Operative report Bunion/ Hallux Valgus

Operative report 1

Preoperative Diagnosis

Painful hallux valgus deformity with degenerative osteoarthritis of the first metatarsophalangeal joint, right foot.

Postoperative Diagnosis

Same.

Procedure Performed

Keller-type resection arthroplasty with resection of the base of the proximal phalanx of the hallux and medial eminence resection, right foot.

Indication

The patient presented with a longstanding painful hallux valgus deformity associated with degenerative osteoarthritis of the first metatarsophalangeal joint. The patient complained of chronic pain, medial eminence irritation, progressive deformity, difficulty wearing normal footwear, and limitation of daily activities. Conservative treatment including shoe modification, orthotics, padding, activity modification, anti-inflammatory medication, and physical therapy failed to provide adequate relief. Because of persistent symptoms and degenerative joint disease, operative intervention with Keller-type resection arthroplasty was recommended. Risks, benefits, alternatives, and expected postoperative recovery were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position on the operating table. Following administration of monitored anesthesia care with an ankle block, a well-padded thigh tourniquet was applied. The operative extremity was prepped with chlorhexidine solution and draped in the standard sterile orthopedic fashion.

Following exsanguination of the extremity using an Esmarch bandage, the tourniquet was inflated to appropriate pressure. A formal surgical time-out was performed confirming the correct patient, operative extremity, planned procedure, and administration of prophylactic intravenous antibiotics.

The first metatarsophalangeal joint was identified by palpation. A longitudinal dorsomedial incision measuring approximately 5 cm was made centered over the first metatarsophalangeal joint extending from the distal first metatarsal neck to the proximal phalanx.

Sharp dissection was carried through the subcutaneous tissues. Bleeding vessels were coagulated with bipolar electrocautery. Careful soft tissue dissection was performed while protecting the dorsal medial cutaneous nerve throughout the procedure.

The extensor hallucis longus tendon was identified, mobilized, and gently retracted laterally to expose the dorsal capsule of the first metatarsophalangeal joint.

A longitudinal medial capsulotomy was performed. The capsule was elevated sharply from both the metatarsal head and the base of the proximal phalanx using a periosteal elevator, exposing the joint surfaces circumferentially.

Significant hypertrophic synovium, osteophyte formation, cartilage degeneration, and medial eminence enlargement were identified. Hypertrophic synovial tissue was excised where necessary to improve visualization.

Attention was directed to the medial eminence of the first metatarsal head. Using an oscillating microsagittal saw, the prominent medial eminence was resected parallel to the medial cortex while preserving the sagittal groove and maintaining the structural integrity of the metatarsal head. Remaining irregular cortical edges were contoured with a rasp to create a smooth bony surface.

Attention was then directed to the proximal phalanx. A periosteal elevator was utilized to circumferentially expose the base of the proximal phalanx while preserving the plantar soft tissue attachments and insertion of the flexor hallucis brevis whenever possible.

Using an oscillating saw, approximately 6 to 8 mm of the base of the proximal phalanx was resected perpendicular to the long axis of the bone. The resected fragment was removed from the operative field.

The resection surfaces were inspected and further contoured using a bone rasp until smooth. Any remaining osteophytes or loose osseous fragments were removed with a rongeur. The joint was copiously irrigated with sterile normal saline to remove bone debris and cartilaginous fragments.

The hallux was then gently manipulated through a full range of motion. Excellent decompression of the first metatarsophalangeal joint was achieved with marked improvement in valgus alignment. Passive dorsiflexion and plantarflexion were significantly improved without evidence of bony impingement or soft tissue tethering.

The medial capsule was advanced and imbricated using interrupted 2-0 absorbable sutures to improve hallux alignment and maintain correction. The capsule demonstrated satisfactory tension without overcorrection.

The extensor hallucis longus tendon was inspected and found to glide freely without subluxation. Final inspection confirmed satisfactory correction of the hallux valgus deformity with restoration of joint alignment and stability.

The surgical field was irrigated once again with copious sterile saline. Meticulous hemostasis was achieved using bipolar electrocautery.

The subcutaneous tissue was closed using interrupted 3-0 absorbable sutures. The skin was approximated with interrupted 4-0 nylon sutures.

The tourniquet was released. Immediate capillary refill was noted in all digits, and the hallux demonstrated excellent perfusion without evidence of vascular compromise.

Sterile Xeroform, 4 × 4 gauze, sterile Webril, and a well-padded compressive bunion dressing were applied with the hallux maintained in corrected alignment.

The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery room in stable condition.

Findings

Severe hallux valgus deformity with a prominent medial eminence, advanced degenerative osteoarthritis of the first metatarsophalangeal joint, hypertrophic synovitis, osteophyte formation, and marked joint space narrowing. Successful Keller-type resection arthroplasty with resection of the proximal phalangeal base resulted in excellent decompression of the first metatarsophalangeal joint, restoration of hallux alignment, and improved passive range of motion.

Implants : None.

Check your answer

28292 – Correction, hallux valgus (bunion), Keller, McBride, or Mayo type procedure.

Bunion Procedure:

Bunionectomy procedures include, the following intraoperative component procedures, if performed.

1. First metatarsophalangeal joint capsulotomy;

2. Arthrotomy with or without removal of loose bodies or bursal tissue, synovectomy, and/or synovial biopsy;

3. Resection of medial, dorsomedial, dorsal, and/or dorsolateral bone prominences at the metatarsal head and proximal phalanx base;

4. Excision of associated osteophytes; articular shaving or drilling; extensor and/or flexor tenorrhaphy, adductor hallucis tendon transfer or tenotomy, and/or tenolysis;

5. Placement of internal fixation; intraoperative supervision and positioning of imaging and/or monitoring equipment by surgeon or assistant;

6. First metatarsophalangeal joint capsule plication and/or repair; closure of surgical site; and the applications of initial dressing, splint, and/or cast.

Operative report 2

Preoperative Diagnosis

Symptomatic hallux valgus deformity of the right foot with increased first intermetatarsal angle.

Postoperative Diagnosis

Same.

Procedure Performed

Correction of hallux valgus by proximal first metatarsal closing wedge osteotomy with internal fixation and medial eminence resection, right foot.

Indication

The patient presented with a progressive, painful hallux valgus deformity of the right foot associated with widening of the first intermetatarsal angle, difficulty with shoe wear, and failure of prolonged conservative treatment including shoe modification, orthotics, activity modification, padding, and anti-inflammatory medication. Radiographs demonstrated a moderate-to-severe hallux valgus deformity with a significantly increased first intermetatarsal angle, making a proximal metatarsal osteotomy appropriate for correction. After discussing risks, benefits, and alternatives, informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and positioned supine on the operating table. Following administration of monitored anesthesia care with an ankle block, a well-padded thigh tourniquet was applied. The operative extremity was prepped with chlorhexidine solution and draped in the usual sterile orthopedic fashion.

Following exsanguination using an Esmarch bandage, the tourniquet was inflated. A formal surgical time-out confirmed the correct patient, operative extremity, and planned procedure. Intravenous prophylactic antibiotics had been administered before incision.

Medial First Metatarsophalangeal Joint Exposure

A longitudinal dorsomedial incision was made over the first metatarsophalangeal joint. Sharp dissection was carried through the subcutaneous tissues with careful protection of the dorsal medial cutaneous nerve. Hemostasis was maintained with bipolar electrocautery.

The extensor hallucis longus tendon was identified and protected. A longitudinal medial capsulotomy was performed, and the capsule was elevated from the first metatarsal head.

The prominent medial eminence was resected using an oscillating saw while preserving the sagittal groove. The resected surface was smoothed with a bone rasp.

A lateral soft-tissue release was then performed through the first web space, releasing the adductor hallucis tendon insertion, the lateral capsule, and the lateral metatarsosesamoid ligament as necessary to allow correction of the hallux valgus deformity. The sesamoids were mobilized and restored beneath the metatarsal head.

Proximal First Metatarsal Osteotomy

Attention was directed to the proximal first metatarsal. A separate longitudinal incision was made over the proximal shaft and metaphyseal region of the first metatarsal. Careful blunt dissection was carried through the subcutaneous tissue while protecting the dorsal neurovascular structures.

The periosteum was incised longitudinally and elevated subperiosteally to expose the proximal metatarsal.

Under fluoroscopic guidance, the planned osteotomy site was identified approximately 1 to 1.5 cm distal to the first tarsometatarsal joint.

Using an oscillating microsagittal saw, a proximal closing wedge osteotomy was created. The lateral cortical hinge was preserved until completion of the osteotomy to facilitate controlled correction. The predetermined wedge of bone was removed.

The osteotomy was gently closed, reducing the first intermetatarsal angle and restoring appropriate alignment of the first metatarsal. Temporary fixation was obtained with Kirschner wires.

Reduction and correction were evaluated clinically and confirmed fluoroscopically in anteroposterior, lateral, and oblique projections. Satisfactory restoration of the hallux valgus angle and intermetatarsal angle was achieved.

Definitive fixation was performed using two cannulated cortical compression screws placed across the osteotomy under fluoroscopic guidance. Excellent compression and rigid fixation were obtained without displacement.

The temporary Kirschner wires were removed. Final fluoroscopic imaging confirmed anatomic osteotomy reduction, appropriate hardware placement, restoration of the first metatarsal alignment, and stable fixation.

Medial Capsulorrhaphy

Attention was returned to the first metatarsophalangeal joint. The medial capsule was advanced and imbricated with interrupted nonabsorbable sutures to maintain correction of the hallux valgus deformity. The hallux was positioned in physiologic alignment with satisfactory joint congruity.

Passive range of motion demonstrated excellent mobility without overcorrection or residual valgus deformity.

Both operative wounds were copiously irrigated with sterile normal saline solution. Meticulous hemostasis was achieved.

The periosteum was reapproximated with absorbable sutures. Subcutaneous tissues were closed using interrupted 3-0 absorbable sutures. Skin closure was performed with interrupted 4-0 nylon sutures.

The tourniquet was released. Immediate capillary refill was present in the hallux and remaining toes with excellent distal perfusion.

Sterile Xeroform dressing, gauze, Webril padding, and a well-padded compressive bunion dressing were applied with the hallux maintained in corrected alignment. A postoperative surgical shoe was placed.

The patient tolerated the procedure well and was transferred to the recovery room in stable condition.

Findings

Moderate-to-severe hallux valgus deformity with increased first intermetatarsal angle and prominent medial eminence. Successful correction was achieved with proximal first metatarsal closing wedge osteotomy, lateral soft-tissue release, medial eminence resection, capsular balancing, and rigid internal fixation. Final fluoroscopic images demonstrated satisfactory alignment and stable fixation.

Implants

* Two cannulated cortical compression screws for osteotomy fixation.

Check your answer

28296 – Correction, hallux valgus (bunion), with proximal first metatarsal osteotomy, any method.

Coding Note: The documentation above supports CPT 28296, as the defining component of the procedure is the proximal first metatarsal osteotomy. The medial eminence resection, lateral soft-tissue release, medial capsulorrhaphy, fluoroscopic guidance, and internal fixation are all integral components of the bunion correction and are not separately reportable.

Operative report 3

Preoperative Diagnosis

Symptomatic moderate-to-severe hallux valgus deformity of the right foot with hallux valgus interphalangeus.

Postoperative Diagnosis

Same.

Procedure Performed

Double osteotomy for correction of hallux valgus consisting of:

1. Proximal first metatarsal closing wedge osteotomy with internal fixation.

2. Akin medial closing wedge osteotomy of the proximal phalanx with internal fixation.

3. Medial eminence resection (Silver exostectomy).

4. Lateral soft tissue release and medial capsulorrhaphy.

Indication

The patient presented with a longstanding painful hallux valgus deformity associated with widening of the first intermetatarsal angle, hallux valgus interphalangeus, difficulty with shoe wear, and progressive functional limitation despite prolonged conservative treatment including orthotics, shoe modification, padding, activity modification, and anti-inflammatory medication. Weight-bearing radiographs demonstrated a significantly increased hallux valgus angle and intermetatarsal angle with residual proximal phalangeal valgus deformity. Because correction could not be adequately achieved with a single osteotomy, a double osteotomy was recommended. The risks, benefits, alternatives, and expected recovery were discussed, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed supine on the operating table. Following administration of monitored anesthesia care with an ankle block, a well-padded thigh tourniquet was applied. The right lower extremity was prepped and draped in the standard sterile orthopedic fashion.

Following exsanguination with an Esmarch bandage, the tourniquet was inflated. A formal surgical time-out confirmed the correct patient, operative extremity, and planned procedure. Intravenous prophylactic antibiotics had been administered before incision.

First Metatarsophalangeal Joint Exposure

A longitudinal dorsomedial incision was made over the first metatarsophalangeal joint. Sharp dissection was carried through the subcutaneous tissues while carefully protecting the dorsal medial cutaneous nerve.

The extensor hallucis longus tendon was identified and retracted laterally. A longitudinal medial capsulotomy was performed, and the capsule was elevated subperiosteally from the metatarsal head and proximal phalanx.

A large medial eminence was identified and resected using an oscillating microsagittal saw. The remaining cortical surface was contoured with a bone rasp until smooth.

Through the first intermetatarsal space, the adductor hallucis tendon insertion was released from the lateral base of the proximal phalanx. The lateral capsule and lateral metatarsosesamoid ligament were released as necessary to restore sesamoid mobility. The sesamoid complex was successfully reduced beneath the first metatarsal head.

Proximal First Metatarsal Osteotomy

A separate longitudinal incision was created over the proximal first metatarsal. The periosteum was incised and elevated subperiosteally to expose the proximal metatarsal.

Using fluoroscopic guidance, a proximal closing wedge osteotomy was planned approximately 1 to 1.5 cm distal to the first tarsometatarsal joint.

An oscillating saw was utilized to create the osteotomy while preserving the lateral cortical hinge. A predetermined wedge of bone was removed.

The osteotomy was gradually closed, reducing the intermetatarsal angle and restoring proper alignment of the first metatarsal. Temporary fixation was achieved with Kirschner wires.

Fluoroscopy confirmed satisfactory correction.

Definitive fixation was obtained using two cannulated compression screws placed across the osteotomy. Compression across the osteotomy site was excellent without displacement.

Akin Osteotomy

Attention was then directed to the proximal phalanx.

A longitudinal incision was extended distally over the medial aspect of the proximal phalanx. The periosteum was elevated while preserving the lateral cortical hinge.

Using an oscillating saw, a medial closing wedge osteotomy was performed at the proximal phalanx. The lateral cortex was intentionally preserved to function as a hinge.

The osteotomy was carefully closed, correcting the residual hallux valgus interphalangeus.

Temporary fixation was obtained with a guidewire. Definitive fixation was achieved using a fully threaded compression screw placed across the osteotomy under fluoroscopic guidance. Stable fixation and excellent compression were confirmed.

Assessment of Correction

The first metatarsophalangeal joint was taken through a complete range of motion. Excellent correction of both the hallux valgus deformity and the interphalangeal valgus deformity was achieved.

The sesamoids remained appropriately reduced beneath the metatarsal head. There was no evidence of overcorrection, malrotation, or instability.

Final fluoroscopic images in anteroposterior, lateral, and oblique projections confirmed:

* Restoration of the hallux valgus angle.

* Correction of the first intermetatarsal angle.

* Correction of hallux valgus interphalangeus.

* Stable fixation of both osteotomy sites.

* Appropriate hardware position.

The medial capsule was advanced and imbricated using interrupted nonabsorbable sutures to maintain correction of the hallux. Excellent soft tissue balance was obtained.

The operative wounds were copiously irrigated with sterile normal saline. Hemostasis was confirmed.

The periosteum was reapproximated using absorbable sutures. The subcutaneous tissues were closed with interrupted 3-0 absorbable sutures. The skin was closed with interrupted 4-0 nylon sutures.

The tourniquet was released. Immediate capillary refill was noted in all toes with excellent distal perfusion.

Sterile Xeroform, gauze, Webril, and a well-padded bunion dressing were applied while maintaining the hallux in corrected alignment. A postoperative forefoot surgical shoe was placed.The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery room in stable condition.

Findings

Moderate-to-severe hallux valgus deformity with increased hallux valgus angle, increased first intermetatarsal angle, hallux valgus interphalangeus, lateral sesamoid displacement, and a prominent medial eminence. Successful correction was achieved with combined proximal first metatarsal osteotomy and Akin proximal phalanx osteotomy, resulting in restoration of normal alignment and stable internal fixation.

Implants

* Two cannulated compression screws for fixation of the proximal first metatarsal osteotomy.

* One compression screw for fixation of the Akin proximal phalanx osteotomy.

Check your answer

28299 – Correction, hallux valgus (bunion), by double osteotomy.

Coding Notes: CPT 28299 is specifically intended for hallux valgus correction using two osteotomies (commonly a proximal first metatarsal osteotomy plus an Akin osteotomy). The medial eminence resection, lateral soft-tissue release, medial capsulorrhaphy, fluoroscopy, and fixation are considered integral parts of the procedure and are not separately reported.

Operative report 4

Preoperative Diagnosis

1. Symptomatic hallux valgus deformity, right foot.

2. First ray hypermobility with instability of the first tarsometatarsal joint.

3. Painful bunion refractory to conservative treatment.

Postoperative Diagnosis

Same.

Procedure Performed

1. Lapidus procedure (first tarsometatarsal arthrodesis) for correction of hallux valgus.

2. Medial eminence resection (Silver bunionectomy).

3. Lateral soft-tissue release.

4. Internal fixation of first tarsometatarsal arthrodesis.

Indication

The patient presented with a longstanding painful hallux valgus deformity associated with instability and hypermobility of the first tarsometatarsal joint. Conservative management including shoe modification, orthotics, activity modification, padding, and anti-inflammatory medications failed to relieve symptoms. Weight-bearing radiographs demonstrated a widened first intermetatarsal angle, hallux valgus deformity, and instability of the first ray. Because of the severity of the deformity and first tarsometatarsal instability, a Lapidus arthrodesis was recommended. The risks, benefits, alternatives, and expected postoperative course were discussed with the patient, and informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and placed in the supine position. Following administration of monitored anesthesia care with a popliteal and saphenous nerve block, a well-padded thigh tourniquet was applied. The right lower extremity was prepped with chlorhexidine solution and draped in the standard sterile orthopedic fashion.

Following exsanguination using an Esmarch bandage, the tourniquet was inflated. A formal surgical time-out confirmed the correct patient, operative extremity, planned procedure, and administration of prophylactic intravenous antibiotics.

Exposure of the First Metatarsophalangeal Joint

A longitudinal dorsomedial incision was made over the first metatarsophalangeal joint. Sharp dissection was carried through the subcutaneous tissues while carefully protecting the dorsal medial cutaneous nerve.

The extensor hallucis longus tendon was identified and retracted laterally. A longitudinal medial capsulotomy was performed, exposing the first metatarsal head.

A prominent medial eminence was resected with an oscillating microsagittal saw while preserving the sagittal groove. The remaining cortex was contoured using a bone rasp.

Through the first web space, the adductor hallucis tendon insertion was released from the lateral base of the proximal phalanx. The lateral capsule and lateral metatarsosesamoid ligament were released as necessary to restore normal sesamoid alignment. The sesamoid complex was successfully reduced beneath the first metatarsal head.

Exposure of the First Tarsometatarsal Joint

Attention was directed proximally. A separate longitudinal incision was made over the first tarsometatarsal joint. Sharp dissection was carried through the subcutaneous tissue while protecting the dorsal sensory nerves and dorsalis pedis vascular structures.

The extensor hallucis longus tendon was identified and protected. The first tarsometatarsal joint capsule was incised longitudinally, and the joint was exposed subperiosteally.

The articular cartilage of both the base of the first metatarsal and the distal medial cuneiform was completely removed using osteotomes, curettes, and powered burrs until healthy subchondral bone was exposed.

Fenestration of both fusion surfaces was performed using a 2.0-mm drill bit to promote vascular access. Multiple fish-scaling cuts were created with an osteotome to further stimulate osseous healing.

Autogenous cancellous bone obtained during the medial eminence resection was morselized and packed into the prepared arthrodesis site to augment fusion.

Reduction and Arthrodesis

The first metatarsal was translated laterally, plantarflexed appropriately, and rotated to restore the normal first intermetatarsal angle, hallux valgus angle, and sagittal alignment.

Temporary fixation was obtained using Kirschner wires. Clinical assessment confirmed correction of the deformity, restoration of the first ray alignment, and appropriate sesamoid reduction.

Reduction was verified using fluoroscopy in anteroposterior, lateral, and oblique projections.

Definitive fixation was performed using two large cannulated compression screws placed across the first tarsometatarsal joint under fluoroscopic guidance to achieve interfragmentary compression.

A low-profile dorsal locking Lapidus plate was then applied spanning the arthrodesis site. The plate was secured with multiple locking and nonlocking cortical screws, producing a rigid construct.

Final fluoroscopic images confirmed excellent correction of the hallux valgus deformity, restoration of the first intermetatarsal angle, congruent sesamoid position, complete compression across the fusion site, and appropriate implant position without intra-articular penetration.

Attention was returned to the first metatarsophalangeal joint. The medial capsule was advanced and imbricated using interrupted nonabsorbable sutures to maintain correction. The hallux was positioned in neutral alignment with excellent joint congruity.

Passive range of motion of the first metatarsophalangeal joint demonstrated satisfactory mobility without residual valgus deformity or overcorrection.

Both operative wounds were copiously irrigated with sterile normal saline solution. Meticulous hemostasis was achieved.

The tarsometatarsal joint capsule and periosteum were repaired using interrupted absorbable sutures.

Subcutaneous tissues were closed with interrupted 3-0 absorbable sutures. Skin closure was performed using interrupted 4-0 nylon sutures.

The tourniquet was released, and excellent perfusion with immediate capillary refill was confirmed in the hallux and remaining toes.

Sterile Xeroform, gauze, Webril, and a bulky compressive dressing were applied. The foot was placed into a well-padded posterior splint with the ankle in neutral position and the hallux maintained in corrected alignment.

The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery room in stable condition.

Findings

Severe hallux valgus deformity with widening of the first intermetatarsal angle, first tarsometatarsal joint hypermobility, lateral sesamoid displacement, and prominent medial eminence. Successful correction was achieved with first tarsometatarsal arthrodesis (Lapidus procedure), medial eminence resection, lateral soft-tissue balancing, and rigid internal fixation. Final fluoroscopic evaluation demonstrated excellent alignment, stable fixation, and satisfactory compression across the arthrodesis site.

## Implants

* Two cannulated compression screws across the first tarsometatarsal arthrodesis.

* Dorsal low-profile locking Lapidus plate with locking and cortical screws.

Check your answer

28297 – Correction, hallux valgus (bunion), with first metatarsal-cuneiform fusion (Lapidus procedure), any method.

Coding Notes

28297 includes the first tarsometatarsal arthrodesis, bunion correction, medial eminence resection, joint preparation, lateral soft-tissue release (when performed), and internal fixation.

Internal fixation (plates, screws, staples) is included in the procedure and is not separately reportable.

Bone graft obtained locally during the procedure is generally considered integral to the arthrodesis. Separate graft coding is reserved for qualifying graft harvests or graft materials when documentation and payer policy support separate reporting.

Operative report 5

Preoperative Diagnosis

1. Sy

Operative report 5

Preoperative Diagnosis

1. Symptomatic hallux valgus deformity, right foot.

2. Painful bunion of the first metatarsophalangeal joint.

Postoperative Diagnosis

Same.

Procedure Performed

1. Austin (Chevron) distal first metatarsal osteotomy for correction of hallux valgus, right foot.

2. Medial eminence resection (Silver exostectomy).

3. Lateral soft-tissue release.

4. Medial capsulorrhaphy.

5. Internal fixation of the osteotomy with cannulated compression screw.

Indication

The patient presented with a painful hallux valgus deformity of the right foot associated with difficulty wearing shoes, medial eminence irritation, and progressive deformity despite prolonged conservative treatment including shoe modifications, orthotics, activity modification, anti-inflammatory medications, and padding. Weight-bearing radiographs demonstrated a mild-to-moderate hallux valgus deformity with an increased hallux valgus angle and congruent first metatarsophalangeal joint, making the patient an appropriate candidate for distal first metatarsal osteotomy. After discussing the risks, benefits, alternatives, and expected postoperative recovery, informed consent was obtained.

Description of the Procedure

The patient was brought to the operating room and positioned supine on the operating table. Monitored anesthesia care was administered along with an ankle block. A well-padded thigh tourniquet was applied. The right lower extremity was prepped with chlorhexidine solution and draped in the standard sterile orthopedic fashion.

Following exsanguination of the extremity using an Esmarch bandage, the tourniquet was inflated. A formal surgical time-out was performed confirming the correct patient, operative extremity, planned procedure, and administration of prophylactic intravenous antibiotics.

Exposure of the First Metatarsophalangeal Joint

A longitudinal dorsomedial incision measuring approximately 5 cm was made over the first metatarsophalangeal joint.

Sharp dissection was carried through the subcutaneous tissue while carefully protecting the dorsal medial cutaneous nerve. Hemostasis was maintained with bipolar electrocautery throughout the procedure.

The extensor hallucis longus tendon was identified and gently retracted laterally. A longitudinal medial capsulotomy was performed, and the capsule was elevated subperiosteally from the first metatarsal head.

The first metatarsophalangeal joint was exposed. A prominent medial eminence was identified and resected using an oscillating microsagittal saw while preserving the sagittal groove. The remaining cortical surface was smoothed with a bone rasp.

Attention was directed to the first web space. The adductor hallucis tendon insertion was released from the lateral base of the proximal phalanx. The lateral capsule and lateral metatarsosesamoid ligament were sequentially released to allow reduction of the sesamoid complex beneath the metatarsal head. Adequate correction of the lateral soft-tissue contracture was achieved.

Austin (Chevron) Osteotomy

Attention was returned to the metatarsal head.

Under direct visualization, a V-shaped Chevron osteotomy with an approximately 60-degree apex was created in the distal first metatarsal using an oscillating microsagittal saw. The apex of the osteotomy was centered within the metatarsal head while preserving adequate plantar cortical support.

Following completion of the osteotomy, the distal metatarsal fragment was translated laterally approximately one-third of the metatarsal width to reduce the first intermetatarsal angle and improve congruency of the first metatarsophalangeal joint.

The amount of translation was assessed clinically and confirmed fluoroscopically.

The osteotomy was temporarily stabilized with a guidewire.

Internal Fixation

Definitive fixation was achieved using a cannulated compression screw inserted from the dorsal-medial aspect of the metatarsal head across the osteotomy into the proximal metatarsal fragment under fluoroscopic guidance.

Excellent interfragmentary compression and rigid fixation were obtained.

The temporary guidewire was removed.

The remaining medial cortical prominence created after lateral translation of the metatarsal head was carefully resected using an oscillating saw, and the bone was contoured with a rasp to create a smooth medial surface.

Assessment of Correction

The hallux was placed through a full range of motion. Excellent correction of the hallux valgus deformity was obtained with restoration of joint congruity.

The sesamoids remained well reduced beneath the first metatarsal head.

Fluoroscopic images obtained in anteroposterior, lateral, and oblique projections confirmed:

* Satisfactory correction of the hallux valgus angle.

* Reduction of the first intermetatarsal angle.

* Stable Chevron osteotomy.

* Appropriate screw position.

* No intra-articular hardware penetration.

* Excellent overall alignment of the first ray.

Medial Capsulorrhaphy

The redundant medial capsule was advanced and imbricated using interrupted nonabsorbable sutures to maintain correction of the hallux.

The first metatarsophalangeal joint demonstrated excellent stability without overcorrection or hallux varus.

The operative field was copiously irrigated with sterile normal saline solution.

Meticulous hemostasis was obtained.

The capsule was repaired using interrupted absorbable sutures.

The subcutaneous tissue was closed using interrupted 3-0 absorbable sutures.

The skin was closed with interrupted 4-0 nylon sutures.

The tourniquet was released. Immediate capillary refill was present in the hallux and all remaining toes, confirming satisfactory distal perfusion.

Sterile Xeroform, gauze, Webril padding, and a well-padded compressive bunion dressing were applied with the hallux maintained in corrected alignment. A postoperative forefoot surgical shoe was placed.

The patient tolerated the procedure well without intraoperative complications and was transferred to the recovery room in stable condition.

Findings

Mild-to-moderate hallux valgus deformity with a prominent medial eminence, increased hallux valgus angle, mild lateral displacement of the sesamoid complex, and preserved articular cartilage of the first metatarsophalangeal joint. Successful correction was achieved with an Austin (Chevron) distal first metatarsal osteotomy, lateral soft-tissue balancing, medial capsulorrhaphy, and rigid internal fixation. Final fluoroscopic imaging demonstrated excellent correction of the deformity, stable fixation, and restoration of normal first ray alignment.

Implants

* One 3.0-mm cannulated headless compression screw for fixation of the distal first metatarsal osteotomy.

Check your answer

28296 – Correction, hallux valgus (bunion), with distal metatarsal osteotomy (e.g., Austin/Chevron), any method.

Coding Note: The Austin (Chevron) osteotomy is one of the most common bunion correction procedures. The medial eminence resection, lateral soft-tissue release, medial capsulorrhaphy, fluoroscopic guidance, and internal fixation are considered integral components of CPT 28296 and are not separately reportable.