Lecture 3: Capsule Tendon Balance Procedures

Note: Know all the lectures that precede Dr. Vans lecture prior to attending that lecture.
Note: The capsule
- Capsule looks white and glistening tissue that surrounds the joint.
- Capsule gets thinner in older people (can be hard to do surgery on older people)
Capsule Tendon Balance Procedures: Anatomy

Purpose
Remove the bump
Note: Removing the bump: roughening up that particular part of the
bone so that when you repair the capsule it sticks there
Assist in relocating the sesamoids back under the metatarsal head
Note: When you perform an osteotomy the sesamoids dont move,
they become in a different position because you just moved the MT.
You will need to relocate them back.
Derotate of the toe
The metatarsal head is actually relocated over the sesamoid apparatus
Literature Debate: Should you release soft tissue for a bunionectomy?
needed to rebalance the soft tissues to facilitate long-lasting correction
sesamoid displacement occurs due to a consequence of valgus rotation of the
first metatarsal, so rotating it to a neutral to slight varus position should correct
the sesamoid position without a lateral release
increase in tibial sesamoid position occurs as the metatarsal head rotates into
valgus
(Scranton, Rutowski, DiDomenico and Dayton)
Note: She thinks in theory it is great but most surgeons dont do this because what
they are doing already works without derotating the head.
Gives it to us for us to be aware of.
She finds it necessary to rebalance it. Like if you have someone in valgus
for a long time the lateral capsule is going to be very tight so even if you
derotated the head it will just go back if you dont do a lateral release. She
always does a lateral release.
Skin Incisions for Bunionectomies
Note: MC incision is the dorsal-medial incision or a medial incision
Longitudinal (curved to straight) medial to EHL

1
7/19/17

Note: Dorsal-medial: important to place it medial to the EHL and lateral to

the most medial aspect of the bump. When I want to repair the capsule and
you go too close to the tendon when you suture its hard to try and not get
the tendon in the suture. This would bind the tendon down not allowing it
to function properly
Should be about 6cm in length
probably about a an inch distal to the joint

Medial incision
Note: Medial: can't really see the interspace well, doing the surgery under
the MT head. Hard to visualize so be careful.

Capsulotomies for HAV
Note: Ostectomy: removing a piece of bone vs. Osteotomy: making a cut
thru and thru bone.
Note: Capsulotomy: making a cut in the capsule to expose the joint vs.
Capsulorrhaphy: taking a piece of capsule out to tighten the capsule
still a capsulotomy bc you are making a cut in capsule.
Medial Capsulotomy
Dorsal Capsulotomy
note: Most commonly dorsal.

Note: When you make the incision on the capsule make sure not to cut the
articular cartilage.

Medial Capsulotomies
Note: Wont ask us to memorize all of them.

2
7/19/17

Medial Types
A. Vertical
Note: take a wedge out of the capsule to tighten it
(Capsulorrhaphy)
B. U shaped
C. H shaped
D. I shaped
Aka T shaped
E. Dorsomedial inverted L shaped
Note: More cuts, leads to more fibrosis, which can lead to stiffness in the
bone after surgery.

Dorsal Capsulotomies
Dorsal types
Dorsal linear
Note: Dr. Pontious preference. Because she doesnt often do a
Capsulorrhaphy bc she often doesnt find the capsule to be that
stretched that require you to make extra cuts and predispose the pt
to fibrosis and stiffness
Dorsal I shaped
Note: Aka T shaped
Inverted L shaped
Note: gives you the option of Capsulorrhaphy
Lenticular
Washington monument

3
7/19/17

Dorsal Capsulotomy : Lenticular

Note: Lenticular capsulotomy: done on an angle
Left is the toe, right is where the met head is
Biasing the sutures to decrease the valgus rotation of the joint
AP on the bottom of the pic
Dorsal Capsulotomy: Washington Monument

Note: Known to be the strongest capsulotomy that there is

4
7/19/17

Left= toe
Make a flap in the capsule and take it and pull it proximally
Suture the underneath flap
Then you will use the flap like a Velcro strap to put the toe into
rectus

Removal of Medial Eminence (Exostectomy) Schede(1980)
Removes the Bump
Note: Why remove the bump? 1) bc it sticks out and 2) by removing the
bump you are exposing cancellous bone so when it heals it assists in
maintaining the correction and allow for attachment of the repaired
capsule
Assists in tightening the medial capsule
Instrumentation for Medial Eminence Removal
Osteotome and mallet

Power equipment

note: oscillating saw
Technique: Sagittal Saw/Angle
Sagittal Saw: slanted Plantar and Medial to preserve the plantar medial facet/tibial
sesamoid articulation
Note: IMPORTANT TO UNDERSTAND: Make sure you angle your
blade so that you dont destroy some of the tibial facet (causing the tibial
sesamoid to sublux medial leading to a hallux varus)

5
7/19/17

hallux varus is nonfunctional, ugly, hurts and can't wear a shoe

with it

Note: Shaded area is medial
OVERAGGRESSIVE EXOSTECTOMY

Note: Hallux varus
Left= caused bc they cut into the head a little and probably over
tightened the capsule
Right= they took too much medial bone, destroyed medial facet,
and tibial sesamoid subluxed medials
Sesamoids should be under the MT heads. Check before you close
and fix it then.
tibial sesamoid is peaking means it is sticking out
medially
Capsule Tendon Balancing Procedures
Note: Overall in all procedures: Removing the bump and performing soft
tissue work to correct the bunion
Silver
McBride
Note: aka True McBride
Modified McBride
Hiss
Mini-Tightrope
SILVER
Silver Bunionectomy
1923 David Silver, M.D.
Pre-Op Symptoms (note: why use a Silver Bunionectomy?)
Bump pain
Note: If someone has just bump pain, the bump really isnt that big

6
7/19/17

Medial pain with shoe gear

Medial skin & soft tissue irritation over the 1st metatarsal head
NO sesamoid or deep pain
Radiographic Angles: WNL
Note: WNL: within normal limits
Op Technique
1. Incision
2. Capsulotomy (Linear)
Note: She usually makes a linear line
3. Resection of bump
4. Closure
***Closure is in layers:
Capsule
Subcutaneous tissue
Skin
Note: If you dont close in layers you get stiffness and
fibrosis.
Pre/Post Silver Bunionectomy

Post-Op
Surgical shoe
Note: for 2 weeks
Sutures: 10-14 days
Note: Why remove sutures in 10-14 days? At 10-14 days the
tensile strength of the skin is the same as the suture so they are no
longer doing anything.
Sneaker: approx. 2-4 weeks
Post-op x-ray 1st visit
ROM exercises
Advantages
Provides removal of bump with minimal amount surgery
Rapid post-op recovery
Minimal anatomical dissection
Technically easy
Disadvantages
Doesnt correct the etiology of HAV
Weakens medial structures: Hallux Abductus
Complications
Recurrence

7
7/19/17

Note: Recurrence often when someone does a silver on a high im

angle
Joint stiffness
Joint Manipulation Under Anesthesia for Arthrofibrosis After Hallux Valgus Surgery*

38 pts. Underwent procedure under anesthesia
Mean f/u 6 years; last visit 2 years. post-op
Successful treatment modality in increasing joint mobility and alleviating pain in
patients that experienced arthrofibrosis
Arthrofibrosis is defined as painful restricted joint motion usually due to excessive
fibrosis after injury or surgery
Note: She finds it helps but you dont get the ideal result.
MCBRIDE
McBride Bunionectomy
Earl McBride, M.D., 1928
Pre-Op Signs
Bump pain
Medial pain with shoe gear
Pain associated with either sesamoid
No deep joint pain
Angles should be WNL
IM angle 9-10 in a rectus foot
Note: Mild increase in IM angle by 1-2 degrees meaning that your
sesamoid position is not normal
Operative Technique
Incision
Capsulotomy
Resection of bump
Lateral release
Note: Go to the lateral interspace and release the lateral capsule take
out the fibular sesamoid
Excision of fibular sesamoid
Possible adductor transfer
Note: She also releases the lateral head of the EHB
reattach it medially to help hold the toe straight
Medial capsulorraphy
Closure
Post-Op
Surgical shoe

8
7/19/17

Suture Removal
Sneaker or soft shoe (2 to 4 weeks)
Post-Op x-ray 1st visit
Post-op ROM exercises
True McBride Procedure

Dissection

Capsulotomy

Remove medial eminence

Interspace Dissection
Lateral Release: includes release of the adductor tendon, lateral
capsule and the fibular sesamoidal ligament
Lateral head of EHB also released

9
7/19/17

Remove Fibular Sesamoid

Note: True mcbride removes the fibular sesamoid vs the
modified mcbride that does not.
Capsular Closure

Advantages
Minimal bone resection
Rapid post-op recovery
Disadvantages
Doesnt correct structural deformity
Limited indications
Complications
**Hallux varus 2 to fibular sesamoid
Recurrence
Joint stiffness
Possible Complication of Both Silver, Mod. McBride and True Mcbride: Staking

10
7/19/17

Note: Modified McBride= same as McBride but not taking out fibular
sesamoid and not doing the adductor tendon release
An Austin often includes a modified mcbride
Note: Staking: if you take too much MT head (right picture)
HISS
Hiss Procedure 1931
Dorsal transfer and advancement of Abductor Hallucis tendon
Indications are similar to the McBride
Procedure: Identify Abductor Hallucis Muscle

Retract Tendon Proximally

Resect Medial Emminence

11
7/19/17

Dorsal Transfer and Advancement

Note: Know the dorsal advancement to pull the hallux
out of valgus
Closure of Capsule

MINI TIGHT ROPE
Mini Tightrope Procedure
Relocates the first and second metatarsal to a normal IM angle without the use
of an osteotomy using a drill hole technique
Suture is FiberWire which is a polyester suture with a polyethylene core

Note: Make 2 incisions= one medial and one on the lateral aspect of
the 2nd MT

12
7/19/17

Note: Button on the lateral aspect of the 2nd MT

Pull the MT close together

Note: Problems with mini tightrope= continued pain and recurrence
(due to wire stretching)
Surgical Procedures of the Hallux in Conjunction with HAV Surgery
Hallux Procedures
Akin osteotomies
Arthrodesis of IPJ

13
7/19/17

AKIN OSTEOTOMY
Akin Osteotomy:
note: Never doing the akin alone to fix a bunion
Indications
Used in conjunction with 1st metatarsal procedure for HAV correction:
3 types:
Proximal Akin
Cylindrical (central) akin
Distal akin
Note: Proximal and distal akin are most common

Proximal akin
Adjunctive procedure in HAV surgery
Medially based wedge resection (transverse or oblique)
Note: 1st cut: 8mm from the 1st MTPJ. 2nd cut: predetermined
wedge to make the correction
Note: True indication for a proximal akin is an abnormal DASA
Metaphyseal bone
5-10mm distal to MPJ
Lateral cortex intact
Note: There are two types of proximal akins. This is a transverse or
standard akin but there is also a juvara (oblique).

14
7/19/17

Fixation for Akin (Transverse Osteotomy)
K-wire(0.062)
Monofilament wire(28g)
Staples

Pre/Post Proximal Akin

Considerations: Pin Placement

15
7/19/17

note: need to bring your pins more dorsal to avoid causing
irritation
Complication: What happens if the lateral cortex breaks when performing the
osteotomy cuts?

Note: Throw another pin in or put them in a cast if you can't fit
a pin

Modified Akin (Juvara) Osteotomy

Note: Another way to do a proximal akin
Smaller wedge from the other akin
Fixation (Oblique Osteotomy)
Screw (2.7mm)*
Note: always Memorize the most common fixation

16
7/19/17

Note: Can use a screw with this version vs the standard

proximal akin where you couldnt following AO
principles
2.0 mm in smaller bone

Central(Cylindrical) Akin
Cylindrical section of bone excised to shorten hallux
Indicated for a long proximal phalanx

Distal Akin:
Indications
Abnormal hallux abductus interphalangeal angle

Note:
5-10mm proximal to IPJ
Base of the wedge is still medial
This fixes an abnormal hallux abductus IP angle
(KNOW) (anything over 10)

17
7/19/17

Procedure: For all Akin osteotomies
Incision
Dorsomedial
Medial longitudinal (isolated procedure)
Avoid neurovascular bundle
Periosteal incision
Bone cuts/Fixate/Close in layers
Post-Op Course
Surgical shoe
Note:
4 weeks in ss
Take an xray after 4 weeks
If not healed keep them in the ss
Darco Wedge Shoe
Note: Darco wedge= walking on the back of the foot
kind of clumsy to walk in and often need to use
crutches
Option: possible casting
Complications
Delayed union
Angular deviation
Inadequate/over correction
Non Union

Overcorrection

18
7/19/17

Note: Large space between 1 and 2
Review of Todays lecture
Be able to name and describe the all the CT balance procedures and how they
differ-why would you pick one over the other?
Know the Akin procedures and why a distal and proximal Akin have different
indications
Be able to draw a proximal and distal Akin and name the typical fixation
Know postop course for all
Assignment
Read and study Distal Metaphyseal Osteotomies in Gerberts Textbook on
Bunion surgery and get familiar with them
Reverdin and its modifications
Austin and its modifications
Apical Axis guide

19