Hallux Osteotomies

Hallux Osteotomies

Thomas F. Smith

Jared L. Moon

The goals of corrective surgical procedures involving the hallux include realigning linear or angular deformities of the proximal and distal phalanx, addressing any catharsis at the hallux interphalangeal joint (HIPJ), or both (1,2). The choice of hallux phalangeal osteotomies or arthrodesis of the HIPJ is based not only on the location of the deformity within the hallux but also on the involvement of the HIPJ with patient complaints and needs. Patient complaints and needs addressed with HIPJ arthrodesis include joint pain with or without angular hallux deformity, muscle imbalance of the hallux, and HIPJ instability. Patient complaints and needs addressed with hallux osteotomies include painful hallux and second toe interdigital keratoses, hallux to shoe irritation problems, extrinsic hallux muscle-tendon positioning and cosmesis. Preoperative evaluation to aid surgical procedure selection involves not only assessment of any clinical and radiographic angular deformities of the first ray but also hallux and first ray joint assessment.

Hallux phalangeal osteotomies are primarily utilized as a component of hallux abducto valgus corrections. As the first ray surgical correction process progresses in hallux valgus surgery, changes in first metatarsal and hallux phalangeal angular positioning can occur through procedures remote from the actual site of correction. Reassessment of these changing angular first ray alignments is important to appreciate for possible intraoperative alterations or adjustments in the preoperative surgical plan. A preoperative plan to perform a hallux osteotomy may be obviated by improved overall hallux positioning following the first metatarsal osteotomy, first metatarsophalangeal joint (MTPJ) soft tissue reconstruction or both (1,3,4,5,6,7 and 8). Proximal phalangeal osteotomies of the hallux can be expected to correct primarily phalangeal hallux angular deformities and not necessarily first ray deformities in general (1,3,9). Similarly, the use of first metatarsal or first MTPJ procedures to address significant hallux phalangeal angular issues can result in other malalignment problems of the first ray.

In terms of surgical technique multiple incisional approaches, osteotomy site orientations and locations, and bone fixation options are available for hallux phalangeal osteotomies. There are advantages and disadvantages to be considered in the choice of each possibility. Their selection and use is determined by both the level of the deformity to be corrected as well as meeting the needs and expectations of the patient. Hallux osteotomies may be performed alone in isolated hallux interphalangeal deformities or as an adjunctive procedure in more complex first ray deformities based on specific patient needs (10,11,12,13 and 14). Since Akin (15) first described the proximal phalangeal osteotomy for hallux valgus correction in 1925 that has come to bear his name, refinements not only in surgical technique but also in indication and application have helped define the role of this procedure in first ray pathology (Fig. 26.1).


A proximal phalangeal osteotomy or Akin osteotomy to correct abductory deformity of the hallux within itself can be performed at the base, midshaft, or head of the proximal phalanx (Fig. 26.5). The osteotomy has a medial base and a lateral apex and may be oriented either transverse or oblique through the proximal phalanx. The goal of the Akin osteotomy is basically to shorten the medial side of the proximal phalanx relative to the lateral side creating a more parallel relationship of the two proximal phalangeal articular surfaces. This goal can be accomplished with an osteotomy of the proximal phalanx regardless of the osteotomy location within the phalanx. The choice of performing a proximal or distal osteotomy within the proximal phalanx of the hallux is the subtle difference between a high DASA and a high HIA. Both represent a longer medial and shorter lateral surface of the proximal phalanx. The distinction of a high DASA relative to a high HIA is more the clinical and radiographic apex of the
deformity within the proximal phalanx. A high DASA is a more proximal malalignment of the proximal joint surface of the proximal phalanx to its long axis resulting in a longer medial surface relative to the lateral surface of the proximal phalanx. The main body of the proximal phalanx is in a relatively normal alignment to the distal phalanx. This relationship results in a more subtly proximal hallux interphalangeal abductory deformity. The distal phalanx does not appear angulated to the proximal phalanx distally within the hallux. A hallux abductus interphalangeus as a result of an increased DASA responds best to a transverse osteotomy of the base of the proximal phalanx or an oblique osteotomy with the apex proximally oriented (Fig.26. 6).

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Jul 26, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Hallux Osteotomies

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