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Oct 29, 1992 - procedure which. J. K. Klosok, FRCS, Consultant. Orthopaedic. Surgeon. Newham. General. Hospital,. Glen. Road, Plaistow,. London. El3 8SL,.

CHEVRON

FOR

OR

HALLUX

K.

From

RANDOMISED

KLOSOK,

the Royal

METATARSAL

DAVID

J. PRING,

Postgraduate

Medical

TRIAL

JULIAN School,

H.

JESSOP,

Hammersmith

and 38 months after operation. The patients in the chevron

group returned to work and mobilised faster, but, at the later review, those in the Wilson group had better functional results and were more satisfied with the appearance of the foot. Correction ofthe hallux valgus angle was better maintained in patients in the Wilson group and they had a better range of motion at the metatarsophalangeal joint; fewer complained of metatarsalgia.

earlier

Joint

Received

Surg

[Br]

29 October

1993 ; 75-B 1992;

:825-9.

Acceptedafter

revisions

25 March

1993

More than 130 operations have been described for hallux valgus (Kelikian 1965). The ‘chevron osteotomy’ uses a horizontal ‘V’ division of the fIrst metatarsal head to correct the deformity (Johnson, Cofield and Morrey 1979 ; Austin and Leventen 1981 ; Lewis and Feffer 1981), and has been reported to give good results with few complications (1982) has cations

(Home, Tanzer warned, however,

include

metatarsal and

avascular

head,

malalignment

shortening

England

causeslittle soft-tissue damage(Helal 1974, 1981). Double obliquity of the cut, in both longitudinal and coronal planes, improves the bony stability and reduces the need for internal fixation (Helal, Gupta and Gojaseni 1974; Helal 1981). We report a prospective randomised trial of the chevron and Wilson osteotomies for the correction of hallux valgus.

PATIENTS Fifty-one

AND

METHODS

consecutive

patients

(44

women

and

7 men)

with unilateral or bilateral hallux valgus gave their informed consent before entering the trial. The type of osteotomy for each patient was randomised by the use of a computer-generated list. In bilateral cases, both feet had the same selected operation during the same operating session. The Wilson group included 42 feet in 26 patients

(3 with

rheumatoid

arthritis)

with

an average

angle

(x,

of the

of the metatarsal,

Wilson

osteotomy

is a simple

procedure

J. K. Klosok, FRCS, Consultant Orthopaedic Surgeon Newham General Hospital, Glen Road, Plaistow, London UK. D. J. Pring, Guernsey

FRCS, Hospital

Consultant Group,

Orthopaedic Guernsey,

MD,

Department

of Orthopaedic

Polwarth

Correspondence ©l993 British 0301-620X/93/5637

75-B,

PhD, Surgery

MIBiol,

N. Maffulli, in Orthopaedic

Surgery,

Building,

should

Senior

Foresterhill,

No. 5, SEPTEMBER

ofBone

El3

8SL,

Islands.

Hertfordshire

Registrar

and Clinical

University

of Aberdeen

Aberdeen

AB9

be sent to Dr N. Maffulli.

Editorial Society $2.00

which

Surgeon

Channel

J. H. Jessop, FRCS, Consultant Orthopaedic Surgeon Watford General Hospital, Vicarage Road, Watford, WD1 8HB, UK.

VOL.

London,

overcorrection.

The

School,

MAFFULLI

and Ford 1984). Mann that the potential compli-

necrosis,

excessive

NICOLA Hospital,

We compared the chevron and the Wilson metatarsal osteotomy for hallux valgus in a prospective randomised trial on 87 feet in 51 patients, reviewed at averages of 5.5

J Bone

OSTEOTOMY

VALGUS

A PROSPECTIVE

JAN

WILSON

and

Joint

Surgery

2ZD,

Lecturer Fig.

Medical UK.

Methods used intermetatarsal from standard

centage operation,

1993

to

measure

the

1

hallux

valgus

left),

the

angle (x, riht), and shortening of the fIrst metatarsal weight-beanng anteroposterior radiographs. The pershortening of the first metatarsal is expressed as a/b before divided by a’/b’ at review, x 100.

825

J. K. KLOSOK,

826

age of 45 years comprised arthritis)

± 11.4 SD

to 77). The

(20

D. J. PRING,

chevron

group

45 feet in 25 patients (4 with rheumatoid with an average age of 45 years ± 8.6 SD (23

to

72).

Preoperative assessments included the site of pain, the degree of discomfort from the exostosis, and the presence ofp!antar callosities and metatarsalgia. We also recorded the major indications for surgery according to the patients ; better appearance was a major concern of five

patients,

easier,

37 wanted

better

relief

of pain,

and

31 wanted

shoe-fitting.

J. H. JESSOP,

N. MAFFULLI

position. tolerated. surgeon

After 48 hours, weight-bearing Dressings were changed after two weeks and discarded

Review. months

Patients and again

later

review,

were reviewed at 38 months

50 patients

not been involved patient, a 20-year-old

were

in

was allowed by the operating at four weeks.

at an average after operation. assessed

of 5.5 At the

by JKK,

the initial treatment. woman, refused to be

as

who

had

Only one reviewed.

She had had bilateral chevron osteotomies and a poor result at the early review. Because some patients were not willing to attend

Radiography. Radiographs were taken preoperatively, at 6, 12 and 24 months and at final review. Standard weightbearing anteroposterior views were studied to measure the hallux valgus angle, the intermetatarsal angle and the shortening of the first metatarsal (Fig. 1). A 60#{176} internal oblique view, giving true laterals of the first metatarsals,

hospital, they were examined at home, and radiographs were not taken. Of the 42 feet in the Wilson group, 31 radiographs of 23 patients were available. Of the 45 feet

was

(Leland 1988). When a patient had bilateral hallux valgus, we used the average of the hal!ux valgus angle, the metatarsal shortening value and range of motion on

used

distal

to

assess

postoperative

displacement

of

the

fragment.

Harris

Footprints. changes

in the

and

Beath

distribution

mats

were

of weight

used

(Harris

to record and

Beath

in the chevron

group,

the

analysis.

two

sides.

(ANOVA)

Operative techniques. All the operations were performed with a thigh tourniquet, through a 5 to 8 cm dorsomedial

the two groups.

centred

(MTPJ).

over

Wilson

exposed.

A double

using an displaced

oscillating laterally.

‘roof’

over

osteotomy After below-knee

oblique

and

to reduce

necessary,

the

in its corrected 48 hours and

used

capsule and the

to mark

of the exostosis

the

the lateral

One-

was then

or

analysed

two-way

analysis

used to evaluate

ANOVA

using

of

differences

for repeated

measures

Systat

variance

between was

used

Ethilon. was not performed was then provided a

spike

of

the

Anteroposterior

A walking heel was discharged

The based

plaster

Fig.

2a

was

‘V’-shaped

MTPJ was raised, the excised with a saw. A

centre

of the

cortex

to facilitate

metatarsal

head

completion

osteotomy.

Soft-tissue stripping was minimised, being preserved to protect the blood supply of the metatarsal head. An oscillating saw was used to cut a horizontal ‘V’-shaped osteotomy in the metatarsal head, taking great care not to split it. The

the lateral

head

were

was not routine. of dressings, a an extension to

position. the patient

the following day. later. (Fig. 2b). A distally

osteotomy

The data

the risk of dorsal

bony

was trimmed, but exostectomy skin closure and application plaster was applied, with

to penetrate

of the

was

fragment

of the medial was opened was

45#{176} osteotomy

were

joint

interrupted first MTPJ

saw. The distal fragment The obliquity of the cut

from hospital on removed six weeks Chevron

metatarsophalangeal

with The

Where

hold the hallux was added after

drill

first

the distal

angulation.

flap joint

the

The skin was closed osteotomy (Fig. 2a).

in 22 patients

available.

Statistical

1947).

incision

36 radiographs

was

capsule

then

displaced

laterally,

rotated

to the

required

position, and impacted on to the metatarsal shaft. The prominent media! shaft was excised flush with the metatarsal head, and the medial capsular flap was sutured to the periosteum of the metatarsal shaft only along its superior margin in order not to limit MTPJ extension.

After

soft-tissue

crepe

bandage

closure, was

used

a carefully to hold

the

applied toe

wool

in its corrected

and

Fig. Diagrams chevron

showing osteotomy

(a) the double (right foot).

2b

oblique

Wilson

osteotomy

and

(b) the

for overall differences between preoperative, early and late postoperative findings. A post hoc Student’s t-test for paired

For

measures

patients

was

with THE

used

bilateral JOURNAL

to assess

hallux OF BONE

differences.

valgus, AND

JOINT

the

pres-

SURGERY

CHEVRON

ence

of

when

callosities

at least

test

was

used

the 0.05

level.

one

OR

and

of

foot

was

affected,

the

data.

to analyse

WILSON

metatarsalgia

METATARSAL

was and

OSTEOTOMY

recorded

(five

a chi-squared

Significance

was

Postoperative

follow-up.

Twenty-six patients

(43

examined

Thirty-seven

Wilson

feet)

was

(42 feet) in the in the chevron

respectively

Wilson group

at an average

827

osteotomy

statistically

increased

central

a chevron

osteotomy

ray

group.

None

of these

significant.

loading

compared

(16%)

(Fig.

with

seven

after

3).

osteotomies

4.

group and 24 were also re-

of 37 months

45) and 38 months (9 to 45) postoperatively. Radiography. The average preoperative

VALGUS

Footprints. Using the Harris and Beath footprint method, 12 feet of the Wilson group (29%) showed evidence of

set at

41 chevron osteotomies in 23 patients at an average of 22 weeks (1 1 to 40).

patients feet)

HALLUX

in the chevron

differences

RESULTS

in 23 patients and were re-examined,

FOR

,*

(10 to

hallux

valgus

angle was 29#{176} ± 7.9#{176} SD (26 to 41) in the Wilson group and 30#{176} ± 8.8#{176} (27 to 40) in the chevron group. At early review,

the

corrected ±

hallux

angle

in the

Wilson

group

to 26) in the chevron group. the Wilson group had maintained an average of 13.3#{176} ± 8. 1#{176} (9 to 22)

with chevron to 27).

group the angle The difference

statistically review

significant

at both

At

the later correction while in the

to 25.7#{176} ± 10#{176} (20 two groups was

(p = 0.004)

early

2 1.2#{176}

and

late

(p = 0.0005). The Wilson of 10 mm

ening

had increased between the

been

with

8.3#{176}(1 5

review,

had

to 14.5#{176} ± 6.9#{176} (9 to 21) compared

6 mm

osteotomy produced (6 to 20) compared

(0 to 1 1) after

the

chevron

an average shortwith an average of procedure

(p = 0.02).

No patient complained ofhaving a short hallux. Elevation of the metatarsal head was only appreciable on the early review radiographs, and was seen in six feet (14% of those in the Wilson group). By the later review, remodelling had obscured the original position of the distal fragment. Depression of the metatarsal head was

Preoperative

(a) and 35-month

seen

in a patient

who

in five patients

after

Wilson

after

osteotomy

and

assessment.

of motion

of the first

±

6#{176} SD

(51 to 72) and

to

62).

At

evidence

Before MTPJ

operation in the

in the chevron review, the mean

early different,

the passive

Wilson

group

patient

to 42) after the after a unilateral

range of less than chevron procedure. weight-bearing Metatarsalgia ening, only

chevron Wilson

30#{176} compared with In both groups

in 86% five

patients

Only one had a final

11 (17 feet) in the the great toe was

of feet.

and callosities. in the

Despite Wilson

ten in the chevron group complained salgia. New central callosities had

the greater group of central developed

short-

as against metatarin seven

patients (nine feet) in the Wilson group and in five feet (three patients) in the chevron group. One foot in a patient with bilateral hallux valgus lost central callosities after a Wilson osteotomy compared with four patients VOL.

75-B, No. 5, SEPTEMBER

1993

had

of increased

review

a double

central

(b) Harris

oblique

3b

and Beath

Wilson

footprints

osteotomy.

There

is

ray loading.

63#{176}

had regained with 36#{176} ±

procedure. osteotomy

Fig.

Functional chevron

results. osteotomy

Rehabilitation because

of

was more the absence

rapid after of plaster

3 1 #{176} ± 9#{176}immobilisation. These patients returned to work at 7 ± 1 .2 weeks SD (5 to 9) after surgery, compared with 10 ±

at 29#{176} ± 7#{176} (2 1 to 45) and

45). At later review, the Wilson group an average of42#{176}± 1 1#{176} (3! to 55) compared

3a

arc

was

group 57#{176} ± 9#{176} (50 ranges were not

(25 to

8#{176} (26

in three

osteotomy.

Functional

significantly

chevron

Fig.

3

weeks At

to 14) for the Wilson early review, 22 of

(7

unlimited Wilson

walking group had

Wilson

group

limited chevron

walking group.

had

distances no limitation. improved

groups

one

Thirty-one patients of the indications

patients Of

were

chevron

: only

four

procedure

had the the

complained

of

with five of of the patients

the in

able to run. gave improved shoe-fitting for surgery. Preoperatively,

in the Wilson group had needed three still needed them

shoes ; only the 1 5 patients

group

while only seven of By the later review,

distance compared About three-quarters

both

fitting

group. the chevron

requiring eight

broad

still required

special broadat late review.

shoes them

as 12

before

the

at late review.

828

J. K. KLOSOK,

Complications. patient

Table

had

I gives

radiological

or

total avascular necrosis Wilson osteotomy failed dures

in eight

five

Wilson

patients

were

probably

signs

failures,

in three

Two ofthe

were

complications.

clinical

of

after chevron to unite. Nine

osteotomies

Chevronprocedure.

group

the

due

D. J. PRING,

J. H. JESSOP,

No partial

or

osteotomy. No chevron proce-

as compared

with

patients.

nine failures

to poor

selection.

good correction, The second was

had

minimal

hallux

metatarsal. The MTPJ

the also

drifted

One

back

in a 34-year-old

valgus

Surgery became

hallux

with

shortened stiff with

woman

a relatively

the only

short

procedure.

group

(in

year-old

One

patients)

3

woman

hallux

valgus

with

bilateral

bilateral

to poor arthritis

subluxed

minor

MTPJ

failure

bilateral

toes and painful

the

in this

group

failure stiffness

after

an

the by

hallux

was

early

second Helal

metatarsal hallux led

shortening to secondary

metatarsal

head.

with loss of plantar flexion metatarsalgia under the

2

0

1

2

0

1

3

0

1

1

0

1

4

4

varus healing

fracture

frequent

after

angle

greater

than

by Cetti

and

Christensen

20#{176} in a series

of 34 osteotomies.

the Wilson

Stiffness

et a! (1979)

of 18#{176} at ten

of the first MTPJ

of a poor result in our series. bearing on the hallux and led

found

that

MTPJ. joint

26 had

lateral metatarsal heads Hughes and Klenerman

less

It is clear causes

stiffness

a! 1974). Shortening our average

than

that

and

is inevitable

incidence osteotomy. years, and

30#{176} of motion

soft-tissue

at

dissection

in proportion

of 10 mm

a high

for the chevron 76 feet for three

the

first

around

the

to its extent

with

is similar

the

to that

(Helal

et

Wilson

osteotomy;

reported

previously

related

caused

that

metatarsalgia

depression

prolong

was

of the

toe-contact

of the second

helps to maintain support Mitchell’s compensate modification,

(1983).

only one a valgus The

cause

This prevented weightto transfer of load to the

(Henry and Waugh 1975 ; Grace, 1988). Such stiffness was less

less with

first

directly

metatarsal

head

obliquity

radiographically

have

caused

chevron

to

this,

more

stiffness.

joint

has

demanding

stability,

and

than no need

osteotomy

and our results also helps to Despite metatarsal

in 20% ofthe

prevented

osteotomy

technically

tended

in the Wilson

plantar displacement concept that this

have

The

to

of the first metatarsal et a! (1988) have shown

for metatarsal shortening. however, elevation of the

may

more

more

time.

Our use of double

First

months.

was the commonest

osteotomy,

insufficient plantar displacement head (Mitchell et a! 1958). Grace

smaller correction achieved by the chevron method has been reported by Lewis and Feffer (1981) and Grill et al (1986) with average corrections of 19#{176} at three years and by Johnson

or hypoaesthesia

has previously been reported Horne et a! (1984) followed

may

Wilson (1963) reported and two patients with

metatarsal

operative

Few comparative or prospective studies have been reported for the many surgical techniques used for this common condition. Our average correction of ha!lux valgus angle is reported

of third

valgus

DISCUSSION

to that

osteotomy

Dysaesthesia

fixation

In his original paper, complete recurrence,

of bunion

spike

was apparent

similar

of wound

with the that post-

metatarsal osteotomies.

case.

8

(Dooley 1968). It did not correlate, however, development of metatarsa!gia. We found

low-grade

was on one side in a bilateral

7

swelling

Stress

A 50-

had

stiff and recurred.

infection. Metatarsalgia under heads was treated satisfactorily

The third

selection.

Early

who

Hela! metatarsal osteotomies of the combined with Wilson osteotomies. slow to heal and there was forefoot

All MTPJs became and metatarsalgia

Another by

due

rheumatoid

of 50#{176} with

plantar callosities. central rays were The wounds were oedema. deformity

was

Chevron (a =45)

Comminuted

in the Wilson

for hallux

Wilson (n=42)

Dorsal

first

of 87 osteotomies

Complication

Recurrence

metatarsal further. 20#{176} movement, the

of the five failures

in 51 patients

into

hallux no longer bore weight, and painful central callosities developed. The other seven failures were multifactorial, due to five stiff MTPJs in four patients, metatarsalgia in four and recurrence of deformity in six. Wilson

I. Complications

valgus

Slow

was a 34-year-old woman with rheumatoid arthritis and valgus deviation of the lesser toes, in addition to hallux valgus. The other toes were not corrected, and after an initially valgus.

Table

Hallux

in the chevron

clinical

N. MAFFULLI

feet.

but increased

been

our head Internal

dissection

considered

a Mitchell for cast

to be

osteotomy,

immobilisation

(Austin and Leventen 1981). Other authors consider that it is less stable, and requires additional fixation by a bone peg (Johnson

et a! 1979),

or by a modification

of its shape

(Lewis and Feffer 1981). In our series, the main cause of poor correction was probably stretching of the medial capsuloplasty. Use of a cast mould reduces loss of correction, but may well have increased stiffness. Excessive capsular dissection may lead to avascular necrosis of part or all ofthe metatarsal head (Mann 1982;

Horne

et

remaining

a!

1984)

blood

since,

supply

after is from

1973). We took care to preserve saw no signs of avascular necrosis.

Both

procedures THE

showed JOURNAL

osteotomy, the the

lateral

a significant OF BONE

the

capsule

AND

only

(Jaworek capsule

and

incidence JOINT

SURGERY

of

CHEVRON

complications. patients relief,

Most

were

valgus

trivial,

dissatisfied

shoe-fitting,

impression operation,

were

with

Patients

before operation, for the correction

METATARSAL

about

result

or appearance.

is normal.

WILSON

but

the

that the hallux not appreciating

successful

OR

20%

of our

in terms

Many

had

the

be

and be made aware of hallux valgus

better

that can

No benefits

in any form party

and

Harris

have

related

been

directly

received

to the

subject

Surg

1986;

B. Surgery

adolescent

Helal

an investigation Research Council 1947.

for adolescent

B, Gupta

SK, Gojaseni

Acta Orthop

hallux

valgus.

Scam!

P. Surgery

for adolescent

Cetti

R, Christensen hallux valgus.

H.

Grace

VOL.

neck

for hallux

osteotomy

for

No. 5, SEPTEMBER

1993

valgus.

supply

Ha//ux

va/gus.

Systat

: the

system

Lewis RJ, Feffer HL. Modified Mann

RA.

allied

Philadelphia,

for the treatment

to the first metatarsal.

Chevron

osteotomy

deformities

of

etc : WB Saunders, for

statistics.

chevron

of J Am

for hallux

the forefoot 1965.

Evanston,

and

IL : Systat

osteotomyofthe

mc,

first metatarsal.

1981; 157:105-9.

Avascular

necrosis

(in letter

to Editor).

Foot

Ank/e

1982;

3:125-9.

valgus.

J Bone

D, Hughes J, Kienerman L A comparison of Wilson and Hohmann osteotomies in the treatment of hallux valgus. J Bone JointSurg[Br] 1988; 70-B :236-41.

75-B,

W. 1988.

C/inOrthop

SE. Double oblique displacement Acta Orthop Scand 1983; 54:938-42.

Dooky BJ. Osteotomy of the metatarsal JointSurg[Br] 1968; 50-B :677.

C/in

hallux

G, Tanzer T, Ford M. Chevron osteotomy hallux valgus. C/in Orthop 1984; 183:32-6.

of

Leland

valgus.

1981 ; 157:

Home

for

REFERENCES

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AP, Waugh W. The use of footprints in assessing the results of operations for hallux valgus : a comparison of Keller’s operation and arthrodesis. J Bone Joint Surg [Br] 1975; 57-B :478-81.

metatarsa/gia.

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C/in

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or indirectly

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Trauma

829

VALGUS

(V-)osteotomy

RI, Beath T. Armyfoot Canadian so/diers. National No. 1574), Ottawa, Canada,

Helal

no operation have totally

FRCS

HALLUX

chevron

Orthop

false

informed

Mr R. R. H. Coombs,

FOR

F, Hetberington

the

results.

from a commercial this article.

Grill

of pain

should be straight after that 10#{176} to 25#{176} of hal!ux should

We thank Mr M. J. Evans, FRCS allowing us to study their patients.

OSTEOTOMY

MItcbellCL, flemmingJL, Allen R, GlenneyC,SanfordGA. bunionectomy for hallux valgus. J Bone Joint Surg A :41-60. Wilson

JN. Oblique Joint

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[Br]

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osteotomy

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[Am]

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valgus.

J Bone

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