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Reverse Transfer of the Abductor Hallucis Tendon a Report of 7 Cases

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Reverse Transfer of the Abductor Hallucis Tendon a Report of 7 Cases Acta Orthop. Belg., 2008, 74, 227-234 ORIGINAL STUDY A new surgical procedure for iatrogenic hallux varus : Reverse transfer of the abductor hallucis tendon A report of 7 cases Thibaut LEEMRIJSE, Bao HOANG, Pierre MALDAGUE, Pierre-Louis DOCQUIER, Bernhard DEVOS BEVERNAGE From Saint-Luc University Hospital, Brussels, Belgium Iatrogenic hallux varus is a possible complication of INTRODUCTION hallux valgus surgery following Mc Bride or Scarf osteotomy, with or without Akin osteotomy of the Hallux varus deformity is a condition in which first phalanx. It may also occur following chevron the great toe is medially oriented on the first osteotomy or Keller’s procedure. One possibility for metatarsal head. It is often a triplane deformity in surgical revision of iatrogenic hallux varus is recon- which the medially deviated hallux is also ham- struction of the lateral stabilising soft-tissue compo- mered and supinated (7). nents of the first metatarsophalangeal joint. Until The condition can be congenital or acquired. now, only dynamic tendon transfers, possibly com- Several subtypes of acquired hallux varus can bined with interphalangeal fusion, have been be seen : iatrogenic, traumatic, following burn, in described. The aim of our study was to develop a systemic disorders (rheumatoid arthritis, psoriatic static, anatomic reconstruction procedure. arthritis), in Charcot-Marie-Tooth disease, in case A new surgical technique of ligamentoplasty using of avascular necrosis of the metatarsal head and in the abductor hallucis tendon is described. The new 2,3,17,23 method was applied in 7 feet (5 patients) with a mean poliomyelitis ( ). follow-up over two years. Hallux varus deformities were operated by transplantation of the abductor hallucis tendon. Subsequent radiographs showed correction of most of the factors considered to be responsible for the iatrogenic deformity. The ■ Thibaut Leemrijse, MD, Orthopaedic surgeon, Professor. American Orthopaedic Foot and Ankle Society ■ Bao Hoang, MD, Resident in Orthopaedic surgery. (AOFAS) hallux metatarsophalangeal-interpha- ■ Pierre Maldague, MD, Orthopaedic surgeon. langeal (MTP-IP) score improved from 61 to 88. ■ Pierre-Louis Docquier, MD, Orthopaedic surgeon. This new technique is a reliable, anatomic recon- ■ Bernhard Devos Bevernage, MD, Orthopaedic surgeon. struction with use of the tendon involved in the Department of Orthopaedic Surgery, Saint-Luc University Hospital, Brussels, Belgium. pathogenesis of the hallux varus deformity. No other Correspondence : Th. Leemrijse, Department of Orthopae- functional tendon is used. dic surgery, Cliniques Universitaires Saint-Luc, 10, avenue Keywords : iatrogenic hallux varus ; failed hallux Hippocrate, B-1200 Bruxelles, Belgium. E-mail : [email protected] valgus surgery ; transfer of abductor hallucis tendon. © 2008, Acta Orthopædica Belgica. No benefits or funds were received in support of this study Acta Orthopædica Belgica, Vol. 74 - 2 - 2008 228 T. LEEMRIJSE, B. HOANG, P. MALDAGUE, P.-L. DOCQUIER, B. DEVOS BEVERNAGE Iatrogenic hallux varus deformity is not fre- The first step is a wide capsular release essentially on quent, but is usually poorly tolerated. When the the medial aspect of the first MTP joint, which is per- deformity is severe or is painful with difficulty formed through a medial approach. One third of the wearing shoes, or when the cosmetic appearance is width of the abductor hallucis tendon (ABH) is harvest- worse than the initial hallux valgus, patients will ed from proximal to distal, keeping its distal bony attachment to the base of the first phalanx (P1) seek treatment (20). untouched. The fibers connecting the ABH tendon to the The incidence of postoperative hallux varus has tibial sesamoid must be released. The tendon strap been reported to range between 2% and 15.4% (4,5, should be as long as possible. 7,8). The goal of surgical treatment is to produce a Another incision in the first web space is then per- painless, cosmetically acceptable foot that can formed in order to free up and resect the fibrosis from a accommodate regular shoes, with a first metatar- possible previous McBride procedure and to prepare the sophalangeal (MTP) joint that will remain stable way for the tendon transplant. Two bone tunnels are then and mobile, and will not develop early degenerative meticulously drilled, with a diameter depending on the changes. The purpose of this article is to present a size of the transplant (generally 3.5 mm diameter). The new surgical technique for reconstruction of the tunnels are slightly oblique : the tunnel in P1 starts a few lateral components of the first MTP joint, and to millimeters distal to the insertion of the ABH tendon and show that it is more anatomical and physiological is directed toward the lateral aspect of the proximal part than other techniques currently used. of P1. The second tunnel should start just proximally and laterally to the articular cartilage of the first metatarsal head and should end just proximally and dor- MATERIALS AND METHODS sally to the entry point of the plantar vascular pedicle of the metatarsal head. Patients Both tunnels must be perfectly centered on the neu- From August 2003 to January 2007, seven patients tral line (in the lateral view) in order to prevent any with iatrogenic hallux varus were treated. Older patients pronation or supination of the phalanx during tightening with a long lasting deformity, degenerative changes in up of the transplant. The transplant is first passed the MTP joint and claw toes with fixed interphalangeal through the tunnel in P1, recovered and tagged in the (IP) joints were excluded from the study as our standard first web space, then pulled without twisting through procedure for such cases is MTP arthrodesis. The the metatarsal tunnel. The purpose is to reconstruct the reconstruction procedure was performed in seven feet, in lateral collateral ligament of the first MTP joint. five female patients (two had bilateral surgery) with an The articular surfaces must remain congruent and average age of 48 years (range, 32 to 58). mobile. The transplant is then sutured under slight ten- Primary treatment of the previous hallux valgus defor- sion and slight valgus of 10-15° using a transosseous mity had consisted in five cases in transfer of the adduc- nonabsorbable suture, secured to the remaining fibers of tor hallucis tendon using the McBride technique, result- the ABH tendon. ing in sesamoidal and phalangeal instability ; the other Caution must be exercised not to close the medial two cases had a scarf osteotomy of the first metatarsal. capsule under tension, as it can be a cause of recurrence Initial clinical examination showed hallux varus, of the deformity. If so, only the skin should be closed. most marked when weight-bearing, with dorsiflexion Postoperatively the patient wears an orthopaedic and supination of P1. shoe, without weightbearing on the forefoot for 6 weeks. All patients were operated with our personal tech- Mobilisation of the first ray is started within the first few ® nique by two senior surgeons (TL, PM). days after operation. A syndactyly with Elastoplast between the first and second toe must be maintained for Surgical technique (fig 1) two months. The technique is based on a physiologic and anatom- Postoperative evaluation ic (static and non dynamic) correction of the hallux varus deformity through reconstruction of the lateral Patients were retrospectively evaluated, both clinically collateral ligament with the help of a “reverse” transfer and radiographically. Radiographic evaluation was done of the abductor hallucis tendon. on preoperative and postoperative standing antero- Acta Orthopædica Belgica, Vol. 74 - 2 - 2008 A NEW SURGICAL PROCEDURE FOR IATROGENIC HALLUX VARUS 229 AD B E Fig. 1. — A. medial release with harvesting of the middle third of the abductor hallucis tendon. B. Illustration of the transplant trajectory. C. passage of the transplant in the phalangeal tunnel after release of the first web space. D & E. passage of the trans- plant in the metatarsal tunnel from lateral to medial. and second metatarsal head were measured. The metatarsal protrusion angle was evaluated as positive when the first metatarsal was longer than the second metatarsal on the standing AP view, as negative when C shorter and 0 when both were of similar length. The presence of cystic or arthritic changes in the articular surfaces of the sesamoids, the metatarsal head and pha- posterior and lateral radiographs of the foot (table I). On langeal base was noted intraoperatively. On the standing the standing anteroposterior (AP) radiographs, the inter- lateral radiographs, we looked for the presence of dorsal metatarsal angle, the MTP angle, the position of the subluxation of the first phalanx and exaggerated plantar tibial sesamoid relative to the medial border of the first flexion of the interphalangeal joint. The AOFAS score metatarsal, the distance between the center of the first was measured pre and post operatively. Acta Orthopædica Belgica, Vol. 74 - 2 - 2008 230 T. LEEMRIJSE, B. HOANG, P. MALDAGUE, P.-L. DOCQUIER, B. DEVOS BEVERNAGE Table I. — Radiographic evaluation, patients pre- and post operative data Patient 1 Patient 2 Patient 2 Patient 3 Patient 4 Patient 5 Patient 5 Initial surgery McBride Scarf Scarf McBride McBride McBride McBride Follow-up period (months) 51 36 25 25 10 10 10 IM angle pre 3° 4° 4° 6° 4° 6° 6° post 7° 7° 8° 7° 6° 10° 9° MTP angle pre 10° VR 20° VR 6° VR 16,5° VR 17° VR 12° VR 12° VR post 10° VL 12°
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