Prospective randomized study of chevron osteotomy versus Mitchell's osteotomy in hallux valgus

Comparison of modified Mitchell and Chevron osteotomies for hallux valgus

BACKGROUND

Good clinical and radiological outcomes in mild-moderate hallux valgus (HV) can be achieved with Chevron osteotomy (CO) and modified-Mitchell osteotomy (MMO). The main goal of the present study was to compare the clinical and radiological outcomes after CO and MMO in HV.

METHODS

The study included 45 patients, comprising 40 females with a mean follow-up of 87.5 ± 27.8 months. The outcome measurements of metatarsal length (MT1), HV angle (HVA), intermetatarsal angle (IMA), clinical outcomes, and metatarsalgia were evaluated pre- and postoperatively.

RESULTS

No significant difference was determined between the MMO and CO groups in respect of metatarsalgia and AOFAS scores. The CO resulted in a significantly larger decrease in the MT1. The mean HVA and IMA correction was significantly greater after MMO than after CO.

CONCLUSION

Since MMO may prevent MT1 shortening, which is a typical problem in the Mitchell osteotomy, MMO may be preferred over CO in patients with preoperative shortened first metatarsal.

Distal chevron osteotomy versus different operative procedures for hallux valgus correction: a meta-analysis

Introduction

Distal chevron osteotomy is commonly used for the operative treatment of hallux valgus (HV). However, there are several operative procedures that can be used to treat HV. The aim of this meta-analysis was to compare the efficacy of distal chevron osteotomy with different operative procedures.

Materials and methods

A systematic search was conducted using the MEDLINE and EMBASE databases to identify randomized clinical trials (RCTs). The variables were radiological (hallux metatarsal phalangeal angle [HVA] and intermetatarsal angle [IMA]) and clinical (American Orthopaedic Foot & Ankle Society Score [AOFAS]). Heterogeneity was assessed with chi² and I² statistics. A random effects model was used for significant heterogeneity. Publication bias was evaluated with funnel plots.

Results

Ten studies involving 985 patients were evaluated in the meta-analysis. Distal chevron osteotomy was associated with a mean IMA correction 2.18° greater than the scarf procedure (MD − 2.18; 95% CI − 3.67, − 0.69; p = 0.004; I² = 0%). In addition, the proximal chevron was associated with a mean IMA correction 1.08° greater than the distal chevron (MD − 1.08; 95% CI − 1.86, − 0.29; p = 0.007; I² = 0%). The AOFAS assessment showed an overall advantage of 3.2 points in favor of the Lingdren group compared with distal chevron osteotomy (MD 3.20; 95% CI 0.37, 6.04; p = 0.03; I² = 0%).

Conclusions

Our findings indicate that distal chevron osteotomy provides a greater HVA correction than scarf osteotomy, and proximal chevron provides a larger IMA correction than distal chevron osteotomy. Lingdren osteotomy provides a greater AOFAS correction than distal chevron osteotomy.

Level of evidence

Level I, meta-analysis.

Overview of randomised controlled trials in hallux valgus surgery (2,184 patients)

BACKGROUND

The aim of this study is to provide an overview of randomised controlled trials (RCTs) in hallux valgus correction surgery summarising the available high-quality evidence.

METHODS

Following PRISMA guidelines, we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE (1946 to 1 February 2020) and Embase (1980 to 1 February 2020). We excluded non-randomised trials, systematic reviews and case-series. We also excluded trials of MTPJ arthrodesis. Trials that met our inclusion criteria were assessed by two authors using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to intervention groups.

RESULTS

32 RCTs met the inclusion criteria and were included. The total number of patients in those trials was 2,184. Only 4 RCTs (12.5%) reported significant differences between the intervention and the control groups. The remaining trials evaluated scarf or chevron osteotomies in 18 RCTs, and 10 RCTs compared other osteotomies or technical aspects of hallux valgus surgery using functional and radiological outcome measures with none reporting significant differences.

CONCLUSION

Evidence from RCTs of hallux valgus surgery suggest that scarf and chevron osteotomies are the most popular techniques and lead to similar clinical outcomes.

Medium-Term Outcomes of Chevron Osteotomy for Hallux Valgus Correction in a Spanish Population: Radiologic and Clinical Parameters and Patient Satisfaction

BACKGROUND

Chevron osteotomy for mild and moderate hallux valgus obtains good effects. It is suitable for a variety of cases, allowing for a significant degree of correction. This study aimed to investigate chevron osteotomy for the correction of hallux valgus in the medium-term by podiatric surgeons. It considers clinical and radiologic findings and patient perspectives and level of satisfaction.

METHODS

Forty-five patients (50 feet) were assessed preoperatively, postoperatively, and at final follow-up. Mean patient age was 59.43 years (range, 32-80 years). The protocols include medical record review, clinical examination, and radiologic assessment. Anteroposterior weightbearing radiographs were analyzed preoperatively and at final follow-up. Clinical effects were analyzed with visual analog scale and American Orthopaedic Foot and Ankle Society (AOFAS) scores.

RESULTS

Interobserver and intraobserver reliability were evaluated. Mean ± SD hallux valgus angle decreased at final follow-up (25.30° ± 7.21° versus 17.25° ± 10.32°; P = .041). There was no significant reduction in mean ± SD intermetatarsal angle at final follow-up (13.13° ± 3.03° versus 7.65° ± 3.47°; P = .078). Final AOFAS score was 82.08 ± 17.66. This study showed the relevance of magnet therapy, nail surgery, and other procedures. No patient was dissatisfied with the aesthetic scarring.

CONCLUSIONS

The radiologic results at final follow-up were not compatible with relapse of the deformity. The definitive clinical results and the degree of patient satisfaction achieved with this technique were favorable from the patients' point of view.

Modified Mitchell technique for treating hallux valgus: Retrospective case series on a Middle-Eastern population and literature review

Introduction

The hallux valgus deformity is a complex deformity of the first ray of the foot, with more than 100 procedures developed for its treatment. The aim of this retrospective study was to assess the clinical and radiographic outcomes of a modified Mitchell's technique.

Methods

Between 2007 and 2018, 75 patients underwent the procedure. Clinical results were assessed by the AOFAS score. Radiological studies were evaluated by measuring pre-operative and post-operative HVA and IMA angles as well as the relative shortening of the first metatarsal.

Results

Of the initial 75 patients, 42 patients remained eligible with a total of 67 feet. The mean age and follow-up were 47.8 and 5.2 years respectively. Global AOFAS score improved from 45.3 to 88.8 (p < 0.01). Mean HVA and IMA improved from 37.0 to 10.2 (p < 0,01) and 12.1 to 5.6 (p < 0.01), respectively. The mean metatarsal shortening was 3.0 mm (p < 0.01). The statistical analysis showed no significant correlation between preoperative HVA and IMA angles with postoperative shortening, metatarsalgia, AOFAS scores nor the difference between the preoperative and postoperative AOFAS scores.

Conclusion

Short- and long-term outcomes of this modified Mitchell's osteotomy have been reported. Compared to other studies, these modifications proved to result in very good clinical and radiological outcomes even in severe cases with HVA>40. It has shown to be reliable, reproducible, and cost-efficient with low complication rates. We would like to highlight the importance of proper patient selection, limited soft tissue stripping, and adherence to the proposed surgical steps to avoid unwanted complications.

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The Modified Mitchell Technique has been shown to be reliable, reproducible, and cost-efficient with low complication rates.

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The addition of intra-articular lateral soft tissue release, preventing a lateral incision, decreasing wound and soft tissue complications.

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The use of autologous bone graft adjacent to the osteotomy stump helps improve union.

First Metatarsal Rotation in Hallux Valgus Deformity

Rotation of the first metatarsal (M1) as a potential etiological factor of hallux valgus (HV) deformity was described relatively early in the description of HV pathoanatomy. However, because biplanar radiographs have been the standard method for imaging HV, clinicians primarily developed measurement methods and corrective operations confined to 2 dimensions, medial-lateral and inferior-superior. Recently, as our understanding of HV pathoanatomy has further developed, aided in part by advanced imaging technology, M1 rotation about its axis ("axial rotation") and its implications for HV deformity and treatment has reemerged. The goal of this review is to summarize M1 rotation in HV from a historical perspective, to present the current understanding of its potential role in the etiology/pathogenesis of HV, and to summarize relevant imaging and operative considerations with respect to M1 rotation.Level of Evidence: Level III, systematic review.

Fixation Principles in Minimal Incision Hallux Valgus Surgery

Minimal incision surgical principals rely on the soft tissue envelope to maintain stability that is supplemented by a variety of clinically recommended fixation methods. The extended distal first metatarsal osteotomy has renewed interest because of the ability to laterally translate, angulate, and rotate the metatarsal head in proper alignment with the sesamoids to a neutral alignment. The soft tissue envelope of capsule, ligaments, and tendons will re-align once the bone deformity is corrected. The periosteum is maintained to provide a biologic scaffold for new bone formation and must be minimally disrupted during the intervention."

Three-Dimensional Analysis of the First Metatarsal Bone in Minimally Invasive Distal Linear Metatarsal Osteotomy for Hallux Valgus

BACKGROUND

Modified Bösch osteotomy (distal linear metatarsal osteotomy [DLMO]) is one of the minimally invasive correctional surgeries for hallux valgus. The 3-dimensional correctional angles and distances of the first metatarsal bone in DLMO have not been clarified. The purpose of this study was to analyze the 3-dimensional postoperative morphological changes of the first metatarsal bone in DLMO.

METHODS

Twenty patients (30 feet) who underwent DLMO were enrolled. Preoperative plain radiographs and computed tomography (CT) scans of the feet were examined. Postoperative radiographs and CT scans were also obtained after bone union. The surface data of the pre- and postoperative first metatarsals were reconstructed from the CT data. The positions of the distal ends of the first metatarsals described with respect to the proximal ends were calculated using CT surface-matching technique.

RESULTS

The distal end of the first metatarsal after DLMO was significantly supinated (10.2 ± 6.0 degrees, P < .001), adducted (6.0 ± 11.8 degrees, P = .004), dorsiflexed (11.1 ± 10.9, P < .001), shortened (7.4 ± 2.5 mm, P < .001), elevated (2.3 ± 3.1 mm, P = .001), and laterally shifted (8.2 ± 3.0 mm, P < .001) compared to the preoperative metatarsal distal end. Supination correction demonstrated a significant correlation with adduction correction (r = 0.659, P < .001) on correlation analyses between these parameters.

CONCLUSION

The 3-dimensional corrections of the first metatarsal bone after DLMO were evaluated. Pronation and abduction were successfully corrected. Furthermore, adduction correction might be an important factor affecting correction of pronation.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Patient-reported outcome after hallux valgus surgery - a two year follow up

BACKGROUND

Patients with hallux valgus deformity may require surgery but prospective patient-reported data is scarce.

METHODS

We evaluated 53 patients with a mean age of 55.3years (SD 14.1, 50 women), who underwent surgery due to hallux valgus. They completed the PROMs SEFAS, EQ-5D and SF-36 before and 6, 12 and 24 months after surgery.

RESULTS

All patient-reported outcomes improved at 6, 12 and 24months compared with the preoperative status. The greatest improvement occurred at 6months: SEFAS Δ 10.0 (95% confidence interval 7.8-12.2), EQ-5D Δ 0.22 (0.15-0.29), EQ-VAS Δ 8.4 (4.4-12.4), PF SF-36 Δ 22.0 (14.6-29.3) and BP SF-36 Δ 30.6 (23.1-38.1).

CONCLUSIONS

Hallux valgus surgery considerably reduced pain and improved function already within 6months after surgery. The improvement between 6 and 24months' follow-up was minimal measured with PROMs.

LEVEL OF CLINICAL EVIDENCE

III - prospective observational cohort study.

Percutaneous minimally invasive Akin osteotomy in hallux valgus interphalangeus: a case series

PURPOSE

Phalangeal Akin osteotomy of the greater toe is a frequently used surgical procedure for correcting hallux valgus interphalangeus deformity. However, previous research did not investigate percutaneous techniques of the Akin osteotomy. It was the aim of this study to investigate feasibility, corrective potential, and safety of a percutaneous minimally invasive Akin osteotomy.

METHODS

We present a series of 81 feet, in which a percutaneous Akin technique was performed using a high-speed burr but no fixation device. The most important outcome parameters were determined as the proximal to distal phalangeal articular angle (PDPAA) (corrective effect of the osteotomy), the osteotomy healing (full, partly, no visibility of the osteotomy gap), and the integrity of the lateral cortical hinge.

RESULTS

With regard to the main hypothesis we found significant changes in the PDPAA over the whole period of time (p < 0.001). Post-hoc tests determined that the PDPAA changed from 10° pre-operatively (Md, IQR 4.3) to 2.3° post-operatively (Md, IQR 3.7) (p < 0.001). Post-operatively no significant changes in PDPAA were found within the first six weeks and from six weeks to three months (no loss of correction). Osteotomy healing was satisfactory as well. Three months post-operatively, there were no patients with a fully visible osteotomy gap, 28.3% with a partly visible osteotomy gap, and 71.7% had no visible gap. Interestingly, we could not observe a statistically significant correlation between bone healing and the integrity of the lateral cortical hinge.

CONCLUSION

From our findings we conclude that the minimally invasive Akin osteotomy without osseous fixation provides effective deformity correction without significant loss of correction thereafter. This procedure appears to be safe with regard to osseous healing. Surprisingly, the healing process of the osteotomy showed no dependence on the integrity of the lateral cortical hinge.

LEVELS OF EVIDENCE

Therapeutic, Level IV, retrospective case series.

First Tarsometatarsal Joint Derotational Arthrodesis for Flexible Hallux Valgus: Results from Follow-Up of 3-8 Years

PURPOSE

We report 3- to 8-year follow-up results for the first tarsometatarsal joint derotational arthrodesis.

METHODS

A total of 70 patients (88 feet) with symptomatic flexible hallux valgus were operated between 2003 and 2009. In all, 66 patients (94.3%) with 84 (95.5%) feet were enrolled in retrospective analysis; of those, 58 (87.9%) patients with 76 (90.5%) feet were followed for a mean of 5.1 (range: 3.0-8.3) years. Preoperative, 6 week postoperative, and late follow-up weightbearing radiographs were evaluated along with clinical examination and questionnaires.

RESULTS

The mean hallux valgus angle improved 13.4° (95% confidence interval: 11.6-15.1, p < .001) at the latest follow-up, while the mean intermetatarsal angle correction was 4.5° (95% confidence interval: 3.7-5.2, p < .001). There were three (4.0%) nonunions, and seven (9.2%) feet needed reoperation during follow-up.

CONCLUSION

First tarsometatarsal joint derotational arthrodesis is an effective procedure for correcting flexible hallux valgus deformity and provides a satisfactory long-term outcome.

Outcomes in chevron osteotomy for Hallux Valgus in a large cohort

Clinical and radiological related outcomes have been reported for Chevron osteotomy as correction for mild to moderate hallux valgus, but only for relatively small patient series. Moreover, evaluation of the patient's point of view has mostly been conducted by means of more physician-based outcome measures. The goal of this study was to evaluate the effect of the Chevron osteotomy for hallux valgus on patients' daily lives using the Foot and Ankle Outcome Score (FAOS) as a validated and a hallux valgus specific patient reported outcome measure (PROM). Secondary outcome measures were radiological correction, complication rate, and re-operations. All 438 Chevron procedures (336 patients), at two surgical hospital sites in the period between January 2010 and October 2014, were retrospectively evaluated with a follow-up of at least 6 months. Patients were invited to fill in a cross-sectional online FAOS. For the FAOS, a total response of 60% was achieved. The FAOS ranged between 71 and 88 with a follow-up of on average 36 months. Patients with an undercorrection of their hallux valgus (11.6% of the procedures) scored significantly lower on three subscales of the FAOS (range between 61 and 77 versus 72-84). Patients who had a reoperation (12.6% of the procedures) also scored significantly lower on four subscales: 58-100 versus 73-89. Postoperative radiological measurements improved significantly with a mean difference of 6.1 (5.9; 6.4) degrees for the intermetatarsal angle and 13.7 (13.0; 14.5) degrees for the hallux valgus angle. In this large study cohort, Chevron osteotomy for hallux valgus offers good PROM scores on FAOS. These scores were significantly lower in patients with radiological undercorrection or with a reoperation. Results of the FAOS appear to modulate with physician based outcomes and therapeutic incidents. Improvement of outcome may therefore well be possible by increased attention on these surgical details.