The foot was exsanguinated with an Esmarch bandage which was wrapped around a blue towel above the ankle to serve as a supramalleolar tourniquet. This stayed in place for two hours. A longitudinal incision was fashioned in the first web space with a 15-scalpel blade in line with the patient's prior incision. She had said that there is a massive scar tissue that really bothered her at that location but I think what she was actually feeling was the abducted metatarsal head. Dissection through the subcutaneous tissues was performed. The lateral capsule was then incised vertically in preparation for the eventual capsulorrhaphy.
We then turned our attention medially where we incised through the prior primary incision, which was over the medial midline overlying the metatarsal and metatarsophalangeal joint. Dissection through the subcutaneous tissues was performed. Subperiosteal exposure of the first metatarsal was carried out with care taken to maintain the dorsal and plantar attachments to the metatarsal for bone healing. The longitudinal incision was extended distally as well overlying the metatarsophalangeal joint and the area where the medial eminence had been removed. The proximal phalanx was exposed.
Attention was turned to the Chevron osteotomy. The osteotomy was planned with a guidewire placed at the apex. We checked its position on fluoroscopy. Then the osteotomy itself was marked out using cautery. A slightly more vertical dorsal limb and a slightly more horizontal plantar limb were created with approximately a 60-degree angle between them. A saw blade was used to create the osteotomy, and I carefully aligned the blade perpendicular to the bone. I was careful not to perforate the lateral structures in order to protect the lateral blood supply of the metatarsal head. We then removed a small piece of lateral bone from the plantar limb to serve as a subtle closing wedge osteotomy to realign the distal metatarsal articular angle which was facing laterally. We chose to remove bone from the plantar limb because the metatarsal head was in slight flexion on radiographs.
The metatarsal neck was carefully held by my right hand while the metatarsal head was then translated medially approximately 5mm. A k-wire was then placed across the osteotomy for provisional fixation and the correction was checked with fluoroscopy. I was pleased with the correction. A guidewire for the screw was then selected and a guidewire was placed from dorsal to plantar. I went to but did not perforate through the plantar cortex. Correct placement was verified on fluoroscopy. The length was measured and the screw was selected. I then drilled along the guide wire and then placed a solid 2.7mm screw. Good compression was seen across the osteotomy. I carefully felt with a freer to confirm no plantar penetration of the screw. I also verified correct placement by rotating the hallux under fluoroscopy. The medial overhanging bone was then shaved down, with care taken to protect the screw.
Attention was then turned to the tightrope and capsular imbrication. K-wires were placed in the distal phalanx and in the metatarsal metaphysis proximal to the chevron osteotomy. They converged slightly per the published technique. The tip of the proximal wire was captured in the lateral incision and pulled subperiosteally into the capsular incision. We then threaded the tight rope into the lateral incision and noted the button to rest well on the medial cortex of the distal metatarsal. Next we dilated the proximal wire tract and placed a suture passer to capture the tight rope, which was again threaded subperiosteally through the proximal phalanx. We then provisionally tightened the tight rope down with a hemostat to try to get the perfect amount of tension. We made sure during this process that we were not overtightening the hallux into valgus or leaving residual varus. We realized that the extensor houses longus was a major deforming force into varus and so we released this and did a Z-lengthening which was repaired with 3-0 Vicryl at the end of the case. We simulated weightbearing to make sure that the toe did not collapse into valgus with pressure. We are satisfied with our provisional tension we tied down the suture with 5 knots to the FiberWire. We then turned our attention laterally where we used 2-0 Vicryl to create a pants over vest lateral capsulorrhaphy.
Our x-rays were analyzed in multiple planes and we felt that the second and third metatarsals were no excessively long and would result in metatarsalgia if a Weil osteotomy were not performed.
A longitudinal incision was fashioned in the prior incision that tracked obliquely over the 2nd and 3rd metatarsal. We chose not to incise in the webspace due to perfusion concerns. Dissection through the subcutaneous tissues was performed. Z-lengthening of the 2nd and 3rd extensor digitorum longus tendons was performed with a 15-scalpel blade and release of the extensor digitorum brevis tendon. The metatarsophalangeal joint was released sharply. The toe was found to be dorsiflexed in each case, and sharp release of the collateral ligaments was carried out. A modified Weil osteotomy was created with the saw, removing a bony segment of approximately 3 mm. Metatarsal heads were translated proximally and then fixed from dorsal to plantar with 2mm screws. We then slightly plantarflexed the MTPs and pinned them to avoid recurrent floating toe. The 2nd was pinned in slight valgus to leave room for the hallux.
We noted her to have excessive curling of the fourth and fifth toes so we did percutaneous fourth and fifth extensor tenotomies to help relax the curling
We then turned our attention medially where we incised through the prior primary incision, which was over the medial midline overlying the metatarsal and metatarsophalangeal joint. Dissection through the subcutaneous tissues was performed. Subperiosteal exposure of the first metatarsal was carried out with care taken to maintain the dorsal and plantar attachments to the metatarsal for bone healing. The longitudinal incision was extended distally as well overlying the metatarsophalangeal joint and the area where the medial eminence had been removed. The proximal phalanx was exposed.
Attention was turned to the Chevron osteotomy. The osteotomy was planned with a guidewire placed at the apex. We checked its position on fluoroscopy. Then the osteotomy itself was marked out using cautery. A slightly more vertical dorsal limb and a slightly more horizontal plantar limb were created with approximately a 60-degree angle between them. A saw blade was used to create the osteotomy, and I carefully aligned the blade perpendicular to the bone. I was careful not to perforate the lateral structures in order to protect the lateral blood supply of the metatarsal head. We then removed a small piece of lateral bone from the plantar limb to serve as a subtle closing wedge osteotomy to realign the distal metatarsal articular angle which was facing laterally. We chose to remove bone from the plantar limb because the metatarsal head was in slight flexion on radiographs.
The metatarsal neck was carefully held by my right hand while the metatarsal head was then translated medially approximately 5mm. A k-wire was then placed across the osteotomy for provisional fixation and the correction was checked with fluoroscopy. I was pleased with the correction. A guidewire for the screw was then selected and a guidewire was placed from dorsal to plantar. I went to but did not perforate through the plantar cortex. Correct placement was verified on fluoroscopy. The length was measured and the screw was selected. I then drilled along the guide wire and then placed a solid 2.7mm screw. Good compression was seen across the osteotomy. I carefully felt with a freer to confirm no plantar penetration of the screw. I also verified correct placement by rotating the hallux under fluoroscopy. The medial overhanging bone was then shaved down, with care taken to protect the screw.
Attention was then turned to the tightrope and capsular imbrication. K-wires were placed in the distal phalanx and in the metatarsal metaphysis proximal to the chevron osteotomy. They converged slightly per the published technique. The tip of the proximal wire was captured in the lateral incision and pulled subperiosteally into the capsular incision. We then threaded the tight rope into the lateral incision and noted the button to rest well on the medial cortex of the distal metatarsal. Next we dilated the proximal wire tract and placed a suture passer to capture the tight rope, which was again threaded subperiosteally through the proximal phalanx. We then provisionally tightened the tight rope down with a hemostat to try to get the perfect amount of tension. We made sure during this process that we were not overtightening the hallux into valgus or leaving residual varus. We realized that the extensor houses longus was a major deforming force into varus and so we released this and did a Z-lengthening which was repaired with 3-0 Vicryl at the end of the case. We simulated weightbearing to make sure that the toe did not collapse into valgus with pressure. We are satisfied with our provisional tension we tied down the suture with 5 knots to the FiberWire. We then turned our attention laterally where we used 2-0 Vicryl to create a pants over vest lateral capsulorrhaphy.
Our x-rays were analyzed in multiple planes and we felt that the second and third metatarsals were no excessively long and would result in metatarsalgia if a Weil osteotomy were not performed.
A longitudinal incision was fashioned in the prior incision that tracked obliquely over the 2nd and 3rd metatarsal. We chose not to incise in the webspace due to perfusion concerns. Dissection through the subcutaneous tissues was performed. Z-lengthening of the 2nd and 3rd extensor digitorum longus tendons was performed with a 15-scalpel blade and release of the extensor digitorum brevis tendon. The metatarsophalangeal joint was released sharply. The toe was found to be dorsiflexed in each case, and sharp release of the collateral ligaments was carried out. A modified Weil osteotomy was created with the saw, removing a bony segment of approximately 3 mm. Metatarsal heads were translated proximally and then fixed from dorsal to plantar with 2mm screws. We then slightly plantarflexed the MTPs and pinned them to avoid recurrent floating toe. The 2nd was pinned in slight valgus to leave room for the hallux.
We noted her to have excessive curling of the fourth and fifth toes so we did percutaneous fourth and fifth extensor tenotomies to help relax the curling