Hallux Valgus Correction with a Suture-Button Construct

Jeremy T. Smith

Christopher P. Chiodo

INDICATIONS

The decision-making process for the surgical treatment of any hallux valgus deformity is complex. Numerous factors must be taken into consideration. These include degree of deformity, presence of arthritis, joint congruency, articular deformity, soft tissue balance, and the exact location of the deformity. While the specifics and subtleties of various surgical options are complex, certain general principles have traditionally guided treatment decisions. These include treating arthritic joints with a fusion, avoiding procedures that cause incongruence, and using a more powerful corrective procedure for larger deformities. For nonarthritic and noncongruent hallux valgus, mild deformities have been traditionally treated with either a distal soft tissue release or a distal metatarsal osteotomy. As the intermetatarsal (IM) angle increases, more powerful proximal osteotomies are indicated.¹

The addition of a metatarsal osteotomy to correct an elevated IM angle adds a degree of complexity to hallux valgus correction. Along with this complexity comes added potential morbidity. Potential complications associated with a first metatarsal osteotomy include metatarsal shortening, malunion, delayed union, nonunion, avascular necrosis, and fixation failure. Metatarsal shortening has been associated with the development of lateral metatar-salgia. After chevron osteotomy, metatarsal shortening has been shown to range from 2 mm to 8 mm.²^, ³^, ⁴ Other metatarsal osteotomy procedures have also been associated with shortening of up to 11 mm.⁴^, ⁵

Recently, suture-button fixation between the first and second metatarsals has been introduced as an alterative to metatarsal osteotomy. This procedure has several distinct advantages. These include a smaller incision, earlier weight bearing, and avoidance of metatarsal shortening as well as the other potential complications associated with metatarsal osteotomy.

The indications for hallux valgus correction with a suture-button construct are still being defined. In general, the technique is indicated primarily for deformities with an incongruent metatarsal-phalangeal joint, with a sufficiently increased IM angle.⁶ We agree with Holmes that it is possible to use this technique even in patients with an IM angle of greater than 15 degrees.⁶ In these patients, however, the flexibility of the IM deformity is as important as the magnitude of the increased IM angle. While the historical literature has investigated the concept of dorsal-plantar instability of the first tarsometatarsal joint,⁷^, ⁸^, ⁹ little attention has been paid to the transverse (medial-lateral) flexibility of the deformity. This is surprising given the traditional emphasis on flexible versus rigid deformity with regard to deformity correction in other parts of the body.

To this end, a more advanced hallux valgus deformity may be effectively treated with a suture-button device if the deformity demonstrates adequate flexibility. Flexibility is in the transverse plane and can be elicited with gentle compression of the first metatarsal head toward the second. Often, the true flexibility of the deformity is not apparent until distal release of the contracted lateral first metatarsophalangeal joint soft tissue structures has been
performed. As such, the surgeon may consider consenting patients with advanced deformity for suture-button fixation and also for proximal metatarsal osteotomy.

Figure 22-1. Proximal intermetatarsal facet between first and second metatarsals with hallux valgus deformity. This patient was treated with a proximal metatarsal osteotomy, not a suture-button construct.

PITFALLS/CONTRAINDICATIONS

Certain anatomic variations may inhibit adequate translation through this joint. An IM facet between the lateral base of the first metatarsal and medial base of the second metatarsal can limit reduction of the 1 to 2 IM angle (Fig. 22-1).¹⁰^, ¹¹^, ¹² Another potential anatomic block to reduction is an os intermetatarseum.¹³ The presence of these anatomic variants has been shown to occur in 8% of feet.¹⁴ Additional contraindications to suture-button fixation include the presence of arthrosis and a congruent deformity. As noted, a rigid IM deformity is also a contraindication.

PATIENT POSITIONING

The patient is placed supine on the operating room table. A peripheral nerve block is used for the majority of patients. Folded blankets are placed under the ipsilateral hip and buttock to bump the operative extremity such that the toes are pointing toward the ceiling. A platform of folded blankets is placed under the operative extremity, elevating the foot to facilitate intraoperative imaging and medial exposure. A thigh or supramalleolar Esmarch tourniquet may be used.

SURGICAL APPROACH AND TECHNIQUE

As with most procedures for hallux valgus, correction of the deformity requires distal release of the contracted lateral soft tissue structures. These structures include the adductor hallucis tendon, the transverse IM ligament, the metatarsal-sesamoid ligament, and the lateral joint capsule. A dorsal longitudinal incision is made over the first IM web space. Dissection is carried down through the deep fascia of the foot to the level of the metatarsal heads. A small Weitlaner retractor is placed between the first and second metatarsal heads to apply tension to the adductor hallucis and transverse IM ligament. The adductor tendon is then sharply transected. A Freer Elevator is then used to open the plane directly deep to the IM ligament and this ligament is transected. Care is taken to protect the deep neurovascular bundle. The metatarsal-sesamoid ligament is then fully released and the soft tissue release completed by sharply opening the lateral metatarsophalangeal joint capsule from the lateral sesamoid to the dorsum of the joint. The lateral sesamoid/flexor hallucis brevis complex should be left in continuity to prevent postoperative hallux varus. A gentle medially directed force is then applied to the hallux while stabilizing the first metatarsal to ensure that the lateral structures have been adequately released and the metatarsal head reduces over the sesamoids. At times, a small capsular band between the metatarsal-sesamoid and capsular release prevents complete reduction of the metatarsal head over the sesamoids. If this is the case, this capsular band is transected to achieve reduction. The surgeon should be able to readily “sweep” a Freer Elevator from the metatarsal-sesamoid articulation to the metatarsal-phalangeal articulation. Flexibility of the IM deformity is then reassessed by applying a laterally directed force to the first metatarsal at the level of the metatarsal head.

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