The Journal of Foot & Ankle Surgery xxx (2015) 1–5
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Correction of Idiopathic Adult Hallux Varus by Tendon Transfer Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS Consultant, Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong Special Administrative Region, China
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Idiopathic adult hallux varus is a rare deformity. In this report, I present a technique for correction of this condition by extensor hallucis longus tenodesis and extensor digitorum brevis transfer. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: deformity extensor digitorum brevis extensor hallucis brevis great toe metatarsal phalanx
Adult hallux varus is an uncommon clinical entity that is usually caused by an inflammatory arthropathy or overcorrection during bunion reconstruction. Idiopathic adult hallux varus without evidence of an underlying inflammatory disease or history of trauma or surgery is a rare entity (1). The lesser toes can also be involved with hallux varus deformity, and the lesser digits tend to drift in the direction of the hallux (Figs. 1 and 2). Although numerous procedures exist for the surgical treatment of hallux varus, I describe a technique for correction of idiopathic hallux varus by means of extensor hallucis longus tenodesis combined with extensor digitorum brevis transfer using a series of small skin incisions.
(Fig. 3B). A small capsulotomy is then made at the medial aspect of the first MTP joint, and the capsule is stripped from the bone with a small periosteal elevator. A Micro VectorÔ drill guide (Smith & Nephew, Inc., Andover, MA) is then used to create a bone tunnel through the neck of the first metatarsal. The ball-tip guide is passed through the toe web incision and plantar to the first intermetatarsal ligament. The sleeve of the drill guide is positioned at the medial incision, and a bone tunnel is created with a 3.5-mm drill, which is directed laterally, distally, and plantarly (Fig. 3C). A 16-gauge, 83-mm AngiocathÔ (Becton-Dickinson, Franklin Lakes, NJ) is passed through the bone tunnel and grasped with a hemostat through the toe web incision (Fig. 4A and B). The core needle of the AngiocathÔ is then
Surgical Technique The patient is positioned supine and a pneumatic tourniquet applied to the thigh on the operative side. The hallux deformity is corrected first. A small incision is made at the dorsolateral aspect of the hallux extensor tendons at the level of the first metatarsophalangeal (MTP) joint line. The extensor hallucis longus tendon is identified, and a proximal incision is made at the proximal end of the tendon near the anterior aspect of the ankle. The lateral half of the tendon is harvested and routed distally by way of an incision in the first interdigital web (Fig. 3A). A third incision is made at the medial aspect of the first metatarsal 1.5 cm proximal to the first MTP joint, and the abductor hallucis tendon is sectioned Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS, Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail address: [email protected]
Fig. 1. Preoperative clinical photographs showing right hallux varus with medial deviation of the lesser toes.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.06.012
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T.H. Lui / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
Fig. 2. Preoperative radiographs showing right hallux varus with medial deviation of the second and third metatarsophalangeal joints (A) without significant sagittal plane deformity of the toes (B).
withdrawn, and the cannula is routed to the toe web incision using the hemostat (Fig. 4C and D). The stay stitch of polydioxanone 0-1 suture, which has been positioned in the distal terminal of the extensor hallucis longus tendon graft, is then positioned into the cannula and suction applied at the other end of the cannula to transfer the suture through the cannula (Fig. 5A). The suture and tendon graft are then passed plantarly to the first intermetatarsal ligament, through the bone tunnel in the metatarsal, and out the medial incision (Fig. 5B), where the suture is tensioned manually to reduce the hallux varus deformity. Once correction has been achieved, the tendon graft is stabilized using an absorbable suture anchor, which is inserted just proximal to the medial opening of the bone tunnel. After correction of the hallux, the second toe deformity is corrected. Dorsomedial and dorsolateral incisions are made at the
medial and lateral aspects of the extensor tendons of the second toe at the second MTP joint line. The medial capsuloligamentous complex is released at the metatarsal neck, and the extensor digitorum brevis tendon to the second toe is identified at the dorsolateral wound and traced proximally (Fig. 6A). The tendon is then sectioned at the proximal wound, and the graft is routed to the dorsolateral wound (Fig. 6B). Another dorsal longitudinal incision is then made at the midshaft level of the third metatarsal, and the extensor digitorum brevis tendon to the second toe is routed to the proximal wound plantarly to the second transverse intermetatarsal ligament, using an aneurysmal needle (or any blunt-pointed, curved needle with an eyelet for passing a ligature around an artery or other soft tissue structure; Fig. 6C). The transferred tendon is then sutured to the extensor digitorum longus tendon of the third toe, under tension, such that correction of the transverse plane deformity is achieved
Fig. 3. (A) The lateral half of the extensor hallucis longus tendon was harvested and a stay stitch applied. The tendon graft was then passed to the toe web incision. (B) The abductor hallucis tendon was transected. (C) A bone tunnel was made at the neck of the first metatarsal with the aid of the drill guide.
T.H. Lui / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
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Fig. 4. (A) A long cannula is passed through the bone tunnel and (B) grasped with a hemostat through the toe web incision under the intermetatarsal ligament. (C) The core needle of the cannula is withdrawn. (D) The cannula is retrieved at the toe web incision.
(Fig. 6D), and the pull of the extensor digitorum longus tendon of the third toe thereafter provides a dynamic corrective force on the second toe. Case Report A 56-year-old female noted a progressive deformity of the toes of her right foot for approximately a 4-year duration. She described no history of preceding injury or other joint pain or swelling. Initially, the deformity was flexible and asymptomatic; however, it had gradually became rigid and painful, and she had developed difficulty wearing shoes. The physical examination showed hallux varus deformity that was semi-reducible with manual manipulation. The lesser toes were also medially deviated. The varus deformity of the second toe was quite rigid, and the other lesser toes were easily realigned passively. The plantar flexion–dorsiflexion range of motion was normal for the remaining toes, and the sensation, power, and reflexes of the foot and
ankle were normal. Serologic testing was negative for both rheumatoid factor and antinuclear antigens, and the erythrocyte sedimentation rate and C-reactive protein levels were within the normal range. Radiographs showed right hallux varus and medial deviation of the second and third MTP joints (Fig. 2). The patient was treated conservatively with reverse last shoes, manipulation and stretching exercises, and splintage of the toes. Despite the nonsurgical efforts, her symptoms persisted, and operative correction by tendon transfer was performed as described. No postoperative complications were encountered, and she was able to wear regular shoes without difficulty. After approximately 40 months of follow-up, the correction was maintained (Fig. 7). Discussion Idiopathic adult hallux varus is a rare clinical entity. Clinically, it starts as a flexible deformity, and the symptoms can possibly be
Fig. 5. (A) A long cannula was passed through the bone tunnel in the first metatarsal to the toe web incision. The stay stitch of the tendon graft was passed through the cannula, and suction was applied at the other end. (B) The stitch and tendon graft were then passed plantarly to the intermetatarsal ligament through the bone tunnel to the medial incision.
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T.H. Lui / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
Fig. 6. (A) The extensor digitorum brevis tendon was identified at the dorsolateral incision and traced proximally. (B) The tendon was cut at the proximal incision, and the graft was retracted to the dorsolateral incision. (C) The extensor digitorum brevis tendon was retrieved through the incision at the midshaft of level of the third metatarsal plantarly to the second transverse intermetatarsal ligament using an aneurysmal needle. (D) The deformity was then corrected by tensioning the tendon graft.
relieved with shoe wear modifications. The deformity can become more rigid with time, and subsequent medial callusing of the first toe and varus deformities of the lesser toes will evolve (1). Operative correction of the deformity is indicated for symptomatic rigid deformity that has not responded to conservative treatment (2). Keller arthroplasty of the first MTP joint and valgus proximal phalangeal osteotomies of the lateral toes have been suggested as surgical options for the treatment of this condition (1). However, it has been postulated that the abductor hallucis tendon inserts more medially on the phalanx and overpowers the adductor, producing a medially directed moment and, with time, a varus deformity (1). First MTP joint arthrodesis (2) and metatarsal osteotomy (3) have been suggested for iatrogenic hallux varus after bunion surgery, but not for idiopathic hallux varus. A soft tissue balancing procedure might be a more
appropriate operative approach (4–7). In the present patient, the first MTP joint was realigned by release of the abductor hallucis tendon and the medial capsule and extensor hallucis longus tenodesis (4). The lesser toes were realigned by release of the medial capsuloligamentous structure, together with extensor digitorum brevis transfer (4,8). Theoretically, this procedure can be performed on the second to fourth toes. Transfer of the extensor digitorum brevis tendon to the extensor digitorum longus of the next lateral ray allowed an effective lateral pull to the medially deviated toe. This procedure was performed on the second toe only in the present patient, because the other lesser toe deformities were flexible and were spontaneously reduced after the second MTP joint was realigned. These soft tissue reconstructive procedures can restore joint congruity, relieve pain, and prevent traumatic arthrosis (9,10). Finally,
Fig. 7. Postoperative clinical photograph and radiograph obtained approximately 40 months postoperatively showing correction of the toe deformities.
T.H. Lui / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
these surgical procedures can be performed in a minimally invasive manner, with satisfactory cosmetic results. References 1. Granberry WM, Hickey CH. Idiopathic adult hallux varus. Foot Ankle Int 15:197– 205, 1994. 2. Davies MB, Blundell CM. The treatment of iatrogenic hallux varus. Foot Ankle Clin 19:275–284, 2014. 3. Choi KJ, Lee HS, Yoon YS, Park SS, Kim JS, Jeong JJ, Choi YR. Distal metatarsal osteotomy for hallux varus following surgery for hallux valgus. J Bone Joint Surg Br 93:1079–1083, 2011. 4. Lui TH. Technique tip: minimally invasive approach of tendon transfer for correction of hallux varus. Foot Ankle Int 30:1018–1021, 2009.
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5. Plovanich EJ, Donnenwerth MP, Abicht BP, Borkosky SL, Jacobs PM, Roukis TS. Failure after soft-tissue release with tendon transfer for flexible iatrogenic hallux varus: a systematic review. J Foot Ankle Surg 51:195–197, 2012. 6. Veljkovic A, Lansang E, Lau J. Forefoot tendon transfers. Foot Ankle Clin 19:123– 137, 2014. 7. Hsu AR, Gross CE, Lin JL. Bilateral hallux varus deformity correction with a suture button construct. Am J Orthop 42:121–124, 2013. 8. Lui TH. Correction of crossover deformity of second toe by combined plantar plate tenodesis and extensor digitorum brevis transfer: a minimally invasive approach. Arch Orthop Trauma Surg 131:1247–1252, 2011. 9. Fuhrmann RA. Split transfer of the extensor hallucis longus tendon in flexible hallux varus deformity. Oper Orthop Traumatol 20:274–282, 2008. 10. Goldner JL, Ward WG. Traumatic horizontal deviation of the second toe: mechanism of deformity, diagnosis, and treatment. Bull Hosp Jt Dis Orthop Inst 47:123– 135, 1987.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Case Reports and Series
Correction of Idiopathic Adult Hallux Varus by Tendon Transfer Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS Consultant, Department of Orthopaedics and Traumatology, North District Hospital, Hong Kong Special Administrative Region, China
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Idiopathic adult hallux varus is a rare deformity. In this report, I present a technique for correction of this condition by extensor hallucis longus tenodesis and extensor digitorum brevis transfer. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: deformity extensor digitorum brevis extensor hallucis brevis great toe metatarsal phalanx
Adult hallux varus is an uncommon clinical entity that is usually caused by an inflammatory arthropathy or overcorrection during bunion reconstruction. Idiopathic adult hallux varus without evidence of an underlying inflammatory disease or history of trauma or surgery is a rare entity (1). The lesser toes can also be involved with hallux varus deformity, and the lesser digits tend to drift in the direction of the hallux (Figs. 1 and 2). Although numerous procedures exist for the surgical treatment of hallux varus, I describe a technique for correction of idiopathic hallux varus by means of extensor hallucis longus tenodesis combined with extensor digitorum brevis transfer using a series of small skin incisions.
(Fig. 3B). A small capsulotomy is then made at the medial aspect of the first MTP joint, and the capsule is stripped from the bone with a small periosteal elevator. A Micro VectorÔ drill guide (Smith & Nephew, Inc., Andover, MA) is then used to create a bone tunnel through the neck of the first metatarsal. The ball-tip guide is passed through the toe web incision and plantar to the first intermetatarsal ligament. The sleeve of the drill guide is positioned at the medial incision, and a bone tunnel is created with a 3.5-mm drill, which is directed laterally, distally, and plantarly (Fig. 3C). A 16-gauge, 83-mm AngiocathÔ (Becton-Dickinson, Franklin Lakes, NJ) is passed through the bone tunnel and grasped with a hemostat through the toe web incision (Fig. 4A and B). The core needle of the AngiocathÔ is then
Surgical Technique The patient is positioned supine and a pneumatic tourniquet applied to the thigh on the operative side. The hallux deformity is corrected first. A small incision is made at the dorsolateral aspect of the hallux extensor tendons at the level of the first metatarsophalangeal (MTP) joint line. The extensor hallucis longus tendon is identified, and a proximal incision is made at the proximal end of the tendon near the anterior aspect of the ankle. The lateral half of the tendon is harvested and routed distally by way of an incision in the first interdigital web (Fig. 3A). A third incision is made at the medial aspect of the first metatarsal 1.5 cm proximal to the first MTP joint, and the abductor hallucis tendon is sectioned Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Tun Hing Lui, MBBS (HK), FRCS (Edin), FHKAM, FHKCOS, Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China. E-mail address: [email protected]
Fig. 1. Preoperative clinical photographs showing right hallux varus with medial deviation of the lesser toes.
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.06.012
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T.H. Lui / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
Fig. 2. Preoperative radiographs showing right hallux varus with medial deviation of the second and third metatarsophalangeal joints (A) without significant sagittal plane deformity of the toes (B).
withdrawn, and the cannula is routed to the toe web incision using the hemostat (Fig. 4C and D). The stay stitch of polydioxanone 0-1 suture, which has been positioned in the distal terminal of the extensor hallucis longus tendon graft, is then positioned into the cannula and suction applied at the other end of the cannula to transfer the suture through the cannula (Fig. 5A). The suture and tendon graft are then passed plantarly to the first intermetatarsal ligament, through the bone tunnel in the metatarsal, and out the medial incision (Fig. 5B), where the suture is tensioned manually to reduce the hallux varus deformity. Once correction has been achieved, the tendon graft is stabilized using an absorbable suture anchor, which is inserted just proximal to the medial opening of the bone tunnel. After correction of the hallux, the second toe deformity is corrected. Dorsomedial and dorsolateral incisions are made at the
medial and lateral aspects of the extensor tendons of the second toe at the second MTP joint line. The medial capsuloligamentous complex is released at the metatarsal neck, and the extensor digitorum brevis tendon to the second toe is identified at the dorsolateral wound and traced proximally (Fig. 6A). The tendon is then sectioned at the proximal wound, and the graft is routed to the dorsolateral wound (Fig. 6B). Another dorsal longitudinal incision is then made at the midshaft level of the third metatarsal, and the extensor digitorum brevis tendon to the second toe is routed to the proximal wound plantarly to the second transverse intermetatarsal ligament, using an aneurysmal needle (or any blunt-pointed, curved needle with an eyelet for passing a ligature around an artery or other soft tissue structure; Fig. 6C). The transferred tendon is then sutured to the extensor digitorum longus tendon of the third toe, under tension, such that correction of the transverse plane deformity is achieved
Fig. 3. (A) The lateral half of the extensor hallucis longus tendon was harvested and a stay stitch applied. The tendon graft was then passed to the toe web incision. (B) The abductor hallucis tendon was transected. (C) A bone tunnel was made at the neck of the first metatarsal with the aid of the drill guide.
T.H. Lui / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
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Fig. 4. (A) A long cannula is passed through the bone tunnel and (B) grasped with a hemostat through the toe web incision under the intermetatarsal ligament. (C) The core needle of the cannula is withdrawn. (D) The cannula is retrieved at the toe web incision.
(Fig. 6D), and the pull of the extensor digitorum longus tendon of the third toe thereafter provides a dynamic corrective force on the second toe. Case Report A 56-year-old female noted a progressive deformity of the toes of her right foot for approximately a 4-year duration. She described no history of preceding injury or other joint pain or swelling. Initially, the deformity was flexible and asymptomatic; however, it had gradually became rigid and painful, and she had developed difficulty wearing shoes. The physical examination showed hallux varus deformity that was semi-reducible with manual manipulation. The lesser toes were also medially deviated. The varus deformity of the second toe was quite rigid, and the other lesser toes were easily realigned passively. The plantar flexion–dorsiflexion range of motion was normal for the remaining toes, and the sensation, power, and reflexes of the foot and
ankle were normal. Serologic testing was negative for both rheumatoid factor and antinuclear antigens, and the erythrocyte sedimentation rate and C-reactive protein levels were within the normal range. Radiographs showed right hallux varus and medial deviation of the second and third MTP joints (Fig. 2). The patient was treated conservatively with reverse last shoes, manipulation and stretching exercises, and splintage of the toes. Despite the nonsurgical efforts, her symptoms persisted, and operative correction by tendon transfer was performed as described. No postoperative complications were encountered, and she was able to wear regular shoes without difficulty. After approximately 40 months of follow-up, the correction was maintained (Fig. 7). Discussion Idiopathic adult hallux varus is a rare clinical entity. Clinically, it starts as a flexible deformity, and the symptoms can possibly be
Fig. 5. (A) A long cannula was passed through the bone tunnel in the first metatarsal to the toe web incision. The stay stitch of the tendon graft was passed through the cannula, and suction was applied at the other end. (B) The stitch and tendon graft were then passed plantarly to the intermetatarsal ligament through the bone tunnel to the medial incision.
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T.H. Lui / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
Fig. 6. (A) The extensor digitorum brevis tendon was identified at the dorsolateral incision and traced proximally. (B) The tendon was cut at the proximal incision, and the graft was retracted to the dorsolateral incision. (C) The extensor digitorum brevis tendon was retrieved through the incision at the midshaft of level of the third metatarsal plantarly to the second transverse intermetatarsal ligament using an aneurysmal needle. (D) The deformity was then corrected by tensioning the tendon graft.
relieved with shoe wear modifications. The deformity can become more rigid with time, and subsequent medial callusing of the first toe and varus deformities of the lesser toes will evolve (1). Operative correction of the deformity is indicated for symptomatic rigid deformity that has not responded to conservative treatment (2). Keller arthroplasty of the first MTP joint and valgus proximal phalangeal osteotomies of the lateral toes have been suggested as surgical options for the treatment of this condition (1). However, it has been postulated that the abductor hallucis tendon inserts more medially on the phalanx and overpowers the adductor, producing a medially directed moment and, with time, a varus deformity (1). First MTP joint arthrodesis (2) and metatarsal osteotomy (3) have been suggested for iatrogenic hallux varus after bunion surgery, but not for idiopathic hallux varus. A soft tissue balancing procedure might be a more
appropriate operative approach (4–7). In the present patient, the first MTP joint was realigned by release of the abductor hallucis tendon and the medial capsule and extensor hallucis longus tenodesis (4). The lesser toes were realigned by release of the medial capsuloligamentous structure, together with extensor digitorum brevis transfer (4,8). Theoretically, this procedure can be performed on the second to fourth toes. Transfer of the extensor digitorum brevis tendon to the extensor digitorum longus of the next lateral ray allowed an effective lateral pull to the medially deviated toe. This procedure was performed on the second toe only in the present patient, because the other lesser toe deformities were flexible and were spontaneously reduced after the second MTP joint was realigned. These soft tissue reconstructive procedures can restore joint congruity, relieve pain, and prevent traumatic arthrosis (9,10). Finally,
Fig. 7. Postoperative clinical photograph and radiograph obtained approximately 40 months postoperatively showing correction of the toe deformities.
T.H. Lui / The Journal of Foot & Ankle Surgery xxx (2015) 1–5
these surgical procedures can be performed in a minimally invasive manner, with satisfactory cosmetic results. References 1. Granberry WM, Hickey CH. Idiopathic adult hallux varus. Foot Ankle Int 15:197– 205, 1994. 2. Davies MB, Blundell CM. The treatment of iatrogenic hallux varus. Foot Ankle Clin 19:275–284, 2014. 3. Choi KJ, Lee HS, Yoon YS, Park SS, Kim JS, Jeong JJ, Choi YR. Distal metatarsal osteotomy for hallux varus following surgery for hallux valgus. J Bone Joint Surg Br 93:1079–1083, 2011. 4. Lui TH. Technique tip: minimally invasive approach of tendon transfer for correction of hallux varus. Foot Ankle Int 30:1018–1021, 2009.
5
5. Plovanich EJ, Donnenwerth MP, Abicht BP, Borkosky SL, Jacobs PM, Roukis TS. Failure after soft-tissue release with tendon transfer for flexible iatrogenic hallux varus: a systematic review. J Foot Ankle Surg 51:195–197, 2012. 6. Veljkovic A, Lansang E, Lau J. Forefoot tendon transfers. Foot Ankle Clin 19:123– 137, 2014. 7. Hsu AR, Gross CE, Lin JL. Bilateral hallux varus deformity correction with a suture button construct. Am J Orthop 42:121–124, 2013. 8. Lui TH. Correction of crossover deformity of second toe by combined plantar plate tenodesis and extensor digitorum brevis transfer: a minimally invasive approach. Arch Orthop Trauma Surg 131:1247–1252, 2011. 9. Fuhrmann RA. Split transfer of the extensor hallucis longus tendon in flexible hallux varus deformity. Oper Orthop Traumatol 20:274–282, 2008. 10. Goldner JL, Ward WG. Traumatic horizontal deviation of the second toe: mechanism of deformity, diagnosis, and treatment. Bull Hosp Jt Dis Orthop Inst 47:123– 135, 1987.
