RU2366375C1 - Surgical correction of hallux valgus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to orthopaedics and traumatology and can be used in surgical treatment of forefoot deformations. Anterolateral projection of metatarsal bone is approached. Cavities of hallux metatarsophalangeal articulations are opened with crucial incision. From the medial side, 5-6 mm in proximal direction from head of hallux metatarsal bone there is oblique cuneiform osteotomy with anterolateral inclined position of wedge base that provides anatomically normal position of hallux and metatarsal bone for the following external rotation thereof. In position of ensured correction, osteosynthesis is applied within osteotomy with drill wires.

EFFECT: method prevents risk of infectious complications, does not cause devascularisation of head of metatarsal bone, and does not activate sites of bone necrosis.

1 ex, 2 dwg, 1 tbl

Description

The present invention relates to medicine, namely to traumatology and orthopedics, and can be used for the surgical treatment of complex deformities of the forefoot.

Currently, there are more than 200 methods of surgical intervention in the forefoot, which indicates an ambiguous approach and existing unresolved problems. Throughout the history of orthopedics, an important problem is the further development of effective surgical methods of surgical treatment for one of orthopedic diseases - complex deformation of the forefoot. According to statistics, the pathology of the forefoot of this type is more common in women. In surgical treatment, this category of patients is one of the most difficult. Surgical treatment of these patients is important for many reasons. There are a number of factors that do not make it possible to unambiguously simply solve several tasks in an operative way during deformation of the forefoot. The provision of specialized orthopedic care for the deformation of the thumb, expressed in excessive abduction, which occurs both in connection with the flattening of the arch, and regardless of the flat foot. With the simultaneous deviation of the outside of the thumb, the head of the first metatarsal bone protrudes under the skin, and in this place an exostosis with a bag above it forms under the pressure of the shoes. Therefore, surgical treatment should be aimed, on the one hand, to remove exostosis and bag, and on the other, to change the ratio between the first metatarsal bone and the finger itself. At the same time, operations are performed, such as (reflected in FIG. 1) according to Schede (a) - resection of exostosis on the lateral surface of the head of the first metatarsal bone; according to Reverden (b) - a wedge-shaped resection of the I metatarsal bone directly proximal to the head; according to Yuvar (c) - oblique osteotomy in the proximal part I of the metatarsal bone with subsequent internal rotation; according to Mokler-Rose (g) - resection of the head of the first metatarsal bone, the articular surface of the main phalanx of the first finger; according to Wreden-Guether-Mayo (e) - resection of the head of the I metatarsal bone, while the support on the I metatarsal bone is completely lost, therefore, indications for this operation are limited; according to Albrecht-Loison (e) - a wedge-shaped resection of the sphenoid-metatarsal joint with correction of the position of the first metatarsal bone and finger; according to Brener-Riedel (g) - a wedge-shaped resection of the metatarsal bone with correction of the position of the first metatarsal bone; by Shapiro (h) - resection of bone-cartilaginous exostosis and the distal part of the head of the first metatarsal bone with articular surface; Balescu (s) - a wedge-shaped resection of the base of the I metatarsal bone with correction of the position of the I metatarsal bone;, according to Bohm (k) - a resection of the head of the 1st metatarsal bone with excision of the trapezium facing the medial side of the base and preservation of the cartilaginous surface of the head; according to Kochev (l) - resection of a bone-cartilaginous exostosis with fenestrated osteotomy in the distal I metatarsal bone; according to Babich (m) - resection of bone-cartilaginous exostosis with proximal oblique, dentate osteotomy; Logroshino (according to Boychev) (n) - excision of a wedge from the head of the first metatarsal bone with its movement to the osteotomy site of the base of the first metatarsal bone. All these operations with varying degrees of success solve the problems of correction of deformities in the forefoot. These problems can also be solved by other methods, where 1 - operation SCARF (Scarf), 2 - operation CITO, 3 - Chaklin. These methods are based on reconstructive operations - aimed at correcting and correcting several major components of the foot deformity, which has various combinations of osteotomy of the first metatarsal bone (Scarf operation, Cytosis operation). In the first case, there is an undoubted complexity of the operation. In the second case, the flawed component of the operation is the Brandes operation, which actually partially eliminates the valgus deviation of the I finger. In the third case, with osteotomies with a turn of the head (Chucklin, Ludloff operation), the medial deviation of the metatarsal bone I is not eliminated and the flattening of the forefoot does not decrease. All this leads to a relapse of hallux valgus deviation of the first finger. This convincingly dictates the need to develop new affordable, minimally invasive methods and new tactics for treating patients with valgus deformity of the first toe. The presence of hallux valgus deformity of the first toe is an absolute indication for surgical treatment, as it allows you to fix, prevent pathophysiological changes, inevitably, progressively leading to more severe deformities. Since the best possible functional and cosmetic result is required, conservative treatment is ineffective without surgical treatment for such deformities. With severe deformities of patients, severe pain in the head region of the metatarsal bone I under static load, lameness, limitation of movement function are disturbing. Unoperated forefoot deformities can lead to inflammatory complications, such as bursitis, phlegmon. Bursitis develops as a result of constant trauma to the bursa of the head region of the first metatarsal bone and as a result of direct infection in this zone. These complications can be avoided by using the earliest possible and anatomical operation and a non-traumatic method of surgical treatment. Analyzing the data of domestic and foreign literature on the surgical treatment of anterior foot deformity - hallux valgus, forefoot, it should be noted that one of the most common and effective methods for their treatment is reconstructive surgery, which involves the removal of deformations in different ways. Among the variety of methods described there is no clear indication for the use of each of them, including for reconstructive operations, as well as the analysis of long-term results of treated, operated patients using various methods. The prognosis of treatment of the patient depends on the severity of the deformation of the forefoot. There is a method of surgical reconstruction of the forefoot in case of hallux valgus of the first finger SCARF (Scarf), which perform an arcuate surgical access on the inner, lateral surface of the foot. A pendulum saw cuts longitudinally along the axis in the middle part of the bone from the sub-head zone to the level of the base in an oblique direction, without crossing the back and plantar cortical of 5 mm. Then, at a 60-degree angle, the back cortical plate is distilled distally and the plantar proximal - two bone fragments are obtained. The distal fragment is displaced relative to the proximal outward by 4-7 mm, the position of the fragments is fixed with bone forceps, two vertical holes are drilled in the cortical part through both halves and osteosynthesis is performed with two cortical screws. The wound is sutured in layers, a plaster cast is applied for 6 weeks. Hallux Valgus. Modifid Scarf Osteotomy Tachnic // J.Bone Joint Surg. - 1997, vol. 79 - B. Suppl. III - P.336.

The disadvantages of reconstructive surgery according to the method of SCARF (Scarf), with hallux valgus:

1) complexity and high invasiveness;

2) it is difficult to perform a regular even cut of a bone in one plane in several stages - a shift of the plane is inevitable, which makes it difficult to accurately match fragments;

3) when screws are inserted, it is possible to split one of the bone fragments;

4) the achieved fixation, when tightening the screws, may be lost during bone resorption in the area of osteosynthesis;

5) the impossibility of individual selection with a severe degree of deformation of the forefoot, the duration of the manipulation;

6) often there is a migration of one or both screws, there is a need to remove them ahead of time.

For the closest analogue, the method of V.D. Chaklin was adopted (Chaklin V.D. Operative orthopedics. - M; Medgiz, 1957. - 469). Perform front access in region I of the metatarsal bone, resection of the bone-cartilaginous exostosis, and then oblique osteotomy proximal to the head of the metatarsal bone in the frontal projection over the lower third, followed by rotation of the head. This allows you to remove the finger from the valgus position and partially eliminate the varus deformity of the metatarsal bone. Subsequently, in patients with incompletely eliminated hallux valgus and varus deformities gradually progressively increase again. Immobilization is carried out for 4-6 weeks, followed by rehabilitation.

Disadvantages of oblique osteotomy of the first metatarsal bone according to Chaklin.

1. The method does not allow to eliminate the medial deviation of the I metatarsal bone.

2. Does not reduce the flatness of the forefoot.

3. All the previous disadvantages of the described method lead to a relapse of the hallux valgus deviation of the first toe.

Tasks

1. Qualitative removal of exostosis of the head of the first metatarsal bone.

2. The elimination of the anatomical method of hallux valgus deviation of the I toe.

3. Elimination of rotational deviation outside the I toe.

4. Elimination of varus deformity of the I metatarsal bone.

5. Reduced lateral flattening of the foot.

6. Relief of pain in the head region of the I metatarsal bone.

7. Reduction of postoperative complications.

8. Preservation of blood supply in the head of the first metatarsal bone.

9. Stable osteosynthesis in the area of operation.

The essence of the invention is a method for surgical correction of valgus deviation of the first toe of the toe, including the removal of bone-cartilaginous exostosis, osteotomy of the first metatarsal bone and its fixation, while for the first time operative access is provided in the anteromedial projection of the metatarsal bone, a longitudinal section, the cavity of the first metatarsophalangeal joint is opened in front of the cross. on the medial side, proximal to the head of the I metatarsal bone by 5-6 mm, perform oblique, wedge-shaped osteotomy with the base of the wedge anterolaterally and at an angle, providing anatomically normal position of the toe and I metatarsal bone, with their subsequent external rotation and in the position of the obtained correction, metal osteosynthesis of the osteotomy zone with Kirschner spokes is performed.

The technical result of the proposal is as follows.

1. Anterolateral, oblique, sphenoid osteotomy proximal above the head of the first metatarsal bone I does not require traumatic surgical access. This reduces the risk of developing infectious complications compared with the operation of Chaklin, SCARF (Scarf).

2. Allows anatomical method to achieve the elimination of hallux valgus deviation of the I toe.

3. Allows anatomical way to achieve the elimination of rotational deviations outside the I toe.

4. Allows you to eliminate the varus deformity of the I metatarsal bone.

5. Allows to reduce lateral flattening of the foot.

6. Relief of pain in the head region of the I metatarsal bone.

7. The method does not disturb blood circulation in the head of the first metatarsal bone (the artery that feeds the head is not damaged), which prevents the development of arthrosis in the first metatarsophalangeal joint, aseptic necrosis. Postoperative complications are reduced by 80-90%. This surgical method is minimally invasive, allows you to correct the anterior foot deformities, in accordance with the physiology of the foot, correcting the hallux valgus deviation of the first toe with anatomical access, taking into account the anatomy of the foot, significantly improves the anatomical state and function of the forefoot. Surgical treatment is carried out, if necessary, in patients of different stages of hallux valgus deviation of the first toe, whether or not combined with transverse flatfoot, elastic or rigid type of foot. At the same time, another component of the deformation, combined with a valgus deviation of the first toe, is taken into account - a rotational deviation outside the first toe of the toe, not taken into account by other authors when choosing an osteotomy of the metatarsal bone.

The method was tested on 16 patients aged 30 to 65 years over the past 17 years. Moreover, in no case of observation was it necessary to conduct a second surgical intervention. Using this method in four cases, it was possible to successfully correct the deformation after previously performed operations in other ways. Almost all operated patients were observed in the immediate postoperative period, as well as in subsequent periods - a year, five years, ten years after surgery. In the control group, where other methods of treatment were used, complications such as gradually progressive relapse of hallux valgus deviation of the first finger, suppuration were noted. In the group of patients treated by the proposed method, low morbidity was noted compared with the control group, the percentage of complications was 2 times less than with other methods, inflammation of the soft tissues of the knitting area was noted from the complications. The terms of treatment by the proposed method in comparison with the control group are on average two weeks less. These observations showed high efficiency of using this method in comparison with other methods (Table No. 1.)

Table number 1 Sick Indicators Number of operations Duration of Treatment Traumatism Postoperative complications Control group 28 8-14 weeks high 11.2% The group according to the proposed method 22 8-10 weeks low 4.4%

The method is as follows. Under the MCA, a longitudinal incision is made along the anteromedial surface, in the region of the I metatarsophalangeal joint, directed and continuing rectilinearly along the I metatarsal bone. The skin flap is dissected and uniformly pulled up and down, the metatarsophalangeal joint is secreted, dissecting and dissecting the transverse ligament of the foot in the region of the main phalanx and articular surfaces of the metatarsophalangeal joint, without disturbing the periosteum. Exostosis is exposed on the medial surface of the head of the first metatarsal bone, it is resected i.e. perform an operation on a sheda. Further, without violating the periosteum, the distal section is exposed, with the head, the inner, anterior and lateral surfaces of the I metatarsal bone, without violating the transverse ligament of the foot, fixed in the region of the metatarsal head I in front, medially and posteriorly. The back surface in the region of the head is not dissected. Further, having retreated 5-6 mm proximal to the head of the first metatarsal bone, an oblique, wedge-shaped osteotomy is performed at an angle with the base of the wedge anteromedially up to 8 mm. After osteotomy, the proximal part of the metatarsal bone acquires mobility, the possibility of displacement to the lateral side. Eliminate the medial deviation of the I metatarsal bone. Then, in the place of the osteotomy, the head of the first metatarsal bone and the first finger are rotated inside, freely without special effort. During rotation, the head of the metatarsal bone I rotates around its axis, pulling the transverse ligament of the foot with moderate tension, displacing the "garland" of the heads of the remaining metatarsal bones, reducing the transverse size of the foot by 5-8 mm. Then, in an anatomical way, the varus deviation of the I metatarsal bone is eliminated.

Hold the metatarsal bone with the correction of the position of the 1st metatarsal bone together with the head and the 1st finger rotated inwards, percutaneously perform osteosynthesis with Kirschner spokes of the osteotomy site transarticularly, from the side of the main phalanx of the finger. Suture is applied layer by layer to the wound, the posterior plaster cast with a foot up to b / 3 lower leg, which provides immobilization of fragments for up to 6 weeks. After that, patients undergo conservative treatment with rehabilitation, physiotherapy, with the help of physiotherapy exercises until restoration of anatomical functions. The total duration of treatment is 8-11 weeks. Additionally, the method is illustrated, schematically shown in figure 2, where 1a) - exostosis is exposed on the medial surface of the head of the first metatarsal bone, it is resected, i.e. perform a Sheda operation; 1b) - a variant of the norm; 2a, 3a) - having retreated 5-6 mm proximal to the head of the first I metatarsal bone, an oblique, wedge-shaped osteotomy is performed at an angle with the base of the wedge anteromedially up to 8 mm of the first metatarsal bone; 2a, 2b, 3a) - at the site of the osteotomy, medial rotation of the head of the first metatarsal bone and the first finger is performed; 3b) - percutaneously perform osteosynthesis with Kirschner spokes of the osteotomy site.

The advantages of oblique, sphenoid, anteromedial, distal osteotomy at an angle above the head of the I metatarsal bone are as follows.

1. Anteromedial, oblique, sphenoid, osteotomy, distally above the head of the first metatarsal bone without disturbing the periosteum, does not require traumatic surgical access and exposure of the bone over a large extent. This reduces the risk of developing infectious complications compared with the operation of Chaklin, SCARF (Scarf).

2. Allows anatomical method to achieve the elimination of hallux valgus deviation of the I finger.

3. Allows an anatomical method to achieve the elimination of varus deviation of the I metatarsal bone.

4. Allows anatomical method to achieve the elimination of rotational deviations outside the I toe.

5. Relief of pain in the head region of the I metatarsal bone.

6. The method does not disturb blood circulation in the head of the first metatarsal bone (the artery supplying the head is not damaged), which prevents the development of arthrosis in the first metatarsophalangeal joint.

The proposed method has application limitations:

1) age

2) the general condition of the patient,

3) diabetes in decompensated form.

Example. Patient P., 39 years old, profession - manager. In 2003 she entered the clinic. Diagnosis: Transverse flatfoot of both feet. Hallux valgus deviation of the first fingers of the II degree. The patient was operated on. The method was carried out as follows (figure 2). Under the MCA, a longitudinal incision was made on the right foot along the anteromedial surface of region I of the metatarsophalangeal joint, directed anteromedially and continuing rectilinearly along the I metatarsal bone. The skin flap was dissected and evenly pulled up and down, and the metatarsophalangeal joint was isolated. Exostosis was exposed on the medial surface of the head of the first metatarsal bone, and it was resected, i.e. performed a Schede operation (position - 1a). Further, without violating the periosteum, the distal section with the head, the inner, anterior, and lateral surfaces of the I metatarsal bone was exposed. The back surface in the region of the head was not dissected. Then (position - 2a), retreating 5 mm proximal to the head of the first metatarsal bone, an oblique, wedge-shaped osteotomy was performed at an angle with the base of the wedge anteromedially up to 8 mm, then (position - 2a, 2b, 3a), the head of the metatarsal bone was rotated at the site of the osteotomy. and I fingers inside. Then, holding the metatarsal bone with the correction of the position of the 1st metatarsal bone together with the head and the 1st finger rotated inwards, we performed osteosynthesis with Kirschner spokes of the osteotomy site (position 3b) from the side of the main phalanx of the finger. Layered stitches on the wound. Then a similar operation was performed on the left foot. An option close to normal has been reached (position - 1b). We placed the posterior plaster casts with the foot up to the on / 3 lower leg on both lower extremities, which ensured the immobilization of fragments for up to 6 weeks. After that, the patient underwent conservative treatment with rehabilitation, physiotherapy, with the help of physiotherapy exercises until restoration of anatomical functions. Pain in the head region of the I metatarsal bones was stopped. The total duration of treatment was 8 weeks. Knitting needles located on the skin are removed 5 weeks after surgery. The patient was examined five years after surgery. She can afford to go in stylish high-heeled shoes, which could not have been before the operation. Surgical correction of the feet has not been lost. The skin is of normal color, without scuffs, corns. We observed long-term results, after 22 operations, 86.8% of patients received excellent results, 8.8% - good, 4.4% - satisfactory, unsatisfactory results were not observed. When analyzing the results of treatment with this method of surgical correction of hallux valgus deviation of the first toe, no relapses of valgus deviation of the first toe, varus deformity of the first metatarsal bone were noted, we can conclude that this method is highly promising.

Claims (1)

Method for surgical correction of hallux valgus deviation of the first toe, including the removal of bone-cartilaginous exostosis, osteotomy of the first metatarsal bone and its fixation, characterized in that a longitudinal incision is made along the anteromedial surface of the first metatarsophalangeal joint and continues rectilinearly along the first metatarsal bone, the cavity of the first is opened crosswise. metatarsophalangeal joint, from the medial side, proximal to the head of the first metatarsal bone by 5-6 mm, perform oblique, sphenoid osteotomy with the base of the wedge anterolaterally and at an angle that ensures the anatomically normal position of the toe and I metatarsal bone during their subsequent external rotation, and in the position of the correction obtained, osteosynthesis of the osteotomy zone with Kirschner spokes is performed.

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