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.
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Dooky BJ. Osteotomy of the metatarsal JointSurg[Br] 1968; 50-B :677.
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Leland
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1981 ; 157:
Home
for
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no operation have totally
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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
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