Intraoperative checking of the first ray rotation and sesamoid position through sonographic assistance

Abstract

Introduction Hallux valgus (HV) deformity affects the orientation of the metatarsophalangeal (MTP) joint in three planes. Displacement in the coronal plane results in axial rotation of the first metatarsal, with progressive subluxation of the first MTP joint. Multiple techniques have been described to correct the malrotation itself. However, none of them have checked intraoperatively the final position of the first metatarsal head and sesamoids previous to the fixation of the Lapidus procedure or first metatarsal bone osteotomies. The aim of this article is to describe a novel technique to check the first ray rotation and sesamoids position through sonographic assistance. Materials and methods Before fixation of the Lapidus procedure, with the ankle in maximal dorsiflexion, the surgeon takes the linear ultrasound probe and places it on the sole to visualize the sesamoids, which should be viewed at the same level, with the flexor hallucis longus (FHL) centered between both. Once the ideal position of the head of the first ray has been achieved, temporary fixation with K-wires is performed over the first TMT joint and M1–M2 joint for further sonographic verification of the sesamoids beneath the first metatarsal head. The height of the sesamoids relative to the second metatarsal head should be checked by sonographic control too. Results Four patients were included. Three females and one male. Their mean age was 76.4 years (R 61–72). Their mean BMI was 29 (R 27.5–32.24). The mean IMA (intermetatarsal angle) was 18.2 (R 17.2–19) degrees and the mean MPA (metatarsophalangeal angle) was 50 (R 36–63) degrees. Conclusions Sonographic assistance, is a widely available, inexpensive, and comparative imaging technique that can guide the first ray rotation and sesamoids position in HV surgery, theoretically improving radiological outcomes.

Role of lateral soft tissue release in percutaneous hallux valgus surgery: a systematic review and meta-analysis of the literature

“…Multiple techniques have been reported with a satisfactory outcome, with no proof of superiority of one technique over another [2] The most common approach for mild to moderate HV generally involves a distal metaphyseal or metaphyso-diaphyseal osteotomy of the first metatarsal aimed to shift the metatarsal head laterally. The value of a simultaneous derotation of the metatarsal in the coronal plane (to correct the excessive pronation) and in the transversal plane (to restore the distal metaphyseal metatarsal angle or DMMA) has been discussed over recent years and is now considered a key element to reduce the risk of recurrence of the deformity [3][4][5][6] In case of residual interphalangeal valgus, a closing wedge osteotomy of the proximal phalanx (i.e., Akin osteotomy) is often recommended [7,8] The use of percutaneous approaches to perform such osteotomies is increasing over time, with an increasing number of studies documenting the non-inferiority as compared to open techniques and overall good results [9][10][11][12][13] With regard to soft tissues, the increased tension of lateral structures such as the abductor tendon of the hallux, the joint capsule, the lateral sesamoid suspensory ligament and the lateral collateral ligament has been well described in anatomical studies [14][15][16] and their release (lateral soft tissue release or LSTR) has been advocated from some authors as paramount to achieve a satisfactory alignment and reduce the risk or recurrence of the condition [3,17,18]. Two main types of percutaneous LSTR have been described, i.e.…”

“…The most common approach for mild to moderate HV generally involves a distal metaphyseal or metaphyso-diaphyseal osteotomy of the first metatarsal aimed to shift the metatarsal head laterally. The value of a simultaneous derotation of the metatarsal in the coronal plane (to correct the excessive pronation) and in the transversal plane (to restore the distal metaphyseal metatarsal angle or DMMA) has been discussed over recent years and is now considered a key element to reduce the risk of recurrence of the deformity [ 3 – 6 ] In case of residual interphalangeal valgus, a closing wedge osteotomy of the proximal phalanx (i.e., Akin osteotomy) is often recommended [ 7 , 8 ] The use of percutaneous approaches to perform such osteotomies is increasing over time, with an increasing number of studies documenting the non-inferiority as compared to open techniques and overall good results [ 9 – 13 ]…”