Operative Techniques in Orthopaedic Surgery - 2nd - Distal Chevron Osteotomy
Operative Techniques in Orthopaedic Surgery - 2nd - Distal Chevron Osteotomy
Operative Techniques in Orthopaedic Surgery - 2nd - Distal Chevron Osteotomy
DEFINITION
The first reports of a distal metatarsal osteotomy date back to Reverdin, who described in 1881 a
subcapital closing wedge osteotomy for the correction of hallux valgus deformity.
The chevron osteotomy has become widely accepted for correction of mild and moderate hallux valgus
deformities. In the initial reports by Austin and Leventen1 and Miller and Croce,13 no fixation was
mentioned. They suggested that the shape of the osteotomy and impaction of the cancellous capital
fragment on the shaft of the first metatarsal provided sufficient stability to forego fixation.
To increase the indication for this technically simple osteotomy, internal fixation and a lateral soft tissue
release have been added.
ANATOMY
The special situation distinguishing the first metatarsophalangeal (MTP) joint from the lesser MTP joints is the
sesamoid mechanism.
On the plantar surface of the metatarsal head are two longitudinal cartilage-covered grooves separated by
a rounded ridge. The sesamoids run in these grooves.
The sesamoid bone is contained in each tendon of the flexor hallucis brevis; they are distally attached by
the fibrous plantar plate to the base of the proximal phalanx.
The head of the first metatarsal is rounded and cartilagecovered and articulates with the smaller concave
elliptic base of the proximal phalanx.
Fan-shaped ligamentous bands originate from the medial and lateral condyles of the metatarsal head and run
to the base of the proximal phalanx and the margins of the sesamoids and the plantar plate.
Tendons and muscles that move the great toe are arranged in four groups:
PATHOGENESIS
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Extrinsic causes
Hallux valgus occurs predominantly in shoe-wearing populations and only occasionally in the unshod
individual.
Although shoes are an essential factor in the cause of hallux valgus, not all individuals wearing fashionable
shoes develop this deformity.
Intrinsic causes
Hardy and Clapham3 found in a series of 91 patients a positive family history in 63%.
Coughlin2 reported that a bunion was identified in 94% of 31 mothers whose children inherited a hallux
valgus deformity.
Association of pes planus with the development of a hallux valgus deformity has been controversial.
Hohmann5 was the most definitive that hallux valgus is always combined with pes planus.
Coughlin2 and Kilmartin and Wallace8 noted no incidence of pes planus in the juvenile patient.
Pronation of the foot imposes a longitudinal rotation of the first ray, which places the axis of the MTP joint in
an oblique plane relative to the floor. In this position, the foot appears to be less able to withstand the
deformity pressures exerted on it by either shoes or weight bearing.
The simultaneous occurrence of hallux valgus and metatarsus primus varus has been frequently described.
The question of cause and effect continues to be debated.
DIFFERENTIAL DIAGNOSIS
Ganglion
Hallux rigidus
NONOPERATIVE MANAGEMENT
Comfortable wider shoes
Orthotics
Spiral dynamics physiotherapy in adolescents
SURGICAL MANAGEMENT
Indications
Symptomatic hallux valgus deformity with a first intermetatarsal angle of up to 16 degrees
Stable first metatarsocuneiform joint
Contraindications
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Narrow metatarsal head so that adequate translation is not possible
Intermetatarsal angle of more than 16 degrees
Impaired vascular status
Skeletally immature patient
Severe osteoarthritic changes
Preoperative Planning
Standard weight-bearing AP and lateral radiographs are mandatory.
The hallux valgus and intermetatarsal angles and tibial sesamoid position are measured.
A preoperative drawing is helpful.
Clinical examination includes measurement of active and passive range of motion of the first MTP joint as well
as inspection of the foot for plantar callus formation indicative of transfer metatarsalgia and stability of the first
tarsometatarsal joint.
Positioning
The foot is prepared in the standard manner.
The patient is positioned supine.
An ankle tourniquet is optional.
Approach
The lateral soft tissue release is performed through a dorsal approach.
The chevron osteotomy is performed through a straight midline incision.
TECHNIQUES
▪ Chevron and Transarticular Lateral Soft Tissue Release
Exposure
The procedure is typically performed under peripheral nerve block.
A straight medial incision over the metatarsal head is performed (TECH FIG 1A).
The medial MTP joint capsule is opened with a longitudinal incision (TECH FIG 1B). The joint is
inspected for degenerative changes.
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Lateral Release and Preparation of the Metatarsal Head
The capsule is released from the plantar and the dorsal aspect of the base of the proximal phalanx
(TECH FIG 2A,B).
While the toe is plantar subluxed (TECH FIG 2C), scissors are placed intra-articular proximal to the
sesamoids from medial to lateral (TECH FIG 2D).
Parallel to this, a beaver knife is inserted and the lateral joint capsule (metatarsosesamoid ligament) is
divided immediately superior to the lateral sesamoid (TECH FIG 2E).
The lateral capsule is fenestrated at the first MTP joint, and a varus stress is applied to the hallux to
complete the lateral release (TECH FIG 2F,G).
The metatarsal head is now exposed, and Hohmann retractors are placed dorsal and plantar just extra-
articular of the first MTP joint.
The plantar Hohmann retractor protects the plantar artery to the metatarsal head and the dorsal
retractor protects the dorsal intra-articular blood supply originating from the capsule.
The medial eminence is now minimally shaved to achieve a plane surface but also to preserve as much
metatarsal head width as possible (TECH FIG 2H).
This is one of the most important principles if a chevron osteotomy is carried out in a moderate to
severe deformity.
Osteotomy Creation
A 1.0-mm Kirschner wire is drilled a little bit dorsal to the center of the exposed medial eminence. This
wire is generally inclined 20 degrees from medial to lateral, aiming at the head of the fourth metatarsal
(TECH FIG 3A,B).
In the situation of an elevated position of the first metatarsal, the inclination may be increased.
If shortening or lengthening of the first metatarsal is needed, the wire can be aimed to the fifth or third
metatarsal head.
By using a saw guide (TECH FIG 3C), two cuts are then made with an oscillating power saw so that they
form an angle of 60 degrees proximal to the drill hole.
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Once the capital fragment is freely mobile, the metatarsal shaft is pulled medially by using a towel clip
while pushing the metatarsal head laterally with the help of the thumb of the other hand (TECH FIG
3D,E).
In the situation that the DMAA is increased, a wedge from the distal dorsal cut can be excised to place
the metatarsal head in a more varus position. If there is only a minor increase of the DMAA, this may also
be achieved by impacting the metatarsal head onto the shaft.
Guidewire Placement
A guidewire for a cannulated Charlotte multiuse compression screw (Wright Medical Technology,
Arlington, TN) is inserted from the distal dorsal metatarsal shaft obliquely to lateral plantar of the
metatarsal head (TECH FIG 4).
It is now advised to check the position of the osteotomy and the guidewire with a C-arm or a Fluoroscan.
TECH FIG 4 • A guidewire for the 3.0 Charlotte multiuse compression screw (Wright Medical Technology) is
placed.
TECH FIG 5 • A. Screw length determination using the depth gauge. B. Prepare a countersunk area with
the Charlotte cannulated head drill. C. Predrilling with the Charlotte cannulated drill. D. Insertion of the
screw until the head is completely counterstunk within the bone. E. The medial eminence is resected. F.
Closing of the medial capsule with U-type sutures.
Lateral tilt of the ▪ Lateral release to avoid lateral tilting of the head, intraoperative
metatarsal head Fluoroscan control
POSTOPERATIVE CARE
Starting immediately postoperatively, ice application to the foot is helpful to reduce swelling.
Provided that the bone quality was intraoperatively sufficient, patients are allowed to walk with a postsurgical
type shoe (OFA Rathgeber, Germany) (FIG 2A) on the same day (limited for 4 weeks).
Weekly changes of the tape dressing are necessary.
An alternative to weekly dressing changes is the postoperative hallux valgus sock, which also reduces
postoperative edema (FIG 2B).
Radiographs are taken intraoperatively and at 4 weeks of follow-up.
After radiographic union is achieved, normal dress shoes with a more rigid sole are allowed.
After 4 weeks, physiotherapy to achieve normal forefoot function is recommended.
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FIG 2 • A. Rathgeber postoperative shoe (OFA Rathgeber). B. Postoperative hallux valgus compression stocking
used after suture removal.
Over a period of 14 years, we have modified and developed the chevron osteotomy. By reviewing each
step of the development with clinical studies, we now perform a chevron osteotomy with lateral soft tissue
release and single screw fixation.
Trnka et al21 reported in 2000 a series of 43 patients (57 feet) with 2-year and 5-year follow-up.
Radiographic evaluation revealed a preoperative average hallux valgus angle of 29 degrees and a
preoperative average intermetatarsal angle of 13 degrees. At the 2-year follow-up, those angles
averaged 15 and 8 degrees, respectively, and at the 5-year follow-up, they averaged 16 and 9 degrees.
The results at these two follow-up periods proved that the chevron osteotomy is a reliable procedure for
mild and moderate hallux valgus deformity and that there are no differences in outcome based on age.
Schneider et al18 reported in 2004 a series of 112 feet (73 patients) with a minimum follow-up of 10
years. For 47 feet (30 patients), the results were compared with those from an interim follow-up of 5.6
years. The American Orthopaedic Foot and Ankle Society (AOFAS) score improved from a preoperative
mean of 46.5 points to a mean of 88.8 points after a mean of 12.7 years. The first MTP angle showed a
mean preoperative value of 27.6 degrees and was improved to 14.0 degrees. The first intermetatarsal
angle improved from a preoperative mean of 13.8 degrees to 8.7 degrees. The mean preoperative grade
of sesamoid subluxation was 1.7 on a scale of 0 to 3 and improved to 1.2. Measured on a scale of 0 to 3,
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arthritis of the first MTP joint progressed from a mean of 0.8 to 1.7. The progression of arthritis of the first
MTP joint between 5.6 and 12.7 years postoperatively was statistically significant. Excellent clinical
results after chevron osteotomy not only proved to be consistent but also showed further improvement
over a longer followup period. The mean radiographic angles were constant, without recurrence of the
deformity. So far, the statistically significant progression of first MTP joint arthritis has not affected the
clinical result, but this needs further observation.
Sanhudo16 retrospectively reviewed 50 feet with moderate to severe hallux valgus deformity in 34
patients with a mean follow-up of 30 months. There was a mean AOFAS score improvement of 39.6 (44.5
to 84.1) points. The hallux valgus angle and intermetatarsal angle improved a mean of 22.7 degrees and
10.4 degrees, respectively. He concluded that the chevron osteotomy is also indicated for moderate to
severe hallux valgus deformity.
Park et al14 performed a level II study to compare chevron osteotomies with dorsolateral approach for
lateral release and chevron osteotomies with transarticular lateral release. One hundred and twenty-two
female patients (122 feet) who underwent a distal chevron osteotomy as part of a distal soft tissue
procedure for the treatment of symptomatic unilateral moderate to severe hallux valgus constituted the
study cohort. The 122 feet were randomly divided into two groups: namely, a dorsal first web space
approach (group D; 60 feet) and a medial transarticular approach (group M; 62 feet). The clinical and
radiographic results of the two groups were compared at a mean follow-up time of 38 months.
The final clinical and radiographic outcomes between the two approaches for distal soft tissue
procedures were comparable and equally successful. Accordingly, the results of
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this study suggest that the medial transarticular approach is an effective and reliable means of lateral soft
tissue release compared with the dorsal first web space approach.
COMPLICATIONS
Avascular necrosis of the metatarsal head
REFERENCES
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osteotomy of the metatarsal head for hallux valgus and primus varus. Clin Orthop Relat Res 1981;(157):25-
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1995;16:682-697.
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corrective factors. Clin Orthop Relat Res 1989;(243):180-198.
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