Soft Tissue Rebalancing Procedures for the Treatment of Hallux - - PowerPoint PPT Presentation

Soft Tissue Rebalancing Procedures for the Treatment of Hallux Valgus Deformities

NO DISCLOSURES

Objectives

• The main objectives of any procedure in hallux abducto

valgus surgery are to correct the deformity, prevent recurrence, and maintain as nearly normal motion

• Discuss Historical Perspective of Soft Tissue Procedure(s) for

Hallux Abducto Valgus

• Review Sequential Soft Tissue Rebalancing procedure(s) for

Hallux Valgus

• Interpretation of the results of soft tissue rebalancing

procedures described in a study are a viable

• ption to adequately correct severe hallux valgus

deformities, when certain factors dictate that an

• steotomy should not be performed.

Historical Perspective

• 1928, Earl D. McBride described in “A

conservative Operation For Bunions”

• 1st to recognize deforming force of the conjoined

tendon of adductor hallucis muscle

• Short shoe would evert Great Toe (Hallucis which

lead to a gradual pulling of fibular sesamoid into Interspace.

• Resulting in sesamoid pushing head of 1st

Metatarsal inward with ambulation

Historical Perspective

Theory of McBride Bunionectomy

• Decrease pathomechanical Forces surrounding first

Metatarsophalangeal joint

• Restore normal anatomic alignment of the joint

Description of Original McBride Procedure

• Dorsal linear incision placed lateral to lateral border of Extensor

Hallucis longus tendon over First Metatarsophalangeal joint.

• Incision carried through 1st Interspace to identity conjoined adductor

tendon and lateral head of Flexor Halluces Brevis (FHB) which was RELEASED and fibular sesamoid excised.

• Conjoined tendon and extensor halluces brevis (lateral Head)

transplanted into dorsum of the head of 1st Metatarsal bone.

• Medial eminence exposed and hypertrophic prominence resected.
• Medial capsulorrhaphy performed.

Modification To Original McBride Procedure

• Attempt to bring 1st and 2nd Metatarsals together
• 1954-1967: McBride advocated either a fascial-periosteal suture

between 1st & 2nd Metatarsal necks to re-approximate distance between 1st and 2nd Metatarsals

• 1950- Joplin took conjoined tendon through a drill hole in 1st

Metatarsal and fixated under tension.

• Extensor tendon of 5th digit to Reduce IM angle of 1st/2nd

Metatarsal

• 1960’s- DuVries took a wedge from medial capsule.
• Conjoined adductor tendon is sutured into capsules of 1st and

2nd Metatarsal.

1985- Kempe and Singer discussed an adductor Hallucis Tendon transport into Medial capsule tibial sesamoid ligament via pulley suture… de-rotation of a fibular sesamoid apparatus (via sesamoid ligament. (Fibular sesamoid ligament sacrificed) Dobbs: Criteria for soft tissue balancing procedures.

• Mild to moderate deformity (deviated joint)
• PASA and DASA normal
• IM angle 12° or less
• ROM-pain free-no crepitus 40 °- 50° of dorsiflexion
• Tibial sesamoid position 4 or greater.

Soft Tissue Rebalancing Procedures

• Retrospective observation review study performed evaluated pre &

post operative radiographs as well as subjective & objective chart review. Inclusion Criteria: 1M angle= to or > 14° PASA & DASA  Normal Procedure:

• Wedge Capsulotomy
• Medial exostosis resection
• Transection of deep transverse
• Intermetatarsal ligament
• TLS Procedure: Conjoined tendon (Oblique Head & Transverse

Head) )Adductor Halluscis Tendon)

• Lateral capsultomy
• Medial Capsulorraphy
• Closure compressive dressing x 2 weeks
• Weight bearing x 3weeks

RESULTS Soft Tissue Rebalancing Procedures

• 21 pts/28 procedures
• Mean age 64.5 years. (40-80)
• Mean post op F/U 15.7 months
• All pts had Modified McBride
• Includes Adductor Tendon Transfer
• Fibular Sesamoid Excised (7)
• Extensor Hallucis Brevis (EHB) transferred in 19/25 procedures.
• Extensor Hallucis Longus (EHL) tendon performed in 3 cases.
• X-ray evaluation: Pre-rebalancing procedures:
• IM angle (16.3-22.0) HA angle (27.5)

X-ray evaluation: Post Rebalancing Procedures)

• IM angle (70.2°) ( 6.1°)
• HA angle- (14.6°) (12.9°)
• HA X-rays demonstrate adequate Reduction of:
• Inter-Metatarsal Angle
• Hallux Adductus angle
• Establishment of Rectus first metatarsal phalangeal joint.

Discussion

• “Rebalancing”= normal position of the Hallux as it articulates

with first Metatarsal head leads to “BALANCE of FORCES” “Varus vs. Valgus”

• Structural Deformity: PASA + DASA= HA

Abnormal  Congruent Joint

• Positioning Deformity: PASA + DASA < HA;

(Normal)  Subluxed or Deviation Joint

• Combined Deformity: PASA + DASA < HA

(Abnormal) Subluxed or Deviated joint.

SUMMARY

• SEQUENTIAL soft tissue approach can be

extremely powerful force in reducing long standing deformity.

• We have an extensive armamentarium of procedures to perform in the

correction of hallux valgus.

• Certain factors can limit

the procedural choices to those consisting of soft tissue correction.

• We have provided an extensive review of soft tissue procedures

utilized in the surgical repair of hallux abducto valgus.

• Twenty-one patients underwent

twenty five soft tissue rebalancing procedures and were reviewed postoperatively on subjective,

• bjective, and radiographic criteria.
• deformities. A detailed description of the soft tissue

rebalancing procedures utilized by the authors has also been provided.

THANK YOU!!!

aiorio@nycpm.edu