Medial Soft Tissue Tightening Capsulorraphy

First, the dorsal medial sensory nerve is isolated and positioned more laterally, an important step in the procedure (Fig. 9). Medial capsular closure is a key step in all corrective surgery for hallux valgus.

The necessity of performing the capsulorraphy is exposed Fig. 10a: In fact, we have to distinguish the cases - rarely encountered - where there is a mild deformity, for which the capsulorraphy is just a medial closure, from the other cases - the majority - for which the capsulorraphy is a medial tightening. In these last cases, we prefer using the term "tightening"

Louis Barouk

Fig. 10a. Soft tissue medial tightening: the necessity.

1, 2. In this case, the M1 lateral shift should be such as the two fragments loose their contact (2).

3. Same case operated on: We see the lateral shift (black arrow). The correction is also due to the MTP lateral release, the medial tightening, the great toe osteotomy.

4, 5, 6. Same case before and after the scarf osteotomy: In spite of a large lateral shift (5) the Load Simulation Test shows that the medial tightening is necessary (6). Result after medial tightening (7).

8, 9, 10. Same foot. 8: before surgery; 9: after MTP lateral release and large lateral shift; 10: finally after medial tightening.

Fig. 10a. Soft tissue medial tightening: the necessity.

1, 2. In this case, the M1 lateral shift should be such as the two fragments loose their contact (2).

3. Same case operated on: We see the lateral shift (black arrow). The correction is also due to the MTP lateral release, the medial tightening, the great toe osteotomy.

4, 5, 6. Same case before and after the scarf osteotomy: In spite of a large lateral shift (5) the Load Simulation Test shows that the medial tightening is necessary (6). Result after medial tightening (7).

8, 9, 10. Same foot. 8: before surgery; 9: after MTP lateral release and large lateral shift; 10: finally after medial tightening.

instead of capsulorraphy, because through the suture all the medial tissues are tightened, particularly the abductor muscle, which is repositio-ned medially and tied.

This suture should insure a good repositioning of the sesamoid complex. Medial capsulor-raphy is particularly useful in cases of severely deformed hallux valgus.

The technique is described Fig. 10 b1: we emphasize two points: 1) To perform only one suture located at the level of the head centre, in order not to decrease the MTP mobility: It is the "rotation point" pointed out by A. Lahm*; 2) To perform this suture while the great toe is held in plantar flexion to increase postoperative great toe ground contact; 3) The long extensor tendon has to remain straight, not curved medially in order not to decrease the MTP plantar flexion and to decrease the risk of over-correction.

* Andreas Lahm, Freiburg, Germany.

Fig. 10b1. Soft tissue medial tightening: operative technique.

1, Abduction test (to assess the amount of the tightening which should be necessary).

2, 3, 4. The medial tightening does not only consist of capsulorraphy but above of all the medial reposition and tightening of the abductor muscle (a). This is performed in its distal end, through the medial capsule, without necessity to approach the muscle itself.

3, 4. We perform only one suture in a crossed fashion. The two plantar threads cross the medial capsule near the medial border of the medial sesamoid, the great toe held in a plantar flexion (4) to increase the postoperative great toe ground contact.

5. The exit holes for this suture on the medial plantar surface should be separated (b) as much as the hallux valgus remaining after the scarf osteotomy.

6. Since the suture it is located on the level of the metatarsal head centre, it constitutes a "rotation point" as pointed out by A. Lahm (Germany).

Fig. 10b1. Soft tissue medial tightening: operative technique.

1, Abduction test (to assess the amount of the tightening which should be necessary).

2, 3, 4. The medial tightening does not only consist of capsulorraphy but above of all the medial reposition and tightening of the abductor muscle (a). This is performed in its distal end, through the medial capsule, without necessity to approach the muscle itself.

3, 4. We perform only one suture in a crossed fashion. The two plantar threads cross the medial capsule near the medial border of the medial sesamoid, the great toe held in a plantar flexion (4) to increase the postoperative great toe ground contact.

5. The exit holes for this suture on the medial plantar surface should be separated (b) as much as the hallux valgus remaining after the scarf osteotomy.

6. Since the suture it is located on the level of the metatarsal head centre, it constitutes a "rotation point" as pointed out by A. Lahm (Germany).

Plastia Capsular Hallux Valgus

Fig. 10b2. Medial tightening: about the extensor tendons.

1, 2, 3. Role of the extensor accessory tendon (c).

1. In cases where the medial soft tissue is of bad quality, this tendon brings a significant help. On the contrary, in cases where it seems to have an overcorrection (2), the proximal section of this tendon should be necessary (3).

4, 5, 6. Hallucis extensor longus: This tendon should be retracted medially by the medial soft tissue tightening. In this case, the tendon release is required (5) to result in straight direction of this tendon (6). Furthermore, this tendon has sometimes to be lengthened on the surgery last step.

Fig. 10b2. Medial tightening: about the extensor tendons.

1, 2, 3. Role of the extensor accessory tendon (c).

1. In cases where the medial soft tissue is of bad quality, this tendon brings a significant help. On the contrary, in cases where it seems to have an overcorrection (2), the proximal section of this tendon should be necessary (3).

4, 5, 6. Hallucis extensor longus: This tendon should be retracted medially by the medial soft tissue tightening. In this case, the tendon release is required (5) to result in straight direction of this tendon (6). Furthermore, this tendon has sometimes to be lengthened on the surgery last step.

Fig. 10c. The four cases encountered for medial tightening.

1. The medial border of the medial sesamoid is correctly located after the scarf osteotomy: Now we have just to perform the medial capsule closing, without tightening.

2. Overcorrection after too much medial tightening. We have to make another suture.

3. 4. In spite of correct lateral shift, the correction is not complete (LST) and needs the medial tightening. 5. In the 4th case, in spite of correct lateral shift (5) and medial tightening (6), the great toe P1 osteotomy is required to complete the correction.

Fig. 10c. The four cases encountered for medial tightening.

1. The medial border of the medial sesamoid is correctly located after the scarf osteotomy: Now we have just to perform the medial capsule closing, without tightening.

2. Overcorrection after too much medial tightening. We have to make another suture.

3. 4. In spite of correct lateral shift, the correction is not complete (LST) and needs the medial tightening. 5. In the 4th case, in spite of correct lateral shift (5) and medial tightening (6), the great toe P1 osteotomy is required to complete the correction.

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