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Minimally invasive surgery in hallux valgus and digital deformities.

26 de julio de 2016


Minimally invasive surgery in hallux valgus and digital deformities.

Migues A, Campaner G, Slullitel Gastón, Sotelano P, Carrasco M, Solari G.
Orthopedics. 2007 Jul;30(7):523-6

Abstract

Minimally invasive surgical techniques are an alternative with potential advantages in the treatment of forefoot deformities.

Several surgical techniques have been described for the treatment of hallux valgus and lesser toe deformities.1-4 However, lack of agreement exists regarding which technique is the most efficacious.

Minimally invasive techniques have become increasingly popular in orthopedics. The application of these concepts in hallux valgus has been questioned in the past, in part due to the lack of scientific validation. However, recent studies have shown satisfactory results using these techniques.5-7

This article describes the minimally invasive techniques we use at the Italian Hospital of Buenos Aires and their indications in the treatment of hallux valgus and lesser digital deformities. All techniques are performed as outpatient procedures under ankle or popliteal block with the patient supine and the operative foot positioned off the end of the table.8 Fluoroscopy is useful to monitor the performance of some of the steps.

Indications

The Bösch technique is used to treat mild to moderate hallux valgus with an intermetatarsal angle of 10° to 20° and a distal metatarsal articular angle <10°.

Figure 1: A 2-mm incision is made in the medial side of the great toe, approximately 5 mm plantar to the proximal edge of the nail. Figure 2: A second incision is made at the distal metaphysis of the first metatarsal, equidistant between the dorsal and plantar aspects of the bone. Figure 3: A 2-mm K-wire is inserted in retrograde form from the first to the second incision.

Surgical Technique

A 2-mm incision is made in the medial side of the great toe, approximately 5 mm plantar to the proximal edge of the nail (Figure 1). The wire entrance may be located dorsally when plantar metatarsal head displacement is desired, and plantarly if dorsal metatarsal head displacement is chosen. A second incision is made at the subcapital region of the first metatarsal, equidistant between the dorsal and plantar aspects of the bone (Figure 2). A 2-mm Kirschner wire is inserted retrograde from the first to the second incision (Figure 3). The K-wire must be placed subcutaneously and extraperiosteally to perform the metatarsal head displacement at the osteotomy site.

In the proximal incision, the periosteum is detached dorsally and plantarly with a small elevator, preserving its continuity to protect the soft tissues during the osteotomy.

The osteotomy is made in the first metatarsal subcapital region under fluoroscopic control, using an end cutting burr Shannon 44 (Miltex Instrument Co Inc, York, Pa). First, a pilot hole is made from medial to lateral. Using the hole as a guide, the bone cutter is swept around the dorsal and plantar cortex, trying to maintain the same angle proximally and distally (Figure 4). The osteotomy is performed perpendicular to the metatarsal shaft in the sagittal plane. In the frontal plane, the mediolateral obliquity of the osteotomy can be varied to shorten or lengthen the first metatarsal according to the preoperative plan. Furthermore, the metatarsal head can be rotated in the axial plane to correct rotational components of the deformity. Once the osteotomy is finished, mobility at the osteotomy site is checked under fluoroscopy.

Figure 4: Intraoperative (A) and fluoroscopic (B) images of the osteotomy.

Next, a bent grooved guide is placed through the proximal incision into the proximal metatarsal bone fragment. The K-wire tip is placed in the concavity of the guide (Figure 5). Using the guide and K-wire as a lever, the metatarsal head lateral displacement and rotation is achieved and maintained during the wire progression into the medullary canal. While holding the hallux in a varus position, the wire is driven…

10.3928/01477447-20070701-12

http://www.healio.com/orthopedics/journals/ortho/2007-7-30-7/%7B63cac653-b270-4d15-81b3-0e3062dda5ae%7D/minimally-invasive-surgery-in-hallux-valgus-and-digital-deformities

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