Treatment of hallux valgus with an increased distal metatarsal articular angle: evaluation of double and triple first ray osteotomies

During a 12-year period in which 878 hallux valgus corrections were performed, 18 patients (21 feet) with symptomatic hallux valgus deformity and an increased distal metatarsal articular angle (DMAA) underwent periarticular osteotomies (double or triple first ray osteotomies). They were studied retrospectively at an average follow-up of 33 months. The surgical technique comprised a closing wedge distal first metatarsal osteotomy combined with either a proximal first metatarsal osteotomy or an opening wedge cuneiform osteotomy (double osteotomy). When a phalangeal osteotomy was added, the procedure was termed a "triple osteotomy." The average age of the patients at the time of surgery was 26 years. At final follow-up, the average hallux valgus correction measured 23 degrees and the average 1-2 intermetatarsal angle correction was 9 degrees. The DMAA averaged 23 degrees preoperatively and was corrected to an average of 9 degrees postoperatively. One patient developed a postoperative hallux varus deformity, and one patient developed a malunion, both of which required a second surgery. A hallux valgus deformity with an increased DMAA can be successfully treated with multiple first ray osteotomies that maintain articular congruity of the first metatarsophalangeal joint.     

Bunion surgery using locking-plate fixation of proximal metatarsal chevron osteotomies

BACKGROUND: Symptomatic large hallux valgus deformities commonly require surgical intervention with a proximal metatarsal osteotomy. A number of fixation methods have been described for proximal chevron osteotomies; one of the most recent is locking plates. METHODS: We retrospectively reviewed the records of 16 consecutive patients (20 feet) with severe bunion deformities who had locking-plate fixation of proximal chevron osteotomies. Clinical evaluation focused on osteotomy healing, transfer lesions, and hardware-related complications. Preoperative and postoperative radiographic evaluation included the hallux valgus angle (HVA), 1-2 intermetatarsal angle (IMA), medial 1-2 intermetatarsal distance (MIMD; the amount of narrowing of the foot), sesamoid position, first metatarsal elevation, and metatarsal length change. A postoperative American Orthopaedic Foot and Ankle Society (AOFAS) score was obtained in all patients. RESULTS: The average radiographic improvements were HVA, 16.0 degrees, IMA, 7.6 degrees, and MIMD, 9.0 mm. Sesamoid position improved in 16 of 20 feet. First metatarsal elevation averaged 0.8 degrees, and the average metatarsal shortening was less than 1 mm. The AOFAS score averaged 94.1 points. Two complications were unrelated to plate fixation. CONCLUSIONS: The locking plate held alignment and position of the first ray after chevron osteotomy without clinical evidence of transfer lesions or hardware-related symptoms. Locking plates may improve stability of the proximal metatarsal after a chevron osteotomy for correction of hallux valgus.     

The oblique proximal phalangeal osteotomy in the correction of hallux valgus

An oblique proximal phalangeal osteotomy is introduced as an alternative to the Akin procedure for the treatment of hallux valgus. It consists of a single oblique osteotomy directed from proximal-dorsal to plantar-distal. A retrospective review of 32 patients who underwent 36 oblique proximal osteotomies is presented. The mean follow-up was 11 months (range, 3 to 21 months). Pre- and postoperative radiographic measurements of the distal articular set angles showed an average correction angle of 12 degrees (range, 7 degrees to 22 degrees; SD = 2.99). Mean range of first metatarsophalangeal joint motion was 82% of the preoperative value when combined with distal metatarsal osteotomy, and 87% of the preoperative value without a distal metatarsal osteotomy. Time to clinical and radiographic healing averaged 5 weeks (range, 4 to 8 weeks). The average amount of phalangeal shortening was 1 mm (range, 0 to 2 mm). There were no delayed or nonunions. Subjective assessment conducted by retrospective review of 19 patients at 6 months postoperatively showed that 17 were completely satisfied (90%), 1 was satisfied (5%), and 1 fairly satisfied (5%). Nineteen would have the surgery again (1 with reservations). Eighteen were very satisfied with appearance and 1 was improved. Fourteen returned to shoe gear at weeks 6 to 8, and 5 returned at weeks 8 to 12. Eighteen were satisfied with pain relief and 1 was improved. The study indicates that the oblique proximal phalangeal osteotomy is an effective, reliable, and technically simple procedure for correction of deformities of the proximal phalanx. The advantages include minimal shortening, ease of adjustability, and a construct conducive to rigid fixation.     

The effect of first ray shortening in the development of metatarsalgia in the second through fourth rays after metatarsal osteotomy

BACKGROUND: The aims of this study were to determine the severity of metatarsalgia of the second through fifth rays after shortening of the first ray for correction of hallux valgus deformity and patient satisfaction of the cosmetic results. METHODS: Two hundred and forty metatarsal osteotomies (Wilson osteotomy as modified by Lindgren and Turan) were evaluated 4.19+/-1.29 years postoperatively. The procedure involved a slightly oblique subcapital osteotomy of the first metatarsal and fixation with one screw. RESULTS: The average decrease in the hallux valgus angle was 26+/-5 degrees, the 1-2 intermetatarsal angle was 8.4+/-4 degrees, and the average shortening of the first metatarsal was 3.8+/-1.8 mm. Positive correlations were found between metatarsalgia of the second through fourth rays and first ray shortening (p<0.001 second ray, p<0.001 third ray, and p<0.001 fourth ray); there was no correlation between the fifth ray and first ray shortening. No correlation was found between a decrease in the hallux valgus angle or 1-2 intermetatarsal angle and metatarsalgia in the second through fifth rays. A positive correlation was detected between postoperative foot alignment and decrease in the hallux valgus (p<0.001) and a negative correlation between postoperative foot alignment and first ray shortening (p<0.01). No correlation was noted between postoperative foot alignment and the 1-2 intermetatarsal angle. CONCLUSION: Excessive shortening of the first metatarsal should be avoided to decrease the occurrence of postoperative transfer metatarsalgia. We found a greater patient satisfaction with foot alignment in patients who had a greater decrease in the hallux valgus angle and less shortening of the first ray.     

Percutaneous distal metatarsal osteotomy for correction of hallux valgus

BACKGROUND: Distal osteotomy of the first metatarsal is indicated for the surgical treatment of mild-to-moderate hallux valgus deformity. The aim of this study was to evaluate the results of a subcapital distal osteotomy of the first metatarsal with use of a percutaneous technique. METHODS: From 1996 to 2001, 118 consecutive percutaneous distal osteotomies of the first metatarsal were performed for the treatment of painful mild-to-moderate hallux valgus in eighty-two patients. The patients were assessed with a clinical and radiographic protocol at a mean of 35.9 months postoperatively. The American Orthopaedic Foot and Ankle Society (AOFAS) hallux-metatarsophalangeal-interphalangeal scale was used for the clinical assessment. RESULTS: The patients were satisfied following 107 (91%) of the 118 procedures. The mean score on the AOFAS scale was 88.2 +/- 12.9 points. The postoperative radiographic assessments showed a significant change (p < 0.05), compared with the preoperative values, in the mean hallux valgus angle, first intermetatarsal angle, distal metatarsal articular angle, and sesamoid position. The valgus deformity recurred after three procedures (2.5%), the first metatarsophalangeal joint was stiff but not painful after eight (6.8%), and a deep infection developed after one (0.8%). The infection resolved with antibiotic therapy. CONCLUSIONS: The percutaneous technique proved to be reliable for the correct execution of a distal linear osteotomy of the first metatarsal for the correction of a painful mild-to-moderate hallux valgus deformity. The clinical results appear to be comparable with those obtainable with traditional open techniques, with the additional advantages of a minimally invasive procedure, a substantially shorter operating time, and a reduced risk of complications related to surgical exposure.     

Clinical results with the Ludloff osteotomy for correction of adult hallux valgus

BACKGROUND: Biomechanically, the Ludloff osteotomy fixed with lag screw compression has been shown to be more rigid than proximal crescentic and other proximal first metatarsal osteotomies for correction of symptomatic hallux valgus with a moderate to severe increase in the first intermetatarsal angle. The Ludloff osteotomy may, therefore, have a lower incidence of dorsal malunion and transfer metatarsalgia than other proximal first metatarsal osteotomies, such as the crescentic or chevron. METHODS: We reviewed the results of 82 consecutive cases of moderate to severe hallux valgus deformities corrected with the Ludloff oblique metaphyseal-diaphyseal osteotomy of the first metatarsal combined with a distal soft-tissue procedure and medial eminence resection. RESULTS: Follow-up was possible in 70 cases (85%) at an average of 30 months (range, 18 to 42 months). Preoperatively, the mean hallux valgus and first intermetatarsal angles were 31 degrees and 16 degrees, respectively. Postoperatively, these values improved to an average of 11 degrees and 7 degrees. In the sagittal plane, the first metatarsal was plantarflexed by an average of 1 mm, and there were no symptomatic transfer lesions of the second metatarsal. The mean AOFAS hindfoot score improved from 54 to 91 points. Complications included prominent hardware requiring removal (5), hallux varus (4), delayed union (3), superficial infection (3), and neuralgia (3). CONCLUSIONS: The use of the Ludloff oblique first metatarsal osteotomy resulted in excellent correction of the first intermetatarsal angle in patients with moderate to severe hallux valgus. With the plane of the osteotomy and rigidity of fixation, immediate ambulation was possible with minimal risk of dorsiflexion malunion of the first metatarsal.     

Basal medial opening wedge first metatarsal osteotomy stabilized with a low profile wedge plate

Twenty patients underwent 25 basal medial opening wedge osteotomies of the first metatarsal stabilized using a low-profile wedge plate in combination with a distal soft tissue release, distal metatarsal osteotomy and Akin osteotomy as required for correction of a hallux valgus deformity. The mean clinical and radiographic follow-up was 12.2 months. Pre- and post operative radiographs available in 15 cases showed that the median hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) were corrected from 45.5 to 13.1, 17.7 to 9.2 and 243 to 10.0 degrees respectively (p < 0.001). Final radiographic assessment for the whole series showed a median final HVA and IMA of 14.1 and 9.1 respectively. Radiographic union was noted in all but one case which was asymptomatic. One wound infection was treated with oral antibiotics, one hallux varus deformity required soft tissue reconstruction and there was one recurrence. The outcome was reported as good or satisfactory by the patients for 20 of 25 feet. Three patients reported stiffness in the first MTP joint, which improved with joint injection and manipulation. Two plates were removed for prominence. The basal medial opening wedge osteotomy stabilized with a low profile wedge plate was an effective addition for correcting a moderate to severe hallux valgus deformity as part of a double or triple first ray osteotomy.     

Short-term Clinical and Radiologic Results of the Scarf Osteotomy: What Factors Contribute to Recurrence?

The present retrospective investigation aimed to determine the factors associated with recurrence of hallux valgus deformity after scarf osteotomy in 50 feet in 43 consecutive patients. We hypothesized that hallux abductovalgus after scarf osteotomy recurs because of the presence of preoperative joint incongruity. The clinical and radiographic findings, including the weightbearing radiographic hallux valgus angle, first intermetatarsal angle, distal metatarsal articular angle, first metatarsophalangeal joint congruence, American Orthopaedic Foot and Ankle Society scores, and pain measured on a visual analog scale, and logistic regression analysis were used to analyze the association of the independent variables with the recurrence of deformity. The mean age of the patients was 47.7 (range 21 to 65) years, and the mean follow-up duration was 26.2 (range 18 to 36) months. The mean American Orthopaedic Foot and Ankle Society scores improved from 50.7 ± 4.9 to 88.7 ± 7.9, and the visual analog scale pain scores improved from 7.5 ± 1.1 to 2.4 ± 1.0 (p < .05). The changes in the radiographic measurements were also statistically significant. Of the 50 feet, 5 (10%) developed recurrent hallux abductovalgus, each of which occurred in feet that had displayed a first metatarsophalangeal joint incongruity on preoperative radiographs. The incongruity was observed to be a statistically significant risk factor for recurrence according to the regression models. From our experience with the patients analyzed in the present report, we believe that first metatarsophalangeal joint congruity should be given particular attention when surgical correction of hallux abductovalgus is undertaken.     

Hallux valgus and first ray mobility. A prospective study

BACKGROUND: There have been few prospective studies that have documented the outcome of surgical treatment of hallux valgus deformities. The purpose of this investigation was to evaluate the effect of operative treatment of hallux valgus with use of a proximal crescentic osteotomy and distal soft-tissue repair on the first metatarsophalangeal joint. METHODS: All adult patients in whom moderate or severe subluxated hallux valgus deformities had been treated with surgical repair between September 1999 and May 2002 were initially enrolled in the study. Those who had a hallux valgus deformity treated with a proximal crescentic osteotomy and distal soft-tissue reconstruction (and optional Akin phalangeal osteotomy) were then invited to return for a follow-up evaluation at a minimum of two years after surgery. Outcomes were assessed by a comparison of preoperative and postoperative pain and American Orthopaedic Foot and Ankle Society scores; objective measurements included ankle range of motion, Harris mat imprints, mobility of the first ray (assessed with use of a validated calibrated device), and radiographic angular measurements. RESULTS: Of the 108 patients (127 feet), five patients (five feet) were unavailable for follow-up, leaving 103 patients (122 feet) with a diagnosis of moderate or severe primary hallux valgus who returned for the final evaluation. The mean duration of follow-up after the surgical repair was twenty-seven months. The mean pain score improved from 6.5 points preoperatively to 1.1 points following surgery. The mean American Orthopaedic Foot and Ankle Society score improved from 57 points preoperatively to 91 points postoperatively. One hundred and fourteen feet (93%) were rated as having good or excellent results following surgery. Twenty-three feet demonstrated increased mobility of the first ray prior to surgery, and only two feet did so following the bunion surgery. The mean hallux valgus angle diminished from 30 degrees preoperatively to 10 degrees postoperatively, and the mean first-second intermetatarsal angle decreased from 14.5 degrees preoperatively to 5.4 degrees postoperatively. Plantar gapping at the first metatarsocuneiform joint was observed in the preoperative weight-bearing lateral radiographs of twenty-eight (23%) of 122 feet, and it had resolved in one-third (nine) of them after hallux valgus correction. Complications included recurrence in six feet. First ray mobility was not associated with plantar gapping. There was a correlation between preoperative mobility of the first ray and the preoperative hallux valgus (r = 0.178) and the first-second intermetatarsal angles (r = 0.181). No correlation was detected between restricted ankle dorsiflexion and the magnitude of the preoperative hallux valgus deformity, the post-operative hallux valgus deformity, or the magnitude of hallux valgus correction. CONCLUSIONS: A proximal crescentic osteotomy of the first metatarsal combined with distal soft-tissue realignment should be considered in the surgical management of moderate and severe subluxated hallux valgus deformities. First ray mobility was routinely reduced to a normal level without the need for an arthrodesis of the metatarsocuneiform joint. Plantar gapping is not a reliable radiographic indication of hypermobility of the first ray in the sagittal plane.     

Outcome after distal metatarsal osteotomy for hallux valgus: a prospective randomized controlled trial of two methods

BACKGROUND: Although surgery is the standard treatment for hallux valgus, there is insufficient evidence from randomized trials to determine which methods of treatment are most appropriate. METHODS: One hundred patients with hallux valgus were randomized to a Lindgren (subcapital, transverse, displacement osteotomy) or a distal chevron osteotomy. Outcome measures, such as the American Orthopaedic Foot and Ankle Society (AOFAS) clinical rating for the hallux, EuroQol (EQ-5D) for health-related quality of life, and visual analogue scales (VAS) for pain were used in addition to radiographic parameters. RESULTS: The AOFAS score and VAS demonstrated significant improvement in both groups (p < 0.001) at 1-year followup. There were no differences in outcome between the two procedures regarding patient satisfaction or health-related quality of life as measured by EuroQol (EQ-5D). Patients with limitations in wearing shoes or who were not satisfied with the cosmetic result had a lower EQ-5D. The hallux valgus angle (HVA) and 1-2 intermetatarsal angles (IMA) improved considerably as a result of both operations. The postoperative improvements in HVA, IMA, and 1-2 intermetatarsal distance (IMD) were greater in the Lindgren group. A remaining postoperative HVA of more than 16 degrees was more common in the chevron group. CONCLUSIONS: Clinical outcomes demonstrated no differences between the procedures, but patients who had a Lindgren osteotomy showed better radiographic correction. Loss of correction was noted in both groups after 3 to 6 years. Neither of the osteotomies is recommended for patients with an HVA of more than 30 degrees or an IMA of more than 15 degrees.     

Multiplanar phalangeal and metatarsal osteotomies for hallux rigidus

Many articles have been published on the various treatments of hallux rigidus/limitus but few, if any, have focused solely on the osteotomies performed in the treatment of this disorder and provided a thorough review of the literature and critique of the procedures. Here, we describe the most commonly used, most widely accepted, and most effective osteotomies in the treatment of hallux limitus/rigidus. Along with this discussion are figures and tables to make the information accessible and user friendly. Among the procedures discussed are Keller arthroplasty, Keller interpositional arthroplasty, Bonney-Kessel, Mayo-Stone, Regnauld, Youngswick, Watermann, Watermann-Green, tricorrectional metatarsal osteotomy, sagittal V, LADO (long-arm decompression osteotomy), Drago, Lambrinudi (plantarflexory closing base wedge osteotomy), sagittal Scarf/sagittal Z, and Weil/Mau/distal oblique osteotomy.     

Distal oblique osteotomy of the first metatarsal for the correction of hallux limitus and rigidus deformity.

The purpose of this study was to evaluate the effectiveness of the distal oblique osteotomy of the first metatarsal (a triplanar shortening decompression osteotomy) to correct stage I and II hallux rigidus. The osteotomy cut is performed from dorsal-distal to plantar-proximal with an angle ranging from 35 degrees to 45 degrees in the sagittal plane. The capital fragment is then displaced plantarly and proximally and fixed with two screws and the metatarsal head is remodeled. From January 1993 through December 1995, a total of 26 patients (21 females and 5 males) underwent 30 distal oblique osteotomies of the first metatarsal (22 unilateral and 4 bilateral). The mean age of the patients was 54 years and the mean follow-up was 21 months. Patient satisfaction and objective clinical and radiographic measurements were evaluated. Patients' satisfaction was measured postoperatively with a modification of the University of Maryland 100-Point Painful Foot Center Scoring System. The results were: 84% good to excellent; 7% fair; and 9% poor. Radiographic measurements included: intermetatarsal angle mean: preop = 12.2 degrees, postop = 8.6 degrees; proximal articular set angle mean: preop = 11.8 degrees; postop = 10.3 degrees. There was no evidence of avascular necrosis in any of the cases. Clinical findings were: dorsiflexion of the first metatarsophalangeal joint: preop = 22 degrees, postop = 45 degrees; plantarflexion of the first metatarsophalangeal joint: preop = 15 degrees, postop = 18 degrees; hallux purchase power: preop = 2.5, postop = 2.3; pain on the second and third metatarsophalangeal joints, associated with excessive pressure on the central metatarsal heads: preop--present in 10 patients, postop--present in 12 patients; forefoot supination angle: preop = 13 degrees, postop = 7 degrees.     

Correction of moderate to severe hallux valgus deformity by a modified chevron shaft osteotomy

BACKGROUND: Hallux valgus is one of the most common foot deformities in women. Despite the large number of techniques described for hallux valgus correction, there has been much controversy regarding the best procedure to use, especially for severe deformities. Proximal osteotomies have long been done for severe deformities; however, diaphyseal osteotomies have gained popularity because of the greater degree of correction and stability obtained. METHODS: This study retrospectively assessed the radiographic and clinical outcomes in 50 feet (34 patients) that had a modified chevron shaft osteotomy for moderate to severe hallux valgus. Additionally, an Akin medial closing wedge osteotomy of the proximal phalanx was done in most patients. Mean followup was 30 months (minimum 13 months). All patients in the study had either moderate or severe deformities. Patients with mild deformities had correction by other techniques. RESULTS: There was a mean AOFAS score improvement of 39.6 (44.5 to 84.1) points. The hallux valgus angle and intermetatarsal angle improved a mean of 22.7 degrees and 10.4 degrees, respectively. Hallux valgus persisted in one foot; however, the patient was not dissatisfied. Two feet developed hallux varus. Revision was necessary in two patients; one needed revision because of loss of fixation and the other because of symptomatic hallux varus. CONCLUSION: Based on radiographic correction and clinical outcomes, this procedure is indicated for the treatment of moderate to severe hallux valgus deformities.     

Surgical treatment of severe hallux valgus: the state of practice among academic foot and ankle surgeons

BACKGROUND: The purpose of this study was to evaluate the operative procedures used for treatment of severe hallux valgus by academic foot and ankle surgeons practicing in the United States. METHODS: A patient with severe hallux valgus deformity was developed as a hypothetical case: a 50-year-old woman with a severe deformity (intermetatarsal angle = 20 degrees; hallux valgus angle = 42 degrees). The patient was symptomatic with pain, did not improve with conservative measures, and wanted the deformity corrected. This case was sent to academic foot and ankle surgeons in a survey to determine their preferred operative treatment for this case. The overall response rate was 84% (128 of 153). To be included in the study group each surgeon had to have 1) foot and ankle patients comprising 50% or more of his clinical practice and 2) direct responsibility for teaching orthopaedic residents. One hundred and five respondents met the inclusion criteria and formed the study group; however, three surveys with invalid responses were deleted. RESULTS: Fifty-two percent (54 of 102) of the respondents chose a metatarsal osteotomy, 26% (26 of 102) a first metatarsophalangeal (MTP) joint arthrodesis, and 24% (24 of 102) a Lapidus procedure. Two respondents chose both an arthrodesis and a metatarsal osteotomy. Among the 54 respondents who chose metatarsal osteotomies, 24 used a Ludloff, 16 a proximal crescentic, eight a proximal chevron, two a scarf, two a distal chevron, and two other. In addition, secondary procedures to enhance the correction included a Weil osteotomy in 46% (47 of 102) and an Akin osteotomy in 30% (31 of 102). CONCLUSIONS: There was a wide variation in the type of procedure used to correct this severe hallux valgus deformity; approximately 50% of the respondents chose a metatarsal osteotomy, 25% chose a first MTP joint arthrodesis, and 25% a Lapidus procedure.     

Scarf osteotomy for hallux valgus deformity: an intermediate followup of clinical and radiographic outcomes

BACKGROUND: The scarf osteotomy is a versatile and reproducible procedure for the correction of moderate to severe hallux valgus deformity (intermetatarsal angle 12 to 20 degrees hallux valgus angle 20 to 46 degrees). METHODS: We evaluated the results of 27 consecutive scarf osteotomies at an average followup of 16.1 months. Radiographic parameters, foot pressure analysis, and AOFAS scores were analyzed before and after surgery. RESULTS: Hallux valgus angles improved from 34.5 to 16.9 degrees, intermetatarsal angles improved from 15.4 to 10.1 degrees, AOFAS scores improved from 54.5 to 86.5. There was no change between the preoperative and postoperative relative lengths of the first and second metatarsals, defined as the difference between the first and second metatarsal lengths. The measurement was based on the anteroposterior standing radiographs and measured by a line intersecting the midway point at the diaphyseal-metaphyseal junction of the metatarsal and extending from the most proximal to distal aspects of the bone. The angle of Meary (talo-first metatarsal angle) did not change, except in one patient. Foot pressure analysis showed no evidence of transfer metatarsal lesions. The complication rate was 1.1% including superficial infection and recurrence. CONCLUSIONS: The scarf osteotomy provides a predictable and effective correction of moderate to severe hallux valgus deformities.     

Surgical treatment of mild hallux valgus deformity: the state of practice among academic foot and ankle surgeons

BACKGROUND: The purpose of this study was to determine the operative procedure of choice among academic foot and ankle surgeons practicing in the United States for treatment of mild hallux valgus deformity. METHODS: A hypothetical patient was created: a 60-year-old woman with a mild hallux valgus deformity (first intermetatarsal angle of 11 degrees and hallux valgus angle of 22 degrees). The patient complained of pain around the bunion, nonoperative treatment had failed, and she desired operative correction. The case was sent to academic foot and ankle surgeons to identify their operative treatment of choice. The overall response rate was 83.7% (128 of 153). To be included in the study group each surgeon had 1) foot and ankle patients comprising 50% or more of their clinical practice and 2) direct responsibility for teaching orthopaedic surgery residents. One hundred and three respondents met the inclusion criteria and formed the study group. RESULTS: Eighty-seven percent (90 of 103) reported that they would use a distal chevron osteotomy as their primary procedure to correct the mild hallux valgus. Ten percent (10 of 103) reported that they would also add an Akin osteotomy of the proximal phalanx to enhance correction. CONCLUSIONS: Most respondents chose a distal chevron osteotomy as their primary procedure to correct the mild hallux valgus deformity.     

Large displacement distal chevron osteotomy for the correction of hallux valgus deformity.

In order to assess outcomes and complications, a retrospective study of 38 bunionectomy cases with large displacement distal chevron osteotomy (greater than or equal to 40% lateral translation) for hallux valgus was performed. Follow-up ranged from 12 to 130 months (average, 31 months). Subjective analysis consisting of the American Orthopedic Foot and Ankle Society (AOFAS) hallux metatarsophalangeal-interphalangeal scale was performed. Preoperative and postoperative radiographic intermetatarsal (IM) angles and hallux abductus angles were measured and compared. The average postoperative AOFAS score was 93.5. The average preoperative IM angle was 15.03 degrees (range 8 degrees-24 degrees) and the average postoperative IM angle was 4.84 degrees (range, -1 degree-11 degrees). The average preoperative hallux abductus angle was 29.39 degrees (range, 16 degrees-53 degrees) compared to the average postoperative hallux abductus angle of 11.39 degrees (range, 2 degrees-28 degrees). It was found that an average lateral translation of 9.8 mm was able to achieve a relative change of the IM angle of 10 degrees. Evidence is presented that supports the fact that large displacement distal chevron osteotomies can be safely performed for the correction of metatarsus primus varus greater than 15 degrees associated with hallux valgus.     

Scarf versus chevron osteotomy in hallux valgus: a randomized controlled trial in 96 patients

BACKGROUND: The degree of correction of hallux valgus deformity using a distal chevron osteotomy is reported as limited. The scarf osteotomy is reported to correct large intermetatarsal angles (IMA). The purpose of this study was to evaluate if one technique gave greater correction of the IMA and hallux valgus angle (HVA) than the other. METHODS: After informed consent, 96 feet in 83 patients were randomized into two treatment groups (49 scarf and 47 chevron osteotomies). The results were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Valgus Scale and radiographic HVA and IMA measurements. RESULTS: At 27 (range 23-31) months followup both groups improved. The AOFAS score in the chevron group improved from 48 to 89 points and in the scarf group from 47 to 91 points. In the chevron group the HVA corrected from 30 to 17 degrees, and in the scarf group the HVA corrected from 29 to 18 degrees. In both groups, the IMA was corrected from 13 to 10 degrees. The differences were not statistically significant. Three patients in the chevron group developed a partial metatarsal head necrosis. In the scarf group, four patients developed grade 1 complex regional pain syndrome compared to one patient in the chevron group. CONCLUSIONS: No differences of statistical significance could be measured between the two groups with respect to the AOFAS score, HVA, and IMA. Although both groups showed good to excellent results, we favor the chevron osteotomy because the procedure is technically less demanding.     

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.     

Maintenance of Correction of First Metatarsal Closing Base Wedge Osteotomies Versus Modified Lapidus Arthrodesis for Moderate to Severe Hallux Valgus Deformity

A retrospective radiographic review of 57 feet was conducted to compare maintenance of correction of the modified Lapidus arthrodesis with the first metatarsal closing base wedge osteotomy for moderate to severe hallux valgus deformity. Radiographic parameters were measured on the preoperative, early postoperative, and greater than 11-month postoperative weightbearing radiographs. These measurements included the intermetatarsal angle, the hallux abductus angle, and the tibial sesamoid position. The patients who underwent the closing base wedge osteotomy had an average initial intermetatarsal correction of 10.4 degrees; for the modified Lapidus arthrodesis, it was 7.6 degrees. The patients who underwent the closing base wedge osteotomy had an average loss of intermetatarsal correction of 2.55 degrees from early to late postoperative radiographs; for the modified Lapidus arthrodesis, it was 1.08 degrees. Our results demonstrated that the modified Lapidus arthrodesis maintains correction to a greater degree than the first metatarsal closing base wedge osteotomy with statistical significance (P = .0039). Both the modified Lapidus arthrodesis and the first metatarsal closing base wedge osteotomy are effective procedures with respect to degree of radiographic correction for moderate to severe hallux valgus deformities.