HAV part 2

• Christina Pratt, DPM
• Part II of HAV Lectures covers:
• Procedures involving distal metatarsal
• Procedures involving metatarsal shaft
• Procedures involving proximal metatarsal

Chevron (1962)

• Also known as Austin Bunionectomy
• Chevron osteotomy involves a 60º cut and lateral transposition of capital fragment
• Corrects Intermetatarsal Angle (IMA) and Proximal Articular Set Angle (PASA) if bicorrectional

The Chevron in 12 Steps

• Skin incision is first
• Capsular incision is next
• Perform a +/- Lateral release
• Resect the medial eminence
• Placement of guidewire for chevron cut comes next
• Perform the Chevron cut.
• Place temporary fixation
• Place permanent fixation
• Next resect overhanging bone and recontour met head
• Perform +/- Medial capsulorrhaphy
• Perform layered closure

How much medial eminence to resect?

• Do not violate sagittal groove
• Staking of met head can lead to hallux varus

Where to place guidewire?

• Place it central in metatarsal head
• Too far distal placement can lead to Avascular Necrosis (AVN)

Positioning of guidewire

• Intended shortening can be achieved
• Plantarflexing is a result of guidewire positioning

Which cut is typically made first?

• The presentation does not mention which cut is typically made first

Kalish modification

• Involves a long dorsal arm
• More stability provided
• Easier to fixate

Youngswick modification

• Involves wedge of bone resected in dorsal cut
• Decompresses joint by slight shortening
• Procedure is utilized in HAV with Hallux limitus
• Kalish long dorsal arm usage is an option

Bicorrectional (biplanar) modification

• Medial wedge resected from dorsal cut
• Extend 80% across metatarsal
• Corrects for PASA
• In addition to IMA correction
• Described by Dr. Gerbert at CSPM

How far can you push the capital fragment?

• Not more than 50% of the width of the metatarsal

Direction of screw(s)?

• Distal to proximal
• Proximal medial to Distal lateral

Recontouring

• Involves Resection of overhang
• Care taken in:
• Not resecting too close to fixation
• Not traveling into metatarsal shaft

Fixation:

• Most common screws 3.0mm
• Kwires (0.062)
• Less common plate, staple
• FYI: Original Austin procedure was not fixated

Post Op:

• Variable, Typically Non Weight Bearing (NWB) 2-6 weeks with serial XR
• Some surgeons immediately Weight Bearing (WB)
• Return to shoe gear around 6 weeks

Complications:

• Undercorrection, Recurrence
• Overcorrection, Hallux varus
• Nonunion
• Hallux limitus/rigidus
• AVN
• Fracture (apex with cut too distal)

Reverdin (1881)

• Medially-based wedge of the metatarsal head
• Typically an incomplete wedge
• Used in mild-moderate HAV
• Corrects for increased PASA
• Lateral MPJ deviation
• Does not directly address IMA
• Not transpositional
• Peabody = same procedure but performed at metatarsal neck

Reverdin

• Resect medial eminence
• Perform a parallel osteotomy cut
• Position 1cm proximal to articular surface
• Make the cut parallel to articular surface to reduce PASA
• Lateral cortex is left intact
• Wedge osteotomy cut
• Wedge cut is dependent on how much correction needed
• Lateral cortex left intact

Fixation

• Does not necessarily need fixation with
• Lateral hinge intact
• Retrograde force of hallux on 1st met
• Most common use Screws (3.0mm)
• Other options: Kwires (0.062), Staple

Post Op

• Weight Bearing As Tolerated (WBAT) typically
• Return to shoe gear around 2-4 weeks

Reverdin Green modification (1977)

• Involves Reverdin + plantar osteotomy
• Prevents disruption of sesamoid articulation
• Plantar osteotomy:
• Parallel to Weight Bearing (WB) surface
• Through and through cut, medial to lateral
• Exit proximally at met neck

Reverdin Green Laird modification (1977)

• Also known as Reverdin Laird
• Modification of Reverdin Green with no lateral hinge
• Through & through wedge cut
• Allows for transposition (IMA correction!)
• Decreased stability (no hinge)
• Requires fixation

Shaft Osteotomies include:

• Ludloff
• Mau
• Vogler
• Scarf
• Consider for moderate IMA, 12-15°
• Avoids Distal Metatarsal Osteotomy (DMO), if met head is cystic
• Can often result in more dissection, larger incisions
• Work at the MPJ is still being performed
• Lateral release
• Medial eminence resection

Ludloff (1918)

• Long oblique osteotomy
• Cut is made proximal to distal
• Can obtain slight length of metatarsal
• Not stable
• Fixation: Screws or K wires
• Post op: 6 weeks NWB

Mau (1926)

• Long oblique osteotomy
• Modified the Ludloff, changed direction of cut
• Cut is made distal to proximal
• More stable than Ludloff (ground reactive force)
• Can obtain slight length of metatarsal
• Fixation: Screws or K wires
• Post op: 6 weeks NWB

Vogler (1983)

• Offset "V" osteotomy
• Modified the Ludloff again
• 45° cut
• Translate lateral like Chevron
• 50-75% of met width
• Stable osteotomy
• Long dorsal arm, short plantar arm
• Apex at metaphyseal-diaphyseal junction
• Fixation: Screws or K wires
• Post op:
• 4-6 weeks NWB
• Some immediately WB

PASA Correction

• Swivel of distal articular piece
• Can achieve moderate correction of PASA

Scarf (1984)

• Modified Sagittal "Z" osteotomy (1976)
• Multiple modifications have been made
• Corrects larger IMA, 13-20°
• Needs wide enough met & good bone stock
• Distal cut in metaphyseal head, Proximal cut at metatarsal flare
• Can adjust met length
• Shorten, make double cut (like Youngswick)
• Lengthen slightly

Technique

• Medial incision
• Resect medial eminence
• Modified lateral release
• Bone cuts
• Typically 60° cuts in metaphyseal bone
• Cut guides helpful
• Translate distal fragment laterally
• Transpositional Scarf
• Rotational Scarf
• Fixation: 2 screws is typical

Complications: Troughing

• dorsal fragment subsides into plantar fragment
• diaphyseal bone
• cortices collapse into medullary canal
• distal fragment can elevate

Traditional Scarf

• osteotomy cuts and fixation are all in diaphyseal bone
• more troughing

Modified Scarf

• High distal cut, larger angle in dense metaphyseal area
• Central cut is parallel to WB surface, allowing GRF to be compressive
• Screw position: diaphysis into metaphysis

Modified Rotational Scarf

• Also decreases troughing
• Can address PASA

Complications

• Troughing
• elevatus
• AVN
• significant dissection
• Stress fracture
• proximally
• Transfer metatarsalgia
• Nonunion, malunion
• Hallux varus

Post op

• Typically 4-6 weeks NWB
• Return to shoe 6-8 weeks

Proximal Metatarsal Osteotomies (PMO) include

• OBWO
• CBWO
• Juvara
• Crescentic
• Logroscino
• Consider for high IMA, > 15°
• Avoids DMO, if met head is cystic
• Can often result in more dissection, larger incisions
• Work at the MPJ is still being performed
• Lateral release
• Medial eminence resection

Anatomical Respect

• Includes awareness medial dorsal cutaneous n., first and second dorsal metatarsal a., deep plantar a. and v., arcuate a., and dorsalis pedis a.

OBWO (1923)

• Opening Base Wedge Osteotomy
• Medially based wedge at met base, 1cm from TMTJ
• Apex is lateral, "abductory wedge"
• Useful for an anatomically short 1st metatarsal
• Lengthen the first ray
• Hinge left intact along lateral cortex
• Osteotomy is made with saw, then gently wedged open with osteotome

Complications of OBWO

• Prolonged NWB
• Nonunion
• Undercorrection > overcorrection
• Difficult to fixate
• Requires grafting & wedged plate fixation
• Ideally cortical bone graft
• Historically, medial eminence and proximal phalanx base (Keller) use
• Elevatus
• Jamming of 1st MPJ
• Hallux limitus
• Post op: Typically 6-8 weeks NWB

CBWO (1903)

• Closing Base Wedge Osteotomy
• Includes a laterally based oblique wedge at met base, 1cm from TMTJ
• Apex is medial, "abductory wedge"
• The most common base osteotomy
• Widely used in JHAV correction, cut made distal enough to avoid growth plate
• Difficult in a narrow metatarsal
• The more distal the osteotomy, larger wedge of bone needed to achieve correction of IMA

Technique of CBWO

• Wedge cut 1 cm distal to MCJ
• Effort made to retain hinge, Leave periosteum intact over the hinge point
• Axis guidewire orientation can DF or PF upon closing down wedge
• Perpendicular to WB surface to avoid
• Proximal cut typically made first, perpendicular to metatarsal shaft
• Remove 3-5mm bone
• Screw fixation

Fixation for CBWO

• 1st screw = Anchor screw, perpendicular to metatarsal, superior/proximal, and prevents shortening if hinge fails
• 2nd screw = Compression screw, perpendicular to osteotomy, inferior/distal

Juvara (1919)

• Modification of a CBWO, with more oblique cuts
• Angled 40° to long axis of 1st met
• Longer arm for rotation of capital fragment, more IMA reduction for each degree of rotation

Complications of CBWO

• Elevation
• 159 feet, 93.7% had post op elevation, 6.68° Schuberth et al
• 33% of CBWO elevated >5° (Haendel & Lindholm)
• Shortening
• 2.6mm (Zlotoff)
• 3.2mm (Schuberth et al)
• 4.58mm (Jeremin et al)
• Nonunion, malunion
• Overcorrection > Undercorrection
• Post op: Typically 4-6 weeks NWB

Crescentic

• Can achieve multiplanar correction without shortening
• Crescentic osteotomy
• Position 1cm distal to TMTJ
• Cut perpendicular to met shaft
• Apex of curve is positioned typically proximal
• Not very common procedure, but can be useful if short 1st metatarsal

Complications of Crescentic

• Unstable
• Modification with plantar shelf can increase stability
• Difficult to fixate
• The Operating Room (OR) often may not have appropriate blade
• Nonunion, Malunion
• Because correction is technically triplanar, malunion can also occur in multiples planes
• Post op: Typically 4-6 weeks NWB

Logroscino (1948)

• Double osteotomy
• Met head osteotomy (often Reverdin)
• Met base osteotomy (often CBWO)
• Addresses high IMA and abnormal PASA
• Can achieve significant correction
• Base procedure performed first, then distal procedure

Complications

• Extensive dissection
• Nonunion, malunion
• Overcorrection
• Maintenance of position difficult
• keeping base stable while distal cuts are made
• fixation in 2 areas
• Post op: Typically 6 weeks NWB