Distal versus Proximal Metatarsal

Osteotomy for the Correction of

Hallux Varus as Complication of

Hallux Valgus Surgery

Joowon Joh, M.D., Kyungjin Choi, M.D.

Dr. Choi's Orthopedic Surgery Clinic, Seoul, Korea

AOFAS Annual Meeting 2015, Long Beach, California

Distal versus Proximal Metatarsal

Osteotomy for the Correction of

Hallux Varus as Complication of

Hallux Valgus Surgery

Joowon Joh, M.D.

My disclosure is in the Final AOFAS Mobile App.

I have no potential conflicts with this presentation.

No Conflict to Disclose

Introduction

Surgical options of hallux varus following surgery for hallux valgus

• Medial capsular release

• Corrective osteotomy

• Tendon transfer

• Arthrodesis

No studies comparing

the results of

corrective metatarsal

osteotomy at different

level

The Purpose of this study

To compare the clinical and radiological outcomes of two types of

metatarsal osteotomy in hallux varus deformity as complication of hallux

valgus surgery

: Distal chevron vs Proximal chevron

Hallux varus after hallux valgus surgery

Material and Methods(I)

Hallux varus correction following hallux valgus surgery by a single surgeon

Underwent chevron metatarsal osteotomy with medial displacement and a medial closing wedge osteotomy along with a medial capsular release, but without tendon transfer

Two groups based on their operative treatment

• Distal chevron metatarsal osteotomies

• 22 patients

• Mean F/U of 23 months(14 to 42)

• All females

• Mean age 46.7 years

Group A

• Proximal chevron metatarsal osteotomies

• 26 patients

• Mean F/U of 20 months(12 to 47)

• All females

• Mean age 42.5yrs

Group B

Case

Pre-op. Pre-op. Post-op. Post-op.

F/52 F/49

Group A Group B

Material and Methods(II)

Clinical and radiographic assessment • American Orthopaedic Foot and Ankle Society(AOFAS) scoring system

• Hallux valgus angle(HVA)

• First-second intermetatarsal angle(IMA)

• Distal metatarsal articular angle(DMAA)

• Mean relative length ratio of the first and second metatarsals

Statistical analysis

• Paired t-test and independent t-test

• Mann-Whitney’s U-test

• P<0.05

• SPSS 12.0 for windows

Results(II) – Intragroup comparison

Pre OP Post OP

P value

Group A 1.01 0.98 P<0.05

Group B 0.98 0.97 P<0.05

0

20

40

60

80

100

Group A Group B

Pre-op.

Post-op.

-20

-10

0

10

20

HVA IMA DMAA

-20

-10

0

10

HVA IMA DMAA

Clinical Assessment

Group A Group B

Mean relative length ratio of the 1st. and 2nd. metatarsals

Radiographic Assessment

AOFAS score

• P<0.05

° °

° ° *

* , Paired t-test. The p values are for intragroup comparisons.

Results(II) – Intergroup comparison

Pre- and Post-operative data Group A

(N = 22) Group B

(N = 26) P-value

AOFAS 77 → 92 72 → 90 0.482

HVA, degree -11.9 → 5.1 -13.1 → 4.8 0.885

IMA, degree -0.5 → 2.7 -1.5 → 8.3 0.041

DMAA, degree 11.7 → 1.2 8.5 → 5.7 0.033

Mean relative length ratio of the

1st. and 2nd. metatarsals 1.01 → 0.98 0.98 → 0.97 0.297

*

*, Mann-Whitney U-test & independent t-test. The p values are for intergroup comparisons.

Discussion(I)

Combined causes of hallux varus following surgery for hallux valgus

• Excessive lateral release

• Excision of the lateral sesamoid or latereal head of the FHB

• Overcorrection of the IMA

• Excessive medial capsulorrhaphy

• Excessive resection of the medial eminence

Main cause from the radiographs of the 48 feet in our study

Overcorrection of the IMA

Excessive excision of the medial eminence with

overcorrection of the IMA

Soft-tissue imbalance with an IMA > 0° 31 feet(65%)

7 feet(15%)

10 feet(20%)

∴ We performed metatarsal osteotomy rather than

soft tissue procedure alone.

Discussion(II)

Chevron ostetotomy with a medial closing wedge is a reliable operation for improvement of the DMAA, IMA and joint congruity.

We found that

Proximal chevron osteotomy with medial closing wedge

“ 6.6° greater increase in the correction of the 1st. And 2nd. IMA”

Distal chevron osteotomy with medial closing wedge “ 7.7° greater decrease in the correction of DMAA ”

Hallux valgus had been treated by scarf osteotomy in 30 patients(63%) and proximal chevron osteotomy in 18 patients(37%), but we could not determine which type of osteotomy is more likely to lead to hallux varus.

Conclusion

Both distal chevron and proximal chevron osteotomy…

• Capable of adequately correcting hallux varus

• Not significantly different except for the correction power of the first-second IMA and DMAA

∴ Precautious review should be taken into

consideration when choosing the level of

metatarsal osteotomy due to different correction

power associated with each technique.

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