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Modified McBride Procedure for Hallux Valgus

- Discussion:
     - modified procedure includes release of adductor hallucis, transverse metatarsal ligament, and lateral capsule combined w/ excision of 
             medial eminence and plication of the capsule medially;
     - this procedure was modified to retain the lateral sesamoid, which helps to prevent hallux varus (which as common w/ original Mcbride 
     - as this procedure attempts to re-align the MTP joint, it is best performed on an incongruent joint;
     - w/ a hallux deformity, the sesamoid bones remain attached to the second metatsal (dissociating from the 1st metatarsal), and operative 
             correction of the HV deformity, should optimally restore the relationship of the sesamoids to the 1st metatarsal;
     - sesamoid view:
             - the only radiographic view that reliably shows sesamoid subluxation is the wt bearing sesamoid view;
             - note that AP views of the foot should not be used to assess sesamoid subluxation since 1st metatarsal pronation or subluxation may 
                     accentuate or diminish the true sesamoid position;

- Indications:
     - incongruent joint;
     - MP joint deformity of less than 30 deg and IMA deformity less than 15 deg;
     - if the IMA is greater than 15 deg, then a proximal metatarsal osteotomy will be required;
     - if intermetatarsal angle is greater than 15 deg, then basilar osteotomy is performed prior to soft tissue procedure;

- Contraindications:
     - include vascular impairment or advanced MTP degenerative joint disease;
     - should not be performed w/ a congruent joint;
     - because the majority of the extrameduallary blood supply to the metatarsal head is derived from vessels entering the lateral periosteum and
               joint capsule, the Mcbride procedure is contra-indicated w/ concomitant distal osteotomy procedures such as Chevron and the Mitchell;

- Technique:
    - Medial Dissection:
         - on medial side, make longitudinal midline incision centered over joint;
         - dorsal and volar skin flaps are created;
                - these flaps are full thickness and are made along capsular plane;
                - by staying along capsular plane, dorsomedial and plantar medial cutaneous nerves, which pass on either side of joint, can be identified & avoided;
         - longitudinal capsulotomy is created across the MTP joint;
                - at the end of the case, the plantar capsular flap is pulled upwards and imbricated over the dorsal flap in an attempt to pull the sesamoids out
                       of their displaced position;
         - joint capsule is then stripped off medial eminence in order to expose prominence;
         - medial eminence is removed in line w/ medial aspect of metatarsal shaft,
                - avoid removing an excessive amount of metatarsal head;
                - attempt to stay on medial side of the saggital sulcus;
         - medial capsular tissues are reparied by holding hallux in correct alignment;
    - Lateral Dissection:
         - standard lateral soft tissue release:
         - 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;
    - Wound Closure:
         - following the hallux valgus reconstructive procedure, the sesamoids may still lie in a subluxed positioned;
         - partial reduction of the sesamoids may be achieved w/ closure of the joint capsule;
         - excise the inferior portion of the joint capsule, place the toe in a slightly over-corrected position, and then oppose inferior joint capsule
                to the superior joint capsule w/ non absorbable sutures;
                - goal of this is to de-rotate the sesamoid out of their laterally subluxed position, to a more anatomic position under the metatarsal;

- Complications:
    - intrinsic weakness caused by an extensive release of plantar lateral capsule may cause an associated clawing of great toe in addition to 
         varus deformity;

- Complications: Hallux Varus:
    - excessive lateral release, particularly w/ lateral sesamoidectomy, predisposes to hallux varus deformity;
    - occasionally a hallux varus associated with hyperextension of the metatarsophalangeal joint, may occur;
    - hallux varus can be corrected by carrying out a transfer of EDL tendon into base of proximal phalanx;
    - EHL tendon may be rerouted beneath area of transverse metatarsal ligament and then placed thru drill hole in base of proximal phalanx;
    - if metatarsophalangeal joint is too severly deformed or arthritic arthrodesis would be indicated

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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.

Bunion correction using proximal Chevron osteotomy: a single incision technique.