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Closing Base Wedge Osteotomy

For patients with moderate to severe hallux valgus and a large intermetatarsal angle, proximal first metatarsal osteotomies may be indicated to achieve an appropriate amount of correction. The closing base wedge osteotomy is a reliable procedure resulting in a strong structural correction and is amenable to multiple fixation techniques. Loison first described and advocated the transverse closing base wedge osteotomy in 1901.1 Juvara modified the procedure in 1919, employing the oblique version of the closing base wedge osteotomy.

Controversy has surrounded this procedure due to its relative difficulty and the possibility of associated complications. Some authors have described the closing base wedge osteotomy as technically demanding with little margin for error and have even called for its extinction and replacement with the Lapidus arthrodesis. Martin and Blitch described the difficulties in the execution of this procedure and presented alternatives to the closing base wedge osteotomy. The osteotomy requires precise wedge resection with preservation of the hinge at the medial cortex of the metatarsal. Once the wedge is resected, intraoperative alterations for over- and under correction of the intermetatarsal angle can be technically challenging.

When the Bunion Correction procedure first became popular, complications included first metatarsal elevatus, shortening, delayed bone healing, and unstable fixation.  However, with advances in surgical technique, fixation methods, and adequate postoperative weight-bearing instruction, outcomes have improved. The closing base wedge osteotomy is a powerful procedure that preserves the first ray range of motion while correcting hallux valgus deformities that may not be amenable to distal metatarsal osteotomies.

The primary indication for the closing base wedge osteotomy is a rigid deformity with an intermetatarsal angle of 15 degrees or greater. A rigid deformity is not manually reducible in the transverse plane and indicates the need for an osteotomy that corrects the larger angular deformity. The closing base wedge osteotomy is more effective at correcting moderate to severe deformities in comparison to distal metatarsal osteotomies. This is because the proximal position of the osteotomy is closer to the apex of the deformity, permitting greater angular correction and a more rectus alignment. When it comes to an intermetatarsal angle of 15 degrees or greater, performing a distal metatarsal osteotomy or soft tissue procedure may result in under-correction and a higher recurrence rate. Cited

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