Current Concepts In Treating Hallux Valgus

By Michael M. Cohen, DPM

In the search to find the perfect osteotomy for treating hallux valgus, podiatrists have developed an extensive surgical armamentarium, which includes modifications, as well as modifications of modifications of procedures, to the point where it has become dizzying. Ultimately, our experiences have led most of us to succumb to the fact that “one size does not fit all” when dealing with this common malady and no osteotomy is completely infallible. We all have our favorites and naturally tend to employ those procedures that we are most comfortable using. Debates and arguments concerning which is the superior osteotomy have been passionate and relentless. Yet what surgeons do agree upon is that a procedure is most effective when proper indications are considered to correct the level of deformity. There are several issues to consider when one evaluates the available options. Generally, what make a surgical procedure attractive are its reliability, stability, reproducibility, technical ease and adjustability. A reliable osteotomy is one that is consistently effective. A stable osteotomy is one that resists displacement and is conducive to rigid fixation. A reproducible osteotomy is one that produces consistently good results with the least amount of complications. A technically simple and adjustable osteotomy is one that has a low learning curve and allows easy intraoperative adjustment without the need for additional wedging or bone cuts. With that said, I believe the crescentic shelf osteotomy (CSO) and the proximal phalangeal osteotomy (OPPO) maintain these attributes, making them very desirable techniques to consider in the correction of hallux valgus. What Advantages Does The CSO Offer? In the early ‘90s, base wedge osteotomies constituted the majority of proximal procedures performed by podiatrists to correct moderate to severe hallux valgus. However, the drawbacks of the procedure became evident and included shortening, elevatus, over/under correction and loss of stability with fracture of the medial hinge. Despite these drawbacks, the base wedge osteotomy remains the principal technique for correcting moderate to severe hallux valgus in the podiatry community. On the other hand, the orthopedic gold standard included and perhaps still includes the crescentic (or the “dial in”) osteotomy. The technique provided a powerful tool to correct wide intermetatarsal angles with minimal shortening. One could also adjust the procedure in order to obtain exact correction without additional wedging and facilitate triplanar correction by angling the osteotomy in various directions. Nevertheless, the crescentic osteotomy was not without its own well-documented skeletons. They included sagittal instability and postoperative elevatus, likely due to poor osteotomy placement and difficulty in fixation. The CSO was developed in an effort to avoid some of the complications encountered with current proximal osteotomies. It emphasizes the advantages of the generic crescentic osteotomy and eliminates its shortcomings. The CSO converts the crescentic osteotomy into a very stable and reproducible construct by simply combining a dorsal to plantar crescentic osteotomy directed at a 90-degree angle to a medial to lateral transverse osteotomy at the base of the metatarsal. The latter provides a thick cortical shelf for seating of the cylindrical bone. By doing so, the CSO maintains length, allows precise intermetatarsal correction, allows triplanar correction, resists dorsal displacement, is easily fixated with screws, wires or a combination, and is technically less demanding. While over a decade has passed since its inception, the CSO continues to be a reliable technique. It has not only become accepted in podiatry circles, but also appears to be gaining steam in the orthopedic world where it has been presented nationally and internationally by orthopedic surgeons. How To Perform the CSO When considering the CSO, one can usually achieve adequate exposure with a dorsal medial approach. Perform distal soft tissue procedures with appropriate releases. The base of the metatarsal should be exposed and one should be able to identify the metatarsal cuneiform joint. Retract the long extensor tendon laterally. Employing a baby Homan retractor may be useful in retracting the dorsal flap. Surgeons will now have exposure of the proximal medial ridge as well as the lateral aspect of the metatarsal.

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