Basal Osteotomy

- It is indicated when the great toe is not long enough (Greek or square type foot).

-It is performed on the proximal P1 meta-physis in cancellous bone, without healing problems.

- It preserves a lateral hinge located on the lateral cortex.

- Its fixation is easy thanks to a special small staple.

We distinguish two kinds of basal osteotomy.

a) Varisation osteotomy (medial closing wedge) (Fig. 11b1-b2)

Fig. 11b1. Great toe 1st phalanx basal varisation.

1. Without great toe osteotomy, some overcorrection should be observed when the great toe varisation is not performed.

2. In spite of correct MTP congruence and sesamoid location, the great toe varisation is required to achieve the correction (revealed by the LST).

3. Indication of great toe varisation without shortening: Greek of square forefoot type.

4. Preservation of a lateral cortical hinge.

5. Use of a special 27° oblique staple (DePuy) instead of a straight one (90°).

6. Care has to be taken to preserve the long hallucis flexor tendon (lft).

7. 8, 9. Operative views. 7. Presentation of the staple, and introduction of a 1 mm K-wire only in the distal fragment. 8, 9. Setting of the staple.

10. In case of rupture of the lateral cortex, a scarf screw use is required.

Fig. 11b1. Great toe 1st phalanx basal varisation.

1. Without great toe osteotomy, some overcorrection should be observed when the great toe varisation is not performed.

2. In spite of correct MTP congruence and sesamoid location, the great toe varisation is required to achieve the correction (revealed by the LST).

3. Indication of great toe varisation without shortening: Greek of square forefoot type.

4. Preservation of a lateral cortical hinge.

5. Use of a special 27° oblique staple (DePuy) instead of a straight one (90°).

6. Care has to be taken to preserve the long hallucis flexor tendon (lft).

7. 8, 9. Operative views. 7. Presentation of the staple, and introduction of a 1 mm K-wire only in the distal fragment. 8, 9. Setting of the staple.

10. In case of rupture of the lateral cortex, a scarf screw use is required.

The interest of performing proximally this osteotomy is to provide a large distal medial displacement in spite of removing a small medial wedge, because of the long distal lever arm.

b) Varisation combined with derotation (Fig. 11b4)

It is an oblique / plane osteotomy, indicated by P. Diebold (Nancy, France). This osteotomy is very useful for completing the hallux valgus correction, but the lateral hinge is more fragile.

The fixation with the special oblique stainless steel staple is detailed on Figures 11b.

When the previous surgery steps for hallux valgus correction are made, resulting in a congruent 1st MTP joint, basal osteotomies are very easy to perform and fix. They are also harmless and at last extremely effective in completing the hallux valgus correction. But they are limited to Greek or square feet. When large varisation, derotation or shortening are necessary, we prefer to do shaft osteotomy, therefore to use the special memory staple.

Fig. 11b2. Great toe 1st phalanx basal varisation: results.

1, 2. Radiological and clinical results of great toe P1 basal varisation.

3, 4. Better correction on the side with P1 varisation: When during the operation we hesitate to do - or not -a varisation, I think we have to do it! I have regretted many not having done P1 varisation in many similar cases.

5. However, excess of varisation (IP joint medially inclined) should result in shoe conflict (white arrow).

Fig. 11b2. Great toe 1st phalanx basal varisation: results.

1, 2. Radiological and clinical results of great toe P1 basal varisation.

3, 4. Better correction on the side with P1 varisation: When during the operation we hesitate to do - or not -a varisation, I think we have to do it! I have regretted many not having done P1 varisation in many similar cases.

5. However, excess of varisation (IP joint medially inclined) should result in shoe conflict (white arrow).

Fig. 11b3. Insufficiency of P1 varisation.

1. P1 varisation is extremely useful to complete the correction but on the condition to have already almost a good correction. 2. When the correction is really insufficient with MTP incongruence, the great toe osteotomy is unable to make complete correction: On the contrary, an excess of varisation may increase the deformity.

Fig. 11b4. P1 basal varisation combined with derotation

1. It is an oblique-plane osteotomy, initially described by M. d'Aubigne for the hip, and adapted to the great toe first phalanx by P. Diebold (Nancy, France). The wedge removed is medial and plantar. The lateral hinge is more fragile.

2. Fixation by the same oblique staple than the varisation.

3. Result. This osteotomy is extremely useful for completing the result.

Fig. 11b4. P1 basal varisation combined with derotation

1. It is an oblique-plane osteotomy, initially described by M. d'Aubigne for the hip, and adapted to the great toe first phalanx by P. Diebold (Nancy, France). The wedge removed is medial and plantar. The lateral hinge is more fragile.

2. Fixation by the same oblique staple than the varisation.

3. Result. This osteotomy is extremely useful for completing the result.

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