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Distal Chevron Osteotomy Increases Anatomic Intermetatarsal Angle in Hallux Valgus.

ABSTRACT:

Background

Distal chevron metatarsal osteotomy (DCO) is a common technique to address hallux valgus (HV), which involves coronal translation of the capital fragment resulting in a nonanatomic first metatarsal. The purpose of this study was to evaluate the radiographic effect of the DCO on the anatomic vs the mechanical axis of the first metatarsal. Our hypothesis was that patients undergoing DCO would have improvement in the mechanical metatarsal axis but worsening of the anatomic axis.

Methods

This was a retrospective case series of consecutive patients who underwent DCO for HV. The primary outcomes were the change in anatomic first-second intermetatarsal angle (a1-2IMA) vs mechanical first-second intermetatarsal angle (m1-2IMA). Secondary outcomes included the change in hallux valgus angle (HVA) and medial sesamoid position.

Results

40 feet were analyzed with a mean follow-up of 21.2 weeks. The a1-2IMA increased significantly (mean, 4.1 degrees) whereas the m1-2IMA decreased significantly (mean, 4.6 degrees) following DCO. There was a significant improvement in HVA (mean, 12.5 degrees). Medial sesamoid position was improved in 21 feet (52.5%). Patients with no improvement in sesamoid position were found to have a larger increase in a1-2IMA (mean, 4.7 vs 3.5 degrees, P = .03) and less improvement in m1-2IMA (mean, 3.8 vs 5.2 degrees, P = .02) compared to patients with improvement in sesamoid position.

Conclusion

Distal chevron osteotomy for HV was associated with worsening of the anatomic axis of the first metatarsal despite improvements in the mechanical metatarsal axis, HVA, and medial sesamoid position. Greater worsening of the anatomic axis was associated with less improvement of sesamoid position. Our findings may suggest the presence of intermetatarsal instability, which could limit the power of DCO in HV correction for more severe deformities and provide a mechanism for HV recurrence.

Level of evidence

Level IV, retrospective case series.

SUBMITTER: Chan JY

PROVIDER: S-EPMC8702972 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundWhile proximal first metatarsal osteotomy combined with distal soft tissue realignment is accepted as standard treatment of moderate to severe hallux valgus with metatarsus primus varus, none of the described proximal metatarsal osteotomies address the hyper-obliquity of the first metatarsocuneiform joint. An opening-wedge osteotomy of the medial cuneiform can potentially correct the 1-2 intermetatarsal angle (IMA) in addition to normalizing the hyper-obliquity of the first tarsometatarsal (TMT) joint. The purpose of this study was to retrospectively review the early radiographic and clinical results of the use of a medial cuneiform opening-wedge osteotomy fixed with a low-profile wedge plate combined with distal soft tissue realignment for the treatment of hallux valgus.MethodsFourteen feet (13 patients; 2 male and 11 female, average age 56 years, range 22-75) with hallux valgus underwent an opening-wedge osteotomy of the medial cuneiform fixed with a low-profile nonlocking wedge plate combined with distal soft tissue realignment. The mean preoperative hallux valgus angle (HVA) was 32 degrees and the IMA was 16 degrees. HVA, 1-2 IMA, proximal first metatarsal inclination (PFMI), and presence of osteoarthritis of the first TMT joint were assessed on preoperative and final postoperative radiographs. Final postoperative radiographs were also evaluated for radiographic union and hardware failure at an average of 7 months (range, 3-19 months) postoperatively.ResultsA mean intraoperative correction of 19 degrees and 7 degrees was achieved for the HVA and IMA, respectively. The mean HVA was 22 degrees and the mean IMA was 11 degrees at the time of final follow-up. At final follow-up, a recurrence of the deformity was observed in 12/14 feet. There were 2 nonunions-one plate failure and one screw failure. No first TMT joint instability or arthritis was observed. All patients were ambulatory without assistive device in either fashionable or comfortable shoe wear.ConclusionMedial cuneiform opening-wedge osteotomy resulted in unreliable correction of HVA and IMA at short-term follow-up with a high rate of early recurrence of hallux valgus deformity and a complication rate similar to that of the Lapidus procedure. This procedure cannot be recommended for addressing hallux valgus in the setting of increased obliquity of the first TMT joint.Level of evidenceLevel IV, case series.

Project description:BackgroundAlthough the etiology of hallux valgus is contested, in some patients it may be failure of the stabilizing soft tissue structures around the first ray of the foot. Because there is lack of effective soft tissue techniques, osteotomies have become the mainstream surgical approach to compensate for the underlying soft tissue deficiency; osteodesis, a soft tissue nonosteotomy technique, may be a third alternative, but its efficacy is unknown.Questions/purposesWe asked: (1) Can an osteodesis, a distal soft tissue technique, correct hallux valgus satisfactorily in terms of deformity correction and improvement in American Orthopaedic Foot and Ankle Society (AOFAS) score? (2) Is the effectiveness of an osteodesis affected by the patient's age or deformity severity? (3) What complications are associated with this procedure?MethodsBetween February and October 2010, we performed 126 operations to correct hallux valgus, of which 126 (100%) were osteodeses. Sixty-one patients (110 procedures) (87% of the total number of hallux valgus procedures) were available for followup at a minimum of 12 months (mean, 23 months; range, 12-38 months). This group formed our study cohort. During the study period, the general indications for this approach included failed conservative measures for pain relief and metatarsophalangeal angle greater than 20° or intermetatarsal angle greater than 9°. Intermetatarsal cerclage sutures were used to realign the first metatarsal and postoperative fibrosis was induced surgically between the first and second metatarsals to maintain its alignment. The radiologic first intermetatarsal angle, metatarsophalangeal angle, and medial sesamoid position were measured by Hardy and Clapham's methods for deformity and correction evaluation. Clinical results were assessed by the AOFAS score.ResultsThe intermetatarsal angle was improved from a preoperative mean of 14° to 7° (p<0.001; Cohen's d=1.8) at followup, the metatarsophalangeal angle from 31° to 18° (p<0.001; Cohen's d=3.1), the medial sesamoid position from position 6 to 3 (p<0.001; Cohen's d=2.4), and AOFAS hallux score from 68 to 96 points (p<0.001). Neither patient age nor deformity severity affected the effectiveness of the osteodesis in correcting all three radiologic parameters; however, the deformities treated in this series generally were mild to moderate (mean intermetatarsal angle, 14°; range, 9°-22°). There were six stress fractures of the second metatarsal (5%), five temporary metatarsophalangeal joint medial subluxations all resolved in one month by the taping-reduction method without surgery, and six metatarsophalangeal joints with reduced dorsiflexion less than 60°.ConclusionsThe osteodesis is a soft tissue nonosteotomy technique, and provided adequate deformity correction and improvement in AOFAS scores for patients with mild to moderate hallux valgus deformities, although a small number of the patients had postoperative stress fractures of the second ray develop. Future prospective studies should compare this technique with osteotomy techniques in terms of effectiveness of the correction, restoration of hallux function, complications, and long-term recurrence.Level of evidenceLevel IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.