Double proximal phalanx osteotomy in percutaneous surgery of severe hallux valgus.

Berezhnoy Sergey.

Medincenter GlavUpDK by the Ministry of Foreign Affairs of Russia, Moscow.

27th Annual Meeting of the AOFAS, Keystone, Colorado.

Berezhnoy S.

My disclosure is in the Final AOFAS Program Book.

I have no potential conflicts with this presentation.

Double proximal phalanx osteotomy in percutaneous surgery of severe hallux

valgus.

INTRODUCTION. Proximal phalanx osteotomy (Akin) without internal fixation is a permanent stage in the HV percutaneous surgery. Stability of the phalangeal fragments is important for obtaining positive result. Preserving the outer cortical layer of the phalanx at the time of osteotomy is essential to achieve maximum stability of the bone fragments.

Lateral cortex preserved –

stable situation. Outer cortical layer rupture – unstable situation.

Before surgery

After surgery – good correction with lateral

cortex rupture

2 months later - delayed union and loss of correction.

4 months later

Case №1.

To understand the importance of the lateral cortex integrity preservation during Akin procedure the results of percutaneous proximal phalanx osteotomies of 72 feet at various degrees of hallux valgus were reviewed. Using pre- and postoperative X-rays, the angle between distal and proximal basal phalanx joint surfaces lines was measured to estimate distal phalangeal fragment deviation after osteotomy. It was indicated, that lateral deviation for more, than 20° in most cases (70%) leads to lateral cortex rupture.

8° 19°

Case №2.

Distal phalangeal fragment deviation 27°

(8+19) – significant lateral cortex rupture.

Lateral cortex rupture leads to subsequent more or less significant loss of correction in 8% of cases. Case №3.

6°

17°

5°

Distal phalangeal fragment deviation after surgery 23°

(6+17): lateral cortex rupture is obvious.

4 months later – significant loss of

correction.

To avoid lateral cortex rupture and loss of correction, double percutaneous proximal phalanx osteotomy was introduced in severe hallux valgus cases as an alternative to standard percutaneous Akin procedure.

MATERIAL AND METHODS. 11 patients (17 feet) underwent double percutaneous non fixed proximal phalanx osteotomy with the mean follow-up of 6 months (range 3 to 15). Two dorsomedial approaches were used to make osteotomies.

Postoperative rehabilitation protocol after double osteotomy and standard Akin procedure did not differ. Immediate full weight bearing was authorized.

RESULTS. In all cases the desired phalangeal fragments deviation without lateral cortex rupture was achieved and delayed unions or losses of correction were avoided.

Case №4.

Femail, 59y. Percutaneous medial cuneometatarsal joint arthrodesis (percutaneous Lapidus procedure) with screw fixation (red arrows) and double percutaneous proximal phalanx osteotomy (yellow arrows) are performed.

CT (next day after surgery): both proximal phalanx osteotomies are closed, no lateral cortex rupture, bone fragments are very stable.

Case №5.

63°

11°

Female, 57y. HV angle 63°. Pes cavus extremely flexible. No bunion pain. No pain and hyperkeratosis under the 1 metatarsal head.

23°Thanks to double proximal phalanx osteotomy (red arrows) the desired hallux deviation (34°=11+23) was achieved without outer cortical ruptures.

THANK YOU!

CONCLUSION. Double proximal phalanx osteotomy is safe, effective and predictable procedure and should be reserved for the treatment of most severe hallux valgus deformities. The surgeon needs an experience in percutaneous forefoot surgery. The effectiveness of the procedure is maximal in cases, when for some reasons 1 metatarsal osteotomies do not performed.

In a 7 months (patient came to operate another foot) – excellent clinical result. No loss of correction.

Case №5 (continued).

References.1. Akin O. The treatment of hallux valgus – a new operative procedure and its results. Med. Sentinel, 1925, vol. 33, P. 678-679. 2. Brahms. M. A. Hallux valgus – the Akin procedure. 1981, Clin. Orthop., vol. 157, P. 47-49. 3. Colloff, B., and Weitz, E. M. Proximal phalangeal osteotomy in hallux valgus. 1967, Clin. Orthop., vol. 54, P. 105-113.4. De Prado M., Ripoll P.L., Golano P. Cirugia percutanea del pie. 2003, Masson, 253 p.5. Isham S. The Reverdin-Isham procedure for the correction of hallux abducto- valgus – a distal metatarsal osteotomy procedure. 1991, Clin. Podiatr. Med. Surgery, №8, Р. 81-94.6. Mitchell L. A., Baxter D. E. The chevron-Akin double osteotomy for correction of hallux valgus. 1991, Foot and Ankle Surgery, №12, Р. 7-14. 7. Plattner P.F., Van Manen, J.W. Results of Akin type proximal phalangeal osteotomy for correction of hallux valgus deformity. 1990, J. Orthopedics, №13б, P. 996-999. 8. Robinson AH, Limbers JP. Modern concepts in the treatment of hallux valgus. J Bone Joint Surg Br. 2005, №8, Р. 1038-45.9. Sabol D. Correction osteotomy of the first phalanx of the great toe (Akin osteotomy). Interactive Surgery. 2007, vol. 2, №1, Р. 66-69.