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Hallux Valgus: Lateral Soft Tissue Release and Capsular Repair

- See: Hallux Valgus Arthroplasty Menu:

- Technique:
    - begins thru a short dorsal incision in 1st web space, which is made in midline in order to avoid superficial branches of deep peroneal 
            nerve which passes on each side;
            - if incision is made to proximally, it may encounter the bifurcation of the deep peroneal nerve;
    - expose the conjoined tendon (adductor hallucis tendon and the FHB);
          - this passes obliquely to insert into the lateral sesamoid, and then goes onto insert into the base of proximal phalanx of great toe;
          - detach this tendon from its insertion onto the lateral sesamoid;
          - lateral sesamoidectomy (performed w/ original procedure, as described by McBride) disrupts lateral head of FHB & adductor hallucis,
                 leading to tendon imbalance & varus deformity and therefore disruption of the sesamoid is avoided;
    - transverse metatarsal ligament (which inserts into the fibular sesamoid) is then identified and released;
         - note that release is carefully performed since common digital nerve to first web space lies just below the transverse ligament;
         - transection of the transverse ligament is facilitated by placement of a self retaining retractor in the interspace;
    - some leave the adductor tendon free to scarr in, where as others reattach the tendon to the neck of the proximal metatarsal;
    - lateral joint capsule is released just dorsal to the insertion of adductor hallucis (which is also just dorsal to the lateral sesamoid);
            - alternatively some surgeons, perforate lateral capsule w/ No 11 blade knife, and the capsular tissues are disrupted by bringing toe into varus;

- intra-articular technique:
                - performed by booking open the joint inorder to expose the lateral side of the joint;
                - this technique is nice because surgeon can titrate amount of soft tissue elevation  needed inorder to achieve correction while not having
                         to directly transect tendons and capsule;
                - a periosteal elevator is then used to strip the attachments of the lateral capsule as well as the attachments of the adductor hallucis and the FHB;
                - identify lateral sesamoid, and use knife to incise ligamentous attachment just above sesamoid (this releases the adductor tendon off of the sesamoid);
                - sequential release of the conjoined adductor tendon, transverse intermetatarsal ligament, and lateral joint capsule

Capsular Repair:
     - Anchor enhanced capsulorraphy in bunionectomies using an L-shaped capsulotomy.

 Extensor hallucis longus transfer for hallux varus deformity.

 Hallux valgus repair. DuVries modified McBride procedure.

 McBride's operation for hallux valgus. A 2-11-year follow-up of 46 cases.

 Repair of the hallux valgus with a distal soft tissue procedure and proximal metatarsal osteotomy.  

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