Why I Advocate The Medial Incision Approach In Hallux Valgus Correction

Allen Jacobs DPM FACFAS

   Many years ago (more than I wish to recall), Guido LaPorta, DPM, turned me on to the medial incision for the correction of hallux valgus deformity. Over the years, I have found that the medial incisional approach to hallux valgus correction has been most effective and is associated with less postoperative problems than I have encountered with the traditional dorsal-medial longitudinal incision for hallux valgus surgery.

   The medial incision is illustrated in photo one. This incision allows for a direct medial approach to the bunion deformity.

   One advantage to the medial incision is that it does not cross branches of the medial dorsal cutaneous nerve as does the dorsal longitudinal incision. Standard textbooks of anatomy clearly demonstrate that variability of anatomy of the superficial and deep branches of the peroneal nerves in this area.1 Typically, these nerves are transversed by the dorsal longitudinal juxta-extensor hallucis longus incisions. One can avoid these nerves with the medial longitudinal incision and, quite frankly, I simply do not encounter the nerve entrapments that are not uncommonly the result of nerve injury from the dorsal longitudinal incision.

   Photograph two illustrates the medial longitudinal capsulotomy, which I typically employ in bunion correction. This allows direct removal of attenuated medial capsule and ligamentous tissues. I can do so with little or no undermining to the skin. Unfortunately, undermining of the skin is necessary with the dorsal incision due to the need for “anatomical dissection” in order to gain medial capsule access and this increases the risk of soft tissue and nerve injury.

   Photo three illustrates the easy access to the fibular sesamoid, which one obtains through a medial approach. Although I seldom find the need to remove the sesamoid, the surgeon can easily extirpate the fibular sesamoid through the medial approach. The intersesamoidal ligament is the first structure one would incise through the medial incision. This ligament is typically the most difficult and inaccessible structure to release through a dorsal incision. Those of us old enough to recall the days of mandatory fibular sesamoid removal can recall many a thenar muscle spasm when removing the sesamoid through a dorsal incision with our assistants pulling and tugging the metatarsals apart.

   Photo 4 illustrates lateral capsular release through the medial incision. One can easily accomplish, when necessary, via subperiosteal/capsular dissection. This is easy to perform contrary to those without experience who claim “you cannot get to the lateral side through a medial incision.”

   The direct medial approach allows easier osteotomy orientation from medial to lateral, and easier dorsal and plantar soft tissue retraction. In addition, I can directly visualize the entire plantar aspect of the joint to confirm the absence of hardware penetration within the joint.

   Since the capsulotomy/casulorrhaphy is directly medial, the surgeon can obtain much greater transverse plane correction in capsular plication.

   Finally, greater dressing compression on the medial incision seems to be associated with a better cosmetic scar than dorsal medial incisions. Pressure is well recognized as a means to reduce hypertrophic and keloid scar complications.

   I frequently utilize the classic dorsal-medial incision for some procedures such as implant arthroplasty, arthrodesis or cheilectomy. Those who are critical of the medial incision as lacking surgical access to lateral first MPJ structures are simply incorrect, and they likely have no true experience with the approach. Additionally, the popularity and enthusiasm for first MPJ for capsular release or sesamoid extirpation has waned in recent years and this has been reflected in recent discussions in Podiatry Today.

   The medial approach to hallux valgus has served my patient population quite well for many years with a minimum of complications and sequela. As an old television commercial used to say, “Try it, you will like it.”

References

1. Sarrafian SK: Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional (2nd edition). Lippincott, Williams and Wilkins, Philadelphia, 1993.

Comments

Dr. Jacobs,

I have been using the medial approach for traditional HAV correction for more than 15 years. Your images are very informative and demonstrates an excellent alternative to the traditional approach.
In all of this time, there has been no complaints of medial shoe irritation.
Thanks for your blog.

Neil Horsley, DPM

Dr. Jacobs,

I whole heartedly agree with your opinions on the medial approach for HAV surgery. The illustration of the medial approach to the sesamoid apparatus you provided is beautiful. I believe that there have been many people that have tried the procedure only to fail at gaining wide exposure for accessing the sesamoids. Once failed and twice shy as they say. Given your illustration perhaps more people will understand just how to execute a liberal medial MTPJ release to allow such visualization. Thanks for your time.

Molly Judge, DPM,
St. Vincent Charity Hospital
Cleveland, Ohio

I was first introduced to this incision approach by Howard Harenstein DPM, when he gave a presentation at our state meeting 25 years ago. It's far superior to the dorsal approach and exposure of the sesamoids and even excision of the fibular sesamoid can be performed with ease. Thanks for your article.

Kent L. Magrini DPM
Fort Smith, Arkansas

I agree complately about the superiority of the medial approach in HAV surgery. Anotehr posint I like to advocate is that if any scar contracture occurs along the incision it will likely aid in our correction instead of possibly elevating the hallux.

Stephen Offutt, DPM
Richmond, Indiana

Add new comment