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OF THE FIRST METATARSAL

FIXATION SCREW
William T. McPeake III, M.D.
Knoxville Orthopedic Clinic, P.A.
Knoxville, TN
USING THE
CHEVRON
BUNIONECTOMY
AcUTRAKr
Introduction
The Standard and Mini-Acutrak

bone screws are fully threaded, conically shaped screws with


variable pitch threads. The conical shape and variable pitch threads cause compression of the
osteotomy when the screw is advanced. I have found little or no need to remove the
hardware and very few complications associated with this fixation procedure. It represents
simple, easy, reliable and appropriate fixation for the osteotomies used in Chevron
bunionectomies.
Step 2 The osteotomy is performed
either directly at the sulcus or just medial
to the sulcus. The medial exostosis is
removed with an osteotome creating a
flat medial surface that is in the same
plane as the medial aspect of the first
metatarsal shaft.
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Step 1 With appropriate anesthesia, the foot is
prepped and draped in a sterile orthopedic man-
ner. A longitudinal incision is made along the
medial aspect of the first metatarsopha-langeal
joint approximately 1.5 inches in length through
the skin and subcutaneous tissue to the capsular
layer along the capsular surface. The dorsal and
plantar skin flaps are developed taking care to
identify and protect the dorsal and plantar medi-
al digital nerve. A transverse section of capsule is
removed just proximal to the joint level. The
width of this capsular excision is dependent upon
the degree of deformity and usually varies
between 1/2 to 3/4 cm in width at its widest
point. This allows exposure of the first metatar-
sophalangeal joint and the medial exostosis is
further visualized by carefully dissecting the por-
tion of the medial capsular ligament from the
exostosis.
Step 3 The length of the screw is determined
by measuring the width from dorsal to plantar
along this flat surface. This can either be per-
formed with the use of a standard ruler or an
osteotome of varying sizes can be laid across
the flat surface to determine the overall width
of this bone. Usually, 14mm or 16mm Mini-
Acutrak

screws are satisfactory. However for


a larger individual, it may go to an 18mm.
Step 4 The soft tissue is freed from the
dorsal and plantar neck areas of the first
metatarsal just posterior to the articular
cartilage and a Chevron osteotomy is per-
formed as described by the late Kenneth
A. Johnson. This allows lateral shift of the
first metatarsal head and also a correction
of the angulation deformity and abnormal
alignment of the articular surface of the
first metatarsal head should this exist.
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Step 5 The osteotomy is held in place while the
guide pin is placed across the osteotomy site under
direct vision. The guide pin is placed where the dor-
sal and plantar cortex of the metatarsal head and
neck are incorporated with the cancellous bone of
the shaft of the first metatarsal crossing the Chevron
osteotomy on the dorsal and plantar legs of the
osteotomy. A measurement can be obtained by meas-
uring the guide pin, if this has not already been accom-
plished.
FATR-33-04 effective: 06/2003
Step 6 The guide pin is advanced thru the
plantar cotex and the drill is used to drill over
the guide pin to the required depth. An
Acutrak

screw one size smaller than drill


depth is inserted.
Alternative Method: The osteotomy is relatively stable
and usually can be held without difficulty in order to insert
the screw without the use of a guide pin for screw place-
ment. In my experience, after the procedure has been
accomplished many times with the use of a guide pin, screw
fixation can easily and adequately be applied without the use
of the guide pin by simply using the non-cannulated drill and
drilling to the predetermined depth, and inserting a screw
one size under the drill depth.
Step 7 Intra-operative x-rays can be obtained or fluorescein can be used to assure the
fixation and placement of the screw. The proximal medial prominence of the osteotomy is removed
and smoothed with a rongeur and the capsular incision is re-approximated with figure of eight sutures
of 2-0 vicryl holding the toe in an anatomical corrected position. The wounds are closed in the usual
fashion and dressings applied.
AcUMEDr
5885 N.W. Cornelius Pass Road
Hillsboro, OR 97124
U.S.A.
(503) 627-9957
(888) 627-9957
www.acumed.net
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