RU2565374C1 - Method of treating valgus deformity of first toe and varus deformity of first metatarsal foot bone - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: access to base of I metatarsal bone for its osteotomy is performed on medial surface at the level of plantar bone edge from 1.8 to 3.0 cm long. Osteotomy plane is placed with concave side forward. Proximal edge of osteotomy is placed not farther than 5-7 mm from joint surface of I metatarsal bone base. Osteotomy is performed with instrument with diameter, which is 2-5 mm larger than value of bone transverse section on osteotomy zone. Osteotomy axis is placed 1-4 mm more laterally than bone axis. Osteotomy is directed from distal bone end from medial-plantar surface of foot and continued proximally-dorsally-laterally: in sagittal plane, passing vertically and coinciding with axis of I metatarsal bone, osteotomy is directed at angle 45-85° from bone axis in said plane, in frontal plane, passing perpendicularly to axis of I metatarsal bone and sagittal plane, osteotomy is directed at angle 5°-45° from line of crossing of said planes. Complex varus-rotary-dorsiflection deformity of I metatarsal bone is eliminated. In case of additional correction of shortening of I metatarsal bone and foot arches distal fragment is displaced plantarly along osteotomy plane. Exostosis of I metatarsal bone head is ablated after its proximal osteotomy, correction of deformity and fixation. Reverse shevron osteotomy of main phalanx of I toe is performed with sawcuts at angle 60-130°.

EFFECT: method makes it possible to improve cosmetic look of operated foot by complete correction of deformity and elimination of its recurrences, and prevent complications.

3 cl, 1 ex

Description

The invention relates to medicine, namely to traumatology and orthopedics, and is intended for the treatment of foot deformities.

There is a method of treating hallux valgus deformity of the first toe and varus deformity of the I metatarsal bone, which consists in exposing the main phalanx from its base to the medial metatarsopharyngeal joint, cutting out a triangular-shaped flap from the joint capsule with a distal base, subsequent bursexostostectomy, and performing an adductorotenotomy in a separate section through interductotenotomy the interval and lateral capsulotomy of the first metatarsophalangeal joint with the reduction and subsequent fixation of the sesamoid bones to the place of their norm anatomical location, while the body of the I metatarsal bone is freed by the parator from the periosteum only on the inner surface for access of the oscillatory saw and a longitudinal Z-shaped osteotomy is performed in the frontal plane in the distal and proximal parts, respectively 3-3.5 mm from the edge of the cartilage of the head and 1.5 cm from the metatarsopharyngeal joint. In order to eliminate pronation of the I metatarsal bone, a small wedge is cut from the medial side of the central fragment. A valgus deflection of the distal fragment is performed to eliminate the varus position of the I metatarsal bone. If necessary, correct the length of the I metatarsal bone. Osteosynthesis of the I metatarsal bone is carried out by two cortical screws. Then, the I finger is fixed in the correct position, the wound is sutured, an immobilization dressing is applied (1).

The disadvantage of this method is the increased invasiveness of the operation, prolonged healing of the postoperative wound, unstable fixation of fragments of the main phalanx of the first toe and first metatarsal bone with screws in patients suffering from osteoporosis, a high percentage of complications (early relapse of the deformity, fusion with rotational deformation and deformation-dorsiflexia I metatarsal bone, "pounding" with loss of height of the metatarsal bone I, metatarsal bone fracture).

Closest to the claimed is a method comprising exposing the surgical field, cutting out a triangular-shaped flap with a distal base from the joint capsule, subsequent bursexostosectomy, osteotomy of the I metatarsal bone, removal of the varus position of the I metatarsal bone, fixation of the correct position of the I metatarsal bone, suturing of the wound. The operative field is the base of the first metatarsal bone and the first metatarsophalangeal joint, the osteotomy is performed in the sagittal plane in the metaphysical area of the base of the first metatarsal bone with an arcuate chisel, due to the maximum valgus deviation of the distal fragment, the varus position of the first metatarsal bone is fixed and fixed crosswise with two Kirschner knitting needles -II sphenoid bones, additionally expose the base of the main phalanx of the first toe and perform an osteotomy in the frontal plane of the gutters with an idylic chisel in an arcuate manner with the formation of a sectional plane of the congruent head of the first metatarsal bone, the valgus deformity of the first finger is removed, its transarticular fixation is performed with the Kirschner spoke, the base metatarsal osteotomy is made at a distance of 1 cm from the articular surface, the base osteotomy is made at the base of the first finger 5 cm from the articular surface (2).

The disadvantages of the method selected as a prototype are as follows:

1. After the operation, a well-visible cosmetic defect remains in the form of a scar from access along the dorsal surface of the foot for osteotomy of the first metatarsal bone.

2. The method does not provide a complete correction of the deformation, as it consists only in correcting the varus deviation of the I metatarsal bone.

However, it is known that the varus deviation of the I metatarsal bone is always accompanied by its rotational-pronational deformation and the displacement of the distal part of this bone to the back side - dorsiflexion, and these components of the complex deformation of the I metatarsal bone are not eliminated by the prototype method.

3. Incomplete correction of the deformation leads to the development of complications - residual pain, metatarsalgia, frequent relapse of the deformity, the need for additional operations.

4. An osteotomy at a distance of 1 cm from the proximal edge of the I metatarsal bone implies some shortening (since the bone is bent at the level of the osteotomy), which leads to a corresponding lengthening of the II metatarsal bone, overload of its head and metatarsalgia. Also, this place is located relatively far from a well-circulated metaphysis and closer to a worse-circulated diaphysis, which slows down bone fusion.

The objective of the invention is to improve the results of treatment in the form of 1) improving the cosmetic appearance of the operated foot, 2) complete and persistent correction of deformation, 3) eliminating residual pain and metatarsalgia, 4) improving the support and dynamic function of the operated feet, 5) eliminating complications and necessity repeated operations.

According to the invention, the technical result of the task is achieved by the fact that in the method of treating hallux valgus deformation of the first finger and varus deformity of the first metatarsal bone, including medial surgical access to the first metatarsophalangeal joint, bursectomy, medial capsulotomy, exostozectomy, surgical access to the first interstitus and lateral release in the form of adductorotenotomy with lateral capsulotomy of the first metatarsophalangeal joint, surgical access to the base of the first metatarsal bone, its osteotomy is grooved form with correction of varus deformity and fixation, osteotomy of the main phalanx of the first finger, correction of its hallux valgus and fixation, medial plastic capsule of the first metatarsophalangeal joint and suturing of wounds, access to the base of the first metatarsal bone for its osteotomy is performed on the medial surface at the level of the plantar edge of the bone lengths from 1.8 to 3.0 cm, the osteotomy plane is placed with the concave side forward, the proximal edge of the osteotomy is placed no further than 5-7 mm from the articular surface of the base of the first metatarsal bone, the osteotomy is performed a tool with a diameter 2-5 mm larger than the bone diameter in the osteotomy zone, the axis of the osteotomy (the axis of the cylinder formed by the osteotomy plane) is 1-4 mm lateral to the bone axis, the osteotomy is directed from the distal end of the bone from the medial-plantar surface of the foot and continue proximal-dorsal-lateral, in the sagittal plane extending vertically and coinciding with the axis of the metatarsal bone I, the osteotomy is directed at an angle of 45 ° -85 ° from the axis of the bone in this plane, the frontal plane passing perpen icularly to the axis of the I metatarsal bone and sagittal plane, the osteotomy is directed at an angle of 5 ° -45 ° from the line of intersection of these planes, eliminate the complex varus-rotational-dorsiflexion deformation of the I metatarsal bone, if necessary, additional correction of shortening of the I metatarsal bone and arch of the foot is displaced plantarly along the osteotomy plane, exostosis of the head of the first metatarsal bone is removed after its proximal osteotomy, correction of deformation and fixation, a reversal chevron osteotomy of the main file is performed I w spilite finger with an angle of 60 ° -130 ° in the case of a combination of varus deformity I metatarsal and hallux valgus I toe with valgus deformity V metatarsal operate proximal metatarsal osteotomy V I similarly metatarsal.

Access to the base I of the metatarsal bone for its osteotomy is performed on the medial surface at the level of the plantar edge of the bone from 1.8 to 3.0 cm long, which eliminates the presence of a well-visible posterior postoperative scar, makes the scar that is inconspicuous and improves the cosmetic appearance of the foot, and the proposed limited access value of 1.8-3.0 cm reduces the morbidity, improves the cosmetic appearance and is sufficient for surgical manipulation. An access value of 1.8-3.0 cm was proposed based on the anatomical measurements of the I metatarsal bones of the feet. Access less than 1.8 cm makes the osteotomy extremely difficult, and more than 3.0 cm is unnecessary for the manipulation and more traumatic.

The plane of the osteotomy of the first metatarsal bone is positioned with the concave side in front so as not to limit the lateral displacement of the distal fragment and to maintain tight contact of the osteotomized surfaces after the deformation is eliminated, and also to better maintain the blood supply to the proximal fragment.

The proximal edge of the osteotomy is placed no further than 5-7 mm from the articular surface of the base of the first metatarsal bone to maximize its length after correction and its better fusion. A distance of less than 5 mm can lead to a split in the proximal fragment during osteotomy, and more than 7 mm increases the shortening and brings the osteotomy closer to the diaphysis, which has worse blood supply and longer growth.

An osteotomy of the metatarsal bone I is performed with an instrument with a diameter 2-5 mm larger than the bone diameter in the osteotomy zone, which prevents fragments from diverging and maintains their tight contact after deformation correction, improves fixation stability, and improves the conditions for fusion. A tool diameter of less than 2 mm can cause fragments to diverge during correction of deformation, and more than 5 mm significantly limits the possibilities of correction of deformation.

The axis of the osteotomy (the axis of the cylinder formed by the plane of the osteotomy) is 1-4 mm lateral to the axis of the metatarsal bone I, which provides a greater end emphasis of the fragments after correction and increases the stability of their fixation. The absence of lateral displacement or medial displacement of the axis of the osteotomy relative to the axis of the bone limits the stability of the osteotomy, and a lateral displacement of more than 4 mm disrupts the implementation of the osteotomy.

An osteotomy of the metatarsal bone I is directed from its distal end of the bone from the medial-plantar surface of the foot and continues proximal-dorsal-lateral, which improves the cosmetic appearance of the foot after surgery, eliminating the need for back access, ensures the formation of an osteotomy plane that allows complete correction and elimination of complications.

An osteotomy of the metatarsal bone I in the sagittal plane, which runs vertically and coincides with the axis of the metatarsal bone I, is directed at an angle of 45 ° -85 ° from the bone axis in this plane, which provides complete lateral and rotational correction of the distal fragment of the metatarsal bone I and, accordingly, the correction of the transverse arch. Osteotomy at an angle of less than 45 ° is accompanied by hypercorrection of rotational deformation, and more than 85 ° practically does not allow the correction of rotational deformation.

The osteotomy of the metatarsal bone I is directed at an angle of 5 ° -45 ° from the intersection line of the sagittal plane, which runs vertically along the axis of the metatarsal bone I, and the frontal plane, which is perpendicular to the sagittal plane and the metatarsal bone axis I, which ensures complete correction of the distal fragment of the metatarsal bone I the form of plantaflexia and, accordingly, the correction of the transverse and longitudinal arches. Osteotomy at an angle of less than 5 ° practically does not allow correction of dorsiflexion deformation, and more than 45 ° is accompanied by its hypercorrection and a decrease in stability.

Eliminate complex varus-rotational-dorsiflexion deformity of the I metatarsal bone, which provides a complete correction of complex deformity and thereby improves results and eliminates complications.

If additional correction of shortening of the I metatarsal bone and arches of the foot is necessary, the distal fragment is displaced plantarly along the osteotomy plane, which makes the deformation correction more complete, improves results and eliminates complications.

Exostosis of the head of the metatarsal bone I is removed after its proximal osteotomy, correction of deformation and fixation, which ensures the exclusion of excessive resection and the prevention of complications - varus deformity of the first finger.

Perform reverse chevron osteotomy of the main phalanx of the first finger with saw cuts at an angle of 60 ° -130 °, which provides more stable fixation of fragments and better conditions for additional fixation with a screw. An osteotomy at an angle of less than 60 ° is traumatic, and more than 130 ° is accompanied by a decrease in stability.

In the case of a combination of varus deformation of the first metatarsal bone and hallux valgus of the first toe and valgus deformity of the fifth metatarsal bone, proximal osteotomy of the fifth metatarsal bone is performed similarly to metatarsal metatarsus for complete correction of transverse flatfoot and improvement of treatment results.

The method is as follows. Perform medial surgical access to the I metatarsophalangeal joint, bursectomy and medial capsulotomy. Surgical access is performed in the I tarsal space, lateral release in the form of an adductorotenomy with lateral capsulotomy of the I metatarsophalangeal joint. Surgical access to the base I of the metatarsal bone is performed along the medial surface at the level of its plantar edge with a length of 1.8 to 3.0 and an osteotomy of the grooved shape is performed, with the osteotomy plane having the concave side forward, the proximal edge of the osteotomy is placed no further than 5-7 mm from the joint surface of the base of the I metatarsal bone, osteotomy is performed with a tool with a diameter 2-5 mm larger than the bone diameter in the osteotomy zone, the axis of the osteotomy is 1-4 mm lateral to the bone axis, osteotomy they are directed from the distal end of the bone from the medial-plantar surface of the foot and continue proximal-dorsal-lateral, in the sagittal plane extending vertically and coinciding with the axis of the metatarsal bone I, the osteotomy is directed at an angle of 45 ° -85 ° from the axis of the bone in this plane, in the frontal plane, perpendicular to the axis of the metatarsal bone I and the sagittal plane, the osteotomy is directed at an angle of 5 ° -45 ° from the line of intersection of these planes, eliminate the complex varus-rotational-dorsiflexion deformation of the first metatarsal bones, if necessary, additional correction of shortening of the first metatarsal bone and arches of the foot, the distal fragment is displaced plantarly along the plane of the osteotomy. Exostosis of the head of the metatarsal bone I is removed after its proximal osteotomy, correction of deformation and fixation. Perform reverse chevron osteotomy of the main phalanx of the first finger with cuts at an angle of 60 ° -130 °. In the case of a combination of varus deformity of the I metatarsal bone and hallux valgus deformation of the first toe and valgus deformity of the V metatarsal bone, proximal osteotomy of the V metatarsal bone is performed similarly to the I metatarsal.

Example. Patient K.M.V. Age 30 years. Diagnosis: bilateral valgus deformity of the I finger of the II century, varus deformation of the I metatarsal bone, transverse flatfoot. Before the operation, she complained of a significant cosmetic defect in the form of deviation of the I toes outwards and expansion of the forefoot, pain in the area of the I metatarsophalangeal joints and under the heads of the II-III metatarsal bones, as well as fatigue of the legs after a short standing and walking, the inconvenience of wearing shoes due to for the deformation of the feet. Before the operation, a standard laboratory examination was performed, radiography of the feet in direct and lateral projections with a load, biomechanical examination on the apparatus Dialed. Operations on the right and left feet were performed with an interval of 6 months: medial bursectomy and lateral release of the first metatarsophalangeal joint, proximal corrective grooved osteotomy of the first metatarsal bone, exostozectomy of the head of the first metatarsal bone, reversible chevron osteotomy of the main first toe neoplastic maxillary phalanga, and medial capsular neoplastic capsule. The operations are performed according to the above method. After surgery, the patient is observed for 4 years. No complaints. Pleased with the cosmetic result. Pain in the feet and fatigue of the legs after standing and walking are absent. Can use ordinary shoes, does not experience difficulties in selecting shoes. Radiologically confirmed persistent elimination of deformation of the feet. A biomechanical examination on the Diasled computer complex showed the restoration of static and dynamic indicators of foot function.

The proposed method allows to improve treatment results by improving the cosmetic appearance of the foot after surgery, complete and permanent correction of deformation, eliminating residual pain and metatarsalgia, improving the support and dynamic function of the operated feet, eliminating complications and the need for repeated operations.

The proposed method allows you to:

1) to improve the cosmetic appearance of the operated foot by completely correcting the deformity and eliminating its recurrence;

2) complete and permanent correction of the deformation (by eliminating all the elements of the deformation: A) I metatarsal bone - varus, rotational, dorsiflexion, and when shortened - lengthening while maintaining complete contact of the osteotomized fragments; B) valgus deformity of the first finger of reversible chevron osteotomy; C) in the presence of hallux valgus deformity of the V metatarsal bone - its correction; D) restoration of the longitudinal and transverse arches by giving the correct position of I and V metatarsal bones);

3) to exclude residual pain and metatarsalgia (complete correction of deformation and restoration of the anatomy of the foot provides a physiological distribution of pressure under the feet and excludes overload as the cause of pain);

4) to improve the support and dynamic function of the operated feet (complete correction of deformation and restoration of the anatomy of the foot are accompanied by an improvement and normalization of its function);

5) to prevent complications in the form of permanent deformation or hypercorrection, pain, in addition, good contact, stability and fusion of osteotomized fragments are ensured, due to the above, the need for repeated operations is eliminated.

Information sources

1. M.G. Divakov, B.C. Osochuk. “SCARF osteotomy in the treatment of patients with hallux valgus deformity of the first toe” in the journal N. N. N. Vestnik Traumatologii i Orthopedii Pirogov ", No. 3. - 2001, p. 41-45.

2. RF patent No. 2330625 dated 10/17/2006.

Claims (3)

1. A method of treating hallux valgus deformity of the first finger and varus deformity of the first metatarsal bone of the foot, including medial surgical access to the first metatarsophalangeal joint, bursectomy, medial capsulotomy, exostozectomy, surgical access to the first metatarsal space and lateral release in the form of lateral adrenocetenotenotomy and latent capsulotenotomy , surgical access to the base of the first metatarsal bone, its gut-shaped osteotomy with correction of the varus deformity and fixation, osteotomy of the main phalanx of the first finger tsa, correction of its hallux valgus deformity and fixation, medial plastic surgery of the capsule I of the metatarsophalangeal joint and suturing of wounds, characterized in that access to the base of the first metatarsal bone for its osteotomy is performed along the medial surface at the level of the plantar edge of the bone from 1.8 to 3.0 length cm, the osteotomy plane is placed with the concave side forward, the proximal edge of the osteotomy is placed no further than 5-7 mm from the articular surface of the base of the first metatarsal bone, the osteotomy is performed with a tool with a diameter 2-5 mm larger than of bone in the osteotomy zone, the axis of the osteotomy is 1-4 mm lateral to the axis of the bone, the osteotomy is directed from the distal end of the bone from the medial-plantar surface of the foot and continues proximal-dorsal-lateral, in the sagittal plane that runs vertically and coincides with the metatarsal axis I bones, osteotomy is directed at an angle of 45 ° -85 ° from the axis of the bone in this plane, in the frontal plane, perpendicular to the axis of the metatarsal bone I and the sagittal plane, the osteotomy is directed at an angle of 5 ° -45 ° from the intersection line tions of these planes, eliminate complicated varus-rotationally dorzifleksionnuyu deformation I metatarsal removed exostosis I metatarsal head after it proximal osteotomy fixation correcting deformation and perform the reversing chevron osteotomy thumb proximal phalanx I spilite with an angle of 60 ° -130 °.  2. The method according to claim 1, characterized in that, if necessary, additional correction of shortening of the I metatarsal bone and arches of the foot, the distal fragment is displaced plantarly along the plane of the osteotomy. 3. The method according to claim 1, characterized in that in the case of a combination of varus deformity of the I metatarsal bone and hallux valgus deformation of the I toe and valgus deformation of the V metatarsal bone, proximal osteotomy of the V metatarsal bone is performed similarly to I metatarsal.