreated (Dunnett test, P < .05). Results: The mean contact force was 47.7 ± 33.5 N for untreated specimens. This increased sequentially with opening wedge size and reached statistical significance for 7-mm opening wedge (129.7 ± 62.3 N, P = .01) and 7-mm wedge + DSTR (134.8 ± 60.5 N, P = .008). The mean peak contact stress was 2.8 ± 1.3 MPa for the untreated specimens and increased incrementally with wedge size to 5.7 ± 3.0 MPa for 7-mm wedge only ( P = .03) and 5.6 ± 2.5 MPa for 7-mm wedge + DSTR ( P = .05). The contact area increased with corrections, but none reached significance. Conclusion: With increasing opening wedge size, loading of the TMT-1 joint increases. Joint stresses higher than 4.7 MPa have been shown to be chondrotoxic, potentially predisposing patients to arthritic joint changes following POWO. Level of Evidence: XXXXXX

scholarly journals Proximal Opening Wedge Osteotomy With Distal Chevron Osteotomy of the First Metatarsal for the Treatment of Moderate to Severe Hallux Valgus

2018 ◽  
Vol 40 (1) ◽  
pp. 89-97 ◽  
Author(s):  
Matthias Braito ◽  
Dietmar Dammerer ◽  
Philipp Hofer-Picout ◽  
Gerhard Kaufmann
Keyword(s):  
Wound Infection ◽  
Hallux Valgus ◽  
Case Series ◽  
Wedge Osteotomy ◽  
Metatarsal Osteotomy ◽  
Level Of Evidence ◽  
Opening Wedge ◽  
First Metatarsal ◽  
Chevron Osteotomy ◽  
Severe Hallux Valgus

Background: The aim of this study was to assess radiographic and clinical outcomes after double osteotomy with proximal opening wedge first metatarsal osteotomy and first metatarsal distal chevron osteotomy in the treatment of moderate to severe hallux valgus. Methods: 33 patients (4 male, 29 female; 36 feet; average age 60.7 years) were included in the study. Radiographic and clinical outcome in terms of intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), and the American Orthopaedic Foot & Ankle Society metatarsophalangeal-interphalangeal hallux score (AOFAS MTP-IP hallux score) were investigated at 6 weeks, 6 months, and after an average of 28 (range, 7-123) months postoperatively. Results: Preoperative IMA, HVA, and DMMA showed statistically significant improvement ( P ≤ .05) from 19.1 ± 3.8 (8.9-27.3) degrees, 45.4 ± 8.7 (25.9-60.9) degrees, and 20.8 ± 8.9 (4.5-38.0) degrees to 6.0 ± 3.3 (0.4-12.2) degrees, 9.1 ± 8.9 (–6.7 to 39.0) degrees, and 6.4 ± 5.6 (–6.8 to 21.0) degrees at last follow-up, respectively. Postoperative AOFAS MTP-IP hallux score averaged 88.1 points. Overall, 10 complications were observed: hallux varus (3 feet), hallux valgus recurrence (3 feet), nonunion (1 foot), loss of fixation (1 foot), and wound infection (2 feet). Conclusion: Proximal opening wedge first metatarsal osteotomy with distal chevron osteotomy provided powerful correction of each component of moderate to severe hallux valgus but had a substantial rate of complications in terms of over- and undercorrection, nonunion, loss of fixation, and wound infection. Level of Evidence: Level IV, case series.

scholarly journals Medial Cuneiform Opening-Wedge Osteotomy for the Treatment of Hallux Valgus

2019 ◽  
Vol 4 (1) ◽  
pp. 247301141881331
Author(s):  
Jason S. Ahuero ◽  
John S. Kirchner ◽  
Paul M. Ryan
Keyword(s):  
Soft Tissue ◽  
Hallux Valgus ◽  
Wedge Osteotomy ◽  
Opening Wedge ◽  
First Metatarsal ◽  
Low Profile ◽  
Medial Cuneiform ◽  
The Mean ◽  
Wedge Plate

Background: While proximal first metatarsal osteotomy combined with distal soft tissue realignment is accepted as standard treatment of moderate to severe hallux valgus with metatarsus primus varus, none of the described proximal metatarsal osteotomies address the hyper-obliquity of the first metatarsocuneiform joint. An opening-wedge osteotomy of the medial cuneiform can potentially correct the 1-2 intermetatarsal angle (IMA) in addition to normalizing the hyper-obliquity of the first tarsometatarsal (TMT) joint. The purpose of this study was to retrospectively review the early radiographic and clinical results of the use of a medial cuneiform opening-wedge osteotomy fixed with a low-profile wedge plate combined with distal soft tissue realignment for the treatment of hallux valgus. Methods: Fourteen feet (13 patients; 2 male and 11 female, average age 56 years, range 22-75) with hallux valgus underwent an opening-wedge osteotomy of the medial cuneiform fixed with a low-profile nonlocking wedge plate combined with distal soft tissue realignment. The mean preoperative hallux valgus angle (HVA) was 32 degrees and the IMA was 16 degrees. HVA, 1-2 IMA, proximal first metatarsal inclination (PFMI), and presence of osteoarthritis of the first TMT joint were assessed on preoperative and final postoperative radiographs. Final postoperative radiographs were also evaluated for radiographic union and hardware failure at an average of 7 months (range, 3-19 months) postoperatively. Results: A mean intraoperative correction of 19 degrees and 7 degrees was achieved for the HVA and IMA, respectively. The mean HVA was 22 degrees and the mean IMA was 11 degrees at the time of final follow-up. At final follow-up, a recurrence of the deformity was observed in 12/14 feet. There were 2 nonunions—one plate failure and one screw failure. No first TMT joint instability or arthritis was observed. All patients were ambulatory without assistive device in either fashionable or comfortable shoe wear. Conclusion: Medial cuneiform opening-wedge osteotomy resulted in unreliable correction of HVA and IMA at short-term follow-up with a high rate of early recurrence of hallux valgus deformity and a complication rate similar to that of the Lapidus procedure. This procedure cannot be recommended for addressing hallux valgus in the setting of increased obliquity of the first TMT joint. Level of Evidence: Level IV, case series.

scholarly journals Proximal Rotational Metatarsal Osteotomy for Hallux Valgus (PROMO)

2018 ◽  
Vol 3 (3) ◽  
pp. 247301141879007 ◽  
Author(s):  
Pablo Wagner ◽  
Emilio Wagner
Keyword(s):  
Hallux Valgus ◽  
Case Series ◽  
Valgus Deformity ◽  
Metatarsal Osteotomy ◽  
Level Of Evidence ◽  
Reliable Technique ◽  
Intermetatarsal Angle ◽  
Hallux Valgus Deformity ◽  
The Mean ◽  
Prospective Case Series

Background: Hallux valgus deformity consists of a lateral deviation of the great toe, metatarsus varus, and pronation of the first metatarsal. Most osteotomies only correct varus, but not the pronation of the metatarsal. Persistent postoperative pronation has been shown to increase deformity recurrence and have worse functional outcomes. The proximal rotational metatarsal osteotomy (PROMO) technique reliably corrects pronation and varus through a stable osteotomy, avoiding fusing any healthy joints. The objective of this research is to show a prospective series of the PROMO technique. Methods: Twenty-five patients (30 feet) were operated with the PROMO technique. The sample included 22 women and 3 men, average age 46 years (range 22-59), for a mean prospective follow-up of 1 year (range 9-14 months). Inclusion criteria included symptomatic hallux valgus deformities, absence of severe joint arthritis, or inflammatory arthropathies, with a metatarsal malrotation of 10 degrees or more, with no tarsometatarsal subluxation or arthritis on the anteroposterior or lateral foot radiograph views. The mean preoperative and postoperative Lower Extremity Functional Scale (LEFS) score, metatarsophalangeal angle, intermetatarsal angle, metatarsal malrotation, complications, satisfaction, and recurrence were recorded. Results: The mean preoperative and postoperative LEFS scores were 56 and 73. The median pre-/postoperative metatarsophalangeal angle was 32.5/4 degrees and the intermetatarsal angle 15.5/5 degrees. The metatarsal rotation was satisfactorily corrected in 24 of 25 patients. An Akin osteotomy was needed in 27 of 30 feet. All patients were satisfied with the surgery, and no recurrence or complications were found. Conclusions: PROMO is a reliable technique, with good short-term results in terms of angular correction, satisfaction, and recurrence. Long-term studies are needed to determine if a lower hallux recurrence rate occurs with the correction of metatarsal rotation in comparison with conventional osteotomies. Level of evidence: IV, prospective case series.

A Simple Method for Fixation of Proximal Opening-Wedge Osteotomy of the First Metatarsal for Correction of Hallux Valgus

Orthopedics ◽  
2016 ◽  
Vol 39 (6) ◽  
pp. e1213-e1217 ◽  
Author(s):  
A. Erdem Bagatur ◽  
Mehmet Albayrak ◽  
Yunus Emre Akman ◽  
Merter Yalcinkaya ◽  
Utku Erdem Ozer ◽  
...  
Keyword(s):  
Hallux Valgus ◽  
Wedge Osteotomy ◽  
Opening Wedge ◽  
Simple Method ◽  
First Metatarsal

scholarly journals Radiological Outcomes of Third Generation Minimally Invasive Chevron Akin Osteotomies (MICA) for Hallux Valgus

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0032
Author(s):  
Thomas L. Lewis ◽  
Robbie Ray; David Gordon
Keyword(s):  
Minimally Invasive ◽  
Hallux Valgus ◽  
Weight Bearing ◽  
Case Series ◽  
Deformity Correction ◽  
Third Generation ◽  
Radiographic Measurements ◽  
Significant Difference ◽  
Patient Reported ◽  
The Mean

Category: Bunion Introduction/Purpose: Minimally invasive surgery for hallux valgus has significantly increased in popularity recently due to smaller incisions, reduced soft tissue trauma, and the ability to achieve large deformity corrections compared to traditional treatments. This study aimed to investigate the radiological outcomes and degree of deformity correction of the intermetatarsal angle (IMA) and the hallux valgus angle (HVA) following third generation (using screw fixation) Minimally Invasive Chevron and Akin Osteotomies (MICA) for hallux valgus. Methods: A single surgeon case series of patients with hallux valgus underwent primary, third generation MICA for hallux valgus. Pre- and post-operative (6 weeks after surgery) radiological assessments of the IMA and HVA were based on weight-bearing dorso-plantar radiographs. Radiographic measurements were conducted by two foot & ankle fellowship trained consultant surgeons (RR, DG). Paired t-tests were used to determine the statistically significant difference between pre- and post-operative measurements. Results: Between January 2017 and December 2019, 401 MICAs were performed in 274 patients. Pre- and post-operative radiograph measurements were collected for 348 feet in 232 patients (219 female; 13 male). The mean age was 54.4 years (range 16.3-84.9, standard deviation (s.d.) 13.2). Mean pre-operative IMA was 15.3° (range 6.5°-27.0°, s.d. 3.4°) and HVA was 33.8° (range 9.3°-63.9°, s.d. 9.7°). Post-operatively, there was a statistically significant improvement in radiological deformity correction; mean IMA was 5.3° (range -1.2°-16.5°, s.d. 2.7°, p<0.001) and mean HVA was 8.8° (range -5.2°-24.0°, s.d. 4.5°, p<0.001). The mean post-operative reduction in IMA and HVA was 10.0° and 25.0° respectively. Conclusion: This is the largest case series demonstrating radiological outcomes following third generation Minimally Invasive Chevron and Akin Osteotomies (MICA) for hallux valgus to date. These data show that this is an effective approach at correcting both mild and severe hallux valgus deformities. Longer term radiological outcome studies are needed to investigate whether there is any change in radiological outcomes. Correlation with patient reported outcomes is planned.

scholarly journals Peak Contact Stress of TMT-1 Joint after Sequential Correction of Hallux Valgus Using a Proximal Opening Wedge Metatarsal Osteotomy (PMO) and Distal Soft Tissue Procedure

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0030
Author(s):  
Jonathan C. Kraus ◽  
Michael Ziegele ◽  
Mei Wang; Brian C. Law ◽  
Glenn G. Shi
Keyword(s):  
Soft Tissue ◽  
Hallux Valgus ◽  
Contact Force ◽  
Contact Stress ◽  
Soft Tissue Release ◽  
Wedge Osteotomy ◽  
Metatarsal Osteotomy ◽  
Opening Wedge ◽  
Joint Contact ◽  
The Mean

Category: Bunion; Midfoot/Forefoot Introduction/Purpose: The proximal opening wedge metatarsal osteotomy (PMO) of the first metatarsal is a common procedure for the surgical treatment of moderate to severe hallux valgus. Although with a long track record of success, limited work has been dedicated to this procedures effect on the first tarsometatarsal (TMT-1) joint. The purpose of this study is to evaluate the changes in TMT-1 joint contact stress in the diseased and corrected state following an opening wedge osteotomy of the proximal metatarsal. In addition, the effect of a distal soft tissue release (DSTR) was evaluated as it related to both radiographic correction and TMT-1 joint contact stress. Methods: Seven fresh-frozen cadaveric below knee specimens (mean age: 69yrs) with hallux valgus deformities (mean HVA: 31.7+-12.0degs) were obtained for the study. The specimen was loaded up to 400N on an MTS servo hydraulic load frame with the tibia at 90-degree to the neutrally position foot. Joint contact characteristics at TMT-1 joint were measured with a Tekscan pressure sensor (Model6900, 1100psi). A standard proximal metatarsal osteotomy was performed. Various sized metal wedges (3, 5, 7 mm) with locking plates and screws were inserted in the osteotomy for correction. Following initial tests, a complete distal soft tissue release (DSTR) was performed and the specimens were retested. Additionally, dorsoplantar weight bearing (400N) radiograph was obtained for each condition to measure intermetatarsal (IMA) and hallux valgus (HVA) angles. The contact force, area, and peak contact stress were compared among groups using ANOVA and post-hoc multiple comparisons over the untreated (Dunnett test, p<0.05). Results: The mean HVA decreased with wedge size and DSTR, reached to significant level with 7mm+DSTR (24.1 degs). The mean contact force was 39.7+-32.6 N for untreated specimens. This increased sequentially with opening wedge size and reached statistical significance 7mm opening-wedge (119.6+-53.8 N, p=0.03) and 7mm-wedge+DSTR (116.7+-58.3 N, p=0.04). The peak contact stress followed a similar trend (Figure 1). The mean peak contact stress was 2.3+-1.5 MPa for the untreated specimens and increased incrementally with wedge size to 5.3+-2.6 MPa for 7mm-wedge only (p=0.03) and 5.2+-2.1 MPa for 7mm- wedge+DSTR (p=0.04). Contact area increased with corrections, but none reached significance. Conclusion: The results from this study demonstrate that with sequentially increasing opening wedge size, loading properties through the TMT-1 joint increase. Prior work has demonstrated that joint stresses of over 4.7 MPa can be chondrotoxic, a value which was surpassed with our peak contact stress with the 7mm wedge. This has significant implications for the long-term health of the TMT-1 joint following PMO, potentially predisposing patients to arthritic joint changes. The optimal degree of correction with PMO to limit chondrotoxicity is not known at this time, and is a direction for future work.

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