A Case Report & Literature Review Bilateral Hallux Varus Deformity Correction With a Suture Button Construct Andrew R. Hsu, MD, Christopher E. Gross, MD, and Johnny L. Lin, MD common surgery for hallux varus correction is transfer of the Abstract extensor hallucis longus partially or completely under the deep Hallux varus deformity typically results from transverse intermetatarsal ligament to the lateral aspect base soft-tissue overcorrection at the metatarsopha- of the proximal phalanx.10,11 However, complications include langeal joint during surgery for hallux valgus. weakened extension and the inability to fix an overcorrected There are several soft-tissue procedures avail- intermetatarsal angle. Alternatively, the abductor hallucis can able for flexible hallux varus deformity includ- be tenotomized or transferred to the base of the proximal ing transfer of the extensor hallucis longus or phalanx to reconstruct the lateral capsular ligaments.8,9 The abductor hallucis. To our knowledge, there have lateral capsular ligaments can be reinforced or reconstructed not been any previous reports in the literature of with fascia lata or soft-tissue anchors, but these procedures rely bilateral hallux varus deformities in the setting of on adequate healthy tissue remaining around the MTP joint.9,12 potential pregnancy-related ligamentous laxity The Mini TightRope (Arthrex Inc, Naples, Florida) is an im- combined with iatrogenic injury. We present the planted suture endobutton device that has previously been used 13 case of an isolated bilateral hallux varus defor- for hallux valgus repair. The suture button technique has also mity occurring after pregnancy and prior bunion been used to recreate ligaments and tendons in syndesmotic 14,15 14 surgery. The simultaneous operations using disruptions of the ankle, Lisfranc fracture dislocations, 16 17 the Mini TightRope device (Arthrex Inc,AJO Naples, acromioclavicular joint dislocations, biceps tendon rupture, Florida) were considered a success with the and general tendon reinforcement and reconstruction proce- 18 patient having pain relief and return to regular dures. The suture button technique can be individually ten- activities with normal shoewear. sioned for each deformity correction and used in a minimally invasive manner to expedite weight-bearing and postopera- tive recovery. Pappas and Anderson19 were the first to describe hallux varus correction using the suture button technique to DOallux varus deformity typicallyNOT results from soft-tis- re-establish COPY the lateral collateral ligaments around the MTP sue overcorrection at the metatarsophalangeal (MTP) joint. Gerbert and colleagues20 have reported the preoperative Hjoint during surgery for hallux valgus.1 The incidence indications, surgical technique, and potential complications of of hallux varus after hallux valgus surgery is reported to range hallux varus repair with the suture button technique. from 2% to 15%.1,2 Deformity can result from over tightening To our knowledge, there are no previous reports of bilateral the medial capsule of the MTP joint, excessive lateral release, hallux varus deformities in the setting of potential pregnancy- excision of the fibular sesamoid, or excessive resection of the related ligamentous laxity combined with iatrogenic injury. medial aspect of the first metatarsal head.2,3 The traditional Mc- We present the case of an isolated bilateral hallux varus defor- Bride procedure with excision of the fibular sesamoid has the mity occurring after pregnancy and previous bunion surgery highest reported incidence of hallux varus.4 Patients with hal- that was successfully treated using the Mini TightRope device lux varus managed conservatively early on have been reported (Arthrex Inc). to have decreased symptoms in 22% of cases.5 In patients that The patient provided written informed consent for print do not respond to conservative treatment, deformity correction and electronic publication of this case report. can be achieved using medial capsular release, corrective oste- otomies,6,7 tendon transfers, and arthrodesis.2 Delayed surgery Case Report can lead to pain, stiffness, and arthritic changes in addition to A 43-year-old African American female actress presented to patient difficulty with shoewear. clinic with progressively worsening bilateral great toe pain A variety of soft-tissue procedures have been described and varus deformity that started during pregnancy and im- for flexible joints without bony abnormality that release the mediately worsened following the birth of her daughter medial capsule and rebalance hallux alignment.2,8,9 The most 3 years ago. The patient had no history of trauma to her feet and Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. www.amjorthopedics.com March 2013 The American Journal of Orthopedics® 121 Bilateral Hallux Varus Deformity Correction A. R. Hsu et al had bilateral bunionectomy proce- capsular release was needed due dures 15 years prior at an outside to the flexible nature of the defor- institution. She noted that both of mity. The identical procedure was her feet developed a crescent moon then performed on the contralat- shape, making it painful and dif- eral foot. Both feet were wrapped ficult to wear normal shoes. Her using a forefoot bandage to main- past medical history was positive tain the alignment of the hallux. for hypertension and migraines. The postoperative regimen con- On physical examination, the pa- sisted of using a postoperative shoe tient had a varus deformity of the for 6 weeks. Forefoot bandages were great toe bilaterally, greater on the changed every 2 weeks for 6 weeks left than the right. Bilateral hal- total. Weight-bearing was restricted lux varus deformities were easily, for the first 2 weeks, followed by passively, correctable. Standing 2 weeks of heel weight-bearing, radiographs showed evidence of Figure 1. Preoperative anteroposterior standing and 2 weeks of flatfoot weight- previous proximal osteotomies radiograph showing retained hardware from previous bearing. No further splinting or and distal first metatarsal osteoto- foot surgeries and increased hallux varus deformity immobilization was recommended mies that were well-healed (Fig- bilaterally greater on the left than the right. after 6 weeks. Use of accommoda- ure 1). The hallux varus deformity tive shoes was permitted based on measured 23° on the left and 16° the level of soft-tissue swelling and on the right. Due to unsuccessful clinical exam. nonoperative management, surgi- At 6-week follow-up, the pa- cal reconstruction was offered. tient was recovering well and had In the operating room, both a hallux valgus angle of 3° on the lower extremities were prepped left and 7° on the right (Figure 2). and draped in the usual sterile There were no signs of hallux varus fashion. An Esmarch bandage was AJO or valgus of either foot with hallux used at the level of the calf for in- dorsiflexion to 80° on the left and traoperative hemostasis. An inci- 60° on the right with no pain at sion was made over the first web either MTP joint. At 9-month fol- space and the lateral capsule of low-up, the patient was pain free the first MTP joint was identified and overall very pleased with the and found to be notably lax. Next, Figure 2. Postoperative weight-bearing radiograph functional and cosmetic results 2 DOseparate incisions were madeNOT at 6-week follow-up showing good alignmentCOPY and of her procedures, with a minor on the medial side of the first consolidation with appropriate hallux valgus angles concern that there was a mild re- MTP joint, one over the proximal bilaterally. currence on the right side. The phalanx and one over the first meta- patient had normal range of mo- tarsal head. After all soft tissue was tion at bilateral MTP joints and cleared and the location verified on full strength. Weight-bearing ra- fluorosopic imaging as being extra- diographs showed a hallux val- articular, two 1.2-mm guidewires gus angle of -3° on the left and were drilled from medial to lat- -6° on the right (Figure 3). The pa- eral exiting at the insertion sites tient is now 1-year status postsur- of the lateral capsule in the proxi- gery and continues to be pain free mal phalanx and first metatarsal. wearing normal shoewear during A 2.7-mm cannulated drill was regular activities with no further then passed over the wire before recurrence and no plans for further passing a Mini TightRope device operative intervention. (Arthrex Inc). The lateral capsule was then incised and oversewn Discussion in a pants-over-vest fashion with The case presented here is unique the joint in a corrected and con- Figure 3. Postoperative weight-bearing radiograph in that the patient had bilateral hal- gruous position. The Mini Tight- at 9-month follow-up showing neutral alignment on lux varus deformities that arose in Rope device (Arthrex Inc) was then the left with a mild amount hallux varus angulation on temporal association with preg- the right with continued proper alignment of the Mini manually tensioned to maintain TightRopes (Arthrex Inc). nancy and childbirth. Although the desired correction. No medial the patient had previous bilateral 122 The American Journal of Orthopedics® March 2013 www.amjorthopedics.com Bilateral Hallux Varus Deformity Correction A. R. Hsu et al bunion surgery 15 years prior to presentation, she reported are significantly higher forces on the forefoot, midfoot, and that her bilateral hallux pain and deformity