A comparison of proximal and distal chevron osteotomy for the correction of moderate hallux valgus deformity

Outcome comparison of minimally invasive proximal and distal chevron Akin osteotomies in patients with severe hallux valgus deformity: A randomized prospective study

PURPOSE

To date, the surgical treatment of severe hallux valgus deformity remains challenging despite the various methods presented. This study aimed to compare the effectiveness of minimally invasive distal chevron Akin osteotomies (d-MICA) and minimally invasive proximal chevron Akin osteotomies (p-MICA) in correcting severe hallux valgus deformities.

METHODS

This prospective follow-up study included patients randomly assigned to undergo p-MICA or d-MICA for hallux valgus deformities with a preoperative hallux valgus angle (HVA) ≥ 40° and/or a first to second intermetatarsal angle (IMA) ≥ 16°. After a minimum follow-up period of two years, we compared various clinico-radiographic parameters of patients whose HVA exceeded 15° at the final follow-up.

RESULTS

In the p-MICA and d-MICA groups, seven of 40 cases (17.5%) and 16 of 41 cases (39.0%), respectively, exhibited HVA > 15° at the final follow-up (P = 0.048). The preoperative parameters showed no significant differences. However, at the first weight-bearing assessment, the HVA, IMA, and relative second metatarsal length were significantly smaller, and the distal metatarsal articular angle (DMAA) was greater in the p-MICA group (all P < 0.05) compared with the d-MICA group. Postoperatively, both groups exhibited significant decreases in HVA and IMA at the final follow-up (P < 0.001 for all parameters). The p-MICA group showed no significant changes in DMAA and the relative length of the second metatarsal (P = 0.253 and 0.185, respectively). However, the d-MICA group showed a significant decrease in DMAA (P < 0.001) and an increase in the relative length of the second metatarsal at the final follow-up (P = 0.01).

CONCLUSIONS

p-MICA and d-MICA procedures demonstrated effective correction potential for severe hallux valgus deformities; however, the d-MICA procedure exhibited a notably higher incidence of unsatisfactory correction at the final follow-up than p-MICA. Therefore, d-MICA may be less predictable in achieving successful outcomes than p-MICA in treating severe hallux valgus deformities.

A Modified 90-Degree Distal Chevron Metatarsal Osteotomy for Correcting Moderate Hallux Valgus Deformity

Various modifications of distal chevron metatarsal osteotomy (DCMO) have been introduced for correcting moderate hallux valgus deformity; however, the amount of correction may be limited, and complications, such as the recurrence of the deformity and avascular necrosis of the metatarsal head, have been a problem. This study aimed to present a modified 90-degree DCMO technique that overcomes the previously reported shortcomings and to report a successful short-term radiographic outcome. Sixty-eight consecutive patients who underwent the operation with our modified DCMO technique and twenty-two consecutive patients with the conventional DCMO technique (control group) were retrospectively analyzed. The radiographic measurements were evaluated preoperatively, at two months post operation, and at the final follow-up. Both groups showed a significant correction of the hallux valgus angle, first-second intermetatarsal angle, distal metatarsal articular angle, and sesamoid position at the final follow-up, while the amount of correction was significantly greater in the modified DCMO group. In both groups, there were no cases of complications such as avascular necrosis of the metatarsal head, nonunion, and surgical site infection appearing throughout the follow-up period. Therefore, the modified 90-degree DCMO technique is effective and safe, which could serve as a favorable option to treat moderate hallux valgus deformity.

Preoperative degree of deformity and underlying disease affect the postoperative deformity of joint-preserving hallux valgus surgery

BACKGROUND

The combination of distal osteotomy with lateral dissection in joint-preserving surgery for severe hallux valgus deformity has recently begun to yield encouraging results. We examined the frequency of complications and risk factors of those for joint-preserving surgery in patients with and without rheumatoid arthritis (RA).

METHODS

A retrospective, observational study of 72 feet (27 patients with RA) was performed. The inclusion criteria were patients who underwent joint-preserving surgery for hallux valgus deformity at our hospital between January 2008 and March 2016 who could be followed up with for longer than 12 months.

RESULTS

The mean preoperative and immediate postoperative hallux valgus angles (HVA) were 41.8 and 4.4, respectively. The mean preoperative and immediate postoperative intermetatarsal angles between the first and second metatarsal bones (M1-M2A) were 14.6 and 5.8, respectively. At the final postoperative evaluation, the mean HVA was 8.8 and the mean M1-M2A was 6.4.Data were compared among the patients with complications (recurrent valgus deformity, varus deformity), and those without complications (normal HVA) at the final postoperative evaluation. The rate of RA in the varus deformity group was 71.4%, which tended to be higher than in other groups (p = .058). The mean preoperative HVA were 48.2 and 52.6 in the group of recurrent valgus deformity and varus deformity, which was higher than the normal HVA group (p = .001).

CONCLUSIONS

High preoperative HVA was a risk factor for the recurrence of valgus deformity. Most of the varus deformities were observed in the RA group with high preoperative HVA; therefore, caution should be exercised in operating on patients with severe deformity or those with RA.

LEVEL OF EVIDENCE

III.

Correlation of Loss of Correction With Postoperative Radiological Factors After Distal Chevron Osteotomy in Dependence of Concomitant Akin Osteotomy

Loss of correction is frequently observed following hallux valgus correction and is associated with recurrence of a hallux valgus deformity. The purpose of this study was to correlate loss of correction and radiological parameters following distal chevron (Group C) and combined chevron/akin (Group AC) osteotomy. A total of 859 feet were included for analysis and grouped according to treatment with a distal chevron osteotomy alone or a combined chevron/akin osteotomy. Radiographs were evaluated preoperatively, postoperatively, after 6 weeks, 3 months and, if available, at long term follow-up with a mean of 34.2 (range 7.5-155.3) months. With the exception of the proximal to distal phalangeal articular angle (PDPAA), preoperative deformity was comparable between both groups. Significant correction of all examined parameters (p < .001) was seen. Loss of correction at 6 weeks with minor deterioration until follow-up was also detected, with group AC somewhat better than Group C. A strong correlation with loss of correction was found for the postoperative hallux valgus angle (HVA) (p < .002), intermetatarsal angle (IMA) (p < .001), distal metatarsal articular angle (DMAA) (p < .002), positioning of the sesamoids (p < .002) and joint congruity (p < .035) in Group C and for the DMAA (p < .033) and HVA (p < .046) in Group AC. Multiple postoperative radiological parameters correlated with loss of correction following distal chevron osteotomy. In Group AC only postoperative HVA and DMAA determined loss of correction. Correction of the deformity in Group AC showed greater stability.

A prospective study to compare the operative outcomes of minimally invasive proximal and distal chevron metatarsal osteotomy for moderate-to-severe hallux valgus deformity

PURPOSE

The effectiveness of minimally invasive surgery (MIS)-distal chevron metatarsal osteotomy (DCMO) for the correction of moderate-to-severe hallux valgus deformity is unclear. This study aimed to compare the radiographic and clinical outcomes of our novel MIS-proximal chevron metatarsal osteotomy (PCMO) with those of MIS-DCMO performed during the same timeframe.

METHODS

We prospectively compared the outcomes of patients who underwent MIS-PCMO (n = 20 patients; 22 cases) with those of patients who underwent MIS-DCMO (n = 23 patients; 26 cases) for moderate-to-severe hallux valgus deformity (hallux valgus angle [HVA] ≥ 30° and first-to-second intermetatarsal angle [IMA] ≥ 13°) between June 2017 and January 2019. The minimum follow-up duration for study inclusion was two years. The HVA, IMA, distal metatarsal articular angle (DMAA), relative length of the second metatarsal, medial sesamoid position, and Meary's angle to evaluate the degree of deformity correction and its maintenance were measured pre-operatively and at the final follow-up.

RESULTS

Compared with MIS-DCMO, MIS-PCMO resulted in significantly greater correction of the HVA (P < 0.001) and IMA (P = 0.01), along with Meary's angle improvement (P < 0.001); however, the DMAA worsened (P = 0 .01). Furthermore, a significantly greater change was found in the relative second metatarsal length in the MIS-DCMO group (P = 0.01). No significant between-group differences were noted in the correction of the medial sesamoid position (P = 0.445).

CONCLUSION

Compared with MIS-DCMO, MIS-PCMO can be a better option for correcting moderate-to-severe hallux valgus deformities. However, this technique should be applied carefully when the pre-operative DMAA is already large because the DMAA can become worse post-operatively.

Midterm Results Following Minimally Invasive Distal Chevron Osteotomy: Comparison With the Minimally Invasive Reverdin-Isham Osteotomy by Means of Meta-analysis

BACKGROUND/AIM

To date, multiple different surgical techniques have been established for hallux valgus surgery, with each technique having its unique advantages and limitations. The open distal chevron osteotomy is widely accepted, but increasing patient demands have led several minimally invasive (MIS) techniques to be described in recent years. The aim of this study was to compare outcomes after minimally invasive (MIS) distal chevron osteotomy and the minimally invasive Reverdin-Isham method.

PATIENTS AND METHODS

We assessed clinical and radiographic outcomes after MIS chevron osteotomy in 57 feet of 49 consecutive patients with a mean follow-up of 58.9 (range=39.0-85.4) months. Outcomes after MIS Reverdin-Isham osteotomy were analyzed by means of a systematic literature review with a minimum follow-up of 6 months.

RESULTS

Radiographic outcomes were significantly better in the MIS chevron cohort for intermetatarsal angle (p<0.001), hallux valgus angle and distal metacarpal articular angle (p<0.05). Concerning clinical outcomes, both methods provided comparable improvement.

CONCLUSION

MIS distal chevron osteotomy in mild to moderate hallux valgus deformity correction results in superior radiographic outcomes compared to the MIS Reverdin-Isham osteotomy. Sufficient correction of IMA cannot be achieved with the MIS Reverdin-Isham osteotomy.

Five-Year Follow-up of Minimally Invasive Distal Metatarsal Chevron Osteotomy in Comparison with the Open Technique: A Randomized Controlled Trial

BACKGROUND

The aim of the present prospective randomized study was to evaluate the long-term outcomes of minimally invasive chevron osteotomy as compared with open distal chevron osteotomy for the correction of hallux valgus deformity.

METHODS

A randomized controlled design was applied. The following parameters were assessed at 6 and 12 weeks, 9 months, and 5 years postoperatively: the American Orthopaedic Foot & Ankle Society (AOFAS) Forefoot Score, a visual analog scale (VAS) score for pain, and a patient-satisfaction score. In addition, several radiographic parameters for hallux valgus correction and joint degeneration were collected. Range of motion was also assessed. Thirty-nine of 47 feet were available for analysis at the time of the latest follow-up.

RESULTS

During the 5-year study period, the outcomes of the minimally invasive technique were comparable with those of the open technique. No significant differences were seen between the 2 groups within 5 years postoperatively in terms of clinical outcomes (VAS, AOFAS, satisfaction), radiographic outcomes, joint degeneration, or range of motion.

CONCLUSIONS

Five years after treatment, the outcome following minimally invasive distal chevron osteotomy is comparable with that for the open technique for hallux valgus surgery.

LEVELS OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

[Effectiveness of double metatarsal osteotomy for severe hallux valgus with increased distal metatarsal articular angle]

Objective

To summarize the technique and effectiveness of double metatarsal osteotomy for treating severe hallux valgus with increased distal metatarsal articular angle (DMAA).

Methods

Between June 2014 and December 2017, 64 patients (94 feet) of severe hallux valgus with an increased DMAA were treated with the double metatarsal osteotomy (distal metatarsal Reverdin osteotomy+proximal metatarsal open wedge osteotomy) combined with Akin osteotomy and soft tissue surgery to correct the deformity. There were 10 males (15 feet) and 54 females (79 feet) with an average age of 44.5 years (range, 26-66 years), including 34 of unilateral foot and 30 of bilateral feet. The Maryland metatarsophalangeal joint score of the American Orthopaedic Foot and Ankle Society (AOFAS) was 54.3±7.4 and the visual analogue scale (VAS) score was 6.0±2.0. The pre- and post-operative AOFAS score, VAS score, DMAA, hallux valgus angle (HVA), first-second intermetatarsal angle (1-2IMA), and the first metatarsal length (FML) were recorded and compared.

Results

All incisions healed by first intention. All patients were followed up 12-15 months, with an average of 13.2 months. The complications occurred in 4 feet, including 1 foot of hallux stiffness, 1 foot of numbness at the edge of the wound, 1 foot of metastatic metatarsalgia, and 1 foot of metatarsal bone necrosis. At 1 year after operation, the Maryland metatarsal joint score of AOFAS was 89.2±7.4, showing significant difference compared with preoperative score ( t=18.427, P=0.000); and the effectiveness was rated as excellent in 78 feet, good in 12 feet, poor in 3 feet, and bad in 1 foot, with an excellent and good rate of 95.7%. The VAS score was 1.5±2.0, showing significant difference compared with the preoperative score ( t=10.238, P=0.000). The X-ray films showed that the osteotomies achieved bony healing at 3 months after operation. There were significant differences ( P<0.05) in HVA, 1-2IMA, and DMAA between preoperation and 6 months and 1 year after operation; but no significant difference was found in FML between preoperation and 1 year after operation ( t=0.136, P=0.863).

Conclusion

For the patients with severe hallux valgus with increased DMAA, the double metatarsal osteotomy can significantly relieve the clinical symptoms and improve the imaging parameters with less postoperative complications.

Minimally invasive vs open distal metatarsal osteotomy for hallux valgus - A systematic review and meta-analysis

BACKGROUND

Numerous publications of the late 20th century have presented the radiological outcome of open technique for distal metatarsal osteotomy for mild to moderate hallux valgus and the clinical outcomes by means of well-established scoring systems which have been published and make these open techniques today's benchmark and gold standard. Minimally invasive procedures reduce surgical trauma because they are performed without large incisions, and injury to the soft tissues is limited. This has the theoretical advantages of improved recovery and decreased rehabilitation times. There is however limited literature to prove the same for minimally invasive surgery for hallux valgus.Our aim was thus to pool all available comparative literature on minimally invasive hallux valgus surgery done for mild to moderate hallux valgus versus open surgical approaches.

METHODS

A PubMed, Embase and Scopus search was performed using the keywords ('hallux valgus' OR bunion) AND ('minimally invasive' OR percutaneous) AND osteotomy. A total of 473 records were identified and out of which nine studies were included in the final review.

RESULTS

Most available studies are either randomized control trials, or prospective cohort studies providing good level of evidence. Radiological analysis showed similar correction with both MIS and open osteotomies. In functional analysis results were different with open techniques providing better results in terms of AOFAS score. (p < 0.0001). VAS score and complication rate were similar in both groups.

DISCUSSION/CONCLUSION

We conclude that based on available literature MIS provides equivalent radiological outcomes with respect to open surgery but functionally despite the promising results (good to excellent in most series), the outcomes in terms of function are not as good as open surgery. MIS techniques provide satisfactory outcomes for mild-to-moderate severity of hallux valgus though not as good as open surgery. There is evolving literature for this relatively new procedure. Longer duration of follow up and bigger numbers would allow for more meaningful data analysis and conclusions to be drawn as more studies come forward.

Introduction the revolving scarf osteotomy for treating severe hallux valgus with an increased distal metatarsal articular angle: a retrospective cohort study

BACKGROUND

Hallux valgus(HV) with an increased distal metatarsal articular angle (DMAA) is one of the most common foot deformities among adults. Double metatarsal osteotomy (DMO) is effective in treating severe HV deformity with an increased DMAA. However, this technique presents the risk of avascular necrosis (AVN) of the metatarsal head and transfer metatarsalgia due to shortening of the first metatarsal. The aim of this study was to introduce a surgical procedure defined as revolving scarf osteotomy (RSO) and compare the clinical and radiological results of RSO and DMO performed for treating severe HV with an increased DMAA.

METHODS

First metatarsal osteotomies and Akin osteotomy were performed in 56 patients (62 ft) with severe HV with an increased DMAA in Honghui Hospital from January 2015 to December 2017. RSO was performed in 32 ft and DMO was performed in 30 ft. The Akin osteotomy was performed in both groups. The American Orthopedic Foot and Ankle Society (AOFAS) score, visual analogue scale (VAS) score, the hallux valgus angle (HVA), intermetatarsal angle (IMA), DMAA, and first metatarsal length (FML) and the rates of complications were compared preoperatively and postoperatively in the two groups.

RESULTS

The mean AOFAS score, VAS score, HVA, IMA, and DMAA showed significant improvements in both groups after surgery, but with no significant differences between the two groups. The postoperative FML was significantly larger in the RSO group than in the DMO group (p < 0.001). One of the 30 ft (3.3%) in the DMO group exhibited transfer metatarsalgia at 12 months postoperatively, while another foot (3.3%) in same group had avascular necrosis of the metatarsal head. One of the 30 ft (3.1%) in the RSO group had hallux varus.

CONCLUSIONS

No differences in the clinical and radiographic results were observed between the two groups with severe HV and an increased DMAA. However, RSO does not cause shortening of the metatarsal and AVN of the metatarsal head. A long-term, randomized, controlled prospective study with a larger sample would provide higher-level evidence for confirming the clinical efficacy and safety of RSO.

Need for concomitant Akin osteotomy in patients undergoing Chevron osteotomy can be determined preoperatively: a retrospective comparative study of 859 cases

Background

The Chevron osteotomy is a frequently used surgical method for hallux valgus correction. This method is often combined with an Akin osteotomy. To date, clear guidelines for the implementation of an additional Akin osteotomy are missing. The purpose of this study was to elucidate the impact of concomitant phalangeal correction on the outcome after hallux valgus surgery and to define indication criteria for an additional Akin osteotomy.

Methods

Patients (859 feet) undergoing distal Chevron osteotomy at our department were retrospectively grouped into group C (Chevron, 785 feet) and group AC (Chevron plus Akin, 74 ft). Radiological assessment including the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA), and the proximal to distal phalangeal articular angle (PDPAA) was performed preoperatively, postoperatively, after 6 weeks, and after 3 months. Longer-term follow-up with a mean of 36.4 months was available for 248 cases (29%).

Results

A significant improvement of all parameters could be found to all points of survey (p < 0.001). Loss of correction was detected for HVA (p < 0.001) and IMA (p < 0.007) with higher levels in group C. Preoperative PDPAA exceeding 8° correlated significantly with loss of HVA correction in group C (p < 0.001).

Conclusion

The combined Chevron and Akin osteotomy allowed for better correction of the hallux valgus deformity with better maintenance of the achieved correction. Recommendation for concomitant Akin osteotomy may be determined by a preoperative PDPAA exceeding 8°.

Trial registration

Retrospectively registered. UN5080.

Level of evidence

Therapeutic, Level III, retrospective comparative series.

Loss of Correction After Chevron Osteotomy for Hallux Valgus as a Function of Preoperative Deformity

BACKGROUND:

Recurrence is relatively common after surgical correction of hallux valgus. Multiple factors are discussed that could have an influence in the loss of correction. The aim of this study was to determine preoperative radiological factors with an influence on loss of correction after distal chevron osteotomy for hallux valgus.

METHODS:

Five hundred twenty-four patients who underwent the correction of a hallux valgus by means of distal chevron osteotomy at our institution between 2002 and 2012 were included. We assessed weightbearing x-rays at 4 time points: preoperatively, postoperatively, and after 6 weeks and 3 months. We investigated the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA), joint congruity, and the position of the sesamoids.

RESULTS:

At all points of the survey, significant correction of the IMA and HVA was detected. The IMA improved from 12.9 (± 2.8) to 4.5 (± 2.4) degrees and the HVA from 27.5 (± 6.9) to 9.1 (± 5.3) degrees. Loss of correction was found in both HVA and IMA during follow-up with a mean of 4.5 and 1.9 degrees, respectively. Loss of correction showed a linear correlation with preoperative IMA and HVA, and a correlation between preoperative DMAA and sesamoid position.

CONCLUSION:

The chevron osteotomy showed significant correction for HVA, IMA, and DMAA. Preoperative deformity, in terms of IMA, HVA, DMAA, and sesamoid position, correlated with the loss of correction and could be assessed preoperatively for HVA and IMA. Loss of correction at 3 months persisted during the follow-up period.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

Is Double Metatarsal Osteotomy Superior to Proximal Chevron Osteotomy in Treatment of Hallux Valgus With Increased Distal Metatarsal Articular Angle?

We compared the results of proximal chevron osteotomy and double metatarsal osteotomy for hallux valgus with an increased distal metatarsal articular angle (DMAA). From October 2008 to December 2012, first metatarsal osteotomies were performed in 64 patients (69 feet) with symptomatic hallux valgus associated with an increased DMAA. Proximal chevron with Akin osteotomy and lateral soft tissue release was performed in 46 feet (PCO group); double metatarsal osteotomy and Akin osteotomy without lateral soft tissue release was performed in 23 feet (DMO group). Clinical assessments were performed using the American Orthopaedic Foot and Ankle Society (AOFAS) scale and visual analog scale (VAS). The hallux valgus angles, intermetatarsal angles, sesamoid positions, metatarsus adductus angles, and DMAAs were compared at different postoperative times. Postoperative shortening of first the metatarsal and complications were compared. The mean AOFAS scale and VAS scores showed significant improvement in both groups after surgery; however, no significant difference was observed between the 2 groups. The immediate postoperative hallux valgus angle and sesamoid position were significantly larger in DMO group; however, no intergroup difference was observed at the last follow-up visit, with the hallux valgus angle gradually increasing in the PCO group. The postoperative DMAA was significantly smaller in the DMO group. The mean shortening of the first metatarsal after surgery was significantly larger in the DMO group than in the PCO group. Transfer metatarsalgia developed in 1 foot (2.2%) in the PCO group and 2 feet (8.7%) in the DMO group. Partial avascular necrosis of the metatarsal head with advanced arthritis of the first metatarsophalangeal joint developed in 1 foot (4.3%) in the DMO group. In conclusion, no differences in the clinical and radiographic results were observed between the 2 groups for hallux valgus deformity with an increased DMAA.

Minimally invasive versus open chevron osteotomy for hallux valgus correction: a randomized controlled trial

PURPOSE

The purpose of this study was to compare a minimally invasive chevron osteotomy technique (MIS group) and the well-established open chevron technique (OC group) for correction of hallux valgus deformity.

METHODS

Patients who were scheduled to undergo a hallux valgus surgery by means of a distal chevron osteotomy were randomly assigned to one of the two groups. Pre-operatively, six weeks, 12 weeks, and nine months post-operatively the following outcome parameters were determined: Visual Analog Scores (VAS) of pain, the American Orthopedic Foot and Ankle Society (AOFAS) forefoot score, radiographic outcome measures, range of motion (ROM), and patient satisfaction.

RESULTS

Forty-seven cases were analyzed (25 MIS group; 22 OC group). Both operative techniques achieved significant correction of the hallux deformity. The intermetatarsal angle (IMA) improved from 15.1° to 5.8° in the OC and from 14° to 6.8°in the MIS group, whereas the hallux valgus angle (HVA) improved from 28.3° to 8.5° in the OC versus 26.4° to 6.9° in the MIS group. No significant differences were observed between the groups by any of the determined outcome parameters. Regarding patient satisfaction, statistically significant differences were found between MIS and open surgery 12 weeks post-operatively in favour of the MIS group (p = 0.022).

CONCLUSION

With the minimally invasive chevron osteotomy, radiological and clinical outcome is comparable to the open technique.

Introduction: Why Are There so Many Different Surgeries for Hallux Valgus?

Hallux valgus is a common pathology of the foot and ankle. Surgical correction of the condition has been described as early as 1836. Since then, numerous different surgical techniques have been documented in the literature. One of the explanations as to why there are so many different surgeries for hallux valgus is the variety of etiologies attributed to causing the condition. This article discusses the etiologies associated with hallux valgus and describes a few of the surgeries commonly used to treat the deformity.

Recurrence of Hallux Valgus Can Be Predicted from Immediate Postoperative Non-Weight-Bearing Radiographs

BACKGROUND

The aims of this study were to identify risk factors for the recurrence of hallux valgus deformity and to clarify whether recurrence after surgery to treat hallux valgus can be predicted using radiographic parameters assessed on immediate postoperative non-weight-bearing radiographs.

METHODS

A proximal chevron osteotomy combined with a distal soft-tissue procedure was performed by a single surgeon to treat moderate to severe hallux valgus deformity in 93 patients (117 feet). The feet were grouped according to nonrecurrence or recurrence. Changes in the hallux valgus angle, the intermetatarsal angle, and sesamoid position over time were analyzed by comparing values measured during each postoperative period. The relative risks of recurrence as indicated by preoperative and postoperative radiographic parameters were determined.

RESULTS

Twenty (17.1%) of the 117 feet showed hallux valgus recurrence at the time of the last follow-up. The hallux valgus angle and the intermetatarsal angle stabilized at 6 months after surgery in the nonrecurrence group. An immediate postoperative hallux valgus angle of ≥8°, an immediate postoperative sesamoid position of grade 4 or greater, a preoperative metatarsus adductus angle of ≥23°, and a preoperative hallux valgus angle of ≥40° were significantly associated with recurrence.

CONCLUSIONS

Recurrence of hallux valgus after a proximal chevron osteotomy can be reliably predicted from immediate postoperative non-weight-bearing radiographs.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effect of Bipartite Hallucal Sesamoid on Hallux Valgus Surgery

BACKGROUND

Bipartite hallucal sesamoids are often found in patients with hallux valgus. However, it is unknown whether bipartite hallucal sesamoids affect the results of hallux valgus surgery or not. The purpose of the present study was to evaluate the outcomes of chevron osteotomy for hallux valgus with and without bipartite hallucal sesamoid.

METHODS

A total of 152 patients (168 feet) treated with distal or proximal chevron osteotomy for hallux valgus constituted the study cohort. The 168 feet were divided into 2 groups: bipartite hallucal sesamoid (31 feet) and without bipartite hallucal sesamoid (137 feet). Hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle (DMAA), tibial sesamoid position, and first metatarsal length were measured for radiographic outcomes and the American Orthopaedic Foot & Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal (MTP-IP) score was measured for clinical outcomes.

RESULTS

All radiographic measurements and the AOFAS score showed significant ( P < .05) improvement at the time of final follow-up compared with preoperative measurements in both groups. No significant differences ( P > .05) were found between the 2 groups in terms of HVA, IMA, DMAA, tibial sesamoid position, metatarsal shortening, and AOFAS score on final follow-up.

CONCLUSIONS

This study suggests that bipartite hallucal sesamoids do not affect the results of hallux valgus surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Correction of moderate to severe hallux valgus with combined proximal opening wedge and distal chevron osteotomies: a reliable technique

AIMS

The mainstay of surgical correction of hallux valgus is first metatarsal osteotomy, either proximally or distally. We present a technique of combining a distal chevron osteotomy with a proximal opening wedge osteotomy, for the correction of moderate to severe hallux valgus.

PATIENTS AND METHODS

We reviewed 45 patients (49 feet) who had undergone double osteotomy. Outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) and the Short Form (SF) -36 Health Survey scores. Radiological measurements were undertaken to assess the correction. The mean age of the patients was 60.8 years (44.2 to 75.3). The mean follow-up was 35.4 months (24 to 51).

RESULTS

The mean AOFAS score improved from 54.7 to 92.3 (p < 0.001) and the mean SF-36 score from 59 to 86 (p < 0.001). The mean hallux valgus and intermetatarsal angles were improved from 41.6(o) to 12.8(o) (p < 0.001) and from 22.1(o) to 7.1(o), respectively (p < 0.001). The mean distal metatarsal articular angle improved from 23(o) to 9.7(o). The mean sesamoid position, as described by Hardy and Clapham, improved from 6.8 to 3.5. The mean length of the first metatarsal was unchanged. The overall rate of complications was 4.1% (two patients).

CONCLUSION

These results suggest that a double osteotomy of the first metatarsal is a reliable, safe technique which, when compared with other metatarsal osteotomies, provides strong angular correction and excellent outcomes with a low rate of complications. Cite this article: Bone Joint J 2016;98-B:1202-7.

Second Metatarsal Transfer Lesions Due to First Metatarsal Shortening After Distal Chevron Metatarsal Osteotomy for Hallux Valgus

BACKGROUND

The first metatarsal bone can shorten after a distal chevron metatarsal osteotomy (DCMO). This shortening can result in a postoperative second metatarsal transfer lesion. The aim of the present study was to investigate the occurrence of second metatarsal transfer lesions after DCMO.

METHODS

This study involved 185 feet (138 patients), with hallux valgus (HV) deformity, treated with DCMO with Akin osteotomy. The mean patient age was 51.7 years (range, 21 to 74). Patients were followed for an average of 28 months, between June 2004 and June 2010. We measured the length of first metatarsal relative to second metatarsal preoperatively and postoperatively, using Morton's and Hardy-Clapham's methods. A second metatarsal transfer lesion was defined as a newly developed lesion, including metatarsalgia, a painful callosity, or a painless callosity, which was not present prior to the DCMO. The relation of the shortened first metatarsal after DCMO with the occurrence of second metatarsal transfer lesion was evaluated.

RESULTS

Second metatarsal transfer lesions (painless callosity) developed in 5 feet (2.7%) of 185 feet. Twenty-four preoperative second metatarsal lesions were improved postoperatively. The median shortening of the first metatarsal bone after DCMO was 0.6 mm according to Morton's method (range, -6.4 to 6.4), and 1.9 according to Hardy-Clapham's method (range, -5.8 to 5.8). According to the extent of first metatarsal shortening after DCMO by Hardy-Clapham's method and Morton's method, there was no significant difference of the occurrence of second transfer metatarsal lesions (P = .259 and P = .176, respectively).

CONCLUSIONS

In our study, second metatarsal transfer lesions developed in 2.7% of feet after DCMO. The occurrence of second metatarsal transfer lesions did not appear to be correlated with the degree of first metatarsal shortening in cases with less than 5.8 mm shortening.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Comparison of Chevron and Distal Oblique Osteotomy for Bunion Correction

The chevron osteotomy is a standard procedure by which bunions are corrected. One of us routinely performs a distal oblique osteotomy, which, to the best of our knowledge, has not been described for the correction of bunion deformities. The purpose of the present study was to compare the short- and medium-term results of the distal oblique and chevron osteotomies for bunion correction. We performed a retrospective clinical and radiographic comparison of patients who had undergone a distal oblique or chevron osteotomy for the correction of bunion deformity. In addition, a prospective patient satisfaction survey was undertaken. A total of 55 patients were included in the present study and were treated from January 2012 to November 2014. Of the 55 patients, 27 (49.2%) were in the chevron group and 28 (50.8%) in the distal oblique group. Radiographically, no statistically significant difference was found between the 2 groups with respect to postoperative first intermetatarsal angle (p < .0001) and hallux valgus angle (p < .0001), but a greater change was found in the intermetatarsal angle in the distal oblique group (p = .467). Prospective patient satisfaction scores were available for 33 patients (60%), 16 (29%) in the chevron group and 17 (31%) in the distal oblique group. When converting the satisfaction score to a numerical score, the chevron group scored 3.3 ± 1.1 and the distal oblique group scored 3.2 ± 0.8 (p = .812). We found that the distal oblique osteotomy used in the present study is simple and reliable and showed radiographic correction and patient satisfaction equivalent to those in the chevron osteotomy.

Preliminary radiographic outcomes of surgical correction in juvenile hallux valgus: single proximal, single distal versus double osteotomies

BACKGROUND

Surgical correction of juvenile hallux valgus has a high risk of recurrence and complications. This short-term follow-up study evaluates the radiographic differences between 3 osteotomy types: distal first metatarsal osteotomy, proximal first metatarsal osteotomy, and double first metatarsal osteotomy with regard to ability to achieve correction and the risk of hallux varus.

METHODS

A total of 106 feet were evaluated. Percent correction of hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) was recorded, as well as complication and reoperation rates. Radiographs were evaluated at the initial visit, intraoperatively, and at final follow-up.

RESULTS

The single distal osteotomy achieved: IMA within normal limits 21% of the time with no cases of overcorrection; HVA within normal limits 42% of the time with 13% overcorrected; and DMAA within normal limits 46% of the time with 4% overcorrected.The single proximal osteotomy achieved: IMA within normal limits 36% of the time with no cases of overcorrection; HVA within normal limits 36% of the time with no cases of overcorrection; and DMAA within normal limits 36% of the time with 7% overcorrected.The double osteotomy achieved: IMA within normal limits 54% of the time with no cases of overcorrection; HVA within normal limits 40% of the time with 7% overcorrected; and DMAA within normal limits 56% of the time with 22% overcorrected.The rate of HVA overcorrection was not found to be correlated with osteotomy type (P=0.37). The double osteotomy was found to have a higher DMAA overcorrection rate than either single osteotomy (P<0.001).

CONCLUSIONS

The single distal osteotomy for juvenile hallux valgus seems to have the most consistent outcomes, with improved radiographic parameters and low risk of complication compared with the other surgical cohorts. However, the double osteotomy can have the best correction of all 3 radiographic parameters at once, but the highest risk for overcorrection of the DMAA.

LEVEL OF EVIDENCE

Level III-retrospective case control study.

Can Double Osteotomy Be a Solution for Adult Hallux Valgus Deformity With an Increased Distal Metatarsal Articular Angle?

No previous study has reported the results of double metatarsal osteotomy for adult hallux valgus deformity with an increased distal metatarsal articular angle (DMAA). The purpose of the present study was to evaluate the results after double metatarsal osteotomy in adult patients with incongruent hallux valgus deformity. We retrospectively reviewed 16 cases of consecutive first metatarsal double metatarsal osteotomy without lateral soft tissue release in 14 patients with symptomatic hallux valgus associated with an increased DMAA (≥15° after proximal chevron osteotomy on intraoperative radiographs). Clinical results were assessed using the American Orthopaedic Foot and Ankle Society scale and the visual analog scale. The radiographic results were assessed over time, and changes in the DMAA and the relative length of the first metatarsal were assessed by measuring each value preoperatively and at the last follow-up visit. The American Orthopaedic Foot and Ankle Society and visual analog scale scores were significantly improved after surgery. The hallux valgus angle and intermetatarsal angle were stabilized >3 months after surgery. The sesamoid position did not increase significantly beyond the immediate postoperative period. The mean DMAA was corrected from 21.6° (range 15° to 29°) preoperatively to 11.1° (range -2° to 17°) at the last follow-up visit. The mean amount of shortening of the first metatarsal after surgery was 5.5 (range 4 to 7) mm. In conclusion, double metatarsal osteotomy without lateral soft tissue release in adult hallux valgus deformity results in high postoperative recurrence and complication rates.

A comparison of proximal and distal Chevron osteotomy, both with lateral soft-tissue release, for moderate to severe hallux valgus in patients undergoing simultaneous bilateral correction

Moderate to severe hallux valgus is conventionally treated by proximal metatarsal osteotomy. Several recent studies have shown that the indications for distal metatarsal osteotomy with a distal soft-tissue procedure could be extended to include moderate to severe hallux valgus.

The purpose of this prospective randomised controlled trial was to compare the outcome of proximal and distal Chevron osteotomy in patients undergoing simultaneous bilateral correction of moderate to severe hallux valgus.

The original study cohort consisted of 50 female patients (100 feet). Of these, four (8 feet) were excluded for lack of adequate follow-up, leaving 46 female patients (92 feet) in the study. The mean age of the patients was 53.8 years (30.1 to 62.1) and the mean duration of follow-up 40.2 months (24.1 to 80.5). After randomisation, patients underwent a proximal Chevron osteotomy on one foot and a distal Chevron osteotomy on the other.

At follow-up, the American Orthopedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal interphalangeal (MTP-IP) score, patient satisfaction, post-operative complications, hallux valgus angle, first-second intermetatarsal angle, and tibial sesamoid position were similar in each group. Both procedures gave similar good clinical and radiological outcomes.

This study suggests that distal Chevron osteotomy with a distal soft-tissue procedure is as effective and reliable a means of correcting moderate to severe hallux valgus as proximal Chevron osteotomy with a distal soft-tissue procedure.

Cite this article: Bone Joint J 2015;97-B:202–7.

Modified Wilson’s Osteotomy for Hallux Valgus Deformity. A New Approach

We introduce a new set of modifications and present the results from 48 patients (a total of 60 feet operated), who underwent this modified Wilson’s osteotomy for the correction of Hallux Valgus. Patients were of an average age of 52 years old (from 21 to 75 years of age) and were followed up for a mean of 12 months post-operatively. Patient evaluation was made with the symptom scoring system as presented by Kataragliset al., with the final outcome being satisfactory in all of the cases. This set of modifications introduced to the original Wilson’s osteotomy, proved to offer a stable, predictable and satisfactory outcome in all cases and we strongly recommend it.

Chevron versus Mitchell osteotomy in hallux valgus surgery: a comparative study

Good clinical results have been reported for chevron and Mitchell osteotomies in mild hallux valgus (HV). The primary aim of the present study was to compare first metatarsal shortening after chevron and Mitchell osteotomies in HV. The secondary outcome measures were the degree of valgus correction, metatarsalgia, and patient satisfaction. A total of 84 patients were included in the present study and were treated from 2005 to 2007; 42 patients were in each group. The outcome measurements-first metatarsal length, HV angle, 1-2 intermetatarsal angle, satisfaction, and metatarsalgia-were taken preoperatively and at follow-up. The Mitchell osteotomy resulted in a significantly larger decrease in the first metatarsal length. No significant difference in transfer metatarsalgia was found. Approximately 30% of patients were mildly or not satisfied after HV surgery. Mitchell osteotomy leads to a larger decrease in the first metatarsal length. Patients with metatarsalgia performed poorly, and no significant differences in metatarsalgia were found. Preventing postoperative metatarsalgia is important for a successful outcome after HV surgery.

Angular correction and complications of proximal first metatarsal osteotomies for hallux valgus deformity

PURPOSE

Proximal first metatarsal osteotomies are recommended for the surgical treatment of moderate to severe hallux valgus deformity. This study aimed to compare correction of intermetatarsal and hallux valgus angles and complications of proximal crescentic, Ludloff, proximal opening wedge, proximal closing wedge, proximal chevron and other proximal first metatarsal osteotomies.

METHODS

A systematic search for the keywords "(bunion OR hallux) AND (proximal OR crescentic OR basilar OR opening OR closing OR shelf OR Ludloff) AND osteotomy" in the online databases MEDLINE, Embase, CINAHL, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews was performed.

RESULTS

There was a mean correction of hallux valgus angle of 20.1° [confidence interval (CI) 18.7-21.4] and of intermetatarsal angle of 8.1° (CI 7.7-8.9). The overall complication rate reached 18.7 %.

CONCLUSIONS

The results of this study reveal higher corrective power of proximal osteotomies compared to meta-analysis data on diaphyseal osteotomies.

Distal soft tissue procedure in hallux valgus surgery: biomechanical background and technique

The distal soft tissue procedure has evolved into an indispensable additional surgical procedure to increase the corrective effect in hallux valgus surgery. Considering the biomechanical development of hallux valgus deformity, degenerative changes of the soft tissues around the first metatarsophalangeal joint contribute much more to the deformity than changes in the bony structures which can rather be seen as degenerative changes secondary to the deformity. Thus the principles in hallux valgus correction should aim to reverse all pathogenetic steps leading to deformity: release of the contracted lateral soft tissue structures, tightening of the torn-out medial structures and reduction and rebalancing the first metatarsal head onto the sesamoid complex. The scientific discussion over the last decades has clarified the impact of different surgical steps and methods on the efficacy of the lateral release, the risk of creating overcorrection or instability of the joint and the risk of avascular necrosis of the first metatarsal head. According to anatomical and clinical data, a lateral soft tissue release can be combined with a distal metatarsal osteotomy, provided that the osteotomy is performed in a defined safe zone without increasing the risk for avascular necrosis of the first metatarsal head. Transecting the lateral metatarsosesamoid suspensory ligament is the key to a successful lateral release in hallux valgus surgery. Release of the deep transverse metatarsal ligament and the adductor hallucis muscle does not contribute to hallux valgus correction. The lateral short sesamophalangeal ligament and the plantar attachment of the articular capsule should be preserved to avoid possible joint instability. Thus today, the distal soft tissue procedure cannot be seen only as a supplementary surgical procedure in cases where the bony procedure needs additional correction, but rather is an indispensable procedure to restore the physiological situation and function of the first metatarsophalangeal joint.